Screening for lung cancer with computed tomography: protocol for systematic reviews for the Canadian Task Force on Preventive Health Care.

PURPOSE: Lung cancer is the leading cause of cancer deaths in Canada, and because early cancers are often asymptomatic screening aims to prevent mortality by detecting cancer earlier when treatment is more likely to be curative. These reviews will inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening for lung cancer. METHODS: We will update the review on the benefits and harms of screening with CT conducted for the task force in 2015 and perform de novo reviews on the comparative effects between (i) trial-based selection criteria and use of risk prediction models and (ii) trial-based nodule classification and different nodule classification systems and on patients' values and preferences. We will search Medline, Embase, and Cochrane Central (for questions on benefits and harms from 2015; comparative effects from 2012) and Medline, Scopus, and EconLit (for values and preferences from 2012) via peer-reviewed search strategies, clinical trial registries, and the reference lists of included studies and reviews. Two reviewers will screen all citations (including those in the previous review) and base inclusion decisions on consensus or arbitration by another reviewer. For benefits (i.e., all-cause and cancer-specific mortality and health-related quality of life) and harms (i.e., overdiagnosis, false positives, incidental findings, psychosocial harms from screening, and major complications and mortality from invasive procedures as a result of screening), we will include studies of adults in whom lung cancer is not suspected. We will include randomized controlled trials comparing CT screening with no screening or alternative screening modalities (e.g., chest radiography) or strategies (e.g., CT using different screening intervals, classification systems, and/or patient selection via risk models or biomarkers); non-randomized studies, including modeling studies, will be included for the comparative effects between trial-based and other selection criteria or nodule classification methods. For harms (except overdiagnosis) we will also include non-randomized and uncontrolled studies. For values and preferences, the study design may be any quantitative design that either directly or indirectly measures outcome preferences on outcomes pertaining to lung cancer screening. We will only include studies conducted in Very High Human Development Countries and having full texts in English or French. Data will be extracted by one reviewer with verification by another, with the exception of result data on mortality and cancer incidence (for calculating overdiagnosis) where duplicate extraction will occur. If two or more studies report on the same comparison and it is deemed suitable, we will pool continuous data using a mean difference or standardized mean difference, as applicable, and binary data using relative risks and a DerSimonian and Laird model unless events are rare (< 1%) where we will pool odds ratios using Peto's method or (if zero events) the reciprocal of the opposite treatment arm size correction. For pooling proportions, we will apply suitable transformation (logit or arcsine) depending on the proportions of events. If meta-analysis is not undertaken we will synthesize the data descriptively, considering clinical and methodological differences. For each outcome, two reviewers will independently assess within- and across-study risk of bias and rate the certainty of the evidence using GRADE (Grading of Recommendations Assessment, Development, and Evaluation), and reach consensus. DISCUSSION: Since 2015, additional trials and longer follow-ups or additional data (e.g., harms, specific patient populations) from previously published trials have been published that will improve our understanding of the benefits and harms of screening. The systematic review of values and preferences will allow fulsome insights that will inform the balance of benefits and harms. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022378858.

Treatment Trends in Paediatric Dentistry with Evolving Training and Education of Postgraduate Students in India: A Retrospective Study

ABSTRACT Objective: To assess and analyse the pattern of dental treatment services and their characteristics provided to children by evaluating the clinical use of materials and prevalence in material research in a major postgraduate paediatric tertiary care hospital in India over three years. Material and Methods: Institutionally approved retrospective analysis was conducted by auditing the clinical records of 2644 patients who visited and had treatment in the Outpatient and Inpatient Department of Paedodontics and Preventive Dentistry from January 2017 to December 2019. Clinical logbooks of postgraduate students were analysed by crosschecking with the department's data warehouse. Results: Out of the 2644 children who had treatment, more than two-thirds of them were in the age group of 4-7 years old. Around 5.6% of the patients were specially-abled children. Extraction (33.5%) was the most common treatment, followed by restorative treatment (29.1%). Endodontic treatment had a prevalence of 19.8%, with a reduced prevalence of preventive treatment care (0.5%). Patients who had traumatic tooth management included 2.8% of the study population. The prevalence of preventive care was found to be 2.1%. The teaching curriculum with theoretical and clinical skill practices was under the country's assigned authority. Conclusion: Despite advancements in paediatric dentistry, more children had extraction treatment with less observed utilization of preventive care. The widening of the training prospectus includes comprehensive care and an amplified focus on preventive care in the academic curriculum of paediatric postgraduates, which is the need of the hour.

Results of an Inpatient Preventive Health Care Program to Improve Quality of Life, Psychosocial Health, and Work Ability in Austria.

Objective: The Austrian Federal Pension Insurance (PVA) developed a preventive inpatient health program, "Gesundheitsvorsorge-Aktiv (GVA)," for patients with musculoskeletal disorders. Individualized modular interventions and therapeutical measures (movement optimization, movement motivation, and mental health) are designed to improve occupational participation by influencing lifestyle factors and health-related quality of life. The study aimed to evaluate the new prevention-oriented and more personalized inpatient health program GVA. Methods: Patients underwent a standard inpatient health program, with emphasis on exercise management, exercise motivation, or psychological aspects. Submodule-dependent outcomes were assessed in patients (n = 330) at the start, end of treatment, and 6 months thereafter. Quality of Life (EQ-5D-5L), psychosocial aspects of the Patient Health Questionnaire (PHQ-D), and Work Ability Index (WAI) were queried. Results: The results consistently showed positive short and long-term effects. The subjective assessments of current work ability improved while the impairment of work performance was reduced. Positive changes in the psychosocial sphere were observed, alongside improvements in the health-related quality of life. Patients in the exercise optimization module performed better in all respects. Conclusion: In summary, GVA represents a valuable preventive health measure that leads to a holistic increase in well-being and can also ensure the maintenance of the ability to work.

Learning from the universal, proactive outreach of the Brazilian Community Health Worker model: impact of a Community Health and Wellbeing Worker initiative on vaccination, cancer screening and NHS health check uptake in a deprived community in the UK.

BACKGROUND: Delays in preventative service uptake are increasing in the UK. Universal, comprehensive monthly outreach by Community Health and Wellbeing Workers (CHW), who are integrated at the GP practice and local authority, offer a promising alternative to general public health campaigns as it personalises health promotion and prevention of disease holistically at the household level. We sought to test the ability of this model, which is based on the Brazilian Family Health Strategy, to increase prevention uptake in the UK. METHODS: Analysis of primary care patient records for 662 households that were allocated to five CHWWs from July 2021. Primary outcome was the Composite Referral Completion Indicator (CRCI), a measure of how many health promotion activities were received by members of a household relative to the ones that they were eligible for during the period July 2021-April 2022. The CRCI was compared between the intervention group (those who had received at least one visit) and the control group (allocated households that were yet to receive a visit). A secondary outcome was the number of GP visits in the intervention and control groups during the study period and compared to a year prior. RESULTS: Intervention and control groups were largely comparable in terms of household occupancy and service eligibilities. A total of 2251 patients in 662 corresponding households were allocated to 5 CHWs and 160 households had received at least one visit during the intervention period. The remaining households were included in the control group. Overall service uptake was 40% higher in the intervention group compared to control group (CRCI: 0.21 ± 0.15 and 0.15 ± 0.19 respectively). Likelihood of immunisation uptake specifically was 47% higher and cancer screening and NHS Health Checks was 82% higher. The average number of GP consultations per household decreased by 7.4% in the intervention group over the first 10 months of the pilot compared to the 10 months preceding its start, compared with a 0.6% decrease in the control group. CONCLUSIONS: Despite the short study period these are promising findings in this deprived, traditionally hard to reach community and demonstrates potential for the Brazilian community health worker model to be impactful in the UK. Further analysis is needed to examine if this approach can reduce health inequalities and increase cost effectiveness of health promotion approaches.

Folic Acid Supplementation to Prevent Neural Tube Defects: US Preventive Services Task Force Reaffirmation Recommendation Statement.

Importance: Neural tube defects are among the most common congenital malformations in the US, with an estimated 3000 pregnancies affected each year. Many of these neural tube defects are caused by low folate levels in the body. Objective: The US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence update on the benefits and harms of folic acid supplementation. Population: Persons who are planning to or could become pregnant. Evidence Assessment: The USPSTF concludes that, for persons who are planning to or could become pregnant, there is high certainty that folic acid supplementation has a substantial net benefit to prevent neural tube defects in their offspring. Recommendation: The USPSTF recommends that all persons planning to or who could become pregnant take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. (A recommendation).

Goal-Oriented Prevention: How to Fit a Square Peg into a Round Hole.

Prevention does not fit well within our problem-oriented medical paradigm in which the focus is on curing or ameliorating existing diseases. It is easier and more satisfying to solve existing problems than it is to advise and motivate patients to implement measures to prevent future problems that may or may not occur. Clinician motivation is further diminished by the time required to help people make lifestyle changes, the low reimbursement rate, and the fact that the benefits, if any, are often not apparent for years. Typical patient panel sizes make it difficult to provide all of the recommended disease-oriented preventive services and to also address the social and lifestyle factors that can impact future health problems. One solution to this square peg-round hole mismatch is to focus on the goals, life extension and prevention of future disabilities.

Use of iron supplement to prevent anemia in children aged six to 59 months attended at the Family Health Strategy (ESF) units in a city in Minas Gerais, Brazil / Uso de suplemento de ferro para prevenção da anemia em crianças de seis a 59 meses atendidas pela Estratégia Saúde da Família de um município de Minas Gerais, Brasil

Abstract Objectives: to evaluate the use of iron supplementation and associated factors in children aged six to 59 months attended at the Family Health Strategy units in a city in Minas Gerais (MG). Methods: a cross-sectional, analytical-exploratory study, carried out with 252 children aged six to 59 months, attended at ten units, between 2014 and 2016. A structured questionnaire was used to collect data on socioeconomic conditions, maternal health, child's health and the knowledge of those responsible regarding anemia and iron supplementation, in addition to analysis of the child's medical records /booklet to collect test results. Descriptive statistics, bivariate association analysis and logistic regression for multivariate analysis were performed. Results: only 22.6% of the children aged between six and 24 months were receiving iron supplement at the time of the interview. Considering children aged six to 59 months, 13.1% were supplemented and breastfeeding time (p=0.006) and the participation in childcare (p=0.042), were positively associated with the use of supplementation. Conclusion: most children aged six to 24 months were not receiving supplementation as recommended by the Ministry of Health, demonstrating the need to implement prevention programs, such as the National Iron Supplementation Program and training of professionals on the importance of health education in preventing childhood anemia.

Resumo Objetivos: avaliar o uso do suplemento de ferro e fatores associados em crianças de seis a 59 meses atendidas em unidades Estratégia Saúde da Família em município de Minas Gerais (MG). Métodos: estudo transversal, analítico-exploratório, realizado com 252 crianças na faixa etária seis a 59 meses, atendidas em dez unidades, entre 2014 e 2016. Utilizou-se questionário estruturado para coleta de dados sobre condições socioeconômicas, saúde materna, saúde da criança e conhecimentos dos responsáveis acerca da anemia e suplementação com ferro, além de análise do prontuário / caderneta da criança para coleta de resultados de exames. Realizou-se análise estatística descritiva, análise de associação bivariada e regressão logística para análise multivariada. Resultados: apenas 22,6% das crianças com idade entre seis e 24 meses estavam recebendo o suplemento de ferro no momento da entrevista. Considerando as crianças de seis a 59 meses, 13,1% eram suplementadas e o tempo de amamentação (p=0,006) e a participação na puericultura (p=0,042) apresentaram associação com o uso de suplemento. Conclusão: a maioria das crianças de seis a 24 meses não recebia a suplementação, demonstrando a necessidade de implementação dos programas de prevenção, como o Programa Nacional de Suplementação de Ferro e capacitação dos profissionais sobre a importância da educação em saúde para prevenção da anemia infantil.

The mediating effect of Covid-19 risk perception on the correlation between levels of mindfulness and preventive health behavior in nursing students.

OBJECTIVE: This study aimed to investigate nursing students' levels of mindfulness and its effect on developing preventive health behaviors, and to examine the mediating role of COVID-19 risk perception on this effect. DESIGN AND MEASURES: This study used a descriptive and correlational study design. RESULTS: The level of mindfulness, accompanied by COVID-19 risk perception caused a.104-unit increase in developing preventive health behavior. CONCLUSIONS: The findings revealed that the indirect effect of the level of mindfulness on developing preventive health behavior was at a significant level; therefore, it is concluded that COVID-19 risk perception mediates the correlation between level of mindfulness. PRACTICE IMPLICATIONS: The present study is important to investigate nursing students' levels of mindfulness and the effect of these on developing preventive health behaviors.

Personalized Disease Prevention (PDP): study protocol for a cluster-randomized clinical trial.

BACKGROUND: The US Preventive Services Task Force recommends 25 primary preventive services for middle-aged adults, but it can be difficult to do them all. METHODS: The Personalized Disease Prevention (PDP) cluster-randomized clinical trial will evaluate whether patients and their providers benefit from an evidence-based decision tool to prioritize preventive services based on their potential to improve quality-adjusted life expectancy. The decision tool will be individualized for patient risk factors and available in the electronic health record. This Phase III trial seeks to enroll 60 primary care providers (clusters) and 600 patients aged 40-75 years. Half of providers will be assigned to an intervention to utilize the decision tool with approximately 10 patients each, and half will be assigned to usual care. Mixed-methods follow-up will include collection of preventive care utilization from electronic health records, patient and physician surveys, and qualitative interviews. We hypothesize that quality-adjusted life expectancy will increase by more in patients who receive the intervention, as compared with controls. DISCUSSION: PDP will test a novel, holistic approach to help patients and providers prioritize the delivery of preventive services, based on patient risk factors in the electronic health record. TRIAL REGISTRATION: ClinicalTrials.gov NCT05463887. Registered on July 19, 2022.

Uptake of USPSTF recommendation to refer pregnant individuals for therapy or counseling to prevent perinatal depression.

PURPOSE: Perinatal depression is the most common complication of pregnancy and childbirth, and it is associated with adverse consequences. The United States Preventive Services Task Force (USPSTF) recommends that pregnant and postpartum (i.e., perinatal) individuals at risk for depression be referred for therapy or counseling interventions; however, it is unclear to what extent this recommendation has been implemented. METHODS: Pregnant individuals were recruited via advertisements on a pregnancy app and a separate study on sleep. Respondents completed the initial screening questions to determine their risk for perinatal depression, defined as self-reported history of depression; recent stressors; history of emotional, sexual, or physical abuse; mild depressive symptoms; anxiety symptoms; single; diabetes diagnosis; or unwanted pregnancy. Eligible respondents reported their providers' recommendations for preventing depression, and their utilization of interventions to prevent depression (n = 303). RESULTS: Fewer than 15% of participants reported that a provider referred them for therapy or counseling to prevent depression; recommendations included cognitive behavioral therapy (4%), interpersonal psychotherapy (2.3%), mindfulness-based cognitive therapy (4.3%), or other/unknown (6.6%). Approximately 12% reported that a provider recommended medication to prevent depression. Provider referral rates varied by risk factor, but not by patient demographics. Nearly 20% of participants reported using therapy or counseling to prevent depression, and nearly 13% reported using medication to prevent depression. CONCLUSIONS: We explore potential factors affecting the uptake of the USPSTF recommendation and underscore the importance of preventing perinatal depression.

Effect of a Digitally-Enabled, Preventive Health Program on Blood Pressure in an Adult, Dutch General Population Cohort: An Observational Pilot Study.

Worldwide, it is estimated that at least one in four adults suffers from hypertension, and this number is expected to increase as populations grow and age. Blood pressure (BP) possesses substantial heritability, but is also heavily modulated by lifestyle factors. As such, digital, lifestyle-based interventions are a promising alternative to standard care for hypertension prevention and management. In this study, we assessed the prevalence of elevated and high BP in a Dutch general population cohort undergoing a health screening, and observed the effects of a subsequent self-initiated, digitally-enabled lifestyle program on BP regulation. Baseline data were available for 348 participants, of which 56 had partaken in a BP-focused lifestyle program and got remeasured 10 months after the intervention. Participants with elevated SBP and DBP at baseline showed a mean decrease of 7.2 mmHg and 5.4 mmHg, respectively. Additionally, 70% and 72.5% of participants showed an improvement in systolic and diastolic BP at remeasurement. These improvements in BP are superior to those seen in other recent studies. The long-term sustainability and the efficacy of this and similar digital lifestyle interventions will need to be established in additional, larger studies.

Does mailing unsolicited HPV self-sampling kits to women overdue for cervical cancer screening impact uptake of other preventive health services in a United States integrated delivery system?

Women overdue for cervical cancer screening often have other preventive care gaps. We examined whether mailing unsolicited human papillomavirus (HPV) self-sampling kits to increase cervical cancer screening impacted receipt of other preventive services women were due for: mammography, colorectal cancer (CRC) screening, influenza vaccination, depression screening, and diabetic HbA1c monitoring. From 2014 to 2016, 16,590 underscreened women were randomized to receive a mailed kit or usual care Pap reminders within Kaiser Permanente Washington. We used logistic regression to estimate odds ratios (ORs) of preventive services receipt within 12-months between the intervention vs. control arms, and within the intervention arm (comparing those returning a kit vs. attending Pap vs. nothing), adjusting models for demographic variables. There were no significant between-arm differences in uptake of any of the preventive services: intervention vs. control: mammography OR = 1.01 (95% confidence interval:0.88-1.17), CRC screening OR = 0.98 (0.86-1.13), influenza vaccination OR = 0.99 (0.92-1.06), depression screening OR = 1.07 (0.99-1.16), HbA1c OR = 0.84 (0.62-1.13). Within the intervention arm, preventive services uptake was higher in women who completed cervical cancer screening vs. did not, with stronger effects for women who attended Pap: Pap vs. nothing: mammography OR = 11.81 (8.11-17.19), CRC screening OR = 7.31 (5.57-9.58), influenza vaccination OR = 2.06 (1.82-2.32), depression screening OR = 1.79 (1.57-2.05), HbA1c OR = 3.35 (1.49-7.52); kit vs. nothing: mammography OR = 2.26 (1.56-3.26), CRC screening OR = 5.05 (3.57-7.14), influenza vaccination OR = 1.67 (1.41-1.98), depression screening OR = 1.09 (0.89-1.33), HbA1c OR = 1.23 (0.57-2.65). Mailing HPV self-sampling kits to underscreened women did not negatively impact uptake of other preventive services. However, overall preventive service uptake was the highest among women who attended in-clinic cervical cancer screening.

Impact of a screen, triage and treat program for identifying chronic disease risk in Indigenous children.

BACKGROUND: The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis project was a point-of-care screening program in rural and remote First Nations communities in Manitoba that aimed to identify and treat hypertension, diabetes and chronic kidney disease. The program identified chronic disease in 20% of children screened. We aimed to characterize clinical screening practices before and after intervention in children aged 10-17 years old and compare outcomes with those who did not receive the intervention. METHODS: This observational, prospective cohort study started with community engagement and followed the principles of ownership, control, access and possession (OCAP). We linked participant data to administrative data at the Manitoba Centre for Health Policy to assess rates of primary care and nephrology visits, disease-modifying medication prescriptions and laboratory testing (i.e., glycosylated hemoglobin [HbA1c], estimated glomerural filtration rate [eGFR] and urine albumin- or protein-to-creatinine ratio). We analyzed the differences in proportions in the 18 months before and after the intervention. We also conducted a 1:2 propensity score matching analysis to compare outcomes of children who were screened with those who were not. RESULTS: We included 324 of 353 children from the screening program (43.8% male; median age 12.3 yr) in this study. After the intervention, laboratory testing increased by 5.8% (95% confidence interval [CI] 1.1% to 10.1%) for HbA1c, by 9.9% (95% CI 4.2% to 15.5%) for eGFR and by 6.2% (95% CI 2.3% to 10.0%) for the urine albumin- or protein-to-creatinine ratio. We observed significant improvements in laboratory testing in screened patients in the group who were part of the program, compared with matched controls. INTERPRETATION: Chronic disease surveillance and care increased significantly in children after the implementation of a point-of-care screening program in rural and remote First Nation communities. Interventions such as active surveillance programs have the potential to improve the chronic disease care being provided to First Nations children.

Pregnant women's perspectives on integrating preventive oral health in prenatal care.

BACKGROUND: Oral diseases are considered a silent epidemic including among pregnant women. Given the prevalence of oral conditions among pregnant women and the reported association with adverse pregnancy outcomes, there have been suggestions for the inclusion of preventive oral care in routine prenatal care. However, due to the different administrative and funding structure for oral health and prenatal care in Canada, progress towards this integration has been slow. Our study sought to qualitatively explore the views of pregnant women in British Columbia (BC) on the strategies for integrating preventive oral health care into prenatal care services. METHODS: A qualitative approach was utilized involving semi-structured interviews with fourteen (14) purposefully selected pregnant women in Vancouver and Surrey, BC. The interviews were audio-recorded and transcribed. The transcripts were analyzed using an inductive thematic approach. Study validity was ensured via memoing, field-notes, and member checking. RESULTS: Interviews ranged from 28 to 65 min producing over 140 pages of transcripts. Analysis resulted in three major themes: oral health experiences during pregnancy, perspectives on integration and integrated prenatal oral care, and strategies for addressing prenatal oral health care. A majority of participants were supportive of integrating preventive oral care in routine prenatal services, with referrals identified as a critical strategy. Oral health education was recognized as important before, during, and after pregnancy; oral health assessments should therefore be included in the prenatal care checklist. Limited funding was acknowledged as a barrier to oral health care access, which may explain why few participants visited their dentists during pregnancy. Interprofessional education surfaced as a bridge to provide prenatal oral health education. CONCLUSION: Pregnant women interviewed in this study support the inclusion of educational and preventive oral care during prenatal care, although their views differed on how such inclusion can be achieved in BC. They advocated the establishment of a referral system as an acceptable strategy for providing integrated prenatal oral health care.

The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007-2016.

BACKGROUND: Low-value care, or patient care that offers no net benefit in specific clinical scenarios, is costly and often associated with patient harm. The US Preventive Services Task Force (USPSTF) Grade D recommendations represent one of the most scientifically sound and frequently delivered groups of low-value services, but a more contemporary measurement of the utilization and spending for Grade D services beyond the small number of previously studied measures is needed. OBJECTIVE: To estimate utilization and costs of seven USPSTF Grade D services among US Medicare beneficiaries. DESIGN: We conducted a cross-sectional study of data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016 to identify instances of Grade D services. SETTING/PARTICIPANTS: NAMCS is a nationally representative survey of US ambulatory visits at non-federal and non-hospital-based offices that uses a multistage probability sampling design. We included all visits by Medicare enrollees, which included traditional fee-for-service, Medicare Advantage, supplemental coverage, and dual-eligible Medicare-Medicaid enrollees. MAIN MEASURES: We measured annual utilization of seven Grade D services among adult Medicare patients, using inclusion and exclusion criteria from prior studies and the USPSTF recommendations. We calculated annual costs by multiplying annual utilization counts by mean per-unit costs of services using publicly available sources. KEY RESULTS: During the study period, we identified 95,121 unweighted Medicare patient visits, representing approximately 2.4 billion visits. Each year, these seven Grade D services were utilized 31.1 million times for Medicare beneficiaries and cost $477,891,886. Three services-screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years-comprised $322,382,772, or two-thirds of the annual costs of the Grade D services measured in this study. CONCLUSIONS: US Medicare beneficiaries frequently received a group of rigorously defined and costly low-value preventive services. Spending on low-value preventive care concentrated among a small subset of measures, representing important opportunities to safely lower US health care spending while improving the quality of care.

Examining Caretaker Attitudes Towards Primary Prevention of Pediatric Behavioral Health Problems in Integrated Care.

Understanding caretaker attitudes towards the prevention of pediatric behavioral disorders is important for the effective delivery of prevention services. Caretakers of children ages 0-18 (N = 385) read a description of pediatric prevention services in an integrated primary care setting. Attitudes towards these services were assessed. The majority of participants (80%) agreed that prevention is important, 87% reported interest in learning their child's risk for a behavioral disorder, 84% were interested in learning the results of a screen for behavioral disorders, and 88% were interested in learning parenting strategies. Participants endorsed similarly positive attitudes towards prevention in integrated care. Perceived risks outweighing perceived benefits, younger caregiver age, and identifying as non-Hispanic White predicted less favorable attitudes towards prevention. Other socio-demographic characteristics (e.g., caretaker education) were associated with disorder-specific beliefs about the importance of prevention, but not general attitudes. Findings suggest generally positive attitudes towards preventing behavioral disorders in an integrated care setting.

Cost-effectiveness of a preventive self-care health management program for community-dwelling older adults: a randomised controlled trial.

OBJECTIVE: To examine the cost-effectiveness of a preventive self-care health management program for community-dwelling older adults as compared to usual care. DESIGN/INTERVENTION: A cost-effectiveness analysis was executed alongside a randomised controlled trial. Nurse case managers provided interventions, including holistic assessment, empowerment of self-care, preventive health behaviours and self-efficacy with co-produced care planning, supported by nursing students. The control group received social control calls. PARTICIPANTS/SETTING: Community-dwelling older adults were randomly assigned to the intervention (n = 271) or control (n = 269) group. The intervention was conducted in collaboration with 11 community centres under four non-government organisations in various districts of Hong Kong. MEASUREMENTS: Cost and quality-adjusted life years (QALYs) were collected pre (baseline, 0 months) and post intervention (3 months) and 3 months after completion of the program (6 months). Incremental cost-effectiveness ratios between the groups were calculated, dividing the difference in cost by the difference in QALYs. RESULTS: Analysis showed that the net incremental QALY gain was 0.0014 (3 months) and 0.0033 (6 months) when the intervention group was compared to the control group. The probability of being cost-effective at 6 months was 53.2% and 53.4%, based on the cost-effectiveness thresholds recommended by both the National Institute for Health and Clinical Excellence ($200,000/QALYs) and the World Health Organization (Hong Kong gross domestic product/capita, HK$381,780). CONCLUSIONS: The results provide some evidence to suggest that the addition of a home-based, preventive self-care health management program may have effects on cost outcomes for community-dwelling older adults in Hong Kong.

Most important advances in preventive cardiology during this past decade: Viewpoint from the American Society for Preventive Cardiology.

The rapidly expanding field of preventive cardiology has brought with it several major advances in the past decade. Changes in guidelines for cholesterol mangement focusing on the identification of "statin eligible groups" and removal of actual low-density lipoprotein cholesterol (LDL-C) targets, in particular, as well as lower targets for blood pressure in updated hypertension guidelines, have made a major impact on healthcare. The availability of the sodium glucose transport protein-2 (SGLT2) inhibitors and glucagon-like peptide -1 receptor antagonists (GLP1-RA) for managing diabetes have shifted our focus in diabetes care beyond glucose lowering to addressing cardiovascular risk reduction. While many prior trials of fish oil therapy have failed to show benefit, the recent Reduction of Cardiovascular Events With EPA - Intervention Trial (REDUCE-IT) testing the efficacy of icosapent ethyl has shown dramatic benefit in further addressing residual atherosclerotic cardiovascular disease (ASCVD) risk beyond statin therapy not only in those with known ASCVD, but also in diabetic patients with multiple risk factors. The past decade also ushered in confirmation of the inflammation hypothesis of atherosclerosis with the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) using canakinumab, despite the fact the therapy was not approved by the Food and Drug Administration (FDA) for cardiovascular risk reduction. Also, to improve our understanding of heart disease in women, the emergence of novel concepts of ischemia or myocardial infarction in those with normal or nonobstructive atherosclerotic disease has been a major advance. Moreover, the past decade brought the emergence of proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody therapy and the cardiovascular risk reduction benefits seen in the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) and Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) trials, providing further evidence-based therapy for additional reduction of ASCVD risk beyond statin therapy. The PCSK9 monoclonal antibodies have facilitated the attainment of LDL-C levels never previously thought possible. Finally with the mRNA interference therapy inclisiran in development, we may soon have a "vaccine-like" approach for addressing dyslipidemia and atherosclerosis.

Change in newly diagnosed Graves' disease phenotype between the twentieth and the twenty-first centuries: meta-analysis and meta-regression.

PURPOSE: According to a few recent studies, the clinical phenotype of Graves' disease (GD) at onset is becoming milder in recent years, in terms of prevalence and severity of hyperthyroidism, goiter and overt eye disease. The aim of this study was to assess the change in GD phenotype across the late twentieth and the early twenty-first centuries. MATERIALS AND METHODS: We carried out a systematic search of studies published between 1/1/1980 and 12/31/2017 describing naïve GD patients at diagnosis. We collected epidemiological, clinical, biochemical and serological data reported in the selected studies, and (1) conducted a single-arm meta-analysis to compare clinical and biochemical characteristics of naïve GD patients before and after year 2000 and (2) performed a meta-regression to identify the trend of the observed clinical presentations. RESULTS: Eighty selected articles were related to the period before the year 2000, 30 to the years 2000-2017. According to demographics, the two defined populations were homogeneous at meta-analysis: overall estimated female prevalence was 81% [95% CI 79-82], mean estimated age of the entire population was 39.8 years [95% CI 38.4-41.1], with no significant differences between pre- and post-2000 groups (p > 0.05). The overall estimated prevalence of smokers was 40% [95% CI 33-46], with no significant difference between the two groups (p > 0.05). Mean estimated free thyroxine (FT4) and free triiodothyronine (FT3) levels at diagnosis were higher in the pre-2000 group: 4.7 ng/dl [95% CI 4.5-4.9] for FT4 and 14.2 pg/ml [95% CI 13.3-15.1] for FT3, as compared to the post-2000 group: 3.9 ng/dl [95% CI 3.6-4.2] for FT4 and 12.1 pg/ml [95% CI 11.0-13.3] for FT3 (all p < 0.01). Goiter estimated prevalence was higher in the pre-2000 group, 87% [95% CI 84-90], than in the post-2000 group, 56% [95% CI 45-67]. Estimated prevalence for Graves' Orbitopathy (GO) was 34% [95% CI 27-41] in the pre-2000 group and 25% [95% CI 19-30] in the post-2000 group (p = 0.03). Accordingly, meta-regression adjusted for covariates showed an average annual reduction of FT4 (- 0.040 ± 0.008 ng/dl, p < 0.0001), FT3 (- 0.316 ± 0.019 pg/ml, p < 0.0001), goiter prevalence (- 0.023 ± 0.008%, p = 0.006), and goiter size (- 0.560 ± 0.031 ml, p < 0.0001). CONCLUSIONS: Our meta-analysis and meta-regression confirmed that GD phenotype at diagnosis is nowadays milder than in the past; we hypothesize that conceivable factors involved in this change are iodoprophylaxis, worldwide decrease in smoking habits, larger use of contraceptive pill and micronutrient supplementation, as well as earlier diagnosis and management.