The burden of premature adult mortality associated with lack of access to electricity in India.

BACKGROUND: The impact of electricity access on all-cause premature mortality is unknown. METHODS: We use a national dataset from India to compare districts with high access to electricity (>90% of households) to districts with middle (50-90%) and low (<50%) access to electricity and estimate the effect of lack of electricity access on all-cause premature mortality. RESULTS: In 2014, out of 597 districts in India, 174 districts had high access, 228 had middle access, and 195 had low access to electricity. When compared to districts with high access, districts with low access had higher rates of age-standardized premature mortality in both women (2.09, 95% CI: 1.43-2.74) and men (0.99, 0.10-1.87). Similarly, these districts had higher rates of conditional probability of premature death in both women (9.16, 6.19-12.13) and men (4.04, 0.77-7.30). Middle access districts had higher rates of age-standardized premature mortality and premature death in women, but not men. The total excess deaths attributable to reduced electricity access were 444,225 (45,195 in middle access districts and 399,030 in low access districts). In low access districts, the proportion of premature adult deaths attributable to low electricity access was 21.3% (14.4%- 28.1%) in women and 7.9% (1.5%- 14.3%) in men. CONCLUSION: Poor access to electricity is associated with nearly half a million premature adult deaths. One out of five premature deaths in adult women were linked to low electricity access making it a major social determinant of health.

The ecological footprint of physicians: A survey of physicians in Canada, India, and USA.

Combating climate change may be the greatest public health opportunity of the 21st century. While physicians play an important role in addressing climate change, given their affluence in society, they may be an important source of greenhouse gas emissions themselves. We sought to examine the size and nature of the ecological footprint of physicians and medical students. We conducted an online survey from December 2021-May 2022 examining resource consumption, changes in consumption patterns over time, and beliefs about climate change. Participants were medical students, residents, and staff physicians in Canada, India, or USA. Only 20 out of 162 valid respondents had a low ecological footprint (12%), defined as meat intake ≤2 times per week, living in an apartment or condominium, and using public transport, bicycle, motorcycle or walking to work. 14 of these 20 participants were from India. 91% of participants were open to reducing their own ecological footprint, though only 40% had made changes in that regard. 49% participants who discussed climate change at work and at home had decreased their ecological footprint, compared to 29% of participants who rarely engaged in such conversations (OR 2.39, 95% CI 1.24-4.63, P = 0.01). We conclude that physicians have a large ecological footprint, especially those from Canada and USA. A majority of physicians are interested in reducing their ecological footprint, and those who engage in conversations around climate change are more likely to have done so. Talking frequently about climate change, at work and at home, will likely increase climate change action amongst physicians.

Effectiveness of Medical Student Counseling for Hospitalized Patients Addicted to Tobacco (MS-CHAT): a Randomized Controlled Trial.

BACKGROUND: Low-middle-income countries face an enormous burden of tobacco-related illnesses. Counseling for tobacco cessation increases the chance of achieving quit outcomes, yet it remains underutilized in healthcare settings. OBJECTIVE: We tested the hypothesis that utilizing trained medical students to counsel hospitalized patients who use tobacco will lead to an increase in patient quit rates, while also improving medical student knowledge regarding smoking cessation counseling. DESIGN: Investigator-initiated, two-armed, multicenter randomized controlled trial conducted in three medical schools in India. PARTICIPANTS: Eligibility criteria included age 18-70 years, active admission to the hospital, and current smoking. INTERVENTION: A medical student-guided smoking cessation program, initiated in hospitalized patients and continued for 2 months after discharge. MAIN MEASURES: The primary outcome was self-reported 7-day point prevalence of smoking cessation at 6 months. Changes in medical student knowledge were assessed using a pre- and post-questionnaire delivered prior to and 12 months after training. KEY RESULTS: Among 688 patients randomized across three medical schools, 343 were assigned to the intervention group and 345 to the control group. After 6 months of follow up, the primary outcome occurred in 188 patients (54.8%) in the intervention group, and 145 patients (42.0%) in the control group (absolute difference, 12.8%; relative risk, 1.67; 95% confidence interval, 1.24-2.26; p < 0.001). Among 70 medical students for whom data was available, knowledge increased from a mean score of 14.8 (± 0.8) (out of a maximum score of 25) at baseline to a score of 18.1 (± 0.8) at 12 months, an absolute mean difference of 3.3 (95% CI, 2.3-4.3; p < 0.001). CONCLUSIONS: Medical students can be trained to effectively provide smoking cessation counseling to hospitalized patients. Incorporating this program into the medical curriculum can provide experiential training to medical students while improving patient quit rates. TRIAL REGISTRATION: URL: http://www. CLINICALTRIALS: gov . Unique identifier: NCT03521466.

Global Variations in Heart Failure Etiology, Management, and Outcomes.

Importance: Most epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries. Objective: To examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development. Design, Setting, and Participants: Multinational HF registry of 23 341 participants in 40 high-income, upper-middle-income, lower-middle-income, and low-income countries, followed up for a median period of 2.0 years. Main Outcomes and Measures: HF cause, HF medication use, hospitalization, and death. Results: Mean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a ß-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper-middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower-middle-income countries (39.5%) (P < .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper-middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower-middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper-middle-income countries (ratio = 2.4), similar in lower-middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper-middle-income countries (9.7%), then lower-middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower-middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies. Conclusions and Relevance: This study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally.

Rationale and Design of a Study to Test the Effect of Personal Protective Aids on Hypertension and Diabetes in People Living With High Levels of Air Pollution-Study Protocol.

BACKGROUND: Air pollution is the largest environmental cause of disease and premature death in the world today, disproportionally affecting low- and middle-income countries (LMIC) such as India. Studies have shown that exposure to particulate matter <2.5 µm (PM2.5) can contribute to cardiovascular disease and increase mortality. We hypothesise that the use of personal protective aids (home indoor air purifiers/N95 masks) can decrease systolic blood pressure (SBP) in people with hypertension and decrease fasting blood glucose levels (FBG) in those with diabetes. METHOD: This is a prospective randomised crossover study in Dalkhola, India-an area of high ambient PM2.5 levels. Participants between 18-70 years of age with hypertension (n=128) and diabetes (n=33) will be invited to participate in the study. They will be randomised to either an intervention or control arm for 4 weeks, after which they will cross over to the other arm following a 2-week washout period. The intervention will consist of using an indoor air purifier at night and N95 mask when outdoors. The control period will involve using an identical air purifier and N95 mask with the filter removed (sham filtration). Participants and outcome assessors will be blinded to study arm assignment. OUTCOME EVALUATION: The primary outcome of the study is the absolute reduction in SBP among people with hypertension and absolute reduction in FBG among people with diabetes. DISCUSSION: This is the first randomised controlled trial to evaluate the use of personal protective aids as a therapeutic measure in people with hypertension and diabetes exposed to high levels of PM2.5. Given the high burden of air pollution in LMIC, there is an urgent need for adaptation measures targeting people at high risk for mortality from this exposure. The results of our study will demonstrate whether personal protective aids can be a viable adaptation measure for people living with hypertension and diabetes in areas with a high burden of air pollution. TRIAL REGISTRATION: This is clinicaltrials.gov Identifier: NCT04854187.

Venous thromboembolism in COVID-19: A meta-summary of cases.

OBJECTIVES: To summarize cases of venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT) among coronavirus disease (COVID-19) patients and discuss their symptoms, diagnostic method, clinical features, and prognosis. METHODS: All major databases were searched for relevant studies published between December 1, 2019 and May 5, 2021. RESULTS: A total of 233 articles were identified, 22 describing 48 patients were included. A total of 79.1% had PE and 20.9% had DVT. Most patients were men, with a mean age of 56 years. Comorbidities were present in 70.8%, and 85.4% had at least one risk factor of VTE. 56.3% had received anticoagulation therapy. Most patients were treated in the general ward. Complications occurred in 27.1% of the patients, and recovery was achieved in 80.4%. CONCLUSION: Venous thromboembolism must be suspected even in patients who had received prior anticoagulant regimens or in stable cases, especially in males, the elderly, and patients with comorbidities and high D-dimer levels.

Variations in the financial impact of the COVID-19 pandemic across 5 continents: A cross-sectional, individual level analysis.

BACKGROUND: COVID-19 has caused profound socio-economic changes worldwide. However, internationally comparative data regarding the financial impact on individuals is sparse. Therefore, we conducted a survey of the financial impact of the pandemic on individuals, using an international cohort that has been well-characterized prior to the pandemic. METHODS: Between August 2020 and September 2021, we surveyed 24,506 community-dwelling participants from the Prospective Urban-Rural Epidemiology (PURE) study across high (HIC), upper middle (UMIC)-and lower middle (LMIC)-income countries. We collected information regarding the impact of the pandemic on their self-reported personal finances and sources of income. FINDINGS: Overall, 32.4% of participants had suffered an adverse financial impact, defined as job loss, inability to meet financial obligations or essential needs, or using savings to meet financial obligations. 8.4% of participants had lost a job (temporarily or permanently); 14.6% of participants were unable to meet financial obligations or essential needs at the time of the survey and 16.3% were using their savings to meet financial obligations. Participants with a post-secondary education were least likely to be adversely impacted (19.6%), compared with 33.4% of those with secondary education and 33.5% of those with pre-secondary education. Similarly, those in the highest wealth tertile were least likely to be financially impacted (26.7%), compared with 32.5% in the middle tertile and 30.4% in the bottom tertile participants. Compared with HICs, financial impact was greater in UMIC [odds ratio of 2.09 (1.88-2.33)] and greatest in LMIC [odds ratio of 16.88 (14.69-19.39)]. HIC participants with the lowest educational attainment suffered less financial impact (15.1% of participants affected) than those with the highest education in UMIC (22.0% of participants affected). Similarly, participants with the lowest education in UMIC experienced less financial impact (28.3%) than those with the highest education in LMIC (45.9%). A similar gradient was seen across country income categories when compared by pre-pandemic wealth status. INTERPRETATION: The financial impact of the pandemic differs more between HIC, UMIC, and LMIC than between socio-economic categories within a country income level. The most disadvantaged socio-economic subgroups in HIC had a lower financial impact from the pandemic than the most advantaged subgroup in UMIC, with a similar disparity seen between UMIC and LMIC. Continued high levels of infection will exacerbate financial inequity between countries and hinder progress towards the sustainable development goals, emphasising the importance of effective measures to control COVID-19 and, especially, ensuring high vaccine coverage in all countries. FUNDING: Funding for this study was provided by the Canadian Institutes of Health Research and the International Development Research Centre.

Variations in the association of height with mortality, cardiovascular disease and cancer in low-, middle- and high-income countries.

BACKGROUND: Final adult height is a useful proxy measure of childhood nutrition and disease burden. Tall stature has been previously associated with decreased risk of all-cause mortality, decreased risk of major cardiovascular events and an increased risk of cancer. However, these associations have primarily been derived from people of European and East Asian backgrounds, and there are sparse data from other regions of the world. METHODS: The Prospective Urban-Rural Epidemiology study is a large, longitudinal population study done in 21 countries of varying incomes and sociocultural settings. We enrolled an unbiased sample of households, which were eligible if at least one household member was aged 35-70 years. Height was measured in a standardized manner, without shoes, to the nearest 0.1 cm. During a median follow-up of 10.1 years (interquartile range 8.3-12.0), we assessed the risk of all-cause mortality, major cardiovascular events and cancer. RESULTS: A total of 154 610 participants, enrolled since January 2003, with known height and vital status, were included in this analysis. Follow-up event data until March 2021 were used; 11 487 (7.4%) participants died, whereas 9291 (6.0%) participants had a major cardiovascular event and 5873 (3.8%) participants had a new diagnosis of cancer. After adjustment, taller individuals had lower hazards of all-cause mortality [hazard ratio (HR) per 10-cm increase in height 0.93, 95% confidence interval (CI) 0.90-0.96] and major cardiovascular events (HR 0.97, 95% CI 0.94-1.00), whereas the hazard of cancer was higher in taller participants (HR 1.23, 95% CI 1.18-1.28). The interaction p-values between height and country-income level for all three outcomes were <0.001, suggesting that the association with height varied by country-income level for these outcomes. In low-income countries, height was inversely associated with all-cause mortality (HR 0.88, 95% CI 0.84-0.92) and major cardiovascular events (HR 0.87, 95% CI 0.82-0.93). There was no association of height with these outcomes in middle- and high-income countries. The respective HRs for cancer in low-, middle- and high-income countries were 1.14 (95% CI 0.99-1.32), 1.12 (95% CI 1.04-1.22) and 1.20 (95% CI 1.14-1.26). CONCLUSIONS: Unlike high- and middle-income countries, tall stature has a strong inverse association with all-cause mortality and major cardiovascular events in low-income countries. Improved childhood physical development and advances in population-wide cardiovascular treatments in high- and middle-income countries may contribute to this gap. From a life-course perspective, we hypothesize that optimizing maternal and child health in low-income countries may improve rates of premature mortality and cardiovascular events in these countries, at a population level.

Rationale and Design of a Randomized Controlled Trial to Evaluate the Effectiveness of Medical Student Counseling for Hospitalized Patients Addicted to Tobacco (the MS-CHAT Trial).

Globally, India is the second largest consumer of tobacco. However, Indian medical students do not receive adequate training in smoking cessation counseling. Each patient hospitalization is an opportunity to counsel smokers. Medical Student Counseling for Hospitalized patients Addicted to Tobacco (MS-CHAT) is a 2-arm multicenter randomized controlled trial (RCT) that compares the effectiveness of a medical student-guided smoking cessation program initiated in inpatients and continued for two months after discharge versus standard hospital practice. Current smokers admitted to the hospital are randomized to receive either usual care or the intervention. The intervention group receives inpatient counseling and longitudinal postdischarge telephone follow-up by medical students. The control group receives counseling at the discretion of the treating physician. The primary outcome is biochemically verified 7-day point prevalence of smoking cessation at 6 months after enrollment. Changes in medical student knowledge and attitude will also be studied using a pre- and postquestionnaire delivered prior to and 12 months after training. This trial tests a unique model that seeks to provide hands-on experience in smoking cessation counseling to medical students while simultaneously improving cessation outcomes among hospitalized smokers in India.

A combined community health worker and text messagingbased intervention for smoking cessation in India: Project MUKTI - A mixed methods study.

INTRODUCTION: We sought to evaluate the effectiveness of a community health worker (CHW) led smoking cessation intervention, supplemented by text messages, and tailored to an individual's readiness to quit. METHODS: We conducted a cluster randomized controlled trial (April 2018-August 2019) in adult smokers residing in a semi-urban region of India. Participants in the intervention arm received CHW-led home visits and had the option of choosing to receive regular text messages. The dose and content of CHW counseling and text messages were tailored to the participant's readiness to quit. The control group received brief education only. Primary outcome was biochemically verified smoking cessation at the end of 12 months. Both intention-to-treat and as-treated analyses were performed. RESULTS: A total of 238 (mean age 43±12.3 years, male 96.2%) participants were enrolled; 151 (64%) in the intervention arm and 83 (35.4%) in the control arm. At 12 months, 31 (20.5%) participants in the intervention arm and 9 (10.8%) in the control arm quit smoking (absolute risk difference=9.7%; RR=1.69; 95% CI: 0.04-71.33, p=0.74). In the as-treated analysis, 17 (36.9%) of the 46 participants who received optimal dose of the intervention quit smoking. CONCLUSIONS: CHW-led home-based counseling, supplemented by regular text messages, led to an increase in quit rates for smoking, especially among those exposed to a higher dose of the intervention. However, the difference in cessation rates was not statistically significant. Future studies should consider testing mobile application-based multimedia messaging with larger populations, as a supplement to CHW-based counseling.

Closing Gaps in Lifestyle Adherence for Secondary Prevention of Coronary Heart Disease.

The secondary prevention (SP) of coronary heart disease (CHD) has become a major public health and economic burden worldwide. In the United States, the prevalence of CHD has risen to 18 million, the incidence of recurrent myocardial infarctions (MI) remains high, and related healthcare costs are projected to double by 2035. In the last decade, practice guidelines and performance measures for the SP of CHD have increasingly emphasized evidence-based lifestyle (LS) interventions, including healthy dietary patterns, regular exercise, smoking cessation, weight management, depression screening, and enrollment in cardiac rehabilitation. However, data show large gaps in adherence to healthy LS behaviors and low rates of enrollment in cardiac rehabilitation in patients with established CHD. These gaps may be related, since behavior change interventions have not been well integrated into traditional ambulatory care models in the United States. The chronic care model, an evidence-based practice framework that incorporates clinical decision support, self-management support, team-care delivery and other strategies for delivering chronic care is well suited for both chronic CHD management and prevention interventions, including those related to behavior change. This article reviews the evidence base for LS interventions for the SP of CHD, discusses current gaps in adherence, and presents strategies for closing these gaps via evidence-based and emerging interventions that are conceptually aligned with the elements of the chronic care model.