Long-term Risk Reduction Research Articles

Hypertension Management in Pregnancy.

Chronic hypertension and preeclampsia spectrum disorders in pregnancy are important contributors to long-term maternal morbidity and mortality. Due to physiologic changes during pregnancy and the postpartum period, blood pressure expectations differ between primary care providers and obstetricians. The goal of this article is to describe the pathophysiology and definitions of hypertension in the obstetric context and review current evidence for management during pregnancy and the postpartum period. Longitudinal follow-up with a primary care provider after delivery is crucial for long-term cardiovascular risk reduction in hypertensive patients.

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 1: Patient presentation through revascularization.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the critical initial phases of care are reviewed. Despite established value in the emergency department (ED), cardiac care, and intensive care settings, there is currently little published literature describing or supporting clinical pharmacist roles in the acute management of STEMI. The high-risk period from hospital presentation through revascularization and stabilization involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. While rife with opportunities for pharmacists to optimize care, this timeframe appears inconsistently targeted by clinical pharmacy services, which may halt after ED evaluation and then resume upon postcatheterization cardiac unit admission. Herein we review the key pharmacotherapeutic modalities and considerations for the patient with STEMI across the critical initial phases of care. These include supportive therapies prior to revascularization, the host of antithrombotics involved in revascularization by percutaneous coronary intervention and/or fibrinolysis, and other periprocedural medications. Important practice guidelines and clinical resources are summarized from the clinical pharmacist perspective, and roles and responsibilities of the responding pharmacist are suggested. A companion article will extend the review to periprocedural adverse event management, key early decision-making regarding long-term risk reduction, and pharmacist involvement in institutional quality improvement efforts. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population, and we call for further research delineating pharmacist impact on patient and institutional STEMI outcomes. Patients presenting with STEMI rapidly traverse multiple phases of care and receive a host of antithrombotic and supportive medications during acute management, presenting many important pharmacotherapeutic decision points and roles for pharmacists.

Understanding Socioeconomic Risk and Vulnerability to Climate Change–Induced Disasters: The Case of Informal Settlements in KwaZulu-Natal, South Africa

This study employs a qualitative research approach to spatially delineate the risk and vulnerability of informal settlements in KwaZulu-Natal, South Africa. This comes after devastating floods that occurred in KwaZulu-Natal, South Africa, in April 2022. This disaster emphasised the necessity for South Africa to proactively address natural hazards by implementing risk reduction strategies rather than attempting to mitigate the impact after the damage has occurred. Evidence indicates that the risk and vulnerability associated with climate-induced disasters, such as flooding, are exacerbated by socioeconomic factors, including housing shortages, which compel individuals to construct dwellings in flood-prone areas. Opportunities exist to enhance the understanding of disaster risk reduction in Africa, and South Africa in particular, through science-informed initiatives employing spatial techniques, including geographic information systems, hazard exposure mapping, and socioeconomic risk and vulnerability mapping. These techniques are crucial for humanitarian planning focused on long-term risk reduction, early recovery, shelter, reconstruction, and psychosocial support for climate change disaster recovery. Furthermore, an understanding of the nature and location of areas with high disaster risk, such as flooding, is essential for the formulation of disaster risk reduction strategies, including early warning systems.

Developing a Paired Whole Genome Sequencing Service for Children With Cancer

BackgroundThe uniqueness of paired (tumor and germline) whole genome sequencing (PWGS) in cancer diagnosis and management lies in not just its ability to uncover oncogenic drivers and potential treatment targets but also on the identification of underlying cancer predisposition syndromes, which has significant implications for the patient and their family. AimsThis is a descriptive article highlighting the processes taken by our team to incorporate PWGS into routine National Health Service (NHS) clinical care for children with cancer. The main aim of this article is to share our experience with other centers that may wish to set up similar services and set the stage for future quantitative/qualitative research. MethodsThis article is further supported by an audit focusing on children in whom an underlying cancer predisposition was confirmed. ResultsThe audit highlights the success of the program to date, with 100% of families identified as being at risk of a cancer predisposition syndrome being offered referral to clinical genetics and 100% of at-risk first-degree relatives being offered predictive counseling and testing. Areas requiring improvement included discussion of reproductive options as only six out of nine families (67%) had a documented discussion. ConclusionsIncorporation of the audit recommendations will improve our service, and sharing of our experience will hopefully encourage more pediatric oncology services to introduce PWGS into routine clinical care and reduce inequity of access. Further work is required to assess the long-term cancer risk reduction and establish the psychosocial impact of PWGS for the child and family.

Variability in flood frequency in sub-Saharan Africa: The role of large-scale climate modes of variability and their future impacts

Sub-Saharan Africa (SSA) is strongly affected by flood hazards, endangering human lives and economic stability. However, the role of internal climate modes of variability in driving fluctuations in SSA flood occurrence remains poorly documented and understood. To address this gap, we quantify the relative and combined contribution of large-scale climate drivers to seasonal and regional flood occurrence using a new 65-year daily streamflow dataset, sea-surface temperatures derived from observations, and 12 Single Model Initial-condition Large Ensembles (SMILEs) from the Coupled Model Intercomparison Project Phases 5 and 6. We find significant relationships between floods and large-scale climate variability across SSA, with climatic drivers accounting for 30–90 % of the variability in floods. Notably, western, central, and the summer-rain region of southern Africa display stronger teleconnections to large-scale climate variability in comparison to East Africa and the winter-rain region of South Africa, where regional circulation patterns and human activities may play a more important role. In southern and eastern Africa, floods are mainly influenced by teleconnections with the Pacific and Indian Oceans, while in western and central Africa, teleconnections with the Atlantic Ocean and Mediterranean Sea play a larger role. We also find that the number of floods is projected to fluctuate by ± 10–50 % during the 21st century in response to different sequences of key modes of climate variability. We also note that the relative contributions of large-scale climate variability to future flood risks are generally consistent across all SMILEs. Our findings thus provide valuable information for long-term disaster risk reduction and management.

Non-diabetes status after diagnosis of impaired glucose tolerance and risk of long-term death and vascular complications: A post hoc analysis of the Da Qing Diabetes Prevention Outcome Study.

The association between years of non-diabetes status after diagnosis of impaired glucose tolerance (IGT) and the risk of long-term death and cardiovascular outcomes needed to be clarified. In this post hoc analysis, we included 540 individuals with IGT who participated in the original Da Qing Diabetes Prevention Study (DQDPS). In the DQDPS, all participants were diagnosed with IGT by a 75 g oral glucose tolerance test and randomized to intervention or control groups with a 6-year lifestyle intervention trial. After the completion of the trial, death, cardiovascular events, and microvascular complications were monitored over a 30-year follow-up. In this post hoc analysis, the Cox analysis assessed the extended risk of these outcomes in individuals who either remained non-diabetes status or progressed to diabetes at the end of 2, 4, and 6 years after diagnosis of IGT. In all participants, the difference in the cumulative incidence rate of the outcomes between the diabetes and non-diabetes group gradually increased over 30 years. Compared with the diabetes group, a significantly lower risk of all-cause death (hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.57 to 0.97, p = 0.026), cardiovascular events (HR: 0.63; 95% CI: 0.49 to 0.82, p < 0.001), and microvascular complications (HR: 0.62; 95% CI: 0.45 to 0.86, p = 0.004) first emerged in individuals who remained non-diabetes at the 4 years visit, whereas the significant risk reduction in cardiovascular death was first observed at the end of 6 years (HR: 0.56; 95% CI: 0.39 to 0.81, p = 0.002) after adjustment for age, sex, smoking status, BMI, systolic blood pressure, blood glucose, total cholesterol, intervention, and medications (including insulin plus oral hypoglycaemics, antihypertensives, and lipid-lowering agents). The results in the original intervention group alone were similar to the whole group. The main limitations of our study are the limited number of participants and the sole ethnicity of the Chinese population. In this study, we observed that maintaining several years of non-diabetes status after IGT diagnosis was associated with a significant reduction in long-term risk of death and vascular complications, and for most of these outcomes, maintaining at least 4 years of non-diabetes status may be needed to achieve a significant risk reduction.

Attributes Influencing Willingness to Pay for Overweight and Obesity Interventions in Adults: A Systematic Literature Review.

This review aims to identify the associated attributes of willingness to pay (WTP) for overweight and obesity interventions.A narrative review was conducted by partially adopting the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline.A non-exhaustive search using a pre-defined strategy and keywords was done on three selected literature databases: Pubmed, Scopus, and Web of Science. The inclusion criteria for the review were original studies written in English, published between 2000 and 2022, and focused on WTP for overweight and obesity interventions in adults. The extracted studies were manually screened for their eligibility through three cascading tiers: the title, the abstract, and the full article. Only nine original studies were eligible for review based on the screening procedure of 40 screened articles. There was heterogeneity in the study designs, methods, target populations, study duration, and perspectives across the studies. The majority of the studies showed that higher WTP was associated with younger age, having higher income, being female, having higher body mass index (BMI), having the perception of being overweight, habits, and attitudes. WTP is also attributed to the associated percentage of weight loss, long-term health risk reduction, time to noticeable weight loss, delivery mode, side effects, lifestyle modification, and costs of interventions.The identification of common attributes of the WTP for overweight and obesity intervention can assist in the formulation and implementation of effective evidence-based policies. Specific sub-groups with low WTP could be targeted via unique initiatives to improve their participation in weight-loss interventions.

Long-term cardiovascular risk reduction after gastric cancer surgery: a nationwide cohort study.

Gastrectomy for gastric cancer is associated with postoperative changes in cardiovascular risk factors, however, the impact of gastrectomy on cardiovascular events remains unclear. We assessed the incidence of cardiovascular events between patients undergoing gastrectomy or endoscopic resection for gastric cancer, and the general population. This retrospective nationwide cohort study included patients with gastric cancer undergoing gastrectomy(n=37,698), endoscopic resection(n=2,773), and matched control population(n=161,887) between 2004 and 2013. We included patients without a history of cancer other than gastric cancer, myocardial infarction, or ischemic stroke. The primary outcome was the incidence of major adverse cardiovascular events (MACE) such as acute myocardial infarction, revascularization, or acute ischemic stroke, in patients with gastric cancer. Among patients who underwent gastrectomy for gastric cancer, 2.9% (4.69 per 1000 person-years) developed novel MACE within the seven-year follow-up period. The gastrectomy group demonstrated a significantly decreased risk for MACE than the control population (hazard ratio[HR], 0.65; 95% confidence interval[CI], 0.61-0.69; P <0.001). Among the patients undergoing endoscopic resection for gastric cancer, 5.4% (8.21 per 1000 person-years) developed novel MACE within the seven-year follow-up period. The risk for MACE in the endoscopic resection group was not significantly different from the control population. Patients with gastric cancer who have undergone gastrectomy exhibit a reduced risk of cardiovascular diseases in comparison to the general population. In contrast, the risk for cardiovascular diseases in patients with gastric cancer who underwent endoscopic resection did not demonstrate a significant difference in cardiovascular risk in comparison to the general population.

Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke

ObjectiveLeft atrial appendage closure (LAAC) concomitant to heart surgery in patients with underlying atrial fibrillation (AF) has gained attention because of long-term reduction of thromboembolic complications. As of mortality benefits in the setting of non-AF, data from both observational studies and randomized controlled trials are conflicting. MethodsOn-line databases were screened for studies comparing LAAC versus no LAAC concomitant to other heart surgery. End points assessed were all-cause mortality and stroke at early and longest-available follow-up. Subgroup analyses stratified on preoperative AF were performed. Risk ratios (RR) with 95% CIs served as primary statistics. ResultsElectronic search yielded 25 studies (N = 660 [158 patients]). There was no difference between LAAC and no LAAC in terms of early mortality. In the overall population analysis, LAAC reduced long-term mortality (RR, 0.86; 95% CI, 0.74-1.00; P = .05; I2 = 88%), reduced early stroke risk by 19% (RR, 0.81; 95% CI, 0.72-0.93; P = .002; I2 = 57%), and reduced late stroke risk by 13% (RR, 0.87; 95% CI, 0.84-0.90; P < .001; I2 = 58%). Subgroup analysis showed lower mortality (RR, 0.85; 95% CI, 0.72-1.01; P = .06; I2 = 91%), short-, and long-term stroke risk reduction only in patients with preoperative AF (RR, 0.81; 95% CI, 0.71-0.93; P = .003; I2 = 71% and RR, 0.87; 95% CI, 0.84-0.91; P < .001; I2 = 70%, respectively). No benefit of LAAC in patients without AF was found. ConclusionsConcomitant LAAC was associated with reduced stroke rates at early and long-term and possibly reduced all-cause mortality at the long-term follow-up but the benefits were limited to patients with preoperative AF. There is not enough evidence to support routine concomitant LAAC in non-AF settings.

Impact of Longitudinal Alcohol Use Patterns on Long-Term Risk of Cirrhosis Among US Veterans With Steatotic Liver Disease

Background & AimsConflicting data exists on impact of alcohol use on risk of liver disease progression in patients with steatotic liver disease. We aim to evaluate the effect of longitudinal alcohol use on risk of cirrhosis among Veterans with steatotic liver disease. MethodsU.S. Veterans with steatotic liver disease were identified from January 2010 to December 2022. Alcohol use was assessed using documented AUDIT-C scores and categorized as no alcohol (AUDIT-C = 0), low-risk alcohol use (AUDIT-C 1-2 for women and 1-3 for men), high-risk alcohol (AUDIT-C > 3 for women and > 4 for men). Incidence of cirrhosis was evaluated with competing risks Nelson-Aalen methods. Adjusted multivariable regression models evaluated risks of cirrhosis associated with baseline alcohol use and changes in alcohol use during follow up. Results1,156,189 Veterans with steatotic liver disease were identified (54.2% no alcohol, 34.6% low-risk alcohol, 11.2% high-risk alcohol). Veterans with steatotic liver disease and high-risk alcohol have 43% higher incidence of cirrhosis compared to patients reporting no alcohol use. Compared to patients with baseline high-risk alcohol who reported no change in alcohol use, those who decreased their alcohol use during follow up experienced a 39% reduction in long-term risk of cirrhosis (HR 0.61, 95% CI 0.45-0.83, p< 0.01). ConclusionsOne in nine Veterans with steatotic liver disease report concurrent high-risk alcohol use, which is associated with 43% greater risk of cirrhosis compared to no alcohol use. However, reducing alcohol use lowers risk of cirrhosis, emphasizing the importance of timely alcohol use assessment and early interventions to address high-risk alcohol use in steatotic liver disease.

Long-Term Mortality and SGLT2 Inhibitors in Type 2 Diabetes with and without Renal Impairment: An Observational Cohort Study

Aim: Sodium-glucose co-transporter 2 (SGLT2) inhibitors have emerged as a vital part of management of type 2 diabetes, as they have been shown to have both cardiovascular and renal benefits along with an improved survival rate in several randomized clinical trials. We designed a retrospective cohort study to investigate the impact of SGLT2 inhibitors on mortality among type 2 diabetes patients. Methods: Patients with type 2 diabetes who presented to the Dasman Diabetes Institute in Kuwait were followed from January 1st, 2015, until January 20th, 2023. To control for non-random allocation of SGLT2 inhibitors and measured confounders, we performed one-to-one propensity score matching and evaluated outcomes in the matched cohorts using a Cox proportional hazards model. The primary treatment variable was SGLT2 inhibitor use; time to mortality from any cause was used as the outcome of interest. Results: 1,551 patients were taking SGLT2 inhibitors, and 1,687 patients were not. After propensity score matching, 845 patients were on SGLT2 inhibitors, and 845 patients were not. In post-matching analysis, all-cause mortality was higher among patients who did not take SGLT2 inhibitors compared to patients taking SGLT2 inhibitors (5.2 vs. 2.1%, p = 0.0012). The hazard ratio of all-cause mortality in patients taking SGLT2 inhibitors was 0.42 (95% confidence interval [95% CI], 0.24–0.72). Additional adjustment of matching factors did not change the results. Conclusion: This observational study demonstrated substantial long-term reduction in mortality risk among patients with type 2 diabetes treated with SGLT2 inhibitors. This is irrespective of the stage of their renal diseases or GLP1 agonist.

An analysis of the recommendations of the 2022 Society for Vascular Surgery clinical practice guidelines for patients with asymptomatic carotid stenosis

ObjectivePatients with asymptomatic carotid artery stenosis currently account for the majority of carotid interventions performed in the United States; therefore, the following article will review the 2022 Society for Vascular Surgery (SVS) clinical practice guidelines perspective in treating patient with asymptomatic carotid stenosis. MethodsA systemic review and meta-analysis were conducted by the evidence practice center of the Mayo Clinic using a specified population, intervention, comparison, outcome (PICO) framework. ResultsBased on published randomized trials and related supporting evidence, the following were noted: the SVS recommends that patients with asymptomatic ≥70% stenosis can be considered for carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TFCAS) for the reduction of long-term risk of stroke, provided the patient has a life expectancy of 3 to 5 years with risk of perioperative stroke and death not exceeding 3%. The type of carotid intervention should be based on the presence or absence of high-risk criteria for each specified intervention. Data from CREST, ACT, and the Vascular Quality Initiative suggest that certain properly selected asymptomatic patients can be treated with carotid stenting with equivalent outcome to CEA in the hands of experienced interventionalists. The institutions and operator performing carotid stenting must exhibit expertise sufficient to meet the established American Heart Association guidelines for treatment of patient with asymptomatic carotid stenosis (ie, combined stroke/death rate of less than 3%). ConclusionsSVS recommends that low surgical risk patients with asymptomatic carotid stenosis of ≥70% to be treated with CEA with best medical therapy over medical therapy alone for the long-term prevention of stroke/death (GRADE 1B). Carotid intervention should also be based on the presence or absence of high-risk criteria for each specified intervention (ie, CEA, TCAR, and TFCAS).

Abstract 12563: Is Cardiometabolic Risk Reduction Sustainable in Routine Practice?

Introduction: Sustained cardiometabolic risk reduction is elusive in routine practice. Hypothesis: A multidisciplinary (endocrinology, cardiology, nutrition, diabetes technology/education, and exercise physiology) preventive cardiology center focused on the cardiometabolic-based chronic disease (CMBCD) model can exert long-term risk reduction in patients with and without cardiometabolic presentations. Methods: Yearly attainment of guideline-directed medical therapy targets of the metabolic driver at the most advanced stage in patients from the Center for Clinical Cardiovascular Health at Mount Sinai Heart with adiposity-, dysglycemia-, hypertension-, and lipid-based chronic disease with predisease, disease, or complications was measured. The main outcome was sustainability rate. Results: A total of 270 patients with a mean follow-up of 4.0±1.2 years were included. Sustainability, defined as target attainment in the year in question and in any other previous year(s), was observed in 93/127 (73%), 81/116 (70%), 55/80 (69%), 40/54 (74%), and 11/13 (85%) patients in years of engagement 2, 3, 4, 5, and 6, respectively. The median (interquartile range) number of years reaching the target for sustainers observed was: 2 (2-2); 3 (2-3); 3 (2-3.5); 4 (2-5); 5 (4-6) for patients with 2, 3, 4, 5, or 6 years of engagement at the Center. Conclusions: High sustainability rates for cardiometabolic risk reduction were observed in a multidisciplinary preventive cardiology center based on the CMBCD model with a focus on lifestyle medicine, in patients with and without cardiometabolic presentations.

What can functional brain imaging teach us about remission of type 2 diabetes?

With a paradigm shift in attitudes to type 2 diabetes (T2D), "weight-loss responsive" diabetes is now thought of as a curable disease state. As a result, national programmes are being orchestrated to induce T2D remission soon after diagnosis with aggressive dietary interventions - such as very-low-calorie diets (VLCD). However, dietary interventions to achieve weight loss and diabetes remission lack the same long-term sustainability and cardiovascular risk reduction evidence as bariatric surgery. Improving our understanding of the neural implications of T2D that promote disadvantageous eating behaviours will enable prevention of disease as well as mitigation against a vicious cycle of metabolic dysfunction and associated cognitive complications. Here we summarise how functional MRI (fMRI) studies have helped to fashion our understanding of the neurobiology of human appetite and obesity. We explore how these neural correlates are affected by insulin resistance and T2D itself as well as its different treatment approaches. Finally, we comment on the need for more personalised approaches to maintaining metabolic health and how fMRI studies may inform this.

Issues and Problems Affecting Post-Disaster Reconstruction Activities in Indonesia

Efforts to mitigate the danger of disasters continue. Both long-term and short-term Disaster Risk Reduction (DRR) activities have been undertaken by governments and International Organizations. One type of long-term post-disaster activity is rehabilitation and reconstruction, which are an important part of the catastrophe recovery phase Long-term reconstruction activities are activities that have uncertainty. The reconstruction necessitates the integration of long-term development plans that account for various catastrophic risks and the possibility of mitigating future dangers. Based on past research, uncertainty variables show a problem with the activity of reconstruction activities. Numerous countries, including Malaysia, Nepal, America, and Estonia, have conducted research on the challenges and issues associated with construction activity. This research variable was developed from several studies conducted in several countries to obtain more comprehensive variables for study in the disaster-prone. Assessment instruments were developed using questionnaires distributed to a sample of respondents who met the initial criteria. Relative importance index (RII) is used in data processing procedures, and this paper examines the concerns and difficulties experienced during the reconstruction process. The data analysis found that the most dominant aspect that influences the construction period is the delay in project completion. With the value of the Relative Importance Index (RII) at the High-Medium (H–M) level (0.6 RI 0.8) with a value of 0.769 and all research variables are included in the High-Medium (H–M), namely (0.6 ≤ RI ≤ 0.8).

Hydrological regimes explain the seasonal predictability of streamflow extremes

Advances in hydrological modeling and numerical weather forecasting have allowed hydro-climate services to provide accurate impact simulations and skillful forecasts that can drive decisions at the local scale. To enhance early warnings and long-term risk reduction actions, it is imperative to better understand the hydrological extremes and explore the drivers for their predictability. Here, we investigate the seasonal forecast skill of streamflow extremes over the pan-European domain, and further attribute the discrepancy in their predictability to the local river system memory as described by the hydrological regimes. Streamflow forecasts at about 35 400 basins, generated from the E-HYPE hydrological model driven with bias-adjusted ECMWF SEAS5 meteorological forcing input, are explored. Overall the results show adequate predictability for both hydrological extremes over Europe, despite the spatial variability in skill. The skill of high streamflow extreme deteriorates faster as a function of lead time than that of low extreme, with a positive skill persisting up to 12 and 20 weeks ahead for high and low extremes, respectively. A strong link between the predictability of extremes and the underlying local hydrological regime is identified through comparative analysis, indicating that systems of analogous river memory, e.g. fast or slow response to rainfall, can similarly predict the high and low streamflow extremes. The results improve our understanding of the geographical areas and periods, where the seasonal forecasts can timely provide information on very high and low streamflow conditions, including the drivers controlling their predictability. This consequently benefits regional and national organizations to embrace seasonal prediction systems and improve the capacity to act in order to reduce disaster risk and support climate adaptation.

Lipid profile levels in HIV-AIDS patients on treatment with efavirenz and atazanavir. Cohort study.

Antiretroviral treatment for HIV generates dyslipidemia, which is associated with cardiovascular risk and atherosclerosis. To compare antiretroviral agents effects on lipids in patients with HIV-AIDS. Retrospective cohort. The lipid profiles of patients receiving efavirenz (EFV) vs. atazanavir (ATV) with a zidovudine + lamivudine backbone for 36 months were compared. 212 patients were included in the study. From baseline to month 36, HDL increase in the group of patients treated with ATV was higher in comparison with that of patients on EFV (8.33 vs. 4.26; p < 0.01); a difference in triglycerides was observed between groups, with a decrease of 19.06 mg/dL in patients on ATV and an increase of 40.62 mg/dL in those who received EFV (p < 0.001). Mean difference in total and LDL-cholesterol change between both treatments was not significant (p = 0.32 and p = 0.951, respectively). ATV-containing regimens were associated with more favorable changes in triglyceride and HDL levels than EFV regimens. This benefit could be associated with a reduction in long-term cardiovascular risk; this relationship requires further study.

Overcoming Namibia’s worst drought in the last 40 years: Ethnographic insights from Okakarara constituency

In 2019, Namibia experienced one of the worst droughts in recent decades, significantly affecting its agricultural economy, especially the livestock production sector. In this context, there is limited literature about how pastoral farmers in the country’s communal agricultural areas navigated this severe dryness. This paper addresses this knowledge gap by introducing a case study involving Ovaherero pastoralists in the Okakarara constituency. Following a mixed-method approach, it describes the practices implemented by local households to keep their cattle herds alive, the challenges they experienced thereby, and the strategies used for recovering their livestock losses. The study reveals that essential drought-coping practices, such as livestock mobility along with various long-term risk reduction mechanisms, such as reservation of emergency pastures, and social institutions of exchange, are limited in the communities described in this research. The paper discusses the main reasons for these conditions and their implications for local farmers, considering that more frequent droughts of similar severity are projected for the coming years in the region.

Referral Pathway for Hypertension with High Cardiovascular Risk: A Review

Hypertension is considered as a common and powerful contributor to all the major cardiovascular diseases (CVDs), including coronary disease, stroke, peripheral artery disease, renal disease, and heart failure. Results from the Framingham study indicated that high blood pressure (BP), even within what is regarded as the non-hypertensive range, imposes an increased risk of CVD. The median BP at which cardiovascular sequelae appeared in the Framingham study was 130/80 mmHg. Epidemiological data have shown that the risk of CVD rises with increasing BP levels, starting at ≥115/75 mmHg in a strong, independent, graded, and continuous manner. Early and aggressive BP lowering is mandatory as it can contribute to long-term CV risk reduction. According to the Framingham study data, 31% of strokes occur in patients with normal or high normal hypertension. Clinical trial data suggest that antihypertensive therapies, particularly those that block the renin-angiotensin-aldosterone system (RAAS), can reduce CVD risks at least partly independently of BP lowering, although a major controversy involves this question. An optimal strategy to reduce CV risk may include lifestyle modifications, promoting adherence to early and aggressive target level achievement, appropriate drug choice, and especially global risk reduction.

A Novel Approach to Measuring Spatiotemporal Changes in Social Vulnerability at the Local Level in Portugal

Social vulnerability, as one of the risk components, partially explains the magnitude of the impacts observed after a disaster. In this study, a spatiotemporally comparable assessment of social vulnerability and its drivers was conducted in Portugal, at the civil parish level, for three census frames. The first challenging step consisted of the selection of meaningful and consistent variables over time. Data were normalized using the Adjusted Mazziotta-Pareto Index (AMPI) to obtain comparable adimensional-normalized values. A joint principal component analysis (PCA) was applied, resulting in a robust set of variables, interpretable from the point of view of their self-grouping around vulnerability drivers. A separate PCA for each census was also conducted, which proved to be useful in analyzing changes in the composition and type of drivers, although only the joint PCA allows the monitoring of spatiotemporal changes in social vulnerability scores and drivers from 1991 to 2011. A general improvement in social vulnerability was observed for Portugal. The two main drivers are the economic condition (PC1), and aging and depopulation (PC2). The remaining drivers highlighted are uprooting and internal mobility, and daily commuting. Census data proved their value in the territorial, social, and demographic characterization of the country, to support medium- and long-term disaster risk reduction measures.