Trends in Secondary Prevention of Coronary Heart Disease in Tunisia: Prevention of Recurrences of MI and Stroke

ObjectivesThe survival benefits achieved by prescription of antiplatelet agents, B-adrenoreceptor antagonists (beta-blockers), angiotensin II receptor blockers (ARB), and lipid lowering agents in patients surviving the myocardial infarction (MI) have been well documented in large clinical trial. Despite well-established benefits, these pharmacological agents continue to be underutilized. The main objective of this study was to evaluate the progress of cardiovascular secondary prevention practices in Tunisia.MethodsThe PREMISE (Prevention of Recurrence of Myocardial Infarction and Stroke) is a descriptive, cross-sectional study conducted in Tunisia in two phases (2002 and 2009). Seven hundred eighty two patients were recruited. The recruitment criteria were: previous MI, stable angina, unstable angina, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), stroke, transient ischemic attack (TIA) or carotid endarterectomy. This analysis is limited to coronary heart disease (CHD) patients. Five hundred hospital patients were interviewed and their medical records were reviewed: 250 in 2002 and 250 in 2009. Patients were included if they had confirmed diagnosis of MI, angina, CABG or PTCA, and if their first cardiovascular event had occurred more than one month but not later than 3 years ago. We compared the total of both patient groups, using the prevalence of Cardio-Vascular Risk Factors (CVRF) and the treatment prescribed at hospital discharge.ResultsThe proportion of patients with reported hypertension, diabetes, hypercholesterolemia and current smoker patients had decreased. Concerning pharmacological prescriptions, a significant increase was observed in prescribing statins (38.9% vs. 70.3%) and ACE inhibitors (49.3% vs. 69.9%), non pharmacological prescriptions as healthy diet or tobacco cessation had opposite trends. Adherence to treatment did not change substantially.ConclusionAlthough the use of cardioprotective drugs had increased in CHD patients, there are still gaps in secondary prevention in Tunisia. The recommended strategies of secondary prevention need to be applied more intensively in clinical practice

Vortex density models for superconductivity and superfluidity

We study some functionals that describe the density of vortex lines in superconductors subject to an applied magnetic field, and in Bose-Einstein condensates subject to rotational forcing, in quite general domains in 3 dimensions. These functionals are derived from more basic models via Gamma-convergence, here and in a companion paper. In our main results, we use these functionals to obtain descriptions of the critical applied magnetic field (for superconductors) and forcing (for Bose-Einstein), above which ground states exhibit nontrivial vorticity, as well as a characterization of the vortex density in terms of a non local vector-valued generalization of the classical obstacle problem.Comment: 34 page

Vortex Rings in Fast Rotating Bose-Einstein Condensates

When Bose-Eintein condensates are rotated sufficiently fast, a giant vortex phase appears, that is the condensate becomes annular with no vortices in the bulk but a macroscopic phase circulation around the central hole. In a former paper [M. Correggi, N. Rougerie, J. Yngvason, {\it arXiv:1005.0686}] we have studied this phenomenon by minimizing the two dimensional Gross-Pitaevskii energy on the unit disc. In particular we computed an upper bound to the critical speed for the transition to the giant vortex phase. In this paper we confirm that this upper bound is optimal by proving that if the rotation speed is taken slightly below the threshold there are vortices in the condensate. We prove that they gather along a particular circle on which they are evenly distributed. This is done by providing new upper and lower bounds to the GP energy.Comment: to appear in Archive of Rational Mechanics and Analysi

The Transition to a Giant Vortex Phase in a Fast Rotating Bose-Einstein Condensate

We study the Gross-Pitaevskii (GP) energy functional for a fast rotating Bose-Einstein condensate on the unit disc in two dimensions. Writing the coupling parameter as 1 / \eps^2 we consider the asymptotic regime \eps \to 0 with the angular velocity $\Omega$ proportional to (\eps^2|\log\eps|)^{-1} . We prove that if \Omega = \Omega_0 (\eps^2|\log\eps|)^{-1} and $\Omega_0 > 2(3\pi)^{-1}$ then a minimizer of the GP energy functional has no zeros in an annulus at the boundary of the disc that contains the bulk of the mass. The vorticity resides in a complementary `hole' around the center where the density is vanishingly small. Moreover, we prove a lower bound to the ground state energy that matches, up to small errors, the upper bound obtained from an optimal giant vortex trial function, and also that the winding number of a GP minimizer around the disc is in accord with the phase of this trial function.Comment: 52 pages, PDFLaTex. Minor corrections, sign convention modified. To be published in Commun. Math. Phy

Ginzburg-Landau model with small pinning domains

We consider a Ginzburg-Landau type energy with a piecewise constant pinning term $a$ in the potential $(a^2 - |u|^2)^2$. The function $a$ is different from 1 only on finitely many disjoint domains, called the {\it pinning domains}. These pinning domains model small impurities in a homogeneous superconductor and shrink to single points in the limit $\v\to0$; here, \v is the inverse of the Ginzburg-Landau parameter. We study the energy minimization in a smooth simply connected domain $\Omega \subset \mathbb{C}$ with Dirichlet boundary condition $g$ on \d \O, with topological degree {\rm deg}_{\d \O} (g) = d >0. Our main result is that, for small \v, minimizers have $d$ distinct zeros (vortices) which are inside the pinning domains and they have a degree equal to 1. The question of finding the locations of the pinning domains with vortices is reduced to a discrete minimization problem for a finite-dimensional functional of renormalized energy. We also find the position of the vortices inside the pinning domains and show that, asymptotically, this position is determined by {\it local renormalized energy} which does not depend on the external boundary conditions.Comment: 39 page

A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries.

BACKGROUND: Coronary Heart Disease (CHD) is rising in middle income countries. Population based strategies to reduce specific CHD risk factors have an important role to play in reducing overall CHD mortality. Reducing dietary salt consumption is a potentially cost-effective way to reduce CHD events. This paper presents an economic evaluation of population based salt reduction policies in Tunisia, Syria, Palestine and Turkey. METHODS AND FINDINGS: Three policies to reduce dietary salt intake were evaluated: a health promotion campaign, labelling of food packaging and mandatory reformulation of salt content in processed food. These were evaluated separately and in combination. Estimates of the effectiveness of salt reduction on blood pressure were based on a literature review. The reduction in mortality was estimated using the IMPACT CHD model specific to that country. Cumulative population health effects were quantified as life years gained (LYG) over a 10 year time frame. The costs of each policy were estimated using evidence from comparable policies and expert opinion including public sector costs and costs to the food industry. Health care costs associated with CHDs were estimated using standardized unit costs. The total cost of implementing each policy was compared against the current baseline (no policy). All costs were calculated using 2010 PPP exchange rates. In all four countries most policies were cost saving compared with the baseline. The combination of all three policies (reducing salt consumption by 30%) resulted in estimated cost savings of $235,000,000 and 6455 LYG in Tunisia;$39,000,000 and 31674 LYG in Syria; $6,000,000 and 2682 LYG in Palestine and$1,3000,000,000 and 378439 LYG in Turkey. CONCLUSION: Decreasing dietary salt intake will reduce coronary heart disease deaths in the four countries. A comprehensive strategy of health education and food industry actions to label and reduce salt content would save both money and lives

Heterozygote Advantage for Fecundity

Heterozygote advantage, or overdominance, remains a popular and persuasive explanation for the maintenance of genetic variation in natural populations in the face of selection. However, despite being first proposed more than 80 years ago, there remain few examples that fit the criteria for heterozygote advantage, all of which are associated with disease resistance and are maintained only in the presence of disease or other gene-by-environment interaction. Here we report five new examples of heterozygote advantage, based around polymorphisms in the BMP15 and GDF9 genes that affect female fecundity in domesticated sheep and are not reliant on disease for their maintenance. Five separate mutations in these members of the transforming growth factor β (TGFβ) superfamily give phenotypes with fitness differentials characteristic of heterozygous advantage. In each case, one copy of the mutant allele increases ovulation rate, and ultimately litter size per ewe lambing, relative to the wildtype. However, homozygous ewes inheriting mutant alleles from both parents have impaired oocyte development and maturation, which results in small undeveloped ovaries and infertility. Using data collected over many years on ovulation rates, litter size, and lambing rates, we have calculated the equilibrium solution for each of these polymorphisms using standard population genetic theory. The predicted equilibrium frequencies obtained for these mutant alleles range from 0.11 to 0.23, which are amongst the highest yet reported for a polymorphism maintained by heterozygote advantage. These are amongst the most frequent and compelling examples of heterozygote advantage yet described and the first documented examples of heterozygote advantage that are not reliant on a disease interaction for their maintenance

Seroprevalence of Toxoplasma gondii infection in arthritis patients in eastern China

Background: There is accumulating evidence for an increased susceptibility to infection in patients with arthritis. We sought to understand the epidemiology of Toxoplasma gondii infection in arthritis patients in eastern China, given the paucity of data on the magnitude of T. gondii infection in these patients. Methods: Seroprevalence of T. gondii infection was assessed by enzyme-linked immunosorbent assay using a crude antigen of the parasite in 820 arthritic patients, and an equal number of healthy controls, from Qingdao and Weihai cities, eastern China. Sociodemographic, clinical and lifestyle information on the study participants were also obtained. Results: The prevalence of anti-T. gondii IgG was significantly higher in arthritic patients (18.8%) compared with 12% in healthy controls (P < 0.001). Twelve patients with arthritis had anti-T. gondii IgM antibodies comparable with 10 control patients (1.5% vs 1.2%). Demographic factors did not significantly influence these seroprevalence frequencies. The highest T. gondii infection seropositivity rate was detected in patients with rheumatoid arthritis (24.8%), followed by reactive arthritis (23.8%), osteoarthritis (19%), infectious arthritis (18.4%) and gouty arthritis (14.8%). Seroprevalence rates of rheumatoid arthritis and reactive arthritis were significantly higher when compared with controls (P < 0.001 and P = 0.002, respectively). A significant association was detected between T. gondii infection and cats being present in the home in arthritic patients (odds ratio [OR], 1.68; 95% confidence interval [CI]: 1.24 – 2.28; P = 0.001). Conclusions: These findings are consistent with and extend previous results, providing further evidence to support a link between contact with cats and an increased risk of T. gondii infection. Our study is also the first to confirm an association between T. gondii infection and arthritis patients in China. Implications for better prevention and control of T. gondii infection in arthritis patients are discussed. Trial registration: This is an epidemiological survey, therefore trial registration was not required

Gender Differences in Clinical Presentation and Outcomes of Epidemic Kaposi Sarcoma in Uganda

The incidence of Kaposi sarcoma (KS) has increased dramatically among women in sub-Saharan Africa since the onset of the HIV pandemic, but data on KS disease in women are limited. To identify gender-related differences in KS presentation and outcomes, we evaluated the clinical manifestations and response in men and women with AIDS-associated KS in Uganda.HIV-infected adults with KS attending the Infectious Diseases Institute (IDI) and Uganda Cancer Institute (UCI) in Kampala, Uganda between 2004 and 2006 were included in a retrospective cohort. Evaluation of KS presentation was based on the clinical features described at the initial KS visit. Response was evaluated as the time to "improvement", as defined by any decrease in lesion size, lesion number, or edema. The cohort consisted of 197 adults with HIV and KS: 55% (108/197) were women. At presentation, the median CD4 T-cell count was significantly lower in women (58 cells/mm(3); IQR 11-156 cells/mm(3)) than men (124 cells/mm(3); IQR 22-254 cells/mm(3)) (p = 0.02). Women were more likely than men to present with lesions of the face (OR 2.8, 95% CI, 1.4, 5.7; p = 0.005) and hard palate (OR 2.0, 95% CI, 1.1, 3.7; p = 0.02), and were less likely than men to have lower extremity lesions (OR 0.54, 95% CI, 0.3, 0.99; p = 0.05). Women were less likely than men to demonstrate clinical improvement (HR = 0.52, CI 0.31, 0.88; p = 0.01) in multivariate analysis.The clinical presentation and response of KS differs between men and women in Uganda. These data suggest that gender affects the pathophysiology of KS, which may have implications for the prevention, diagnosis, and treatment of KS in both men and women. Prospective studies are needed to identify predictors of response and evaluate efficacy of treatment in women with KS, particularly in Africa where the disease burden is greatest