Raising the priority of preventing chronic diseases: a political process

Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases,are neglected globally despite growing awareness of the serious burden that they cause. Global and national policies have failed to stop, and in many cases have contributed to, the chronic disease pandemic. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. We seek to understand this failure and to position chronic disease centrally on the global health and development agendas. To identify strategies for generation of increased political priority for chronic diseases and to further the involvement of development agencies, we use an adapted political process model. This model has previously been used to assess the success and failure of social movements. On the basis of this analysis,we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build one merging strategic and political opportunities, such as the World Health Assembly 2008–13 Action Plan and the high level meeting of the UN General Assembly in 2011 on chronic disease. Until the full set of threats—which include chronic disease—that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate.     

Is depression associated with microvascular disease in patients with type 2 diabetes?

We hypothesize that late-life depression is a manifestation of microvascular disease in patients with type 2 diabetes. We conducted a clinic-based cross-sectional study, comparing retinal vascular caliber, a marker of microvascular disease, in participants with type 2 diabetes with major depression (n=34), without depression (n=27) and healthy non-diabetic controls (n=38). Retinal vascular caliber was measured from digital retinal photographs using a validated computer-assisted method. After adjusting for age and gender, there was a trend of increasing retinal arteriolar caliber from healthy controls (132.6 microm), to diabetic patients without depression (139.2 microm), and diabetic patients with major depression (145.3 microm, P=0.008). The trend in retinal arteriolar caliber remains significant after adjusting for duration of diabetes, but not after further adjusting for vascular risk factors. Our findings suggest that there is variation in the retinal vascular caliber between type 2 diabetic patients with and without major depression and non-diabetic controls. This variation was largely related to poorer diabetes control and a higher frequency of vascular risk factors in diabetic patients, particularly those with depression. Studies with larger sample size may provide further insights into this association.     

Prevalence of recurrent otitis media in habitually snoring school-aged children

INTRODUCTION: The pathophysiology of obstructive sleep apnea (OSA) and recurrent otitis media (ROM) is intimately associated with the presence of adenotonsillar hypertrophy in children. However, it remains unclear whether habitually snoring children have a higher prevalence of ROM and whether they require tympanostomy tube placement more frequently. METHODS: Questionnaires collected from parental surveys of 5- to 7-year-old children attending the public schools in Louisville, KY were retrospectively reviewed for the presence of habitual snoring (HS), ROM, and the need for tympanostomy tube insertion. RESULTS: There were 16,321 surveys with complete datasets (51.2% boys; 18.6% African American (AA) with a mean age of 6.2+/-0.7 years). Of these children, 1844 (11.3%) were HS (53% boys; 25.9% AA); and, of these, 827 HS had also a positive history of ROM (44.8%) with a slight predominance in males (55%). In addition, 636 of these children underwent placement of tympanostomy tubes (i.e., 34.4% of all HS and 76.9% of ROM). Among the 14,477 non-snoring children (NS), ROM was reported in 4247 NS children (29.3%; p<0.000001; odds ratio [OR]: 1.95; confidence interval [CI]: 1.77-2.16) of which 57.6% were boys, and 1969 NS with ROM underwent tympanostomy tube placement (i.e., 46.3% of those with ROM and 13.6% of all non-snoring children). Thus, the risk for tympanostomy tube placement was also greater among HS compared to NS children (p<0.00001; OR: 2.19; CI: 1.98-2.43). CONCLUSIONS: Habitual snoring is associated with a significant increase in the prevalence of recurrent otitis media and the need for tympanostomy tube placement. Further studies aiming to assess the prevalence of obstructive sleep apnea among children with ROM are needed.     

Ischemic preconditioning is lost in aging hypertensive rat heart: independent effects of aging and longstanding hypertension

Although in experimental hypertension the cardioprotective effects of ischemic preconditioning (PC) appear to be maintained, most studies have examined the short-term hypertension in juvenile animals. However, aging may be an additional factor that influences the effectiveness of PC. The aim of this study was to characterise the effects on PC of LVH and aging simultaneously. Hearts from spontaneously hypertensive rats (SHR) and age-matched normotensive Wistar-Kyoto rats (WKY) were studied. Excised hearts were Langendorff-perfused to give equivalent coronary flow per gram heart weight. The left main coronary artery was occluded for 35 min followed by 120 min reperfusion. Infarct size was determined by tetrazolium staining. Heart size was assessed as left ventricle/body weight ratio (LV/BW). PC was effected with 2 x 5 min periods of global ischemia prior to coronary occlusion. Hearts were studied at 3-4 months (juvenile), 7-8 months (mature) or 12-13 months (aging). LV/BW ratio in SHR increased relative to WKY controls by 20%, 32% and 40% in juvenile, mature and aging hearts, respectively, but ischemic risk zone size was similar in all groups (52-59% of LV). PC was equally effective at limiting infarct size in juvenile and mature SHR and WKY hearts but was ineffective in aging hearts from both WKY and SHR. Since angiotensin-converting enzyme inhibitors enhance sub-threshold PC in normal myocardium, we also examined the action of captopril (Cap) in aging hearts. Additional aging hearts received treatment with Cap 200 microM as an adjunct to PC. Although Cap+PC was able to induce modest protection in aging WKY hearts, this was not seen in aging SHR hearts. We conclude that PC is lost in longstanding hypertension through independent contributions of both hypertension and aging. These findings may have implications for the clinical development of preconditioning-based therapies since elderly patients with longstanding hypertension are at high risk of developing ischemic heart disease.     

Determinants of reduced walking speed in people with musculoskeletal pain

OBJECTIVE: Maintenance of good walking speed is essential to independent living. People with musculoskeletal disease often have reduced walking speed. We investigated determinants of slower walking, other than musculoskeletal disease, that might provide valuable additional targets for therapy. METHODS: We analyzed data from the Somerset and Avon Survey of Health, a community based survey of people aged over 35 years. A total of 2703 participants who reported hip or knee pain at baseline (1994/1995) were studied, and reassessed in 2002-2003; 1696 were available for followup, and walking speed was tested in 1074. Walking speed (m/s) was used as outcome measure. Baseline characteristics, including comorbidities and socioeconomic factors, were tested for their ability to predict reduced walking speed using multiple linear regression analysis. RESULTS: Age, female sex, and immobility at baseline were predictive of slower walking speed. Other independent risk factors included the presence of cataract, low socioeconomic status, intermittent claudication, and other cardiovascular conditions. Having a cataract was associated with a decrease of 0.10 m/s (95% CI 0.03, 0.16). Those in social class V had a walking speed 0.22 m/s (95% CI 0.126, 0.31) slower than those in social class I. CONCLUSION: Comorbidities, age, female sex, and lower socioeconomic position determine walking speed in people with joint pain. Issues such as poor vision and social-economic disadvantage may add to the effect of musculoskeletal disease, suggesting the need for a holistic approach to management of these patients.     

Evaluation of [67Ga]-insulin for insulin receptor imaging

BACKGROUND: Radiolabelled human recombinant insulin can be used for the imaging of insulin receptors in some tumours where FDG has natural uptake and diminishes the value of its imaging. MATERIAL AND METHODS: Insulin was successively labelled with [(67)Ga]-gallium chloride after conjugation with freshly prepared cyclic DTPA-dianhydride (HPLC radiochemical purity assay > 96%) followed by biodistribution studies in normal rats, white blood cell labelling and preliminary SPECT studies. RESULTS: In vitro studies demonstrated the retention of radiolabelled insulin receptor affinity using freshly prepared human white blood cells at different blood sugar conditions. Preliminary in vivo studies in a normal rat model was performed to determine the biodistribution of the radioimmunoconjugate at up to 44 h. SPECT images revealed high uptake of the liver. CONCLUSION: Radiolabelled insulin is stable enough to be used in biological studies in order to image insulin receptors in diabetic conditions as well as possible tumour imaging applications. The data was consistent with other radiolabelled insulin studies.