Vascular endothelial growth factor (VEGF) can promote angiogenesis but may also exert certain effects to alter the rate of atherosclerotic plaque development. To evaluate this potential impact on plaque progression, we treated cholesterol-fed mice doubly deficient in apolipoprotein E/apolipoprotein B100 with low doses of VEGF (2 microg/kg) or albumin. VEGF significantly increased macrophage levels in bone marrow and peripheral blood and increased plaque area 5-, 14- and 4-fold compared with controls at weeks 1, 2 and 3, respectively. Plaque macrophage and endothelial cell content also increased disproportionately over controls. In order to confirm that the VEGF-mediated plaque progression was not species-specific, the experiment was repeated in cholesterol-fed rabbits at the three-week timepoint, which showed comparable increases in plaque progression.
In countries severely affected by HIV/AIDS, shortages of health workers present a major obstacle to scaling up HIV services. Adopting a task shifting approach for the deployment of community health workers (CHWs) represents one strategy for rapid expansion of the health workforce. This study aimed to evaluate the contribution of CHWs with a focus on identifying the critical elements of an enabling environment that can ensure they provide quality services in a manner that is sustainable. The method of work included a collection of primary data in five countries: Brazil, Ethiopia, Malawi, Namibia, and Uganda. The findings show that delegation of specific tasks to cadres of CHWs with limited training can increase access to HIV services, particularly in rural areas and among underserved communities, and can improve the quality of care for HIV. There is also evidence that CHWs can make a significant contribution to the delivery of a wide range of other health services. The findings also show that certain conditions must be observed if CHWs are to contribute to well-functioning and sustainable service delivery. These conditions involve adequate systems integration with significant attention to: political will and commitment; collaborative planning; definition of scope of practice; selection and educational requirements; registration, licensure and certification; recruitment and deployment; adequate and sustainable remuneration; mentoring and supervision including referral system; career path and continuous education; performance evaluation; supply of equipment and commodities. The study concludes that, where there is the necessary support, the potential contribution of CHWs can be optimized and represents a valuable addition to the urgent expansion of human resources for health, and to universal coverage of HIV services.
If the absolute risk approach for assessment of risk and effective management of hypertension is to be implemented in low-resource settings, appropriate policy measures need to be taken to improve the competency of health-care providers, to provide basic laboratory facilities and to develop affordable financing mechanisms.
Objective To ascertain the reliability of applying the WHO Cardiovascular Risk Management Package by non-physician health-care workers (NPHWs) in typical primary health-care settings. Methods Based on an a priori 80% agreement level between the NPHWs and the "expert" physicians (gold standard), 649 paired (matched) applications of the protocol were obtained for analysis using Kappa statistic and multivariate logit regression. Findings Results indicate over 80% agreement between raters, from moderate to perfect levels of agreement in almost all of the sections in the package. The odds of obtaining a difference between raters and a benchmark are not statistically significant. Conclusion Applying the WHO Cardiovascular Risk Management Package, NPHWs can be retrained to reliably and effectively assess and manage cardiovascular risks in primary health-care settings where there are no attending physicians. The package could be a useful tool for scaling up the management of cardiovascular diseases in primary health care.
IntroductionChronic noncommunicable diseases, especially cardiovascular diseases, are a major and increasing cause of death and disability worldwide, and may have retarding effects on the economies of affected individuals, households and countries. 1,2 The epidemiological and economic effects of cardiovascular diseases (specifically stroke and heart diseases) and diabetes, are especially pervasive in low-and middle-income countries 1-3 where health systems are less likely to adequately respond to the challenges of the increasing burden. Socioeconomic barriers and inequalities in access to treatment, suboptimal staffing of health-care facilities and limited capacity for ancillary investigations that complement cardiovascular risk profiling are some of the common problems limiting these countries' control of chronic diseases, especially at the primary healthcare level. 4 This situation is worsened by the brain-drain syndrome 5-9 resulting in shortages of skilled workers.Can non-physician health-care workers assess and manage cardiovascular risk in primary care? 29 However, such risk profiling protocols lack universal applicability 11,13,14,[29][30][31][32][33][34][35][36][37][38][39][40][41][42] and may be of limited applicability in developing countries, whose populations were not sampled for the Framingham 31,32 and other studies. Uncritical adoption of such protocols may result in negative clinical and economic consequences. 43 To address the absence of a CVD risk profiling tool for developing countries, WHO in 2000 developed a package for the assessment and management of cardiovascular risk in low-resource settings. 44 The package, developed through consultations with experts from all WHO regions, was designed as an adaptable, cost-effective tool for systematic case management at all health-care levels, and consequently for scaling up countries' health systems. The expert panel based the design of the package on the graded evidence available.The package includes three scenarios that reflect commonl...
Francesca Celletti and colleagues from WHO argue that a transformation in the scale-up of medical education in low- and middle-income countries is needed, and detail what this might look like.
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