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ABSTRACT: There has recently been increased publicity on the risk of venous thrombosis after long-haul flights. This paper reviews the evidence base related to the association between air travel and venous thromboembolism. The evidence consists only of case reports, clinical case-control studies and observational studies involving the use of intermediate end-points, or expert opinion. Some studies have suggested that there is no clear association, whereas others have indicated a strong relationship. On the whole it appears that there is probably a link between air travel and venous thrombosis. However, the link is likely to be weak, mainly affecting passengers with additional risk factors for venous thromboembolism. The available evidence is not adequate to allow quantification of the risk. There are insufficient scientific data on which to base specific recommendations for prevention, other than that leg exercise should be taken during travel. Further studies are urgently needed in order to identify prospectively the incidence of the condition and those at risk.

Objective To assess the prevalence of cardiovascular (CV) risk factors in Seychelles, a middle-income African country, and compare the cost-effectiveness of single-risk-factor management (treating individuals with arterial blood pressure ≥ 140/90 mmHg and/or total serum cholesterol ≥ 6.2 mmol/l) with that of management based on total CV risk (treating individuals with a total CV risk ≥ 10% or ≥ 20%). Methods CV risk factor prevalence and a CV risk prediction chart for Africa were used to estimate the 1 O-year risk of suffering a fatal or non-fatal CV event among individuals aged 40-64 years. These figures were used to compare single- risk-factor management with total risk management in terms of the number of people requiring treatment to avert one CV event and the number of events potentially averted over 10 years. Treatment for patients with high total CV risk (≥ 20%) was assumed to consist of a fixed-dose combination of several drugs (polypill). Cost analyses were limited to medication. Findings A total CV risk of ≥ 10% and ≥ 20% was found among 10.8% and 5.1% of individuals, respectively. With single-risk-factor management, 60% of adults would need to be treated and 157 cardiovascular events per 100 000 population would be averted per year, as opposed to 5% of adults and 92 events with total CV risk management. Management based on high total CV risk optimizes the balance between the number requiring treatment and the number of CV events averted. Conclusion Total CV risk management is much more cost-effective than single- risk-factor management. These findings are relevant for all countries, but especially for those economically and demographically similar to Seychelles. Objectif Evaluer la prevalence des facteurs de risque cardiovasculaire (CV) aux Seychelles, un pays africain a revenu moyen, et comparer le rapport cout/efficacite de la prise en charge du facteur de risque principal (traiter les individus presentant une tension arterielle [superieur ou egal a] 140/90 mmHg et/ ou une cholesterolemie serique totale [superieur ou egal a] 6,2 mmol/l) avec celui de la prise en charge fondee sur le risque cardiovasculaire total (traiter les individus presentant un risque cardiovasculaire total [superieur ou egal a] 10% ou [superieur ou egal a] 20%). Methodes La prevalence des facteurs de risque cardiovasculaire et un tableau de prediction des risques cardiovasculaires pour l'Afrique ont ete utilises pour estimer le risque de survenue d'un evenement CV mortel ou non mortel sur une periode de 10 ans chez des individus Ages de 40 a 64 ans. Ces chiffres ont servi a comparer la prise en charge du facteur de risque principal et celle du facteur de risque total en termes du nombre de personnes necessitant un traitement afin de prevenir un evenement CV et du nombre d'evenements potentiellement evites sur une periode de 10 ans. Le traitement chez des patients presentant un risque CV total eleve ([superieur ou egal a] 20%) etait suppose consister en une combinaison des doses predeterminees de piusieurs medicaments (polypill). Les analyses de coot se sent limitees aux medicaments. Resultats Un risque CV total [superieur ou egal a] 10% et [superieur ou egal a] 20% a ete constate chez 10,8% et 5,1% des individus, respectivement. Avec une prise en charge du facteur de risque principal, il faudrait traiter 60% des adultes, et 157 evenements cardiovasculaires sur une population de 100 000 personnes seraient evites chaque annie, par rapport a 5% des adultes et 92 evenements pour la prise en charge du facteur de risque CV total. Une prise en charge fondee sur un risque CV total eleve optimise l'equilibre entre le nombre de personnes necessitant un traitement et le nombre d'evenements cardiovasculaires evites. Conclusion La prise en charge du facteur de risque CV total a un bien meilleur rapport cout/efficacite que la prise en charge du facteur de risque principal. Ces resultats sent pertinents pour tous les pays, mais plus particulierement pour ceux presentant des caracteristiques economiques et demographiques similaires a celles des Seychelles. Objetivo Evaluar la prevalencia de los factores de riesgo cardiovascular (CV) en las Seychelles, un pals africano de ingresos medios, y comparar la rentabilidad de la gestion basada en un solo factor de riesgo (tratamiento de personas con una tension arterial superior o igual a 140/90 mm Hg y/o una concentracion serica de colesterol superior o igual a 6,2 mmol/l) con la gestion del riesgo CV total (tratamiento de personas con un riesgo CV total mayor o igual al 10% o mayor o igual al 20%). Metodos Para calcular el riesgo de padecer un episodio CV mortal o no mortal de las personas de entre 40 y 64 anos a Io largo de un periodo de 10 anos, se emplearon la prevalencia del factor de riesgo CV y una grafica de prediccion del riesgo CV en Africa. Estas cifras se emplearon para comparar la gestion del riesgo individual con la gestion del riesgo total, en cuanto al numero de personas que necesitarian tratamiento para evitar un episodio CV y el numero de episodios que podrian evitarse durante un periodo de 10 anos. Se presupuso que el tratamiento de los pacientes con un riesgo CV total ([mayor que o igual a] 20%) consistia en una asociacion de varies farmacos en dosis fijas (policomprimido). Los analisis de costes se limitaron a la medicacion. Resultados Se observo un riesgo CV total [mayor que o igual a] al 10% y [mayor que o igual a] al 20% en el 10,8% y el 5,1% de los individuos, respectivamente. En el caso de la gestion del riesgo individual, el 60% de los adultos necesitarian recibir tratamiento y se evitarian anualmente 157 episodios cardiovasculares por cada 100 000 personas, en contraposicion al 5% de los adultos y los 92 episodios que se evitarfan con una gestion del riesgo CV total. El tratamiento en funcion del riesgo CV total elevado optimiza el equilibrio entre el numero de personas que necesitarian tratamiento y el numero de episodios CV que se podrian evitar. Conclusion La gestion del riesgo CV total es mucho mas rentable que la individual basada en un solo factor de riesgo. Estos resultados son aplicables a todos los paises, en especial a aquellos que sean economica y demograficamente similares alas Seychelles., Introduction Every year approximately 17 million people die from cardiovascular (CV) disease. Of the deaths attributable to CV disease, which comprise roughly 29% of all deaths, about 80% occur in [...]

Objective To evaluate a simple cardiovascular risk management package for assessing and managing cardiovascular risk using hypertension as an entry point in primary care facilities in low-resource settings. Methods Two geographically distant regions in two countries (China and Nigeria) were selected and 10 pairs of primary care facilities in each region were randomly selected and matched. Regions were then randomly assigned to a control group, which received usual care, or to an intervention group, which applied the cardiovascular risk management package. Each facility enrolled 60 consecutive patients with hypertension. Intervention sites educated patients about risk factors at baseline and initiated treatment with hydrochlorothiazide at 4 months in patients at medium risk of a cardiovascular event, according to a standardized treatment algorithm. Systolic blood pressure change from baseline to 12 months was the primary outcome measure. Findings The study included 2397 patients with baseline hypertension: 1191 in 20 intervention facilities and 1206 in 20 control facilities. Systolic and diastolic blood pressure decreased more in intervention patients than in controls. However, at 12 months more than half of patients still had uncontrolled hypertension (systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg). Behavioural risk factors had improved among intervention patients in Nigeria but not in China. Only about 2% of hypertensive patients required referral to the next level of care. Conclusion Even in low-resource settings, hypertensive patients can be effectively assessed and managed in primary care facilities. Objectif Evaluer un module simple de prise en charge du risque cardiovasculaire permettant d'estimer et de prendre en charge le risque cardiovasculaire en utilisant I'hypertension comme point d'entree dans les etablissements de soins de sante primaires des pays a faibles ressources. Methodes Deux regions geographiquement distantes ont ete choisies dans deux pays (Chine et Nigeria) et 10 paires d'etablissements de soins de sante primaires ont ete selectionnes au hasard dans chaque region et apparies. Les regions ont ensuite ete reparties au hasard entre un groupe temoin qui recevait les soins habituels et un groupe d'intervention, auquel etait applique le module de prise en charge du risque cardiovasculaire. Chaque etablissement a recrute successivement 60 patients hypertendus. Sur les sites d'intervention, on a fourni au depart aux patients un enseignement sur les facteurs de risque et debute au bout de 4 mois un traitement par i'hydrochlorothiazide chez ceux presentant un risque moyen d'accident cardiovasculaire, conformement a un algorithme de traitement standardise, La variation de la pression arterielle systolique du stade de depart a 12 mois a constitue la principale mesure de resultat. Resultats L'etude a porte sur 2397 patients presentant une hypertension au depart: 1191 dans 20 etablissements mettant en oeuvre l'intervention et 1206 dans 20 etablissements temoins. Les pressions systolique et diastolique ont davantage diminue chez les patients b6n6ficiant de I'intervention que chez les patients temoins. Cependant, a 12 mois, plus de la moitie des patients presentaient encore une hypertension non controlee (pression systolique > 140 mm Hg et/ou pression diastolique > 90 mm Hg). Les facteurs de risque comportementaux s'etaient ameliores chez les patients beneficiant de I'intervention au Nigeria, mais pas en Chine. Seuls 2 % environ des patients hypertendus ont du etre orientes vers le niveau de soins superieur. Conclusion Meme dans les pays disposant de faibles ressources, il est possible d'evaluer et de prendre en charge efficacement les patients hypertendus dans les etablissements de soins de sante primaires. Objetivo Evaluar un paquete sencillo de gestion del riesgo cardiovascular para evaluar y gestionar ese riesgo usando la hipertension como punto de acceso en los centros de atencion primaria en los entornos con pocos recursos. Metodos Se seleccionaron dos regiones geograficamente distantes de dos paises (China y Nigeria), para proceder luego a elegir al azar y emparejar diez pares de centros de atencion primaria de cada region. Las regiones fueron asignadas aleatoriamente a un grupo de control, que recibio la atencion habitual, o a un grupo de intervencion, al que se aplico el paquete de gestion del riesgo cardiovascular. En cada estabiecimiento se estudio a 60 pacientes consecutivos con hipertension arterial. En los centros de intervencion se informo a los pacientes acerca de los factores de riesgo al comienzo del estudio y se instaur6 tratamiento con hidroclorotiazida a los 4 meses en los pacientes con riesgo medio de evento cardiovascular, de acuerdo con un algoritmo de tratamiento normalizado. El criterio de valoracion principal fue la variacion de la tension arterial sistolica respecto al nivel basal al cabo de 12 meses. Resultados El estudio abarc6 a 2397 pacientes con hipertension basal: 1191 en 20 centros de intervencion y 1206 en 20 centros de control. La tension arterial, sistolica y diastolica, disminuyo mas en los pacientes del grupo de intervencion queen los de control. Sin embargo, transcurridos 12 meses, mas de la mitad de los pacientes seguJan con la hipertension no controlada (tension arterial sistolica > 140 mmHg, o diastolica > 90 mmHg). Los factores de riesgo asociados al comportamiento habian mejorado entre los pacientes del grupo de intervencion en Nigeria, pero no en China. Solo un 2% de los pacientes hipertensos tuvieron que ser derivados al siguiente nivel asistencial. Conclusion Incluso en los entornos con recursos escasos, es posible evaluar y tratar eficazmente a los pacientes hipertensos en los centros de atencion primaria., Introduction The burden of cardiovascular disease (CVD) is substantially greater in low- and middle-income countries than in high-income countries. (1,2) CVD is associated with several modifiable risk factors, and effective [...]

Objective To ascertain the reliability of applying the WHO Cardiovascular Risk Management Package by non-physician health-care workers (NPHWs)in typical primary health-care settings. Methods Based on an a priori 80% agreement level between the NPHWs and the "expert" physicians (gold standard), 649 paired (matched) applications of the protocol were obtained for analysis using Kappa statistic and multivariate Iogit regression. Findings Results indicate over 80% agreement between raters, from moderate to perfect levels of agreement in almost all of the sections in the package. The odds of obtaining a difference between raters and a benchmark are not statistically significant. Conclusion Applying the WHO Cardiovascular Risk Management Package, NPHWs can be retrained to reliably and effectively assess and manage cardiovascular risks in primary health-care settings where there are no attending physicians. The package could be a useful tool for scaling up the management of cardiovascular diseases in primary health care. Resume Objectif S&apos;assurer de la fiabilite de l&apos;utilisation du module de prise en charge du risque cardiovasculaire de l&apos;OMS par des agents de sante non medecins, dans le cadre d&apos;etablissements de soins de sante primaire ordinaires. Methodes Sur la base d&apos;un accord de 80 % entre les resultats de l&apos;utilisation du module par des agents de sante non medecins et par des medecins competents (reference), on a obtenu 649 paires d&apos;applications (applications appariees) du protocole par analyse statistique Kappa et regression logistique multivariee (logit). Resultats L&apos;etude indique un accord global de plus de 80 % entre les evaluateurs, la concordance allant d&apos;un niveau moyen a celui de la perfection pour presque tous les volets du module. La difference entre les evaluateurs et une evaluation de reference n&apos;etait pas statistiquement significative. Conclusion II est possible de renforcer la formation des agents de sante de maniere a ce qu&apos;ils soient en mesure, en utilisant le module OMS, d&apos;evaluer et de prendre en charge de maniere fiable et efficace le risque cardiovasculaire dans les etablissements de soins de sante primaire en l&apos;absence de medecin. Ce module pourrait etre utile au developpement de la prise en charge des maladies cardiovasculaires dans le contexte des soins de sante primaire. Resumen Objetivo Determinar la fiabilidad de la aplicacion del Modulo de Gestion del Riesgo Cardiovascular de la OMS por personal sanitario no medico (PSNM) en los entornos de atencion primaria habituales. Metodos Partiendo de un nivel de concordancia a priori del 80% entre el PSNM y los medicos << expertos >> (criterio de referencia), se reunieron 649 aplicaciones del protocolo emparejadas para analizarlas mediante el estadistico Kappa y un modelo de regresion Iogit multifactorial. Resultados Los resultados muestran una concordancia de mas del 80% entre los evaluadores, con niveles de coincidencia entre moderados y perfectos en casi todas las secciones del modulo. Las diferencias entre los evaluadores y la referencia utilizada no son estadisticamente significativas. Conclusion Aplicando el Modulo de Gestion del Riesgo Cardiovascular de la OMS, es posible formar al PSNM para que evalue y controle de manera fiable y eficaz el riesgo cardiovascular en entornos de atencion primaria en los que no hay ningun medico. El modulo podria ser un valioso instrumento para expandir el manejo de las enfermedades cardiovasculares en los entornos de atencion primaria. [TEXT NOT REPRODUCIBLE IN ASCII], Introduction Chronic noncommunicable diseases, especially cardiovascular diseases, are a major and increasing cause of death and disability worldwide, and may have retarding effects on the economies of affected individuals, households [...]

Objective To assess the availability and affordability of medicines used to treat cardiovascular disease, diabetes, chronic respiratory disease and glaucoma and to provide palliative cancer tare in six low- and middle-income countries. Methods A survey of the availability and price of 32 medicines was conducted in a representative sample of public and private medicine outlets in four geographically defined areas in Bangladesh, Brazil, Malawi, Nepal, Pakistan and Sri Lanka. We analysed the percentage of these medicines available, the median price versus the international reference price (expressed as the median price ratio) and affordability in terms of the number of days&apos; wages it would cost the lowest-paid government worker to purchase one month of treatment. Findings In all countries [less than or equal to] 7.5% of these 32 medicines were available in the public sector, except in Brazil, where 30% were available, and Sri Lanka, where 28% were available. Median price ratios varied substantially, from 0.09 for losartan in Sri Lanka to 30.44 for aspirin in Brazil. In the private sector in Malawi and Sri Lanka, the cost of innovator products (the pharmaceutical product first given marketing authorization) was three times more than generic medicines. One month of combination treatment for coronary heart disease cost 18.4 days&apos; wages in Malawi, 6.1 days&apos; wages in Nepal, 5.4 in Pakistan and 5.1 in Brazil; in Bangladesh the cost was 1.6 days&apos; wages and in Sri Lanka it was 1.5. The cost of one month of combination treatment for asthma ranged from 1.3 days&apos; wages in Bangladesh to 9.2 days&apos; wages in Malawi. The cost of a one-month course of intermediate-acting insulin ranged from 2.8 days&apos; wages in Brazil to 19.6 in Malawi. Conclusion Context-specific policies are required to improve access to essential medicines. Generic products should be promoted by educating professionals and consumers, by implementing appropriate policies and incentives, and by introducing market competition and/or price regulation. Improving governance and management efficiency, and assessing local supply options, may improve availability. Prices could be reduced by improving purchasing efficiency, eliminating taxes and regulating mark-ups. Bulletin of the World Health Organization 2007;85:279-288. Resume Objectif Evaluer la disponibilite et l&apos;accessibilite economique dans six pays a revenu faible ou moyen de medicaments utilises pour le traitement de maladies cardiovasculaires, des diabetes, d&apos;affections respiratoires chroniques et du glaucome, ainsi que pour les soins palliatifs dispenses aux cancereux. Methodes Une enquete sur la disponibilite et le prix de 32 medicaments a ete menee sur un echantillon representatif d&apos;officines pharmaceutiques publiques et privees, situees dans quatre regions geographiquement definies du Bengladesh, du Bresil, du Malawi, du Nepal, du Pakistan et du Sri Lanka. Nous avons analyse le pourcentage de ces medicaments disponible, leur prix median par rapport au prix international de reference (exprime sous forme de ratio de prix median) et leur accessibilite economique, evaluee d&apos;apres le nombre de jours de salaire que devrait debourser le fonctionnaire le moins paye pour acheter un mois de traitement. Resultats Dans tous les pays etudies, 7,5 % ou moins de ces 32 medicaments etaient disponibles dans le secteur public, sauf au Bresil, ou la proportion de medicaments disponibles etait de 30 %, et au Sri Lanka, ou elle etait de 28 %. Les ratios de prix medians etaient tres variables, allant de 0,09 pour le losartan au Sri Lanka a 30,44 pour l&apos;aspirine au Bresil. Dans le secteur pharmaceutique prive du Malawi et du Sri Lanka, le cout des produits innovants etait trois fois plus eleve que celui des generiques. Un mois de traitement associe pour une maladie coronarienne coutait 18,4 jours de salaire au Malawi, 6,1 au Nepal, 5,4 au Pakistan, 5,1 au Bresil, 1,6 au Bangladesh et 1,5 au Sri Lanka. Le cout d&apos;un mois de traitement associe contre l&apos;asthme allait de 1,3 jour de salaire au Bangladesh a 9,2 jours de salaire au Malawi. Celui d&apos;une cure d&apos;un mois d&apos;insuline a action intermediaire variait de 2,8 jours de salaire au Bresil a 19,6 jours de salaire au Malawi. Conclusion Des strategies adaptees au contexte sont necessaires pour ameliorer l&apos;acces aux medicaments essentiels. Il convient de promouvoir l&apos;usage des medicaments generiques a travers l&apos;education des professionnels et des consommateurs, la mise en ceuvre de politiques et d&apos;incitations appropriees et la mise en place d&apos;une concurrence commerciale et/ou d&apos;une reglementation des prix. Une administration et une gestion plus efficaces, ainsi qu&apos;une evaluation des options d&apos;approvisionnement locales, pourraient permettre une plus grande disponibilite des medicaments. Une baisse des prix serait possible en ameliorant l&apos;efficacite des services d&apos;achat, en supprimant les taxes et en reglementant les marges beneficiaires. Resumen Objetivo Evaluar la disponibilidad y asequibilidad de diversos medicamentos utilizados para tratar las enfermedades cardiovasculares, la diabetes, las enfermedades respiratorias cronicas y el glaucoma y para proporcionar atencion paliativa contra el cancer en seis paises de ingresos bajos y medios. Metodos Se llevo a cabo una encuesta sobre la disponibilidad y el precio de 32 medicamentos en una muestra representativa de puntos de venta publicos y privados en cuatro zonas geograficas concretas de Bangladesh, el Brasil, Malawi, Nepal, el Pakistan y Sri Lanka. Analizamos el porcentaje disponible de esos medicamentos, el precio mediano en comparacion con el precio de referencia internacional (expresado como proporcion del precio mediano) y la asequibilidad expresada en funcion del numero de dias de sueldo que le costaria al funcionario publico peor pagado adquirir el tratamiento necesario para un mes. Resultados En el conjunto de todos los paises, se podia disponer en el sector publico de un porcentaje inferior o igual al 7,5% de esos 32 medicamentos, exceptuando los casos del Brasil, donde se tenia acceso al 30%, y de Sri Lanka, donde se podia acceder al 28%. Las proporciones del precio mediano diferian muy ampliamente, desde el 0,09 para el losartan en Sri Lanka hasta el 30,44 para la aspirina en el Brasil. En el sector privado de Malawi y Sri Lanka, el costo de los productos innovadores era tres veces superior al de los genericos. Un mes de tratamiento combinado para la cardiopatia coronaria costaba 18,4 dias de sueldo en Malawi, 6,1 dias en Nepal, 5,4 en el Pakistan y 5,1 en el Brasil; en Bangladesh el costo era de 1,6 dias de sueldo, y en Sri Lanka de 1,5. EI costo de un mes de tratamiento combinado para el asma se situaba entre 1,3 dias de sueldo en Bangladesh y 9,2 dias en Malawi. Y el costo de un regimen de un mes de insulina de accion intermedia oscilaba entre 2,8 dias de sueldo en el Brasil y 19,6 en Malawi. Conclusion Se requieren politicas adaptadas al contexto para conseguir mejorar el acceso a los medicamentos esenciales. Es necesario promover los productos genericos educando a los profesionales y a los consumidores, implementando politicas e incentivos apropiados, e introduciendo medidas de regulacion de los precios ylo de la competencia en el mercado. La mejora de la gobernanza y la eficiencia de la gestion, asi como la evaluacion de las opciones de suministro locales, pueden contribuir a mejorar la disponibilidad. Y es posible reducir los precios mejorando la eficiencia de las compras, eliminando impuestos y regulando los margenes de beneficio., Introduction Globally, approximately 35 million deaths (60% of all deaths) are attributable to chronic diseases each year, with more than 30 million deaths (52% of all deaths) due to cardiovascular [...]

Objective To determine the extent of secondary prevention of coronary heart disease (CHD) and cerebrovascular disease (CVD) in low- and middle-income countries. Methods A descriptive cross-sectional survey of a sample of 10 000 CHD (85.2%) and CVD (14.8%) patients (6252 men; 3748 women) was conducted over 6 months in geographically defined areas. The mean age was 59.2 years (standard donation (SD), 10.8). Consecutive patients were recruited from a stratified random sample of primary, secondary and tertiary care facilities in defined areas in 10 countries (Brazil, Egypt, India, Indonesia, Islamic Republic of Iran, Pakistan, Russian Federation. Sri Lanka, Tunisia and Turkey).The man outcome measures were levels of lifestyle and physiological risk factors, and the use of drugs for secondary prevention of CHD and CVD. Findings Approximately 82%, 89% and 77% of patients were aware of the cardiovascular benefits of quitting smoking, a heart-healthy diet and regular physical activity, respectively. About half (52.5%) engaged in less than 30 minutes of physical activity per day, 35% did not follow a heart-healthy diet and 12.5 % were current tobacco users. Blood pressure had been measured in 93.8% (range 71-100%), blood cholesterol in 85.5% (range 29-97%)and blood sugar in 75.5% (range 65-99%)in the preceding 12 months. The proportions who had received medications among CHD and CVD patients were: aspirin, 81.2%, 70.6%; beta-blockers, 48.1%. 22.8%; angiotensin-converting enzyme inhibitor, 39.8%, 37.8%; statins, 29.8%. 14.1%, respectively. About one-fifth of patients with CHD had undergone revascularization. Conclusion A significant proportion of patients did not receive appropriate medications. About 47% of patients had at least two or more modifiable risk factors (smoking, physical inactivity, hypertension, diabetes or hypercholesterolaemia). There are considerable missed opportunities for prevention of recurrences in those with established CVD in low- and middle-income countries. Keywords Myocardial ischemia/drug therapy; Cerebrovascular accident/drug therapy; Cardiovascular diseases/drug therapy; Aspirin/therapeutic use; Adrenergic beta-agonists/therapeutic use; Angiotensin-converting enzyme inhibitors/therapeutic use; Hydroxymethylglutaryl-CoA reductase inhibitors/therapeutic use; Life style; Risk factors; Developing countries (source: MESH, NLM). Mots cles Ischemie myocardique/chimiotherapie; Accident vascutaire cerebral/chimiotherapie; Cardiovasculaires, Maladies/chimiotherapie; Acide acetylsalicylique/usage therapeutique; Sympathomimetiques beta/usage therapeutique; Inhibiteurs dipeptidyl carboxypeptidase I/usage therapeuttque; Inhibiteurs hydroxymethylglutaryl CoA reductases/usage therapeutique; Style vie; Facteur risque; Pays en developpement (source: MeSH, INSERM). Palabras clave tsquemia miocardicalquimioterapia; Accidente cerebrovascular/quimioterapia; Enfermedades cardiovasculares/ quimioterapia; Aspinna/uso terapeutico; betaagonistas Adrenergicos/uso terapeutico; Inhibidores de la enzima convertidora de angiotensina/uso terapeutico; Iinhibidores de la hidrmimetilgtutaril-CoA reductasa/uso terapeutico: Estilo de vida; Factores de riesgo; Palses en desarrollo (fuente: DeCS, BIREME). Bulletin of the World Health Organization 2005;83:820-828. Voir page 826 le resume en francais. En la pagina 826 figura un resumen en espanol., Introduction Every year about 32 million individuals suffer acute coronary and cerebral vascular events and at least half of these occur in people with established coronary heart disease (CHD) and [...]

With population ageing worldwide, dementia poses one of the greatest global challenges for health and social care in the 21st century. In 2019, around 55 million people were affected by dementia, with the majority living in low- and middle-income countries. Dementia leads to increased costs for governments, communities, families and individuals. Dementia is overwhelming for the family and caregivers of the person with dementia, who are the cornerstone of care and support systems throughout the world. To assist countries in addressing the global burden of dementia, the World Health Organisation (WHO) developed the Global Action Plan on the Public Health Response to Dementia 2017–2025. It proposes actions to be taken by governments, civil society, and other global and regional partners across seven action areas, one of which is dementia risk reduction. This paper is based on WHO Guidelines on risk reduction of cognitive decline and dementia and presents recommendations on evidence-based, multisectoral interventions for reducing dementia risks, considerations for their implementation and policy actions. These global evidence-informed recommendations were developed by WHO, following a rigorous guideline development methodology and involved a panel of academicians and clinicians with multidisciplinary expertise and representing geographical diversity. The recommendations are considered under three broad headings: lifestyle and behaviour interventions, interventions for physical health conditions and specific interventions. By supporting health and social care professionals, particularly by improving their capacity to provide gender and culturally appropriate interventions to the general population, the risk of developing dementia can be potentially reduced, or its progression delayed. [ABSTRACT FROM AUTHOR]

Only 14 countries are on track to attain the Sustainable Development Goal (SDG) target of reducing premature mortality from Noncommunicable Diseases (NCDs) by one-third by 2030. This target cannot be reached without reducing the burden of cardiovascular diseases (CVDs) which is the major contributor to premature mortality from NCDs. Sustainable and scalable national responses to address both CVDs and their risk factors are urgently needed. Although smoking rates have decreased globally, consumption of alcohol and physical inactivity are on the rise. No country is on course to achieve the target to halt the rise in obesity or to reduce salt intake: targets critical for reducing the diabetes related cardiovascular burden and for hypertension control. Although very cost-effective scalable interventions are available, they are underutilized. Unless pathways selected to tackle CVDs prioritize prevention, primary health care and universal health coverage, countries will fall further behind in the attainment of the SDG target. [ABSTRACT FROM AUTHOR]

Abstract Background Noncommunicable diseases are an increasing health concern worldwide, but particularly in low- and middle-income countries. This study quantified and compared education- and wealth-based inequalities in the prevalence of five noncommunicable diseases (angina, arthritis, asthma, depression and diabetes) and comorbidity in low- and middle-income country groups. Methods Using 2002–04 World Health Survey data from 41 low- and middle-income countries, the prevalence estimates of angina, arthritis, asthma, depression, diabetes and comorbidity in adults aged 18 years or above are presented for wealth quintiles and five education levels, by sex and country income group. Symptom-based classification was used to determine angina, arthritis, asthma and depression rates, and diabetes diagnoses were self-reported. Socioeconomic inequalities according to wealth and education were measured absolutely, using the slope index of inequality, and relatively, using the relative index of inequality. Results Wealth and education inequalities were more pronounced in the low-income country group than the middle-income country group. Both wealth and education were inversely associated with angina, arthritis, asthma, depression and comorbidity prevalence, with strongest inequalities reported for angina, asthma and comorbidity. Diabetes prevalence was positively associated with wealth and, to a lesser extent, education. Adjustments for confounding variables tended to decrease the magnitude of the inequality. Conclusions Noncommunicable diseases are not necessarily diseases of the wealthy, and showed unequal distribution across socioeconomic groups in low- and middle-income country groups. Disaggregated research is warranted to assess the impact of individual noncommunicable diseases according to socioeconomic indicators.

Abstract Background The feasibility of conducting a large-scale Polypill clinical trial in developing countries remains unclear. More information is needed regarding the efficacy in reducing the risk factors of cardiovascular disease (CVD), side effects, improvement in adherence and physician/patient "acceptability" of the Polypill. Methods We conducted an open-label, parallel-group, randomized clinical trial involving three sites in Sri Lanka that enrolled a total of 216 patients without established CVD. The trial compared a Polypill (75 mg aspirin, 20 mg simvastatin, 10 mg lisinopril and 12.5 mg hydrochlorothiazide) to Standard Practice. After randomization, patients were followed monthly for three months. Pre-specified primary outcomes included reduction in systolic blood pressure, total cholesterol and estimated 10-year CVD risk. We also evaluated the recruitment process and acceptability of the Polypill by both physicians and patients. Results Patients were recruited in a six-month period as planned. Two hundred three patients (94.0%) completed the treatment program and returned for their three-month follow-up visits. No safety concerns were reported. These findings suggest a high rate of patient acceptability, a finding that is bolstered by the majority of patients completing the trial (90%) indicating that they would take the Polypill "for life" if proven to be effective in reducing CVD risk. Approximately 86% of the physicians surveyed agreed with and supported use of the Polypill for primary prevention and 93% for secondary prevention of CVD. Both the Polypill and Standard Practice resulted in marked reductions in systolic blood pressure, total cholesterol and 10-year risk of CVD. However, the differences between the treatment groups were not statistically significant. Conclusions We successfully completed a Polypill feasibility trial in Sri Lanka. We were able to document high acceptability of the Polypill to patients and physicians. We were unable to estimate the risk factor reductions on the Polypill because the control group received similar treatment with individual drugs. The Polypill was however simpler and achieved comparable risk factor reductions, highlighting its potential usefulness in the prevention of CVD. Trial registration number ISRCTN: NCT00567307

Background: Household air pollution (HAP) resulting from the use of solid fuels presents a major public health hazard. Improved stoves have been offered as a potential tool to reduce exposure to HAP and improve health outcomes. Systematic information on stove interventions is limited. Methods: We conducted a systematic review of the current evidence of improved stove interventions aimed at reducing HAP in real life settings. An extensive search of ten databases commenced in April 2014. In addition, we searched clinical trial registers and websites for unpublished studies and grey literature. Studies were included if they reported on an improved stove intervention aimed at reducing HAP resulting from solid fuel use in a low or middle-income country. Results: The review identified 5,243 records. Of these, 258 abstracts and 57 full texts were reviewed and 36 studies identified which met the inclusion criteria. When well-designed, implemented and monitored, stove interventions can have positive effects. However, the impacts are unlikely to reduce pollutant levels to World Health Organization recommended levels. Additionally, many participants in the included studies continued to use traditional stoves either instead of, or in additional to, new improved options. Conclusions: Current evidence suggests improved stove interventions can reduce exposure to HAP resulting from solid fuel smoke. Studies with longer follow-up periods are required to assess if pollutant reductions reported in the current literature are sustained over time. Adoption of new technologies is challenging and interventions must be tailored to the needs and preferences of the households of interest. Future studies require greater process evaluation to improve knowledge of implementation barriers and facilitators. [ABSTRACT FROM AUTHOR]

Abstract: If a combination of cost-effective health-care interventions and population-wide prevention interventions is implemented in a sustainable manner, a significant impact can be made on the cardiovascular disease and diabetes burden. Given the limited resources, weak health systems and competing health issues in Africa, the focus should be on interventions prioritized on the basis not only of cost effectiveness but also of affordability, feasibility and high impact. The Global Action Plan for prevention and control of noncommunicable diseases 2013–2020 identifies such a core set. Financing the effective delivery of this core set as part of the basic health care package through a strengthened health system is a pragmatic approach to address cardiovascular disease and diabetes in Africa. Cost of implementation of this core set of interventions represents an annual investment of under US$ 1 in low income countries, US$ 1.50 in lower middle income countries and US$ 3 in upper middle income countries. [Copyright &y& Elsevier]

INTRODUCTION Over the last decade, total cardiovascular risk assessment and management has been recommended by cardiovascular prevention guidelines in most high-income countries and by WHO. Cardiovascular risk prediction charts have been developed based on multivariate equations of values of some well-known risk factors such as age, sex, smoking, systolic blood pressure and diabetes, including or omitting total blood cholesterol. OBJECTIVE The objectives of this study were: to determine the distribution of cardiovascular risk in a Cuban population using the WHO/ International Society of Hypertension risk prediction charts with and without cholesterol; and to assess applicability of the risk prediction tool without cholesterol in a middle-income country, by evaluating concordance between the two approaches and comparing projected drug requirements resulting from each (at risk thresholds of ≥20% and ≥30%) and for the single-risk-factor approach. METHODS From April through December 2008, a cross-sectional study was conducted in 1287 persons (85.8% of the sample selected), aged 40–80 years living in a polyclinic catchment area of Havana, Cuba, based on the protocol and data from a WHO multinational study. The study used the two sets of the WHO and the International Society of Hypertension (WHO/ISH) risk prediction charts, with and without cholesterol. Percentages and means were calculated, as well as prevalence (%) of risk factors. The chi-square test was used to compare means (p ≤0.05). Concordance between the two prediction charts was calculated for different risk levels, using the chart with cholesterol as a reference. RESULTS Using the risk assessment tools with and without cholesterol, 97.1% and 95.4% respectively of the study population were in the ten-year cardiovascular risk category of <20%, while 2.9% and 4.6% respectively were in the category of ≥20%. Risk categories were concordant in 88.1% of the population; overestimation was higher among the nonconcordant (136/153). When risk assessment did not include cholesterol, there was 2.6% (34/1287) overestimation of drug requirements and 0.5% (6/1287) underestimation, compared to estimates including cholesterol. CONCLUSION Total cardiovascular risk assessment using the WHO/ ISH charts without cholesterol could be a useful approach to predict cardiovascular risk in settings where cholesterol cannot be measured. This does not introduce overconsumption of drugs, but does enable better targeting of resources to those who are more likely to develop cardiovascular disease. [ABSTRACT FROM AUTHOR]

Background: This study describes chronic kidney disease of uncertain aetiology (CKDu), which cannot be attributed to diabetes, hypertension or other known aetiologies, that has emerged in the North Central region of Sri Lanka. Methods: A cross-sectional study was conducted, to determine the prevalence of and risk factors for CKDu. Arsenic, cadmium, lead, selenium, pesticides and other elements were analysed in biological samples from individuals with CKDu and compared with age- and sex-matched controls in the endemic and non-endemic areas. Food, water, soil and agrochemicals from both areas were analysed for heavy metals. Results: The age-standardised prevalence of CKDu was 12.9% (95% confidence interval [CI] = 11.5% to 14.4%) in males and 16.9% (95% CI = 15.5% to 18.3%) in females. Severe stages of CKDu were more frequent in males (stage 3: males versus females = 23.2% versus 7.4%; stage 4: males versus females = 22.0% versus 7.3%; P < 0.001). The risk was increased in individuals aged >39 years and those who farmed (chena cultivation) (OR [odds ratio] = 1.926, 95% CI = 1.561 to 2.376 and OR = 1.195, 95% CI = 1.007 to 1.418 respectively, P < 0.05). The risk was reduced in individuals who were male or who engaged in paddy cultivation (OR = 0.745, 95% CI = 0.562 to 0.988 and OR = 0.732, 95% CI = 0.542 to 0.988 respectively, P < 0.05). The mean concentration of cadmium in urine was significantly higher in those with CKDu (1.039 μg/g) compared with controls in the endemic and non-endemic areas (0.646 μg/g, P < 0.001 and 0.345 μg/g, P < 0.05) respectively. Urine cadmium sensitivity and specificity were 70% and 68.3% respectively (area under the receiver operating characteristic curve = 0.682, 95% CI = 0.61 to 0.75, cut-off value ⩾0.397 μg/g). A significant dose-effect relationship was seen between urine cadmium concentration and CKDu stage (P < 0.05). Urine cadmium and arsenic concentrations in individuals with CKDu were at levels known to cause kidney damage. Food items from the endemic area contained cadmium and lead above reference levels. Serum selenium was <90 μg/l in 63% of those with CKDu and pesticides residues were above reference levels in 31.6% of those with CKDu. Conclusions: These results indicate chronic exposure of people in the endemic area to low levels of cadmium through the food chain and also to pesticides. Significantly higher urinary excretion of cadmium in individuals with CKDu, and the dose-effect relationship between urine cadmium concentration and CKDu stages suggest that cadmium exposure is a risk factor for the pathogensis of CKDu. Deficiency of selenium and genetic susceptibility seen in individuals with CKDu suggest that they may be predisposing factors for the development of CKDu. [ABSTRACT FROM AUTHOR]

Noncommunicable diseases (NCDs) have become a major public health problem in India accounting for 62% of the total burden of foregone DALYs and 53% of total deaths. In this paper, we review the social and economic impact of NCDs in India. We outline this impact at household, health system and the macroeconomic level. Cardiovascular diseases (CVDs) figure at the top among the leading ten causes of adult (25-69 years) deaths in India. The effects of NCDs are inequitable with evidence of reversal in social gradient of risk factors and greater financial implications for the poorer households in India. Out-of-pocket expenditure associated with the acute and long-term effects of NCDs is high resulting in catastrophic health expenditure for the households. Study in India showed that about 25% of families with a member with CVD and 50% with cancer experience catastrophic expenditure and 10% and 25%, respectively, are driven to poverty. The odds of incurring catastrophic hospitalization expenditure were nearly 160% higher with cancer than the odds of incurring catastrophic spending when hospitalization was due to a communicable disease. These high numbers also pose significant challenge for the health system for providing treatment, care and support. The proportion of hospitalizations and outpatient consultations as a result of NCDs rose from 32% to 40% and 22% to 35%, respectively, within a decade from 1995 to 2004. In macroeconomic term, most of the estimates suggest that the NCDs in India account for an economic burden in the range of 5-10% of GDP, which is significant and slowing down GDP thus hampering development. While India is simultaneously experiencing several disease burdens due to old and new infections, nutritional deficiencies, chronic diseases, and injuries, individual interventions for clinical care are unlikely to be affordable on a large scale. While it is clear that "treating our way out" of the NCDs may not be the efficient way, it has to be strongly supplemented with population-based services aimed at health promotion and action on social determinants of health along with individual services. Since health sector alone cannot deal with the "chronic emergency" of NCDs, a multi-sectoral action addressing the social determinants and strengthening of health systems for universal coverage to population and individual services is required. [ABSTRACT FROM AUTHOR]