Heart Failure Care in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Background

Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs.

Methods and Findings

Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%–64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%–41%) with beta-blockers, and 32% (95% CI: 25%–39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%–7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%–10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified.

Conclusions

The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors'' Summary     

Soils selenium level and esophageal cancer: An ecological study in a high risk area for esophageal cancer

ProjectGolestan province, located in northeast of Iran, has been known as a high risk area for esophageal cancer (EC). This study was conducted to assess the relationship between soils selenium (Se) level and development of EC in this region.ProceduresIn this ecological study, 135 blocks were identified in Golestan province based on geographical altitude and longitude on the map. One soil sample was collected from the center of each block. Then we investigated Se concentration in soil samples by flame atomic absorption spectrometry. Statistical analysis was performed by the Pearson correlation test and Student t-tests. P-values of less than 0.05 were considered as significant.ResultsThe mean±SD of soils Se level in Golestan province was 3.7±1.61 mg/kg. There was a positive correlation between soils Se level and EC rates in this area (P=0.03) (Pearson correlation coefficient=0.19). Soils Se concentration was significantly higher in high (4.13 mg/kg) than in the low (3.39 mg/kg) EC rate areas (P=0.01).ConclusionsWe found high soils Se concentration and a significant positive relationship between soils Se level and EC rate in Golestan province of Iran. So, high soils Se level may play a possible role in developing EC in this area, specifically in Turkmensahra (very high EC rates).     

Differential transform semi-numerical analysis of biofluid-particle suspension flow and heat transfer in non-Darcian porous media

The differential transform method (DTM) is semi-numerical method which is used to study the steady, laminar buoyancy-driven convection heat transfer of a particulate biofluid suspension in a channel containing a porous material. A two-phase continuum model is used. A set of variables is implemented to reduce the ordinary differential equations for momentum and energy conservation (for both phases) to a dimensionless system. DTM solutions are obtained for the dimensionless system under appropriate boundary conditions. We examine the influence of momentum inverse Stokes number (Sk_m), Darcy number (Da), Forchheimer number (Fs), particle loading parameter (p_L), particle-phase wall slip parameter (Ω) and buoyancy parameter (B) on the fluid-phase velocity (U) and particle-phase velocity (U_p). Padé approximants are also employed to achieve satisfaction of boundary conditions. Excellent correlation is obtained between the DTM and numerical quadrature solutions. The results indicate that there is a strong decrease in fluid-phase velocities with increasing Darcian (first-order) drag and the second-order Forchheimer drag, and a weaker reduction in particle-phase velocity field. Fluid and particle-phase velocities are also strongly affected with inverse momentum Stokes number. DTM is shown to be a powerful tool providing engineers with an alternative simulation approach to other traditional methods for multi-phase computational biofluid mechanics. The model finds applications in haemotological separation and biotechnological processing.     

Real-time observation of flow-induced cytoskeletal stress in living cells

The mechanical stress due to shear flow has profound effects on cell proliferation, transport, gene expression, and apoptosis. The mechanisms for flow sensing and transduction are unclear, but it is postulated that fluid flow pulls upon the apical surface, and the resulting stress is eventually transmitted through the cytoskeleton to adhesion plaques on the basal surface. Here we report a direct observation of this flow-induced stress in the cytoskeleton in living cells using a parallel plate microfluidic chip with a fluorescence resonance energy transfer (FRET)-based mechanical stress sensor in actinin. The sensing cassette was genetically inserted into the cytoskeletal host protein and transfected into Madin-Darby canine kidney cells. A shear stress of 10 dyn/cm(2) resulted in a rapid increase in the FRET ratio indicating a decrease in stress across actinin with flow. The effect was reversible, and cells were able to respond to repeated stimulation and showed adaptive changes in the cytoskeleton. Flow-induced Ca(2+) elevation did not affect the response, suggesting that flow-induced changes in actinin stress are insensitive to intracellular Ca(2+) level. The reduction in FRET ratio suggests actin filaments are under normal compression in the presence of flow shear stress due to changes in cell shape, and/or actinin is not in series with actin. Treatment with cytochalasin-D that disrupts F-actin reduced prestress and the response to flow. The FRET/flow method is capable of resolving changes of stress in multiple proteins with optical spatial resolution and time resolution >1 Hz. This promises to provide insight into the force distribution and transduction in all cells.     

Probing the role of asparagine mutation in thermostability of Bacillus KR-8104 α-amylase

Asparagine deamidation is one of the important determinants of protein thermostability. Here, structure based mutagenesis has been done in order to probe the role of Asn residues in thermostability of a Ca independent Bacillus sp. KR-8104 α-amylase (BKA). Residues involved in potential deamidation processes have been selected and replaced using a site directed mutagenesis. Fourteen different variants were tested for thermostability by measuring residual activities after incubation at high temperature. In comparison to the wild-type enzyme, four mutated variants are able to increase the half life of the protein at high temperatures. The highest stabilization resulted from the substitution of asparatate in place of asparagine at position 112, leading to a nearly fivefold increase of the enzyme's half-life at 70°C. Also replacement of Asn129 to aspartic acid and Asn312 to serine markedly increased the half-life of the enzyme at 70°C indicating that the deamination of these residues may have a deleterious effect on BKA.     

Evaluation of Residence Time on Nitrogen Oxides Removal in Non-Thermal Plasma Reactor

Non-thermal plasma (NTP) has been introduced over the last few years as a promising after- treatment system for nitrogen oxides and particulate matter removal from diesel exhaust. NTP technology has not been commercialised as yet, due to its high rate of energy consumption. Therefore, it is important to seek out new methods to improve NTP performance. Residence time is a crucial parameter in engine exhaust emissions treatment. In this paper, different electrode shapes are analysed and the corresponding residence time and NO_x removal efficiency are studied. An axisymmetric laminar model is used for obtaining residence time distribution numerically using FLUENT software. If the mean residence time in a NTP plasma reactor increases, there will be a corresponding increase in the reaction time and consequently the pollutant removal efficiency increases. Three different screw thread electrodes and a rod electrode are examined. The results show the advantage of screw thread electrodes in comparison with the rod electrode. Furthermore, between the screw thread electrodes, the electrode with the thread width of 1 mm has the highest NO_x removal due to higher residence time and a greater number of micro-discharges. The results show that the residence time of the screw thread electrode with a thread width of 1 mm is 21% more than for the rod electrode.     

Direct and indirect roles of His‐418 in metal binding and in the activity of β‐galactosidase (E. coli)

The active site of ß‐galactosidase (E. coli) contains a Mg²⁺ ion ligated by Glu‐416, His‐418 and Glu‐461 plus three water molecules. A Na⁺ ion binds nearby. To better understand the role of the active site Mg²⁺ and its ligands, His‐418 was substituted with Asn, Glu and Phe. The Asn‐418 and Glu‐418 variants could be crystallized and the structures were shown to be very similar to native enzyme. The Glu‐418 variant showed increased mobility of some residues in the active site, which explains why the substitutions at the Mg²⁺ site also reduce Na⁺ binding affinity. The Phe variant had reduced stability, bound Mg²⁺ weakly and could not be crystallized. All three variants have low catalytic activity due to large decreases in the degalactosylation rate. Large decreases in substrate binding affinity were also observed but transition state analogs bound as well or better than to native. The results indicate that His‐418, together with the Mg²⁺, modulate the central role of Glu‐461 in binding and as a general acid/base catalyst in the overall catalytic mechanism. Glucose binding as an acceptor was also dramatically decreased, indicating that His‐418 is very important for the formation of allolactose (the natural inducer of the lac operon).     

Cell-phone-based platform for biomedical device development and education applications

In this paper we report the development of two attachments to a commercial cell phone that transform the phone's integrated lens and image sensor into a 350x microscope and visible-light spectrometer. The microscope is capable of transmission and polarized microscopy modes and is shown to have 1.5 micron resolution and a usable field-of-view of 150 x 50 with no image processing, and approximately 350 x 350 when post-processing is applied. The spectrometer has a 300 nm bandwidth with a limiting spectral resolution of close to 5 nm. We show applications of the devices to medically relevant problems. In the case of the microscope, we image both stained and unstained blood-smears showing the ability to acquire images of similar quality to commercial microscope platforms, thus allowing diagnosis of clinical pathologies. With the spectrometer we demonstrate acquisition of a white-light transmission spectrum through diffuse tissue as well as the acquisition of a fluorescence spectrum. We also envision the devices to have immediate relevance in the educational field.