JCL Roundtable. Making prevention a priority.

Clinical lipidology belongs par excellence to the preventive mode of medical practice. This Roundtable brings two long-time advocates of cardiometabolic prevention and a newly minted preventive cardiologist into a discussion that expands their recent JCL editorial on this topic. Atherosclerosis is a single disease process that leads to approximately 25% of deaths in economically advanced nations and a growing fraction of mortality and morbidity in nations with developing and emerging economies. Our discussants suggest that at least 75% of atherosclerotic cardiovascular disease can be prevented. Diet and lifestyle including physical activity are the cornerstones for this effort. Public and private choices about diet-lifestyle are influenced by economics, education (especially in childhood), inequities, technology, misinformation, and trust. Lipid clinics perform well with pharmacologic treatment of lipid disorders and increasingly give attention to hypertension, obesity, and diabetes as needed. Cardiometabolic prevention in the clinic works best through provider teams. Business considerations and exemplary programs are highlighted.

Things must not fall apart: the ripple effects of the COVID-19 pandemic on children in sub-Saharan Africa.

Zero to 19 year-old children in sub-Saharan Africa bear a disproportionate proportion of the global burden of communicable and non-communicable diseases. Significant public health gains have been made in the fight against these diseases, however, factors such as underequipped health systems, disease outbreaks, conflict, and political instability continue to challenge prevention and control. The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) introduces new challenges to public health programs in sub-Saharan Africa. Of particular concern are programs targeting major conditions among children, such as undernutrition, vaccine-preventable pneumonia and diarrhea, malaria, tuberculosis, HIV, and sickle cell disease. This article focuses on the impact of the COVID-19 pandemic on child health in sub-Saharan Africa. We review the epidemiology of major pediatric diseases and, referencing modeling projections, discuss the short- and long-term impact of the pandemic on major disease control. We deliberate on potential complications of SARS-CoV-2 co-infections/co-morbidities and identify critical social and ethical issues. Furthermore, we highlight the paucity of COVID-19 data and clinical trials in this region and the lack of child participants in ongoing studies. Lastly, approaches and interventions to mitigate the pandemic's impact on child health outcomes are discussed. IMPACT: Children in sub-Saharan Africa bear a disproportionate burden of communicable and non-communicable diseases globally; this remains true even as the COVID-19 pandemic persists. Amidst the fast-expanding COVID-19 literature, there is little comprehensive coverage of the pandemic's indirect impact on child health in sub-Saharan Africa. This article comprehensively outlines the threat that the pandemic poses to major disease prevention and control for children in sub-Saharan Africa. It discusses the potential impact of SARS-CoV-2 co-infections/co-morbidities, highlights research gaps, and advocates for data and action to mitigate the ripple effects of the pandemic on this population.

Human Immunodeficiency Virus Testing, Diagnosis, Linkage to Care, and Prevention Services Among Persons Who Inject Drugs, United States, 2012-2017.

BACKGROUND: Human immunodeficiency virus (HIV) testing and early diagnosis is associated with effective disease management and reduction in HIV transmission among persons who inject drugs (PWID). We examined trends in HIV testing outcomes among PWID during 2012-2017. METHODS: Centers for Disease Control and Prevention (CDC)-funded HIV testing data submitted by 61 health departments and 150 directly-funded community-based organizations during 2012-2017 were analyzed. We calculated estimated annual percentage changes (EAPC) to assess trends for HIV testing and testing outcomes. RESULTS: A total of 19 739 857 CDC-funded HIV tests were conducted during 2012-2017. Of these, 529 349 (2.7%) were among PWID. The percentage of newly diagnosed HIV increased from .7% in 2012 to .8% in 2017 (EAPC, 4.15%). The percentage interviewed for partner services increased from 46.7% in 2012 to 66.3% in 2017 (EAPC, 1.81%). No significant change was identified in trends for linkage to HIV medical care ≤90 days after diagnosis (EAPC, 0.52%) or referral to HIV prevention services (EAPC, 0.98%). CONCLUSIONS: Human immunodeficiency virus testing data revealed an increasing trend in newly diagnosed HIV among PWID but not linkage to HIV medical care or referral to prevention services. Expanding efforts to increase HIV testing and enhance linkage to services can lead to reductions in HIV transmission and improved health outcomes.

Global burden of oesophageal and gastric cancer by histology and subsite in 2018.

OBJECTIVES: To provide updated estimates of the global burden of oesophageal and gastric cancer by subsite and type. METHODS: Using data from population-based cancer registries, proportions of oesophageal adenocarcinoma (OAC) and squamous cell carcinoma (OSCC) out of all oesophageal as well as cardia gastric cancer (CGC) and non-CGC (NCGC) out of all gastric cancer cases were computed by country, sex and age group. Proportions were subsequently applied to the estimated numbers of oesophageal and gastric cancer cases from GLOBOCAN 2018. Age-standardised incidence rates (ASR) were calculated. RESULTS: In 2018, there were an estimated 572 000 new cases of oesophageal cancer worldwide, 85 000 OACs (ASR 0.9 per 100 000, both sexes combined) and 482 000 OSCCs (ASR 5.3). Out of 1.03 million gastric cancers, there were an estimated 181 000 cases of CGC (ASR 2.0) and 853 000 cases of NCGC (ASR 9.2). While the highest incidence rates of OSCC, CGC and NCGC were observed in Eastern Asia (ASRs 11.1, 4.4 and 17.9, respectively), rates of OAC were highest in Northern Europe (ASR 3.5). While globally OSCC and NCGC remain the most common types of oesophageal and gastric cancer, respectively, rates of OAC exceed those of OSCC in an increasing number of high-income countries. CONCLUSIONS: These updated estimates of the global burden of oesophageal and gastric cancer by subtype and site suggest an ongoing transition in epidemiological patterns. This work will serve as a cornerstone for policy-making and will aid in developing appropriate cancer control strategies.

CAR T-cell treatment during the COVID-19 pandemic: Management strategies and challenges.

The pandemic of coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is spreading rapidly across the world. Currently, the COVID-19 pandemic is affecting the continuity of essential routine healthcare services and procedures, including chimeric antigen receptor T-cell (CAR-T) therapy, a life-saving option for patients with relapsed/refractory (R/R) hematologic malignancies. Due to the rapid disease progression of hematological malignancies, there is an urgent need to manufacture and utilize CAR T-cells. However, CAR-T treatment has become extraordinarily challenging during this COVID-19 pandemic. Thus, many medical and technical factors must now be taken into consideration before, during, and after CAR-T therapy. The purpose of this review is to provide brief suggestions for rational decision-making strategies in evaluating and selecting CAR T-cell treatment and appropriate CAR T-cell products, and protective strategies for medical staff and patients to prevent infection in the midst of the current COVID-19 pandemic.

Evolution of the Pharmacy Benefit Manager/Community Pharmacy Relationship: An Opportunity for Success.

DISCLOSURES: No funding supported the writing of this commentary. The author has nothing to disclose.

Aging Women and the Office Assessment: Clinical Updates in Women's Health Care Primary and Preventive Care Review.

This monograph is intended to serve as a practical guide to the office assessment of the aging woman and recognizes the time constraints that characterize current office practice. Obstetrician-gynecologists are increasingly becoming the primary care providers to women in their practices and especially to older women who have been long-time patients. This monograph should serve as a guide to the many tools needed to assess the health and functional and cognitive status of the aging woman. Illustrative cases demonstrate how to use these tools in a time-efficient manner to achieve a positive effect on the well-being of the patient.

Inequalities in the use of gynecological visits and preventive services for breast and cervical cancer in Roma women in Spain.

OBJECTIVES: The Roma population in Spain makes up about two percent of the population and has worse health indicators than the general population. We analyzed both populations in 2006 and 2014 to discover whether there are differences in terms of gynecological visits and preventive services for breast and cervical cancer in Spain. METHODS: Cross-sectional study is based on the Spanish National Health Survey (SNHS) of 2006 and 2012 and the National Health Survey of the Roma Population (NHSRP) of 2006 and 2014. RESULTS: Roma women used gynecological visits less than the general population in 2006 (ORa 0.5 [0.4; 0.6] and in 2014 (ORa 0.2 [0.2; 0.3)]. In addition, use of the mammogram was lower in Roma women (ORa 0.7 [0.6; 0.8]), especially in the ages of the screening tests, and they had lower probability of receiving cervical examinations in 2006 (ORa 0.5 [0.4; 0.6]) and in 2014 (ORa 0.7 [0.6; 0.9]). CONCLUSIONS: This study shows that the inequality gap in gynecological visits and preventive services for breast and cervical cancer in Roma women has persisted during the years studied (2006 and 2014), despite Spanish prevention policies.

Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017.

Importance: Improvements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist. Objective: To identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States. Design, Setting, and Participants: Survey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services. Main Outcomes and Measures: The proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income. Results: Among the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (-6.7% [95% CI, -7.8 to -5.5]). Conclusions and Relevance: Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.

A Comparison of Smoking History in the Electronic Health Record With Self-Report.

INTRODUCTION: Knowing patients' smoking history helps guide who may benefit from preventive services such as lung cancer screening. The accuracy of smoking history electronic health records remains unclear. METHODS: This was a secondary analysis of data collected from a portal-based lung cancer screening decision aid. Participants of an academically affiliated health system, aged 55-76 years, completed an online survey that collected a detailed smoking history including years of smoking, years since quitting, and smoking intensity. Eligibility for lung cancer screening was defined using the Centers for Medicare and Medicaid Services criteria. Data analysis was performed May-December 2018, and data collection occurred between November 2016 and February 2017. RESULTS: A total of 336 participants completed the survey and were included in the analysis. Of 175 participants with self-reported smoking intensity, 72% had packs per day and 62% had pack-years recorded in the electronic health record. When present, smoking history in the electronic health records correlated well with self-reported years of smoking (r =0.78, p≤0.0001) and years since quitting (r =0.94, p≤0.0001). Self-reported smoking intensity, including pack-years (r =0.62, p<0.0001) and packs per day (r =0.65, p≤0.0001), was less correlated. Of those participants eligible for lung cancer screening by self-report, only 35% met criteria for screening by electronic health records data alone. Others were either incorrectly classified as ineligible (23%) or had incomplete data (41%). CONCLUSIONS: The electronic health records frequently misses critical elements of a smoking history, and when present, it often underestimates smoking intensity, which may impact who receives lung cancer screening.

Programmes for the prevention of mother-to-child HIV infection transmission have made progress in Yunnan Province, China, from 2006 to 2015: a cost effective and cost-benefit evaluation.

BACKGROUND: Prevention of mother-to-child transmission (PMTCT) of HIV programmes have substantially reduced HIV infections among infants in Yunnan Province, China. We conducted a macro-level economic evaluation of Yunnan's PMTCT programmes over the 10 years from 2006 to 2015 from a policymaker perspective. METHODS: The study methodology was in accordance with the guidelines from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. We quantified the output from the Yunnan's PMTCT programmes by estimating the number of paediatric HIV infections averted and the relative savings to both the health care system and society. The return-on-investment ratio (ROI) was calculated as the output (numerator) divided by the input (denominator). RESULTS: We have found that the US$ 49 million investment in Yunnan's PMTCT programmes over the period from 2006 to 2015 averted an estimated 2725 new paediatric HIV infections and resulted in an estimated 134,008 QALY acquired. It saved an estimated US$ 0.5 billion in treatment expenditures for Yunnan's healthcare system and nearly US$ 3.9 billion in productivity. The ROI was 88.4, meaning every US$ 1 invested brought about US$ 88.4 in benefits. CONCLUSIONS: Our results support the ongoing investment in PMTCT programmes in Yunnan Province. The PMTCT strategy is a cost effective and cost-benefit strategy in the periods from 2006 to 2015. Despite higher investments in the future, the overall investment in the PMTCT programmes in Yunnan province could be offset by averting more paediatric infections.

The effect of Medicare's Annual Wellness Visit on preventive care for the elderly.

The study aim was to assess the effect of receiving an Annual Wellness Visit (AWV) between 2011 and 2013 on the annual rate of eight preventive services recommended for the Medicare population following the AWV. We used retrospective Medicare claims from 2009 to 2014 for a 5% national sample of fee-for-service beneficiaries in the United States. Propensity score-adjusted logistic regressions were performed to estimate the log odds of the probability of receiving the preventive services between beneficiaries who received AWVs during 2011-13 and those who did not during the same period. The average marginal effect was also reported. Among 845,318 patients who met the inclusion and exclusion criteria, 23% had an AWV in 2011-2013. In a propensity-matched sample of 381,934 patients, AWV participants are more likely to undergo subsequent preventive services within a year (adjusted odds ratio ranges from 1.46 (95% CI, 1.44, 1.49) to 2.43 (95% CI, 2.38, 2.49). The findings are consistent using secondary outcomes or with subgroups defined by baseline primary care provider visits or baseline preventive services. These analyses showed that AWV is associated with a significant increase in all the preventive services examined. As Healthy People 2020 has established a target goal to increase the proportion of older adults who receive a core set of clinical preventive services by 10%, AWV represents a promising opportunity to facilitate the delivery of preventive care for the elderly and to advance our knowledge about effective strategies for healthy aging.

Qué significa vivir con diabetes en una comunidad del conurbano bonaerense: representaciones sociales de la diabetes mellitus tipo 2 / What it means to live with diabetes in a community of Buenos Aires: social representations of type 2 diabetes mellitus

Objetivo: conocer e interpretar las representaciones sociales que tienen las personas con diabetes mellitus (DM) tipo 2 en una comunidad de bajo nivel socioeconómico del Gran Buenos Aires. Metodología: investigación cualitativa, tipo estudio de caso. Se realizaron entrevistas semiestructuradas a personas con diagnóstico de DM tipo 2, atendidas en un centro de atención primaria del Bajo Boulogne, partido de San Isidro, Buenos Aires. Mediante un muestreo teórico o por conveniencia, a partir de las historias clínicas generadas entre enero de 2001 y julio de 2017. Se incluyeron personas con diagnóstico reciente y otras con más de 15 años de evolución, hasta la saturación del discurso. Se realizó un análisis temático. Resultados: se realizaron 20 entrevistas. La mayoría de las personas entrevistadas tenían entre 60 y 69 años y eran de sexo femenino. La DM es vivida como una enfermedad que no tiene cura y que no condiciona a quienes la padecen en lo cotidiano. No impresionó ser una carga, excepto para las personas insulinizadas, quienes le asignan una connotación negativa a esa terapia. No encontramos diferencias de acuerdo con el sexo, la edad o los años de evolución. Los entrevistados asociaron la DM con malos hábitos alimentarios y escasa o nula actividad física. Conclusiones: en esta comunidad, la DM es vivida con naturalidad, en especial por quienes llevan años padeciéndola. La red familiar constituye la principal fuente de apoyo, acompañamiento, contención y provisión de cuidados. No se identificaron otras redes además de la familia o el sistema médico tradicional. (AU)

Objective: to recognize and to understand the social representations of people with type 2 diabetes mellitus (DM) in a community with a low socioeconomic level of suburban Buenos Aires. Methods: qualitative research, case study type. Semi-structured interviews were administered to people diagnosed with type 2 DM, who attended a primary care center in Bajo Boulogne, San Isidro district, Buenos Aires. Through a theoretical or convenience sampling, from the clinical records generated between January 2001 and July 2017. We included people with a recent diagnosis and others with more than 15 years of evolution, until speech saturation. We carried out a thematic analysis. Results: we conducted 20 interviews. Most of the people were aged between 60 and 69 years and were female. DM is lived as a disease without a cure and which does not condition the daily activities of people who suffer from it. It did not impress to be a burden, except for insulinized people, who assigned a negative connotation to that therapy. We did not find differences according to sex, age or years of evolution. Patients associated DM with poor eating habits and little or no physical activity. Conclusions: in this community, DM is lived naturally, especially by those who have been suffering from it for years. The family network constitutes the main source of support, accompaniment, containment, and provision of care. No other networks were identified, besides the family or the traditional medical system. (AU)

Neglected Tropical Diseases, Neglected Communities, and Conflict: How Do We Leave No One Behind?

Most well established neglected tropical disease (NTD) programs have seen great progress towards disease control or elimination. Areas in conflict, however, are a looming challenge to reaching control and elimination targets. To be successful, programs and partners need to creatively adapt to local circumstances and embrace new colleagues not traditionally seen as NTD implementers.