Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study

BACKGROUND: To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches. METHODS: The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years. FINDINGS: This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs. INTERPRETATION: Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care. (AU)

The household economic burden of non-communicable diseases in 18 countries

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries. METHODS: Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China. RESULTS: The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs. CONCLUSIONS: Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs. (AU)

Cardiovascular risk and events in 17 low-,middle-, and high-income countries

BACKGROUNDMore than 80% of deaths from cardiovascular disease are estimated to occur inlow-income and middle-income countries, but the reasons are unknown.METHODSWe enrolled 156,424 persons from 628 urban and rural communities in 17 countries(3 high-income, 10 middle-income, and 4 low-income countries) and assessedtheir cardiovascular risk using the INTERHEART Risk Score, a validated score forquantifying risk-factor burden without the use of laboratory testing (with higherscores indicating greater risk-factor burden). Participants were followed for incidentcardiovascular disease and death for a mean of 4.1 years.RESULTSThe mean INTERHEART Risk Score was highest in high-income countries, intermediatein middle-income countries, and lowest in low-income countries (P<0.001).However, the rates of major cardiovascular events (death from cardiovascularcauses, myocardial infarction, stroke, or heart failure) were lower in high-incomecountries than in middle- and low-income countries (3.99 events per 1000 personyearsvs. 5.38 and 6.43 events per 1000 person-years, respectively; P<0.001). Casefatality rates were also lowest in high-income countries (6.5%, 15.9%, and 17.3%in high-, middle-, and low-income countries, respectively; P = 0.01). Urban communitieshad a higher risk-factor burden than rural communities but lower ratesof cardiovascular events (4.83 vs. 6.25 events per 1000 person-years, P<0.001) andcase fatality rates (13.52% vs. 17.25%, P<0.001). The use of preventive medicationsand revascularization procedures was significantly more common in high-incomecountries than in middle- or low-income countries (P<0.001).CONCLUSIONSAlthough the risk-factor burden was lowest in low-income countries, the rates ofmajor cardiovascular disease and death were substantially higher in low-incomecountries than in high-income countries. The high burden of risk factors in highincome...

Non-communicable diseases--finally on the global agenda.

After the UN Millennium Development Goals were declared in September 2000 (see Table 1), one of the major short-comings recognized world-wide was the lack of mention of non-communicable diseases (NCDs). While AIDS and malaria were included, none of the leading and universal non-communicable causes of death made the list. There was no mention of cardiovascular diseases, cancer or diabetes, even though these place a far greater burden on global health and economic development than the infectious diseases, and are predicted to continue to increase in epidemic proportions. After much public discussion and intense lobbying, a significant-and uncommon-achievement occurred: on May 13th, 2010, the United Nations General Assembly voted in favour of convening a summit on non-communicable diseases, to take place in September 2011.

The incidence of cancer in a population-based cohort of Canadian heart transplant recipients.

To assess the long-term risk of developing cancer among heart transplant recipients compared to the Canadian general population, we carried out a retrospective cohort study of 1703 patients who received a heart transplant between 1981 and 1998, identified from the Canadian Organ Replacement Register database. Vital status and cancer incidence were determined through record linkage to the Canadian Mortality Database and Canadian Cancer Registry. Cancer incidence rates among heart transplant patients were compared to those of the general population. The observed number of incident cancers was 160 with 58.9 expected in the general population (SIR = 2.7, 95% CI = 2.3, 3.2). The highest ratios were for non-Hodgkin's lymphoma (NHL) (SIR = 22.7, 95% CI = 17.3, 29.3), oral cancer (SIR = 4.3, 95% CI = 2.1, 8.0) and lung cancer (SIR = 2.0, 95% CI = 1.2, 3.0). Compared to the general population, SIRs for NHL were particularly elevated in the first year posttransplant during more recent calendar periods, and among younger patients. Within the heart transplant cohort, overall cancer risks increased with age, and the 15-year cumulative incidence of all cancers was estimated to be 17%. There is an excess of incident cases of cancer among heart transplant recipients. The relative excesses are most marked for NHL, oral and lung cancer.

Strengthening information systems for heart health in Canada.

Information plays a key role in monitoring, management, evaluation and policy development related to cardiovascular diseases. Canada currently lacks a comprehensive, integrated pan-Canadian system to address the growing burden of cardiovascular diseases, including reliable and timely data that can be used by policy-makers, health care providers, researchers and the public. Theme Working Group 1 (one of six Theme Working Groups) aimed to address different aspects of the Canadian Heart Health Strategy and Action Plan, with a focus on strengthening information systems. Members of the group, who are experts in the cardiovascular field and/or information systems, defined the scope of the issue, identified gaps and solutions, and discussed priorities. The process is described and suggestions for final recommendations are presented. These suggestions were made taking into consideration the needs of health care providers, patients and consumers, the needs for planning, innovation, evaluation and system improvement, and the needs for information on populations and environments. A sustained integrated system that meets cardiovascular information needs requires a major commitment of expertise, leadership and funding.

Biobehavioral factors in the context of ischemic cardiovascular diseases.

OBJECTIVE: We set out to examine the development of current thinking on the relationship between behavioral factors and ischemic heart disease, with the latter being viewed as an epidemic. METHODS: The present work is a nonsystematic review of the subject. RESULTS: Atherogenic components of the coronary-prone or type A behavior pattern (TABP), including hostility, cynicism, and suppression of anger, as well as stress reactivity, depression, and social isolation, are emerging as particularly significant behavioral characteristics, although their pathophysiology is not yet fully understood. Effective patient management, particularly for lifestyle modification, requires an appreciation of an individual's stage in their readiness to change. CONCLUSION: The control and prevention of cardiovascular diseases depend on a multidisciplinary approach that recognizes the importance and intricacies of lifestyle behaviors.

[Cyclophosphamide pulse therapy in patients with primary glomerulonephritis]. / Leczenie pulsami cyklofosfamidu pacjentów z pierwotnymi glomerulopatiami.

UNLABELLED: Cyclophosphamide is a cytostatic drug, widely used in therapy of secondary glomerulonephritis. Because pulse therapy bears less side effects than oral one we aimed to follow the cyclophosphamide effect on the course of patients with primary glomerulonephritis. We observed 20 pts (7 women and 13 men), mean age 33 +/- 10.0 yrs, age range 18-50 yrs with primary glomerulonephritis and proteinuria more than 3.5 g. 12 patients also had erythro-cyturia. In all pts kidney biopsy was performed, but in one woman the biopsy was not diagnostic. Renal biopsy revealed: FSG in 2 pts, membranous glomerulonephritis in 2 pts, in 9 pts mesangial proliferative changes and in 6--mesangiocapillary lesions. In 5 pts renal failure was observed. Cyclophosphamide was administered i.v. in the dose 0.75 g/m2 b.s., no more than 1.0 g per dose, in renal failure 0.5 g/m2. During the first six months patients received cyclophosphamide every month and then every three months. Before cyclophosphamide pulse therapy all patients were pretreated with steroids, 3 pulses of 1.0 g Methylprednisolone and then oral prednisone in the dose 20 mg/m2 body surface. RESULTS: In 3 patients we obtained remission of proteinuria, in 11 patients decrease of proteinuria but 6 patients didn't answer to the introduced treatment. In whole group of examined patients we obtained the statistically significant decrease of proteinuria from 12.2 +/- 10.5 to 5.3 +/- 5.2 g (p < 0.05) after the treatment. The creatinine clearance did not change in the time of the treatment and any special complications during the treatment were observed. We suggest that cyclophosphamide pulse therapy could be an effective treatment in pts with primary glomerulonephritis. Our results showed that the answer of proposed treatment was independent of the type to the changes found in kidney biopsy.

Cardiovascular risk factors in supersonic pilots in Poland.

Selected cardiovascular risk factors were examined in 272 active pilots of supersonic aircraft in Poland. Hypercholesterolemia was present in 72.4% and hypertriglyceridemia in 17.1% of the pilots. Decreased levels of HDL-cholesterol and increased levels of LDL-cholesterol were found in 86.9% and 69.9% of pilots, respectively. Slightly over half (52.2%) were found to be mildly overweight while 6.6% were obese. The prevalence of smoking was 25.4%. Risk factor modification included non-pharmacological treatment of hyperlipidemia supported by lipid-lowering drugs, depending on the serum lipid level. A significant improvement in lipid profiles was obtained with this strategy, at least over 3 to 6 mo of follow up. The challenge is to develop strategies that will result in maintained improvements.

High refractive errors and the accident/incident rate in Canadian medical category 1 pilots.

BACKGROUND: Since 1982, the Canadian Civil Aviation Medicine Division has medically certified to Category 1 standard commercial and airline transport pilots whose visual correction was in excess of +/- 3.5 diopters (D). METHOD: A review between the years 1982 and 1991 of the 253 pilots who had been medically certified, although they were outside the standard, was conducted. We determined if there was any difference in the accident/incident rate in this group as compared with the Canadian general aviation population standardized to a rate per 100,000 flying hours. The 253 pilots were divided into two groups with Group A having a refractive error outside the range +/- 5.7 D and Group B having a refractive error range of +/- 3.5 to +/- 5.6 D. RESULTS: The Group A rate was within the expected range of accidents and incidents per 100,000 flying hours. The accident/incident rate in Group B was significantly lower than the expected average. CONCLUSION: In conclusion, the Canadian Civil Aviation Medicine Division's policy on granting "flexibility" to applicants with moderate to high refractive errors has not affected adversely the accident or incident rate and therefore has not compromised aviation safety.

Angiotensin-converting enzyme inhibition in myocardial infarction--Part 1: Clinical data.

There is an increasing body of clinical trial evidence to support the use of angiotensin-converting enzyme (ACE) inhibitors in the management of patients following myocardial infarction (MI). Enthusiasm for the use of ACE inhibitors in the acute phase of MI had previously been tempered by the adverse results of an early trial. However, exciting new information is available from several large, randomized studies that has not only quelled those initial concerns but also attests to the efficacy of using this class of medication in the first 24 h after an acute MI. A Canadian National Opinion Leader Symposium was held in November 1995 to review the results of the major ACE inhibitor clinical trials and to discuss key issues and controversies surrounding their use in acute MI. The focus of this paper, the first of two parts, is on the results of the major ACE inhibitor clinical trials.

Angiotensin-converting enzyme inhibition in myocardial infarction--Part 2: Clinical issues and controversies.

Over the past 10 years, several clinical studies have concluded that, in patients already receiving conventional therapies, angiotensin-converting enzyme (ACE) inhibitors further reduce the risk of death following myocardial infarction (MI). Post-MI ACE inhibitors have proven to be effective as long term therapy in high risk patients as well as when used for much shorter periods in a broad patient population. However, while considerable mortality data have been collected, the effects of ACE inhibitors post-MI on other cardiovascular outcomes have not been as well documented. In addition, a number of issues regarding the most effective use of these agents remain unresolved. This paper, the second of two parts, focuses on the clinical issues and controversies surrounding the use of ACE inhibitors following acute MI. The effects of ACE inhibitors on the outcomes of sudden death, nonsudden death, recurrent angina, mitral regurgitation and left ventricular dysfunction are reviewed and potential mechanisms of action are proposed. In addition, ACE inhibitor therapy is discussed in terms of patient selection criteria, choice of agent, optimal dosing regimen, concomitant use of other therapies and relative costs of treatment. Finally, potential mechanisms of action of ACE inhibitors are proposed for each of the outcomes examined.

Managing acute enigmatic chest pain.

The author comments on the report by Dr. Akbar Panju and associates (see pages 541 to 547 of this issue) on patient outcomes associated with a discharge diagnosis of "chest pain not yet diagnosed." Acute chest pain without evidence of cardiac involvement presents a diagnostic challenge for the clinician, particularly in the present climate of cost containment. Esophageal disorders and psychiatric conditions appear to be the most prevalent causes of noncardiac chest pain. Although screening by means of electrocardiography and cardiac enzyme testing may rule out acute ischemia, and other tests may clearly point to a gastrointestinal cause, it is possible for cardiac and gastrointestinal problems to present simultaneously. Understanding and managing persistent chest pain even after a diagnosis has been made continues to challenge clinicians and researchers, and further progress in this area will depend on multidisciplinary collaboration.

Impact of the social environment on blood pressure in women.

A remarkable increase in life expectancy, a decrease in fertility and delayed first birth as well as increased literacy have all contributed to major changes in women's lifestyles and their social environment. Several factors such as level of education, unemployment and low income have been associated in epidemiological studies with elevations in blood pressure. Social support appears to be an important buffer modulating the cardiovascular effects of a variety of stressors. Studies to date suggest that there may be important gender differences in the way socioenvironmental factors affect blood pressure, thus warranting development of intervention strategies directed uniquely at women.

[Development of renal transplantation in the Gdansk center]. / Rozwój transplantacji nerek w osrodku Gdanskim.

The kidney transplantation is one of the renal replacement therapy methods, which prolongs live of the patients with the end stage renal disease for many years. Moreover, this method is well known, safe and not so expensive as dialysotherapy. Our purpose was to present the 15-year activity of the transplantation center in Gdansk. The first renal transplantation took place on the 31st of March 1980 and there have been 137 renal transplantations in Gdansk until now. We can divide the time between the 31st of March 1980 and the end of 1994 into two periods: I from 31.03.80 to 31.12.89 and II from 1991 to 1994. During the first were 46, and during the second were 91 renal transplantations performed. It means that since the second half of 1991 the activity of the center in Gdansk has increased. The graft function was noted in 29 patients (63%) during the first period and in 75 (82%) during the second. The acute graft failure was observed in the most of the cases mentioned above. The 5-year living of the transplanted patients and the dialysed patients is comparable and amounts to 90%. Infections were the main reason of death during the first period, and cardiovascular complications during the second. The 5-year graft's functioning is 60%. Nowadays the results of the kidney transplantation center in Gdansk are good and comparable with the results of other centers in Poland and Europe. Our center, as similar ones in Poland is prepared to extend the kidney transplantation activity. So it is necessary to intensify an effort to gain more organs for transplantations.

What do we really know about secondary prevention after myocardial infarction?

Secondary prevention following acute myocardial infarction begins at the time of the in initial hospitalization. An aggressive approach should focus on appropriate lifestyle changes as well as pharmacotherapy. Smoking cessation, increased physical activity and lipid lowering are key lifestyle objectives, while beta blockade and aspirin should be routinely prescribed for all patients following acute myocardial infarction, unless there are specific contraindications. Improvement in survivorship, prevention of nonfatal reinfarction, regression of atheromatous disease as well as a better quality of life are all proven benefits of secondary prevention.