Assessing the potential outcomes of achieving the World Health Organization global non-communicable diseases targets for risk factors by 2025: is there also an economic dividend?

OBJECTIVES: This study assesses the change in premature mortality and in morbidity under the scenario of meeting the World Health Organization (WHO) global targets for non-communicable disease (NCD) risk factors (RFs) by 2025 in France. It also estimates medical expenditure savings because of the reduction of NCD burden. STUDY DESIGN: A microsimulation model is used to predict the future health and economic outcomes in France. METHODS: A 'RF targets' scenario, assuming the achievement of the six targets on RFs by 2025, is compared to a counterfactual scenario with respect to disability-adjusted life years and healthcare costs differences. RESULTS: The achievement of the RFs targets by 2025 would save about 25,300 (and 75,500) life years in good health in the population aged 25-64 (respectively 65+) years on average every year and would help to reduce healthcare costs by about €660 million on average per year, which represents 0.35% of the current annual healthcare spending in France. Such a reduction in RFs (net of the natural decreasing trend in mortality) would contribute to achieving about half of the 2030 NCD premature mortality target in France. CONCLUSIONS: The achievement of the RF targets would lead France to save life years and life years in good health in both working-age and retired people and would modestly reduce healthcare expenditures. To achieve RFs targets and to curb the growing burden of NCDs, France has to strengthen existing and implement new policy interventions.

Mycotic aneurysms of the aortic root. A pathologic study of 20 cases.

Twenty specimens of heart with mycotic aneurysms at the aortic root were studied. In ten cases, mycotic aneurysm followed infection of the aortic valve. In one case, it developed following infection of an aortic jet lesion, and in nine patients, the aneurysm was at the seat of a prosthetic aortic valve. In seven of the 11 cases with a natural aortic valve, the valve was either unicuspid or bicuspid. A retrospective evaluation of the data on the clinical records of the 20 patients revealed that infective endocarditis or noncardiac postoperative sepsis was present in 11. The most frequently isolated microorganism was Staphylococcus aureus. Conduction disturbances were found in six patients, all of them with involvement of the atrioventricular node by the aneurysm. Perforation into intracardiac cavities was found in four, two into the right ventricular infundibulum and one each into each atrium. Pericardial tamponade was caused by bleeding from the aneurysm in two cases, and myocardial infarction was a probable consequence of coronary arterial compression by the aneurysm in two cases. Mycotic aneurysms of the aortic root, in spite of their being partially or completely healed of active infection, carry a high risk of the complications enumerated. Among the 20 cases, cultures were positive in 11 and negative in nine. Staphylococcus aureus was cultured from five of the cases.

Accessory tissue of the tricuspid valve protruding into the left ventricle through a septal defect.

We report the pathologic findings in 13 cases with accessory tissue originating from the tricuspid valve and protruding into the left ventricular outflow tract through a ventricular septal defect (VSD). In eight cases the accessory tissue formed a pouch, the walls of which were similar to the tissue of the normal tricuspid valve. In five cases, papillarylike masses of young connective tissue formed the accessory tissue. The degree of left ventricular outflow tract obstruction was mild in five cases, intermediate in five, and severe in three. Adhesions to the rims of the VSD causing obstruction of the VSD were seen in ten cases. Associated anomalies were present in all cases. The most frequent associated anomalies other than the tricuspid valvular anomalies and the VSDs were transposition of the great arteries and a variety of vascular anomalies.

Aneurysm of the fossa ovalis in infants: a pathologic study.

An aneurysm of the fossa ovalis was identified at autopsy in 17 infants. In each case the aneurysm of the fossa ovalis was considered to have resulted from excessive elevation of pressure in that atrium contralateral to the side into which the aneurysm bulged. The aneurysms were divided into two types: intrinsic (three cases) and extrinsic (14 cases). The intrinsic types of aneurysms of the fossa ovalis were considered to have started in fetal life and were consequences of abnormally narrow states of interatrial ostium II. Each intrinsic aneurysm bulged toward the left. Among the extrinsic types of aneurysm of the fossa ovalis, each was considered to have resulted from the hemodynamic consequences of a congenital anomaly in one side of the heart or other. Six aneurysms of extrinsic type bulged toward the left and eight toward the right. Aneurysm of the fossa ovalis should be included in the differential diagnosis of space-occupying conditions within the atria.

Involvement of the aortic valve cusps in discrete subaortic stenosis.

A review of 18 cases with discrete subaortic stenosis (DSS) revealed that involvement of the aortic valve cusps in the basic process was present in 16. In these 16 cases, extensions of fibroelastic tissue from the site of the DSS toward the base or superior to the base of one or more cusps were seen. In seven of the involved cases, deformity of a cusp was associated with these extensions. Valvular aortic insufficiency in cases with DSS might be caused by extensions of the fibroelastic tissue to the aortic cusps.

Homozygosity for autosomal dominant Marfan syndrome.

Marfan syndrome is an autosomal dominant condition with varying phenotypic manifestations. Affected persons are usually heterozygotes. A family is presented in which the gene for this syndrome is segregating in a large number of members. Two sibs suffered from unusually severe, identical, and fatal manifestations from birth, their parents having mild cardiovascular and somatic symptoms common in Marfan syndrome. Investigation of collagen biosynthesis in fibroblasts revealed no abnormalities in fibronectin and procollagen I and III synthesis and secretion or in the procollagen to collagen conversion. We suggest that these two sibs are examples of homozygosity for the Marfan syndrome gene, based on the large number of affected members, the absence of additional consanguinity, manifestation of the syndrome in both parents, and the severity of the disease in the two sibs.

Amiodarone in control of sustained tachyarrhythmias in children with Wolff-Parkinson-White syndrome.

Oral amiodarone was administered to ten children aged 3 months to 15 years who had recurrent SVT associated with the Wolff-Parkinson-White syndrome. In nine patients, amiodarone was used following failure of oral digoxin, quinidine, propranolol, and verapamil. Each patient received an oral loading dose of 10 to 15 mg/kg followed by 5 mg/kg daily. All children became asymptomatic of tachyarrhythmias within five days of therapy and remained asymptomatic for 5 to 36 months. In one patient, amiodarone therapy was discontinued because of generalized urticaria after a positive initial response. After high-dose oral verapamil failed to eliminate recurrent bouts of SVT, the patient was again given amiodarone and he had a complete recovery. All ten children had normal results on thyroid function tests, and no other adverse effects were detected. Amiodarone has been shown to be highly effective and well tolerated in this series of children. Therefore, we recommend its use for the control and prevention of sustained arrhythmias in pediatric patients with Wolff-Parkinson-White syndrome when the traditional antiarrhythmic drugs fail.

Treatment of premature labor contractions with combined ritodrine and indomethacine.

The results of combined ritodrine and indomethacine treatment (RI) in premature labor contractions were compared with ritodrine alone (R). One hundred and twenty patients with threatened premature labor in weeks 26-34 were studied. Sixty RI women received 100 mg ritodrine in infusion followed by 60 mg daily orally until 35 weeks and indomethacine 200 mg on the first day of treatment only. The R group included 60 women with identical tocolysis indices, age of pregnancy and anamnestic parameters who received ritodrine only. The mean prolongation index (PI) was 18.2 in the RI group, against 11.5 in the R patients (P less than 0.05). The mean prolongation of pregnancy was 5.6 weeks in the first and 3.6 in the control group (P less than 0.05). Birthweight and Apgar scores were similar in the two groups. In order to examine the possible early closure of the ductus arteriosus due to the indomethacin therapy, echocardiograms were done on all newborn in the RI group: the pre-ejection period and right ventricular ejection time ratio was 0.19-0.26 after delivery and 0.17-0.22 1 month later, which excludes pulmonary diastolic hypertension due to premature closure of the duct. The combined RI treatment is more effective that R alone and does not give rise to any complications in the mother or the fetus.

Supravalvular aortic and peripheral pulmonary arterial stenoses. A report of eight cases in two generations.

Peripheral pulmonary arterial stenosis, either alone or in combination with supravalvular aortic stenosis, is described in two generations of one family. The last child born in the first generation ws the only fatal case and showed severe narrowing and thrombosis of the pulmonary arteries and significant narrowing of the descending aorta. Physical and mental development were normal in the seven surviving patients. Five had slight dyspnea on effort. Hemodynamic and angiocardiogrphic studies showed multiple peripheral pulmonary stenosis in six patients and supravalvular aortic stenosis or aortic hypoplasia in the last three of the first generation and in one of the second generation. The younger children were more severely affected. A marked systolodiastolic caliber variation of the main pulmonary arteries was noted angiographically in all those studied. We suggest that this finding can be used as an indirect sign of the presence of peripheral pulmonary arterial stenosis.

Prenatally diagnosed blocked atrial premature beats.

A case of persistent severe bradycardia in labor, diagnosed as blocked atrial premature beats, is presented. Simultaneous recording of fetal heart rate (FHR) and fetal electrocardiogram (FECG) during labor established an accurate diagnosis of an innocent fetal sinus bradycardia and differentiated it from fetal distress. This method should be applied in all cases of persistent fetal dysrhythmia, in order to differentiate it from hypoxic distress, and thus enable the obstetrician to avoid unnecessary cesarean sections.

Congenital atrial flutter.

Two cases of congenital atrial flutter, one of which was documented electrocardiographically before birth, are reported. In both patients sinus rhythm was restored with digoxin treatment; in one patient the transition was preceded by various arrhythmias. No cardiac malformation was found in either case, and no materal disease occurred during pregnancy. Both mothers had received medication during pregnancy, but its role as a causative factor is questionable.