AK Azad

BACKGROUND: Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development. METHODS: We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level. FINDINGS: The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and middle-income countries (except for India) than in high-income countries. The proportion of communities with four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90), 71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13% in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of 65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in communities that had all four drug classes available were more likely to use at least one blood pressure-lowering medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59-3·12); p<0·0001), combination therapy (1·53, 1·13-2·07; p=0·054), and have their blood pressure controlled (2·06, 1·69-2·50; p<0·0001) than were those in communities where blood pressure-lowering medicines were not available. Participants with known hypertension from households able to afford four blood pressure-lowering drug classes were more likely to use at least one blood pressure-lowering medicine (adjusted OR 1·42, 95% CI 1·25-1·62; p<0·0001), combination therapy (1·26, 1·08-1·47; p=0·0038), and have their blood pressure controlled (1·13, 1·00-1·28; p=0·0562) than were those unable to afford the medicines. INTERPRETATION: A large proportion of communities in low-income and middle-income countries do not have access to more than one blood pressure-lowering medicine and, when available, they are often not affordable. These factors are associated with poor blood pressure control. Ensuring access to affordable blood pressure-lowering medicines is essential for control of hypertension in low-income and middle-income countries. FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Canadian Institutes of Health Research Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, the Ontario Ministry of Health and Long-Term Care, pharmaceutical companies (with major contributions from AstraZeneca [Canada], Sanofi Aventis [France and Canada], Boehringer Ingelheim [Germany amd Canada], Servier, and GlaxoSmithKline), Novartis and King Pharma, and national or local organisations in participating countries.

PURPOSE: To prospectively determine incidence, prevalence, and extent of lipodystrophy (LD) and associated metabolic changes. METHOD: This was a prospective cohort study. Body habitus changes were determined by anthropometrics, photography, and regional dual-energy X-ray absorptiometry (DXA) scan. Metabolic parameters included triglyceride (TG), total (TC), LDL and HDL cholesterol, glucose, and insulin. RESULTS: 68 patients were included. 51 (75%) received protease inhibitor (PI)-based and 17 (25%) non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy (ARV) and 90% a thymidine analogue. Statistically significant increases in TC, TG, LDL, and HDL by 12 months developed on PI but only in TC for NNRTI. At 24 months, on DXA scanning, there were no statistically significant changes in median limb or total body fat on NNRTI but a statistically significant decrease in limb fat on PI (p = .01). There was considerable individual variation with overall 3 (7%) patients having >20% increases and 16 (36%) with >20% decreases in limb fat and 6 (14%) having >20% increases and 7 (16%) with >20% decreases in total body fat. CONCLUSIONS: Lipid changes occurred early and progressed. Median changes in body fat were minor and more common on PI, but individual variation in change was large, challenging the use of medians or threshold changes to predict impact of different ARV agents.

Abstract The reliability of a recently developed potential model is tested by extending the study to various anharmonic properties, e.g., third and fourth‐order elastic constants, Grüneisen parameters, and the pressure derivatives of second‐order elastic constants of hydrides and deuterides of lithium and sodium. A comparison of the calculated properties with the limited experimental results and other theoretical estimates gives an indication of the applicability of the derived potential in the study of crystal anharmonicity. However, the need for further experimental data is stressed in order to judge clearly the reliability of the present calculations for all the compounds.