Cardiovascular Diseases on the Global Agenda: The United Nations High Level Meeting, Sustainable Development Goals, and the Way Forward

County Health Leadership Practices and Readiness for Noncommunicable Disease Services in Kenya

Background:

Premature mortality from noncommunicable diseases (NCDs) is a contemporary development challenge. Low-income and lower-middle-income countries are disproportionately affected, with the poorest in society considered the most vulnerable. A paucity of literature exists on how leadership practices at the implementation level relate to ensuring readiness for NCD services.

Objective:

This study investigated any relationship between leadership practices and readiness for NCD services.

Methods:

This correlational study investigated any relationship between leadership practices at the county level and readiness for NCD services in Kenya using secondary data from a 2013 Service Availability and Readiness Assessment survey. Correlation and multiple linear regression tests were used to determine the strength and direction of any relationship between leadership practices (annual work planning, therapeutic committees, and supportive supervision), and NCD readiness (county readiness score).

Findings:

The findings indicated a statistically significant relationship between therapeutic committee (p = .002) and supportive supervision practices (p = .023) and NCD readiness. Leadership practices also had a statistically significant predictive relationship with NCD readiness (p = .009).

Conclusion:

Health leaders should ensure that leadership practices that have a predictive relationship with NCD readiness, such as therapeutic committee activities and supportive supervision visits, are implemented appropriately. Further, county health leaders should pay particular attention to the implementation of these leadership practices at nonpublic and Tiers 2, 3, and 4 health facilities that had lower NCD readiness scores.

Valuing tonsillitis manifestations in schoolchildren in Rio de Janeiro

Objective:

To evaluate the importance attributed to tonsillitis by guardians and their level of knowledge about the disease, correlating their management with their schooling and socioeconomic profiles.

Methods:

A quantitative, descriptive and observational cross-sectional study involving students aged 5 to 17 years from state-owned and private schools. A questionnaire was applied on management of tonsillitis and knowledge about rheumatic fever, addressing demographic and socioeconomic data.

Results:

A total of 323 students were included, predominantly females (61.3%), from state-owned schools (77.1%), with a mean age of 9.7±0.3 years. Among the guardians, 48.6% completed high school. Among the students 75.2% had at least one episode of odynophagia in the previous 12 months. Considering the previous 2 years, 89.8% reported this symptom. There was no collection of bacteriological specimens in 67.8%, and in 83% if taking into account only the last episode, despite the search for medical care in most cases (92.6%). The use of anti-inflammatory drugs was very frequent (43.0% “always” and 42.4% “sometimes”). Among the guardians, 81.7% denied being aware of the relation between rheumatic fever and inappropriate treatment of odynophagia; 85.8% said they wished they had received more information.

Conclusion:

Although it is quite common in schoolchildren, tonsillitis is neglected by many guardians and health professionals, and the ignorance of its relation with rheumatic fever is practically universal, which may contribute to its high prevalence.

Genetically predicted selenium is negatively associated with serum TC, LDL-C and positively associated with HbA1C levels

BACKGROUND & AIMS

Pervious epidemiological evidence on the associations of selenium, zinc with lipid profile and glycemic indices was contradictory. The aim of this study was to investigate whether selenium and zinc were casually associated with lipid profile and glycemic indices using mendelian randomization (MR) analysis.

METHOD

A two-sample MR was used to evaluate the causal-effect estimations. Summary statistics for selenium, zinc, lipids and glycemic indices were retrieved from previous large-scale genome-wide association study (GWAS). Single nucleotide polymorphisms (SNPs) that independently and strongly associated with the selenium and zinc were selected as the instrumental variables. The casual estimates were calculated using inverse variance weighted method (IVW), with weighted median, MR-Egger, and MR-PRESSO test as sensitivity analysis, respectively.

RESULTS

In the standard IVW analysis, per SD increment in selenium was associated with an 0.077 mmol/L decrease of TC (95 %CI: -0.102,-0.052) and 0.074 mmol/L of LDL-C (95 %CI: -0.1,-0.048). Suggestive casual associations were found between selenium and insulin or HbA1c. With IVW method, per SD increase in selenium was associated with an 0.023 mmol/L increase of insulin (95 %CI: 0.001,0.045), and an 0.013 mmol/L increase of HbA1c (95 %CI: 0.003,0.023). The results were robust in the sensitivity analysis. Zinc was not casually associated with any of lipid and glycemic markers.

CONCLUSION

Our MR analysis provides evidence of the potential causal effect of Se on beneficial lipid profile, including decreased TC and LDL-C. Furthermore, suggestive casual evidence was suggested between Se and increased serum HbA1c levels. Careful consideration is required for the protective effects of Se supplementation. No casual-effect association was found between Zn and any indices of the lipid and glucose parameters.

Diagnosis of heart diseases by a secure Internet of Health Things system based on Autoencoder Deep Neural Network

Objective of this study is to introduce a secure IoHT system, which acts as a clinical decision support system with the diagnosis of cardiovascular diseases. In this sense, it was emphasized that the accuracy rate of diagnosis (classification) can be improved via deep learning algorithms, by needing no hybrid-complex models, and a secure data processing can be achieved with a multi-authentication and Tangle based approach. In detail, heart sounds were classified with Autoencoder Neural Networks (AEN) and the IoHT system was built for supporting doctors in real-time. For developing the diagnosis infrastructure by the AEN, PASCAL B-Training and Physiobank-PhysioNet A-Training heart sound datasets were used accordingly. For the PASCAL dataset, the AEN provided a diagnosis-classification performance with the accuracy of 100%, sensitivity of 100%, and the specificity of 100% whereas the rates were respectively 99.8%, 99.65%, and 99.13% for the PhysioNet dataset. It was seen that the findings by the developed AEN based solution were better than the alternative solutions from the literature. Additionally, usability of the whole IoHT system was found positive by the doctors, and according to the 479 real-case applications, the system was able to achieve accuracy rates of 96.03% for normal heart sounds, 91.91% for extrasystole, and 90.11% for murmur. In terms of security approach, the system was also robust against several attacking methods including synthetic data impute as well as trying to penetrating to the system via central system or mobile devices.

Towards Population Salt Reduction to Control High Blood Pressure in Ghana: A Policy Direction

Although population salt reduction is considered a "best buy" in addressing hypertension and cardiovascular disease, Ghana shares a high hypertension burden with a seemingly high salt consumption. This article discusses best practices in reducing population salt intake and provides preliminary data on salt and potassium intake, as well as the process to develop a road map and identification of actions needed to support the development of a strategic national document towards salt reduction in Ghana. In February 2019, a 2-d stakeholder meeting was held with government agencies, researchers, nongovernmental organizations, civil society organizations, and international partners to deliberate on salt reduction strategies and interventions needed in the face of rising hypertension and other noncommunicable diseases (NCDs) in Ghana. Recommendations were developed from the stakeholder meeting and are being considered for inclusion in the revision of Ghana's national NCD policy.

Stakeholder Engagement in Planning the Design of a National Needs Assessment for Cardiovascular Disease Prevention and Management in Nepal

BACKGROUND

There is growing support for stakeholder engagement in health research, but the actual impact of such engagement has not been well established.

OBJECTIVES

This paper describes the stakeholder engagement process and evaluation during the planning of the national needs assessment for cardiovascular disease in Nepal.

METHODS

We used personal and professional networks to identify relevant stakeholders within the 7Ps framework (Patients and the Public, Providers, Purchasers, Payers, Public Policy Makers and Policy Advocates, Product Makers and the Principal Investigators) to develop a plan for assessing cardiovascular health needs in Nepal. We consulted 40 stakeholders through 2 meetings in small groups and a workshop in a large group to develop the study methods, conceptual framework, and stakeholder engagement process. We interviewed 33 stakeholders to receive feedback on the stakeholder engagement process.

RESULTS

We engaged 80% of the targeted stakeholders through small group discussions and a workshop. Three of 5 recommendations from the small group discussion were aimed at improving the stakeholder engagement process and 2 were aimed to improve the research methods. Eleven of 27 recommendations from the workshop aimed to improve the research methods, 4 aimed to improve stakeholder engagement, and 2 helped to expand the scope of dissemination. Ten were irrelevant or could not be incorporated due to resource limitation. Most stakeholders noted that the workshop provided an open platform for a multisectoral group to colearn from one another and share ideas. Others highlighted that the discussion generated insights to enhance research by incorporating expertise and ideas from different perspectives. The major challenges discussed were about committing the time for engagement.

CONCLUSIONS

The stakeholder engagement process positively affected the design of our research. This study provides important insights for future researchers that aim to engage stakeholders in national-level assessment programs in the health care system in the context of Nepal.

Exercise-associated prevention of adult cardiovascular disease in children and adolescents: monocytes, molecular mechanisms, and a call for discovery

Atherosclerosis originates in childhood and adolescence. The goal of this review is to highlight how exercise and physical activity during childhood and adolescence, critical periods of growth and development, can prevent adult cardiovascular disease (CVD), particularly through molecular mechanisms of monocytes, a key cell of the innate immune system. Monocytes are heterogeneous and pluripotential cells that can, paradoxically, play a role in both the instigation and prevention of atherosclerosis. Recent discoveries in young adults reveal that brief exercise affects monocyte gene pathways promoting a cell phenotype that patrols the vascular system and repairs injuries. Concurrently, exercise inhibits pro-inflammatory monocytes, cells that contribute to vascular damage and plaque formation. Because CVD is typically asymptomatic in youth, minimally invasive techniques must be honed to study the subtle anatomic and physiologic evidence of vascular dysfunction. Exercise gas exchange and heart rate measures can be combined with ultrasound assessments of vascular anatomy and reactivity, and near-infrared spectroscopy to quantify impaired O2 transport that is often hidden at rest. Combined with functional, transcriptomic, and epigenetic monocyte expression and measures of monocyte-endothelium interaction, molecular mechanisms of early CVD can be formulated, and then translated into effective physical activity-based strategies in youth to prevent adult-onset CVD.

Global Updates on Cardiovascular Disease Mortality Trends and Attribution of Traditional Risk Factors

PURPOSE OF REVIEW

The last 2-3 decades have witnessed a decline in age-standardized cardiovascular mortality rates in high-income regions, whereas this has only slightly decreased or even increased in most of the low- and middle-income countries. A systematic comparison of global CVD mortality by regions attributable to various modifiable risk factors such as diabetes, obesity, hypertension, poor diet, and physical inactivity is not available.

RECENT FINDINGS

We present a summary of time trends and heterogeneity in the distribution of global CVD mortality and the attribution of risk factors between 1990 and 2017 using the Global Burden of Disease (GBD) 2017 study. Globally, an estimated ~ 17.8 million (233.1 per 100,000) people died of CVD in 2017. The rate of CVD death was decreased in high-income countries (1990: 271.8 (95% UI (uncertainty interval), 270.9-273.5); 2017: 128.5 (95% UI, 126.4-130.7) per 100,000)) whereas it remained the same in lower- and middle-income countries (1990: 368.2 (95% UI, 335.6-383.3); 2017: 316.9 (95% UI, 307.0-325.5) per 100,000). Among the various traditional risk factors, high systolic blood pressure, unhealthy diet, high fasting plasma glucose, and high low-density lipoprotein levels were attributed to most of the CVD death and disability-adjusted life year lost. We also observed gender variations in tobacco and increased alcohol consumption. In addition to the traditional risk factors, poor air quality is associated with increased CVD burden in developing countries. Surveillance, country-specific guidelines, evidence-based policies, reinforcement of multisectoral health systems, and innovative solutions are urgently needed in resource-challenged settings to curb CVD risk factors and overall burden.

The changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990-2016

BACKGROUND

The burden of cardiovascular diseases is increasing in India, but a systematic understanding of its distribution and time trends across all the states is not readily available. In this report, we present a detailed analysis of how the patterns of cardiovascular diseases and major risk factors have changed across the states of India between 1990 and 2016.

METHODS

We analysed the prevalence and disability-adjusted life-years (DALYs) due to cardiovascular diseases and the major component causes in the states of India from 1990 to 2016, using all accessible data sources as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016. We placed states into four groups based on epidemiological transition level (ETL), defined using the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We assessed heterogeneity in the burden of major cardiovascular diseases across the states of India, and the contribution of risk factors to cardiovascular diseases. We calculated 95% uncertainty intervals (UIs) for the point estimates.

FINDINGS

Overall, cardiovascular diseases contributed 28·1% (95% UI 26·5-29·1) of the total deaths and 14·1% (12·9-15·3) of the total DALYs in India in 2016, compared with 15·2% (13·7-16·2) and 6·9% (6·3-7·4), respectively, in 1990. In 2016, there was a nine times difference between states in the DALY rate for ischaemic heart disease, a six times difference for stroke, and a four times difference for rheumatic heart disease. 23·8 million (95% UI 22·6-25·0) prevalent cases of ischaemic heart disease were estimated in India in 2016, and 6·5 million (6·3-6·8) prevalent cases of stroke, a 2·3 times increase in both disorders from 1990. The age-standardised prevalence of both ischaemic heart disease and stroke increased in all ETL state groups between 1990 and 2016, whereas that of rheumatic heart disease decreased; the increase for ischaemic heart disease was highest in the low ETL state group. 53·4% (95% UI 52·6-54·6) of crude deaths due to cardiovascular diseases in India in 2016 were among people younger than 70 years, with a higher proportion in the low ETL state group. The leading overlapping risk factors for cardiovascular diseases in 2016 included dietary risks (56·4% [95% CI 48·5-63·9] of cardiovascular disease DALYs), high systolic blood pressure (54·6% [49·0-59·8]), air pollution (31·1% [29·0-33·4]), high total cholesterol (29·4% [24·3-34·8]), tobacco use (18·9% [16·6-21·3]), high fasting plasma glucose (16·7% [11·4-23·5]), and high body-mass index (14·7% [8·3-22·0]). The prevalence of high systolic blood pressure, high total cholesterol, and high fasting plasma glucose increased generally across all ETL state groups from 1990 to 2016, but this increase was variable across the states; the prevalence of smoking decreased during this period in all ETL state groups.

INTERPRETATION

The burden from the leading cardiovascular diseases in India-ischaemic heart disease and stroke-varies widely between the states. Their increasing prevalence and that of several major risk factors in every part of India, especially the highest increase in the prevalence of ischaemic heart disease in the less developed low ETL states, indicates the need for urgent policy and health system response appropriate for the situation in each state.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Civil society in global health policymaking: a critical review

BACKGROUND

A social science approach to the study of civil society's role and influence in global health policymaking is a new area of scholarly research. In this article, I conduct a critical literature review to assess the recent research done on this topic.

MAIN BODY

I find that most research has been narrowly focused on the agenda-setting and policy implementation stages, failing to account for all stages of the policymaking process and civil society's role in it. Additionally, very little effort has been made to test and develop theoretical and analytical policymaking frameworks, clearly and consistently defining and conceptualizing civil society's role and influence in global health policymaking, provide methodological specificity and diversity, while emphasizing the importance of causal mechanisms.

CONCLUSION

I conclude by encouraging scholars to address these lacuna in the literature and to explore the utility of political science theory and alternative policymaking models to better define and explain the complexity of civil society's role and influence in global health policymaking processes.

Prevention and control of rheumatic heart disease: Overcoming core challenges in resource-poor environments

Rheumatic heart disease (RHD) has long receded as a significant threat to public health in high-income countries. In low-resource settings, however, the specter of RHD remains unabated, as exemplified by recent data from the Global Burden of Diseases Study. There are many complex reasons for this ongoing global disparity, including inadequate data on disease burden, challenges in effective advocacy, ongoing poverty and inequality, and weak health systems, most of which predominantly affect developing nations. In this review, we discuss how each of these acts as a core challenge in RHD prevention and control. We then examine key lessons learnt from successful control programs in the past and highlight resources that have been developed to help create strong national RHD control programs.

Trace minerals intake: Risks and benefits for cardiovascular health

Minerals play a major role in regulating cardiovascular function. Imbalances in electrolyte minerals are frequent and potentially hazardous occurrences that may lead to the development of cardiovascular diseases (CVDs). Transition metals, such as iron, zinc, copper and selenium, play a major role in cell metabolism. However, there is controversy over the effects of dietary and supplemental intake of these metals on cardiovascular risk factors and events. Since their pro-oxidant or antioxidant functions can have different effects on cardiovascular health. While deficiency of these trace elements can cause cardiovascular dysfunction, several studies have also shown a positive association between metal serum levels and cardiovascular risk factors and events. Thus, a J- or U-shaped relationship between the transition minerals and cardiovascular events has been proposed. Given the existing controversies, large, well-designed, long-term, randomized clinical trials are required to better examine the effects of trace mineral intake on cardiovascular events and all-cause mortality in the general population. In this review, we discuss the role of dietary and/or supplemental iron, copper, zinc, and selenium on cardiovascular health. We will also clarify their clinical applications, benefits, and harms in CVDs prevention.