Changes in body weight and blood pressure: paradoxical outcome events in overweight and obese subjects with cardiovascular disease.

BACKGROUND/OBJECTIVES: The Sibutramine Cardiovascular OUTcomes (SCOUT) trial showed a significantly increased relative risk of nonfatal cardiovascular events, but not mortality, in overweight and obese subjects receiving long-term sibutramine treatment with diet and exercise. We examined the relationship between early changes (both increases and decreases) in body weight and blood pressure, and the impact of these changes on subsequent cardiovascular outcome events. SUBJECTS/METHODS: A total of 9804 male and female subjects, aged 55 years or older, with a body mass index of 27-45 kg m(-2) were included in this current subanalysis of the SCOUT trial. Subjects were required to have a history of cardiovascular disease and/or type 2 diabetes mellitus with at least one cardiovascular risk factor (hypertension, dyslipidemia, current smoking or diabetic nephropathy) to assess cardiovascular outcomes. Post hoc subgroup analyses of weight change (categories) and blood pressure were performed overall and by treatment group (6-week sibutramine followed by randomized placebo or continued sibutramine). The primary outcome event (POE) was a composite of nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death. Time-to-event analyses of the POE were performed using Cox regression models with factors for treatment, subgroups and interactions. RESULTS: During the initial 6-week sibutramine treatment period, systolic blood pressure decreased progressively with increasing weight loss in hypertensive subjects (-8.1±10.5 mm Hg with <5 kg weight loss to -10.8±11.0 mm Hg with ⩾5 kg weight loss). The highest POE incidence occurred mainly in groups with increases in both weight and blood pressure. However, with long-term sibutramine treatment, a markedly lower blood pressure tended to increase POEs. CONCLUSION: Modest weight loss and modest lower blood pressure each reduced the incidence of cardiovascular events, as expected. However, the combination of early marked weight loss and rapid blood pressure reduction seems to be harmful in this obese elderly cardiovascular diseased population.

Late presentation for HIV care in central Haiti: factors limiting access to care.

OBJECTIVE: Many patients with HIV infection present for care late in the course of their disease, a factor which is associated with poor prognosis. Our objective was to identify factors associated with late presentation for HIV care among patients in central Haiti. METHODS/DESIGN: Thirty-one HIV-positive adults, approximately 10% of the HIV-infected population followed at a central Haiti hospital, participated in this research study. A two-part research tool that included a structured questionnaire and an ethnographic life history interview was used to collect quantitative as well as qualitative data about demographic factors related to presentation for HIV care. RESULTS: Sixty-five percent of the patients in this study presented late for HIV care, as defined by CD4 cell count below 350 cells/mm3. Factors associated with late presentation included male sex, older age, patient belief that symptoms are not caused by a medical condition, greater distance from the medical clinic, lack of prior access to effective medical care, previous requirement to pay for medical care, and prior negative experience at local hospitals. Harsh poverty was a striking theme among all patients interviewed. CONCLUSIONS: Delays in presentation for HIV care in rural Haiti are linked to demographic, socioeconomic and structural factors, many of which are rooted in poverty. These data suggest that a multifaceted approach is needed to overcome barriers to early presentation for care. This approach might include poverty alleviation strategies; provision of effective, reliable and free medical care; patient outreach through community health workers and collaboration with traditional healers.

Prevalence of rheumatoid arthritis in Dublin, Ireland: a population based survey.

The prevalence of Rheumatoid Arthritis (RA) in Ireland has never been established. Studies from different countries show varying rates, being almost 100 per cent greater in the highlands of Scotland (10/1,000) than in rural Lesotho (6/1,000). A recent study also suggests a fall in the prevalence of RA among women in the London urban area. Given these variations the validity of extrapolating prevalence rates established for other countries to Ireland is questionable. This study aimed to establish a prevalence rate for RA in a defined Dublin population. A self-administered questionnaire was sent to 2,500 people chosen at random from the electoral register. The questionnaire was designed to select out both undiagnosed patients and those with definite arthritis. Respondents whose replies indicated an arthritic process, but in whom no diagnosis had been made, were asked to attend for further assessment and investigations as appropriate. Those who responded that they had been diagnosed with arthritis were asked for consent to inspect their hospital or general practitioner records. A diagnosis of RA was based on American Rheumatism Association (ARA) criteria. Valid responses were received from 1,227 people surveyed (response rate = 49 per cent). Six cases of RA were identified including 2 previously undiagnosed cases. A prevalence rate of 5/1,000 has been estimated based on these findings.