Myocardial fibrosis in rheumatic heart disease: emerging concepts and clinical implications.

Rheumatic heart disease (RHD) remains a significant cardiovascular burden in the world even though it is no longer common in affluent countries. Centuries of history surrounding this disease provide us with a thorough understanding of its pathophysiology. Infections in the throat, skin, or mucosa are the gateway for Group A Streptococcus (GAS) to penetrate our immune system. A significant inflammatory response to the heart is caused by an immunologic cascade triggered by GAS antigen cross-reactivity. This exaggerated immune response is primarily responsible for cardiac dysfunction. Recurrent inflammatory processes damage all layers of the heart, including the endocardium, myocardium, and pericardium. A vicious immunological cycle involving inflammatory mediators, angiotensin II, and TGF-ß promotes extracellular matrix remodeling, resulting in myocardial fibrosis. Myocardial fibrosis appears to be a prevalent occurrence in patients with RHD. The presence of myocardial fibrosis, which causes left ventricular dysfunction in RHD, might be utilized to determine options for treatment and might also be used to predict the outcome of interventions in patients with RHD. This emerging concept of myocardial fibrosis needs to be explored comprehensively in order to be optimally utilized in the treatment of RHD.

HIV treatment outcomes following antiretroviral therapy initiation and monitoring: A workplace program in Papua, Indonesia.

BACKGROUND: Papua Province, Indonesia is experiencing an on-going epidemic of Human Immunodeficiency Virus (HIV) infection, with an estimated 9-fold greater prevalence than the overall national rate. This study reviewed the treatment outcomes of an HIV-infected cohort on Antiretroviral Therapy (ART) and the predictors in terms of immunological recovery and virological response. METHODS: ART-naïve individuals in a workplace HIV program in southern Papua were retrospectively analyzed. Patients were assessed at 6, 12 and 36 months after ART initiation for treatment outcomes, and risk factors for virological suppression (viral load (VL) <1,000 copies/ml), poor immune response (CD4 <200 cells/mm3) and immunological failure (CD4 <100 cells/ mm3) after at least 6 months on ART, using a longitudinal Generalized Estimating Equations multivariate model. RESULTS: Assessment of 105 patients were included in the final analysis with a median age of 34 years, 88% male, median baseline CD4 236 cells/ mm3, and VL 179,000 copies/ml. There were 74, 73, and 39 patients at 6, 12, and 36 months follow-up, respectively, with 5 deaths over the entire period. For the three observation periods, 68, 80, and 75% of patents achieved virological suppression, poor immune responders decreased from 15, 16 to 10%, whilst 15, 16, 10% met the immunological failure criteria, respectively. Using multivariate analysis, the independent predictor for viral suppression at 12 and 36 months was ≥1 log decrease in VL at 6 months (OR 19.25, p<0.001). Higher baseline CD4 was significantly correlated with better immunological outcomes, and lower likelihood of experiencing immunological failure (p <0.001). CONCLUSION: Virological response at six months after beginning ART is the strongest predictor of viral suppression at 12 and 36 months, and may help in identifying patients needing additional adherence therapy support. Higher baseline CD4 positively affects the immunological outcomes of patients. The findings indicate HIV control programs should prioritize the availability of VL testing and begin ART regardless of CD4 counts in infected patients.

Non-communicable diseases and tuberculosis: Anticipating the impending global storm.

The epidemiological transitions that have occurred in low and middle income countries (LMIC) during the past decades have led to an increased prevalence on non-communicable diseases (NCDs) in these countries, where the burden of infectious diseases (IDs), especially tuberculosis (TB), remains high. Although the true dimensions of this comorbidity have not yet been fully understood, there is a growing amount of data, over the last 10 years, that suggest a clear association between NCDs and TB. In particular, there is a continuously increasing body of evidence that diabetes mellitus, chronic respiratory conditions, tobacco use, mental health illnesses and chronic kidney disease increase TB morbidity and mortality and vice versa. This bidirectional negative association between diseases may jeopardise the achievement of the Sustainable Development Goals (SDGs) specific TB targets, thus underlying the importance of integrated public health responses towards both epidemics. Population as well as individual based approaches are required, along with both strategic and operation integration on a global scale. This year's United Nations High Level Meetings (ΗLMs) presented a rare opportunity for the political foundations of the TB and NCD responses to be dug together, thus creating a potential breakthrough in the global response to both epidemics.

Carga de enfermedad de diabetes mellitus en Bogotá, D. C., 2009-2015 / Loading of the diabetes mellitus disease in Bogotá, D. C., 2009-2015 / Carga da doença de diabetes mellitus em Bogotá, D. C., 2009-2015

Objetivo: estimar la carga de enfermedad de diabetes mellitus en Bogotá, D. C., para el periodo 2009-2015. Fechas y lugares de ejecución: el estudio se realizó con la información actualizada de la Secretaría Distrital de Salud (SDS) en 2016 y 2017. Métodos: es un estudio de carga de enfermedad retrospectivo; para estimar los años de vida perdidos por discapacidad (AVD) se utilizaron las bases de datos del Registro Individual de Prestación de Servicios (RIPS), y para los años de vida perdidos por muerte prematura (AVP) se emplearon los registros de estadísticas vitales de defunción del Departamento Administrativo Nacional de Estadística (DANE), en contraste con la esperanza de vida calculada para Colombia para 2010; posteriormente, se sumaron estos dos indicadores para estimar los años de vida perdidos por muerte prematura ajustados por discapacidad (AVAD) en diabetes mellitus. Resultados: las tasas de mortalidad y AVP presentan una tendencia a la disminución; en la proporción de prevalencia y en los AVPD, tienen una tendencia significativa al aumento; la carga de enfermedad está a expensas de la discapacidad en un 56,49 %; por sexo, las mujeres presentan mayor carga de enfermedad, y por grupo de edad se observa un aumento cronológico con la edad; por régimen de seguridad, la mayor cantidad de carga la presenta el subsidiado. En cuanto a los tipos de diabetes, la mayor proporción se presenta en la diabetes tipo 2, seguida de la diabetes tipo 1, la diabetes gestacional y la diabetes específica. Conclusión: la diabetes mellitus en Bogotá durante el periodo 2009- 2015 muestra que la carga de enfermedad tiene una tendencia al aumento, a expensas del incremento en la carga de discapacidad

Objective: To estimate the burden of diabetes mellitus disease in Bogotá D.C., 2009 - 2015. Material and Methods: This is a study of retrospective disease burden. In order to estimate the years of life lost due to disability (YLD), we used the databases Individual Service Provider Records (RIPS) and for the years of life lost due to premature death (YLL), the vital death statistics registers were used of the DANE, in contrast to the life expectancy calculated for Colombia in 2010; later these two indicators are added to estimate Years of life lost due to premature death adjusted for disability (DALYs) in diabetes mellitus. Results: Mortality rates and YLL, the tendency is to decrease; instead, in the proportion of prevalence and in the YLD, a significant tendency to increase; the disease burden is at the expense of disability, this is due to a 56.49 % disability; by sex, women present a greater burden of disease, by age group a chronological increase is observed with age, by safety regime the largest amount of burden is presented by the subsidized. In the types of diabetes the highest proportion occurs in type 2 diabetes, followed by type 1 diabetes, gestational diabetes and specific diabetes. Conclusion: Diabetes mellitus in Bogotá during 2009-2015 shows that the burden of disease has a tendency to increase, at the expense of the increase in the burden of disability

Objetivo: Estimar a carga de diabetes mellitus em Bogotá D.C., 2009 - 2015. Material e Métodos: Trata-se de um estudo de carga de doença retrospectiva. Para estimar os anos de vida perdidos por invalidez (YLD), utilizamos os bancos de dados Registros Individuais de Prestação de Serviços (RIPS) e, para os anos de vida perdidos por morte prematura (YLL), foram utilizados os registros estatísticos de óbitos vitais o DANE, em contraste com a expectativa de vida calculada para a Colômbia em 2010; mais tarde, esses dois indicadores são adicionados para estimar os anos de vida perdidos devido a morte prematura ajustada por incapacidade (DALYs) no diabetes mellitus. Resultados: As taxas de mortalidade e o YLL tendem a diminuir; na proporção de prevalência e na YLD, eles têm uma tendência significativa a aumentar; o ônus da doença é à custa da deficiência, que é de 56,49 % devido à deficiência; por sexo, as mulheres apresentam maior carga de doença, por faixa etária observa- se um aumento cronológico com a idade, pelo regime de segurança o maior montante de sobrecarga é apresentado pelos subsidiados. Nos tipos de diabetes, a maior proporção ocorre no diabetes tipo 2, seguido pelo diabetes tipo 1, diabetes gestacional e diabetes específico Conclusão: O diabetes mellitus em Bogotá durante 2009-2015 mostra que o ônus da doença tende a aumentar, em detrimento do aumento da carga de incapacidade

Know Your Noodles! Assessing Variations in Sodium Content of Instant Noodles across Countries.

Reducing salt intake is a cost-effective public health intervention to reduce the global burden of non-communicable disease (NCDs). Ultra-processed foods contribute ~80% of dietary salt in high income countries, and are becoming prominent in low-middle income countries. Instant noodle consumption is particularly high in the Asia Pacific region. The aim of this study was to compare the sodium content of instant noodles sold worldwide to identify potential for reformulation. Analysis was undertaken for 765 instant noodle products from 10 countries using packaged food composition databases of ultra-processed foods compiled by the Global Food Monitoring Group (GFMG) and national shop survey data. Sodium levels were high and variable, within and between countries. Instant noodles in China had the highest mean sodium content (1944 mg/100 g; range: 397-3678/100 g) compared to New Zealand (798 mg/100 g; range: 249-2380 mg/100 g). Average pack size ranged from 57 g (Costa Rica) to 98 g (China). The average packet contributed 35% to 95% of the World Health Organization recommended daily salt intake of <5 g. Forty-one percent of products met the Pacific Island (PICs) regional sodium targets, 37% met the South Africa 2016 targets, and 62% met the UK 2017 targets. This study emphasises a need for stronger regulation and closer monitoring to drive rigorous reformulation of salt in ultra-processed foods.

The double burden of disease among mining workers in Papua, Indonesia: at the crossroads between Old and New health paradigms.

BACKGROUND: As the global shift toward non-communicable diseases overlaps with the unfinished agenda of confronting infectious diseases in low- and middle-income countries, epidemiological links across both burdens must be recognized. This study examined the non-communicable disease-infectious disease overlap in the specific comorbidity rates for key diseases in an occupational cohort in Papua, Indonesia. METHODS: Diagnosed cases of ischaemic heart disease, stroke, hypertension, diabetes (types 1 and 2), chronic obstructive pulmonary disease, asthma, cancer, HIV and AIDS, tuberculosis, and malaria were extracted from 22,550 patient records (21,513 men, 1037 women) stored in identical electronic health information systems from two clinic sites in Papua, Indonesia. Data were collected as International Classification of Diseases, 10th Revision, entries from records spanning January-December 2013. A novel application of Circos software was used to visualize the interconnectedness between the disease burdens as overlapping prevalence estimates representing comorbidities. RESULTS: Overall, NCDs represented 38 % of all disease cases, primarily in the form of type 2 diabetes (n = 1440) and hypertension (n = 1398). Malaria cases represented the largest single portion of the disease burden with 5310 recorded cases, followed by type 2 diabetes with 1400 cases. Tuberculosis occurred most frequently alongside malaria (29 %), followed by chronic obstructive pulmonary disease (19 %), asthma (17 %), and stroke (12 %). Hypertension-tuberculosis (4 %), tuberculosis-cancer (4 %), and asthma-tuberculosis (2 %) comorbidities were also observed. CONCLUSIONS: The high prevalence of multimorbidity, preponderance of non-communicable diseases, and extensive interweaving of non-communicable and infectious disease comorbidities highlighted in this cohort of mining workers in Papua, Indonesia reflect the markedly double disease burden increasingly plaguing Indonesia and other similar low- and middle-income countries - a challenge with which their over-stretched, under-resourced health systems are ill-equipped to cope. Integrated, person-centered treatment and control strategies rooted in the primary healthcare sector will be critical to reverse this trend.

Rheumatic heart disease among adults in a mining community of Papua, Indonesia: findings from an occupational cohort.

BACKGROUND: Rheumatic heart disease (RHD) remains a significant cause of cardiovascular morbidity and mortality in developing countries such as Indonesia. Yet, despite being one of the most readily preventable chronic diseases, RHD has received scant research or policy attention, particularly in South-East Asia. AIM: To describe the pattern of RHD occurrence in a sample of presenting cases from an occupational cohort in Papua Province, Indonesia. METHODS: Clinical records of 15 608 mining workers (96.4% men, mean age 36.3±7.4 years) were reviewed retrospectively to identify and extract data on all rheumatic fever (RF) and RHD cases admitted to two hospitals in Papua during 2008-2013. Collected data included basic demographics, employment history and echocardiographic findings. RESULTS: 83 RHD cases (95.6% men, mean age 39.6±12.5 years) and 3 RF cases were identified between 2008 and 2013. Increased RHD risk was observed among those aged 35-44 (HR=3.60) and 45-68 (HR=4.46) years relative to the youngest age group (p<0.01). RHD incidence density was 6.84 per 10 000 person years of follow-up. Among cases, mitral stenosis was the most common valvular lesion at initial presentation (41.0%), and 6.0% were multivalvular. CONCLUSIONS: The prevalence of RHD in Papuan mining workers correlates with adult prevalence data in other populations with a high RHD burden, highlighting RHD as a significant health issue into adulthood. The late stage at which most patients presented points to a strong need for earlier intervention. Both primary and secondary preventive measures must be considered critical tools to prevent and reduce RHD burden, particularly among older age groups.

Non-communicable disease risk factor patterns among mining industry workers in Papua, Indonesia: longitudinal findings from the Cardiovascular Outcomes in a Papuan Population and Estimation of Risk (COPPER) Study.

OBJECTIVES: Non-communicable diseases (NCDs) constitute an increasing slice of the global burden of disease, with the South-East Asia region projected to see the highest increase in NCD-related deaths over the next decade. Mining industry employees may be exposed to various factors potentially elevating their NCD risk. This study aimed to assess the distribution and 5-year longitudinal trends of key metabolic NCD risk factors in a cohort of copper-gold mining company workers in Papua, Indonesia. METHODS: Metabolic indicators of NCD risk were assessed among employees (15 580 at baseline, 6496 prospectively) of a large copper-gold mining operation in Papua, Indonesia, using routinely collected 5-year medical surveillance data. The study cohort comprised individuals aged 18-68 years employed for ≥1 year during 2008-2013. Assessed risk factors were based on repeat measures of cholesterol, blood glucose, blood pressure and body weight, using WHO criteria. RESULTS: Metabolic risk indicator rates were markedly high and increased significantly from baseline through 5-year follow-up (p<0.001). Adjusting for gender and age, longer duration of employment (≥10 years) predicted raised cholesterol (adjusted OR (AOR)=1.13, p=0.003), raised blood pressure (AOR=1.16, p=0.009) and overweight/obesity (AOR=1.14, p=0.001) at baseline; and persistent raised cholesterol (AOR=1.26, p=0.003), and both incident (AOR=1.33, p=0.014) and persistent raised blood glucose (AOR=1.62, p=0.044) at 3-year follow-up. CONCLUSIONS: Individuals employed for longer periods in a mining operations setting in Papua, Indonesia, may face elevated NCD risk through various routes. Workplace health promotion interventions and policies targeting modifiable lifestyle patterns and environmental exposures present an important opportunity to reduce such susceptibilities and mitigate associated health risks.

Salt Reduction Initiatives around the World - A Systematic Review of Progress towards the Global Target.

OBJECTIVE: To quantify progress with the initiation of salt reduction strategies around the world in the context of the global target to reduce population salt intake by 30% by 2025. METHODS: A systematic review of the published and grey literature was supplemented by questionnaires sent to country program leaders. Core characteristics of strategies were extracted and categorised according to a pre-defined framework. RESULTS: A total of 75 countries now have a national salt reduction strategy, more than double the number reported in a similar review done in 2010. The majority of programs are multifaceted and include industry engagement to reformulate products (n = 61), establishment of sodium content targets for foods (39), consumer education (71), front-of-pack labelling schemes (31), taxation on high-salt foods (3) and interventions in public institutions (54). Legislative action related to salt reduction such as mandatory targets, front of pack labelling, food procurement policies and taxation have been implemented in 33 countries. 12 countries have reported reductions in population salt intake, 19 reduced salt content in foods and 6 improvements in consumer knowledge, attitudes or behaviours relating to salt. CONCLUSION: The large and increasing number of countries with salt reduction strategies in place is encouraging although activity remains limited in low- and middle-income regions. The absence of a consistent approach to implementation highlights uncertainty about the elements most important to success. Rigorous evaluation of ongoing programs and initiation of salt reduction programs, particularly in low- and middle- income countries, will be vital to achieving the targeted 30% reduction in salt intake.

Current salt reduction policies across gradients of inequality-adjusted human development in the WHO European region: minding the gaps.

OBJECTIVE: To assess current salt reduction policies in countries of the WHO European Region against the backdrop of varying levels of human development adjusted for income, education and health (longevity) inequalities. DESIGN: Population-based, cross-sectional study, with data gathered through systematic review of relevant databases and supplementary information provided by WHO Nutrition Counterparts. SETTING: Member States of the WHO European Region. SUBJECTS: Inequality-adjusted Human Development Index scores were analysed against assessed levels of development and implementation of national nutrition policies and initiatives targeting population-level salt reduction. RESULTS: Within the WHO European Region, Inequality-adjusted Human Development Index values among countries with no existing salt reduction initiatives (mean 0·643 (se 0·022)) were significantly lower than among those with either partially implemented/planned salt initiatives (mean 0·766 (se 0·017), P < 0·001) or fully implemented salt initiatives (mean 0·780 (se 0·021), P < 0·001). CONCLUSIONS: Where salt reduction strategies are implemented as an integral part of national policy, outcomes have been promising. However, low- and middle-income countries may face severe resource constraints that keep them from emulating more comprehensive strategies pursued in high-income countries. Care must be taken to ensure that gaps are not inadvertently widened by monitoring differential policy impacts of salt policies, particularly regarding trade flows.

Visual three-dimensional representation of beat-to-beat electrocardiogram traces during hemodiafiltration.

This study evaluated the usefulness of the three-dimensional representation of electrocardiogram traces (3DECG) to reveal acute and gradual changes during a full session of hemodiafiltration (HDF) in end-stage renal disease (ESRD) patients. Fifteen ESRD patients were included (six men, nine women, age 46 ± 19 years old). Serum electrolytes, blood pressure, heart rate, and blood urea nitrogen (BUN) were measured before and after HDF. Continuous electrocardiograms (ECGs) obtained by Holter monitoring during HDF were used to produce the 3DECG. Several major disturbances were identified by 3DECG images: increase in QRS amplitude (47%), decrease in T-wave amplitude (33%), increase in heart rate (33%), and occurrence of arrhythmia (53%). Different arrhythmia types were often concurrent and included isolated supraventricular premature beats (N = 5), atrial fibrillation or atrial bigeminy (N = 2), and isolated premature ventricular beats (N = 6). Patients with decrease in T-wave amplitude had higher potassium and BUN (both before HDF and total removal) than those without decrease in T-wave amplitude (P < 0.05). Concurrent acute and gradual ECG changes during HDF are identified by the 3DECG, which could be useful as a preventive and prognostic method.

Advocacy and resource mobilization for rubella elimination in Guatemala.

This review describes the advocacy efforts to mobilize resources for the campaign to vaccinate men and women aged 9-39 years, with a goal of eliminating rubella and congenital rubella syndrome in Guatemala. The country's investment in health has been historically low (0.9% of gross domestic product), and there has been a wide gap between the availability of economic resources and the need for economic resources for the immunization campaign. The review contains a summary of the investment made, the results of advocacy and resource mobilization, the vaccination coverage attained, and the campaign's impact on the disease.