Significant challenges remain to achieve risk reduction targets for cardiovascular secondary prevention and diabetes

Objective: To examine population-level evidence treatment gaps for cardiovascular risk among rural patients with existing cardiovascular disease or diabetes.

Methods: Three population surveys were undertaken in the Greater Green Triangle region of southeastern Australia 2004-2006. Adults aged 25-84 yrs were randomly selected using age/sex stratified electoral role samples. A representative 1690 participants were recruited (48% participation rate). Anthropometric, clinical and self-administered questionnaire chronic disease risk data were collected in accordance with the WHO MONICA protocol. Detailed investigation of cardiovascular and diabetes history, key cardiovascular risk factors, medication use and health behaviours were included.

Results: After adjusting for age and sex, an estimated 12% (sample n=272) of the population had one or more of coronary heart disease, stroke, or diabetes. Blood pressure was at target (<130/80 mmHg) for 26% of these individuals, and 61% were treated with antihypertensive medications. Lipid targets were achieved by 17% for total cholesterol (<4 mmol/L), 18% for LDL cholesterol (<2 mmol/L), 77% for HDL cholesterol (>1.0 mmol/L) and 44% for triglycerides (<1.5 mmol/L); overall 6% achieved all four lipid targets and 60% reported use of lipid-lowering therapy, including 51% overall using statins. Ten percent were current smokers, and four in every five patients (82%) had suboptimal BMI (outside the range 18.5 - 25.0).

Conclusions: All participants with uncontrolled blood pressure and most with uncontrolled lipids should be taking medications. The magnitude of evidence treatment gaps suggests existing models of care need fundamental reform and renewed focus on prevention.

Ontogeny of energy allocation reveals selective pressure promoting risk-taking behaviour in young fish cohorts

Given limited food, prey fishes in a temperate climate must take risks to acquire sufficient reserves for winter and/or to outgrow vulnerability to predation. However, how can we distinguish which selective pressure promotes risk-taking when larger body size is always beneficial? To address this question, we examined patterns of energy allocation in populations of age-0 trout to determine if greater risk-taking corresponds with energy allocation to lipids or to somatic growth. Trout achieved maximum growth rates in all lakes and allocated nearly all of their acquired energy to somatic growth when small in early summer. However, trout in low-food lakes took greater risks to achieve this maximal growth, and therefore incurred high mortality. By late summer, age-0 trout allocated considerable energy to lipids and used previously risky habitats in all lakes. These results indicate that: (i) the size-dependent risk of predation (which is independent of behaviour) promotes risk-taking behaviour of age-0 trout to increase growth and minimize time spent in vulnerable sizes; and (ii) the physiology of energy allocation and behaviour interact to mediate growth/mortality trade-offs for young animals at risk of predation and starvation.

Predators select against high growth rates and risk-taking behaviour in domestic trout populations

Domesticated (farm) salmonid fishes display an increased willingness to accept risk while foraging, and achieve high growth rates not observed in nature. Theory predicts that elevated growth rates in domestic salmonids will result in greater risk–taking to access abundant food, but low survival in the presence of predators. In replicated whole–lake experiments, we observed that domestic trout (selected for high growth rates) took greater risks while foraging and grew faster than a wild strain. However, survival consequences for greater growth rates depended upon the predation environment. Domestic trout experienced greater survival when risk was low, but lower survival when risk was high. This suggests that animals with high intrinsic growth rates are selected against in populations with abundant predators, explaining the absence of such phenotypes in nature. This is, to our knowledge, the first large–scale field experiment to directly test this theory and simultaneously quantify the initial invasibility of domestic salmonid strains that escape into the wild from aquaculture operations, and the ecological conditions affecting their survival.

The effectiveness of health interventions in cardiovascular risk reduction among emergency service personnel

Purpose
The physical demands and hazards associated with emergency service work place particular stress on responders’ cardiovascular systems. Indeed, cardiovascular disease (CVD) is a significant problem for emergency service personnel. Although it may be difficult to alter the cardiovascular health hazards associated with the work environment, it is possible for personnel to control their modifiable CVD risk factors, cardiovascular fitness levels and subsequently, reduce their CVD risk. This review aimed to determine the effectiveness and methodological quality of health interventions designed to mitigate CVD risk in emergency service personnel.

Methods
A literature search of electronic journal databases was performed. Sixteen relevant studies were assessed for methodological quality using a standardised assessment tool. Data regarding the effectiveness of each intervention were extracted and synthesised in a narrative format.

Results
Fifteen studies were rated ‘Weak’ and one study was rated ‘Strong’. Interventions which combined behavioural counselling, exercise and nutrition were more effective in improving cardiovascular health than nutrition, exercise or CVD risk factor assessment-based interventions alone. Further, CVD risk factor assessment in isolation proved to be an ineffective intervention type to reduce CVD risk.

Conclusion
Combined interventions appear most effective in improving the cardiovascular health of emergency service personnel. Accordingly, fire and emergency service agencies should consider trialling multifaceted interventions to improve the cardiovascular health of personnel and avoid interventions focused only on one of nutrition, exercise or CVD risk factor assessment. However, as most studies were methodologically weak, further studies of a higher methodological quality are needed.

Flocking and feeding in the fiddler crab (UCA tangeri): prey availability as risk-taking behaviour

For a full understanding of prey availability, it is necessary to study risk-taking behaviour of the prey. Fiddler crabs are ideally suited for such a study, as they have to leave their safe burrow to feed on the surface of the intertidal flats during low tide, thereby exposing themselves to avian predators. A study in an intertidal area along the coast of Mauritania showed that small crabs always stayed in the vicinity of their burrow, but large crabs wandered in large flocks (also referred to as droves) to feed on sea-grass beds downshore. Transplanting downshore feeding substrate to the burrowing zone of the small crabs proved that they too preferred to feed on it. Since small crabs can be preyed upon by more species of birds, this suggests that the decision not to leave the burrowing zone might be related to the risk of being fed upon by birds. We calculated predation risk from measurements on the density and feeding activity of the crabs, as well as the feeding density, the intake rate and the size selection of the avian predators. Per hour on the surface, crabs in a flock were more at risk than crabs feeding near their burrow. Thus, though flocking crabs may have benefited from ‘swamping the predator’ by emerging in maximum numbers during some tides only, this did not reduce their risk of predation below that of non-flocking crabs. Furthermore we found that irrespective of activity, large crabs suffered a higher mortality per tide from avian predators than small crabs. This suggests that large crabs could not sufficiently reduce their foraging time to compensate for the increased risk while foraging in a flock, even though they probably experienced better feeding conditions than small crabs staying near their burrow. The greater energy demands of large crabs were reflected in a greater surface area grazed. Thus, with increasing size a fiddler crab has to feed further away from its burrow and so may derive less protection from staying near to it. It seems that growing big does not reduce the risk of predation for fiddler crabs, as it does in many other species with indeterminate growth. As in such species, the most probable advantage of growing big is increased mating success. Ultimately, therefore, prey availability must be understood from the life-history decisions of the prey species.

Disaster risk reduction in the education sector among selected Caribbean small island developing states

Caribbean Small Island Developing States (SIDS), by their very nature, are vulnerable to external shocks. Research shows that the Caribbean subregion experienced 165 natural disasters between 1990 and 2008 and the total impact of natural disasters on the subregion was estimated at US$136 billion. The impact on the social sectors was estimated at US$57 billion, or 42% of the total effect. As small open economies, the Caribbean SIDS are also vulnerable to the vagaries of the international economic system and have experienced declines in tourism, merchandise exports receipts, remittances and capital flows throughout the financial crisis. The negative impact of natural hazards exacerbates the capacity of Caribbean SIDS to overcome the development challenges, such as those posed by the current global economic and financial crisis. Disaster risk reduction (DRR), therefore, is of critical concern to subregional governments and their people. For the purpose of this study, six Caribbean SIDS were selected for detailed analyses on the macro socio-economic impact of extreme events to the education sector. They are the Cayman Islands, Grenada, Guyana, Haiti, Jamaica, and Montserrat. This paper proposes that better integration of DRR in the education sector cannot be easily achieved if policymakers do not recognize the social nature of risk perception and acceptance in Caribbean SIDS, which necessitates that risk reduction be treated as a negotiated process which engages all stakeholders.

Cardiometabolic risk reduction through lifestyle intervention programs in the Brazilian public health system

Public health strategies to reduce cardiovascular morbidity and mortality should focus on global cardiometabolic risk reduction. The efficacy of lifestyle changes to prevent type 2 diabetes have been demonstrated, but low-cost interventions to reduce cardiometabolic risk in Latin-America have been rarely reported. Our group developed 2 programs to promote health of high-risk individuals attending a primary care center in Brazil. This study compared the effects of two 9-month lifestyle interventions, one based on medical consultations (traditional) and another with 13 multi-professional group sessions in addition to the medical consultations (intensive) on cardiometabolic parameters. Adults were eligible if they had pre-diabetes (according to the American Diabetes Association) and/or metabolic syndrome (International Diabetes Federation criteria for Latin-America). Data were expressed as means and standard deviations or percentages and compared between groups or testing visits. A p-value < 0.05 was considered significant. Results: 180 individuals agreed to participate (35.0% men, mean age 54.7 ± 12.3 years, 86.1% overweight or obese). 83 were allocated to the traditional and 97 to the intensive program. Both interventions reduced body mass index, waist circumference and tumor necrosis factor-α. Only intensive program reduced 2-hour plasma glucose and blood pressure and increased adiponectin values, but HDL-cholesterol increased only in the traditional. Also, responses to programs were better in intensive compared to traditional program in terms of blood pressure and adiponectin improvements. No new case of diabetes in intensive but 3 cases and one myocardial infarction in traditional program were detected. Both programs induced metabolic improvement in the short-term, but if better results in the intensive are due to higher awareness about risk and self-motivation deserves further investigation. In conclusion, these low-cost interventions are able to minimize cardiometabolic risk factors involved in the progression to type 2 diabetes and/or cardiovascular disease.

Effect of vagus nerve stimulation in an adult patient with Dravet syndrome: contribution to sudden unexpected death in epilepsy risk reduction?

We report on a patient who developed, from 5 months of age, multiple seizure types, including myoclonic, associated with severe psychomotor delay, leading to the diagnosis of Dravet syndrome. Over the years, he developed refractory epilepsy and was implanted with a vagus nerve stimulator at the age of 19. After 3 months, he experienced a progressive improvement of partial and generalized seizures, with a >90% reduction, and better alertness. This meaningful clinical improvement is discussed in the light of the sudden unexpected death in epilepsy risk, which is high in this setting, and seems remarkably diminished in our patient in view of the reduction of generalized convulsions.

Risk Reduction Strategies: Past, Present, and Future

Several respected authors have proposed short lists of all strategies for controlling hazards or reducing risks from hazards. This article reviews those attempts and proposes an improved list of nine risk reduction strategies.