Mohammed F. Faramawi

Cardiovascular risk management and its impact on hypertension control in primary care in low-resource settings: a cluster-randomized trial

OBJECTIVE To evaluate a simple cardiovascular risk management package for assessing and managing cardiovascular risk using hypertension as an entry point in primary care facilities in low-resource settings. METHODS Two geographically distant regions in two countries (China and Nigeria) were selected and 10 pairs of primary care facilities in each region were randomly selected and matched. Regions were then randomly assigned to a control group, which received usual care, or to an intervention group, which applied the cardiovascular risk management package. Each facility enrolled 60 consecutive patients with hypertension. Intervention sites educated patients about risk factors at baseline and initiated treatment with hydrochlorothiazide at 4 months in patients at medium risk of a cardiovascular event, according to a standardized treatment algorithm. Systolic blood pressure change from baseline to 12 months was the primary outcome measure. FINDINGS The study included 2397 patients with baseline hypertension: 1191 in 20 intervention facilities and 1206 in 20 control facilities. Systolic and diastolic blood pressure decreased more in intervention patients than in controls. However, at 12 months more than half of patients still had uncontrolled hypertension (systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg). Behavioural risk factors had improved among intervention patients in Nigeria but not in China. Only about 2% of hypertensive patients required referral to the next level of care. CONCLUSION Even in low-resource settings, hypertensive patients can be effectively assessed and managed in primary care facilities.

Increased Risk of Cancer Mortality Associated with Cadmium Exposures in Older Americans with Low Zinc Intake

Cadmium (Cd) exposure has been associated with increased cancer risk, and zinc (Zn) appears to reduce that risk. However, little is known about the combined influence of Cd and Zn on cancer risk. The aim of this study was to examine relationships between Cd exposure, Zn intake, and cancer mortality risks. The analyses used 5204 subjects aged 50 yr or older from the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994) and the mortality follow-up through December 31, 2006. Cox proportional hazards models were used to test associations. In total, 569 cancer deaths were recorded during an average follow-up of 12.4 yr, including 155 from lung, 61 from prostate, and 26 from breast cancer. A positive association between Cd and cancer mortality risk was identified for both genders. Despite limited cause-specific deaths, the increased risk associated with Cd was significant for lung cancer in men. All-cause cancer mortality risk was significantly elevated among women with Zn intakes below the recommended dietary allowance (RDA) compared with women who met the RDA. The effect of low dietary Zn was not observed in men. Similar trends for prostate and breast cancer deaths were not significant. There was a significant inverse association between cancer deaths and the Zn-to-Cd ratio for both genders. Cd exposure is an important independent risk factor of cancer mortality in older Americans and the risk appears exaggerated in those with inadequate dietary Zn. Additional studies are required to elucidate the mechanism(s) by which Zn participates in the carcinogenic influence of Cd.

Consumption of different types of meat and the risk of renal cancer: meta-analysis of case–control studies

BackgroundKidney cancers account for almost 2% of all cancers worldwide, with 150,000 new cases and 78,000 deaths from the disease occurring annually. An increase in the incidence of kidney neoplasm in western countries was noticed in the past few years. Between 1988 and 1992, the incidence of renal cancer per 100,000 person-year among males in USA, Norway, and France was 34.1, 9.00, and 16.10, respectively. Among females in the same countries, it was 5.70, 5.00, and 7.30, respectively. Although several individual case–control studies examined the association of meat intake and renal cancer risk, the results were inconsistent because of the insufficient statistical power of the individual studies. Therefore, the following meta-analysis was designed to help in clarifying the association.MethodsElectronic search of MEDLINE, OVID, and PUBMED databases which have articles published between (1966 and 2006) was conducted to select studies for this meta-analysis.Statistical analysisFixed and random-effects meta-analytical techniques were used to estimate the overall association between meat consumption and kidney cancer.ResultsThirteen case–control studies were found. This meta-analysis supported a positive relationship between meat consumption and risk of renal cancer. Summary results indicated that there was from 20% to 22% higher risk of renal cancer among those in the highest relative to the lowest category of poultry and processed meat consumption. Consumption of all meat and red meat was associated with 27% and 30% higher risk, respectively. The increased risks were statistically significant.ConclusionsIncreased consumption of all meat, red meat, poultry, and processed meat is associated with an increase risk of kidney cancer. Reduction of meat consumption is an important approach to decreasing the incidence of kidney cancer in the general population.

The incidence of hepatitis E virus infection in the general population of the USA

Hepatitis E virus (HEV) infection is as an emerging disease of global importance because it is one of the major causes of acute hepatitis worldwide. There are few reports on the incidence of HEV in the USA. For better assessing the burden of primary HEV infection as well as understanding the epidemiology of HEV in the US population this analysis was conducted to estimate the force of infection of HEV in the USA. HEV force of infection in the general US population was calculated using catalytic models as cumulative markers of past infection from HEV seroprevalence data from the NHANES Survey. In the US population the force of infection was seven infections per 1000 susceptible persons per year. This study shows that in the USA HEV can be acquired locally and from developing countries. HEV is circulating more frequently in the non-Hispanic White racial/ethnic group and those who consume fish more frequently.

Frequency, molecular pathology and potential clinical significance of partial chromosome 3 aberrations in uveal melanoma

The clinical significance of partial chromosome 3 alteration in uveal melanoma is still not clear. Also, the reported frequencies vary considerably in the published literature from 0 to 48%. The aims of the following study were to identify the frequency, molecular pathology and potential clinical significance of partial chromosome 3 alteration in uveal melanoma. We studied 47 uveal melanomas with an average follow-up of 36 months. Of these, 14 had confirmed metastasis. Allelic imbalance/loss of heterozygosity was studied using microsatellite markers on chromosome 3 enriched in markers located in the previously reported smallest regions of deletion overlap. Chromosomal alterations were assessed by conventional cytogenetics or comparative genomic hybridization (CGH) in a subset of patients. Utilizing genotyping, partial chromosome 3 alteration was detected in 14/47 tumors (30%). In the 23 tumors with available cytogenetic/CGH, partial chromosome 3 alteration was detected in 8/23 (38%) and was caused by both gains (4/8) and losses (4/8) of chromosome 3 with high frequency of complex chromosome 3 aberrations detected by cytogenetics. Out of the 14 tumors with confirmed metastasis, only 1 showed partial chromosome 3 alteration and the remaining showed monosomy 3. By limiting the aggressive disease marker to monosomy 3, genotyping showed 93% sensitivity and 67% specificity for detection of aggressive uveal melanoma. In conclusion, partial chromosome 3 alterations are common in uveal melanoma and mostly caused by complex cytogenetic changes leading to partial gains and/or partial losses of chromosome 3. Partial chromosome 3 alteration is not likely to be associated with highly aggressive uveal melanoma that metastasizes within the first 3 years after treatment. Microsatellite-based genotyping of chromosome 3 is highly sensitive for detection of aggressive uveal melanoma.

Environmental exposure to dioxin-like compounds and the mortality risk in the U.S. population

BACKGROUND Little is known about the mortality risk associated with chronic dioxin exposure in the general U.S. populations. OBJECTIVE To explore the association between dioxin-like chemicals and mortality risk in a large population-based cohort study. METHODS The analysis included 2361 subjects aged 40 years or older from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). Exposure to a mixture of dioxin-like chemicals, including dibenzo-p-dioxins, dibenzofurans, and polychlorinated biphenyls was estimated using toxic equivalency values (TEQs) calculated with 2005 World Health Organization toxic equivalency factors. All-cause and cause-specific mortalities were obtained from the NHANES-linked follow-up data through December 31, 2006. Cox proportional-hazards models were applied to assess the associations of interest. RESULTS A total of 242 deaths occurred during the follow-up period, including 75 from cardiovascular disease and 72 from cancer. There was an increased mortality risk associated with logarithmically expressed dioxin TEQs for all-cause deaths (hazard ratio=1.19, 95% confidence interval=1.02-1.39, p=0.02). Similar graded dose-response trends were found for cardiovascular and cancer mortality which did not reach statistical significance. CONCLUSIONS In general, higher dioxin exposure is associated with an increased mortality risk among subjects aged 40 and above. The cause-specific analyses and responsible mechanisms will require further investigation.

Metabolic syndrome is associated with visit-to-visit systolic blood pressure variability in the US adults

Epidemiological studies have shown that blood pressure is not a constant variable. Evidence has accumulated showing that the blood pressure variability is associated with organ damage. A substantial increase in the prevalence of the metabolic syndrome has been documented globally. We examined the association of visit-to-visit blood pressure variability with the metabolic syndrome and its components, using data collected in the Third National Health and Nutrition Examination Survey. A multivariable generalized linear model was performed. The metabolic syndrome and its components, particularly hypertension, increased waist circumference and hyperglycemia, were significantly associated with systolic blood pressure variability across study visits (P<0.05). After adjusting for the effect of age, gender, race and antihypertensive medication, the multivariable analyses did not show significant relationships between the metabolic syndrome and diastolic blood pressure variability (P-values >0.05). Additional research is required to verify the observed results in prospective studies and evaluate approaches to reduce blood pressure variability observed in clinical settings among persons with the metabolic syndrome to reduce its subsequent complications.

The Association of the Metabolic Syndrome with T-wave Axis Deviation in NHANES III

PURPOSE We sought to study the association between metabolic syndrome (MetS) and abnormal T-wave axis deviation. METHODS A representative sample of the adult U.S. population, 3810 individuals 40 years of age or older, was categorized as having metabolic syndrome and not having the syndrome as defined by Adult Treatment Panel III. T-wave axis deviation was measured from the standard 12-lead electrocardiogram. RESULTS The odds of having abnormal T-wave axis deviation was calculated for those with metabolic syndrome versus those without after multivariable adjustment for age, race, daily alcohol consumption, body mass index categories, left ventricular hypertrophy, and heart rate. In multivariable weighted regression analysis, the odds were 2.03 times greater in those persons with MetS compared to those without (odds ratio, 1.79; 95% confidence interval, 1.04-3.11). The population-attributable risk percentage of abnormal T-wave axis deviation associated with MetS was 23.94%. Additionally, a graded relationship was observed between the number of MetS components and the odds ratio of abnormal T-wave axis (p trend < 0.01). CONCLUSION These data indicate that MetS is independently associated with an abnormal T-wave axis shift. This study calls for careful electrocardiographic monitoring among persons with MetS for early detection of abnormal T-wave axis in clinical practice to prevent severe and often fatal arrhythmias.

A comparative study of open, laparoscopic and robotic partial nephrectomy in obese patients

Objectives: Partial nephrectomy is a standard intervention for the treatment of small renal tumors. Our study compares the outcomes of three different partial nephrectomy methods (open, laparoscopic and robotic assisted) in obese (≥30 Kg/m 2 ) patients with renal tumors. Materials and Methods: Between 2005-2011, 66 obese patients had partial nephrectomy. Patients were divided into three groups according to intervention received: Open (n = 21), laparoscopic (n = 31) and robotic (n = 14). The outcome variables of blood loss, length of hospital stay, and complications were assessed. Results: Mean blood loss in the laparoscopic group (100 mls) was significantly less than open group (300 mls) and no difference between laparoscopic and robotic groups (150 mls). We observed a shorter median hospital stay in the laparoscopic group (two days) than open group (four days) and no difference between laparoscopic and robotic groups (three days). Three patients in the laparoscopic group had complications: Two grade II and one with grade III (based on Clavien-Dindo classification). Tumor location, pathology, grade, stage, patient gender, age, preoperative creatinine and postoperative creatinine were not different among the groups (P > 0.05). The mean tumor size in the laparoscopic group (2.70 cms) was significantly smaller than that of the open group (4.22 cm) (P; < 0.05), but not statistically different from that of the robotic group (2.99 cm). Conclusions: Our study demonstrates that in obese patients, both laparoscopic and robotic partial nephrectomy are associated with less blood loss than open partial nephrectomy. Second, the length of the hospital stay was not related to the type of utilized intervention.

Mortality in workers employed in pig abattoirs and processing plants.

OBJECTIVE workers in slaughterhouses and processing plants that handle pigs, and pork butchers/meatcutters have been little studied for health risks associated with employment, in spite of the fact that they are potentially exposed to oncogenic and non-oncogenic transmissible agents and chemical carcinogens at work. We report here on an update of mortality in 510 workers employed in abattoirs and processing plants that almost exclusively handled pigs and pork products. METHODS standardized mortality ratios (SMRs) were estimated for the cohort as a whole, and in subgroups defined by race and sex, using the corresponding US general population mortality rates for comparison. Study subjects were followed up from January 1950 to December 2006, during which time 45% of them died. RESULTS mortality was significantly increased overall in the cohort. A statistically significant excess of deaths was observed for colon and lung cancers in the entire cohort, SMR=2.7 (95% CI, 1.2-5.1), SMR=1.8 (95% CI, 1.1-2.7), respectively. Significant SMRs in the cohort as a whole were also observed for senile and pre-senile psychotic conditions (SMR=5.1, 95% CI, 1.4-13.1), and pneumonia (SMR=2.6, 95% CI, 1.3-4.8). An observed excess of subarachnoid hemorrhage was seen mainly in whites (SMR=10.1, 95% CI, 1.2-36.3). There was a suggestion of an excess of deaths from ischemic heart disease also, but the elevated SMR was confined to men and was not statistically significant. CONCLUSION this study confirms the excess occurrence of lung and colon cancers, and stroke previously reported in this occupational group. New findings are the excess of risk for senile and pre-senile psychotic conditions and pneumonia, which together with the excess of colon cancer appear specific for pig/pork workers, as they were not evident in much larger studies of workers in abattoirs and processing plants handling cattle and sheep. However, caution should be exercised in interpreting these findings, since some of them could have occurred by chance, resulting from our examination of a large number of causes of death in multiple study subgroups. For the moment, the significance of these findings remains unknown until they are confirmed in larger studies of adequate statistical power. Studies that will take into account possible occupational and non-occupational confounding factors are needed.