Community screening for cardiovascular risk factors and levels of treatment in a rural Māori cohort

A Polynesian-specific missense CETP variant alters the lipid profile

Identifying population-specific genetic variants associated with disease and disease-predisposing traits is important to provide insights into the genetic determinants of health and disease between populations, as well as furthering genomic justice. Various common pan-population polymorphisms at CETP associate with serum lipid profiles and cardiovascular disease. Here, sequencing of CETP identified a missense variant rs1597000001 (p.Pro177Leu) specific to Māori and Pacific people that associates with higher HDL-C and lower LDL-C levels. Each copy of the minor allele associated with higher HDL-C by 0.236 mmol/L and lower LDL-C by 0.133 mmol/L. The rs1597000001 effect on HDL-C is comparable with CETP Mendelian loss-of-function mutations that result in CETP deficiency, consistent with our data, which shows that rs1597000001 lowers CETP activity by 27.9%. This study highlights the potential of population-specific genetic analyses for improving equity in genomics and health outcomes for population groups underrepresented in genomic studies.

Readiness of the primary health care units and associated factors for the management of hypertension and type II diabetes mellitus in Sidama, Ethiopia

Background

In low-income nations such as Ethiopia, noncommunicable diseases (NCDs) are becoming more common. The Ethiopian Ministry of Health has prioritized NCD prevention, early diagnosis, and management. However, research on the readiness of public health facilities to address NCDs, particularly hypertension and type II diabetes mellitus, is limited.

Methods

The study used a multistage cluster sampling method and a health facility-based cross-sectional study design. A total of 83 health facilities were evaluated based on WHO's Service Availability and Readiness Assessment (SARA) tool to investigate the availability of services and the readiness of the primary health care unit (PHCU) to manage type II diabetes and Hypertension. Trained data collectors interviewed with PHCU head or NCD focal persons. The study tried to investigate (1) the availability of basic amenities and the four domains: staff and guidelines, basic equipment, diagnostic materials, and essential medicines used to manage DM and HPN, (2) the readiness of the PHCU to manage DM and HPN. The data were processed by using SPSS version 24. Descriptive statistics, including frequency and percentage, inferential statistics like the chi-square test, and logistic regression models were used to analyze the data.

Results

Of the 82 health facilities, only 29% and 28% of the PHCU identified as ready to manage HPN and DM. Facility type, facility location, presence of guidelines, trained staff, groups of antihypertensive and antidiabetic medicines had a significant impact (P < 0.05) on the readiness of the PHCU to manage HPN and DM at a 0.05 level of significance. Facilities located in urban were 8.2 times more likely to be ready to manage HPN cases than facilities located in rural (AOR = 8.2, 95% CI [2.4-28.5]) and P < 0.05.

Conclusion and recommendation

The results identified comparatively poor and deprived readiness to offer HPN and DM services at lower-level health facilities(health centers). Equipping the lower-level health facilities with screening and diagnostic materials, essential medicines, and provision of basic training for the health care providers and NCD guidelines should be available, especially in the lower health care facilities.

Echocardiography for latent rheumatic heart disease in first degree relatives of children with acute rheumatic fever: Implications for active case finding in family members

BACKGROUND

Individuals with Acute Rheumatic Fever (ARF) often report a family history of ARF or Rheumatic Heart Disease (RHD) however the degree of familial susceptibility to RHD is poorly defined. This study aimed to determine RHD prevalence among first degree relatives of ARF patients using echocardiography.

METHODS

Children with ARF were recruited from Auckland, New Zealand. Parents and siblings ≥ 4years were offered echocardiography. Echocardiograms were reported according to World Heart Federation 2012 criteria. RHD prevalence in first degree relatives was compared to previously established population rates in the region.

FINDINGS

In total, 70 index cases with ARF were recruited. Echocardiography was performed in 94 parents and 132 siblings. There were 3 siblings with definite RHD and 9 with borderline RHD. There were 4 parents with definite RHD. Overall prevalence of RHD (definite and borderline) in siblings was 90/1,000 (95% CI 45-143/1,000) compared to 36/1,000 (95% CI 30-42/1,000) in New Zealand children from high ARF incidence populations (p 0.001). Prevalence of definite RHD in parents was 42/1,000 (95% CI 7-87/1,000) compared to 22/1,000 (95% CI 9-36/1,000) in adults from a high ARF incidence New Zealand population (p 0.249).

INTERPRETATION

RHD prevalence in siblings and parents of ARF cases is significantly greater than in comparable background populations. The contribution of hereditary versus environmental risk factors remains uncertain. We recommend targeted echocardiographic case-finding among siblings and parents of ARF/RHD cases in order to detect previously unrecognized latent RHD.

Primary Prevention of Cardiovascular Disease in Minority Indigenous Populations: A Systematic Review

INTRODUCTION

Cardiovascular disease (CVD) is the commonest cause of death across the globe; incidence and prevalence rates are increasing. Together, CVD and diabetes mellitus are responsible for a quarter of the health gap observed between Aboriginal Australians and Torres Strait Islanders, and non-Indigenous Australians. Numerous programs have been proposed and implemented to Close the Gap; ideally, these should be evidence-based.

OBJECTIVE

The aim of this review is to evaluate primary prevention measures and programs that aim to reduce CVD risk in minority Indigenous populations around the world.

METHODS

A search of PubMed, the Cochrane Library and the Elsevier Scopus Database was initially conducted using the terms "cardiovascular disease", "population groups", "primary prevention", "health services, indigenous", "indigenous health", "risk assessment" and "risk management". Results were then assessed per inclusion/exclusion criteria. A second reviewer independently evaluated the publications and review process to ensure agreement.

RESULTS

The initial search produced 37 publications; 19 met the inclusion criteria and were incorporated into a comparative table. Most were descriptive, mixed-methods, audit or intervention studies. Heterogeneity of study design prevented statistical analysis.

CONCLUSION

Addressing CVD risk in minority Indigenous populations is a multifactorial challenge; there is substantial room for improvement in routine risk assessment and management. Holistic approaches need to embrace local cultural perceptions of health and wellbeing. Validated risk reduction tools, individualised management plans, polypills and computer based decision support tools are promising to improve outcomes for those at risk.

Primary prevention of stroke and cardiovascular disease in the community (PREVENTS): Methodology of a health wellness coaching intervention to reduce stroke and cardiovascular disease risk, a randomized clinical trial

Rationale Stroke is a major cause of death and disability worldwide, yet 80% of strokes can be prevented through modifications of risk factors and lifestyle and by medication. While management strategies for primary stroke prevention in high cardiovascular disease risk individuals are well established, they are underutilized and existing practice of primary stroke prevention are inadequate. Behavioral interventions are emerging as highly promising strategies to improve cardiovascular disease risk factor management. Health Wellness Coaching is an innovative, patient-focused and cost-effective, multidimensional psychological intervention designed to motivate participants to adhere to recommended medication and lifestyle changes and has been shown to improve health and enhance well-being. Aims and/or hypothesis To determine the effectiveness of Health Wellness Coaching for primary stroke prevention in an ethnically diverse sample including Māori, Pacific Island, New Zealand European and Asian participants. Design A parallel, prospective, randomized, open-treatment, single-blinded end-point trial. Participants include 320 adults with absolute five-year cardiovascular disease risk ≥ 10%, calculated using the PREDICT web-based clinical tool. Randomization will be to Health Wellness Coaching or usual care groups. Participants randomized to Health Wellness Coaching will receive 15 coaching sessions over nine months. Study outcomes A substantial relative risk reduction of five-year cardiovascular disease risk at nine months post-randomization, which is defined as 10% relative risk reduction among those at moderate five-year cardiovascular disease risk (10-15%) and 25% among those at high risk (>15%). Discussion This clinical trial will determine whether Health Wellness Coaching is an effective intervention for reducing modifiable risk factors, and hence decrease the risk of stroke and cardiovascular disease.

Systematic review of disparities in surgical care for Māori in New Zealand

BACKGROUND

Health equity for Indigenous peoples in the context of surgery has recently become topical amongst surgeons in Australasia. Health inequities are amongst the most consistent and compelling disparities between Māori and New Zealand Europeans (NZE) in New Zealand (NZ). We aimed to investigate where ethnic disparities in surgical care may occur and highlight some of the potential contributing factors, over all surgical specialties, between Māori and NZE adults in NZ.

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A series of electronic searches were performed in Medline, Embase, PubMed and CINAHL.

RESULTS

Ten studies met the inclusion criteria. All studies employed a range of indicators for surgical care including receipt of surgery following diagnosis, delays to treatment and post-operative morbidity and mortality. Disparities in the receipt of surgical treatment for several cancers were observed for Māori and remained after adjustment for socioeconomic variables and extent of disease. Māori were more likely to experience delays in treatment and referral to other medical specialties involved in their care.

CONCLUSION

Despite the significant variation in the types of diseases, procedures and indicators of surgical care of the included studies, consistent findings are that disparities in different aspects of surgical care exist between Māori and NZE in NZ. This review highlights the need to better quantify the important issue of health equity for Māori in surgery given the lack of studies over the majority of surgical specialties.

Effectiveness of a community screening program for metabolic syndrome and cardiovascular risk factor identification in young South Asians adults

AIMS

Metabolic syndrome has been associated with increased risk of cardiovascular disease. We aimed to determine the effectiveness of a community-based screening program in identifying cardiovascular risk factors in healthy young South Asian population.

MATERIALS AND METHODS

Between 2006 and 2011, 3314 patients of all ages were recruited as a part of a prospective cohort study investigating cardiovascular risk in South Asians. We analyzed 1537 patients between the ages of 18 and 40. Demographic and baseline characteristics including baseline laboratory markers and blood pressures were obtained at initial visit.

RESULTS

The total cohort of 1537 patients was 66.5% male, and the mean age was 35±5 years. Among participants who denied a history of hypercholesterolemia, 62% had elevated LDL-C (>100 mg/dL), and 8% had markedly elevated LDL-C (>160 mg/dL). Overall, diabetes was present in 4%, hypertension was present in 12% and hyperlipidemia was present in 46%. Low HDL-C (50% of men, 52% of women) and elevated triglycerides (44% of men, 18% of women) were the most prevalent components of metabolic syndrome. Metabolic syndrome was present in 14% of men and 8% of women and one-third (30%) of men and one-fifth (19%) of women had at least two component risk factors.

CONCLUSIONS

This is the largest study to date assessing effectiveness of a community based screening program aiming to identify cardiovascular risk in young South Asians. We note significant modifiable risk at a young age. Such community based interventions can be effective at detecting and managing risk factors early in this vulnerable population.

Hyperuricaemia and gout in New Zealand rural and urban Māori and non-Māori communities

BACKGROUND

There are few current data on the prevalence of hyperuricaemia and gout in New Zealand, particularly among the indigenous Māori population.

AIMS

To determine the prevalence of gout and hyperuricaemia in rural and urban Māori and non-Māori community samples and describe the treatment and comorbidities of participants with gout.

METHODS

Participants aged 20-64 years were recruited by random selection from the electoral roll. Māori samples were selected from among those identified as being of Māori descent on the roll and who self-identified as being of Māori ethnicity at interview. Personal medical history, blood pressure, anthropometrics, fasting lipids, glucose, HbA1c and urate were recorded.

RESULTS

There were 751 participants. Mean serum urate (SU) was 0.30 mmol/L (0.06-0.69 mmol/L). Māori had a significantly higher prevalence of hyperuricaemia (SU > 0.40 mmol/L) compared with non-Māori (17.0% vs 7.5%, P = 0.0003). A total of 57 participants had a history of gout, with a higher prevalence in Māori compared with non-Māori (10.3% vs 2.3%, P < 0.0001). Of the participants, 18/57 (31.6%) with gout were receiving urate-lowering therapy, but in 38.9%, SU was >0.36 mmol/L. Participants with gout were more likely to have metabolic syndrome, diabetes, cardiac disease or hypertension.

CONCLUSIONS

Gout and hyperuricaemia were more prevalent in Māori, and participants with gout were more likely to have comorbidities. There was not a higher overall adjusted cardiovascular disease risk in Māori participants with gout. Despite the high prevalence of gout, management remains suboptimal.

A cohort study comparing cardiovascular risk factors in rural Maori, urban Maori and non-Maori communities in New Zealand

OBJECTIVES

To understand health disparities in cardiovascular disease (CVD) in the indigenous Māori of New Zealand, diagnosed and undiagnosed CVD risk factors were compared in rural Māori in an area remote from health services with urban Māori and non-Māori in a city well served with health services.

DESIGN

Prospective cohort study.

SETTING

Hauora Manawa is a cohort study of diagnosed and previously undiagnosed CVD, diabetes and risk factors, based on random selection from electoral rolls of the rural Wairoa District and Christchurch City, New Zealand.

PARTICIPANTS

Screening clinics were attended by 252 rural Māori, 243 urban Māori and 256 urban non-Māori, aged 20-64 years.

MAIN OUTCOME MEASURES

The study documented personal and family medical history, blood pressure, anthropometrics, fasting lipids, insulin, glucose, HbA1c and urate to identify risk factors in common and those that differ among the three communities.

RESULTS

Mean age (SD) was 45.7 (11.5) versus 42.6 (11.2) versus 43.6 (11.5) years in rural Māori, urban Māori and non-Māori, respectively. Age-adjusted rates of diagnosed cardiac disease were not significantly different across the cohorts (7.5% vs 5.8% vs 2.8%, p=0.073). However, rural Māori had significantly higher levels of type-2 diabetes (10.7% vs 3.7% vs 2.4%, p<0.001), diagnosed hypertension (25.0% vs 14.9% vs 10.7%, p<0.001), treated dyslipidaemia (15.7% vs 7.1% vs 2.8%, p<0.001), current smoking (42.8% vs 30.5% vs 15.2%, p<0.001) and age-adjusted body mass index (30.7 (7.3) vs 29.1 (6.4) vs 26.1 (4.5) kg/m(2), p<0.001). Similarly high rates of previously undocumented elevated blood pressure (22.2% vs 23.5% vs 17.6%, p=0.235) and high cholesterol (42.1% vs 54.3% vs 42.2%, p=0.008) were observed across all cohorts.

CONCLUSIONS

Supporting integrated rural healthcare to provide screening and management of CVD risk factors would reduce health disparities in this indigenous population.