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1.
J Hypertens ; 38(6): 982-1004, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32371787

RESUMO

DOCUMENT REVIEWERS: Hind Beheiry (Sudan), Irina Chazova (Russia), Albertino Damasceno (Mozambique), Anna Dominiczak (UK), Anastase Dzudie (Cameroon), Stephen Harrap (Australia), Hiroshi Itoh (Japan), Tazeen Jafar (Singapore), Marc Jaffe (USA), Patricio Jaramillo-Lopez (Colombia), Kazuomi Kario (Japan), Giuseppe Mancia (Italy), Ana Mocumbi (Mozambique), Sanjeevi N.Narasingan (India), Elijah Ogola (Kenya), Srinath Reddy (India), Ernesto Schiffrin (Canada), Ann Soenarta (Indonesia), Rhian Touyz (UK), Yudah Turana (Indonesia), Michael Weber (USA), Paul Whelton (USA), Xin Hua Zhang, (Australia), Yuqing Zhang (China).

3.
Hypertension ; 2020 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-32419505

RESUMO

Elevated blood pressure remains the single biggest risk factor contributing to the global burden of disease and mortality. May Measurement Month is an annual global screening campaign aiming to improve awareness of blood pressure at the individual and population level. Adults ({greater than or equal to}18 years) recruited through opportunistic sampling were screened at sites in 92 countries during May 2019. Ideally three blood pressure readings were measured for each participant, and data on lifestyle factors and co-morbidities were collected. Hypertension was defined as a systolic BP {greater than or equal to} 140 mmHg, and/or a diastolic BP {greater than or equal to} 90 mmHg (mean of the second and third readings) or taking antihypertensive medication. When necessary, multiple imputation was used to estimate participants' mean blood pressure. Mixed-effects models were used to evaluate associations between blood pressure and participant characteristics. Of 1,508,130 screenees 482,273 (32.0%) had never had a blood pressure measurement before and 513,337 (34.0%) had hypertension, of whom 58.7% were aware and 54.7% were on antihypertensive medication. Of those on medication, 57.8% were controlled to <140/90 mmHg, and 28.9% to <130/80mmHg. Of all those with hypertension, 31.7% were controlled to <140/90mmHg and 350,825 (23.3%) participants had untreated, or inadequately treated hypertension. Of those taking antihypertensive medication, half were taking only a single drug and 25% reported using aspirin inappropriately. This survey is the largest ever synchronised and standardised contemporary compilation of global blood pressure data. This campaign is needed as a temporary substitute for systematic blood pressure screening in many countries worldwide.

4.
J Ren Nutr ; 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32247648

RESUMO

OBJECTIVE: Sparse data exist on population distributions of serum fibroblast growth factor-23 (FGF23) levels from developing, middle-income economies. FGF23 levels may differ substantially across regions based on differences in diet and urbanization. In a population-based study from North India, we tested the hypothesis that urinary phosphate excretion and FGF23 levels are lower among rural compared with urban participants, and among vegetarian compared with nonvegetarian participants. METHODS: We measured 24-hour urinary phosphate, and serum parathyroid hormone and FGF23 in a subsample of the population-based Cardiometabolic Risk Reduction in South Asia and Indian Council of Medical Research Coronary Heart Disease surveys. We categorized participants according to diet and residence: urban nonvegetarians (n = 70), urban vegetarians (n = 564), and rural vegetarians (n = 558). Using least square means, we compared the groups' 24-hour urinary phosphate (with urban vegetarians as reference) and FGF23 levels after accounting for age, sex, diabetes, and body mass index. RESULTS: Among 1,192 study participants, mean FGF23 was 41 ± 18 pg/mL, median parathyroid hormone was 44 (interquartile range [IQR] 31-60) pg/mL, and median 24-hour urinary phosphate excretion was 419 (IQR: 47-622) mg/day. Urinary phosphate was significantly higher in rural compared with urban vegetarians (median, 503; IQR, 334-543 versus 365; IQR, 199-399 mg/day), but adjusted mean FGF23 levels did not differ across study groups. CONCLUSION: In rural and urban India, urinary phosphate excretion was low, but FGF23 levels did not differ by residence or dietary preference. Homogenously low dietary phosphate intake across different settings and diets may partly explain the lack of differences in FGF23.

5.
J Am Coll Cardiol ; 75(13): 1551-1561, 2020 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-32241371

RESUMO

BACKGROUND: Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). OBJECTIVES: This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. METHODS: The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life-5 Dimensions-5 Level visual analogue scale at 12 weeks. RESULTS: MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). CONCLUSIONS: Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).

6.
Circulation ; 141(10): 800-802, 2020 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-32150471
7.
J Stroke Cerebrovasc Dis ; 29(4): 104670, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32057650

RESUMO

INTRODUCTION: Elevated serum apolipoprotein B and the apolipoprotein B/A1 ratio have been associated with ischemic stroke and intracranial atherosclerotic disease. We sought to assess the relationship between serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio with ischemic stroke subtypes and large artery atherosclerosis location. MATERIALS AND METHODS: We evaluated serum apolipoprotein B and apolipoprotein A1 levels in consecutive, statin-naïve, adult ischemic stroke patients admitted to an academic medical center in southern India. We evaluated for differences in the mean serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio between patients with ischemic stroke attributed to intracranial atherosclerotic disease, extracranial atherosclerotic disease, small vessel disease, and cardioembolism. In secondary analysis, we assessed for differences in these serum apolipoproteins between patients with moderate-severe intracranial atherosclerotic disease and extracranial atherosclerotic disease, irrespective of ischemic stroke subtype. RESULTS: Among the 156 ischemic stroke patients enrolled in this study, there were no significant differences in serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio between patients with distinct ischemic stroke subtypes. No significant differences were found in serum levels of apolipoprotein B, A1 and the apolipoprotein B/A1 ratio between patients with moderate-severe intracranial atherosclerotic disease and moderate-severe extracranial atherosclerotic disease. DISCUSSION: Serum levels of apolipoprotein B and A1 did not differ between ischemic stroke subtypes. Additional studies are needed to validate our findings and to better understand the relationship between serum apolipoproteins and stroke.

8.
BMC Med ; 18(1): 7, 2020 Jan 24.
Artigo em Inglês | MEDLINE | ID: mdl-31973762

RESUMO

BACKGROUND: Low- and middle-income countries now experience the highest prevalence and mortality rates of cardiovascular disease. MAIN TEXT: While improving the availability and delivery of proven, effective therapies will no doubt mitigate this burden, we posit that studies evaluating cardiovascular disease risk factors, management strategies and service delivery, in diverse settings and diverse populations, are equally critical to improving outcomes in low- and middle-income countries. Focusing on examples drawn from four cardiovascular diseases - coronary artery disease, stroke, diabetes and kidney disease - we argue that ethnicity, culture and context matter in determining the risk factors for disease as well as the comparative effectiveness of medications and other interventions, particularly diet and lifestyle interventions. CONCLUSION: We believe that a host of cohort studies and randomized control trials currently being conducted or planned in low- and middle-income countries, focusing on previously understudied race/ethnic groups, have the potential to increase knowledge about the cause(s) and management of cardiovascular diseases across the world.

9.
Am J Prev Med ; 58(2): 302-312, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31959324

RESUMO

INTRODUCTION: Most Indians are vegetarian or eat very little meat, which could imply high potassium intake. Because a high-potassium diet could counterbalance the adverse health effects of high-sodium intake, this study aimed to describe potassium relative to sodium intake and investigate the relationship between blood pressure and potassium intake relative to sodium intake in rural and urban India. METHODS: Investigators collected 24-hour urines from 1,445 participants in a subset of 2 population-based surveys in North India in 2012-2013. Standardized questionnaires were used to collect information on demography, behaviors (tobacco, alcohol consumption, physical activity, and diet [food frequency and 24-hour recall]), and medical history. After evaluating expected versus measured creatinine excretion, the authors calculated median urine potassium excretion and sodium/potassium ratio, according to sex and urban or rural residence, and estimated least square means for the urine measures by participant demographics and comorbidities, after accounting for caloric intake. Two-year blood pressure follow-up data were available in the urban study, and ANCOVA regression was used to determine the association with urine measures. All the statistical analyses of the data were done in January 2019. RESULTS: Acceptable 24-hour urine collections were available in 1,397 participants (rural, n=730). Median urine potassium excretions were 1,492 (IQR=1,012-2,063) and 975 (615-1,497) mg/day; sodium/potassium ratios met the recommended target of <1 in 2.9% rural and 6.6% urban participants. Rural participants did not have higher potassium or lower (better) sodium/potassium ratios when diagnosed with hypertension or other cardiovascular conditions. Higher potassium excretion was associated with lower blood pressure during follow-up among the urban participants (mean systolic blood pressure, 129 vs 133 mm Hg in highest vs lowest potassium excretion tertiles; p=0.029). CONCLUSIONS: Low potassium intake in India warrants dietary policies promoting intake of potassium-rich foods to improve heart health. This approach may be more acceptable than programs focused on sodium reduction alone.

10.
Artigo em Inglês | MEDLINE | ID: mdl-31936772

RESUMO

Aims: In this study, we aimed to estimate cross-sectional associations of fish or shellfish consumption with diabetes and glycemia in three South Asian mega-cities. Methods: We analyzed baseline data from 2010-2011 of a cohort (n = 16,287) representing the population ≥20 years old that was neither pregnant nor on bedrest from Karachi (unweighted n = 4017), Delhi (unweighted n = 5364), and Chennai (unweighted n = 6906). Diabetes was defined as self-reported physician-diagnosed diabetes, fasting plasma glucose ≥126 mg/dL (7.0 mmol/L), or glycated hemoglobin A1c (HbA1c) ≥6.5% (48 mmol/mol). We estimated adjusted and unadjusted odds ratios for diabetes using survey estimation logistic regression for each city, and differences in glucose and HbA1c using survey estimation linear regression for each city. Adjusted models controlled for age, gender, body mass index, waist-height ratio, sedentary lifestyle, educational attainment, tobacco use, an unhealthy diet index score, income, self-reported physician diagnosis of high blood pressure, and self-reported physician diagnosis of high cholesterol. Results: The prevalence of diabetes was 26.7% (95% confidence interval: 24.8, 28.6) in Chennai, 36.7% (32.9, 40.5) in Delhi, and 24.3% (22.0, 26.6) in Karachi. Fish and shellfish were consumed more frequently in Chennai than in the other two cities. In Chennai, the adjusted odds ratio for diabetes, comparing more than weekly vs. less than weekly fish consumption, was 0.81 (0.61, 1.08); in Delhi, it was 1.18 (0.87, 1.58), and, in Karachi, it was 1.30 (0.94, 1.80). In Chennai, the adjusted odds ratio of prevalent diabetes among persons consuming shellfish more than weekly versus less than weekly was 1.08 (95% CI: 0.90, 1.30); in Delhi, it was 1.35 (0.90, 2.01), and, in Karachi, it was 1.68 (0.98, 2.86). Conclusions: Both the direction and the magnitude of association between seafood consumption and glycemia may vary by city. Further investigation into specific locally consumed seafoods and their prospective associations with incident diabetes and related pathophysiology are warranted.

11.
PLoS One ; 15(1): e0228269, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31995593

RESUMO

BACKGROUND: Dyslipidemia and abnormal glycemic traits are leading causes of morbidity and mortality. Although the association between the two traits is well established, there still exists a gap in the evidence for the direction of causality. OBJECTIVE: This study aimed to examine the direction of the causal relationship between lipids and glycemic traits in an Indian population using bidirectional Mendelian randomization (BMR). METHODS: The BMR analysis was conducted on 4900 individuals (2450 sib-pairs) from the Indian Migration Study. Instrument variables were generated for each lipid and glycemic trait (fasting insulin, fasting glucose, HOMA-IR, HOMA-ß, LDL-cholesterol, HDL-cholesterol, total cholesterol and triglycerides) to examine the causal relationship by applying two-stage least squares (2SLS) regression in both directions. RESULTS: Lipid and glycemic traits were found to be associated observationally, however, results from 2SLS showed that only triglycerides, defined by weighted genetic risk score (wGRS) of 3 SNPs (rs662799 at APOAV, rs780094 at GCKR and rs4420638 at APOE/C1/C4), were observed to be causally effecting 1.15% variation in HOMA-IR (SE = 0.22, P = 0.010), 1.53% in HOMA- ß (SE = 0.21, P = 0.001) and 1.18% in fasting insulin (SE = 0.23, P = 0.009). No evidence for a causal effect was observed in the reverse direction or between any other lipid and glycemic traits. CONCLUSION: The study findings suggest that triglycerides may causally impact various glycemic traits. However, the findings need to be replicated in larger studies.


Assuntos
Glicemia/análise , Lipídeos/sangue , Característica Quantitativa Herdável , Adulto , Colesterol/sangue , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Estudos Transversais , Feminino , Técnicas de Genotipagem , Humanos , Índia , Insulina/sangue , Resistência à Insulina/genética , Análise dos Mínimos Quadrados , Masculino , Análise da Randomização Mendeliana , Polimorfismo de Nucleotídeo Único , Triglicerídeos/sangue
12.
Indian J Ophthalmol ; 68(Suppl 1): S67-S69, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31937734

RESUMO

In India, more than 72 million people have diabetes. Diabetic retinopathy (DR), a vision-threatening complication of people with diabetes, is an important cause of avoidable blindness. The delay in the detection of DR is due to lack of awareness and shortage of ophthalmologists trained in the management of DR. With this background, in 2015, we initiated a capacity-building program "Certificate Course in Evidence Based Management of Diabetic Retinopathy (CCDR)" with an objective to build the skills and core competencies of the physicians across India in the management of diabetes and DR. The program has completed four cycles and 578 physicians have been trained. The course elicited an excellent response, which reflects the much-felt need for skill improvement in DR diagnosis and management for physicians in India. This model demonstrates an innovative modality to address DR-related avoidable blindness in a resource-restraint country like India.

13.
Obes Rev ; 21(1): e12938, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31701653

RESUMO

The Lancet Commission on Obesity (LCO), also known as the "syndemic commission," states that radical changes are required to harness the common drivers of "obesity, undernutrition, and climate change." Urban design, land use, and the built environment are few such drivers. Holding individuals responsible for obesity detracts from the obesogenic built environments. Pedestrian priority and dignity, wide pavements with tree canopies, water fountains with potable water, benches for the elderly at regular intervals, access to open-green spaces within 0.5-km radius and playgrounds in schools are required. Facilities for physical activity at worksite, prioritization of staircases and ramps in building construction, redistribution of land use, and access to quality, adequate capacity, comfortable, and well-networked public transport, which are elderly and differently abled sensitive with universal design are some of the interventions that require urgent implementation and monitoring. An urban barometer consisting of valid relevant indicators aligned to the sustainable development goals (SDGs), UN-Habitat-3 and healthy cities, should be considered a basic human right and ought to be mounted for purposes of surveillance and monitoring. A "Framework Convention on Built Environment and Physical Activity" needs to be taken up by WHO and the UN for uptake and implementation by member countries.

14.
Int J Behav Nutr Phys Act ; 16(1): 134, 2019 12 19.
Artigo em Inglês | MEDLINE | ID: mdl-31856826

RESUMO

BACKGROUND: Adults in urban areas spend almost 77% of their waking time being inactive at workplaces, which leaves little time for physical activity. The aim of this systematic review and meta-analysis was to synthesize evidence for the effect of workplace physical activity interventions on the cardio-metabolic health markers (body weight, waist circumference, body mass index (BMI), blood pressure, lipids and blood glucose) among working adults. METHODS: All experimental studies up to March 2018, reporting cardio-metabolic worksite intervention outcomes among adult employees were identified from PUBMED, EMBASE, COCHRANE CENTRAL, CINAHL and PsycINFO. The Cochrane Risk of Bias tool was used to assess bias in studies. All studies were assessed qualitatively and meta-analysis was done where possible. Forest plots were generated for pooled estimates of each study outcome. RESULTS: A total of 33 studies met the eligibility criteria and 24 were included in the meta-analysis. Multi-component workplace interventions significantly reduced body weight (16 studies; mean diff: - 2.61 kg, 95% CI: - 3.89 to - 1.33) BMI (19 studies, mean diff: - 0.42 kg/m2, 95% CI: - 0.69 to - 0.15) and waist circumference (13 studies; mean diff: - 1.92 cm, 95% CI: - 3.25 to - 0.60). Reduction in blood pressure, lipids and blood glucose was not statistically significant. CONCLUSIONS: Workplace interventions significantly reduced body weight, BMI and waist circumference. Non-significant results for biochemical markers could be due to them being secondary outcomes in most studies. Intervention acceptability and adherence, follow-up duration and exploring non-RCT designs are factors that need attention in future research. Prospero registration number: CRD42018094436.


Assuntos
Glicemia , Pressão Sanguínea/fisiologia , Índice de Massa Corporal , Tamanho Corporal/fisiologia , Exercício Físico/psicologia , Lipídeos/sangue , Local de Trabalho/psicologia , Adulto , Humanos , Comportamento Sedentário
15.
Environ Int ; 133(Pt A): 105089, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31654984

RESUMO

BACKGROUND: Previous epidemiological studies, largely conducted in high-income countries and cross-sectional, have suggested a relatively strong association between exposure to dichlorodiphenyldichloroethylene (DDE), a metabolite of the pesticide dichlorodiphenyltrichloroethane (DDT), and type 2 diabetes. DDT is widely used in India and the prevalence of type 2 diabetes there is increasing, but the association between these factors has not been explored to date. OBJECTIVE: The objective was to estimate the association of the p,p' isomer of DDE with incident type 2 diabetes in India. METHODS: A nested case-control study was conducted in a representative prospective cohort of adults from two cities in India. Participants were enrolled in 2010-11 (n = 12,271) and followed for annual assessment of chronic diseases including type 2 diabetes. Baseline plasma samples from incident cases of diabetes (n = 193) and sex-city-matched controls (n = 323) were selected for analysis of p,p-DDE. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression. RESULTS: At baseline, cases had higher p,p-DDE concentrations: geometric mean (95% CI) 330 (273-399) ng/g lipid compared to 223 (189-262) ng/g lipid among controls. Delhi participants had higher p,p-DDE concentrations: 579 (521-643) ng/g lipid compared to 122 (102-145) ng/g lipid in Chennai. In unadjusted models, being in the highest versus lowest quartile of p,p-DDE was associated with a more than doubling of the odds of diabetes: unadjusted OR (95% CI), 2.30 (1.19, 4.43). However, this effect was no longer significant after adjustment for age: adjusted (95% CI), 0.97 (0.46, 2.06). DISCUSSION: Results suggest that levels of p,p'-DDE in Delhi are exceptionally high, but we did not observe a significant association between p,p-DDE and incident type 2 diabetes. As this is the first study to evaluate this association in India, more studies are needed to inform our understanding of the association in this context, including potential routes of exposure.


Assuntos
DDT/toxicidade , Diabetes Mellitus Tipo 2/induzido quimicamente , Diclorodifenil Dicloroetileno/sangue , Praguicidas/toxicidade , Adulto , Estudos de Casos e Controles , Estudos de Coortes , DDT/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/epidemiologia , Diclorodifenil Dicloroetileno/efeitos adversos , Feminino , Humanos , Incidência , Índia/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Praguicidas/sangue , Estudos Prospectivos
16.
Lancet Glob Health ; 7(10): e1359-e1366, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31477545

RESUMO

BACKGROUND: Elevated blood pressure incurs a major health and economic burden, particularly in low-income and middle-income countries. The Triple Pill versus Usual Care Management for Patients with Mild-to-Moderate Hypertension (TRIUMPH) trial showed a greater reduction in blood pressure in patients using fixed-combination, low-dose, triple-pill antihypertensive therapy (consisting of amlodipine, telmisartan, and chlorthalidone) than in those receiving usual care in Sri Lanka. We aimed to assess the cost-effectiveness of the triple-pill strategy. METHODS: We did a within-trial (6-month) and modelled (10-year) economic evaluation of the TRIUMPH trial, using the health system perspective. Health-care costs, reported in 2017 US dollars, were determined from trial records and published literature. A discrete-time simulation model was developed, extrapolating trial findings of reduced systolic blood pressure to 10-year health-care costs, cardiovascular disease events, and mortality. The primary outcomes were the proportion of people reaching blood pressure targets (at 6 months from baseline) and disability-adjusted life-years (DALYs) averted (at 10 years from baseline). Incremental cost-effectiveness ratios were calculated to estimate the cost per additional participant achieving target blood pressure at 6 months and cost per DALY averted over 10 years. FINDINGS: The triple-pill strategy, compared with usual care, cost an additional US$9·63 (95% CI 5·29 to 13·97) per person in the within-trial analysis and $347·75 (285·55 to 412·54) per person in the modelled analysis. Incremental cost-effectiveness ratios were estimated at $7·93 (95% CI 6·59 to 11·84) per participant reaching blood pressure targets at 6 months and $2842·79 (-28·67 to 5714·24) per DALY averted over a 10-year period. INTERPRETATION: Compared with usual care, the triple-pill strategy is cost-effective for patients with mild-to-moderate hypertension. Scaled up investment in the triple pill for hypertension management in Sri Lanka should be supported to address the high population burden of cardiovascular disease. FUNDING: Australian National Health and Medical Research Council.

17.
Indian Heart J ; 71(3): 235-241, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31543196

RESUMO

OBJECTIVE: Heart failure is a leading cause of death worldwide and in India, yet the qualitative data regarding heart failure care are limited. To fill this gap, we studied the facilitators and barriers of heart failure care in Kerala, India. METHODS AND RESULTS: During January 2018, we conducted a qualitative study using in-depth, semi-structured interviews with 21 health-care providers and quality administrators from 8 hospitals in Kerala to understand the context, facilitators, and barriers of heart failure care. We developed a theoretical framework using iteratively developed codes from these data to identify 6 key themes of heart failure care in Kerala: (1) need for comprehensive patient and family education on heart failure; (2) gaps between guideline-directed clinical care for heart failure and clinical practice; (3) national hospital accreditation contributing to a culture of systematically improving quality and safety of in-hospital care; (4) limited system-level attention toward improving heart failure care compared with other cardiovascular conditions; (5) application of existing personnel and technology to improve heart failure care; and (6) longitudinal and recurrent costs as barriers for optimal heart failure care. CONCLUSIONS: Key themes emerged regarding heart failure care in Kerala in the context of a health system that is increasingly emphasizing health-care quality and safety. Targeted in-hospital quality improvement interventions for heart failure should account for these themes to improve cardiovascular outcomes in the region.


Assuntos
Atitude do Pessoal de Saúde , Administradores de Instituições de Saúde , Pessoal de Saúde , Acesso aos Serviços de Saúde , Insuficiência Cardíaca/terapia , Educação em Saúde , Humanos , Índia , Entrevistas como Assunto , Pesquisa Qualitativa , Melhoria de Qualidade
18.
BMJ Glob Health ; 4(5): e001644, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31544000

RESUMO

Introduction: Although deaths due to chronic kidney disease (CKD) have doubled over the past two decades, few data exist to inform screening strategies for early detection of CKD in low-income and middle-income countries. Methods: Using data from three population-based surveys in India, we developed a prediction model to identify a target population that could benefit from further CKD testing, after an initial screening implemented during home health visits. Using data from one urban survey (n=8698), we applied stepwise logistic regression to test three models: one comprised of demographics, self-reported medical history, anthropometry and point-of-care (urine dipstick or capillary glucose) tests; one with demographics and self-reported medical history and one with anthropometry and point-of-care tests. The 'gold-standard' definition of CKD was an estimated glomerular filtration rate <60 mL/min/1.73 m2 or urine albumin-to-creatinine ratio ≥30 mg/g. Models were internally validated via bootstrap. The most parsimonious model with comparable performance was externally validated on distinct urban (n=5365) and rural (n=6173) Indian cohorts. Results: A model with age, sex, waist circumference, body mass index and urine dipstick had a c-statistic of 0.76 (95% CI 0.75 to 0.78) for predicting need for further CKD testing, with external validation c-statistics of 0.74 and 0.70 in the urban and rural cohorts, respectively. At a probability cut-point of 0.09, sensitivity was 71% (95% CI 68% to 74%) and specificity was 70% (95% CI 69% to 71%). The model captured 71% of persons with CKD and 90% of persons at highest risk of complications from untreated CKD (ie, CKD stage 3A2 and above). Conclusion: A point-of-care CKD screening strategy using three simple measures can accurately identify high-risk persons who require confirmatory kidney function testing.

19.
BMJ Open ; 9(9): e027134, 2019 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-31501100

RESUMO

OBJECTIVE: Recent data on sustained hypertension and obesity among school-going children and adolescents in India are limited. This study evaluates the prevalence of sustained hypertension and obesity and their risk factors among urban and rural adolescents in northern India. SETTING: A school-based, cross-sectional survey was conducted in the urban and rural areas of Ludhiana, Punjab, India using standardised measurement tools. PARTICIPANTS: A total of 1959 participants aged 11-17 years (urban: 849; rural: 1110) were included in this school-based survey. PRIMARY AND SECONDARY OUTCOME MEASURES: To measure sustained hypertension among school children, two distinct blood pressure (BP) measurements were recorded at an interval of 1 week. High BP was defined and classified into three groups as recommended by international guidelines: (1) normal BP: <90th percentile compared with age, sex and height percentile in each age group; (2) prehypertension: BP=90th-95th percentile; and (3) hypertension: BP >95th percentile. The Indian Academy of Pediatrics classification was used to define underweight, normal, overweight and obesity as per the body mass index (BMI) for specific age groups. RESULTS: The prevalence of sustained hypertension among rural and urban areas was 5.7% and 8.4%, respectively. The prevalence of obesity in rural and urban school children was 2.7% and 11.0%, respectively. The adjusted multiple regression model found that urban area (relative risk ratio (RRR): 1.7, 95% CI 1.01 to 2.93), hypertension (RRR: 7.4, 95% CI 4.21 to 13.16) and high socioeconomic status (RRR: 38.6, 95% CI 16.54 to 90.22) were significantly associated with an increased risk of obesity. However, self-reported regular physical activity had a protective effect on the risk of obesity among adolescents (RRR: 0.4, 95% CI 0.25 to 0.62). Adolescents who were overweight (RRR: 2.66, 95% CI 1.49 to 4.40) or obese (RRR: 7.21, 95% CI 4.09 to 12.70) and reported added salt intake in their diet (RRR: 4.90, 95% CI 2.83 to 8.48) were at higher risk of hypertension. CONCLUSION: High prevalence of sustained hypertension and obesity was found among urban school children and adolescents in a northern state in India. Hypertension among adolescents was positively associated with overweight and obesity (high BMI). Prevention and early detection of childhood obesity and high BP should be strengthened to prevent the risk of cardiovascular diseases in adults.

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