Factors associated with the availability and affordability of essential cardiovascular disease medicines in low- and middle-income countries: A systematic review

Despite their potential to prevent or delay the onset and progression of cardiovascular disease (CVD), medicines for CVD remain unavailable and unaffordable to many in low- and middle-income countries (LMICs). We systematically reviewed the literature to identify factors associated with availability and affordability of CVD medicines in LMICs. A protocol for this study was registered on the PROSPERO register of systematic reviews (CRD42019135393). We searched Medline, EMBASE, Global Health, Cumulative Index to Nursing and Allied Health Literature, EconLit, Social Policy and Practice, and Africa Wide Information for studies analyzing factors associated with the presence of medicines (availability) or the price of these medicines as it relates to ability to pay (affordability) in LMICs. We performed a narrative synthesis of the results using an access to medicines framework that examines influences at different levels of the health system. We did not conduct a meta-analysis because of the differences in analytic approaches and outcome measures in different studies. The search was conducted in accordance with PRISMA guidelines. Of 43 studies meeting inclusion criteria, 41 were cross-sectional. Availability and affordability were defined and measured in different ways. A range of factors such as sociodemographic characteristics, facility tier, presence of medicines on national essential medicine lists, and international subsidy programs were examined. The studies had variable quality and findings were often inconsistent. We find gaps in the literature on factors associated with availability and affordability of CVD medicines, particularly at the health program level. We conclude that there is a need for experimental and quasi-experimental studies that could identify causal factors and effective responses. Such studies would help further our understanding of how complex multifactorial influences impact these outcomes, which could inform policy decisions. Along with this, greater standardization of definitions and measurement approaches of availability and affordability are needed to allow for more effective comparisons.

Radiofrequency Therapy and Noncosmetic Cutaneous Conditions

BACKGROUND

The need for noninvasive methods in treatment of cutaneous disease has continued to evolve exponentially. Amidst the search for technologies, radiofrequency (RF) has proven efficacious in numerous skin disease processes. Although RF is well known for its cosmetic utility, its mechanism is valued in the treatment of many noncosmetic cutaneous conditions of various etiologies.

OBJECTIVE

To identify and describe studies in which RF was used to treat noncosmetic skin conditions and to explore the potential of this modality for further application in dermatologic diseases.

MATERIALS AND METHODS

The PubMed database was used to find relevant articles.

RESULTS

This search strategy yielded 54 articles that met the eligibility criteria. Noncosmetic indications discussed in these articles include varicose veins (n = 10,550), lymphangioma circumscriptum (n = 72), cutaneous neoplasms (n = 42), cutaneous leishmaniasis (n = 743), acne and acne scarring (n = 158), non-acne scarring (n = 43), primary axillary hyperhidrosis (n = 76), and acute and chronic wounds (n = 94).

CONCLUSION

Treatment with RF is an effective, generally noninvasive modality with a relatively short postprocedure recovery time and little potential for severe adverse effects in the treatment of several cutaneous conditions. Further clinical studies would prove useful to assess the efficacy and cost-effectiveness of this treatment.

Opium Addiction and Risk of Laryngeal and Esophageal Carcinoma

INTRODUCTION

Cigarette smoking and alcohol consumption have a well-known effect on the development of upper aerodigestive tract carcinomas, but such a role for opium is questionable. This study was designed to assess the correlation between opium inhalation and cancer of the larynx and upper esophagus.

MATERIALS AND METHODS

Fifty eight patients with laryngeal cancer, ninety eight patients with upper esophageal cancer and twenty seven healthy individuals with no evidence of head and neck or esophageal malignancies were selected from Otolaryngology and Radiation Oncology Department of Mashhad University of Medical Sciences. Duration and amount of cigarette smoking and opium consumption were recorded through comprehensive interviews.

RESULTS

The crude odds ratio for laryngeal cancer was 5.58 (95% CI 2.05-15.15, P=0.000) in cigarette smokers relative to non-smokers and 9.09 (95% CI 3.21-25.64, P=0.000) in opium users relative to non-users. The crude odds ratio for esophageal cancer was 0.44 (95% CI 0.18-1.09, P=0.07) in cigarette smokers relative to non-smokers and 1.44 (95% CI 0.57-3.62, P=0.43) in opium users relative to non-users. After adjusting for smoking, the odds ratio for laryngeal cancer in opium users relative to non-users was 6.06 (95% CI 1.10-33.23, P=0.05). Laryngeal cancer was detected at a significantly lower age in opium users (54.54±10.93 vs 62.92±10.10 years, P=0.02) than in smokers. This effect was not observed in esophageal cancer. Although the duration (year 17.50±14.84 vs 21.91±14.03; P=0.34) and amount (pack/day 0.625 vs 0.978; P=0.06) of smoking were higher among those who were opium dependent, these differences were not statistically significant (P=0.34 and P=0.06, respectively).

CONCLUSION

Opium addiction by snuffing is an independent risk factor for the development laryngeal cancer but not esophageal cancer. Cigarette smoking increases this risk. Opium dependency increases the likelihood of developing laryngeal cancer at a younger age.

High hepatitis C virus prevalence among drug users in Iran: systematic review and meta-analysis of epidemiological evidence (2001-2012)

OBJECTIVE

Drug users, particularly drug injectors, are at elevated risk of blood-borne diseases. This study systematically reviewed the prevalence of hepatitis C virus (HCV) mono-infection and its co-infections with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in drug users in Iran.

METHODS

Searches were conducted in international, regional, and Iranian databases. Documents were screened, data extracted, and pooled point prevalence and 95% confidence intervals (CI) were calculated.

RESULTS

Overall, 13,821 subjects (87.4% male) with an average age of 32.4 years (95% CI 31-33 years) from 24 original studies were included in the analysis. The pooled HCV prevalence (95% CI) among drug users with and without an injection history was 45% (37-54%) and 8% (4-13%), respectively. The pooled HCV prevalences (95% CI) among individuals with vs. without a history of imprisonment and needle sharing were 58% (39-77%) vs. 44% (20-68%) and 56% (41-71%) vs. 49% (26-71%), respectively. The prevalence of HCV/HIV co-infection among injectors was 11% (95% CI 5-16%).

CONCLUSIONS

HCV prevalence is high in drug users in Iran, especially among those with a history of injection drug use, needle sharing, and imprisonment. Drug user-focused HCV prevention and treatment programs are urgently needed.

S202 – Patterns of Dysphagia in Hospital Inpatients

Objectives

To evaluate the patterns of dysphagia, aspiration, and vocal cord motion abnormality (VCMA) among inpatients at a tertiary care referral hospital.

Methods

The medical records of all patients undergoing fiberoptic endoscopic evaluation of swallowing (FEES) between July 2005 and June 2007 were reviewed retrospectively. Demographic information, and presence of aspiration or VCMA was documented. Patients were categorized according to indication for hospitalization as well as into surgical and non-surgical categories. Dysphagia severity was assessed and variations in the prevalence of aspiration and VCMA were ascertained using correlation analysis.

Results

418 inpatients underwent FEES. Commonly observed patient categories included: 1) neurological/neurosurgical, 2) liver disease/transplant, 3) cardiac surgery, 4) medicine, 5) other surgical. The overall prevalence of aspiration and VCMA were 51% and 21% respectively. VCMA was observed twice as frequently in surgical patients (p = 0.0005), while aspiration was seen at similar rates (p = 0.85) among surgical and non-surgical patients. Dysphagia was most severe in neurological/neurosurgical patients. The prevalence of VCMA was highest in cardiac surgery patients (p = 0.007), but the incidence of aspiration did not differ markedly among the groups (p = 0.18).

Conclusions

Swallowing dysfunction is associated with a multitude of medical and surgical conditions. The severity of dysphagia, and the prevalence of associated VCMA vary among different patient categories, while aspiration occurs at similar rates. Understanding these patterns is crucial in guiding the diagnosis and management of inpatients with dysphagia.

Release of Ca(2+) from intracellular stores and entry of extracellular Ca(2+) are involved in sea squirt sperm activation

A rise in intracellular free Ca(2+) concentration ([Ca(2+)](i)) is required to activate sperm of all organisms studied. Such elevation of [Ca(2+)](i) can occur either by influx of extracellular Ca(2+) or by release of Ca(2+) from intracellular stores. We have examined these sources of Ca(2+) in sperm from the sea squirt Ascidia ceratodes using mitochondrial translocation to evaluate activation and the Ca(2+)-sensitive dye fura-2 to monitor [Ca(2+)](i) by bulk spectrofluorometry. Sperm activation artificially evoked by incubation in high-pH seawater was inhibited by reducing seawater [Ca(2+)], as well as by the presence of high [K(+)](o) or the Ca channel blockers pimozide, penfluridol, or Ni(2+), but not nifedipine or Co(2+). The accompanying rise in [Ca(2+)](i) was also blocked by pimozide or penfluridol. These results indicate that activation produced by alkaline incubation involves opening of plasmalemmal voltage-dependent Ca channels and Ca(2+) entry to initiate mitochondrial translocation. Incubation in thimerosal or thapsigargin, but not ryanodine (even if combined with caffeine pretreatment), evoked sperm activation. Activation by thimerosal was insensitive to reduced external calcium and to Ca channel blockers. Sperm [Ca(2+)](i) increased upon incubation in high-pH or thimerosal-containing seawater, but only the high-pH-dependent elevation in [Ca(2+)](i) could be inhibited by pimozide or penfluridol. Treatment with the protonophore CCCP indicated that only a small percentage of sperm could release enough Ca(2+) from mitochondria to cause activation. Inositol 1,4,5-trisphosphate (IP(3)) delivered by liposomes or by permeabilization increased sperm activation. Both of these effects were blocked by heparin. We conclude that high external pH induces intracellular alkalization that directly or indirectly activates plasma membrane voltage-dependent Ca channels allowing entry of external Ca(2+) and that thimerosal stimulates release of Ca(2+) from IP(3)-sensitive intracellular stores.