Faculty Bibliography

The World Health Organization estimates the existence of a global shortage of over 4 million health-care workers. Given the growing global burden of cardiovascular disease (CVD), the shortfall in global human resources for health (HRH) is probably even greater than predicted. A critical challenge going forward is to determine how to integrate CVD-related human resource needs into the overall global HRH agenda. We describe the CVD implications of core HRH objectives, including coverage, motivation, and competence, in addition to issues such as health-care worker migration and the need for input from multiple stakeholders to successfully address the current problems. We emphasize gaps in knowledge regarding HRH for global CVD-related care and research opportunities. In light of the current global epidemiologic transition from communicable to noncommunicable diseases, now is the time for the global health community to focus on CVD-related human resource needs.

Background: In a previous study we derived high-risk ECG features associated with adverse cardiovascular events (ACVEs) in emergency department (ED) patients with acute drug overdose. Objectives: We aimed to externally validate that ischemia, non- sinus rhythm, and ectopy are associated with ACVE in this population. Methods: This prospective cohort study evaluated consecutive ED patients with acute drug overdose over 5 months at two urban teaching hospitals uninvolved in the original derivation cohort. Data included demographics, history, vital signs, and elements of the initial ECG (rhythm, intervals, ischemia, infarction), interpreted by a masked cardiologist. ECG evidence of ischemia and infarction were defined according to AHA criteria. In-hospital ACVE was defined by composite outcome: shock (vasopressors), myocardial injury (troponin I > 0.09ng/mL), severe dysrhythmia (VT/VF), or cardiac arrest (loss of pulse). Results: of 238 initially screened, 81 were excluded (30 age <18, 41 no ECG, 2 alternate diagnosis, 8 insufficient data), leaving 157 for analysis (48% female, mean age 40.8, 14% prior coronary disease). Most common drug classes ingested were acetamino- phen-containing (24%), sympathomimetics (20%), and opioids (19%). Included patients had mean pulse=84/minute (range 32-156), mean QRS=90 msec (range 68-174), mean QTc=433 msec (range 296-704), while 17% had ischemia, 9% infarction, and 4% ectopy. In-hospital ACVE occurred in 11 patients (7%), of whom 18% had prior coronary disease (p=NS). There were 9 myocardial injury, 3 shock, 2 dysrhythmia, and 3 cardiac arrests. Ischemia (OR 15.2, p<0.001), non-sinus rhythm (OR 8.6, p<0.01), and ectopy (OR 7.4, p<0.05) were highly associated with ACVE, while QRS, QTc, and infarction were not significantly predictive. Conclusion: This study validates the predictive utility of high- risk ECG features for ED patients with acute drug overdose. A screening ECG may be an important tool to evaluate in-hospital prognosis for acute drug overdose

OBJECTIVE:Cardiovascular diseases (CVD) are a major cause of mortality and morbidity in Poland. Data on risk factors of CVD in this country are limited. The presented study investigated risk factors of self-reported CVD within the Polish- Norwegian Study (PONS). METHODS:PONS is an ongoing prospective study in Poland. The data used was provided by 3,853 participants, aged 45-64, during baseline interviews. RESULTS:Prevalence of chronic diseases among participants was as follows: hypertension, 38.4%; diabetes, 5.9%; and CVD, 11.0%. There was no association between CVD and gender and place of residence. CVD was associated with ever-smoking (OR= 1.25; 95% CI: 1.00-1.55), whereas there was an inverse association with alcohol drinking in the year preceding enrolment in the study (OR= 0.50; 95% CI: 0.39-0.63). CVD was associated with body mass index (BMI), as well as with measures of abdominal adiposity, in the following order: waist to height ratio>waist circumference>waist to hip ratio; however, none of these measures showed a stronger association with CVD than BMI. Both hypertension (OR= 1.33; 95% CI: 1.05-1.68) and diabetes (OR= 1.33; 95% CI: 1.05-1.68) were associated with CVD in adjusted models. CONCLUSIONS:This study shows the association between several risk factors and prevalence of self-reported CVD and provides information about distribution of those factors among an adult population in Poland. The results of the ongoing PONS study in a prospective setting will provide more accurate risk estimates for the observed associations, as well as risk estimates for other risk factors of CVD, including dietary factors, and attributable risks for various factors.

OBJECTIVES/OBJECTIVE:To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could replace clinic-based HIV care. DESIGN/METHODS:Prospective cluster randomized controlled clinical trial. SETTING/METHODS:Villages surrounding 1 rural clinic in western Kenya. SUBJECTS/METHODS:HIV-infected adults clinically stable on antiretroviral therapy (ART). INTERVENTION/METHODS:The intervention group received monthly Personal Digital Assistant supported home assessments by PLWAs with clinic appointments every 3 months. The control group received standard of care monthly clinic visits. MAIN OUTCOMES MEASURED/METHODS:Viral load, CD4 count, Karnofsky score, stability of ART regimen, opportunistic infections, pregnancies, and number of clinic visits. RESULTS:After 1 year, there were no significant intervention-control differences with regard to detectable viral load, mean CD4 count, decline in Karnofsky score, change in ART regimen, new opportunistic infection, or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P < 0.001). CONCLUSIONS:Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.

BACKGROUND:A major obstacle facing many lower-income countries in establishing and maintaining HIV treatment programmes is the scarcity of trained health care providers. To address this shortage, the World Health Organization has recommend task shifting to HIV-infected peers. METHODS:We designed a model of HIV care that utilizes HIV-infected patients, community care coordinators (CCCs), to care for their clinically stable peers with the assistance of preprogrammed personal digital assistants (PDAs). Rather than presenting for the standard of care, monthly clinic visits, in this model, patients were seen every three months in clinics and monthly by their CCCs in the community during the interim two months. This study was conducted in Kosirai Division, western Kenya, where eight of the 24 sub-locations (defined geographic areas) within the division were randomly assigned to the intervention with the remainder used as controls.Prior to entering the field, CCCs underwent intensive didactic training and mentoring related to the assessment and support of HIV patients, as well as the use of PDAs. PDAs were programmed with specific questions and to issue alerts if responses fell outside of pre-established parameters. CCCs were regularly evaluated in six performance areas. An impressionistic analysis on the transcripts from the monthly group meetings that formed the basis of the continuous feedback and quality improvement programme was used to assess this model. RESULTS:All eight of the assigned CCCs successfully passed their training and mentoring, entered the field and remained active for the two years of the study. On evaluation of the CCCs, 89% of their summary scores were documented as superior during Year 1 and 94% as superior during Year 2. Six themes emerged from the impressionistic analysis in Year 1: confidentiality and "community" disclosure; roles and responsibilities; logistics; clinical care partnership; antiretroviral adherence; and PDA issues. At the end of the trial, of those patients not lost to follow up, 64% (56 of 87) in the intervention and 52% (58 of 103) in the control group were willing to continue in the programme (p = 0.26). CONCLUSION/CONCLUSIONS:We found that an antiretroviral treatment delivery model that shifted patient monitoring and antiretroviral dispensing tasks into the community by HIV-infected patients was both acceptable and feasible. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov ID NCT00371540.

The cardiovascular community has witnessed an important transition over the past two decades-from awareness of the global nature of the cardiovascular disease epidemic, to identification of interventions to control it, and now to a resolution that global action is urgently required.

A debate has emerged as to what should be the 'appropriate' cardiovascular agenda for sub-Saharan Africa. This Clinical Advance article reviews a recent study by Sliwa et al., which describes patients with newly diagnosed cardiovascular disease (CVD) presenting to a tertiary-care center in South Africa. The most common conditions among these patients were hypertension, heart failure, valvular heart disease, and coronary artery disease. Atherosclerotic risk factors were widely prevalent--only 13% of patients had no risk factors at all. Furthermore, a substantial proportion of patients presented at an advanced stage of disease. This study, which used state-of-the-art diagnostic technology, is an important addition to the growing database of information indicating that CVD in sub-Saharan Africa spans the spectrum from 'traditional', nonischemic etiologies to 'modern' diseases of lifestyle. The societal response to this diverse epidemiology should be similarly multifaceted. Moreover, efforts should be made to improve primary-care screening, early detection and treatment of CVD, and prompt referral of patients at early stages of disease.

We present the case of a 67-year-old woman with chronic cor pulmonale. She never smoked tobacco and had no other risk factors for pulmonary disease. In developed nations, chronic obstructive lung disease and cor pulmonale are overwhelmingly associated with tobacco use. However, indoor air pollution, most commonly due to burning of solid biomass fuel such as wood, can cause similar clinical syndromes. At our teaching hospital, there is an epidemic of chronic cor pulmonale among nonsmoking women. We attribute this sex predilection to women's greater exposure to wood smoke. Physicians must be cognizant of its risks and counsel patients on prevention strategies such as improved ventilation.