Current treatment options for cluster headache: limitations and the unmet need for better and specific treatments-a consensus article

AIM

Treatment for cluster headache is currently based on a trial-and-error approach. The available preventive treatment is unspecific and based on few and small studies not adhering to modern standards. Therefore, the authors collaborated to discuss acute and preventive treatment in cluster headache, addressing the unmet need of safe and tolerable preventive medication from the perspectives of people with cluster headache and society, headache specialist and cardiologist.

FINDINGS

The impact of cluster headache on personal life is substantial. Mean annual direct and indirect costs of cluster headache are more than 11,000 Euros per patient. For acute treatment, the main problems are treatment response, availability, costs and, for triptans, contraindications and the maximum use allowed. Intermediate treatment with steroids and greater occipital nerve blocks are effective but cannot be used continuously. Preventive treatment is sparsely studied and overall limited by relatively low efficacy and side effects. Neurostimulation is a relevant option for treatment-refractory chronic patients. From a cardiologist's perspective use of verapamil and triptans may be worrisome and regular follow-up is essential when using verapamil and lithium.

CONCLUSION

We find that there is a great and unmet need to pursue novel and targeted preventive modalities to suppress the horrific pain attacks for people with cluster headache.

Predicting patients who are likely to develop Lupus Nephritis of those newly diagnosed with Systemic Lupus Erythematosus

Patients diagnosed with systemic lupus erythematosus (SLE) suffer from a decreased quality of life, an increased risk of medical complications, and an increased risk of death. In particular, approximately 50% of SLE patients progress to develop lupus nephritis, which oftentimes leads to life-threatening end stage renal disease (ESRD) and requires dialysis or kidney transplant1. The challenge is that lupus nephritis is diagnosed via a kidney biopsy, which is typically performed only after noticeable decreased kidney function, leaving little room for proactive or preventative measures. The ability to predict which patients are most likely to develop lupus nephritis has the potential to shift lupus nephritis disease management from reactive to proactive. We present a clinically useful prediction model to predict which patients with newly diagnosed SLE will go on to develop lupus nephritis in the next five years.

Machine learning for emerging infectious disease field responses

Emerging infectious diseases (EIDs), including the latest COVID-19 pandemic, have emerged and raised global public health crises in recent decades. Without existing protective immunity, an EID may spread rapidly and cause mass casualties in a very short time. Therefore, it is imperative to identify cases with risk of disease progression for the optimized allocation of medical resources in case medical facilities are overwhelmed with a flood of patients. This study has aimed to cope with this challenge from the aspect of preventive medicine by exploiting machine learning technologies. The study has been based on 83,227 hospital admissions with influenza-like illness and we analysed the risk effects of 19 comorbidities along with age and gender for severe illness or mortality risk. The experimental results revealed that the decision rules derived from the machine learning based prediction models can provide valuable guidelines for the healthcare policy makers to develop an effective vaccination strategy. Furthermore, in case the healthcare facilities are overwhelmed by patients with EID, which frequently occurred in the recent COVID-19 pandemic, the frontline physicians can incorporate the proposed prediction models to triage patients suffering minor symptoms without laboratory tests, which may become scarce during an EID disaster. In conclusion, our study has demonstrated an effective approach to exploit machine learning technologies to cope with the challenges faced during the outbreak of an EID.

Trends in Differences Across Subgroups of Adults in Preventive Services Utilization

BACKGROUND

There were large differences across subgroups of adults in preventive services utilization before 2010. The Affordable Care Act had numerous provisions aimed at increasing utilization as well as at reducing disparities.

OBJECTIVE

This study examines whether preventive services utilization changed over time, across subgroups of adults defined by race/ethnicity, insurance coverage, poverty status, Census region, and urbanicity.

METHODS

Data from the Medical Expenditure Panel Survey Household Component are used to examine service utilization before the passage of the Affordable Care Act (2008/2009), after the implementation of the preventive services mandate and the dependent coverage provision (2012/2013), and after Medicaid expansions (2015/2016). Four preventive services are examined for adults aged 19-64-general checkups, blood cholesterol screening, mammograms, and colorectal cancer screening. Multivariate logistic regression models are used to predict preventive services utilization of adult subgroups in each time period, and to examine how differences across subgroups changed between 2008/2009 and 2015/2016.

RESULTS

There were modest increases in utilization between 2008/2009 and 2015/2016 for blood cholesterol and colorectal cancer screenings. For 3 of 4 preventive services, differences between the Northeast and the Midwest regions narrowed. However, large gaps in utilization across income groups and between those with and without coverage persisted. Disparities across racial/ethnic groups in general checkups persisted over time as well.

CONCLUSION

While some differences have narrowed, large gaps in preventive service utilization across population subgroups remain.

Effect of Individualized Preventive Care Recommendations vs Usual Care on Patient Interest and Use of Recommendations: A Pilot Randomized Clinical Trial

Importance

This randomized clinical trial examines the feasibility and acceptability of a decision-making tool for increasing patient interest in individualized recommendations for preventive care services.

Objective

To pilot a tool to help patients compare life expectancy gains from evidence-based preventive services.

Design, Setting, and Participants

This randomized clinical trial examined patient and physician responses to a pilot decision tool incorporating personalized risk factors at 3 US primary care clinics between 2017 and 2020. Eligible patients were between ages 45 to 70 years with 2 or more high-risk factors. Patients were followed-up after 1 year.

Interventions

The gain in life expectancy associated with guideline adherence to each recommended preventive service was estimated. Personalized estimates incorporating risk factors in electronic health records were displayed in a physician-distributed visual aid. During development, physicians discussed individualized results with patients using shared decision-making (SDM). During the trial, patients were randomized to receive individualized recommendations or usual care (nonmasked, parallel, 1:1 ratio).

Main Outcomes and Measures

Primary outcome was patient interest in individualized recommendations, assessed by survey. Secondary outcomes were use of SDM, decisional comfort, readiness to change, and preventive services received within 1 year.

Results

The study enrolled 104 patients (31 development, 39 intervention, 34 control), of whom 101 were included in analysis (mean [SD] age, 56.5 [5.3] years; 73 [72.3%] women; 80 [79.2%] Black patients) and 20 physicians. Intervention patients found the tool helpful and wanted to use it again, rating it a median 9 of 10 (IQR, 8-10) and 10 of 10 (8-10), respectively. Compared with the control group, intervention patients more often correctly identified the service least likely (18 [46%] vs 0; P = .03) to improve their life expectancy. A greater number of patients also identified the service most likely to improve their life expectancy (26 [69%] vs 10 [30%]; P = .07), although this result was not statistically significant. Intervention patients reported greater mean [SD] improvement in SDM (4.7 [6.9] points) and near-term readiness to change (13.8 points for top-3-ranked recommendations). Point estimates indicated that patients in the intervention group experienced greater, although non-statistically significant, reductions in percentage of body weight (-2.96%; 95% CI, -8.18% to 2.28%), systolic blood pressure (-6.42 mm Hg; 95% CI, -16.12 to 3.27 mm Hg), hemoglobin A1c (-0.68%; 95% CI, -1.82% to 0.45%), 10-year atherosclerotic cardiovascular disease risk score (-1.20%; 95% CI, -3.65% to 1.26%), and low-density lipoprotein cholesterol (-8.46 mg/dL; 95% CI, -26.63 to 9.70 mg/dL) than the control group. Nineteen of 20 physicians wanted to continue using the decision tool in the future.

Conclusions and Relevance

In this clinical trial, an individualized preventive care decision support tool improved patient understanding of primary prevention and demonstrated promise for improved shared decision-making and preventive care utilization.

Trial Registration

ClinicalTrials.gov Identifier: NCT03023813.

Screens for infants and preschool children: Assessment of medical prevention with parents and assessment of exposure

BACKGROUND

Regarding the massive increase of interactive mobile screen household equipment and the omnipresence of television, many recommendations are in favor of a limitation of use, especially among the youngest.

OBJECTIVE

We aimed to evaluate the proportion of parents who report having discussed the subject of their child's exposure to screens during a consultation with a health professional. We also aimed to assess preschool exposure to television and mobile media devices, and to explore parents' views on the benefits and risks of exposing their children under 3 years old.

METHODS

A questionnaire was administered to parents of children aged 6 months to 3 years in a pediatric emergency ward and several nurseries. This observational, cross-sectional and multicenter study was conducted from January to May 2019.

RESULTS

We included 451 responses in the analyses. Only 99 (22.7%; 95% CI: 18.7-26.6) parents reported having discussed their child's exposure to screens with a doctor, on the initiative of the parents themselves for 52 households (53.1%; 95% CI: 43.2-62.9). Feelings of a benefit of screens on child learning concerned 134 (34.5%; 95% CI: 29.8-39.3) parents; 300 (68.5%; 95% CI: 64.1-72.8) said they were sufficiently informed about benefits and risks. In a typical week, 240 (53.7%; 95% CI: 49.1-58.3), 160 (35.8%; 95% CI: 31.3-40.2), and 58 (13.0%; 95% CI: 9.9-16.1) children were exposed at least once a week to television, smartphones, and tablets, respectively.

CONCLUSIONS

Our study showed that the theme of exposure to screens was hardly addressed by physicians in consultation. Our findings help target prevention messages, including fighting the widespread belief that media are beneficial to child development, emphasizing the importance of screen-free time (eating, going to bed, after waking up) and encouraging support and interaction during exposure in families who choose to expose their children.

"He who pays the piper calls the tune": Researcher experiences of funder suppression of health behaviour intervention trial findings

BACKGROUND

Governments commonly fund research with specific applications in mind. Such mechanisms may facilitate 'research translation' but funders may employ strategies that can also undermine the integrity of both science and government. We estimated the prevalence and investigated correlates of funder efforts to suppress health behaviour intervention trial findings.

METHODS

Our sampling frame was lead or corresponding authors of papers (published 2007-2017) included in a Cochrane review, reporting findings from trials of interventions to improve nutrition, physical activity, sexual health, smoking, and substance use. Suppression events were based on a previous survey of public health academics. Participants answered questions concerning seven suppression events in their efforts to report the trial, e.g., [I was…] "asked to suppress certain findings as they were viewed as being unfavourable." We also examined the association between information on study funder, geographical location, targeted health behaviour, country democracy rating and age of publication with reported suppression.

FINDINGS

We received responses from 104 authors (50%) of 208 eligible trials, from North America (34%), Europe (33%), Oceania (17%), and other countries (16%). Eighteen percent reported at least one of the seven suppression events relating to the trial in question. The most commonly reported suppression event was funder(s) expressing reluctance to publish because they considered the results 'unfavourable' (9% reported). We found no strong associations with the subject of research, funding source, democracy, region, or year of publication.

CONCLUSIONS

One in five researchers in this global sample reported being pressured to delay, alter, or not publish the findings of health behaviour intervention trials. Regulation of funder and university practices, establishing study registries, and compulsory disclosure of funding conditions in scientific journals, are needed to protect the integrity of public-good research.

Knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana

Background

COVID-19 is a novel respiratory disease associated with severe morbidity and high mortality in the elderly population and people with comorbidities. Studies have suggested that pregnant women are more susceptible to COVID-19 compared to non-pregnant women. However, it’s unclear whether pregnant women in Ghana are knowledgeable about COVID-19 and practice preventive measures against it. This study sought to assess the knowledge and preventive practices towards COVID-19 among pregnant women seeking antenatal services in Northern Ghana.

Methods

A cross-sectional study was conducted using a structured questionnaire in the Nabdam district in Ghana. A total of 527 pregnant women were randomly sampled from health facilities offering antenatal care services in the district. Multivariable logistic regression analysis was used to assess the association between the predictors and outcome variables.

Results

The prevalence of adequate knowledge and good COVID-19 preventive practices were 85.6%, (95% CI: 82.57, 88.59) and 46.6%, (95% CI: 42.41, 50.95) respectively. Having at least a primary education, residing in an urban area, and receiving COVID-19 education at a health facility were positively associated with adequate knowledge on COVID-19. Factors positively associated with good COVID-19 preventive practices were older age, having at least a primary education, pregnant women with a chronic disease, and living in an urban area. Multiparity was negatively associated with good COVID-19 preventive practices.

Conclusion

Although majority of women had adequate knowledge of COVID-19, less than half of them were engaged in good COVID-19 preventive practices. Education of pregnant women on COVID-19 preventive practices should be intensified at health facilities while improving upon the water, sanitation and hygiene need particularly in rural communities.

Heart failure management; a perspective from diabetes care

People with type 2 diabetes (T2DM) are recognized as having a 2-4 times increased risk of heart failure (HF). Ambulatory diabetes care has long concentrated on the prevention of microvascular and arterial disease, and surveillance for manageable problems such as with the feet and retinae. Accordingly, management of heart failure has never been a specific focus, although the preventative management of cardiac and kidney disease through glucose-lowering, blood pressure (BP) control, and blood lipid control, have had a positive impact on its incidence. Indeed, the very complexity of routine diabetes care, and its enormous prevalence, has generally excluded the management of any of the advanced late complications, whether cardiac, arterial, retinal, renal, or neurodegenerative. Furthermore, advances in HF management itself, in diagnostics, medications, and technology, has carried it deeper into the remit of specialist cardiological care. More recently and in addition to medications already routinely used in diabetes care such as renin-angiotensin system (RAS) blockers, some glucose-lowering therapies such as sodium glucose transporter inhibitors 2 (SGLT-2 inhibitors), have been found to have very positive effects on hospitalization for HF, indeed even in people who do not have T2DM. Here, from the perspective of the diabetologist, we review the clinical scenario of ambulatory diabetes care, in regard of how HF prevention and management should fit in to clinical practice.

Quality-Adjusted Life-Year Losses Averted With Every COVID-19 Infection Prevented in the United States

OBJECTIVE

To estimate the overall quality-adjusted life-years (QALYs) gained by averting 1 coronavirus disease 2019 (COVID-19) infection over the duration of the pandemic.

METHODS

A cohort-based probabilistic simulation model, informed by the latest epidemiological estimates on COVID-19 in the United States provided by the Centers for Disease Control and Prevention and literature review. Heterogeneity of parameter values across age group was accounted for. The main outcome studied was QALYs for the infected patient, patient's family members, and the contagion effect of the infected patient over the duration of the pandemic.

RESULTS

Averting a COVID-19 infection in a representative US resident will generate an additional 0.061 (0.016-0.129) QALYs (for the patient: 0.055, 95% confidence interval [CI] 0.014-0.115; for the patient's family members: 0.006, 95% CI 0.002-0.015). Accounting for the contagion effect of this infection, and assuming that an effective vaccine will be available in 3 months, the total QALYs gains from averting 1 single infection is 1.51 (95% CI 0.28-4.37) accrued to patients and their family members affected by the index infection and its sequelae. These results were robust to most parameter values and were most influenced by effective reproduction number, probability of death outside the hospital, the time-varying hazard rates of hospitalization, and death in critical care.

CONCLUSION

Our findings suggest that the health benefits of averting 1 COVID-19 infection in the United States are substantial. Efforts to curb infections must weigh the costs against these benefits.

Preventing Breast Cancer Through Identification and Pharmacologic Management of High-Risk Patients

Breast cancer remains the most common cancer in women in the United States. For certain women at high risk for breast cancer, endocrine therapy (ET) can greatly decrease the risk. Tools such as the Breast Cancer Risk Assessment Tool (or Gail Model) and the International Breast Cancer Intervention Study risk calculator are available to help identify women at increased risk for breast cancer. Physician awareness of family history, reproductive and lifestyle factors, dense breast tissue, and history of benign proliferative breast disease are important when identifying high-risk women. The updated US Preventive Services Task Force and American Society of Clinical Oncology guidelines encourage primary care providers to identify at-risk women and offer risk-reducing medications. Among the various ETs, which include tamoxifen, raloxifene, anastrozole, and exemestane, tamoxifen is the only one available for premenopausal women aged 35 years and older. A shared decision-making process should be used to increase the usage of ET and must be individualized. This individualized approach must account for each woman's medical history and weigh the benefits and risks of ET in combination with the personal values of the patient.

COVID-19 and Preparing Planetary Health for Future Ecological Crises: Hopes from Glycomics for Vaccine Innovation

A key lesson emerging from COVID-19 is that pandemic proofing planetary health against future ecological crises calls for systems science and preventive medicine innovations. With greater proximity of the human and animal natural habitats in the 21st century, it is also noteworthy that zoonotic infections such as COVID-19 that jump from animals to humans are increasingly plausible in the coming decades. In this context, glycomics technologies and the third alphabet of life, the sugar code, offer veritable prospects to move omics systems science from discovery to diverse applications of relevance to global public health and preventive medicine. In this expert review, we discuss the science of glycomics, its importance in vaccine development, and the recent progress toward discoveries on the sugar code that can help prevent future infectious outbreaks that are looming on the horizon in the 21st century. Glycomics offers veritable prospects to boost planetary health, not to mention the global scientific capacity for vaccine innovation against novel and existing infectious agents.

A wearable light-touch contact device for human balance support

There is an urgent need for the development of ways to address the major issue of falls among today's globally aging population. The authors here outline a new approach referred to as virtual light-touch contact to mitigate postural sway during ambulatory and stationary periods, and propose a wearable light-touch (WLT) system featuring a virtual partition around the user that allows determination of virtual forces resulting from related contact. The data produced are used to create vibrotactile fingertip feedback, which supports comprehensive perception of the partition. Non-impaired subjects were recruited to support evaluation of the prototype system (incorporating tactile stimulation and motion-capture technology), with outcomes showing successful mitigation of postural sway in a heel-to-toe tandem stance. Research performed with 150 able-bodied volunteers to validate the performance of the new set-up (incorporating an acceleration sensor and a voice coil motor to render the light-touch effect) suggested that the proposed WLT approach supports human balance on a level comparable to that of the light-touch effect.

An Observational Study in Manipur State, India on Preventive Behavior Influenced by Social Media During the COVID-19 Pandemic Mediated by Cyberchondria and Information Overload

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic is a public health emergency posing unprecedented challenges for health authorities. Social media may serve as an effective platform to disseminate health-related information. This study aimed to assess the extent of social media use, its impact on preventive behavior, and negative health effects such as cyberchondria and information overload.

METHODS

A cross-sectional observational study was conducted between June 10, 2020 and August 9, 2020 among people visiting the outpatient department of the authors' institution, and participants were also recruited during field visits for an awareness drive. Questions were developed on preventive behavior, and the Short Cyberchondria Scale and instruments dealing with information overload and perceived vulnerability were used.

RESULTS

The study recruited 767 participants with a mean age of about 45 years. Most of the participants (>90%) engaged in preventive behaviors, which were influenced by the extent of information received through social media platforms (β=3.297; p<0.001) and awareness of infection when a family member tested positive (β=29.082; p<0.001) or a neighbor tested positive (β=27.964; p<0.001). The majority (63.0%) of individuals often searched for COVID-19 related news on social media platforms. The mean±standard deviation scores for cyberchondria and information overload were 9.09±4.05 and 8.69±2.56, respectively. Significant and moderately strong correlations were found between cyberchondria, information overload, and perceived vulnerability to COVID-19.

CONCLUSIONS

This study provides evidence that the use of social media as an information- seeking platform altered preventive behavior. However, excessive and misleading information resulted in cyberchondria and information overload.

COVID-19: An Update on the Epidemiological, Clinical, Preventive, and Therapeutic Management of 2019 Novel Coronavirus Disease

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) remains a serious issue for global health, given widespread infectivity and a high contagion rate. A tremendous amount of data has been generated since it was first identified in December 2019. It is vital to keep up with these data from across the world at a time of uncertainty and continuously evolving guidelines and clinical practice. This review provides an update on recent developments concerning epidemiology, clinical presentation, treatment options, and scientific advancements to combat the COVID-19 pandemic.

Toward targeted prevention: risk factors for prediabetes defined by impaired fasting glucose, impaired glucose tolerance and increased HbA1c in the population-based KORA study from Germany

AIMS

To identify socioeconomic, behavioral and clinical factors that are associated with prediabetes according to different prediabetes definition criteria.

METHODS

Analyses use pooled data of the population-based Cooperative Health Research in the Region of Augsburg (KORA) studies (n = 5312 observations aged ≥ 38 years without diabetes). Prediabetes was defined through either impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or elevated HbA1c according to thresholds of the American Diabetes Association. Explanatory variables were regressed on prediabetes using generalized estimating equations.

RESULTS

Mean age was 58.4 years; 50% had prediabetes (33% had IFG, 16% IGT, and 26% elevated HbA1c, 10% fulfilled all three criteria). Age, obesity, hypertension, low education, unemployment, statutory health insurance, urban residence and physical inactivity were associated with prediabetes. Male sex was a stronger risk factor for IFG (OR = 2.5; 95%-CI: 2.2-2.9) than for IGT or elevated HbA1c, and being unemployed was a stronger risk factor for IGT (OR = 3.2 95%-CI: 2.6-4.0) than for IFG or elevated HbA1c.

CONCLUSIONS

The overlap of people with IFG, IGT and elevated HbA1c is small, and some factors are associated with only one criterion. Knowledge on sociodemographic and socioeconomic risk factors can be used to effectively target interventions to people at high risk for type 2 diabetes.

COVID-19 in children: Could pertussis vaccine play the protective role?

While COVID-19 continues to spread across the globe, diligent efforts are made to understand its attributes and dynamics to help develop treatment and prevention measures. The paradox pertaining to children being the least affected by severe illness poses exciting opportunities to investigate potential protective factors. In this paper, we propose that childhood vaccination against pertussis (whooping cough) might play a non-specific protective role against COVID-19 through heterologous adaptive responses in this young population. Pertussis is a vaccine-preventable infectious disease of the respiratory tract and it shares many similarities with COVID-19 including transmission and clinical features. Although pertussis is caused by a bacterium (Bordetella pertussis) while COVID-19 is a viral infection (SARS-CoV-2), previous data showed that cross-reactivity and heterologous adaptive responses can be seen with unrelated agents of highly divergent groups, such as between bacteria and viruses. While we build the arguments of this hypothesis on theoretical and previous empirical evidence, we also outline suggested lines of research from different fields to test its credibility. Besides, we highlight some concerns that may arise when attempting to consider such an approach as a potential public health preventive intervention against COVID-19.

Presenting a conceptual framework for an HIV prevention and care continuum and assessing the feasibility of empirical measurement in Estonia: A case study

Objective

We aim to show the feasibility of using an integrated prevention and care continuum (PCC) model as a complete and improved tool for HIV control measurement and programming. Alignment of prevention and care continua is essential to further improve health outcomes and minimize HIV transmission risk.

Design

Cross-sectional study.

Methods

Data from 977 persons who inject drugs (PWID) collected in 2011–2016 in Tallinn, Estonia, were used to construct an HIV PCC for PWID, stratified by risk for acquiring or transmitting HIV infection and by coverage of combined interventions. We also estimated the average protective effect of current levels of intervention provision.

Results

74.4%, 20.3% and 35.2% of PWID were currently using needle and syringe programmes (NSP), drug treatment and HIV testing, respectively. 51.1% of current PWID were HIV seropositive and of those 62.5% were currently on ART and 19.0% were virally suppressed. Across the PCC, individuals moved between categories of being aware and ever using drug treatment (resulting in -50% “leakage”); from ever having used to currently using drug treatment (-59%); between “ever testing” and “current (continuous) testing” (-62%); and from self-reported antiretroviral therapy (ART) adherence to viral suppression (-70%). Use of prevention services was higher among those at risk of transmission (HIV positive). The overall reduction in acquisition risk among HIV-negative PWID was 77.7% (95% CrI 67.8–84.5%), estimated by the modelled protective effects of current levels of NSP, drug treatment and ART compared to none of these services.

Conclusions

Our findings suggest that developing a cohesive model for HIV prevention and treatment is feasible and reflects the bi-directional relationships between prevention and care. The integrated continuum model indicates the major factors which may predict the epidemic course and control response.

Willingness to Pay for Health Improvements Using Stated Preferences: Prevention Versus Treatment

OBJECTIVES

This study aimed to investigate whether there was a difference in willingness to pay (WTP) between prevention and treatment for health benefits of equal magnitude.

METHODS

We used a web-based survey instrument in a sample of the Swedish general population to perform a contingent valuation study assessing the WTP for prevention and treatment. We analyzed the WTP as a continuous variable using a two-part regression model to adjust for a mass point around 0 and a skewed distribution among respondents with a positive WTP.

RESULTS

The study found that people were less willing, on average, to pay at all for prevention than treatment, but those who were willing to pay for prevention had a higher WTP than for treatment. The latter effect was more substantial, and in total mean WTP for prevention was about 85% higher than for treatment.

CONCLUSIONS

The findings from this study contribute to the ongoing discussion on the appropriate cost-effectiveness thresholds by adding prevention as a parameter affecting the demand-side value of health improvements. As such, it can provide support to decision makers in healthcare and in health promotion priority setting.

Omics Biomarkers in Obesity: Novel Etiological Insights and Targets for Precision Prevention

PURPOSE OF REVIEW

Omics-based technologies were suggested to provide an advanced understanding of obesity etiology and its metabolic consequences. This review highlights the recent developments in "omics"-based research aimed to identify obesity-related biomarkers.

RECENT FINDINGS

Recent advances in obesity and metabolism research increasingly rely on new technologies to identify mechanisms in the development of obesity using various "omics" platforms. Genetic and epigenetic biomarkers that translate into changes in transcriptome, proteome, and metabolome could serve as targets for obesity prevention. Despite a number of promising candidate biomarkers, there is an increased demand for larger prospective cohort studies to validate findings and determine biomarker reproducibility before they can find applications in primary care and public health. "Omics" biomarkers have advanced our knowledge on the etiology of obesity and its links with chronic diseases. They bring substantial promise in identifying effective public health strategies that pave the way towards patient stratification and precision prevention.

Preventive Cardiology and Risk Assessment: Beyond LDL

PURPOSE OF REVIEW

Risk assessment is the foundational cornerstone for cardiovascular prevention. The goal of this review is to apprise the reader of the latest evidence and guideline-based stepwise method for clinical risk assessment for future atherosclerotic events. We also discuss caveats to the current approach and review future directions including the promise of precision medicine.

RECENT FINDINGS

The most recent cholesterol and prevention guidelines improve upon the widely used pooled cohort equations by incorporating risk-enhancing factors to further personalize risk assessment. For those in whom uncertainty remains, there is mounting evidence for using the coronary calcium score to uncover subclinical disease to either up- or down-classify risk. Although still in its infancy, progress in high-throughput molecular analysis is edging the field closer to more precise risk stratification. Atherosclerosis is the leading cause of global morbidity and mortality. Emphasis on cardiovascular prevention is essential to mitigate the burden of disease. Here, we introduce a "4 + 2" paradigm for approaching preventive cardiology based on recent guidelines. Risk stratification is performed in four steps: qualitative risk approximation to initiate counseling and education, quantitative risk estimation based on a validated model, personalization with risk-enhancing factors, and measurement of coronary artery calcium score in select patients. The two foundational principles of preventive management are to promote a healthy lifestyle in all and to escalate preventive pharmacotherapy based on increasing risk. Shared decision-making remains central throughout this process.

The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review

BACKGROUND

Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum.

METHODS

A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria.

RESULTS

A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities.

CONCLUSIONS

Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion.

Assessment of Physician Priorities in Delivery of Preventive Care

IMPORTANCE

Primary care physicians have limited time to discuss preventive care, but it is unknown how they prioritize recommended services.

OBJECTIVE

To understand primary care physicians' prioritization of preventive services.

DESIGN, SETTING, AND PARTICIPANTS

This online survey was administered to primary care physicians in a large health care system from March 17 to May 12, 2017. Physicians were asked whether they prioritize preventive services and which factors contribute to their choice (5-point Likert scale). Results were analyzed from July 8, 2017, to September 19, 2019.

EXPOSURES

A 2 × 2 factorial design of 2 hypothetical patients: (1) a 50-year-old white woman with hypertension, type 2 diabetes, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of breast cancer; and (2) a 45-year-old black man with hypertension, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of colorectal cancer. Two visit lengths (40 minutes vs 20 minutes) were given. Each patient was eligible for at least 11 preventive services.

MAIN OUTCOMES AND MEASURES

Physicians rated their likelihood of discussing each service during the visit and reported their top 3 priorities for patients 1 and 2. Physician choices were compared with the preventive services most likely to improve life expectancy, using a previously published mathematical model.

RESULTS

Of 241 physicians, 137 responded (57%), of whom 74 (54%) were female and 85 (62%) were younger than 50 years. Physicians agreed they prioritized preventive services (mean score, 4.27 [95% CI, 4.12-4.42] of 5.00), mostly by ability to improve quality (4.56 [95% CI, 4.44-4.68] of 5.00) or length (4.53 [95% CI, 4.40-4.66] of 5.00) of life. Physicians reported more prioritization in the 20- vs 40-minute visit, indicating that they were likely to discuss fewer services during the shorter visit (median, 5 [interquartile range {IQR}, 3-8] vs 11 [IQR, 9-13] preventive services for patient 1, and 4 [IQR, 3-6] vs 9 [IQR, 8-11] for patient 2). Physicians reported similar top 3 priorities for both patients: smoking cessation, hypertension control, and glycemic control for patient 1 and smoking cessation, hypertension control, and colorectal cancer screening for patient 2. Physicians' top 3 priorities did not usually include diet and exercise or weight loss (ranked in their top 3 recommendations for either patient by only 48 physicians [35%]), although these were among the 3 preventive services most likely to improve life expectancy based on the mathematical model.

CONCLUSIONS AND RELEVANCE

In this survey study, physicians prioritized preventive services under time constraints, but priorities did not vary across patients. Physicians did not prioritize lifestyle interventions despite large potential benefits. Future research should consider whether physicians and patients would benefit from guidance on preventive care priorities.

Effectiveness of embedding a specialist preventive care clinician in a community mental health service in increasing preventive care provision: A randomised controlled trial

OBJECTIVE

Clinical practice guidelines recommend that community mental health services provide preventive care for clients' chronic disease risk behaviours; however, such care is often not routinely provided. This study aimed to assess the effectiveness of offering clients an additional consultation with a specialist clinician embedded within a community mental health service, in increasing client-reported receipt of, and satisfaction with, preventive care.

METHOD

A randomised controlled trial was undertaken in one Australian community mental health service. Participants (N = 811) were randomised to receive usual care (preventive care in routine consultations; n = 405) or usual care plus the offer of an additional consultation with a specialist preventive care clinician (n = 406). Blinded interviewers assessed at baseline and 1-month follow-up the client-reported receipt of preventive care (assessment, advice and referral) for four key risk behaviours individually (smoking, poor nutrition, alcohol overconsumption and physical inactivity) and all applicable risks combined, acceptance of referrals and satisfaction with preventive care received.

RESULTS

Analyses indicated significantly greater increases in 12 of the 18 preventive care delivery outcomes in the intervention compared to the usual care condition from baseline to follow-up, including assessment for all risks combined (risk ratio = 4.00; 95% confidence interval = [1.57, 10.22]), advice for all applicable risks combined (risk ratio = 2.40; 95% confidence interval = [1.89, 6.47]) and offer of referral to applicable telephone services combined (risk ratio = 20.13; 95% confidence interval = [2.56, 158.04]). For each component of care, there was a significant intervention effect for at least one of the individual risk behaviours. Participants reported high levels of satisfaction with preventive care received, ranging from 77% (assessment) to 87% (referral), with no significant differences between conditions.

CONCLUSION

The intervention had a significant effect on the provision of the majority of recommended elements of preventive care. Further research is needed to maximise its impact, including identifying strategies to increase client uptake.

Clinical research methods for treatment, diagnosis, prognosis, etiology, screening, and prevention: A narrative review

This narrative review is an introduction for health professionals on how to conduct and report clinical research on six categories: treatment, diagnosis/differential diagnosis, prognosis, etiology, screening, and prevention. The importance of beginning with an appropriate clinical question and the exploration of how appropriate it is through a literature search are explained. There are three methodological directives that can assist clinicians in conducting their studies from a methodological perspective: (1) how to conduct an original study or a systematic review, (2) how to report an original study or a systematic review, and (3) how to assess the quality or risk of bias for a previous relevant original study or systematic review. This methodological overview article would provide readers with the key points and resources regarding how to perform high-quality research on the six main clinical categories.

[Better compliance with therapy in preventative medication use]

Prescription of medication is one of the most common medical interventions. Just half of patients use a prescribed preventative medication in accordance with the doctor's instructions; this leads to a smaller effect from the medication, side effects and higher care costs. Therapy-non-compliant patients are hardly recognisable on the basis of clinical, demographic or medication-related characteristics. The prescriber can make use of pharmacist data, questionnaires, or technical aids, or broach the subject with the patient to discover whether or not the patient is therapy-compliant. Reasons for non-compliance with therapy can be roughly divided into unintentional or practical reasons and intentional reasons. Tailored intervention can be offered on the basis of the underlying reasons.

Rinse-free hand wash for reducing absenteeism among preschool and school children

BACKGROUND

Illness-related absenteeism is an important problem among preschool and school children for low-, middle- and high- income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse-free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness-related absenteeism in preschool and school children.

OBJECTIVES

1. To assess the effectiveness of rinse-free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse-free hand washing products are the most effective (if head-to-head comparisons exist), and what effect additional strategies in combination with rinse-free hand washing have on the outcomes of interest.

SEARCH METHODS

In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse-free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions.

DATA COLLECTION AND ANALYSIS

Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings.

MAIN RESULTS

This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day-care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most-notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse-free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low-certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse-free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse-free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low-certainty evidence), which indicates rinse-free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse-free' group (eight days absent per 1000). There may be little to no difference between rinse-free hand washing and 'no rinse-free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low-certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very-low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse-free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very-low certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review may have identified a small yet potentially beneficial effect of rinse-free hand washing regimes on illness-related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse-free hand washing regimens in order to provide more conclusive, higher-certainty evidence regarding its impact. When considering the use of a rinse-free hand washing program in a local setting, there needs to be consideration of the current rates of illness-related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings.

A pragmatic and scalable strategy using mobile technology to promote sustained lifestyle changes to prevent type 2 diabetes in India and the UK: a randomised controlled trial

AIMS/HYPOTHESIS

This randomised controlled trial was performed in India and the UK in people with prediabetes to study whether mobile phone short message service (SMS) text messages can be used to motivate and educate people to follow lifestyle modifications, to prevent type 2 diabetes.

METHODS

The study was performed in people with prediabetes (n = 2062; control: n = 1031; intervention: n = 1031) defined by HbA1c ≥42 and ≤47 mmol/mol (≥6.0% and ≤6.4%). Participants were recruited from public and private sector organisations in India (men and women aged 35-55 years) and by the National Health Service (NHS) Health Checks programme in the UK (aged 40-74 years without pre-existing diabetes, cardiovascular disease or kidney disease). Allocation to the study groups was performed using a computer-generated sequence (1:1) in India and by stratified randomisation in permuted blocks in the UK. Investigators in both countries remained blinded throughout the study period. All participants received advice on a healthy lifestyle at baseline. The intervention group in addition received supportive text messages using mobile phone SMS messages 2-3 times per week. Participants were assessed at baseline and at 6, 12 and 24 months. The primary outcome was conversion to type 2 diabetes and secondary outcomes included anthropometry, biochemistry, dietary and physical activity changes, blood pressure and quality of life.

RESULTS

At the 2 year follow-up (n = 2062; control: n = 1031; intervention: n = 1031), in the intention-to-treat population the HR for development of type 2 diabetes calculated using a discrete-time proportional hazards model was 0.89 (95% CI 0.74, 1.07; p = 0.22). There were no significant differences in the secondary outcomes.

CONCLUSIONS/INTERPRETATION

This trial in two countries with varied ethnic and cultural backgrounds showed no significant reduction in the progression to diabetes in 2 years by lifestyle modification using SMS messaging.

TRIAL REGISTRATION

The primary study was registered on www.ClinicalTrials.gov (India, NCT01570946; UK, NCT01795833).

FUNDING

The study was funded jointly by the Indian Council for Medical Research and the UK Medical Research Council.

Willingness to adopt wearable devices with behavioral and economic incentives by health insurance wellness programs: results of a US cross-sectional survey with multiple consumer health vignettes

BACKGROUND

The number of health-related wearable devices is growing but it is not clear if Americans are willing to adopt health insurance wellness programs based on wearables and the incentives with which they would be more willing to adopt.

METHODS

In this cross-sectional study we used a survey methodology, usage vignettes and a dichotomous scale to examine U.S. residents' willingness to adopt wearables (WTAW) in six use-cases where it was mandatory to use a wearable device and share the resulting data with a health insurance company. Each use-case was tested also for the influence of additional economic incentives on WTAW.

RESULTS

A total of 997 Americans across 46 states participated in the study. Most of them were 25 to 34 years old (40.22%), 57.27% were female, and 74.52% were white. On average, 69.5% of the respondents were willing to adopt health-insurance use-cases based on wearable devices, though 77.8% of them were concerned about issues related to economic benefits, data privacy and to a lesser extent, technological accuracy. WTAW was 11-18% higher among consumers in use-cases involving health promotion and disease prevention. Furthermore, additional economic incentives combined with wearables increased WTAW overall. Notably, financial incentives involving providing healthcare credits, insurance premium discount, and/or wellness product discounts had particularly greater effectiveness for increasing WTAW in the consumer use-cases involving participation: for health promotion (RR = 1.06 for financial incentive, 95% CI: 1.01-1.11; P = 0.018); for personalized products and services (RR = 1.11 for financial incentive, 95% CI: 1.01-1.21; P = 0.018); and for automated underwriting discount at annual renewal (RR = 1.28 for financial incentive, 95% CI: 1.20-1.37; P < 0.001).

CONCLUSIONS

Under the adequate economic, data privacy and technical conditions, 2 out of 3 Americans would be willing to adopt health insurance wellness programs based on wearable devices, particularly if they have benefits related to health promotion and disease prevention, and particularly with financial incentives.

Detection and management of atypical femur fractures

PURPOSE OF REVIEW

This article summarizes the risk factors for atypical femur fractures (AFF), discusses current and emerging imaging modalities for early identification of AFF, and offers recommendations for prevention and management of AFFs based on the current concepts.

RECENT FINDINGS

Antiresorptive therapies are widely recommended for prevention and treatment of osteoporosis. Despite their well established effectiveness to reduce fracture risk, emerging concerns related to potential adverse effects have led to a substantial decline in the use of bisphosphonates. Although, the pathogenesis of AFF has not yet been elucidated, the bulk of evidence supports that the well known therapeutic benefits of bisphosphonate far outweigh the relatively low risk of AFFs. Recommendations for early identification of patients at risk for AFF using radiographic imaging have been established. Consensus on the management of AFF and osteoporosis in patients with AFF needs to be formulated.

SUMMARY

AFF is a rare event associated with long-term bisphosphonate therapy, which represents an apparent paradox in the management of osteoporosis. Improved understanding of pathogenetic mechanisms will be helpful in further refining of screening guidelines and standardization of management and treatment strategies.

The role of circadian rhythm in male reproduction

PURPOSE OF REVIEW

To integrate evidence on the role of circadian rhythm in male reproduction. Several studies report on various aspects of the association between the circadian system and male reproductive function in animals and humans both in physiological condition as well as in the case of subfertility.

RECENT FINDINGS

Epidemiological data demonstrate diurnal and seasonal changes as well as the effect of sleep/wake cycles on the quality of semen. Rare and common genetic variation in circadian clock genes in humans and animal models support the role of circadian rhythms in male fertility in humans.

SUMMARY

Current data support the modest effect of the circadian clock on male reproductive potential; however, the evidence available is still fragmented and inconclusive. Additional well designed and sufficiently powered studies are needed to delineate the role of the circadian clock both in cause and potential interventional and preventive approaches in male subfertility.

Rare adverse effects of bisphosphonate therapy

PURPOSE OF REVIEW

To give an update on the latest developments regarding rare adverse effects of bisphosphonate therapy.

RECENT FINDINGS

Recent studies covering osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFFs) provided several updates to the literature. Identification of ONJ in large population databases is a challenge but based on one systematic review, the ICD-10 diagnosis code K10.2 (inflammatory conditions of the jaw) seems to be the most commonly used code for this condition. Duration of bisphosphonate therapy was determined to be an important predictor of AFFs. Appropriate duration of therapy followed by a timely drug holiday was shown to be the best strategy for improving bone mineral density and reducing fracture risk, while minimizing risk of rare adverse effects of therapy. The utility of bone turnover markers as a monitoring tool during drug holidays needs to be further investigated.

SUMMARY

ONJ and AFFs are two of the rare adverse effects associated with bisphosphonate therapy. Population-level trends of bisphosphonate use suggest a decline in prescriptions, pointing to broad fears of these side effects. Careful patient evaluation, duration of bisphosphonate therapy, and use of drug holidays can help limit any risk associated with therapy.

Diet and Physical Activity Prevention Research Supported by the U.S. NIH From 2012-2017

INTRODUCTION

Poor diet and inadequate physical activity are common contributors to preventable death in the U.S. This paper provides a summary of the NIH-sponsored research on disease prevention that underlies public health and clinical recommendations to improve diet and physical activity.

METHODS

A representative sample (n=11,082) of research grants and cooperative agreements (research projects) representing the NIH prevention research portfolio between 2012 and 2017 were hand coded by trained analysts in 2017-2018. This manuscript describes the rationale(s), exposure(s), outcome(s), population(s), and study design(s) in prevention research focused on diet and physical activity and compares this research to identified research gaps in the field.

RESULTS

A relatively stable 7.8% (95% CI=7.0%, 8.8%) and 5.0% (95% CI=4.4%, 5.7%) of the NIH prevention research projects were focused on diet and physical activity, respectively, during 2012-2017. These projects often explored diet and physical activity together in the context of obesity, included observational studies, and focused on a general adult population. Few of these projects focused on development of improved assessment methods. Approximately 50% of these studies were related to research gaps identified by the 2015 Dietary or 2018 Physical Activity Guidelines Advisory Committee Scientific Reports.

CONCLUSIONS

Opportunities exist for more engagement by NIH and scientific investigators in diet- and physical activity-focused prevention research, particularly around assessment and known research gaps.

[Preventive approach to healthy aging by occupational risk prevention services]

OBJECTIVE

The aging of the working population is already a fact in Spain. International reference bodies (the ILO, the European Commission, the European Agency -EU_OSHA- ...) and national organizations have begun to address this problem. Preventing and adapting working conditions to health problems linked to age is a fundamental task of the Occupational Risk Prevention Services (ORPS) although it is unknown to what extent it is being carried out. The objective of this study was to estimate how this emerging risk is being addressed.

METHODS

A descriptive, multicenter and crosssectional study was conducted based on the data provided by the ORPS of Public Administrations of three Autonomous Communities, Madrid, the Basque Country and Navarre, Period 2012-2016. The actions performed according to age, economic activity, occupation and size of the work center were analyzed by calculating distribution percentages and association analysis by Prevalence Ratios with 95% confidence intervals (95% CI).

RESULTS

Information was collected from 14 ORPS, all with their own resources. In the majority (11 out of 14) age was not considered in either risk assessments or health surveillance. Small centers performed more frequently the adaptation of job, Risk of Prevalence 1.25 (95% CI 1.12-1.40). In those with more than 5,000 workers, the proportion of relocations was greater (9/1,000 vs 6/1,000). The age of 55 was the risk threshold. In addition to the risks inherent in the tasks, psychosocials were identified in all activities.

CONCLUSIONS

Age is especially sensitive to occupational risks, it must be considered in the evaluation, as well as in the design and adaptation of jobs, a fundamental task of the ORPS.

Evaluation of effectiveness of (elements of) parenting support in daily practice of preventive youth health care; design of a naturalistic effect evaluation in 'CIKEO' (consortium integration knowledge promotion effectiveness of parenting interventions)

BACKGROUND

The number of interventions to support parents is growing. The level of evidence regarding these intervention varies. In this paper we describe a study that aims to assess the effectiveness of specific 'elements' within such parenting interventions for families with children up to 7 years. A naturalistic effect evaluation will be applied. Study questions are: 1. What is the exposure of parents to (elements of) parenting interventions in the daily practice of preventive youth health care? 2. What are the associations between the exposure to (elements of) parenting interventions and outcomes in parents/children related to parenting and child development?

METHODS/DESIGN

Thousand parents/caregivers are recruited by preventive youth health care providers in the Netherlands. Measurements will be performed after inclusion and after 12-months follow up. Data regarding child/parent/caregiver characteristics, use of (parenting) interventions and care, and outcomes with regard to parenting skills, family functioning and child development will be collected. Outcomes will be compared between parents/children exposed and non-exposed to the (elements of) parenting interventions (adjusting for confounders).

DISCUSSION

We hypothesize that parents/caregivers with exposure to (elements of) parenting interventions show (relatively more) improvements in parenting outcomes. Results will support intervention selection/development, and support communities/professionals to select appropriate intervention-elements.

TRIAL REGISTRATION

Netherlands National Trial Register number NL7342 . Date of registration: 05-November-2018, retrospectively registered.

Assessment of Prevention Research Measuring Leading Risk Factors and Causes of Mortality and Disability Supported by the US National Institutes of Health

IMPORTANCE

No studies to date have examined support by the National Institutes of Health (NIH) for primary and secondary prevention research in humans and related methods research that measures the leading risk factors or causes of death or disability as outcomes or exposures.

OBJECTIVE

To characterize NIH support for such research.

DESIGN AND SETTING

This serial cross-sectional study randomly sampled NIH grants and cooperative agreements funded during fiscal years 2012 through 2017. For awards with multiple subprojects, each was treated as a separate project. Study characteristics, outcomes, and exposures were coded from October 2015 through February 2019. Analyses weighted to reflect the sampling scheme were completed in March through June 2019. Using 2017 data from the Centers for Disease Control and Prevention and 2016 data from the Global Burden of Disease project, the leading risk factors and causes of death and disability in the United States were identified.

MAIN OUTCOMES AND MEASURES

The main outcome was the percentage of the NIH prevention research portfolio measuring a leading risk factor or cause of death or disability as an outcome or exposure.

RESULTS

A total of 11 082 research projects were coded. Only 25.9% (95% CI, 24.0%-27.8%) of prevention research projects measured a leading cause of death as an outcome or exposure, although these leading causes were associated with 74.0% of US mortality. Only 34.0% (95% CI, 32.2%-35.9%) measured a leading risk factor for death, although these risk factors were associated with 57.3% of mortality. Only 31.4% (95% CI, 29.6%-33.3%) measured a leading risk factor for disability-adjusted life-years lost, although these risk factors were associated with 42.1% of disability-adjusted life-years lost. Relatively few projects included a randomized clinical trial (24.6%; 95% CI, 22.5%-26.9%) or involved more than 1 leading cause (3.3%; 95% CI, 2.6%-4.1%) or risk factor (8.8%; 95% CI, 7.9%-9.8%).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, the leading risk factors and causes of death and disability were underrepresented in the NIH prevention research portfolio relative to their burden. Because so much is already known about these risk factors and causes, and because randomized interventions play such a vital role in the development of clinical and public health guidelines, it appears that greater attention should be given to develop and test interventions that address these risk factors and causes, addressing multiple risk factors or causes when possible.

Patient factors affecting successful linkage to treatment in a cervical cancer prevention program in Kenya: A prospective cohort study

Objective

To identify patient factors associated with whether women who screened positive for high-risk human papillomavirus (hrHPV) successfully accessed treatment in a cervical cancer prevention program in Kenya.

Methods

A prospective cohort study was conducted as part of a trial of implementation strategies for hrHPV-based cervical cancer screening in western Kenya from January 2018 to February 2019. In this larger trial, women underwent hrHPV testing during community health campaigns (CHCs), and hrHPV+ women were referred to government facilities for cryotherapy. For this analysis, we looked at rates of and predictors of presenting for treatment and presenting within 30 days of receiving positive hrHPV results (“timely” presentation). Data came from questionnaires completed at the time of screening and treatment. Multivariable logistic regression was used to identify factors associated with each outcome.

Results

Of the 505 hrHPV+ women, 266 (53%) presented for treatment. Cryotherapy was performed in 236 (89%) of the women who presented, while 30 (11%) were not treated: 15 (6%) due to gas outage, six (2%) due to pregnancy, five (2%) due to concern for cervical cancer, and four (2%) due to an unknown or other reason. After adjusting for other factors in the multivariable analysis, higher education level and missing work to come to the CHC were associated with presenting for treatment. Variables that were associated with increased likelihood of timely presentation were missing work to come to the CHC, absence of depressive symptoms, told by someone important to come to the CHC, and shorter distance to the treatment site.

Conclusion

The majority of hrHPV+ women who did not get treated were lost at the stage of decision-making or accessing treatment, with a small number encountering barriers at the treatment sites. Patient education and financial support are potential areas for intervention to increase rates of hrHPV+ women seeking treatment.

Does diabetes prevention translate into reduced long-term vascular complications of diabetes?

The global epidemic of type 2 diabetes has prompted numerous studies and public health efforts to reduce its development. A variety of interventions, including lifestyle modifications and pharmacological agents directed at ameliorating the major risk factors for type 2 diabetes, are of proven efficacy in reducing the development of type 2 diabetes in people with impaired glucose tolerance. While prevention of the hyperglycaemia characteristic of diabetes is arguably an important, clinically relevant outcome, a more compelling outcome with greater clinical significance is the prevention or reduction of the relatively diabetes-specific microvascular and less-specific cardiovascular disease (CVD) complications associated with diabetes. These complications cause the majority of morbidity and excess mortality associated with diabetes. Any reduction in diabetes should, logically, also reduce the occurrence of its long-term complications; however, most diabetes prevention trials have not been of sufficient duration to allow such an evaluation. The limited long-term data, largely from the Da Qing Diabetes Prevention Study (DQDPS) and the Diabetes Prevention Program (DPP) and their respective follow-up studies (DQDPOS and DPPOS), suggest a reduction in microvascular complications and amelioration of CVD risk factors. Only the DQDPOS and Study to Prevent Non-Insulin-Dependent Diabetes Mellitus (STOP-NIDDM) studies have shown a reduction in CVD events and only DQDPOS has demonstrated a decrease in CVD and overall mortality. While these limited data are promising, whether diabetes prevention directly reduces complication-related morbidity and mortality remains unclear. Longer follow-up of prevention studies is needed to supplement the limited current clinical trial data, to help differentiate the effects of diabetes prevention itself from the means used to reduce diabetes development and to understand the balance among benefits, risks and costs of prevention.

How to Evolve the Response to the Global HIV Epidemic With New Metrics and Targets Based on Pre-Treatment CD4 Counts

PURPOSE OF THE REVIEW

Early diagnosis and treatment of HIV following seroconversion improves individual and population health. Using published data on pre-treatment CD4 cell counts, we benchmarked the level of immunodeficiency at HIV diagnosis and ART initiation in the "real world" against those of the treatment and control arms of landmark controlled trials that successfully reduced HIV-related deaths (INSIGHT/START) and onward HIV transmission (HPTN 052).

RECENT FINDINGS

The median CD4 count in the treatment vs. control arms of the INSIGHT/START trial and HPTN 052 were 650 vs. 408 cells/μL and 442 vs. 221 cells/μL, respectively. In the real world, recent global estimates of the median CD4 count at start of ART range from 234 to 350 cells/μL, and only 25% of those initiating ART do so early (i.e., with CD4 > 500 cells/μL). Recent global data on trends in the median CD4 count at diagnosis and ART initiation are not encouraging. We identify a critical need for new targets and metrics for persons newly diagnosed with HIV, newly enrolling in HIV care, and newly initiating ART, based on pre-treatment CD4 counts, to help increase the focus of implementation efforts on achieving earlier diagnosis, linkage to care, and ART initiation.

A Comprehensive Review of Autophagy and Its Various Roles in Infectious, Non-Infectious, and Lifestyle Diseases: Current Knowledge and Prospects for Disease Prevention, Novel Drug Design, and Therapy

Autophagy (self-eating) is a conserved cellular degradation process that plays important roles in maintaining homeostasis and preventing nutritional, metabolic, and infection-mediated stresses. Autophagy dysfunction can have various pathological consequences, including tumor progression, pathogen hyper-virulence, and neurodegeneration. This review describes the mechanisms of autophagy and its associations with other cell death mechanisms, including apoptosis, necrosis, necroptosis, and autosis. Autophagy has both positive and negative roles in infection, cancer, neural development, metabolism, cardiovascular health, immunity, and iron homeostasis. Genetic defects in autophagy can have pathological consequences, such as static childhood encephalopathy with neurodegeneration in adulthood, Crohn's disease, hereditary spastic paraparesis, Danon disease, X-linked myopathy with excessive autophagy, and sporadic inclusion body myositis. Further studies on the process of autophagy in different microbial infections could help to design and develop novel therapeutic strategies against important pathogenic microbes. This review on the progress and prospects of autophagy research describes various activators and suppressors, which could be used to design novel intervention strategies against numerous diseases and develop therapeutic drugs to protect human and animal health.

Gendered perceptions of osteoporosis: implications for youth prevention programs

The presentation of osteoporosis as a woman's disease in prevention information influences how osteoporosis is perceived and how prevention information is internalized and applied. Using the Health Belief Model as a framework, gendered perceptions of osteoporosis were investigated in Canadian young adults to inform the design of prevention programs. A combination of the Osteoporosis Health Belief Scale (OHBS) and semi-structured interviews were used to explore participants' perceptions of osteoporosis severity, susceptibility, and motivation to engage in prevention activities. Sixty multiethnic men and women aged 17-30 years living in Hamilton, Ontario, Canada participated in the study. While the findings from the OHBS indicated that both genders scored high for self-efficacy, the results from the qualitative interviews showed ambivalent attitudes toward prevention behaviors, indicating a disconnect between quantitative and qualitative findings. Perceptions related to severity and susceptibility revealed that while osteoporosis was generally viewed as a woman's disease, perceived individual risk of disease was a negotiation between larger gender constructs of osteoporosis and a variety of risk factors. This study indicates that osteoporosis prevention programs should consider actively acknowledging gendered and youth-based conceptions of osteoporosis in order to increase prevention behaviors in the whole population to reduce future disease.

On the utilization of polygenic risk scores for therapeutic targeting

The promise of personalized genomic medicine is that knowledge of a person's gene sequences and activity will facilitate more appropriate medical interventions, particularly drug prescriptions, to reduce the burden of disease. Early successes in oncology and pediatrics have affirmed the power of positive diagnosis and are mostly based on detection of one or a few mutations that drive the specific pathology. However, genetically more complex diseases require the development of polygenic risk scores (PRSs) that have variable accuracy. The rarity of events often means that they have necessarily low precision: many called positives are actually not at risk, and only a fraction of cases are prevented by targeted therapy. In some situations, negative prediction may better define the population at low risk. Here, I review five conditions across a broad spectrum of chronic disease (opioid pain medication, hypertension, type 2 diabetes, major depression, and osteoporotic bone fracture), considering in each case how genetic prediction might be used to target drug prescription. This leads to a call for more research designed to evaluate genetic likelihood of response to therapy and a call for evaluation of PRS, not just in terms of sensitivity and specificity but also with respect to potential clinical efficacy.

Controlling latent TB tuberculosis infection in high-burden countries: A neglected strategy to end TB

In a Perspective, Gavin Churchyard and Sue Swindells discuss the importance of strategies to target latent tuberculosis infection in high risk populations and thus disrupt a reservoir for new infections in high burden countries.

The politics of institutionalizing preventive health

Prevention is an attractive idea to policymakers in theory, particularly in health where the burden of spending and care is increasingly taken up by complex and chronic conditions associated with lifestyle choices. However, prevention in general, and preventive health in particular, has proven hard to implement in practice. In this paper, we look to one tangible legacy of the recent rise of the prevention agenda: agencies with responsibility for preventive health policy. We ask how this form of institutionalizing preventive health happens in practice, and what consequences it has for the advancement of the prevention agenda. We draw on qualitative data to compare the trajectories of newly formed agencies in Australia, New Zealand and England. We find that building and maintaining legitimacy for such agencies may come at the expense of quick progress or radical action in service of the prevention agenda.

Investigating How Geography, Citizenship, and Insurance Influence HPV Vaccination

Research on the human papillomavirus (HPV) suggests a possible relation between HPV type and geography. It also demonstrates that insurance status affects HPV vaccine uptake, which currently provides protection against 9 of the high-risk HPV types known to cause HPV-related cancers. This article reviews this literature with a focus on health justice in HPV vaccination programs. It also describes University of Illinois Health System research with members of Chicago communities to determine the prevalence of HPV, the distribution of HPV types, and strategies for better serving this population.

The Effect of a Respiratory Algorithm on Respiratory Transition to Extrauterine Life

PURPOSE

This evidence-based practice project evaluated the efficacy of a respiratory algorithm administered by specially trained transition nurses on the reduction of preventable NICU admissions for infants experiencing mild respiratory distress during transition.

DESIGN

A retrospective chart review compared a cohort of newborn admission rates for seven months before and seven months after initiation of a respiratory algorithm.

SAMPLE

Records of infants were included if they were born >35 weeks' gestation, had documented mild respiratory distress after birth, required <48 hours of noninvasive respiratory support, and had a length of stay less than four days.

RESULTS

Ninety-six infants (before n = 34, after n = 62) were included. Before implementation of the respiratory algorithm, infants requiring noninvasive respiratory support were admitted to the NICU. Following implementation of the algorithm, NICU admissions for mild respiratory distress significantly decreased (86 percent), despite a concurrent increase in maternal acuity.

Prevention and reversal of Type 2 diabetes: highlights from a symposium at the 2019 Diabetes UK Annual Professional Conference

AIM

This symposium covers the gamut of Type 2 diabetes prevention, reversing established Type 2 diabetes, population-level delivery of weight loss programmes and personal insights into achieving and retaining substantial weight loss.

RESULTS

The NHS Diabetes Prevention Programme was launched in 2016 and rates of referral and attendance have both exceeded expectations. By March 2018, mean weight loss for completers (those attending more than 60% of sessions) was 3.2 kg reflecting considerable health benefits. Established Type 2 diabetes is now known to be a reversible condition in the early years, and the underlying mechanism is the removal of the excess fat from within liver and pancreas in these susceptible individuals. The Diabetes Remission Clinical Trial has shown that around half of a primary care population of people with Type 2 diabetes of less than 6 years' duration can be returned to non-diabetic blood glucose control which lasts at least 12 months. This raises the question of population-level intervention to achieve weight loss. The success of some mass weight loss programmes requires to be recognized. Reframing mass provision of weight loss support should be a vital part of our clinical strategy to prevent and treat Type 2 diabetes. However, the current obesogenic environment is a reality in which individuals must live. A personal account of achieving substantial and maintaining substantial weight loss provides an invaluable insight into practical problems encountered. All health professionals dealing with weight control should assimilate and reflect upon this understanding.

CONCLUSIONS

Effective prevention and long term reversal of Type 2 diabetes is feasible. The impact upon the individual must be considered during delivery of advice and support.