Comparison of Cardiovascular Health Profiles Across Population Surveys From 5 High- to Low-Income Countries

Background

To facilitate the shift from risk-factor management to primordial prevention of cardiovascular disease, the American Heart Association developed guidelines to score and track cardiovascular health (CVH). How the prevalence and trajectories of a high level of CVH across the life course compare among high- and lower-income countries is unknown.

Methods

Nationally representative survey data with CVH variables (physical activity, cigarette smoking, body mass index, blood pressure, blood glucose, and total cholesterol levels) were identified in Ethiopia, Bangladesh, Brazil, England, and the US for adults (aged 18-69 years and not pregnant). Data were harmonized, and CVH metrics were scored using the American Heart Association guidelines, as high (2), moderate (1), or low (0), with the prevalence of high scores (better CVH) across the life course compared across countries.

Results

Among 28,092 adults (Ethiopia n = 7686, 55.2% male; Bangladesh n = 6731, 48.4% male; Brazil n = 7241, 47.9% male; England n = 2691, 49.5% male, and the US n = 3743, 50.3% male), the prevalence of high CVH scores decreased as country income level increased. Declining CVH with age was universal across countries, but differences were already observable in those aged 18 years. Excess body weight appeared to be the main driver of poor CVH in higher-income countries, and the prevalence of current smoking was highest in Bangladesh.

Conclusions

Our findings suggest that CVH decline with age may be universal. Interventions to promote and preserve CVH throughout the life course are needed in all populations, tailored to country-specific time courses of the decline. In countries where the level of CVH remains relatively high, protection of whole societies from risk-factor epidemics may still be feasible.

Comparison of cardiovascular health profiles across population surveys from five high- to low-income countries

Aims

With the greatest burden of cardiovascular disease morbidity and mortality increasingly observed in lower-income countries least prepared for this epidemic, focus is widening from risk factor management alone to primordial prevention to maintain high levels of cardiovascular health (CVH) across the life course. To facilitate this, the American Heart Association (AHA) developed CVH scoring guidelines to evaluate and track CVH. We aimed to compare the prevalence and trajectories of high CVH across the life course using nationally representative adult CVH data from five diverse high- to low-income countries.

Methods

Surveys with CVH variables (physical activity, cigarette smoking, body mass, blood pressure, blood glucose, and total cholesterol levels) were identified in Ethiopia, Bangladesh, Brazil, England, and the United States (US). Participants were included if they were 18-69y, not pregnant, and had data for these CVH metrics. Comparable data were harmonized and each of the CVH metrics was scored using AHA guidelines as high (2), moderate (1), or low (0) to create total CVH scores with higher scores representing better CVH. High CVH prevalence by age was compared creating country CVH trajectories.

Results

The analysis included 28,092 adults (Ethiopia n=7686, 55.2% male; Bangladesh n=6731, 48.4% male; Brazil n=7241, 47.9 % male; England n=2691, 49.5% male, and the US n=3743, 50.3% male). As country income level increased, prevalence of high CVH decreased (>90% in Ethiopia, >68% in Bangladesh and under 65% in the remaining countries). This pattern remained using either five or all six CVH metrics and following exclusion of underweight participants. While a decline in CVH with age was observed for all countries, higher income countries showed lower prevalence of high CVH already by age 18y. Excess body weight appeared the main driver of poor CVH in higher income countries, while current smoking was highest in Bangladesh.

Conclusion

Harmonization of nationally representative survey data on CVH trajectories with age in 5 highly diverse countries supports our hypothesis that CVH decline with age may be universal. Interventions to promote and preserve high CVH throughout the life course are needed in all populations, tailored to country-specific time courses of the decline. In countries where CVH remains relatively high, protection of whole societies from risk factor epidemics may still be feasible.

Cardiovascular health metrics in low and middle-income countries: A scoping review

BACKGROUND

In 2010 the American Heart Association defined the concept of ideal cardiovascular health to renew the focus on primordial prevention for cardiovascular disease. Evidence primarily from high-income countries suggests ideal CVH prevalence is low and decreases with age, with vulnerable populations differentially affected. We aimed to identify and characterize the evidence relevant to CVH metrics in low- and middle-income countries (LMICs).

METHODS

We followed the Joanna Briggs Institute guideline for the conduct of this scoping review. We searched MEDLINE, Embase, LILACS and study registers from inception to 14 March 2022. We included cross-sectional and cohort studies in populations representing a geographically-defined unit (urban or rural) in LMICs, and with data on CVH metrics i.e. all health or clinical factors (cholesterol, blood pressure, glycemia and body mass index) and at least one health behavior (smoking, diet or physical activity). We report findings following the PRISMA-Scr extension for scoping reviews.

RESULTS

We included 251 studies; 85% were cross-sectional. Most studies (70.9%) came from just ten countries. Only 6.8% included children younger than 12 years old. Only 34.7% reported seven metrics; 25.1%, six. Health behaviors were mostly self-reported; 45.0% of studies assessed diet, 58.6% physical activity, and 90.0% smoking status.

CONCLUSIONS

We identified a substantial and heterogeneous body of research presenting CVH metrics in LMICs. Few studies assessed all components of CVH, especially in children and in low-income settings. This review will facilitate the design of future studies to bridge the evidence gap. This scoping review protocol was previously registered on OSF: https://osf.io/sajnh.

Rural-Urban Differences in Diabetes Care and Control in 42 Low- and Middle-Income Countries: A Cross-sectional Study of Nationally Representative Individual-Level Data

OBJECTIVE

Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs.

RESEARCH DESIGN AND METHODS

We pooled individual-level data from nationally representative health surveys in 42 countries. We used Poisson regression models to estimate age-adjusted differences in the proportion of individuals with diabetes in rural versus urban areas achieving performance measures for the diagnosis, treatment, and control of diabetes and associated cardiovascular risk factors. We examined differences across the pooled sample, by sex, and by country.

RESULTS

The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared with urban populations with diabetes, rural populations had ∼15-30% lower relative risk of achieving performance measures for diabetes diagnosis and treatment. Rural populations with diagnosed diabetes had a 14% (95% CI 5-22%) lower relative risk of glycemic control, 6% (95% CI -5 to 16%) lower relative risk of blood pressure control, and 23% (95% CI 2-39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, whereas among men, differences were small.

CONCLUSIONS

Rural populations with diabetes experience substantial inequities in the achievement of diabetes performance measures in LMICs. Programs and policies aiming to strengthen global diabetes care must consider the unique challenges experienced by rural populations.

[Pillars and lines of action for integrated and people- and community-centered health systemsPilares e linhas de ação para sistemas integrados de saúde centrados nas pessoas e nas comunidades]

Se presenta el posicionamiento del grupo de trabajo latinoamericano de la Fundación Internacional para los Cuidados Integrados (1) (IFIC, por su sigla en inglés). Este reúne a diversos actores y organizaciones de América Latina, con el objeto de apoyar acciones que faciliten la transformación de los sistemas de salud en la Región hacia sistemas integrados y centrados en las personas, no como individuos aislados, sino como sujetos de derecho, en los contextos sociales y ambientales complejos donde viven y se vinculan. El grupo de trabajo plantea nueve pilares de la atención integrada para ser utilizados como marco conceptual en la elaboración de políticas y de cambios en las prácticas: 1) visión y valores compartidos, 2) salud de las poblaciones, 3) las personas y las comunidades como socias, 4) comunidades resilientes, 5) capacidades del talento humano en salud, 6) gobernanza y liderazgo, 7) soluciones digitales, 8) sistemas de pago alineados, y 9) transparencia ante la ciudadanía. Desde estos pilares se proponen líneas de trabajo en los ámbitos del fortalecimiento de alianzas y redes, la abogacía, la investigación y generación de capacidades, que contribuyan a materializar sistemas de salud y sociales efectivamente integrados y centrados no solo en las personas, sino también en las comunidades en América Latina.

Geriatric co-management and interdisciplinary transitional care reduced hospital readmissions in frail older patients in Argentina: results from a randomized controlled trial

BACKGROUND

Hospitalization is a moment of extreme vulnerability for frail older adults. There is scarce evidence on the effectiveness of geriatric co-management or transitional care interventions in Latin America.

AIMS

To assess whether geriatric co-management combined with an interdisciplinary transitional care intervention could reduce 30-day hospital readmission rate compared to usual care in hospitalized frail older patients in a tertiary hospital in Argentina.

METHODS

Single-blinded randomized controlled trial. Usual care treatment arm: all procedures performed during hospitalization were overseen by a senior internal medicine specialist and complied with pre-defined protocols. Patients had access to specialist care if needed, as well as hospital-at-home or home-based primary care services after discharge. Intervention treatment arm: in addition to usual care, a geriatric co-management team performed a comprehensive geriatric assessment during hospitalization, provided tailored recommendations to minimize geriatric syndromes and planned transition of care. A health and social care counselor oversaw continuity of care in patients' homes after discharge.

RESULTS

We included 120 participants in each of the intervention and usual care (control) arms. Thirty-day hospital readmissions were 47.7% lower in the intervention arm (18.3% vs 35.0%; P = 0.040); and emergency room visits within the first 6 months after discharge were 27.8% lower (43.3% vs 60.0%; P = 0.010). There was a non-statistically significant decrease in 6-month mortality in the intervention arm (25.0% vs 35.0%; P = 0.124).

CONCLUSION

Geriatric co-management of frail older patients during hospitalization combined with an interdisciplinary transitional care intervention reduced 30-day hospital readmissions and emergency visits 6 months after discharge.

TRIAL REGISTRATION NUMBER

Trial registration number: RENIS IS003081.

A multifactorial intervention to lower potentially inappropriate medication use in older adults in Argentina

BACKGROUND

Adverse drug reactions are a common cause of potentially avoidable harm, particularly in older adults.

AIMS

To evaluate the feasibility and efficacy of a pilot multifactorial intervention to reduce potentially inappropriate medication (PIM) use in older adults.

METHODS

We conducted a phase 2, feasibility, open-label study in the ambulatory setting of an integrated healthcare network in Buenos Aires, Argentina. We recruited primary care physicians (PCPs) and measured PIM use in a sample of their patients (65 years or older). Educational workshops for PCPs were organized with the involvement of clinician champions. Practical deprescribing algorithms were designed based on Beers criteria. Automatic email alerts based on specific PIMs recorded in each patient's electronic health record were used as a reminder tool. PCPs were responsible for deprescribing decisions. We randomly sampled 879 patients taking PIMs from eight of the most commonly used drug classes at our institution and compared basal (6 months prior to the intervention) and final (12 months after) prevalence of PIM use using a test of proportions.

RESULTS

There was a significant reduction (p < 0.05) in all drug classes evaluated. Non-Steroidal Anti-Inflammatory Drugs (basal prevalence 5.92%; final 1.59%); benzodiazepines (10.13%; 6.94%); histamine antagonists (7.74%; 3.07%); opioids (2.16%; 1.25%); tricyclic antidepressants (8.08%; 4.10%); muscle relaxants (7.74%; 3.41%), anti-hypertensives (3.53%; 1.82%) and oxybutynin (2.96%; 1.82%). The absolute reduction in the overall prevalence was 8.5 percentage points (relative reduction of 51.4%).

CONCLUSION

This multifactorial intervention is feasible and effective in reducing the use of potentially inappropriate medication in all drug classes evaluated.

P–455 Breast cancer recurrence in women with and without controlled ovarian stimulation for fertility preservation. Cohort study

Study question

Do patients diagnosed with breast cancer who undergo ovarian stimulation for fertility preservation prior to chemotherapy have a higher risk of recurrence of the disease?

Summary answer

There was no statistically significant difference in the hazard ratio for breast cancer recurrence in fertility preservation-stimulated women compared to non-stimulated ones

What is known already

While many women with early breast cancer benefit from chemotherapy treatments in increasing disease-free survival, they are also at risk of permanent chemotherapy induced ovarian failure.

Oocyte cryopreservation with an adapted protocol with letrozole may reduce the possible deleterious effect of the hyper estrogenic state during the controlled ovarian hyperstimulation (COH). Although fertility preservation in women diagnosed with breast cancer seems safe, the follow-up periods of most studies are short in time. In addition, follow-up data of COH before neoadjuvant chemotherapy in women with hormone negative tumor receptors is still scarce and briefly reported.

Study design, size, duration

It was a retrospective cohort study, where 208 women with non-metastatic breast cancer were included. The recruitment period was from 01/01/2009 to 01/12/2019. The minimum follow-up period was 6 months, and the maximum, 130 months.

Participants were divided into two cohorts, those who received controlled ovarian hyperstimulation prior to their cancer treatment and those who did not. Patients were followed until disease recurrence, death, loss to follow-up, or end of the study

Participants/materials, setting, methods

Setting: university hospital in Buenos Aires, Argentina. We included women aged 18 to 45 years with a recent histological diagnosis of non-metastatic breast cancer who had to receive chemotherapy with gonadal toxicity. We excluded patients with a history of previous chemotherapy or radiotherapy for another cancer disease, or menopause. Follow-up was at least an annual clinical check-up and breast imaging.

Cohorts were analysed using a Cox-proportional hazards model, adjusted for propensity score for receiving stimulation.

Main results and the role of chance

We included 208 women, 39 in the COH group and 169 in the non-stimulated group (NSG). The only statistically significant difference was in age: median years 33.7 (interquartile range -IQR- 30.9 to 36.9) and 40.0 years (IQR 36.8 to 44.0), respectively. The median size of cancer nodules was 19.0 millimetres (IQR 10.0–30.0) and 17.0 (IQR 11.0–25.0), p 0.547; percentage of positive lymph nodes: 41.0% vs 39.3%, p 0.841; positive hormonal receptors: 84.6% vs 85.2%, p 0.925; percentage of neoadjuvant chemotherapy: 20.5% vs 11.4%, p 0.128. There were also no statistically significant differences regarding tumour stage, high Ki–67 labelling index, positive breast cancer genes (BRCA 1 or 2), and radiotherapy.

Overall, 18.0% of patients had cancer recurrence in the COH group and 20.7% in the NSG (p 0.699). Crude cancer recurrence rates were similar: 5.96 per 100 patients/year (95%CI 2.84–12.50), and 4.65 per 100 patients/year (95%CI 3.34–6.47), respectively. The crude hazard ratio (HR), comparing the COH group vs the NSG was 1.32 (95%CI 0.58–2.97; p 0.507). The adjusted HR using a propensity score for receiving ovarian stimulation treatment was 1.08 (95%CI 0.39–2.98; p 0.887). Results were similar if adjusted for age, neoadjuvant chemotherapy, and other confounders.

Limitations, reasons for caution

This was a single-center retrospective cohort study. There might be unknown or residual confounders that could influence results. Nevertheless, we accounted for treatment bias using a propensity score for ovarian stimulation. Results should be extrapolated with caution, especially in other non-university institutions and populations.

Wider implications of the findings: This study provides new evidence on the safety of controlled ovarian stimulation in breast cancer patients prior to chemotherapy treatment, in a Latin American population. Letrozole continues to show safety and efficacy as an adapted protocol in breast cancer.

Trial registration number

Not applicable

Effectiveness of a health and social care integration programme for home-dwelling frail older persons in Argentina

Introduction

The evidence of effectiveness of integrated care initiatives for home-dwelling frail older persons is still inconclusive. There is a need for more studies, especially in developing countries. Our objective was to assess the effectiveness of a health and social care integration programme versus the best standard of care to date in this population.

Methods

Quasi-experimental study performed in patients' homes in Buenos Aires, Argentina. The intervention arm had a health and social care counsellor that systematically reviewed the social and biological situation following a structured process, evaluating: functionality, nutrition, mobility, pain, cognition, medication reconciliation and adherence, need for care, quality of care, and environmental safety. The control group received the best standard of care to date, with access to the same health or social care services, but without the counsellor and related processes. The main outcome was the adjusted hazard ratio for hospitalizations after one year using a Cox-proportional hazards model.

Results

We recruited 121 persons in each group. The crude hazard ratio for hospital admissions, comparing the intervention to the control group was 0.622 (95% CI: 0.427–0.904; p = 0.013). The adjusted hazard ratio (aHR) was 0.503 (95% CI: 0.340–0.746; p = 0.001). The aHR for death was 0.993 (95% CI: 0.492–2.002; p = 0.984). The absolute difference in the quality of life was 16.59 points (95% CI: 12.03–21.14; p < 0.001).

Discussion

The integration programme had lower hospital admissions and better quality of life than the usual care. There was no significant difference in death rates.

Prescribed hypocaloric nutrition support for critically-ill adults

BACKGROUND

There are controversies about the amount of calories and the type of nutritional support that should be given to critically-ill people. Several authors advocate the potential benefits of hypocaloric nutrition support, but the evidence is inconclusive.

OBJECTIVES

To assess the effects of prescribed hypocaloric nutrition support in comparison with standard nutrition support for critically-ill adults SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, Embase and LILACS (from inception to 20 June 2017) with a specific strategy for each database. We also assessed three websites, conference proceedings and reference lists, and contacted leaders in the field and the pharmaceutical industry for undetected/unpublished studies. There was no restriction by date, language or publication status.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials comparing hypocaloric nutrition support to normo- or hypercaloric nutrition support or no nutrition support (e.g. fasting) in adults hospitalized in intensive care units (ICUs).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We meta-analysed data for comparisons in which clinical heterogeneity was low. We conducted prespecified subgroup and sensitivity analyses, and post hoc analyses, including meta-regression. Our primary outcomes were: mortality (death occurred during the ICU and hospital stay, or 28- to 30-day all-cause mortality); length of stay (days stayed in the ICU and in the hospital); and Infectious complications. Secondary outcomes included: length of mechanical ventilation. We assessed the quality of evidence with GRADE.

MAIN RESULTS

We identified 15 trials, with a total of 3129 ICU participants from university-associated hospitals in the USA, Colombia, Saudi Arabia, Canada, Greece, Germany and Iran. There are two ongoing studies. Participants suffered from medical and surgical conditions, with a variety of inclusion criteria. Four studies used parenteral nutrition and nine studies used only enteral nutrition; it was unclear whether the remaining two used parenteral nutrition. Most of them could not achieve the proposed caloric targets, resulting in small differences in the administered calories between intervention and control groups. Most studies were funded by the US government or non-governmental associations, but three studies received funding from industry. Five studies did not specify their funding sources.The included studies suffered from important clinical and statistical heterogeneity. This heterogeneity did not allow us to report pooled estimates of the primary and secondary outcomes, so we have described them narratively.When comparing hypocaloric nutrition support with a control nutrition support, for hospital mortality (9 studies, 1775 participants), the risk ratios ranged from 0.23 to 5.54; for ICU mortality (4 studies, 1291 participants) the risk ratios ranged from 0.81 to 5.54, and for mortality at 30 days (7 studies, 2611 participants) the risk ratios ranged from 0.79 to 3.00. Most of these estimates included the null value. The quality of the evidence was very low due to unclear or high risk of bias, inconsistency and imprecision.Participants who received hypocaloric nutrition support compared to control nutrition support had a range of mean hospital lengths of stay of 15.70 days lower to 10.70 days higher (10 studies, 1677 participants), a range of mean ICU lengths of stay 11.00 days lower to 5.40 days higher (11 studies, 2942 participants) and a range of mean lengths of mechanical ventilation of 13.20 days lower to 8.36 days higher (12 studies, 3000 participants). The quality of the evidence for this outcome was very low due to unclear or high risk of bias in most studies, inconsistency and imprecision.The risk ratios for infectious complications (10 studies, 2804 participants) of each individual study ranged from 0.54 to 2.54. The quality of the evidence for this outcome was very low due to unclear or high risk of bias, inconsistency and imprecisionWe were not able to explain the causes of the observed heterogeneity using subgroup and sensitivity analyses or meta-regression.

AUTHORS' CONCLUSIONS

The included studies had substantial clinical heterogeneity. We found very low-quality evidence about the effects of prescribed hypocaloric nutrition support on mortality in hospital, in the ICU and at 30 days, as well as in length of hospital and ICU stay, infectious complications and the length of mechanical ventilation. For these outcomes there is uncertainty about the effects of prescribed hypocaloric nutrition, since the range of estimates includes both appreciable benefits and harms.Given these limitations, results must be interpreted with caution in the clinical field, considering the unclear balance of the risks and harms of this intervention. Future research addressing the clinical heterogeneity of participants and interventions, study limitations and sample size could clarify the effects of this intervention.

[Not Available]

Celiac disease is an autoimmune enteropathy. The only known treatment consists of a permanent adherence to a strict gluten-free diet, which represents an important challenge for patients. Objective. To describe the gluten-free processed food offer in food locals from 3 neighborhoods representative of high, middle and low economic status in Buenos Aires, Argentina.

METHODS

Cross-sectional study. Specially trained monitors performed a standardized direct assessment of food locals. Whenever direct observation was not possible, we interviewed the personnel as an indirect assessment. We classified dish offer in different categories, and evaluated the processes of food elaboration, storage and distribution.

RESULTS

We included 112 food locals. Results for neighborhoods representative of high, middle and low economic status were, respectively: no gluten free dish available in 27.5% (45/62), 27.0% (27/37) and 30.8% (9/13), (p = 0.96); adequate elaboration in 17.7%, 13.5% and 7.7%, (p = 0.61); appropriate food storage in 12.9% (8), 13.5% (5) and 7.7% (1); (p = 0.85); adequate distribution in 8.1%, 8.1% and 0% (0), (p = 0.56). Conclusion. In 1 out of 4 food locals there was not even one gluten free dish. In addition, there was a lack of compliance with safety measures to avoid gluten cross-contamination.

[Medication adherence to secondary prevention for coronary artery disease]

We compared the use of evidence-based secondary prevention drugs for coronary artery disease at hospital discharge and 3 years of follow-up in a group of patients associated to an integrated network of health services. We conducted a retrospective group study that included 125 patients under 80 years of age who were hospitalized for acute coronary syndrome. McNemar's test was used to compare values at baseline and 3 years. The mean age of of participants was 63.7 years (SD ± 10.08) and 65.6% (95% CI 56.6-73.9) of male sex. The average follow-up time was 2.94 years (SD ± 0.25). The use of secondary prevention drugs for coronary heart disease decreased at 3 years of follow-up: anti-platelet 97.6 to 88.0% (p = 0.012), beta-blockers 94.4 to 84.8% (p = 0.021) and statins 83.7 to 91.2% (p = 0.035). Patients medicated with a combination of anti-platelet, beta blockers and statins showed a decrease from 86.4 to 66.3% (p < 0.0001). It is necessary to study the causes for the decreased adherence to long-term cardio-protective drugs.

[Resources use and direct medical costs in a pediatric population with chronic diseases]

OBJECTIVES

To evaluate the distribution and analyze the use of resources and direct medical costs in children and adolescents diagnosed with a chronic disease and compare them with healthy children of the same age from a health insurer perspective.

METHODS

We analyzed the resources used and direct medical costs generated during 2008 in 21-year-old patients or younger affiliated to a health plan of community hospital in Buenos Aires, Argentina. We compared the outcomes of patients with at least one chronic disease as defined by Stein with healthy patients from a health insurer perspective with a one year time horizon. The costs were expressed in U.S. dollars for 2008.

RESULTS

We identified 1885 children and adolescents with chronic illness, accounting for 6.7% of the total pediatric population studied. This group had a greater number and length of hospitalization, greater use of medications, practices and medical consultations than the healthy pediatric population. The mean total annual costs were US$ 501 (95% CI: 419-583) and US$ 212 (95% CI: 188-236), respectively (p < 0.001). Overweight, obesity and asthma, even with relatively low or moderate costs per patient, generated almost 39% of the total costs of chronic diseases due to its high prevalence.

CONCLUSION

The pediatric population with diagnosis of at least one chronic disease had significantly greater utilization of medical services and increased costs in all areas studied. It is also important to recognize that diseases of low or moderate cost per patient, but highly prevalent, generate the largest share of expenditure of chronic diseases in the population.

Mortality in an elderly type 2 diabetic patients' cohort who attended a self-management educational workshop

AIMS

To compare the all-cause mortality rate in elderly type 2 diabetic patients who attended self-management educational workshops compared with those who did not.

METHODS

Retrospective cohort study in a Health Maintenance Organization in Buenos Aires, Argentina. Patients older than 64 years with type 2 diabetes before December 2003 conformed the cohort followed from January 01, 2001 until death, censored date or December 31, 2007. All-cause mortality rate was ascertained from vital status reports and assessed according to educational workshops attendance. Results were adjusted for baseline variables, co-morbidities and A1C levels using Cox proportional hazards model.

RESULTS

1730 elderly diabetic patients were included, yielding 8685 person/years of observation. Educated and non-educated groups were similar regarding sex, co morbidities, diabetes duration, prevalent cases, insulin treatment, tobacco use, clinical and laboratory measures. All-cause mortality rate was 5.53 (4.04-5.07) per 100 person/years for non-attendants and 3.06 (2.39-3.91) for attendants. Crude hazard ratio for exposure to workshops was 0.68 (0.52-0.88); p = 0.004. After adjustment, attendance to diabetic workshops decreased its effect from 33% to 18% (HR 0.82; 95%CI: 0.61-1.08).

CONCLUSIONS

Workshop attendants had 33% lower all-cause crude mortality rate at 6 years of follow-up. More research is needed to explore whether these findings are explained by education itself, behavioural or personal characteristics of workshop attendants, the intensified participation in an integral diabetes programme, or a combination of them.

Neuropathy and anti-myelin-associated glycoprotein IgM M proteins: T cell regulation of M protein secretion in vitro

In patients with plasma cell dyscrasia, individual clones of antibody-producing cells proliferate abnormally and secrete monoclonal antibodies or M proteins in excess. The cause of the monoclonal proliferation of lymphocytes and M protein secretion is unknown and it is not known whether the M protein-secreting B cells are autonomous or capable of responding to regulatory T cells. We carried out experiments using lymphocytes from a patient with neuropathy and plasma cell dyscrasia whose IgM M protein bound to the myelin-associated glycoprotein (MAG) to determine whether secretion of the M protein in vitro was responsive to T cell help or suppression. M protein secretion was measured by an enzyme-linked immunosorbent assay system for measuring anti-MAG IgM, and the number of M protein-secreting lymphocytes was enumerated by a reverse hemolytic plaque assay specific for the M protein idiotype. The patient's B cells were maximally stimulated by pokeweed mitogen-activated autologous OKT4+ T-helper cells and the helper effect was inhibited by OKT8+ suppressor/cytotoxic T cells. Low levels of M protein secretion in the absence of T cells were also observed and there was partial stimulation of M protein secretion by T cells in the absence of pokeweed mitogen.

Specificity of mouse and human monoclonal antibodies to myelin-associated glycoprotein

Some patients with neuropathy have IgM M-proteins that bind to myelin and to myelin-associated glycoprotein (MAG). We compared the binding properties of a human anti-MAG M-protein with three mouse monoclonal anti-MAG antibodies (GEN-S1, GEN-S3, GEN-S8) and with a mouse monoclonal antibody (HNK-1) that binds to both MAG and to human natural killer cells. The antibodies GEN-S1, GEN-S3, and GEN-S8 bound to different epitopes in the polypeptide portion of MAG as shown by peptide mapping, deglycosylation and competitive binding studies. The M-protein and HNK-1 bound to both CNS and PNS MAG and to several additional protein bands of 70K, 30K, 26K, and 23K daltons in peripheral, but not in central myelin; they did not bind to deglycosylated MAG. The M-protein and HNK-1 immunostained myelin diffusely, whereas GEN-S8 immunostained only the periaxonal and outer regions of myelin sheath, and there was no staining with GEN-S1 or GEN-S3. The human M-proteins probably bind to a carbohydrate moiety in MAG that is also present in other PNS myelin proteins. This may explain the observed differences in immunostaining and the sparing of the CNS in patients with anti-MAG M-proteins.