A paradigm shift for socioeconomic justice and health: from focusing on inequalities to aiming at sustainable equity

OBJECTIVES: To measure the \u27best possible health for all\u27, incorporating sustainability, and to establish the magnitude of global health inequity. STUDY DESIGN: Observational, retrospective. METHODS: We identified countries with three criteria: (1) a healthy population-life expectancy above world average; (2) living conditions feasible to replicate worldwide-per-capita gross domestic product (GDP-pc) below the world average; and (3) sustainability-per-capita carbon dioxide emissions lower than the planetary pollution boundary. Using these healthy, feasible, and sustainable (HFS) countries as the gold standard, we estimated the burden of global health inequity (BGHiE) in terms of excess deaths, analyzing time-trends (1950-2012) by age, sex, and geographic location. Finally, we defined a global income \u27equity zone\u27 and quantified the economic gap needed to achieve global sustainable health equity. RESULTS: A total of 14 countries worldwide met the HFS criteria. Since 1970, there has been a BGHiE of approximately 17 million avoidable deaths per year ( approximately 40% of all deaths), with 36 life-years-lost per excess death. Young children and women bore a higher BGHiE, and, in recent years, the highest proportion of avoidable deaths occurred in Africa, India, and the Russian Federation. By 2012, the most efficient HFS countries had a GDP-pc/year of USD$2,165, which we proposed as the lower equity zone threshold. The estimated USD$2.58 trillion economic gap represents 3.6% of the world\u27s GDP-twenty times larger than current total global foreign aid. CONCLUSIONS: Sustainable health equity metrics provide a benchmark tool to guide efforts toward transforming overall living conditions, as a means to achieve the \u27best possible health for all.\u2

Association between Depression and C-Reactive Protein

Objective. Depression has been associated with increased cardiovascular disease risk, and a depression-related elevation of high sensitivity C-reactive protein (hs-CRP) has been proposed as a possible mechanism. The objective of this paper is to examine association between depression and high sensitivity C-reactive protein (hs-CRP). Methods. Subjects consisted of 508 healthy adults (mean age 48.5 years; 49% women, 88% white) residing in central Massachusetts. Data were collected at baseline and at quarterly intervals over a one-year period per individual. Multivariable linear mixed models were used to assess the association for the entire sample and by gender. Results. The mean Beck Depression Inventory score was 5.8 (standard deviation (SD) 5.4; median 4.3), and average serum hs-CRP was 1.8 mg/L (SD 1.7; median 1.2). Results from the multivariable linear mixed models show that individuals with higher depression scores have higher levels of hs-CRP. Analyses by gender show persistence of an independent association among women, but not among men. Body mass index (BMI = weight(kg)/height(m)2) appears to be a partial mediator of this relationship. Conclusion. Depression score was correlated to hs-CRP levels in women. Further studies are required to elucidate the biological mechanisms underlying these associations and their implications

Seasonal variation in food intake, physical activity, and body weight in a predominantly overweight population

OBJECTIVE: To describe seasonal variation in food intake, physical activity, and body weight in a predominantly overweight population. DESIGN: A longitudinal observational study. SETTING: Most of the study participants were recruited from a health maintenance organization (HMO) in central Massachusetts, USA. Additional individuals of Hispanic descent were recruited from outside of the HMO population to increase the ethnic diversity of this sample. SUBJECTS: Data from 593 participants, aged 20-70, were used for this investigation. Each participant was followed quarterly (five sampling points: baseline and four consecutive quarters) for 1-year period. Body weight measurements and three 24-h dietary and physical activity recalls were obtained on randomly selected days (including 2 weekdays and 1 weekend day) per quarter. Sinusoidal regression models were used to estimate peak-to-trough amplitude and phase of the peaks. RESULTS: Daily caloric intake was higher by 86 kcal/day during the fall compared to the spring. Percentage of calories from carbohydrate, fat and saturated fat showed slight seasonal variation, with a peak in the spring for carbohydrate and in the fall for total fat and saturated fat intake. The lowest physical activity level was observed in the winter and the highest in the spring. Body weight varied by about 1/2 kg throughout the year, with a peak in the winter (P\u3c0.001 winter versus summer). Greater seasonal variation was observed in subjects who were male, middle aged, nonwhite, and less educated. CONCLUSIONS: Although there is seasonal variation in diet, physical activity and body weight, the magnitude of the change is generally small in this population. SPONSORSHIP: US National Heart, Lung and Blood Institute

Rents, knowledge and neo-structuralism: transforming the productive matrix in Ecuador

This paper explores the relationship between ground rent, production and knowledge in Ecuador’s neo-structuralist, state-led project to transform the productive matrix. Based upon insights from the Marxian approach to the critique of political economy, we interrogate how neo-structuralism has conceptualised the relationship between ‘natural resource income’ and ‘knowledge-based’ economic development. The paper argues that a rent-theoretical perspective, which takes seriously the regional unfolding of uneven geographical development in Latin America, can highlight the limits of a national development plan conceived according to the logic of Schumpeterian efficiency. In doing so, the paper identifies the contradictory relationship between natural resource exports, state-led ‘knowledge’-based development and capital accumulation. On this basis the paper offers a historically and empirically informed critical analysis of selective import substitution industrialisation and vanguard science and technology strategies designed to transition Ecuador away from primary resource dependence

The diversity and evolution of pollination systems in large plant clades: Apocynaceae as a case study

Background and Aims Large clades of angiosperms are often characterized by diverse interactions with pollinators, but how these pollination systems are structured phylogenetically and biogeographically is still uncertain for most families. Apocynaceae is a clade of >5300 species with a worldwide distribution. A database representing >10 % of species in the family was used to explore the diversity of pollinators and evolutionary shifts in pollination systems across major clades and regions. Methods The database was compiled from published and unpublished reports. Plants were categorized into broad pollination systems and then subdivided to include bimodal systems. These were mapped against the five major divisions of the family, and against the smaller clades. Finally, pollination systems were mapped onto a phylogenetic reconstruction that included those species for which sequence data are available, and transition rates between pollination systems were calculated. Key Results Most Apocynaceae are insect pollinated with few records of bird pollination. Almost three-quarters of species are pollinated by a single higher taxon (e.g. flies or moths); 7 % have bimodal pollination systems, whilst the remaining approx. 20 % are insect generalists. The less phenotypically specialized flowers of the Rauvolfioids are pollinated by a more restricted set of pollinators than are more complex flowers within the Apocynoids + Periplocoideae + Secamonoideae + Asclepiadoideae (APSA) clade. Certain combinations of bimodal pollination systems are more common than others. Some pollination systems are missing from particular regions, whilst others are over-represented. Conclusions Within Apocynaceae, interactions with pollinators are highly structured both phylogenetically and biogeographically. Variation in transition rates between pollination systems suggest constraints on their evolution, whereas regional differences point to environmental effects such as filtering of certain pollinators from habitats. This is the most extensive analysis of its type so far attempted and gives important insights into the diversity and evolution of pollination systems in large clades

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. // Methods: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. // Findings: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. // Interpretation: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Fitness in Young Adults as an Independent Predictor of Risk for Cardiovascular Disease

Comment on: Association of Fitness in Young Adulthood With Survival and Cardiovascular Risk: The Coronary Artery Risk Development in Young Adults (CARDIA) Study. [JAMA Intern Med. 2016

Barriers to preventive interventions for coronary heart disease

Many barriers exist to the delivery of preventive services by cardiologists and other physicians. Appropriate training and the development of supportive infrastructures can effectively overcome these barriers. In addition, institutional priorities must change to encourage such efforts. Cardiologists must continue to recognize the importance of risk-factor modification, and training programs in cardiology should teach appropriate counseling techniques, the use of risk-factor-lowering pharmacologic agents, and the manner in which cardiologists should interface with dietitians and other ancillary personnel [77]. In addition, it is important to recognize and teach, both didactically and by example, that counseling patients and carrying out long-term preventive interventions can be as gratifying and interesting as performing dramatic procedures that, although valuable and rewarding, take place at a very late point in the patient\u27s clinical course, a point that might have been averted by greater attention to risk-factor modification. Increasingly, the public and governmental agencies are becoming involved in encouraging such an approach [66], and health care provider groups [78] and organizations [67] are also facilitating the development of a more comprehensive approach to the delivery of preventive intervention [79]

Limited English Proficiency and Trajectories of Depressive Symptoms Among Mexican American Older Adults

Background and Objectives: This study examined the effect of limited English proficiency (LEP) on trajectories of depressive symptoms among Mexican American older adults in the United States. Research Design and Methods: The sample was drawn from Waves 1 to 6 (1993–2007) of the Hispanic Established Population for Epidemiological Studies of the Elderly (H-EPESE). A total of 2,945 Mexican American older adults were included in the analyses. A latent growth curve modeling was conducted. Results: After adjusting for covariates, results show that Mexican American older adults with LEP had higher levels of depressive symptoms than those with English proficiency (EP) at baseline as well as over a 14-year period. Differential trajectories were observed between those with LEP and EP over time, indicating that those with LEP had a significantly steeper curve of depressive symptom trajectories over time than those with EP. Discussion and Implications: These results suggest that LEP is a risk factor not merely for greater depressive symptomatology at each time point, but for an accelerated trajectory of depressive symptoms over time among Mexican American older adults. Overall, the findings emphasize the need to assist not only the informal support system of Mexican American older adults with LEP, but also the formal system