Effects of aspirin on cardiovascular outcomes in patients with chronic kidney disease.

Patients with chronic kidney disease (CKD) carry a high cardiovascular (CV) risk. Since whether this risk is reduced by aspirin is unclear, we examined if the effect of aspirin on cardiovascular outcomes varied by baseline kidney function in a primary cardiovascular disease prevention trial. The International Polycap Study-3 (TIPS-3) trial had randomized people without previous cardiovascular disease to aspirin (75 mg daily) or placebo. We now examined aspirin versus placebo on cardiovascular events in participants grouped by estimated glomerular filtration rate (eGFR), using a threshold of 60 ml/min/1.73 m2, and by using tertiles of eGFR. The primary outcome was a composite of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. A total of 5712 participants were randomized with a mean follow-up of 4.6 years. Of these, 983 (17.2%) had an eGFR under 60 ml/min/1.73 m2 (mean eGFR 49 ml/min/1.73 m2) and 4,729 over 60 ml/min/1.73 m2 (mean 84 ml/min/1.73 m2). In participants with an eGFR under 60 ml/min/1.73 m2 there were 26 primary outcomes in 502 participants on aspirin and 39/481 on placebo (hazard ratio 0.57; 95% confidence interval 0.34-0.94). In participants with an eGFR over 60 ml/min/1.73 m2 there were 90 primary outcomes in 2357 participants on aspirin and 95/2372 on placebo (0.95; 0.71-1.27). With tertiles of eGFR under 70, 70-90, and over 90 ml/min/1.73 m2, risk reductions with aspirin for the primary outcome were larger at lower eGFR levels (0.62; 0.43-0.91) for the lowest tertile, (0.96; 0.62-1.49) for the middle, and (1.30; 0.77-2.18) for the highest tertile. Thus, our findings support aspirin may reduce cardiovascular events in people with moderate to advanced stage CKD.

Long-term exposure to outdoor and household air pollution and blood pressure in the Prospective Urban and Rural Epidemiological (PURE) study

Exposure to air pollution has been linked to elevated blood pressure (BP) and hypertension, but most research has focused on short-term (hours, days, or months) exposures at relatively low concentrations. We examined the associations between long-term (3-year average) concentrations of outdoor PM2.5 and household air pollution (HAP) from cooking with solid fuels with BP and hypertension in the Prospective Urban and Rural Epidemiology (PURE) study. Outdoor PM2.5 exposures were estimated at year of enrollment for 137,809 adults aged 35­70 years from 640 urban and rural communities in 21 countries using satellite and ground-based methods. Primary use of solid fuel for cooking was used as an indicator of HAP exposure, with analyses restricted to rural participants (n = 43,313) in 27 study centers in 10 countries. BP was measured following a standardized procedure and associations with air pollution examined with mixed-effect regression models, after adjustment for a comprehensive set of potential confounding factors. Baseline outdoor PM2.5 exposure ranged from 3 to 97 µg/m3 across study communities and was associated with an increased odds ratio (OR) of 1.04 (95% CI: 1.01, 1.07) for hypertension, per 10 µg/m3 increase in concentration. This association demonstrated non-linearity and was strongest for the fourth (PM2.5 > 62 µg/m3) compared to the first (PM2.5 < 14 µg/m3) quartiles (OR = 1.36, 95% CI: 1.10, 1.69). Similar non-linear patterns were observed for systolic BP (ß = 2.15 mmHg, 95% CI: −0.59, 4.89) and diastolic BP (ß = 1.35, 95% CI: −0.20, 2.89), while there was no overall increase in ORs across the full exposure distribution. Individuals who used solid fuels for cooking had lower BP measures compared to clean fuel users (e.g. 34% of solid fuels users compared to 42% of clean fuel users had hypertension), and even in fully adjusted models had slightly decreased odds of hypertension (OR = 0.93; 95% CI: 0.88, 0.99) and reductions in systolic (−0.51 mmHg; 95% CI: −0.99, −0.03) and diastolic (−0.46 mmHg; 95% CI: −0.75, −0.18) BP. In this large international multi-center study, chronic exposures to outdoor PM2.5 was associated with increased BP and hypertension while there were small inverse associations with HAP.

[Concordance of the assessment of pubertal development with the Tanner scale between adolescents and a trained physician]. / Concordancia en la evaluación del desarrollo puberal mediante la escala de Tanner entre adolescentes y un médico entrenado.

OBJECTIVES.: To assess the concordance between self-assessment of pubertal development with the Tanner scale performed by adolescents compared to the assessment performed by a trained physician. MATERIALS AND METHODS.: As part of the SIMAC project, data was collected on 244 adolescents. At baseline, we included an anthropometric and pubertal development assessment, with a self-assessment by the participants. RESULTS.: We included 229 teenagers from 12 to 17 years old. The agreement between the self-assessment and the clinical evaluation with the Tanner scale presented an 88.3% agreement and a weighted kappa coefficient of 0.554. The self-assessment in women showed a good agreement ( kappaweighted=0.653) and in men a moderate agreement (kappaweighted=0.464). The only variable with a significant influence on the agreement ability was gender; the disagreement probability in males was 63% greater than in females, regardless of age, height, or weight (95% CI: 1,18-2, 26). CONCLUSIONS: . Self-assessment was not accurate enough to replace medical examination, especially in males. More research is needed on this subject considering the impact that self-assessment of sexual development could have.

OBJETIVOS.: Evaluar la concordancia entre la autoevaluación del desarrollo puberal mediante la escala de Tanner realizada por adolescentes, comparado con la evaluación efectuada por un médico entrenado. MATERIALES Y MÉTODOS.: Los datos de 244 adolescentes fueron recolectados como parte del proyecto SIMAC. En la línea de base incluimos una evaluación antropométrica y del desarrollo puberal, con una autoevaluación por parte de los participantes. RESULTADOS.: Incluimos 229 adolescentes de 12 a 17 años. La concordancia entre la autoevaluación y la evaluación clínica de la escala de Tanner presentó un acuerdo obtenido de 88,3% y un coeficiente kappa ponderado de 0,554. La autoevaluación en mujeres demostró una concordancia buena (kappapond=0,653), y en varones una concordancia moderada (kappapond=0,464). La única variable con una influencia significativa sobre la capacidad de acuerdo fue el sexo; la probabilidad de desacuerdo en los varones fue 63% mayor que en las mujeres, independiente de edad, talla y peso (IC 95%:1,18-2,26). CONCLUSIONES.: La autoevaluación no fue lo suficientemente precisa para reemplazar el examen médico, sobre todo en los varones. Se requieren más estudios en relación con este tema, reconociendo el impacto que podría llegar a tener la autoevaluación del desarrollo sexual.

Concordancia en la evaluación del desarrollo puberal mediante la escala de Tanner entre adolescentes y un médico entrenado / Concordance of the assessment of pubertal development with the Tanner scale between adolescents and a trained physician

RESUMEN Objetivos. Evaluar la concordancia entre la autoevaluación del desarrollo puberal mediante la escala de Tanner realizada por adolescentes, comparado con la evaluación efectuada por un médico entrenado. Materiales y métodos. Los datos de 244 adolescentes fueron recolectados como parte del proyecto SIMAC. En la línea de base incluimos una evaluación antropométrica y del desarrollo puberal, con una autoevaluación por parte de los participantes. Resultados. Incluimos 229 adolescentes de 12 a 17 años. La concordancia entre la autoevaluación y la evaluación clínica de la escala de Tanner presentó un acuerdo obtenido de 88,3% y un coeficiente kappa ponderado de 0,554. La autoevaluación en mujeres demostró una concordancia buena (kappapond=0,653), y en varones una concordancia moderada (kappapond=0,464). La única variable con una influencia significativa sobre la capacidad de acuerdo fue el sexo; la probabilidad de desacuerdo en los varones fue 63% mayor que en las mujeres, independiente de edad, talla y peso (IC 95%:1,18-2,26). Conclusiones. La autoevaluación no fue lo suficientemente precisa para reemplazar el examen médico, sobre todo en los varones. Se requieren más estudios en relación con este tema, reconociendo el impacto que podría llegar a tener la autoevaluación del desarrollo sexual.

ABSTRACT Objectives. To assess the concordance between self-assessment of pubertal development with the Tanner scale performed by adolescents compared to the assessment performed by a trained physician. Materials and Methods. As part of the SIMAC project, data was collected on 244 adolescents. At baseline, we included an anthropometric and pubertal development assessment, with a self-assessment by the participants. Results. We included 229 teenagers from 12 to 17 years old. The agreement between the self-assessment and the clinical evaluation with the Tanner scale presented an 88.3% agreement and a weighted kappa coefficient of 0.554. The self-assessment in women showed a good agreement ( kappaweighted=0.653) and in men a moderate agreement (kappaweighted=0.464). The only variable with a significant influence on the agreement ability was gender; the disagreement probability in males was 63% greater than in females, regardless of age, height, or weight (95% CI: 1,18-2, 26). Conclusions . Self-assessment was not accurate enough to replace medical examination, especially in males. More research is needed on this subject considering the impact that self-assessment of sexual development could have.

Dulaglutide and renal outcomes in type 2 diabetes: an exploratory analysis of the REWIND randomised, placebo-controlled trial

Background Two glucagon-like peptide-1 (GLP-1) receptor agonists reduced renal outcomes in people with type 2 diabetes at risk for cardiovascular disease. We assessed the long-term effect of the GLP-1 receptor agonist dulaglutide on renal outcomes in an exploratory analysis of the REWIND trial of the effect of dulaglutide on cardiovascular disease. Methods REWIND was a multicenter, randomized, double-blind, placebo-controlled trial at 371 sites in 24 countries. Men and women aged at least 50 years with type 2 diabetes who had either a previous cardiovascular event or cardiovascular risk factors were randomly assigned (1:1) to either weekly subcutaneous injection of dulaglutide (1·5 mg) or placebo and followed up at least every 6 months for outcomes. Urinary albumin-to-creatinine ratios (UACRs) and estimated glomerular filtration rates (eGFRs) were estimated from urine and serum values measured in local laboratories every 12 months. The primary outcome (first occurrence of the composite endpoint of non-fatal myocardial infarction, non-fatal stroke, or death from cardiovascular causes), secondary outcomes (including a composite microvascular outcome), and safety outcomes of this trial have been reported elsewhere. In this exploratory analysis, we investigate the renal component of the composite microvascular outcome, defined as the first occurrence of new macroalbuminuria (UACR >33·9 mg/mmol), a sustained decline in eGFR of 30% or more from baseline, or chronic renal replacement therapy. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01394952. Findings Between Aug 18, 2011, and Aug 14, 2013, 9901 participants were enrolled and randomly assigned to receive dulaglutide (n=4949) or placebo (n=4952). At baseline, 791 (7·9%) had macroalbuminuria and mean eGFR was 76·9 mL/min per 1·73 m² (SD 22·7). During a median follow-up of 5·4 years (IQR 5·1­5·9) comprising 51 820 person years, the renal outcome developed in 848 (17·1%) participants at an incidence rate of 3·5 per 100 person-years in the dulaglutide group and in 970 (19·6%) participants at an incidence rate of 4·1 per 100 person-years in the placebo group (hazard ratio [HR] 0·85, 95% CI 0·77­0·93; p=0·0004). The clearest effect was for new macroalbuminuria (HR 0·77, 95% CI 0·68­0·87; p<0·0001), with HRs of 0·89 (0·78­1·01; p=0·066) for sustained decline in eGFR of 30% or more and 0·75 (0·39­1·44; p=0·39) for chronic renal replacement therapy. (AU)

Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study

Background Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status­wealth and education­differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management. Methods In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorized as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family. (AU)

Health effects of household solid fuel use: findings from 11 countries within the prospective urban and rural epidemiology study

Approximately 2.5 billion individuals globally are exposed to household air pollution (HAP) from cooking with solid fuels such as coal, wood, dung, or crop residues (Smith et al. 2014). Concentrations of air pollutants, especially fine particulate matter [PM≤2:5 lminaerodynamicdiameterðPM2:5)], can be several orders of magnitude higher in homes cooking with solid fuels compared with those using clean fuels such as electricity or liquefied petroleum gas (LPG) (Clark et al. 2013; Shupler et al. 2018). PM2:5 in outdoor air has been linked to mortality, Address correspondence to Perry Hystad, School of Public Health and Human Sciences, Oregon State University, Milam Hall 10, 2520 SW Campus Way, Corvallis, OR 97331 USA. Telephone: (541) 737-4829. Email: Perry. hystad@oregonstate.edu SupplementalMaterialisavailableonline(https://doi.org/10.1289/EHP3915). The authors declared hey have no actual or potential competing financial interests. Received 16 May 2018; Revised 16 April 2019; Accepted 16 April 2019; Published 8 May 2019. Note to readers with disabilities: EHP strives to ensure that all journal content is accessible to all readers. However, some figures and Supplemental Material published in EHP articles may not conform to 508 standards due to the complexity of the information being presented. If you need assistance accessing journal content, please contact ehponline@niehs.nih.gov. Our staff will work with you to assess and meet your accessibility needs within 3 working days.is chemic heart disease (IHD), stroke, and respiratory diseases (Kim et al. 2015). Despite the large population exposed and the potential for adverse health effects, few prospective cohort studies have examined the health effects of HAP. Only four studies have examined HAP and mortality and reached contradictory conclusions (Alam et al. 2012; Kim et al. 2016; Mitter et al. 2016; Yu et al. 2018). Further, studies have not examined HAP and fatal as well as nonfatal cardiovascular disease (CVD) events. There is growing evidence of the adverse effects of HAP on respiratory diseases and lung cancer; however, most studies are cross sectional or case control in design, with relatively small sample sizes and limited geographic coverage (Gordon et al. 2014). To date, few prospective studies have examined HAP exposures and respiratory events in adults, and the existing studies have reported contradictory findings (Chanetal.2019; Ezzati and Kammen 2001; Mitter et al. 2016). Given the absence of direct epidemiological data, the Global Burden of Disease (GBD) study estimated the potential impact of HAP on health using exposure response relationships that pooled data from studies on outdoor air pollution, secondhand smoke, and active smoking (Burnett et al. 2014). These predictions indicated that 1.6 million deaths were attributable to HAP exposure in 2017, of which 39% were from IHD and stroke and 55% from respiratory outcomes [>90% from chronic obstructive pulmonary disease (COPD) and acute lower respiratory infections (ALRI)] (GBD 2017 Risk Factor Collaborators 2018). Given the lack of direct epidemiological evidence and this large predicted burden, there is an urgent need to directly characterize the health effects associated with HAP. Within the Prospective Urban and Rural Epidemiology (PURE) study, we conducted an analysis of 91,350 adults from 467 urban and rural communities in 11 low to middle-income countries (LMICs) where solid fuels are commonly used for cooking. We examined associations between cooking with solid fuels as a proxy indicator of HAP exposure and cause specific mortality, incident cases of CVD [ CVD death and incidence of nonfatal myocardial infarction (MI), stroke, and heart failure (HF)] and incident cases of respiratory disease [respiratory death, nonfatal COPD, pulmonary tuberculosis (TB), pneumonia, or lung cancer].We estimated associations between solid fuel use for cooking and these outcomes, controlling for extensive individual, household, and community covariates. (AU)

Heart failure in low- and middle-income countries: background, rationale, and design of the INTERnational Congestive Heart Failure Study (INTER-CHF).

BACKGROUND: Although heart failure (HF) has been referred to as a global epidemic, most HF information comes from high-income countries, with little information about low-income countries (LIC) and middle-income countries (MIC) in Africa, Asia, the Middle East, and South America, which make up the majority of the world's population. METHODS: The INTERnational Congestive Heart Failure Study is a cohort study of 5,813 HF patients enrolled in 108 centers in 16 LIC and MIC. At baseline, data were recorded on sociodemographic and clinical risk factors, HF etiology, laboratory variables, management, and barriers to evidence-based HF care at the patient, physician, and system levels. We sought to enroll consecutive and consenting patients ≥18 years of age with a clinical diagnosis of HF seen in outpatient clinics (2/3 of patients) or inpatient hospital wards (1/3 of patients). Patients were followed up at 6 and 12 months post-enrollment to record clinical status, treatments, and clinical outcomes such as death and hospitalizations. In the 5,813 enrolled HF patients, the mean age was 59 ± 15 years, 40% were female, 62% had a history of hypertension, 30% had diabetes, 21% had prior myocardial infarction, 64% were recruited from outpatient clinics, 36% lived in rural areas, and 29% had HF with preserved left ventricular ejection fraction. CONCLUSIONS: This unique HF registry aims to systematically gather information on sociodemographic and clinical risk factors, etiologies, treatments, barriers to evidence-based care, and outcomes of HF in LIC and MIC. This information will help improve the management of HF globally.

Latin American guidelines on hypertension. Latin American Expert Group.

Hypertension is a highly prevalent cardiovascular risk factor in the world and particularly overwhelming in low and middle-income countries. Recent reports from the WHO and the World Bank highlight the importance of chronic diseases such as hypertension as an obstacle to the achievement of good health status. It must be added that for most low and middle-income countries, deficient strategies of primary healthcare are the major obstacles for blood pressure control. Furthermore, the epidemiology of hypertension and related diseases, healthcare resources and priorities, the socioeconomic status of the population vary considerably in different countries and in different regions of individual countries. Considering the low rates of blood pressure control achieved in Latin America and the benefits that can be expected from an improved control, it was decided to invite specialists from different Latin American countries to analyze the regional situation and to provide a consensus document on detection, evaluation and treatment of hypertension that may prove to be cost-utility adequate. The recommendations here included are the result of preparatory documents by invited experts and a subsequent very active debate by different discussion panels, held during a 2-day sessions in Asuncion, Paraguay, in May 2008. Finally, in order to improve clinical practice, the publication of the guidelines should be followed by implementation of effective interventions capable of overcoming barriers (cognitive, behavioral and affective) preventing attitude changes in both physicians and patients.