Suchergebnisse

INTRODUCTION: Progress to democracy in South Africa in 1994 was followed by the adoption of a primary health care approach with free access for all. State health facilities serve 80% of the population, and a private sector comprising general practitioners, specialists and private hospitals, serves the remainder. NATIONAL POLICIES AND MODELS: There are national prescribing guidelines for common diseases, and these specify the medicines on the Essential Drugs List that are available at primary care facilities for respiratory diseases including asthma, COPD, pneumonia and tuberculosis. EPIDEMIOLOGY: Asthma prevalence is average among children (13%) but morbidity is high. COPD rates are high owing to concurrent risk factors of smoking (in both men and women), occupational exposures, biomass fuel use and previous lung infections including tuberculosis. Tuberculosis and HIV are rampant, and together with pneumococcal co-infection account for considerable mortality. ACCESS TO CARE: Primary care facilities are within reach of most communities, but major barriers to care include loss of income, waiting times in clinics, cost of transportation, and inconvenient hours. FACILITIES AVAILABLE: The country is divided into districts each served by a hospital, several community health centres and many fixed or mobile clinics. The latter provide predominantly nurse-led care by nurse practitioners with additional qualifications. Some clinics and most community health centres are served by doctors. Referrals are made to secondary and tertiary hospitals served by specialists. FUTURE: Innovations to address staff shortages include the creation of the specialty of family medicine for physicians and development of the clinical associate who is trained to perform a limited clinical role, as well as in-service on-site training of nurses through programmes of integrated care for infectious and chronic diseases. There is an urgent need to address low staff morale and medical migration resulting from a decade of poor leadership and AIDS ...

To access publisher full text version of this article. Please click on the hyperlink in Additional Links field. ; Chronic obstructive pulmonary disease (COPD) is predicted to become the third most common cause of death and disability worldwide by 2020. The prevalence of COPD defined by the lower limit of normal was estimated using high-quality spirometry in surveys of 14 populations aged ≥ 40 yrs. The strength and consistency of associations were assessed using random effects meta-analysis. Pack-years of smoking were associated with risk of COPD at each site. After adjusting for this effect, we still observed significant associations of COPD risk with age (OR 1.52 for a 10 yr age difference, 95% CI 1.35-1.71), body mass index in obese compared with normal weight (OR 0.50, 95% CI 0.37-0.67), level of education completed (OR 0.76, 95% CI 0.67-0.87), hospitalisation with a respiratory problem before age 10 yrs (OR 2.35, 95% CI 1.42-3.91), passive cigarette smoke exposure (OR 1.24, 95% CI 1.05-1.47), tuberculosis (OR 1.78, 95%CI 1.17-2.72) and a family history of COPD (OR 1.50, 95% CI 1.19-1.90). Although smoking is the most important risk factor for COPD, other risk factors are also important. More research is required to elucidate relevant risk factors in low- and middle-income countries where the greatest impact of COPD will occur. ; ALTANA Aventis AstraZeneca Boehringer-Ingelheim Chiesi GlaxoSmithKline Merck Novartis Pfizer Schering-Plough Sepracor University of Kentucky Boehringer Ingelheim China (Guangzhou, China) Turkish Thoracic Society Pfizer (Adana, Turkey) Merck Sharpe Dohme Salzburger Gebietskrankenkasse Salzburg Local Government (Salzburg, Austria) Research for International Tobacco Control International Development Research Centre South African Medical Research Council South African Thoracic Society GlaxoSmithKline University of Cape Town Lung Institute (Cape Town, South Africa) Landspitali-University Hospital GlaxoSmithKline Iceland AstraZeneca Iceland (Reykjavik, Iceland) GlaxoSmithKline ...

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked Files. This article is open access. ; Chronic obstructive pulmonary disease (COPD) is a commonly reported cause of death and associated with smoking. However, COPD mortality is high in poor countries with low smoking rates. Spirometric restriction predicts mortality better than airflow obstruction, suggesting that the prevalence of restriction could explain mortality rates attributed to COPD. We have studied associations between mortality from COPD and low lung function, and between both lung function and death rates and cigarette consumption and gross national income per capita (GNI). ; National COPD mortality rates were regressed against the prevalence of airflow obstruction and spirometric restriction in 22 Burden of Obstructive Lung Disease (BOLD) study sites and against GNI, and national smoking prevalence. The prevalence of airflow obstruction and spirometric restriction in the BOLD sites were regressed against GNI and mean pack years smoked. ; National COPD mortality rates were more strongly associated with spirometric restriction in the BOLD sites (<60 years: men rs=0.73, p=0.0001; women rs=0.90, p<0.0001; 60+ years: men rs=0.63, p=0.0022; women rs=0.37, p=0.1) than obstruction (<60 years: men rs=0.28, p=0.20; women rs=0.17, p<0.46; 60+ years: men rs=0.28, p=0.23; women rs=0.22, p=0.33). Obstruction increased with mean pack years smoked, but COPD mortality fell with increased cigarette consumption and rose rapidly as GNI fell below US$15 000. Prevalence of restriction was not associated with smoking but also increased rapidly as GNI fell below US$15 000. ; Smoking remains the single most important cause of obstruction but a high prevalence of restriction associated with poverty could explain the high 'COPD' mortality in poor countries. ; Wellcome Trust 085790/Z/08/Z ALTANA Aventis AstraZeneca Boehringer-Ingelheim Chiesi ...