Search

Background: Sub-Saharan Africa (SSA) has the highest age-adjusted burden of hypertension and cardiovascular disease (CVD). SSA also experiences many viral infections due to unique environmental and societal factors. The purpose of this narrative review is to examine evidence around how hypertension, CVD, and emerging viral infections interact in SSA. Methods: In September 2021, we conducted a search in MEDLINE, Embase, and Scopus, limited to English language studies published since 1990, and found a total of 1169 articles. Forty-seven original studies were included, with 32 on COVID-19 and 15 on other emerging viruses. Results: Seven articles, including those with the largest sample size and most robust study design, found an association between preexisting hypertension or CVD and COVID-19 severity or death. Ten smaller studies found no association, and 17 did not calculate statistics to compare groups. Two studies assessed the impact of COVID-19 on incident CVD, with one finding an increase in stroke admissions. For other emerging viruses, 3 studies did not find an association between preexisting hypertension or CVD on West Nile and Lassa fever mortality. Twelve studies examined other emerging viral infections and incident CVD, with 4 finding no association and 8 not calculating statistics. Conclusions: Growing evidence from COVID-19 suggests viruses, hypertension, and CVD interact on multiple levels in SSA, but research gaps remain especially for other emerging viral infections. SSA can and must play a leading role in the study and control of emerging viral infections, with expansion of research and public health infrastructure to address these interactions.

Introduction: Hypertension (HTN) is the leading cardiovascular risk factor in low-income countries including Haiti. Understanding blood pressure (BP) variation at the individual, neighborhood and population levels may help target interventions for multi-level risk reduction. This study aims to identify systolic BP (SBP) and diastolic BP (DBP) variation by neighborhood census blocks in Port-au-Prince to determine if this level should be targeted for future HTN interventions. Methods: Using data from the Haiti Cardiovascular Disease Cohort (March 2019-August 2021), a population-based cohort of Haitians ≥ 18 years, HTN was defined as SBP ≥140 mmHg or DBP ≥80 mmHg. Census blocks were defined as geographic areas of approximately 100-200 residential buildings per the Haitian Institute of Statistics. The geographic distribution of SBP and DBP was mapped based on household location. The proportion of SBP and DBP variation in block membership was calculated using intra-class correlations (ICC) from linear mixed models. Results: Among 2,972 participants, median (IQR) age was 40 (28-55) years and 57.6% were female. HTN prevalence was 33.0% and median (IQR) SBP and DBP were 120 (108-140) mmHg and 73.0 (64.0-85.0) mmHg, respectively. No distinct geographic pattern was present for SBP or DBP across blocks (Figure 1). The variation of SBP was 0.7% and DBP was 1.0% across census block membership. Conclusion: HTN prevalence in urban Port-au-Prince is high without a significant variation in SBP and DBP by census block. This may be due to outdated census data, crossover of individuals living informally across households, and/or the need for different household-level neighborhood geographic constructs such as shared household units. Moreover, these data suggest that interventions may need to target the population level, which span neighborhoods, given the uniformity of hypertension across these communities in Port-au-Prince.

Introduction: Cardiovascular disease (CVD) is the leading cause of mortality in low-income countries (LICs). Neighborhood social vulnerability has been associated with increased CVD risk in high-income countries, but the relationship is unknown in LICs. Our objective was to determine the association between neighborhood social vulnerability and prevalent CVD in urban Haiti. Hypothesis: We hypothesize that adults living in neighborhoods with increased social vulnerability will have a greater prevalence of hypertension (HTN) and CVD. Methods: We used cross-sectional enrollment data from the Haiti CVD Cohort study, a population-based cohort of adults ≥18 years living in Port-au-Prince distributed across 97 census blocks. To quantify vulnerability, we created a Haiti-specific Neighborhood Social Vulnerability Index (NSVI) based on the US CDC Social Vulnerability Index. The NSVI included three socioeconomic variables (income, sex, education), two household variables (single parent household, household with child Results: Among 2932 participants, median age was 40 years (IQR 28-55) and 58% were female. Age-standardized prevalence of HTN and CVD was 32.3% and 13.8%, respectively. The age-standardized prevalence of HTN and CVD was 35.7% and 17.3% across 4 th NSVI quartile blocks, compared to 29.1% and 14.1% across 1 st quartile NSVI blocks (p < 0.001). After adjusting for age, BMI, smoking, and alcohol use, participants living in 4 th NSVI quartile blocks had a greater risk of HTN (Adjusted Odds Ratio (aOR) 1.42; 95% CI 1.07-1.88; p-value 0.01) and CVD (aOR 1.36; CI: 0.99-1.88; p-value 0.06) compared to participants in the 1 st NSVI quartile blocks. NSVI was significantly associated with HTN in males but not females; conversely, NSVI was significantly associated with CVD in females and not males. Conclusions: Individuals living in neighborhoods with the greatest social vulnerability had a higher prevalence of HTN and CVD. Even in a setting of severe poverty such as urban Haiti, gradients in social vulnerabilities are associated with CVD disparities. Screening for social vulnerabilities should be incorporated into CVD prevention and treatment interventions in LICs.

Introduction: Over 80% of the global cardiovascular disease (CVD) burden is in low-income countries, including Haiti. Emerging data from these settings indicate CVD risk factors occur earlier in the life-course, but our knowledge of the age of onset and associated factors is limited. This study provides the first population-based estimates of CVD risk factors among young people ages 18-30 years in Haiti. Hypothesis: We hypothesized that elevated blood pressure (pre-hypertension (SBP/DBP >120-140/80-89) or hypertension (SBP/DBP >140/90 or on treatment) is the most common CVD risk factor among young people ages 18-30 years with an estimated prevalence >15%. Methods: This is a cross-sectional analysis within the Haiti CVD Cohort Study, a population-based longitudinal study of adults ≥18 years in Port au Prince. Participants were enrolled between March 2019-April 2021 using multistage random sampling. At enrollment, sociodemographic and health behaviors were assessed coupled with a physical exam and laboratory measures. CVD risk factors included: elevated BP, dyslipidemia (LDL-C ≥100mg/dL), kidney disease (urine albumin creatinine ratio (ACR) or estimated glomerular filtration rate (eGFR)), obesity (BMI > 30kg/m 2 ), and smoking, alcohol use, and physical activity using the WHO STEPS survey. Results: Among 957 participants ages 18-30 years, median age was 24 years (IQR 21-27) and 52% were female. Prevalence of elevated BP was 23% (20% pre-hypertension, 3% hypertension), 34% dyslipidemia, 5% ACR ≥30mg/g, 0.21% eGFR < 60 mL/min/1.73, and 7% obese. Other CVD risk factors include: 4% were current smokers, 6% reported any lifetime tobacco use, 19% reported one or more alcoholic drinks per day, and 47% reported low physical activity. Compared to participants ages 18-24 years, those ages 25-30 years had higher odds of pre-hypertension/hypertension (aOR=1.56, 95% CI: 1.13-2.15), but lower odds of dyslipidemia (aOR=0.55, 95% CI: 0.41-0.74). Females had lower odds of pre-hypertension/hypertension (aOR= 0.24, 95% CI: 0.17-0.35) and dyslipidemia (aOR=0.47, 95% CI: 0.35-0.64). Being obese was associated with a higher odds of pre-hypertension/hypertension (aOR=2.21, 95% CI: 1.14-4.16) but lower odds of dyslipidemia (aOR= 0.35, 95%CI: 0.20-0.61) compared to normal weight. Conclusion: These data provide previously unknown population-based estimates of CVD risk factors among young people in a low-income country. Rates of elevated BP and dyslipidemia are alarmingly high and occur prematurely in the life-course in this cohort and are associated with risk of future CVD events and mortality. Despite low prevalence of smoking and drinking alcohol, smoking tobacco was still associated with an increased odds of dyslipidemia. Additional drivers of early-onset CVD risk factors must be identified to guide targeted interventions for primordial and primary prevention as well as treatment.

Background: Hypertension (HTN) is the leading cardiovascular disease (CVD) risk factor in Haiti and is likely driven by poverty-related social and dietary factors. Salt consumption in Haiti is hypothesized to be high but has never been rigorously quantified.Methods: We used spot urine samples from a subset of participants in the population-based Haiti Cardiovascular Disease Cohort to estimate population mean daily sodium intake. We compared three previously validated formulas for estimating dietary sodium intake using urine sodium, urine creatinine, age, sex, height, and weight. We explored the association between dietary sodium intake and blood pressure, stratified by age group.Results: A total of 1,240 participants had spot urine samples. Median age was 38 years (range 18–93), and 48% were female. The mean dietary sodium intake was 3.5–5.0 g/day across the three estimation methods, with 94.2%–97.9% of participants consuming above the World Health Organization (WHO) recommended maximum of 2 g/day of sodium. Among young adults aged 18–29, increasing salt intake from the lowest quartile of consumption (5.88 g/day) was associated with a mean 8.71 mmHg higher systolic blood pressure (SBP) (95% confidence interval: 3.35, 14.07; p = 0.001). An association was not seen in older age groups. Among participants under age 40, those with SBP ≥120 mmHg consumed 0.5 g/day more sodium than those with SBP

Background: Cardiovascular disease disproportionately affects persons living in low- and middle-income countries and heart failure (HF) is thought to be a leading cause. Population-based studies characterizing the epidemiology of HF in these settings are lacking. We describe the age-standardized prevalence, survival, subtypes, risk factors, and 1-year mortality of HF in the population-based Haiti Cardiovascular Disease Cohort. Methods: Participants were recruited using multistage cluster-area random sampling in Port-au-Prince, Haiti. A total of 2981 completed standardized history and exam, laboratory measures, and cardiac imaging. Clinical HF was defined by Framingham criteria. Kaplan-Meier and Cox proportional hazard regression assessed mortality among participants with and without HF; logistic regression identified associated factors. Results: Among all participants, the median age was 40 years (interquartile range, 27–55), and 58.2% were female. Median follow-up was 15.4 months (interquartile range, 9–22). The age-standardized HF prevalence was 3.2% (93/2981 [95% CI, 2.6–3.9]). The average age of participants with HF was 57 years (interquartile range, 45–65), and 67.7% were female. The first significant increase in HF prevalence occurred between 30 to 39 and 40 to 49 years (1.1% versus 3.7%, P =0.003). HF with preserved ejection fraction was the most common HF subtype (71.0%). Age (adjusted odds ratio, 1.36 [1.12–1.66] per 10-year increase), hypertension (2.14 [1.26–3.66]), obesity (3.35 [95% CI, 1.99–5.62]), poverty (2.10 [1.18–3.72]), and renal dysfunction (5.42 [2.94–9.98]) were associated with HF. One-year HF mortality was 6.6% versus 0.8% (hazard ratio, 7.7 [95% CI, 2.9–20.6]; P Conclusions: The age-standardized prevalence of HF in this low-income setting was alarmingly high at 3.2%—5-fold higher than modeling estimates for low- and middle-income countries. Adults with HF were two decades younger and 7.7× more likely to die at 1 year compared with those in the community without HF. Further research characterizing the population burden of HF in low- and middle-income countries can guide resource allocation and development of pragmatic HF prevention and treatment interventions, ultimately reducing global cardiovascular disease health disparities. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03892265.

Haiti is one of the most food-insecure (FIS) nations in the world, with increasing rates of overweight and obesity. This study aimed to characterize FIS among households in urban Haiti and assess the relationship between FIS and body mass index (BMI) using enrollment data from the Haiti Cardiovascular Disease Cohort Study. FIS was characterized as no/low, moderate/high, and extreme based on the Household Food Security Scale. Multinomial logistic generalized estimating equations were used to evaluate the association between FIS categories and BMI, with obesity defined as BMI ≥ 30 kg/m2. Among 2972 participants, the prevalence of moderate/high FIS was 40.1% and extreme FIS was 43.7%. Those with extreme FIS had higher median age (41 vs. 38 years) and were less educated (secondary education: 11.6% vs. 20.3%) compared to those with no/low FIS. Although all FIS categories had high obesity prevalence, those with extreme FIS compared to no/low FIS (15.3% vs. 21.6%) had the lowest prevalence. Multivariable models showed an inverse relationship between FIS and obesity: moderate/high FIS (OR: 0.77, 95% CI: 0.56, 1.08) and extreme FIS (OR: 0.58, 95% CI: 0.42, 0.81) versus no/low FIS were associated with lower adjusted odds of obesity. We found high prevalence of extreme FIS in urban Haiti in a transitioning nutrition setting. The inverse relationship between extreme FIS and obesity needs to be further studied to reduce both FIS and obesity in this population.

Despite the increasing role of chronic kidney disease (CKD) as a major cause of global morbidity and mortality, there is limited understanding of its prevalence and risk factors in low-income countries, including Haiti. We hypothesized the prevalence of CKD is high in urban Haiti due to high rates of uncontrolled risk factors, primarily hypertension (HTN). We evaluated the prevalence and risk factors for CKD in a population-based cohort from Haiti. Among 2426 participants ≥18 years, serum creatinine and urinary albumin and creatinine were measured at time of study enrollment. Estimated glomerular filtration rate (eGFR) was dichotomized at 2 . Albuminuria was defined as an albumin to creatinine ratio (ACR) ≥30 mg/g. CKD was defined as reduced eGFR and/or albuminuria. HTN was defined as a systolic blood pressure (BP) ≥140 mmHg, diastolic BP ≥90 mmHg, or use of antihypertensive medication. Factors associated with CKD were assessed with logistic regression. National Health and Nutrition Examination Survey (NHANES) 2015-2018 data was used for cohort comparison. Median age was 41 years (IQR 28-55), 57% of participants were female, and 69% earned

BackgroundMultidrug therapy is a World Health Organization “best buy” for the prevention and control of noncommunicable diseases. CVD polypills, including ≥2 blood pressure medications, and a statin with or without aspirin, are an effective, scalable strategy to close the treatment gap that exists in many low- and middle-income countries, including Haiti. We estimated the number of Haitian adults eligible for an atherosclerotic CVD (ASCVD) polypill, and the number of potentially preventable CVD events if polypills were implemented nationally.MethodsWe used cross-sectional data from the Haiti CVD Cohort, a population-based cohort of 3,005 adults ≥18 years in Port-au-Prince, to compare two polypill implementation strategies: high-risk primary prevention and secondary prevention. High-risk primary prevention included three scenarios: (a) age ≥40 years, (b) hypertension, or (c) predicted 10-year ASCVD risk ≥7.5%. Secondary prevention eligibility included history of stroke or myocardial infarction. We then used the 2019 Global Burden of Disease database and published polypill trials to estimate preventable CVD events, defined as nonfatal MI, nonfatal stroke, and cardiovascular death over a 5-year timeline.ResultsAmong 2,880 participants, the proportion of eligible adults for primary prevention were: 51.6% for age, 32.5% for hypertension, 19.3% for high ASCVD risk, and 5.8% for secondary prevention. Based on current trends, an estimated 462,509 CVD events (95% CI: 369,089–578,475) would occur among adults ≥40 years in Haiti from 2019–2024. Compared with no polypill therapy, we found 32% or 148,003 CVD events (95% CI: 70,126–248,744) could be prevented by a combined primary and secondary prevention approach in Haiti if polypills were fully implemented over 5 years.ConclusionThese modeling estimates underscore the potential magnitude of preventable CVD events in low-income settings like Haiti. Model calibration using observed CVD events, costs, and implementation assumptions are future directions.Clinical trial registrationclinicaltrials.gov, identifier: NCT03892265.

Aims: Modeling estimates indicate that heart failure (HF) prevalence may be lowest in low-income (LICs). Conversely, HF has been shown to be the leading cause of hospital admission in hospitals in many LICs. This disconnect between estimates and hospital-based observations may be explained by the underlying data. Modeling studies may have selection bias reporting data on individuals presenting with symptomatic disease and may introduce ascertainment bias based on accessibility of care and other structural factors in these communities. Population-based studies are needed to identify the true clinical epidemiology of HF in order to improve HF-related health outcomes in these under-resourced settings where four billion persons live. Haiti is the poorest, most under-resourced country in the Western Hemisphere. We describe HF prevalence, survival, subtypes, risk factors, and one-year mortality in the population-based Haiti Cardiovascular Disease Study. Methods and Results: Multistage cluster-area random sampling identified 2,981 adults, who completed standardized history and exam, laboratory measures, and cardiac imaging. Kaplan-Meier and Cox proportional hazard regression assessed survival; logistic regression identified associated factors. Median follow-up was 15.4 months (IQR 9-22). Age-standardized HF prevalence was 3.2% (93/2,981 [CI:2.6-3.9]). One-year HF mortality was 6.6% versus 0.8% (HR: 7.7 [CI 2.9-20.6], p Conclusion: The age-standardized prevalence of HF in this low-income setting was alarmingly high at 3.2%--50% higher than rates in high-income countries and 5-fold higher than modeling estimates for LMICs. Adults with HF were two decades younger as compared to high-income settings and 7.7 times more likely to die at one year. These data serve as a warning sign and may have implications for policy makers and future HF interventions in LMICs.

Introduction: Cardiovascular disease is the leading cause of death in Haiti and many low-middle income countries. Environmental lead exposure is associated with higher blood pressure (BP) and cardiovascular disease mortality in high income countries but has not been systematically evaluated in lower income countries where 6.5 billion people reside. Hypothesis: We hypothesized higher lead levels would be associated with higher BP in Haiti. Methods: Blood lead levels (BLLs) were measured among 2,257 participants ≥18 years enrolled in a population-based longitudinal cohort study in Port-au-Prince (Haiti Cardiovascular Disease Cohort Study). BLL screening was conducted using LeadCare II (detection limit ≥3.3 μg/dL). BLLs below detection were imputed. Associations between BLLs (quartiles) and systolic BP (SBP) and diastolic BP (DBP) were assessed, adjusting for age, sex, obesity, smoking, physical activity, and income. BLLs were also categorized as ≥5 versus Results: The median age was 40 years; 62.6% were female. The geometric mean BLL was 4.60 μg/dL, 67.3% had detectable BLLs >3.3 μg/dL, and 40.9% had elevated BLLs ≥5 μg/dL. BLLs in quartile four (≥6.5 μg/dL) in both unadjusted and adjusted analyses were associated with higher SBP (adjusted 3.02 mmHg; 95%CI 0.80, 5.25) and DBP (adjusted 2.19 mmHg; 95%CI 0.70, 3.67). BLL ≥5 μg/dL were associated with a higher SBP (2.21 mmHg; 95%CI 0.15, 4.26) and DBP (1.50 mmHg; 95%CI 0.20, 2.81) in unadjusted analysis. After adjustment there was no difference in SBP (1.41; 95%CI -0.25, 3.09) and 1.15 mmHg (95%CI 0.01, 2.30) higher DBP. Conclusions: Widespread environmental lead exposure is evident in urban Haiti, with higher BLLs associated with higher SBP and DBP. Lead is a modifiable pollutant in low-income countries that warrants urgent public health remediation.

Introduction: Cardiovascular diseases (CVD) are rapidly increasing in low-middle income countries. Accurate risk assessment is essential to reduce premature CVD by targeting primary prevention. Available CVD risk prediction models are built on predominantly Caucasian, high-income country populations, and have not been evaluated in lower-income countries. We aimed to compare six existing models for predicted 10-year risk of CVD and identify high-risk groups for targeted prevention in Haiti. Methods: We used cross-sectional data within the Haiti CVD Cohort Study, including 653 adults ≥ 40 years without known history of CVD. Six CVD risk prediction models were compared: pooled cohort equations (PCE), adjusted PCE with updated cohorts, Framingham CVD Lipids, Framingham CVD Body Mass Index (BMI), WHO Lipids, and WHO BMI. Risk factors were measured during clinical exams. Primary outcome was continuous and categorical predicted 10-year CVD risk. Secondary outcome was statin eligibility. Results: Seventy percent (460/653) were female, 65.5% (428/653) lived on a daily income of ≤1 USD, 57.0% (372/653) had hypertension, 14.5% (95/653) had hypercholesterolemia, 9.3% (61/653) had diabetes mellitus, and 5.5% (36/653) were current smokers. Predicted 10-year CVD risk ranged from 3.9% in adjusted PCE (IQR 1.7-8.4) to 9.8% in Framingham-BMI (IQR 5.0-17.8), and Spearman correlation coefficients ranged from 0.87 to 0.98. The percent of the cohort categorized as high risk using the uniform threshold of 10-year CVD risk ≥ 7.5% ranged from 28.8% in the adjusted PCE model to 62.0% in the Framingham-BMI model (χ 2 = 331, p value < 0.001). Statin eligibility also varied widely. Conclusions: In the Haiti CVD Cohort, there was substantial variation in the proportion identified as high-risk and statin eligible using existing models, leading to very different treatment recommendations and public health implications depending on model choice. There is a need to design and validate CVD risk prediction tools for low-middle income countries.

Introduction: Neighborhood social context including violence and cohesion may impact cardiovascular disease risk factors in countries like Haiti with high civil unrest. We describe these factors using validated instruments (Neighborhood Collective Efficacy, City Stress Inventory), and hypothesized higher cohesion and lower violence were associated with lower stress, depression, blood pressure (BP), and hypertension. Methods: We collected data from a population-representative cohort of adults in Port-au-Prince, Haiti between March 2019 to April 2021, including stress (Perceived Stress Scale), depression (PHQ-9), blood pressure, and hypertension (SBP ≥ 140 mmHg, DBP ≥ 90 mmHg, or on medications). Adjusting for age and sex, multivariable linear and Poisson regressions assessed the relationship between exposures (neighborhood violence, neighborhood cohesion) and outcomes (stress, depression, BP, hypertension). Results: Among 2,799 adults, 59.7% were female and median age was 41 years (IQR:28-55). Participants reported high cohesion (median 15/25, IQR:14-17) and moderate violence (9/20, IQR:7-11). Stress was moderate (8/16), 12.8% had at least moderate depression, and 30.4% had hypertension. In regressions, higher violence at all levels was associated with higher depressive symptoms (Q4 vs Q1: +2.94 score, 95%CI 2.51, 3.38). Violence was also weakly associated with slightly higher stress (Q4 vs Q1: +0.32 score, 95%CI 0.04, 0.59), and lower hypertension prevalence (Q2 vs Q1: PR 0.86, 95%CI 0.75, 0.99). Cohesion was weakly associated with lower stress (T3 vs T1: -0.43 score, 95%CI -0.71, -0.16), depression (T2 vs T1: -0.63 score, 95%CI -1.02, -0.24), and higher DBP (T2 vs T1: 1.23 mmHg, 95%CI 0.065, 2.39). Conclusions: In conclusion, we found high perceived cohesion and moderate violence. The strongest association was between higher violence and higher depression. Paradoxically, higher violence and lower cohesion were associated with lower hypertension and DBP, possibly due to unmeasured confounding.

Introduction: Stress is associated with multiple adverse health outcomes, including hypertension. The impact of stress on health may be moderated by social support. The distribution of stress, support, and their association with hypertension have not been well described in low-income countries that face severe poverty. Over the past decade, Haiti has suffered massive natural disasters including the 2010 earthquake, cholera outbreak, COVID-19 pandemic, and recurrent civil instability—all of which may act as prolonged stressors. Hypothesis: We assessed the hypotheses that 1) there are high levels of both stress and support in Haiti, and 2) high support would moderate the relationship between high stress and hypertension. Methods: We measured stress and social support using validated instruments in a population-representative cohort of adults living in urban Port-au-Prince, Haiti between March 2019 and April 2021. Stress was measured using the Perceived Stress Scale, while social support was measured using the Multidimensional Scale of Perceived Social Support. For visualization, continuous scores were categorized using equal-width groups (stress: low (1-5), moderate (6-10), high (11-16); support: low (7-21), low-moderate (22-35), moderate (36-49), moderate-high (50-64), high (65-77)). Linear regression models were used to quantify the associations between: 1) stress and support adjusting for age and sex, 2) blood pressure and stress adjusting for age and sex. A formal moderation analysis was conducted to assess if support moderated the relationship between stress and blood pressure. Results: Among 2,817 adults, 59.7% female and the median age was 40 years (IQR 28-55). The majority had an income of less than 1 US dollar a day (69.7%). The median stress score was 8 out of 16 points, and median support score was 61 out of 77 points. Stress was higher with older ages (60+ years versus 18-29 years: +0.79 points, 95% CI 0.51 to 1.08) and in females (+0.85 points, 95% CI +0.65 to +1.06). Support was higher in males (+3.29 points, 95% CI 2.19 to 4.39). Support was inversely associated with stress, adjusting for age and sex (-0.04 points, 95% CI -0.04 to -0.03). Stress was not associated with systolic or diastolic blood pressure after adjustment for age and sex. Support did not moderate the association between stress and blood pressure. Conclusion: In this urban cohort of Haitian adults living with chronic civil instability, stress was moderate and support was high. While support was associated with lower stress, it did not moderate the relationship between stress and blood pressure. Despite the high levels of instability in Haiti, participants displayed resiliency through high levels of support, which may be an underutilized resource in reducing stress and long-term negative health outcomes.

Poor diets are responsible for a large burden of noncommunicable disease (NCD). The prevalence of modifiable dietary risk factors is rising in lower-income countries such as Haiti, along with increasing urbanization and shifts to diets high in sugar, salt, and fat. We describe self-reported dietary patterns (intake of fruits, vegetables, fried food, sugar-sweetened beverages, and added salt and oil) among a population-based cohort of low-income adults in Port-au-Prince and assess for associated sociodemographic factors (age, sex, income, education, body mass index). Among 2989 participants, the median age was 40 years, and 58.0% were women. Less than 1% met the World Health Organization recommendation of at least five servings/day of fruits and vegetables. Participants consumed fried food on average 1.6 days/week and sugar-sweetened beverages on average 4.7 days/week; young males of low socioeconomic status were the most likely to consume these dietary risk factors. The vast majority of participants reported usually or often consuming salt (87.1%) and oil (86.5%) added to their meals eaten at home. Our findings underscore the need for public health campaigns, particularly those targeting young males and household cooks preparing family meals at home, to improve dietary patterns in Haiti in order to address the growing NCD burden.

IntroductionDiabetes mellitus is a chronic noncommunicable disease associated with death and major disability, with increasing prevalence in low- and middle-income countries. There is limited population-based data about diabetes in Haiti. The objective of this study was to assess the prevalence of diabetes and associated factors among adults in Port-au-Prince, Haiti using a population-based cohort.MethodsThis study analyzes cross-sectional enrollment data from the population-based Haiti Cardiovascular Disease Cohort Study, conducted using multistage sampling with global positioning system waypoints in census blocks in the metropolitan area of Port-au-Prince, Haiti. A total of 3,005 adults ≥18 years old were enrolled from March 2019 to August 2021. We collected socio-demographic data, health-related behaviors, and clinical data using standardized questionnaires. Diabetes was defined as any of the following criteria: enrollment fasting glucose value ≥ 126 mg/dL or non-fasting glucose ≥ 200 mg/dL, patient self-report of taking diabetes medications, or study physician diagnosis of diabetes based on clinical evaluation.ResultsAmong 2985 (99.3%) with complete diabetes data, median age was 40 years, 58.1% were female, and 17.2% were obese. The prevalence of diabetes was 5.4% crude, and 5.2% age standardized. In unadjusted analysis, older age, higher body mass index (BMI), low physical activity, low education were associated with a higher odds of diabetes. After multivariable logistic regression, older age [60+ vs 18-29, Odds Ratio (OR)17.7, 95% CI 6.6 to 47.9] and higher BMI (obese vs normal/underweight, OR 2.7, 95% CI 1.7 to 4.4) remained statistically significantly associated with higher odds of diabetes.ConclusionThe prevalence of diabetes was relatively low among adults in Port-au-Prince, but much higher among certain groups (participants who were older and obese). The Haitian health system should be strengthened to prevent, diagnose, and treat diabetes among high-risk groups.

Cardiovascular disease is the leading cause of death in lower-income countries including Haiti. Environmental lead exposure is associated with high blood pressure and cardiovascular mortality in high-income countries but has not been systematically measured and evaluated as a potential modifiable cardiovascular risk factor in lower-income countries where 6.5 billion people reside. We hypothesized lead exposure is high in urban Haiti and associated with higher blood pressure levels. Blood lead levels were measured in 2504 participants ≥18 years enrolled in a longitudinal population-based cohort study in Port-au-Prince. Lead screening was conducted using LeadCare II (detection limit ≥3.3 µg/dL). Levels below detection were imputed by dividing the level of detection by √2. Associations between lead (quartiles) and systolic blood pressure and diastolic blood pressure were assessed, adjusting for age, sex, obesity, smoking, alcohol, physical activity, income, and antihypertensive medication use. The median age of participants was 40 years and 60.1% were female. The geometric mean blood lead level was 4.73µg/dL, 71.1% had a detectable lead level and 42.3% had a blood lead level ≥5 µg/dL. After multivariable adjustment, lead levels in quartile four (≥6.5 µg/dL) compared with quartile 1 ( Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03892265.

BackgroundHypertension is a major contributor to global morbidity and mortality. In South Africa, the government has employed a whole systems approach to address the growing burden of non-communicable diseases. We used a novel incident care cascade approach to measure changes in the South African health system’s ability to manage hypertension between 2008 and 2017.MethodsWe used data from Waves 1-5 of the National Income Dynamics Study (NIDS) to estimate trends in the hypertension care cascade and unmet treatment need across four successive cohorts with incident hypertension. We used a negative binomial regression to identify factors that may predict higher rates of hypertension control, controlling for socio-demographic and healthcare factors. The largest cascade attrition occurred prior to diagnosis.ResultsIn 2011, 19·6% (95%CI 14·2, 26·2) of individuals with incident hypertension were diagnosed, 15·4% (95%CI 10·8, 21·4) were on treatment and 7.1% had controlled blood pressure. By 2017, the proportion of individuals with diagnosed incident hypertension had increased to 24·4% (95%CI 15·9, 35·4) with increases in treatment (23·3%, 95%CI 15·0, 34·3) and control (22·1%, 95%CI 14·1, 33·.0) were also observed, translating to a decrease in unmet need from 92·9% in 2011 to 77·9% in 2017. Multivariable regression showed that participants with incident hypertension in 2017 were 3·01 (95%CI 1·77, 5·13) times more likely to have a controlled blood pressure compared to those in 2011.ConclusionsThe proportion of people with incident hypertension who successfully progressed to controlled blood pressure tripled between 2011 and 2017 in South Africa. Despite these improvements, a low absolute proportion of the population were able to control their blood pressure and a high burden of unmet need remains.Summary BoxWhat is already knownPrevalent cascades provide insight to where losses in care cascades occur.While mostly used in the management of HIV, recently they have also been adopted in studying the management of non-communicable diseases on a population level.Prevalent hypertension cascades in South Africa showed a high burden of unmet need, with the biggest losses where lost between disease development and diagnosis.What are the new findingsIncident hypertension cascades improved from 2008 to 2017 in South Africa.What do the new findings implyIncident cascades provide an improved means to measure changes in management cascades as this allows us to distinguish between historical and current health system performance.Our data show that while substantial improvements in the care cascade occurred between 2008 and 2017, a large burden of unmet need remains.

Background People living with HIV (PLWH) are at increased risk of cardiovascular disease (CVD) and death, with greater burdens of both HIV and CVD in lower-middle income countries. Treating prehypertension in PLWH may reduce progression to hypertension, CVD risk and potentially mortality. However, no trial has evaluated earlier blood pressure treatment for PLWH. We propose a randomized controlled trial to assess the feasibility, benefits, and risks of initiating antihypertensive treatment among PLWH with prehypertension, comparing prehypertension treatment to standard of care following current WHO guidelines. Methods A total of 250 adults 18–65 years and living with HIV (PLWH) with viral suppression in the past 12 months, who have prehypertension will be randomized to prehypertension treatment versus standard of care. Prehypertension is defined as having a systolic blood pressure (SBP) 120–139 mmHg or diastolic blood pressure (DBP) 80–89 mmHg. In the prehypertension treatment arm, participants will initiate amlodipine 5 mg daily immediately. In the standard of care arm, participants will initiate amlodipine only if they develop hypertension defined as SBP ≥ 140 mmHg or DBP ≥ 90 mmHg. The primary outcome is the difference in mean change of SBP from enrollment to 12 months. Secondary outcomes include feasibility, acceptability, adverse effects, HIV viral suppression, and medication adherence. Qualitative in-depth interviews with providers and participants will explore attitudes about initiating amlodipine, satisfaction, perceived CVD risk, and implementation challenges. Discussion PLWH have a higher CVD risk and may benefit from a lower BP threshold for initiation of antihypertensive treatment. Trial registration Clinicaltrials.gov registration number NCT04692467, registration date December 15, 2020, protocol ID 20–03021735.

BackgroundCardiovascular diseases (CVD) are rapidly increasing in low-middle income countries (LMICs). Accurate risk assessment is essential to reduce premature CVD by targeting primary prevention and risk factor treatment among high-risk groups. Available CVD risk prediction models are built on predominantly Caucasian, high-income country populations, and have not been evaluated in LMIC populations.ObjectiveTo compare the predicted 10-year risk of CVD and identify high-risk groups for targeted prevention and treatment in Haiti.MethodsWe used cross-sectional data within the Haiti CVD Cohort Study, including 653 adults ≥ 40 years without known history of CVD and with complete data. Six CVD risk prediction models were compared: pooled cohort equations (PCE), adjusted PCE with updated cohorts, Framingham CVD Lipids, Framingham CVD Body Mass Index (BMI), WHO Lipids, and WHO BMI. Risk factors were measured during clinical exams. Primary outcome was continuous and categorical predicted 10-year CVD risk. Secondary outcome was statin eligibility.ResultsSeventy percent were female, 65.5% lived on a daily income of ≤1 USD, 57.0% had hypertension, 14.5% had hypercholesterolemia, 9.3% had diabetes mellitus, 5.5% were current smokers, and 2.0% had HIV. Predicted 10-year CVD risk ranged from 3.9% in adjusted PCE (IQR 1.7-8.4) to 9.8% in Framingham-BMI (IQR 5.0-17.8), and Spearman rank correlation coefficients ranged from 0.87 to 0.98. The percent of the cohort categorized as high risk using the uniform threshold of 10-year CVD risk ≥ 7.5% ranged from 28.8% in the adjusted PCE model to 62.0% in the Framingham-BMI model (χ2= 331, p value < 0.001). Statin eligibility also varied widely.ConclusionsIn the Haiti CVD Cohort, there was substantial variation in the proportion identified as high-risk and statin eligible using existing models, leading to very different treatment recommendations and public health implications depending on which prediction model is chosen. There is a need to design and validate CVD risk prediction tools for low-middle income countries that include locally relevant risk factors.Trial registrationclinicaltrials.govNCT03892265

Background The electrocardiogram (ECG) is the most relied upon tool for cardiovascular diagnosis, especially in low-resource settings because of its low cost and straightforward usability. It is imperative that internal medicine (IM) and emergency medicine (EM) specialists are competent in ECG interpretation. Our study was designed to improve proficiency in ECG interpretation through a competition among IM and EM residents at a teaching hospital in rural central Haiti in which over 40% of all admissions are due to CVD. Methodology The 33 participants included 17 EM residents and 16 IM residents from each residency year at the Hôpital Universitaire de Mirebalais (HUM). Residents were divided into 11 groups of 3 participants with a representative from each residency year and were given team-based online ECG quizzes to complete weekly. The format included 56 ECG cases distributed over 11 weeks, and each case had a pre-specified number of points based on abnormal findings and complexity. All ECG cases represented cardiovascular pathology in Haiti adapted from the Association of Program Directors in Internal Medicine evaluation list. The main intervention was sharing group performance and ECG solutions to all participants each week to promote competition and self-study without specific feedback or discussion by experts. To assess impact, pre- and post-intervention assessments measuring content knowledge and comfort for each participant were performed. Results Overall group participation was heterogeneous with groups participating a median of 54.5% of the weeks (range 0–100%). 22 residents completed the pre- and post-test assessments. The mean pre- and post-intervention assessment knowledge scores improved from 27.3% to 41.7% (p = 0.004). 70% of participants improved their test scores. The proportion of participants who reported comfort with ECG interpretation increased from 57.6% to 66.7% (p = 0.015). Conclusion This study demonstrates improvement in ECG interpretation through a team-based, asynchronous ECG competition approach. This method is easily scalable and could help to fill gaps in ECG learning. This approach can be delivered to other hospitals both in and outside Haiti. Further adaptations are needed to improve weekly group participation.

Background Adherence to regular outpatient visits is vital to managing noncommunicable diseases (NCDs), a growing burden in low and middle-income countries. We characterized visit adherence among patients with NCDs in rural Haiti, hypothesizing higher poverty and distance from the clinic were associated with lower adherence. Methods We analyzed electronic medical records from a cohort of adults in an NCD clinic in Mirebalais, Haiti (April 2013 to June 2016). Visit adherence was: 1) visit constancy (≥1 visit every 3 months), 2) no gaps in care (> 60 days between visits), 3) ≥1 visit in the last quarter, and 4) ≥6 visits per year. We incorporated an adapted measure of intensity of multidimensional poverty. We calculated distance from clinic as Euclidean distance or self-reported transit time. We used multivariable logistic regressions to assess the association between poverty, distance, and visit adherence. Results We included 463 adult patients, mean age 57.8 years (SE 2.2), and 72.4% women. Over half of patients had at least one visit per quarter (58.1%), but a minority (19.6%) had no gaps between visits. Seventy percent of patients had a visit in the last quarter, and 73.9% made at least 6 visits per year. Only 9.9% of patients met all adherence criteria. In regression models, poverty was not associated with any adherence measures, and distance was only associated with visit in the last quarter (OR 0.87, 95% CI [0.78 to 0.98], p = 0.03) after adjusting for age, sex, and hardship financing. Conclusions Visit adherence was low in this sample of adult patients presenting to a NCD Clinic in Haiti. Multidimensional poverty and distance from clinic were not associated with visit adherence measures among patients seen in the clinic, except for visit in the last quarter. Future research should focus on identifying and addressing barriers to visit adherence.

Introduction The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined. Methods A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008–2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18–64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020. Results In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= −16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment. Conclusions Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.

Background Diabetes is a growing challenge in Thailand. Data to assess health system response to diabetes is scarce. We assessed what factors influence diabetes care cascade retention, under universal health coverage. Methods We conducted a cross-sectional analysis of the 2014 Thai National Health Examination Survey. Diabetes was defined as fasting plasma glucose ≥126mg/dL or on treatment. National and regional care cascades were constructed across screening, diagnosis, treatment, and control. Unmet need was defined as the total loss across cascade levels. Logistic regression was used to examine the demographic and healthcare factors associated with cascade attrition. Findings We included 15,663 individuals. Among Thai adults aged 20+ with diabetes, 67.0% (95% CI 60.9% to 73.1%) were screened, 34.0% (95% CI 30.6% to 37.2%) were diagnosed, 33.3% (95% CI 29.9% to 36.7%) were treated, and 26.0% (95% CI 22.9% to 29.1%) were controlled. Total unmet need was 74.0% (95% CI 70.9% to 77.1%), with regional variation ranging from 58.4% (95% CI 45.0% to 71.8%) in South to 78.0% (95% CI 73.0% to 83.0%) in Northeast. Multivariable models indicated older age (OR 1.76), males (OR 0.65), and a higher density of medical staff (OR 2.40) and health centers (OR 1.58) were significantly associated with being diagnosed among people with diabetes. Older age (OR 1.80) and higher geographical density of medical staff (OR 1.82) and health centers (OR 1.56) were significantly associated with being controlled. Conclusions Substantial attrition in the diabetes care continuum was observed at diabetes screening and diagnosis, related to both individual and health system factors. Even with universal health insurance, Thailand still needs effective behavioral and structural interventions, especially in primary health care settings, to address unmet need in diabetes care for its population.

Graves thyrotoxicosis rarely presents with painless jaundice resulting from hyperthyroidism-associated hepatotoxicity, without preexisting liver disease. Management in patients with this presentation is challenging, given that the thionamides, methimazole and propylthiouracil, have both been associated with drug-induced liver injury. Radioactive iodine ablation and thyroidectomy are well-established alternatives, but each have their associated risks and contraindications. We present an unusual case of severe hyperthyroidism-associated hepatotoxicity, in which adjuvant therapies, including glucocorticoids, saturated solution of potassium iodide, and cholestyramine, were used as a bridge to definitive therapy with thyroidectomy., Patient presented with jaundice and transaminitis. Workup revealed Graves disease, with no separate hepatic pathology. Thionamides was avoided; dexamethasone, SSKI and cholestyramine were used.

BACKGROUND: Antibiotics prescribed for acute respiratory tract infections in the telemedicine setting are often unwarranted. OBJECTIVE: We hypothesized that education plus individualized feedback, compared with education alone, would significantly reduce antibiotic prescription rates for upper respiratory infections, bronchitis, sinusitis, and pharyngitis in a telemedicine setting. DESIGN: Two-arm, parallel-group randomized controlled trial conducted at a telemedicine practice from January 1, 2018, to November 30, 2018. PARTICIPANTS: Clinicians employed at the practice on or after January 1, 2017 (n = 45). INTERVENTIONS: The control group received education (treatment guideline presentation and online course) in April 2018. The intervention group received education plus individualized feedback via an online dashboard with monthly rates of personal and practice-wide antibiotic prescription rates starting May 2018. MAIN MEASURES: Antibiotic prescription for any visit with at least one target condition: upper respiratory tract infection, bronchitis, sinusitis, and pharyngitis. KEY RESULTS: Baseline antibiotic prescription rates in control and intervention groups across conditions were as follows: upper respiratory infection (URI): 626/3410 (18.4%), 413/2752 (15.0%), bronchitis: 689/1471 (46.8%), 742/1162 (64.0%), sinusitis: 5154/6131 (84.1%), 4250/4876 (87.2%), pharyngitis: 2308/2838 (81.3%), 1593/2126 (74.9%). Antibiotic prescriptions for all conditions decreased in the post-intervention period compared with those in the pre-intervention period, for both control and intervention groups. Reduction of antibiotic prescriptions for URI and bronchitis was greater for the group receiving education plus individualized feedback compared with that for the group receiving education alone (interaction term ratio 0.60, 95% CI 0.47 to 0.77 for URI; and interaction term ratio 0.42, 95% CI 0.32 to 0.55 for bronchitis), but not sinusitis and pharyngitis. CONCLUSION: Education plus individualized feedback in a telemedicine practice significantly decreased antibiotic prescription rates for upper respiratory tract infections and bronchitis, compared with education alone. Future studies should focus on tailoring antibiotic stewardship programs based on underlying conditions, and the maintenance of early reductions in antibiotic prescription. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06134-0) contains supplementary material, which is available to authorized users.

Background: Noncommunicable diseases (NCDs) are a major and growing cause of death and disability in low-income countries, and contribute a substantial portion of outpatient clinic visits. Poverty can be a major barrier to accessing healthcare in rural low-income countries. The objective of this study is to describe the demographics and socioeconomic status of patients attending an NCD clinic in rural Haiti, where poverty is highly prevalent. Methods: We analyzed routinely collected clinic data from adult patients in rural Haiti presenting to the NCD clinic at Hôpital Universitaire de Mirebalais. We collected data during routine initial clinic visits from July 2013 through October 2016. We performed descriptive statistics to assess patient demographics and socioeconomic status using available data. We evaluated poverty based on the Multidimensional Poverty Index by evaluating 9 indicators within three dimensions: health, education, and standard of living - we did not assess electricity. We assessed deprivation within each indicator. The “poorest” patients were defined as those deprived in 4 of the 9 poverty indicators. We also assessed measures of catastrophic health spending. Results: A total of 518 adults were included, with 72% (373/508) women. The mean overall age was 52.8 years (SD 14.7) and 21% (108/518) were 40 years old or younger. Of the patients, 32% had only hypertension, 18% had only diabetes, 32% had both diabetes and hypertension, 5% had heart failure, and 13% had no recorded diagnosis. 45% of patients travel more than 1 hour for clinic visits. Almost half (49%, 146/296) of adults sold belongings and 61% (178/292) borrowed money to pay for healthcare. Among the poverty measures, the top indicators with deprivation were cooking fuel with charcoal or wood (96%, 290/302), child death in household (70%, 169/243), and no household members completing primary school (25%, 83/324), lack of household assets (25%, 79/313), poor sanitation (19%, 59/304), dirt floor (16%, 50/304), and lack of improved drinking water (9%, 29/308). Of all patients, 21% (78/378) were among the poorest. Throughout Haiti, however, 55% of the population are among the poorest. There were more patients among the poorest living closer to the hospital (27%) than living farther away (10%). Interpretation: The great majority of patients were middle-aged women, with predominantly hypertension and/or diabetes. Socioeconomic deprivation was high among many poverty indicators and most patients experienced catastrophic health spending. At this clinic in rural Haiti, the proportion of patients presenting for care who are among the poorest is less than that overall in Haiti. Patients who travel far distances have less poverty. Health systems for chronic disease management in rural low-income countries must account for patient poverty.

Objective To assess how quality and availability of reproductive, maternal, neonatal (RMNH) services vary by district wealth and urban/rural status in Zambia. Methods We conducted a retrospective analysis of data from the Millennium Development Goal Acceleration Initiative baseline assessment of 117 health facilities in 9 districts. Quality was assessed through a composite score of 23 individual RMNH indicators, ranging from 0 to 1. Availability was evaluated by density of providers and facilities. Districts were divided into wealth groups based on the multidimensional poverty index (MPI). Relative inequity was calculated using the concentration index for quality indicators (positive favours rich, negative favours poor). Multivariable linear regression was performed for the dependent variable composite quality indicator using MPI, urban/rural, and facility level of care as independent variables. Results 13 hospitals, 85 health centres and 19 health posts were included. The RMNH composite quality indicator was 0.64. Availability of facilities and providers was universally low. The concentration index for the composite quality indicator was -0.015 [-0.043, 0.013], suggesting no clustering to favour either rich or poor districts. Rich districts had the highest absolute numbers of health facilities and providers, but lowest numbers per facility per 1 000 000 population. Urban districts had slightly better service quality, but not availability. Using regression analysis, only facility level of care was significantly associated with quality outcome. Conclusions Composite quality of RMNH services did not vary by district wealth, but was slightly higher in urban districts. The availability data suggest that the higher population in richer districts outpaces health infrastructure.

Background Emergency medicine is a young specialty in many low- and middle-income countries (LMICs). Although many patients seeking emergency or acute care are children, little information is available about the needs and current treatment of this group in LMICs. In this observational study, we sought to describe characteristics, chief complaints, management, and outcomes of children presenting for unscheduled visits to two Cambodian public hospitals. Methods Children enrolled in the study presented without appointment for treatment at one of two Cambodian public referral hospitals during a 4-week period in 2012. Researchers used standardized questionnaires and hospital records to collect demographic and clinical data. Patients were followed up at 48 h and 14 days after initial presentation. Multivariate logistic regression identified factors associated with hospital admission. Results This study included 867 unscheduled visits. Mean patient age was 5.7 years (standard deviation 4.8 years). Of the 35 different presenting complaints, fever (63%), respiratory problems (25%), and skin complaints (24%) were most common. The majority of patients were admitted (51%), while 1% were transferred to another facility. Seven patients (1%) died within 14 days. Follow-up rates were 83% at 48 h and 75% at 14 days. Predictors of admission included transfer or referral from another health provider, seeking prior care for the presenting problem, low socioeconomic status, onset of symptoms within 24 h of seeking care, abnormal vital signs or temperature, and chief complaint of abdominal pain or fever. Conclusions While the admission rate in this study was high, mortality was low. More effective identification and management of children who can be treated and released may free up scarce inpatient resources for children who warrant admission. Electronic supplementary material The online version of this article (10.1186/s12245-018-0172-0) contains supplementary material, which is available to authorized users.

Background Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension. Our objective was to evaluate hypertension management in Zambian rural primary care clinics using process and outcome indicators to assess the screening, monitoring, treatment and control of high blood pressure. Methods Better Health Outcomes through Mentoring and Assessment (BHOMA) is a 5-year, randomized stepped-wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics. Clinical data were collected as part of routine patient care from an electronic medical record system, and reviewed for site performance over time according to hypertension related indicators: screening (blood pressure measurement), management (recorded diagnosis, physical exam or urinalysis), treatment (on medication), and control. Quantitative data was used to develop guides for qualitative in-depth interviews, conducted with health care providers at a proportional sample of half (20) of clinics. Qualitative data was iteratively analyzed for thematic content. Results From January 2011 to December 2014, 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included. Blood pressure measurement at vital sign screening was initially high at 89.1% overall (range: 70.1–100%), but decreased to 62.1% (range: 0–100%) by 48 months after intervention start. The majority of hypertensive patients made only one visit to the clinics (57.8%). Out of 9022 patients with at least two visits with an elevated blood pressure, only 49.3% had a chart recorded hypertension diagnosis. Process indicators for monitoring hypertension were

To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals.Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation.In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients' mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi or tuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired.In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques.Décrire les caractéristiques et les principales affections des adultes qui ont recours aux soins d'urgence dans deux hôpitaux cambodgiens provinciaux de référence.Les adultes âgés de plus de 18 ans qui se sont présentés sans rendez-vous à deux hôpitaux publics de référence, ont été inscrits à une étude observationnelle. Les données cliniques et démographiques ont été recueillies et les facteurs associés à l'hospitalisation ont été identifiés. Les patients ont été suivis 48 heures et 14 jours après leur présentation.Au total, 1295 présentations à l'hôpital ont été documentées. Nous avons pu suivre 85% (1098) des patients 48 heures et 77% (993) 14 jours après leur présentation. L'âge moyen des patients était de 42 ans et 64% (823) des patients étaient des femmes. La plupart des patients étaient arrivés en moto (722), en taxi ou en tuk-tuk (312). Les principales affections communes étaient en majorité des douleurs abdominales (36%; 468), des problèmes respiratoires (15%; 196) et des maux de tête (13%; 174). Parmi les 1050 patients dont les signes vitaux ont été enregistrés, 280 avaient des valeurs anormales, hormis la température, lors de leur arrivée. Les tests diagnostiques réalisés ont été enregistrés pour 539 patients: 1,2% (15) des patients avait bénéficié d'une électrocardiographie et 14% (175) des patients avaient bénéficié de l'imagerie diagnostique. Par la suite, 783 (60%) patients ont été hospitalisés et 166 d'entre eux ont subi une opération chirurgicale. Les indicateurs significatifs d'hospitalisation comprenaient l'apparition des symptômes dans les 3 jours précédant la présentation, des signes vitaux anormaux et la fièvre. À l'issue du suivi des 14 jours, 3,9% (39/993) des patients étaient décédés et 19% (192/993) des patients présentaient des capacités fonctionnelles diminuées.Dans les hospitalisations d'urgence dans les deux hôpitaux publics au Cambodge, il y a un rapport hospitalisation-décès élevé et une application limitée des techniques de diagnostic. Nous avons identifié des moyens pour améliorer les procédures, y compris la meilleure documentation des signes vitaux et l'utilisation accrue des techniques de diagnostic.Describir las características y quejas principales de los adultos que solicitan atención de emergencia en dos hospitales provinciales de remisión de Camboya.Se inscribió a adultos mayores de 18 años que acudieron sin cita previa a dos hospitales públicos de remisión en un estudio observacional. Se recogieron datos clínicos y demográficos y se identificaron los factores relacionados con el ingreso hospitalario. Se realizó un seguimiento a los pacientes durante 48 horas y 14 días después de la visita hospitalaria.En total, se documentaron 1295 visitas hospitalarias. Se logró realizar un seguimiento del 85 % (1098) y del 77 % (993) de los pacientes a las 48 horas y a los 14 días, respectivamente. La edad media de los pacientes fue de 42 años y el 64 % (823) eran mujeres. La mayoría acudió en motocicleta (722), taxi o tuk-tuk (312). Las quejas principales más comunes fueron dolor abdominal (36 %; 468), problemas respiratorios (15 %; 196) y cefalea (13 %; 174). De los 1050 pacientes con registro de constantes vitales, 280 presentaron valores anómalos, a excepción de la temperatura corporal, a su llegada. Se registraron las pruebas diagnósticas realizadas en 539 pacientes: se realizó una electrocardiografía al 1,2 % (15) e imágenes diagnósticas al 14 % (175) de los pacientes. Posteriormente, 783 (60 %) de los pacientes fueron ingresados, de los cuales 166 se sometieron a cirugía. Los predictores significativos para el ingreso incluyeron la aparición de los síntomas 3 días antes de la visita hospitalaria, constantes vitales anómalas y fiebre. Antes de finalizar el seguimiento de 14 días, el 3,9 % (39/993) de los pacientes había fallecido y el 19 % (192/993) seguía presentando discapacidades funcionales.Las hospitalizaciones de emergencia de dos hospitales públicos de Camboya presentan una elevada relación entre ingreso y defunción, así como un uso limitado de las técnicas de diagnóstico. Se identificaron formas de mejorar los procedimientos, como una mejor documentación de las constantes vitales y un mayor uso de las técnicas de diagnóstico.وصف خصائص البالغين الذين يلتمسون رعاية الطوارئ في مستشفيين للإحالة على مستوى المقاطعات في كمبوديا وشكاواهم الرئيسية.تم تسجيل البالغين في سن 18 عاماً فأكثر الذين تواجدوا في مستشفيين عامين للإحالة دون موعد في دراسة قائمة على الملاحظة. وتم جمع البيانات السريرية والديمغرافية وتحديد العوامل ذات الصلة بدخول المستشفى. وتم متابعة المرضى لمدة 48 ساعة و14 يوماً بعد دخولهم إلى المستشفى.بشكل إجمالي، تم توثيق 1295 حالة دخول إلى المستشفى. وتمكنا من متابعة 85 % (1098) من المرضى لمدة 48 ساعة و77 % (993) لمدة 14 يوماً. وكان متوسط عمر المرضى 42 سنة وكانت نسبة الإناث 64 % (823). وكان وصول معظمهم إلى المستشفى باستخدام الدراجة النارية (722) أو سيارة الأجرة أو التوك توك (312). وكانت أكثر الشكاوى الرئيسية شيوعاً ألم بالبطن (36 %؛ 468 شخصاً) ومشكلات تنفسية (15 %؛ 196 شخصاً) والصداع (13%؛ 174 شخصاً). ومن أصل 1050 مريضاً تم تسجيل علاماتهم الحيوية لدى وصولهم، كان لدى 280 مريضاً قيم شاذة، باستثناء درجة الحرارة. وتم على النحو التالي تسجيل الاختبارات التشخيصية التي تم إجراؤها بخصوص 539 مريضاً: خضع 1.2 % (15) من المرضى لإجراء تخطيط كهربائية القلب وخضع 14 % (175) لإجراء التصوير التشخيصي. وتلى ذلك إدخال 783 (60 %) مريضاً إلى المستشفى وخضع 166 مريضاً من هؤلاء المرضى إلى الجراحة. واشتملت عوامل التكهن الهامة بدخول المستشفى على بدء الأعراض قبل دخول المستشفى بثلاثة أيام وشذوذ العلامات الحيوية والحمى. وأسفرت نتائج المتابعة التي بلغت مدتها 14 يوماً عن وفاة 3.9 % (39/993) وظل 19 % (192/993) يعانون من قصور وظيفي.ثمة ارتفاع في نسبة دخول المستشفى إلى الوفاة ومحدودية في استخدام تقنيات التشخيص لدى دخول المستشفى في حالات الطوارئ في مستشفيين عامين في كمبوديا. وقمنا بتحديد طرق لتحسين الإجراءات، بما في ذلك تحسين توثيق العلامات الحيوية وزيادة استخدام تقنيات التشخيص.描述两所柬埔寨省级转诊医院成年人寻求急诊治疗的特征和主诉。.将两所公共转诊医院没有预约的18岁及以上成年人纳入观察性研究。收集临床和人口数据，并确定与入院相关的因素。在就医48小时和14天后对患者进行跟踪随访。.总计记录了1295个医院就医情况。我们能够在48小时随访85%（1098）的病人，在14天随访77%（993）的病人。病人平均年龄为42岁，64%（823）为女性。大多数通过摩托车（722）或者的士或嘟嘟车（312）前来就医。最普遍的主诉是腹痛（36%；468）、呼吸道问题（15%；196）和头痛（13%；174）。在记录生命体征的1050位患者中，280位抵达时有异常值（除体温外）。对539位病人记录了执行过的诊断性测试：1.2%（15）病人有心电图，14%（175）有诊断性影像。其后，783（60%）位病人入院，其中166位病人接受了手术。住院的显著预测因子包括前来就医之前3天内的症状发作、异常生命体征和发烧。截至14天随访时，有3.9%（39/993）病人死亡，19%（192/993）病人依然保持功能性受损状态。.在柬埔寨两所公立医院的紧急住院中，住院死亡率较高，诊断技术的应用有限。我们确定改进流程的方法，包括更好的生命体征病案记录和对诊断技术的更多使用。.Описать характеристики и основные жалобы взрослых, обратившихся за неотложной помощью в два камбоджийских провинциальных лечебно-диагностических центра.В данное обсервационное исследование были включены взрослые старше 18 лет, которые самостоятельно, без назначения, обратились в два государственных лечебно-диагностических центра. Были собраны клинические и демографические данные и определены факторы, связанные с госпитализацией. Пациенты повторно наблюдались спустя 48 часов и 14 дней после обращения в центры.В общей сложности, было задокументировано 1295 случаев обращения в центры. Наблюдение велось за 85% (1098) пациентов спустя 48 часов и 77% (993) пациентов спустя 14 дней. Средний возраст пациентов составлял 42 года, и 64% (823) из них были женщины. Большинство пациентов прибыли в центры на мотоцикле (722), на такси или тук-туке (312). Основными, наиболее распространенными жалобами являлись боли в области живота (36%; 468), нарушения со стороны дыхательной системы (15%; 196) и головная боль (13%; 174). Из 1050 пациентов с зарегистрированными основными показателями жизнедеятельности у 280 пациентов по прибытии были выявлены несоответствующие нормам показатели жизнедеятельности, за исключением температуры. Результаты диагностических исследований были зарегистрированы у 539 пациентов: 1,2% (15) пациентов прошли электрокардиографию и 14% (175) пациентов – диагностическую визуализацию. Впоследствии 783 (60%) пациента были госпитализированы и 166 из них перенесли операцию. В число значимых параметров для госпитализации входили следующие: появление симптомов в течение трех дней до обращения, несоответствующие нормам показатели жизнедеятельности и повышенная температура. При проведении 14-дневного наблюдения выяснилось, что 3,9% (39/993) пациентов скончались и 19% (192/993) оставались с ограниченной подвижностью.При проведении экстренной госпитализации в двух государственных больницах в Камбодже наблюдается высокий коэффициент смертности относительно числа принимаемых на лечение пациентов и ограниченное применение диагностических методов. Были определены способы улучшения процедур лечения, включая улучшенное документирование основных показателей жизнедеятельности и более частое использование диагностических методов.

Background Direct-to-patient (DTP) telemedicine has been noted to have highly variable antibiotic prescribing practices. This study explores the effect of education and individualized provider prescribing feedback on antibiotic prescribing for acute upper respiratory tract infections (ARTIs) in a telemedicine practice. Methods Doctor on Demand is a national DTP video visit medical practice that provides primary and mental healthcare to 1.6 million people. In April 2016, 62 physicians were randomized to two antibiotic stewardship intervention groups: Group A received education on best practices for antibiotic prescribing for sinusitis, pharyngitis and bronchitis, and Group B received education plus individualized and practice-wide feedback reports on antibiotic prescribing rates for two consecutive months (April–May) and again in October. In November, both groups received feedback reports. Antibiotic prescribing rates for all three conditions were tracked for both groups for the baseline period (January to March) and throughout the study duration. Results During the baseline period, antibiotic prescribing rates for the three conditions combined was 71% for Group A and 69% for Group B. Antibiotic prescribing rates for both groups throughout the baseline and study periods are displayed in Figure 1. For Group A, prescribing rates declined from 71% (baseline) to 66% in May and for Group B declined from 69% (baseline) to 55%. During June–September, the monthly prescribing rate remained 66–69% for Group A and 56–57% for Group B. In November, following the additional individualized feedback report provided to both groups, the prescribing rate was 63% for Group A and 46% for Group B. Conclusion Individualized prescribing feedback reports coupled with education to telemedicine providers was more effective than education alone in reducing unnecessary antibiotic prescriptions for ARTIs. These findings should be used to promote antibiotic stewardship across telemedicine and other care settings. Disclosures I. Tong, Doctor On Demand: Shareholder, Salary. K. Dean, Doctor On Demand: Shareholder, Salary. J. Thompson, Doctor On Demand: Shareholder, Salary.

An array of signals regulating the early stages of postnatal subventricular zone (SVZ) neurogenesis has been identified, but much less is known regarding the molecules controlling late stages. Here, we investigated the function of the activity-dependent and morphogenic microRNA miR-132 on the synaptic integration and survival of olfactory bulb (OB) neurons born in the neonatal SVZ. In situ hybridization revealed that miR-132 expression occurs at the onset of synaptic integration in the OB. Using in vivo electroporation we found that sequestration of miR-132 using a sponge-based strategy led to a reduced dendritic complexity and spine density while overexpression had the opposite effects. These effects were mirrored with respective changes in the frequency of GABAergic and glutamatergic synaptic inputs reflecting altered synaptic integration. In addition, timely directed overexpression of miR-132 at the onset of synaptic integration using an inducible approach led to a significant increase in the survival of newborn neurons. These data suggest that miR-132 forms the basis of a structural plasticity program seen in SVZ-OB postnatal neurogenesis. miR-132 overexpression in transplanted neurons may thus hold promise for enhancing neuronal survival and improving the outcome of transplant therapies.

Background Hypertension constitutes a growing burden of illness in developing countries like Zambia. Adequately screening and treating hypertension could greatly reduce the complications of stroke and coronary disease. Our objective was to determine the prevalence of hypertension and identify current treatment practices among adult patients presenting for routine care to rural health facilities in the Better Health Outcomes through Mentoring and Assessments (BHOMA) project. Methods We conducted a retrospective analysis of routinely collected clinical data from 46 rural government clinics in Zambia. Our analysis cohort comprised patients ≥ 25 years with recorded blood pressure measurements, who sought care at primary health centers. Consistent with prior research, in our primary analysis, we only included data from first visits. Hypertension was defined as a systolic blood pressure ≥140 mmHg, or diastolic blood pressure ≥90 mmHg, or reported use of antihypertensive medication. A sensitivity analysis was performed using median blood pressure for individuals with multiple visits. Results and Discussion From January 2011 to December 2014, 116,130 first visits by adult patients met eligibility criteria. The crude prevalence of hypertension by onsite measurement or reported use of antihypertensive medication was 23.1 % [95 % CI: 22.8-23.3] (23.6 % in females, 22.3 % in males). The age standardized prevalence of hypertension across participating sites was 28.0 % [95 % CI: 27.7-28.3] (29.7 % in females, 25.8 % in males). Sensitivity analysis revealed a similar prevalence using data from all visits. Only 5.6 % of patients had a diagnosis of hypertension documented in their medical record. Among patients with hypertension, only 18.0 % had any antihypertensive drug prescribed, with nifedipine (8.9 %), furosemide (8.3 %), and propranolol (2.4 %) as the most common. Conclusions Age standardized prevalence of hypertension in rural primary health clinics in Zambia was high compared to other studies in rural Africa; however, we diagnosed hypertension with only one measurement and this may have biased our findings. Future efforts to improve hypertension control should focus on population preventive care and primary healthcare provider education on individual management. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-2258-4) contains supplementary material, which is available to authorized users.

Neurogenesis is continually occurring in two regions within the mammalian central nervous system (CNS) and increasing evidence suggests that it is important for selective learning and memory. How this plasticity is maintained in isolated niches within mature networks has been extensively studied in recent years, and a large body of evidence has accumulated describing many different regulatory factors and points of regulation. In this review, we attempt to organize the current research by summarizing findings affecting early neurogenesis: during proliferation, fate commitment and migration, versus late neurogenesis: including dendritic development, synaptic integration, and survival. We discuss the roles of three different classes of factors regulating early and late phases of neurogenesis: intrinsic factors, extrinsic factors, and neurotransmitters. Finally, we suggest that neurotransmitters may act upstream from extracellular other factors and cell-intrinsic mechanisms by coupling network activity to the niche microenvironment and intracellular machinery to ultimately regulate neurogenesis.