Management of hypertension at the community level in Sub-Saharan Africa (SSA): towards a rational use of available resources

Hypertension is emerging in many developing nations as a leading cause of cardiovascular mortality, morbidity and disability in adults. In sub-Saharan African (SSA) countries it has specificities such as occurring in young and active adults, resulting in severe complications dominated by heart failure and taking place in limited-resource settings in which an individual's access to treatment (affordability) is very limited. Within this context of restrained economic conditions, the greatest gains for SSA in controlling the hypertension epidemic lie in its prevention. Attempts should be made to detect hypertensive patients early before irreversible organ damage becomes apparent, and to provide them with the best possible and affordable non-pharmacological and pharmacological treatment. Therefore, efforts should be made for detection and early management at the community level. In this context, a standardized algorithm of management can help in the rational use of available resources. Although many international and regional guidelines have been published, they cannot apply to SSA settings because the economy of the countries and affordability of the patients do not allow access to advocated treatment. In addition, none of them suggest a clear algorithm of management for limited-resource settings at the community level. In line with available data and analysing existing guidelines, a practical algorithm for management of hypertension at the community level, including treatment affordability, has been suggested in the present work

Discussion of "Breakdown and groups" by P. L. Davies and U. Gather

Discussion of ``Breakdown and groups'' by P. L. Davies and U. Gather [math.ST/0508497]Comment: Published at http://dx.doi.org/10.1214/009053604000001138 in the Annals of Statistics (http://www.imstat.org/aos/) by the Institute of Mathematical Statistics (http://www.imstat.org

Determinants of Product Upgrading in the Argentine Wine Industry

In this thesis, I examine the impact that a firm\u27s connections and internal resources has on the firm\u27s ability to develop new products. The capability to make improvements to products is crucial to the long term success and growth of a firm. By using structural equation modeling, I take a different approach to network analysis to analyze data from the Argentine wine industry. While I did not find strong evidence to support the hypothesis that the combination of external networks and internal knowledge are key drivers to product upgrading, there was strong evidence to support each individual determinant’s impact on upgrading

Coping with novel environments: how birds have adapted to urban environments

Urbanization presents a major threat to biodiversity. However, it also represents a unique opportunity to study evolution in novel environments. As cities are constantly reshaping, birds living in these areas face continuous challenges and, as its co-dwellers, they need to adapt to these changes as they happen using different strategies. Here, we aim to identify some of the traits selected by urban habitats and explore the relationship between brain size and brood value as two forms of plasticity. Identifying these traits may help us mitigate biotic homogenization and it could also be an effective approach for preserving ecosystem functions and services in urban areas, as well as to identify which species are more sensitive to urbanization processes

Silence of the limbs: pharmacological symptomatic treatment of intermittent claudication

Several oral "vasoactive" drugs claim to increase walking capacity in patients with intermittent claudication (IC). Naftidrofuryl, cilostazol, buflomedil, and pentoxifylline are the most studied molecules. Although spanning several decades, several studies underlying these claims were not properly designed, underpowered or showed clinically doubtful outcomes. The evidence for these "vasoactive" drugs has always been received with scepticism, creating the need for systematic reviews and meta-analyses. This brief review discusses the benefit-risk assessment of vasoactive drugs, by applying a systematic review to evaluate randomized, placebo-controlled trials. Oral naftidrofuryl and cilostazol have an acceptable safety profile as well as sustained evidence (documented by Cochrane analyses) of increased walking capacity. Subsequently, these drugs entered recommendations for peripheral arterial disease (PAD). In contrast, buflomedil and pentoxifylline have limited and/or doubtful evidence to increase walking capacity. Moreover, there were safety concerns about the narrow therapeutic range of buflomedil. Most other "vasoactive" drugs were either inappropriately or insufficiently tested or showed no significant if not negative effects on IC. "Vasoactive" drugs are no substitutes for lifestyle or exercise therapy but are adjuvant treatment to the well-appreciated triad of cardiovascular prevention (antiplatelet agents, statins and ACE-inhibitors), of which statins in their own right have documented claims to significantly increase walking capacity. "Vasoactive" drugs may have a place in the pharmacological management of symptomatic PAD in addition to the basic cardiovascular pharmacotherapy, when revascularization is not indicated, when exercise therapy is not feasible or when there is still insufficient benefit

Accidents On the Information Superhighway: On-Line Liability And Regulation

In one way or another, the Internet has affected or will affect our lives in a profound fashion. The Internet has fundamentally changed the way society works and plays by providing an inexpensive medium to obtain information and communicate with others. The current generation of children will be educated through computer communication, rather than from the confines of a dusty library with outdated books. However, the benefits of rapid Internet development have also opened a Pandora\u27s box of legal issues and concerns which merit careful consideration. With roots in over 160 countries, and without a centralized authority, many now consider the Internet the last free marketplace of ideas. Civil libertarians and on-line activists are currently fighting a Sisyphean battle to keep the Internet free of all constraints. Such regulation threatens to curtail the expansion of the Internet by imposing formidable civil and criminal liabilities for negligent or allegedly illegal on-line activities. This comment examines recent efforts by legislators, regulators and the judiciary to tame the seemingly untamable on-line universe. First, it considers the prominent legal cases concerning the liability of on-line access providers for electronic transmissions. Second, it examines congressional and state legislative efforts aimed at regulating on-line activities. Finally, it will analyze whether the Internet is a proper candidate for regulation, and to what extent our existing framework of laws can be adequately used to prosecute illegal on- line activities

Assessment of model based (input) impedance, pulse wave velocity, and wave reflection in the Asklepios Cohort

Objectives : Arterial stiffness and wave reflection parameters assessed from both invasive and non-invasive pressure and flow readings are used as surrogates for ventricular and vascular load. They have been reported to predict adverse cardiovascular events, but clinical assessment is laborious and may limit widespread use. This study aims to investigate measures of arterial stiffness and central hemodynamics provided by arterial tonometry alone and in combination with aortic root flows derived by echocardiography against surrogates derived by a mathematical pressure and flow model in a healthy middle-aged cohort. Methods : Measurements of carotid artery tonometry and echocardiography were performed on 2226 ASKLEPIOS study participants and parameters of systemic hemodynamics, arterial stiffness and wave reflection based on pressure and flow were measured. In a second step, the analysis was repeated but echocardiography derived flows were substituted by flows provided by a novel mathematical model. This was followed by a quantitative method comparison. Results : All investigated parameters showed a significant association between the methods. Overall agreement was acceptable for all parameters (mean differences: -0.0102 (0.033 SD) mmHg*s/ml for characteristic impedance, 0.36 (4.21 SD) mmHg for forward pressure amplitude, 2.26 (3.51 SD) mmHg for backward pressure amplitude and 0.717 (1.25 SD) m/s for pulse wave velocity). Conclusion : The results indicate that the use of model-based surrogates in a healthy middle aged cohort is feasible and deserves further attention