Cultural challenges to secondary prevention: Implications for Saudi women

Like other highly developed countries, cardiovascular disease (CVD) and coronary heart disease (CHD) are major health problems in Saudi Arabia. The aetiology of cardiovascular disease (CVD) burden within the Saudi population is similar to Western countries with atherosclerosis, hypertension, ischemic heart disease and diabetes highly prevalent with the main risk factors being smoking, obesity and inactivity. There are differences between Saudi men and women in epidemiology, risk factors and health service provision for CHD. These sex and gender based factors are important in considering the health and well-being of Saudi women. Currently, there is limited focus on the cardiovascular health of Saudi women. The aim of this paper is to examine culturally specific issues for Saudi women and the implications for secondary prevention.

Secondary stroke prevention: patent foramen ovale, aortic plaque, and carotid stenosis

Stroke is the most debilitating cardiovascular event. It has a variety of causes that may be present simultaneously. In young or otherwise healthy people, the search for a patent foramen ovale (PFO) has become standard. In stroke of the elderly, atherosclerosis and atrial fibrillation are in the foreground but the PFO should not be ignored. The risk of a PFO-related stroke over time is controversial and so is its prevention by device closure. The association of proximal aortic plaques in arteries subtending the brain and stroke is considered strong, ignoring that it is as putative as that of the PFO. Statins can prevent progression of such plaques. Antiplatelet agents in asymptomatic and surgical endarterectomy in symptomatic patients or highly ulcerated lesions are the treatment of choice. Stenting with protection devices was shown competitive in selected patients.

A randomised controlled trial of triple antiplatelet therapy (Aspirin, Clopidogrel and Dipyridamole) in the secondary prevention of stroke: safety, tolerability and feasibility

Background: Aspirin, dipyridamole and clopidogrel are effective in secondary vascular prevention. Combination therapy with three antiplatelet agents might maximise the benefit of antiplatelet treatment in the secondary prevention of ischaemic stroke. Methodology/Principal Findings: A randomised, parallel group, observer-blinded phase II trial compared the combination of aspirin, clopidogrel and dipyridamole with aspirin alone. Adult patients with ischaemic stroke or transient ischaemic attack (TIA) within 5 years were included. The primary outcome was tolerability to treatment assessed as the number of patients completing randomised treatment. Recruitment was halted prematurely after publication of the ESPRIT trial (which confirmed that combined aspirin and dipyridamole is more effective than aspirin alone). 17 patients were enrolled: male 12 (71%), mean age 62 (SD 13) years, lacunar stroke syndrome 12 (71%), median stroke/TIA onset to randomisation 8 months. Treatment was discontinued in 4 of 9 (44%) patients receiving triple therapy vs. none of 8 taking aspirin (p = 0.08). One recurrent stroke occurred in a patient in the triple group who was noncompliant of all antiplatelet medications. The number of patients with adverse events and bleeding complications, and their severity, were significantly greater in the triple therapy group (p,0.01). Conclusions/Significance: Long term triple antiplatelet therapy was asociated with a significant increase in adverse events and bleeding rates, and their severity, and a trend to increased discontinuations. However, the patients had a low risk of recurrence and future trials should focus on short term therapy in high risk patients characterised by a very recent event or failure of dual antiplatelet therapy.

Development and validation of the Diet Quality Tool for use in cardiovascular disease prevention settings

The aim of this study was to develop and evaluate a dietary screening tool for use in a secondary cardiovascular disease (CVD) prevention setting to identify an individual’s overall dietary quality. The Diet Quality Tool (DQT) was validated against a 4-day food diary for 37 individuals with established CVD attending cardiac rehabilitation. Construct validity was demonstrated for % energy from saturated fat (P = 0.002, r = –0.500), dietary fibre (P < 0.001, r = 0.559) and omega-3 fatty acids (P = 0.048, r = 0.327). Criterion validity was established with a significant difference found between mean (95% CI) dietary intakes of fibre (28.2 g, 4.4 to 17.3) and % total energy from saturated fat (10.6%, –4.8 to –0.8) for those with better DQT scores (>60%) versus those with poorer scores (≤60%) when compared with 4-day food diary nutrient values. The usefulness of the DQT was confirmed by both patients (n = 25) and cardiac rehabilitation health professionals (n = 8). The DQT was found to be a valid and useful dietary assessment tool with potential for use in a secondary CVD prevention setting. The tool has the capacity to be used in a wider variety of settings and further refinement of the tool would enable a greater amount of nutrients to be reliably screened.

Influence of fluoride-releasing restorative material on root dentine secondary caries in situ

The usefulness of fluoride-releasing restorations in secondary caries prevention may be questioned because of the presence of other common sources of fluoride and because of ageing of the restorations. This study tested the hypothesis that glass-ionomer cement restorations, either aged or unaged, do not prevent secondary root caries, when fluoride dentifrice is frequently used. Sixteen volunteers wore palatal appliances in two phases of 14 days, according to a 2 x 2 crossover design. In each phase the appliance was loaded with bovine root dentine slabs restored with either glass-ionomer or resin composite, either aged or unaged. Specimens were exposed to cariogenic challenge 4 times/day and to fluoridated dentifrice 3 times/day. The fluoride content in the biofilm (FB) formed on slabs and the mineral loss (Delta Z) around the restorations were analysed. No differences were found between restorative materials regarding the FB and the Delta Z, for either aged (p = 0.792 and p = 0.645, respectively) or unaged (p = 1.00 and p = 0.278, respectively) groups. Under the cariogenic and fluoride dentifrice exposure conditions of this study, the glass-ionomer restoration, either aged or unaged, did not provide additional protection against secondary root caries. Copyright (c) 2006 S. Karger AG, Basel.

Rationale and design of a randomized, double-blind, parallel-group study of terutroban 30 mg/day versus aspirin 100 mg/day in stroke patients: the prevention of cerebrovascular and cardiovascular events of ischemic origin with terutroban in patients with a history of ischemic stroke or transient ischemic attack (PERFORM) study

BACKGROUND: Ischemic stroke is the leading cause of mortality worldwide and a major contributor to neurological disability and dementia. Terutroban is a specific TP receptor antagonist with antithrombotic, antivasoconstrictive, and antiatherosclerotic properties, which may be of interest for the secondary prevention of ischemic stroke. This article describes the rationale and design of the Prevention of cerebrovascular and cardiovascular Events of ischemic origin with teRutroban in patients with a history oF ischemic strOke or tRansient ischeMic Attack (PERFORM) Study, which aims to demonstrate the superiority of the efficacy of terutroban versus aspirin in secondary prevention of cerebrovascular and cardiovascular events. METHODS AND RESULTS: The PERFORM Study is a multicenter, randomized, double-blind, parallel-group study being carried out in 802 centers in 46 countries. The study population includes patients aged > or =55 years, having suffered an ischemic stroke (< or =3 months) or a transient ischemic attack (< or =8 days). Participants are randomly allocated to terutroban (30 mg/day) or aspirin (100 mg/day). The primary efficacy endpoint is a composite of ischemic stroke (fatal or nonfatal), myocardial infarction (fatal or nonfatal), or other vascular death (excluding hemorrhagic death of any origin). Safety is being evaluated by assessing hemorrhagic events. Follow-up is expected to last for 2-4 years. Assuming a relative risk reduction of 13%, the expected number of primary events is 2,340. To obtain statistical power of 90%, this requires inclusion of at least 18,000 patients in this event-driven trial. The first patient was randomized in February 2006. CONCLUSIONS: The PERFORM Study will explore the benefits and safety of terutroban in secondary cardiovascular prevention after a cerebral ischemic event.

A parent-led family-focused treatment program for overweight children aged 5 to 9 years : The PEACH RCT

OBJECTIVE: To evaluate a healthy lifestyle intervention to reduce adiposity in children aged 5 to 9 years and assess whether adding parenting skills training would enhance this effect. PARTICIPANTS AND METHODS: We conducted a single-blinded randomized controlled trial of prepubertal moderately obese (International Obesity Task Force cut points) children, aged 5 to 9 years. The 6-month program targeted parents as the agents of change for implementing family lifestyle changes. Only parents attended group sessions. We measured BMI and waist z scores and parenting constructs at baseline, 6, 12, 18, 24 months. RESULTS: Participants (n = 169; 56% girls) were randomized to a parenting skills plus healthy lifestyle group (n = 85) or a healthy lifestyle–only group (n = 84). At final 24-month assessment 52 and 54 children remained in the parenting skills plus healthy lifestyle and the healthy lifestyle–only groups respectively. There were reductions (P < .001) in BMI z score (0.26 [95% confidence interval: 0.22–0.30]) and waist z score (0.33 [95% confidence interval: 0.26–0.40]). There was a 10% reduction in z scores from baseline to 6 months that was maintained to 24 months with no additional intervention. Overall, there was no significant group effect. A similar pattern of initial improvement followed by stability was observed for parenting outcomes and no group effect. CONCLUSIONS: Using approaches that specifically target parent behavior, relative weight loss of ∼10% is achievable in moderately obese prepubertal children and can be maintained for 2 years from baseline. These results justify an investment in treatment as an effective secondary obesity-prevention strategy.

Report: The Canadian Best Practices Educational Toolkits: Translating evidence-based stroke recommendations into practical implementation resources

The Canadian Best Practice Recommendations for Stroke Care are intended to reduce variations in stroke care and facilitate closure of the gap between evidence and practice (Lindsay et al., 2010). The publication of best practice recommendations is only the beginning of this process. The guidelines themselves are not sufficient to change practice and increase consistency in care. Therefore, a key objective of the Canadian Stroke Network (CSN) Best Practices Working Group (BPWG) is to encourage and facilitate ongoing professional development and training for health care professionals providing stroke care. This is addressed through a multi-factorial approach to the creation and dissemination of inter-professional implementation tools and resources. The resources developed by CSN span pre-professional education, ongoing professional development, patient education and may be used to inform systems change. With a focus on knowledge translation, several inter-professional point-of-care tools have been developed by the CSN in collaboration with numerous professional organizations and expert volunteers. These resources are used to facilitate awareness, understanding and applications of evidence-based care across stroke care settings. Similar resources are also developed specifically for stroke patients, their families and informal caregivers, and the general public. With each update of the Canadian Best Practice Recommendations for Stroke Care, the BPWG and topic-specific writing groups propose priority areas for ongoing resource development. In 2010, two of these major educational initiatives were undertaken and recently completed—one to support continuing education for health care professionals regarding secondary stroke prevention and the other to educate families, informal caregivers and the public about pediatric stroke. This paper presents an overview of these two resources, and we encourage health care professionals to integrate these into their personal learning plans and tool kits for patients.

Study protocol of the YOU CALL - WE CALL TRIAL: Impact of a multimodal support intervention after a "mild" stroke

Background More than 60% of new strokes each year are "mild" in severity and this proportion is expected to rise in the years to come. Within our current health care system those with "mild" stroke are typically discharged home within days, without further referral to health or rehabilitation services other than advice to see their family physician. Those with mild stroke often have limited access to support from health professionals with stroke-specific knowledge who would typically provide critical information on topics such as secondary stroke prevention, community reintegration, medication counselling and problem solving with regard to specific concerns that arise. Isolation and lack of knowledge may lead to a worsening of health problems including stroke recurrence and unnecessary and costly health care utilization. The purpose of this study is to assess the effectiveness, for individuals who experience a first "mild" stroke, of a sustainable, low cost, multimodal support intervention (comprising information, education and telephone support) - "WE CALL" compared to a passive intervention (providing the name and phone number of a resource person available if they feel the need to) - "YOU CALL", on two primary outcomes: unplanned-use of health services for negative events and quality of life. Method/Design We will recruit 384 adults who meet inclusion criteria for a first mild stroke across six Canadian sites. Baseline measures will be taken within the first month after stroke onset. Participants will be stratified according to comorbidity level and randomised to one of two groups: YOU CALL or WE CALL. Both interventions will be offered over a six months period. Primary outcomes include unplanned use of heath services for negative event (frequency calendar) and quality of life (EQ-5D and Quality of Life Index). Secondary outcomes include participation level (LIFE-H), depression (Beck Depression Inventory II) and use of health services for health promotion or prevention (frequency calendar). Blind assessors will gather data at mid-intervention, end of intervention and one year follow up. Discussion If effective, this multimodal intervention could be delivered in both urban and rural environments. For example, existing infrastructure such as regional stroke centers and existing secondary stroke prevention clinics, make this intervention, if effective, deliverable and sustainable.

Sobrevida e fatores prognósticos para o câncer de mama em Juiz de Fora, Minas Gerais, na coorte diagnosticada entre 1998 e 2000

Este estudo teve como objetivo analisar a sobrevida e fatores prognósticos para o câncer de mama feminino, com ênfase no papel de variáveis relacionadas aos serviços de saúde. Foram analisadas 782 mulheres com câncer invasivo da mama e submetidas à cirurgia curativa, que realizaram tratamento cirúrgico e/ou terapia complementar no município de Juiz de Fora, Minas Gerais, com diagnóstico da doença entre 1998 e 2000. O recrutamento dos casos foi efetuado a partir de busca ativa nos registros médicos de todos os serviços de saúde que prestam atendimento em oncologia na cidade. O seguimento foi realizado mediante retorno aos prontuários e complementado por busca no banco do Sistema de Informação sobre Mortalidade (SIM), contato telefônico e consulta de situação cadastral no Cadastro de Pessoas Físicas (CPF). As principais variáveis analisadas foram: cor da pele, idade ao diagnóstico, tamanho do tumor, comprometimento de linfonodos, estadiamento, cidade de residência e variáveis relativas aos serviços de saúde, entre outras. As funções de sobrevida foram calculadas por meio do método de Kaplan-Meier. Foi utilizado o modelo de riscos proporcionais de Cox para avaliação dos fatores prognósticos. No primeiro artigo, foi observada taxa de sobrevida específica em cinco anos de 80,9%, sendo identificados tamanho tumoral e comprometimento de linfonodos axilares como importantes fatores prognósticos associados de forma independente à sobrevida pela doença na população de estudo (HR=1,99, IC95%: 1,27-3,10 e HR=3,92, IC95%: 2,49-6,16, respectivamente). No segundo artigo, quando consideradas as variáveis relativas aos serviços de saúde, foi verificada pior sobrevida para as mulheres assistidas no serviço público, embora com significância limítrofe (p=0,05), e para aquelas que não tinham plano privado de saúde, apesar de não significativa (p=0,1). As funções de sobrevida não ajustadas e estratificadas por natureza do serviço de saúde exibiram sobrevida mais desfavorável para as mulheres não brancas e para os casos com nenhum ou menos de 10 linfonodos isolados somente no serviço público, embora com significâncias estatísticas apenas marginais (p=0,09 e p=0,07, respectivamente). Na análise multivariada, foi observado maior risco de óbito nas mulheres que não fizeram uso de hormonioterapia apenas para os casos assistidos no serviço público (HR=1,56; IC95%: 1,01-2,41), independentemente do tamanho tumoral e do status ganglionar axilar. Tais achados sugerem desigualdades sociais e disparidades na prevenção primária e secundária da doença na região estudada, com desvantagem para o serviço público de saúde, enfatizando a maior necessidade de esclarecimento sobre a doença, assim como de diagnóstico e tratamento dos casos em estádios mais precoces. Destacou-se, ainda, o valor de se trabalhar com informações produzidas pelos serviços de saúde responsáveis pela assistência oncológica no país, possibilitando a caracterização do perfil e da sobrevida das pacientes assistidas e fornecendo subsídios aos órgãos competentes do setor saúde local para nortear a adoção de estratégias de prevenção direcionadas ao controle da doença na população avaliada.

BRCA1: mechanisms of inactivation and implications for management of patients.

The BRCA1 gene was cloned in 1994 as one of the genes that conferred genetic predisposition to early-onset breast and ovarian cancer. Since then, a genetic test for identification of high-risk individuals has been developed. Despite being implicated in many important cellular pathways, including DNA repair and regulation of transcription, the exact mechanism by which inactivation of BRCA1 might lead to malignant transformation of cells remains unknown. We examine the mechanisms that underlie inactivation of BRCA1 and assess how they affect management of patients, in terms of both primary and secondary cancer prevention strategies. Furthermore, we look at the potential usefulness of BRCA1 as a prognostic tool and as a predictive marker of response to different classes of drugs. Finally, throughout this review, we draw links between the functional consequences of BRCA1 inactivation, in terms of key cellular signalling pathways, and how they might explain specific clinical observations in individuals who carry mutations in the gene.