Influenza Vaccination Coverage among People with Self-Reported Cardiovascular Diseases-Findings from the Hungarian Implementation of the European Health Interview Survey.

Worldwide, cardiovascular diseases are the leading cause of mortality. This has significant implications for public health. Influenza, a common infectious disease, poses an increased risk for individuals with chronic conditions, such as cardiovascular diseases. However, little is known about influenza vaccination coverage in this group. This study utilized data from the Hungarian implementation of the European Health Interview Survey to assess influenza vaccination coverage and its determinants among cardiovascular respondents from 2009 to 2019. The findings reveal a downward trend in the vaccination rates over the years (from 24% to 21%), despite the availability of free vaccination in Hungary for this high-risk population. The main factors influencing low influenza vaccine uptake were identified, as follows: young age, a lower level of education, good self-perceived health status, smoking, a lower frequency of medical visits, and not suffering from respiratory diseases. Addressing these disparities necessitates targeted vaccination strategies supported by enhanced education, better access to healthcare services, and the promotion of preventive healthcare measures. Improving vaccination coverage among patients with cardiovascular diseases is imperative for reducing influenza-related morbidity and mortality. This highlights the importance of comprehensive public health interventions and healthcare provider engagement in promoting vaccination among groups at increased risk.

Changes in Antibiotic Redemption Related to Hungarian Dental Care During COVID-19.

INTRODUCTION AND AIMS: Antibiotic resistance is a global health problem that can affect individuals, health systems, and the economy. Our aim was to investigate how the redemption of antibiotics and the associated dental care changed during COVID-19 in Hungary. METHODS: The ICD codes for the infections for which antibiotics should be prescribed in dental care were identified based on the professional recommendation. The database was provided by the National Health Insurance Fund Manager of Hungary. Pearson's chi-squared test with Bonferroni correction was used to compare both the redemption of antibiotics and the associated dental care based on the recommendations in the year 2020 of the COVID-19 and the 2 preceding years. RESULTS: There were fewer antibiotic redemptions and associated dental care in 2020 than in 2018 and 2019. The ratio of professionally relevant and nonrelevant antibiotics redeemed did not change significantly between 2018 and 2019, but the proportion of antibiotics redeemed following recommendations increased significantly during the COVID-19 year of 2020 compared to the previous 2 years. The proportion of all dental care involving antibiotic redemptions increased significantly from 2018 to 2019, and then showed a further increase in 2020. The sex and age of the patient did not affect these findings, while the type of dental care did alter the trends in some cases. CONCLUSIONS: Antibiotics in dentistry are required only for very low proportion of cases, due to the nature of dental care where most infections such as caries and periodontal disease could be managed without resorting to antibiotics. Antibiotic redemptions during COVID-19 pandemic period increased compared to the pre-pandemic period in Hungary. Therefore, Hungarian policy makers need to develop control systems to promote the correct use of antibiotics in dental care. CLINICAL RELEVANCE: It is important to reduce unjustified use of antibiotics so as to curb the emergence of antibiotic resistance organisms.

Evaluation of the Diagnostic Performance of Two Automated SARS-CoV-2 Neutralization Immunoassays following Two Doses of mRNA, Adenoviral Vector, and Inactivated Whole-Virus Vaccinations in COVID-19 Naïve Subjects.

BACKGROUND: Limited data are available on humoral responses determined by automated neutralization tests following the administration of the three different types of COVID-19 vaccinations. Thus, we here evaluated anti-SARS-CoV-2 neutralizing antibody titers via two different neutralization assays in comparison to total spike antibody levels. METHODS: Healthy participants (n = 150) were enrolled into three subgroups who were tested 41 (22-65) days after their second dose of mRNA (BNT162b2/mRNA-1273), adenoviral vector (ChAdOx1/Gam-COVID-Vac) and inactivated whole-virus (BBIBP-CorV) vaccines, with no history or serologic evidence of prior SARS-CoV-2 infection. Neutralizing antibody (N-Ab) titers were analyzed on a Snibe Maglumi® 800 instrument and a Medcaptain Immu F6® Analyzer in parallel to anti-SARS-CoV-2 S total antibody (S-Ab) levels (Roche Elecsys® e602). RESULTS: Subjects who were administered mRNA vaccines demonstrated significantly higher SARS-CoV-2 N-Ab and S-Ab levels compared to those who received adenoviral vector and inactivated whole-virus vaccinations (p < 0.0001). N-Ab titers determined by the two methods correlated with each other (r = 0.9608; p < 0.0001) and S-Ab levels (r = 0.9432 and r = 0.9324; p < 0.0001, respectively). Based on N-Ab values, a new optimal threshold of Roche S-Ab was calculated (166 BAU/mL) for discrimination of seropositivity showing an AUC value of 0.975 (p < 0.0001). Low post-vaccination N-Ab levels (median value of 0.25 µg/mL or 7.28 AU/mL) were measured in those participants (n = 8) who were infected by SARS-CoV-2 within 6 months after immunizations. CONCLUSION: Both SARS-CoV-2 N-Ab automated assays are effective to evaluate humoral responses after various COVID-19 vaccines.

The Emergency Performance of the Hungarian Ambulance Service during the COVID-19 Pandemic.

The COVID-19 pandemic had a considerable impact on the whole health sector, particularly on emergency services. Our aim was to examine the performance of the Hungarian National Ambulance Service during the first four waves of the pandemic. We defined the 2019 performance of the service as the baseline and compared it with the activity during the pandemic years of 2020 and 2021. The data contained deliveries related to acute myocardial infarction, hemorrhagic stroke, ischemic stroke, overall non-COVID-related ambulance deliveries, COVID screenings performed by the ambulance service, and COVID-related ambulance deliveries. The data were aggregated for each week of the investigated time period and stratified by gender and age. Compared with the pre-pandemic era, we found a significant increase in all three medical conditions and overall deliveries (p < 0.001 in all cases). As a result of the increased burden, it is important for emergency services to prepare for the next global epidemic and to improve organizational performance and rescue activities. The Hungarian example highlights that in a pandemic, it can be beneficial to organize the emergency care of a country or a larger region under a single provider with a single decision maker supported by business intelligence.

Investigation of the relationship between incidence of mental disorders and economic growth among the Visegrad countries.

Prevention and care for mental disorders represent an important public health task in achieving global development goals. Proper access to adequate healthcare and social services is an important step related to care for mental disorders, which is presumably strongly related to economic growth. The main aim of the study was to investigate the relationship between the economic growth and the incidence of mental disorders in the V4 countries. An ecological correlation study was conducted regarding the four Visegrad countries. Indicators were derived from the World Health Organization (WHO) 'Health for All' (HFA) online database and Penn World Table version 10. The incidence of mental disorders increased in the V4 countries throughout the years between 2000-2018 except in Hungary, where a decreasing trend was observed. The prevalence of mental disorders increased in all countries as well, but it stagnated in Hungary. At the same time standardized death rate due to mental disorders increased in all Visegrad countries. According to the Hungarian data, while the prevalence of the disease did not change remarkably, the incidence decreased and the mortality increased as well as the prescription of drugs used in the treatment of mental disorders. This could indicate a serious hidden morbidity.

Preference for patient-centered communication among the citizens of the Visegrad countries.

OBJECTIVES: The aim of the study was to investigate and compare the preferences that citizens of four Visegrad countries hold concerning the communication between patient and provider. METHODS: The patient-practitioner orientation scale was used on a general population in our research, which consists of the Sharing and Caring subscales and assesses patient-centered or doctor-centered orientation toward communication. The statistical analysis included 4000 respondents of citizens from the Czech Republic, Slovakia, Poland and Hungary. When comparing the various demographic data and the four countries with each other univariate and multivariate logistic regressions were performed. RESULTS: Being female, middle aged, having a higher education and a poor health status were associated with significantly higher Sharing and Caring scores. Also, Hungarian citizens had a significantly higher Caring score compared to the other three countries. CONCLUSIONS: Key demographic variables were identified that affect how citizens perceive the communication between patient and provider. With the exception of Caring among Hungarian citizens, no differences were observed among the Visegrad countries. PRACTICE IMPLICATIONS: These findings have potential implications for understanding the preferences of the citizens and thus better promote a more patient-centered communication.

Differences in Beliefs About Cholesterol-Lowering Medications Among the Visegrad Group Countries: A Cross-Sectional Study.

Background: New cholesterol guidelines highlight more personalized risk assessments and new cholesterol-lowering drugs for people at the highest risk for cardiovascular disease. Adherence due to fear of and lack of trust in medications prevents treatment to provide better health outcomes. Objectives: The aim of our study was to investigate the possible differences in the beliefs about the necessity and concerns regarding lipid-lowering drugs among the Visegrad Group countries. Methods: The Beliefs About Medicines Questionnaire (BMQ-Specific) was used in our research. The responses of 205 Hungarian, 200 Slovak, 235 Czech, and 200 Polish participants, all taking cholesterol-lowering medications, were compared to each other. Results: Hungarian participants' belief in the necessity of cholesterol-lowering drugs was significantly lower compared to the Slovak (P = 0.001), Czech (P = 0.037), and Polish (P < 0.001) participants. While no difference was observed between the Czech and Slovak responses (P = 0.154), both the Czech (P < 0.001) and Slovak (P = 0.006) respondents' belief regarding necessity was lower than that of the Polish. Regarding concerns, the only significant difference was observed between the Czech and the Polish respondents (P = 0.011). Conclusions: While the beliefs about benefits (necessity) are most prominent among the Polish participants, except in comparison to Czech responses, the Visegrad Group countries do not differ considerably regarding their beliefs about the fear (concerns) of the treatment.

Inequalities in the Global Burden of Chronic Kidney Disease Due to Type 2 Diabetes Mellitus: An Analysis of Trends from 1990 to 2019.

The prevalence of type 2 diabetes mellitus (T2DM) and the burden of complications are increasing worldwide. Chronic kidney disease (CKD) is one serious complication. Our aim was to investigate the trends and inequalities of the burden of CKD due to T2DM between 1990 and 2019. Data were obtained from the Global Health Data Exchange database. Age-standardized incidence, mortality, and DALYs rates of CKD were used to estimate the disease burden across the Human Development Index (HDI). Joinpoint regression was performed to assess changes in trend, and the Gini coefficient was used to assess health inequality. A higher incidence was observed in more developed countries (p < 0.001), while higher mortality and DALYs rates were experienced in low and middle HDI countries in 2019 (p < 0.001). The trend of incidence has increased since 1990 (AAPC: 0.9-1.5%), while slight decrease was observed in low HDI countries in mortality (APC: -0.1%) and DALYs (APC: -0.2%). The Gini coefficients of CKD incidence decreased from 0.25 in 2006 to 0.23 in 2019. The socioeconomic development was associated with disease burden. Our findings indicate that awareness of complications should be improved in countries with high incidence, and cost-effective preventive, diagnostic, and therapeutic tools are necessary to implement in less developed regions.

Broadening the concept of patient safety culture through value-based healthcare.

PURPOSE: Decision-makers are looking for innovative approaches to improve patient experience and outcomes with the finite resources available in healthcare. The concept of value-based healthcare has been proposed as one such approach. Since unsafe care hinders patient experience and contributes to waste, the purpose of this paper is to investigate how the value-based approach can help broaden the existing concept of patient safety culture and thus, improve patient safety and healthcare value. DESIGN/METHODOLOGY/APPROACH: In the arguments, the authors use the triple value model which consists of personal, technical and allocative value. These three aspects together promote healthcare in which the experience of care is improved through the involvement of patients, while also considering the optimal utilisation and allocation of finite healthcare resources. FINDINGS: While the idea that patient involvement should be integrated into patient safety culture has already been suggested, there is a lack of emphasis that economic considerations can play an important role as well. Patient safety should be perceived as an investment, thus, relevant questions need to be addressed such as how much resources should be invested into patient safety, how the finite resources should be allocated to maximise health benefits at a population level and how resources should be utilised to get the best cost-benefit ratio. ORIGINALITY/VALUE: Thus far, both the importance of patient safety culture and value-based healthcare have been advocated; this paper emphasizes the need to consider these two approaches together.

Investigating the Geographic Disparities of Amenable Mortality and Related Ambulance Services in Hungary.

The aim of this study was to investigate how amenable mortality and related ambulance services differ on a county level in Hungary. The differences in mortality rates and ambulance services could identify counties where stronger ambulance services are needed. The datasets for 2018 consisted of county level aggregated data of citizens between the ages 15-64. The study examined how both the mortality rates and the ambulance rescue deliveries differ from the national average. The analyses were narrowed down to disease groups, such as acute myocardial infarction, hemorrhagic and ischemic stroke. Inequalities were identified regarding the distribution of number of ambulance deliveries, several counties had rates more than double that of the national average. For both mortality and ambulance services some of the counties had significantly better results and others had significantly worse compared to the national average. In Borsod-Abaúj-Zemplén county's case, hemorrhagic stroke mortality was significantly higher (1.73 [1.35-2.11]), while ambulance deliveries were significantly lower (0.58 [0.40-0.76]) compared to the national average. The research has shown that regarding the investigated mortality rates and ambulance services there are considerable differences between the counties in Hungary. In this regard policy makers should implement policies to tackle these discrepancies.

Cross-Cultural Adaptation and Lingual Validation of the Beliefs about Medicines Questionnaire (BMQ)-Specific for Cholesterol Lowering Drugs in the Visegrad Countries.

The goal of this study was to translate the Beliefs about Medicines Questionnaire-Specific (BMQ-Specific) for cholesterol-lowering drugs, into the Hungarian, Slovak, Czech and Polish languages and test their reliability with statistical methods. For this purpose, Cronbach's alpha, confirmatory and exploratory factor analyses were conducted. The analyses included 235 Czech, 205 Hungarian, 200 Polish, and 200 Slovak respondents, all of whom were taking cholesterol-lowering drugs. The translations from English into the target languages were always done by two independent translators. As part of the validation process these translations were pilot tested and after the necessary alterations, they were translated back into English by a third translator. After the approval by the creator of the questionnaire, nationwide surveys were conducted in all four countries. The results of the confirmatory factor analysis were exceptionally good for the Czech and Slovak translations, while the Polish and Hungarian translations marginally crossed the predetermined thresholds. With the exception of a single Polish question, the results of the exploratory factor analysis were deemed acceptable. The translated versions of BMQ-Specific are reliable and valid tools to assess patients' beliefs about medication, especially medication adherence among patients taking cholesterol-lowering medication. A comparison between the four countries with this questionnaire is now possible.

Investigating the knowledge of and public attitudes towards genetic testing within the Visegrad countries: a cross-sectional study.

BACKGROUND: Previous studies have investigated various factors that can determine the attitudes of the citizens considering genetic testing. However, none of them investigated how these attitudes may differ between the Visegrad countries. METHODS: In this cross-sectional study a questionnaire developed by Dutch researchers was translated and used in Hungary, Slovakia, Czechia and Poland. In each country 1000 adult citizens were asked on the topics of personal benefits regarding genetic tests, genetic determinism, and finally, the availability and usage of genetic testing. Multivariate robust regression model was created including several possible influencing factors (such as age, sex, education, marital status, religiousness, and having a genetic test within the nuclear family) to identify the possible differences between the four countries. RESULTS: The Hungarian citizens had the most positive opinion on the personal benefits of genetic testing followed by the Czech, Slovak and Polish. All differences were significant in this regard. Considering genetic determinism, the Slovak citizens had a significantly firmer belief in this issue compared to the Hungarians. No other significant differences were observed in this domain. On the topic of the availability and use of genetic testing the Hungarian citizens had the most accepting opinion among the four countries, followed by the Czech citizens. In this domain the Polish and Slovak answers did not differ significantly from each other. CONCLUSIONS: Significant differences were observed even when considering various confounding effects. As the underlying reasons for these discrepancies are unknown, future studies should investigate this enigma among the four countries.

[Comparative analysis of the full and shortened versions of the Oldenburg Burnout Inventory]. / Az Oldenburg Kiégés Kérdôív és rövidített változatának összehasonlító elemzése.

Background - The two free-to-use versions of the Oldenburg Burnout Inventory (OLBI) have been increasingly utilised to assess the prevalence of burnout among human service workers. The OLBI has been developed to overcome some of the psychometric and conceptual limitations of the Maslach Burnout Inventory, the gold standard of burnout measures. There is a lack of data on the structural validity of the Mini Oldenburg Burnout Inventory and the Oldenburg Burnout Inventory in Hungary. Purpose - To assess the structural validity of the Hungarian versions of the Oldenburg Burnout Inventory and the Mini-Oldenburg Burnout Inventory. Methods - We enrolled 564 participants (196 healthcare workers, 104 nurses and 264 clinicians) in three cross-sectional surveys. In our analysis we assessed the construct validity of the instruments using confirmatory factor analysis and internal consistency using coefficient Cronbach's α. Results - We confirmed the two-dimensional structure (exhaustion and disengagement) of the Mini-Oldenburg Inventory and a shortened version of the Oldenburg Burnout Inventory Internal consistency coefficient confirmed the reliability of the instruments. The burnout appeared more than a 50 percent of the participants in every subsample. The prevalence of exhaustion was above 54.5% in each of the subsamples and the proportion of disengaged clinicians was particularly high (92%). Conclusions - Our findings provide support for the construct validity and reliability of the Hungarian versions of the Mini-Oldenburg Burnout Inventory and a shortened version of the Oldenburg Burnout Inventory in the assessment of burnout among clinicians and nurses in Hungary.

Prevalence of Insulin Resistance in the Hungarian General and Roma Populations as Defined by Using Data Generated in a Complex Health (Interview and Examination) Survey.

Data mainly from one-off surveys clearly show that the health of Roma, the largest ethnic minority of Europe, is much worse than that of the general population. However, results from comprehensive exploratory studies are missing. The aim of our study was to create a complex database for comparative and association studies to better understand the background of the very unfavourable health of Roma, especially the high burden of cardiometabolic diseases. A three-pillar (questionnaire-based, physical and laboratory examinations) health survey was carried out on randomly selected samples of the Hungarian general (HG, n = 417) and Roma (HR, n = 415) populations, and a database consisting of more than half a million datapoints was created. Using selected data, the prevalence rates of metabolic syndrome (MetS) and of its components were determined, and to estimate the risk of insulin resistance (IR), surrogate measures (the homeostasis model assessment of insulin resistance index, quantitative insulin sensitivity check index, McAuley and TyG indices and the TG/HDL-C ratio) were calculated. Receiver operating characteristic curve analysis and Youden's method were used to define the optimal cut-off values of each IR index. The prevalence of MetS was very high in both study populations (HG: 39.8%, HR: 44.0%) with no statistically significant difference between the two groups in females or males. The prevalence of MetS showed a very marked increase in the HR 35-49 years age group. Among surrogate measures, the TyG index showed the greatest power for predicting IR/MetS at a cut-off value of 4.69 (77% sensitivity, 84% specificity) and indicated a 42.3% (HG) and 40.5% (HR) prevalence of IR. The prevalence of MetS and IR is almost equally very unfavourable in both groups; thus, the factors underlying the high premature mortality burden of Roma should be further clarified by investigating the full spectrum of risk factors available in the database, with a special focus on the access of Roma people to preventive and curative health services.

Health mediators as members of multidisciplinary group practice: lessons learned from a primary health care model programme in Hungary.

BACKGROUND: A Model Programme of primary care group practices was implemented in Hungary between 2013 and 2017 - where virtually all GPs had worked in single practices - aiming to increase preventive service uptake and reduce inequalities based on a bilateral agreement between the Swiss and Hungarian governments. Group practices employed a wide variety of health professionals as well as support workers called health mediators. Employment of the latter was based on two decades of European experience of health mediators who specifically facilitate access to and use of health services in Roma minority groups. Health mediators had been recruited from local communities, received training on the job, and were tasked to increase uptake of new preventive services provided by the group practices by personal contacts in the local minority populace. The paper describes the contribution of the work of health mediators to the uptake of two new services provided by group practices. METHODS: Quantitative analysis of depersonalized administrative data mandatorily reported to the Management of the Programme during 43 months of operation was carried out on the employment of health mediators and their contribution to the uptake of two new preventive services (health status assessment and community health promoting programmes). RESULTS: 80% of all clients registered with the GPs participated at health status assessment by invitation that was 1.3-1.7 times higher than participation at the most successful national screening programmes in the past 15 years. Both the number of mediator work minutes per client and participation rate at health status assessment, as well as total work time of mediators and participants at community health events showed high correlation. Twice as many Roma minority patients were motivated for service use by health mediators compared to all patients. The very high participation rate reflects the wide impact of health mediators who probably reached not only Roma minority, but vulnerable population groups in general. CONCLUSION: The future of general practices lays in multidisciplinary teams in which health mediators recruited from the serviced communities can be valuable members, especially in deprived areas.

Value-based genomic screening: exploring genomic screening for chronic diseases using triple value principles.

BACKGROUND: Genomic screening has unique challenges which makes it difficult to easily implement on a wide scale. If the costs, benefits and tradeoffs of investing in genomic screening are not evaluated properly, there is a risk of wasting finite healthcare resources and also causing avoidable harm. MAIN TEXT: If healthcare professionals - including policy makers, payers and providers - wish to incorporate genomic screening into healthcare while minimizing waste, maximizing benefits, and considering results that matter to patients, using the principles of triple value (allocative, technical, and personal value) could help them to evaluate tough decisions and tradeoffs. Allocative value focuses on the optimal distribution of limited healthcare resources to maximize the health benefits to the entire population while also accounting for all the costs of care delivery. Technical value ensures that for any given condition, the right intervention is chosen and delivered in the right way. Various methods (e.g. ACCE, HTA, and Wilson and Jungner screening criteria) exist that can help identify appropriate genomic applications. Personal value incorporates preference based informed decision making to ensure that patients are informed about the benefits and harms of the choices available to them and to ensure they make choices based on their values and preferences. CONCLUSIONS: Using triple value principles can help healthcare professionals make reasoned and tough judgements about benefits and tradeoffs when they are exploring the role genomic screening for chronic diseases could play in improving the health of their patients and populations.

Determinants of Primary Nonadherence to Medications Prescribed by General Practitioners Among Adults in Hungary: Cross-Sectional Evaluation of Health Insurance Data.

Background: Primary nonadherence to prescribed medications occurs when patients do not fill or dispense prescriptions written by healthcare providers. Although it has become an important public health issue in recent years, little is known about its frequency, causes, and consequences. Moreover, the pattern of risk factors shows remarkable variability across countries according to the published results. Our study aimed to assess primary nonadherence to medications prescribed by general practitioners (GPs) and its associated factors among adults in Hungary for the period of 2012-2015. Methods: Data on all general medical practices (GMPs) of the country were obtained from the National Health Insurance Fund and the Central Statistical Office. The ratio of the number of dispensed medications to the number of prescriptions written by a GP for adults was used to determine the medication adherence, which was aggregated for GMPs. The effect of GMP characteristics (list size, GP vacancy, patients' education provided by a GMP, settlement type [urban or rural], and geographical location [by county] of the center) on adherence, standardized for patients' age, sex, and eligibility for an exemption certificate, were investigated through generalized linear regression modeling. Results: A total of 281,315,386 prescriptions were dispensed out of 438,614,000 written by a GP. Overall, 64.1% of prescriptions were filled. According to the generalized linear regression coefficients, there was a negative association between standardized adherence and urban settlement type (b = -0.099, 95%CI = -0.103 to -0.094), higher level of education (b = -0.440, 95%CI = -0.468 to -0.413), and vacancy of the general practices (b = -0.193, 95%CI = -0.204 to -0.182). The larger GMP size proved to be a risk factor, and there was a significant geographical inequality for counties as well. Conclusions: More than one-third of the written prescriptions of GPs for adults in Hungary were not dispensed. This high level of nonadherence had great variability across GMPs, and can be explained by structural characteristics of GMPs, the socioeconomic status of patients provided, and the quality of cooperation between patients and GPs. Moreover, our findings suggest that the use of the dispensed-to-prescribed medication ratio in routine monitoring of primary health care could effectively support the necessary interventions.

High Inequalities Associated With Socioeconomic Deprivation in Cardiovascular Disease Burden and Antihypertensive Medication in Hungary.

The wide life expectancy gap between the old and new member states of the European Union is most strongly related to the high rate of premature mortality caused by cardiovascular diseases (CVDs). To learn more about the background of this gap, the relationship of socioeconomic status (SES) with CVD mortality, morbidity and the utilization of antihypertensive drugs was studied in Hungary, a Central-Eastern European country with an extremely high relative risk of premature CVD mortality. Risk analysis capabilities were used to estimate the relationships between SES, which was characterized by tertiles of a multidimensional composite indicator (the deprivation index) and CVD burden (mortality and morbidity) as well as the antihypertensive medications at the district level in Hungary. The excess risks caused by premature mortality from CVDs showed a strong correlation with deprivation using the Rapid Inquiry Facility. The distribution of prevalence values related to these diseases was found to be similar, but in the areas of highest deprivation, where the prevalence of chronic ischaemic heart diseases and cerebrovascular diseases was found to be higher than the national average by 30 and 20%, the prevalence of hypertension exceeded the national average by only 4%. A linear association between the relative frequency of prescriptions/redemptions and deprivation for most antihypertensive drugs, except angiotensinogen receptor blockers, was shown. More intense screening for hypertension is proposed to improve the control of CVDs in countries affected by high disease burden.

'Proactive' use of cue-context congruence for building reinforcement learning's reward function.

BACKGROUND: Reinforcement learning is a fundamental form of learning that may be formalized using the Bellman equation. Accordingly an agent determines the state value as the sum of immediate reward and of the discounted value of future states. Thus the value of state is determined by agent related attributes (action set, policy, discount factor) and the agent's knowledge of the environment embodied by the reward function and hidden environmental factors given by the transition probability. The central objective of reinforcement learning is to solve these two functions outside the agent's control either using, or not using a model. RESULTS: In the present paper, using the proactive model of reinforcement learning we offer insight on how the brain creates simplified representations of the environment, and how these representations are organized to support the identification of relevant stimuli and action. Furthermore, we identify neurobiological correlates of our model by suggesting that the reward and policy functions, attributes of the Bellman equitation, are built by the orbitofrontal cortex (OFC) and the anterior cingulate cortex (ACC), respectively. CONCLUSIONS: Based on this we propose that the OFC assesses cue-context congruence to activate the most context frame. Furthermore given the bidirectional neuroanatomical link between the OFC and model-free structures, we suggest that model-based input is incorporated into the reward prediction error (RPE) signal, and conversely RPE signal may be used to update the reward-related information of context frames and the policy underlying action selection in the OFC and ACC, respectively. Furthermore clinical implications for cognitive behavioral interventions are discussed.

Changes in triglyceride, HDL-C, and non-HDL-C levels in patients with acute coronary syndrome.

BACKGROUND: Changes in high-density lipoprotein cholesterol (HDL-C) and triglyceride (TG) levels have been linked to residual cardiovascular risk, whereas non-HDL-C levels have been shown to be more predictive of cardiovascular risk than are low-density lipoprotein cholesterol (LDL-C) levels. We aimed to investigate the impact of HDL-C, TG, and non-HDL-C levels on acute coronary syndrome (ACS) risk with on-target LDL-C levels. METHODS: In all, 424 Caucasian patients aged over 50 years who had LDL-C levels below 3.4 mmol/l with a first or subsequent ACS event were enrolled in a multicenter, retrospective study. Lipid samples were collected within 4 days after the cardiovascular event. The subjects of the age-matched, gender-balanced control group (n = 443) had LDL-C levels below 3.4 mmol/l and were free of cardiovascular diseases. RESULTS: Patients with ACS had significantly higher TG and lower HDL-C levels compared with the control patients; however, we did not find any significant difference regarding non-HDL-C levels between the two groups. In regression analysis, the risk of coronary heart disease increased significantly with 1 standard deviation (SD) increase in TG and 1 SD decrease in HDL-C levels. CONCLUSION: High TG and low HDL-C levels may contribute to residual cardiovascular risk in patients with well-controlled LDL-C levels; however, non-HDL-C levels at admission did not seem to be predictive for patients with ACS. Detection and treatment of secondary lipid targets such as high TG and low HDL-C levels may be important for the prevention of cardiovascular diseases.