State Requirements for Automated External Defibrillators in American Schools: Framing the Debate About Legislative Action.

Installation of automated external defibrillators (AEDs) in schools has been associated with increased survival after sudden cardiac arrest. An authoritative academic research database was interrogated to identify all current state statutes pertaining to AEDs in schools. As of February 2016, 17 of 50 U.S. states (34%) require AED installation in at least some of their schools; the remaining states have no legislation. However, requirements are far from comprehensive in these 17 states. Only 5 states offer unequivocal funding to schools for purchasing AEDs. A minority of U.S. states have legislation requiring AED placement in schools, and even fewer provide funding. State legislatures that have not yet enacted legislation requiring AEDs in schools may look to neighboring states for examples of child and adult lifesaving law. Placement of an AED in schools should be implemented with an emergency response plan that trains staff in the recognition and response to cardiac arrest.

The need for leadership in global health.

Globalisation has brought with it many advances in health, but also a new range of challenges. There is a need to move from "nation-focused" (international) public health to global public health--and the terminology we use here matters. Global public health leadership requires that respect be shown to evidence, especially that about the changing nature of disease worldwide. The Australian medical and research communities have a significant opportunity to provide global public health leadership.

Obesity and cardiovascular disease in developing countries: a growing problem and an economic threat.

PURPOSE OF REVIEW: This review examines the rise of risk factors for cardiovascular disease, especially obesity, in developing countries and the implications for both health and economics. RECENT FINDINGS: In the majority of developing countries fertility and infant and child mortality have fallen markedly, and life expectancies have increased. Rapid urbanization, falling food prices, and globalization of economies have contributed to an increase in risk factors for chronic disease. Recent work indicates that the prevalence of these risk factors, including obesity, is rising faster than the historical experience of the West. The transition is affecting women in particular, and increases in risk factors are more marked among lower incomes in growing economies than among the wealthy. Rather than the stereotypical problem of the rich, chronic disease is now a problem for the poor. SUMMARY: Significant research in this area of global health has only been undertaken in the last decade. Additional field research is needed in every dimension of the transition, both to document the problem itself and to determine its economic and societal impact and cost effective responses. Two critical factors are virtually absent from existing work and should be emphasized. First, the impact of rising risk factors for, and mortality from, cardiovascular disease in the work force may imply a growing threat to continued economic progress. Second, because risk factor reduction requires society-wide strategies, broad public-private coalitions will be needed to mobilize sectors beyond healthcare.

Multicenter automatic defibrillator implantation trial-cardiac resynchronization therapy (MADIT-CRT): design and clinical protocol.

The planned MADIT-CRT trial is designed to determine if CRT-D will reduce the risk of mortality and HF events by approximately 25% in subjects with ischemic (NYHA class I-II) and non-ischemic (NYHA class II) cardiomyopathy, left ventricular dysfunction (EFor=130 ms).

Identification and management of patients with hypertension in the polyclinic system of the Russian Federation.

BACKGROUND: Cardiovascular diseases, including hypertension and type 2 diabetes mellitus, are the major determinants of poor health in the Russian Federation. METHODS: This study assessed the feasibility of establishing a program to identify and manage hypertension and associated cardiovascular risk factors in an outpatient clinic within the Russian polyclinic system. In urban polyclinic in Kazan, Tatarstan, which is responsible for 77,000 covered lives, we enrolled 192 patients with hypertension of whom 68 had type 2 diabetes mellitus screened from various clinics within the polyclinic. After collection of baseline data, patients were treated for hypertension and those risk factors amenable to pharmaceutic intervention and counseled on those that required behavior modification. RESULTS: Baseline blood pressure was 173.9+/-20.7/104.2+/-15.3 mm Hg in those with hypertension only (n=124) and 172.9+/-26.0/97.9+/-16.4 mm Hg in those with both hypertension and type 2 diabetes mellitus. More than 80% of the entire group had a body mass index >25 kg/m2 and left ventricular hypertrophy. Nearly 70% had total cholesterol >5.2 mmol/L. Of the diabetics, more than 50% had glycosylated hemoglobin (HbA1c)>or=8%. Less than 10% of this self-selected population smoked. Blood pressure decreased modestly, but significantly, in both groups of patients. There were no significant changes in obesity, cholesterol, smoking, or HbA1c in the diabetics. CONCLUSIONS: Identification, recruitment, management, and follow-up of patients with chronic disorders is feasible within the Russian polyclinic system. However, to have a more profound effect on risk factor profiles, a wider effort is needed than one restricted to the clinic itself.

Beyond reproduction: women's health in today's developing world.

BACKGROUND: The concept of women's health is tethered strongly to reproductive health. At present, international attention and resources are focused on obstetric events and, recently, HIV/AIDS because of the significance of these problems in the least developed nations. This limited concept of women's health, however, is decreasingly relevant to the global community, and needs to be revisited in the light of decreasing fertility and increasing life expectancy in many countries where it was previously applicable. It should be expanded to embrace the full spectrum of health experienced by women, and preventive and remedial approaches to the major conditions that afflict women. Allocation of health service resources should be aligned with the epidemiological realities of these threats to women's health. METHODS: Cause of death data for women aged 15-34 years and 35-44 years were examined for nine less developed countries. Deaths associated with pregnancy and child birth, and HIV were compared with deaths due to three chronic disease categories (cancer, cardiovascular disease, and diabetes). The women's health research literature for developing countries appearing in the American Journal of Public Health and British Medical Journal was also examined. RESULTS: In seven out of the nine countries, among women aged 15-34 years, chronic diseases caused over 20% of deaths, while reproductive causes and HIV together accounted for approximately 10% of deaths, in all countries except in India. Among women aged 35-44 years, in all but India, chronic diseases accounted for over four times the deaths attributable to reproductive causes and HIV. The causes of death were not related to the level of development in these countries as measured by GNI PPP. Papers pertaining to women's health published in public health and medical research journals focused principally on reproduction. CONCLUSIONS: Extending the definition of women's health to include a concern for chronic diseases is critical if the needs of women in less developed nations are to be met. In less developed countries, chronic disease is the most important cause of female death even during childbearing years and for women with young families. Development agencies and private philanthropy must begin to fund the studies that will further refine our understanding of the role of chronic diseases in women's health in the developing world.

The Russian health care system today: can American-Russian CME programs help?

The health of the Russian people has deteriorated dramatically since the fall of communism, due particularly to cardiovascular disease. The Eurasian Medical Education Program was developed in response to provide continuing medical education for Russian physicians. Programs are directed mainly toward primary care physicians and focus on outpatient management of diseases that cause high rates of mortality and morbidity. This experience provides an opportunity to assess the structure and functioning of the Russian health care system and emphasizes the importance of general internal medicine training in detection, management, and prevention of disease complications.

Usefulness of standard electrocardiographic parameters for predicting cardiac events after acute myocardial infarction during modern treatment era.

Comprehensive information about the independent value of different electrocardiographic (ECG) variables in predicting cardiac events after acute myocardial infarction (AMI) in the era of modern therapy is limited. Patients (n = 1,034) underwent standard electrocardiography from 5 to 7 days after an AMI. Several time intervals and PQRST abnormalities were analyzed from the electrocardiogram. During a mean +/- SD follow-up of 752 +/- 301 days on average, 42 patients (4%) experienced cardiac death, and 259 patients (25%) a cardiac death, nonfatal AMI, or unstable angina. Several ECG variables had a significant association with cardiac events in univariate comparisons. After adjustment for all risk variables in the Cox hazards model, lateral ST-segment depression (hazard ratio [HR] 4.76, 95% confidence interval [CI] 2.40 to 9.44, p <0.0001) and atrial abnormality with a terminal deflection of the P wave > or =0.1 mV deep and > or =40 ms in duration in lead V(1) (HR 2.46, 95% CI 1.25 to 4.82, p = 0.009) were the only ECG variables that independently predicted cardiac death. Lateral ST-segment depression also predicted the combined end point of cardiac death/nonfatal AMI/unstable angina in this model (HR 1.49, 95% CI 1.14 to 1.94, p = 0.003). In conclusion, lateral ST depression and atrial abnormality on the electrocardiogram are independent predictors of cardiac death after AMI. Lateral ST depression is also associated with ischemic cardiac events.

Global health assistance: a new perspective.

Health care priorities for many emerging economies have undergone a dramatic transition in the recent past because of the rise in chronic illness, increased longevity, and lessened infant mortality. Two additional major societal forces, democratization and the information revolution, will alter the nature of global health assistance. Because of democratization, governments will feel increasing pressure to provide adequate health care. Because of the information revolution, all practitioners will know what is available. The convergence of these three forces will create an enormous financial burden for emerging economies. Adapting to these new realities will be the challenge to donor organizations. What is likely to emerge as a critical health care problem around the world is the need to balance priorities between acute care and prevention or modification of chronic disease. These efforts will be directed at different populations, one manifestly ill and one potentially so, and each will need to be recognized politically as having valid claims on governmental resources. External support will need to include demonstration within the recipient communities that data collection permits an accurate identification of disease burden, that risk factor modification ameliorates the impact of disease, that continuity of care is essential to long term outcomes, and that therapy of developed disease can be rationally carried out utilizing evidence based medicine to insure efficiency and appropriateness.