Secondary Prevention Approaches Research Articles

Leucine Supplementation Prevents the Development of Skeletal Muscle Dysfunction in a Rat Model of HFpEF.

Heart failure with preserved ejection fraction (HFpEF) is associated with exercise intolerance due to alterations in the skeletal muscle (SKM). Leucine supplementation is known to alter the anabolic/catabolic balance and to improve mitochondrial function. Thus, we investigated the effect of leucine supplementation in both a primary and a secondary prevention approach on SKM function and factors modulating muscle function in an established HFpEF rat model. Female ZSF1 obese rats were randomized to an untreated, a primary prevention, and a secondary prevention group. For primary prevention, leucine supplementation was started before the onset of HFpEF (8 weeks of age) and for secondary prevention, leucine supplementation was started after the onset of HFpEF (20 weeks of age). SKM function was assessed at an age of 32 weeks, and SKM tissue was collected for the assessment of mitochondrial function and histological and molecular analyses. Leucine supplementation prevented the development of SKM dysfunction whereas it could not reverse it. In the primary prevention group, mitochondrial function improved and higher expressions of mitofilin, Mfn-2, Fis1, and miCK were evident in SKM. The expression of UCP3 was reduced whereas the mitochondrial content and markers for catabolism (MuRF1, MAFBx), muscle cross-sectional area, and SKM mass did not change. Our data show that leucine supplementation prevented the development of skeletal muscle dysfunction in a rat model of HFpEF, which may be mediated by improving mitochondrial function through modulating energy transfer.

Primary results of the brazilian registry of atherothrombotic disease (NEAT)

There is limited contemporary prospective real-world evidence of patients with chronic arterial disease in Latin America. The Network to control atherothrombosis (NEAT) registry is a national prospective observational study of patients with known coronary (CAD) and/or peripheral arterial disease (PAD) in Brazil. A total of 2,005 patients were enrolled among 25 sites from September 2020 to March 2022. Patient characteristics, medications and laboratorial data were collected. Primary objective was to assess the proportion of patients who, at the initial visit, were in accordance with good medical practices (domains) for reducing cardiovascular risk in atherothrombotic disease. From the total of patients enrolled, 2 were excluded since they did not meet eligibility criteria. Among the 2,003 subjects included in the analysis, 55.6% had isolated CAD, 28.7% exclusive PAD and 15.7% had both diagnoses. Overall mean age was 66.3 (± 10.5) years and 65.7% were male patients. Regarding evidence-based therapies (EBTs), 4% were not using any antithrombotic drug and only 1.5% were using vascular dose of rivaroxaban (2.5 mg bid). Only 0.3% of the patients satisfied all the domains of secondary prevention, including prescription of EBTs and targets of body-mass index, blood pressure, LDL-cholesterol, and adherence of lifestyle recommendations. The main barrier for prescription of EBTs was medical judgement. Our findings highlight that the contemporary practice does not reflect a comprehensive approach for secondary prevention and had very low incorporation of new therapies in Brazil. Large-scale populational interventions addressing these gaps are warranted to improve the use of evidence-based therapies and reduce the burden of atherothrombotic disease.ClinicalTrials.gov NCT04677725

Effect of chronic lung diseases on angina pectoris among Indian adults: longitudinal ageing study in India

The study aimed to evaluate the effect of chronic lung diseases, namely chronic obstructive pulmonary diseases (COPD) and asthma, on angina pectoris in individuals aged 45 years and above. Identifying vulnerable subpopulations suffering from COPD and asthma at higher risk of future cardiovascular events using the rose angina questionnaire is imperative for tailored primary and secondary prevention approaches. The present study utilizes the data from the Longitudinal Ageing Study in India, wave 1, conducted during 2017–2018. The sample size included 58,830 individuals aged 45 years and above. Angina was measured based on seven questions from Rose's questionnaires. Descriptive statistics and bivariate analysis were employed to examine the prevalence of angina among individuals with COPD and asthma. Further, multivariable logistic regression and propensity score matching (PSM) methods were used to assess the independent effect of COPD and asthma on angina after controlling the selected background characteristics. We employed PSM in two different models and included various additional factors in model 2, such as smoking, chewing tobacco, alcohol use, ADL, IADL, body mass index, physical activity, high cholesterol, hypertension, diabetes, and chronic heart disease. The current study shows that the prevalence of angina pectoris, COPD and asthma was 6.0%, 2.3% and 4.7%, respectively, among individuals aged 45 years and above in India. The prevalence of angina pectoris was higher among individuals with COPD (9.6% vs. 5.8%) and asthma (9.9% vs. 5.7%) than those without COPD and asthma, respectively. Additionally, angina pectoris was more prevalent among females and rural respondents with COPD (10.8% and 11.0%) and asthma (10.3% and 10.3%) compared to males and urban respondents with COPD (8.0% and 5.7%) and asthma (8.9% and 7.9%). Moreover, in the adjusted model, individuals with COPD (AOR 1.43, 95% CI 1.03 1.98) and asthma (AOR 1.44, 95% CI 1.17 1.77) had nearly 1.5-fold higher odds of having angina pectoris than those without COPD and asthma. The PSM estimates showed that individuals with COPD had 8.4% and 5.0% increased risk of angina pectoris compared to those without COPD in model 1 and model 2, respectively. We observed that, after adjusting to lifestyle, health-related and morbidity factors in model 2, both average treatment effect on untreated (ATU) and average treatment effect (ATE) values decreased by nearly 3.5%. Additionally, the PSM estimates demonstrated that individuals with asthma had a 3.4% and 2.9% increased risk of angina pectoris compared to those without asthma in model 1 and model 2, respectively. The study suggests that COPD and asthma are significantly associated with angina pectoris, and individuals with COPD and asthma have a higher risk of developing angina pectoris. Additionally, angina pectoris was more prevalent among females, rural respondents and adults aged 45–54 with COPD compared to males, urban respondents and those aged 65 and above, respectively, with COPD. Moreover, the findings of our study underscore the targeted primary and secondary interventions and team-based care approach among individuals with COPD and asthma to reduce the risk of CVD events in future.

A Pathway to Prevention – Concept of the Tyrolean Approach

Health is an ongoing, natural process rather than a temporary state. To preserve and promote health, a structured, personalized, holistic, and coherent approach for primary and secondary prevention is needed. A study by Widschwendter et al. investigated to the effect of different health interventions on the epigenome. Based on this information, the Tyrolean Federal Institute for Integrated Care (LIV Tyrol) developed a concept for a prevention pathway, which aims to increase the number of healthy life years for the Tyrolean population. 
 The key to prevention is the adherence of the people. To increase adherence, a therapy goal, which is mutually defined by the patient and the caregiver, is essential. The definition of a therapy goal leads to a joint development of a therapy concept. This is the starting point of the Tyrolean prevention pathway: (1) The Prevention pathway starts with the annual checkup of (healthy) people with their general practitioner (GP). These people are usually perceived to be healthy and make a point in preserving their health. (2) Based on the findings of the checkup, risk factors are discussed with the GP and health potentials, such as overweight/obesity, lack of exercise or the smoking status, are defined. (3) The Tyrolean prevention pathway offers different interventions for different health potentials. Thus, the information regarding the developed therapy concept is sent to a central coordination office, which will be located at LIV Tyrol. The coordination office thereafter contacts the person concerned and provides an overview of the interventions and measures based on the therapy plan in a transparent manner. The decision to follow the pathway is therefore made jointly and consciously. 
 In order to develop and identify prevention interventions and provide a broad overview over the variety of the prevention intervention offers, many different stakeholders had to be taken into account and contacted. This included therapists (e.g. physiotherapists, psychologists), dieticians, clubs and associations, clinicians, the federal government, and national insurances. 
 To evaluate the success of the prevention pathway, specific data needs to be collected, stored and analyzed. Therefore, a so-called IT-based prevention record will be implemented. It will enable a person-/patient-centered approach and provide a holistic view of the person concerned to all involved caregivers (read or write permission). This allows the GDs to see, how the preventive measures are being accepted and how the person/patient is doing. Additionally, clearly defined intervention providers (which need to be in a treatment context with the person) can document information regarding the progress of the person/patient. This enables the whole preventive care team to be on the same page regarding their level of knowledge of the person. This allows the person to take responsibility for their own health and acquire health competence. 
 Further steps are the launch of a pilot project for the health prevention pathway and the step-wise development of the prevention record. Also, the networking activities and updating of the catalogue of interventions will be continued. Additionally, an evaluation plan for the effectiveness of the pathway will be developed and implemented.

Screening for HPV-Related Oropharyngeal Cancer in Gay and Bisexual Men: Acceptability and Predicting Possible Use of "Oral Selfies" by Smartphone as a Secondary Prevention Approach.

Oropharyngeal cancers (OPCa) caused by HPV have emerged as one of the leading causes of malignancies caused by HPV infection. They are also significantly more likely to occur in males and in people with a history of oral sex with multiple partners. Gay and bisexual men are disproportionately affected by HPV-positive oropharyngeal cancers. We studied 1699 gay and bisexual men on 2 major dating sites in the US to assess their knowledge about HPV-related OPCa, attitudes toward screening for it, beliefs about oropharyngeal cancer screening based on the Health Belief Model, and attitudes toward possible screening approaches for OPCa. Knowledge on a 12-item scale was low, with a median of 5 items correct: 72% knew of the benefits of HPV vaccination. Significant predictors of needing OPCa screening included perception of risk for OPCa, seeing it as severe, having lower barriers, fewer reasons to avoid screening, higher knowledge, and being HPV vaccinated were significant predictors, explaining half the total variance. Most participants would accept routine, virtual/online doctor or dental appointments, and over half would accept an in-person screening. Nearly two-thirds stated that they would accept getting checked for OPCa if they could do self-screening at home, and half were prepared to use an online screening tool or app, where they could take an "oral selfie" and send it to a healthcare provider for examination. One-third stated that they would trust the results of a home screening completed by themselves and posted to a website equally as cancer screening completed online by a healthcare provider. Data indicate that despite low OPCA knowledge levels, the risk of HPV-associated OPCa was known. Being at personal risk and having knowledge of disease severity had 70% of the sample thinking about, or preparing to get, screening. Self-screening by a smartphone "oral selfie" transmitted to a screening website was acceptable to many gay and bisexual men, and online screening by a doctor or dentist was acceptable to most. OPCa screening in this population using electronic technology, together with the increasing incidence of HPV-associated OPCa in gay and bisexual men, brings together an opportunity to detect OPCa early.

Abstract 14453: Patent Foramen Ovale Closure in Patients With and Without Nickel Hypersensitivity Using Two Different Devices

Background: Transcatheter PFO closure has been established as a safe and effective approach for secondary prevention in patients with ESUS. The Amplatzer® PFO occluder and Gore Helex® septal occluder are two FDA-approved devices, which consist of a nickel-titanium alloy frame. While nickel is the first cause of hypersensitivity reaction worldwide, the potential occurrence of nickel hypersensitivity following PFO closure is still under investigation. Aim: Our aim is to investigate whether patients with nickel allergy are more susceptible to experiencing adverse events after device implantation and to explore the potential role of device selection. Methods: We prospectively enrolled patients undergoing PFO closure. Before the procedure, nickel skin patch tests were performed in all the patients. The patients were randomized to receive either Amplatzer® or Gore® device. During a three-month follow-up period, we evaluated the primary endpoint, which was a composite outcome including patient-reported chest pain, palpitations, headaches, and rash. We used the chi-squared test to evaluate the primary endpoint and performed multivariate binary logistic regression analysis to assess the effect of device selection on the primary endpoint. Results: A total of 50 patients (50% female, 45.4±10.3 years old) completed the follow-up and were included in the present analysis. Among them, 29 patients received the Gore device, while the remaining 21 patients received the Amplatzer device. Fourteen patients were diagnosed with nickel hypersensitivity. The primary endpoint was reached in 40% of the analyzed patients. The occurrence of the primary endpoint was significantly higher in patients with nickel hypersensitivity compared to those without (50% vs. 13.3%, p=0.005). Additionally, multivariate binary logistic regression analysis demonstrated no association between device selection and the composite outcome (p=0.892). Conclusions: Our preliminary results indicate that patients with nickel hypersensitivity are more likely to develop symptoms such as chest pain, palpitations, headaches, and rash following the procedure. However, the completion of our study is necessary to obtain more reliable and conclusive results.

Evidence-Based Approach for Secondary Prevention of Uterine Fibroids (The ESCAPE Approach).

Uterine fibroids (UFs) are common tumors in women of reproductive age. It is imperative to comprehend UFs' associated risk factors to facilitate early detection and prevention. Simple relying on surgical/pharmacological treatment of advanced disease is not only highly expensive, but it also deprives patients of good quality of life (QOL). Unfortunately, even if the disease is discovered early, no medical intervention is traditionally initiated until the disease burden becomes high, and only then is surgical intervention performed. Furthermore, after myomectomy, the recurrence rate of UFs is extremely high with the need for additional surgeries and other interventions. This confused approach is invasive and extremely costly with an overall negative impact on women's health. Secondary prevention is the management of early disease to slow down its progression or even halt it completely. The current approach of watchful observation for early disease is considered a major missed opportunity in the literature. The aim of this article is to present an approach named the ESCAPE (Evidence-Based Approach for Secondary Prevention) of UF management. It comprises simple, inexpensive, and safe steps that can arrest the development of UFs, promote overall reproductive health, decrease the number of unnecessary surgeries, and save billions of health care systems' dollars worldwide.

Retinopathy of prematurity in India - what can we learn from the polio legacy?

Retinopathy of prematurity (ROP) is a vasoproliferative disease of the preterm retina that has the potential to cause vision impairment and blindness. Timely screening and treatment are hence critical for infants at risk for ROP. Screening for ROP is challenging in India owing to the limited resources, a vast at-risk population and lack of awareness among paediatricians and the public. Addressing ROP in India requires a comprehensive approach involving multiple sectors, considering the magnitude of the problem and the expected increase in need for ROP services due to the increased survival of preterm infants following improvements in neonatal care. The success of the Global Polio Eradication Initiative (GPEI) offers valuable lessons for improving ROP services in developing nations by applying its strategies. An approach for primary and secondary prevention of ROP is proposed, and the current challenges and a neonatal-led care model for ROP are discussed.

Mineralizing agents to manage early carious lesions. Part I: mode of action

Dental caries remains a major global health challenge affecting millions of people worldwide, with both major health and financial implications. The minimum intervention oral healthcare (MIOC) delivery framework aims to improve caries management through early diagnosis and the use of remineralization strategies in primary and secondary preventive approaches. The landmark discovery of fluoride in caries remineralization resulted in an increase in research on such non-operative approaches. With an improved understanding of the biochemistry of caries and the demineralization-remineralization balance within dental hard tissues, researchers and clinicians currently seek new therapies to improve the non-operative management of early carious lesions. New remineralization technologies have been introduced in recent years, with varying chemistries, modes of action and degrees of success. This article, the first of a two-part series, explores the chemistry and mode of action of currently available remineralization technologies, outlining their clinical effectiveness and use in dental caries management. CPD/Clinical Relevance: A scientific understanding of ever-evolving remineralization technologies is necessary for clinicians.

2023 National Heart Center/Saudi Heart Association Focused Update of the 2019 Saudi Heart Association Guidelines for the Management of Heart Failure.

The burden of cardiovascular diseases is undeniable in local populations, who have high mortality rates and a young age of disease onset. A systematic review of emerging evidence and update of the Saudi Heart Association (SHA) 2019 heart failure (HF) guidelines was therefore undertaken. A panel of expert cardiologists reviewed recommendations of the 2019 guidelines following the Saudi Heart Association methodology for guideline recommendations. When needed, the panel provided updated and new recommendations endorsed by the national heart council that are appropriate for clinical practice and local resources in Saudi Arabia. The focused update describes the appropriate use of clinical assessment as well as invasive and non-invasive modalities for the classification and diagnosis of HF. The prevention of HF was emphasized by expanding on both primary and secondary prevention approaches. Pharmacological treatment of HF was supplemented with recommendations on newer therapies, such as SGLT-2 inhibitors. Recommendations were also provided on the management of patients with cardiovascular and non-cardiovascular co-morbidities, with a focus on cardio-oncology and pregnancy. Updated clinical algorithms were included in support of HF management in both the acute and chronic settings. The implementation of this focused update on HF management in clinical practice is expected to lead to improved patient outcomes by providing evidence-based comprehensive guidance for practitioners in Saudi Arabia.

Colorectal Cancer Screening in the Middle East: What, Why, Who, When, and How?

The incidence of colorectal cancer (CRC) in the Middle East is increasing, especially among those younger than 50 years. Risk factors including obesity, sedentary lifestyle, and dietary changes are associated with the epidemiologic shift and are a result of socioeconomic changes happening in the region. Worldwide, CRC screening is associated with decreased incidence and mortality of CRC, but screening uptake is still low in the Middle East because of cultural barriers and lack of awareness; in addition, most countries do not have national screening programs. Knowledge of CRC screening and participation rates vary among different countries, but overall they are low. Both primary and secondary prevention approaches are needed in the Middle East, and cost-effectiveness is important in choosing screening modalities. Although colonoscopy is considered the most robust screening method, stool-based testing may be an acceptable screening strategy in resource-limited settings, and focusing on high-risk individuals such as those with hereditary CRC might be the most cost-effective strategy. In addition to financial limitations in many countries in the Middle East, human displacement places an extra toll on cancer control strategies in the region.

A qualitative exploration of the rehabilitation perceptions and experiences of persons with early multiple sclerosis.

Since the advent of disease-modifying therapies (DMTs), people with MS are living longer. The management of MS requires use of DMTs, symptom management, and prevention for those with access to these aspects of health care. Although DMTs are used as part of early intervention to manage disease pathophysiology in those with MS, physical rehabilitation still focuses on symptomatic management of MS (tertiary prevention) and has not embraced a primary or secondary prevention approach to holistically manage MS. Although rehabilitation has been found to be beneficial for people with MS, there is currently limited information for persons in their early years of MS diagnosis. More importantly there is limited engagement of persons with early MS in rehabilitation care. Thus, the purpose of this study was to elucidate the perceptions of people living with early MS and their overall experiences with physical rehabilitation for MS management. The study team used semi-structured interviews to collect qualitative data to ascertain the experiences and perceptions of 15 persons with early MS who were within 5 years of diagnosis (mean age 36.5±10.4 years). Using a phenomenological approach, the researchers sought to understand the lived experiences of 15 people living with early MS. Using inductive thematic analysis, authors coded each interview separately and arrived at themes with consensus. Our study discovered six main themes and several subthemes offering insight into the lived experiences of the participants. Themes uncovered included: insight to condition, awareness of rehabilitation, resource availability, information seeking, clinician expertise in MS, and therapeutic use of self. Our study offered a small but poignant glimpse into the lived experiences of people living with early MS. There is still poor public awareness of MS-specific rehabilitation and its benefits for people with early MS. People with early MS seek information about their diagnosis but information and resources that are reliable and easily accessible are still needed, especially from their neurologists, to improve engagement in MS-specific rehabilitation. More research exploring these experiences and more diversity in the participant pool would lead to best practices in physical rehabilitation.

S152 Gastrointestinal Tract Injuries Associated With Sevelamer: A Systematic Review

Introduction: Sevelamer is a phosphate binder that is used to treat hyperphosphatemia in patients with chronic kidney disease. Sevelamer is known to cause multiple gastrointestinal side effects including nausea, vomiting, constipation, and abdominal pain. However, sevelamer crystals were observed in rare cases in the gastrointestinal tract (GIT) with associated serious injuries including inflammation, ulceration, ischemia, and perforation. In this study, we conducted a systematic review to investigate the association of sevelamer with GIT injuries. Methods: We conducted a systematic search in MEDLINE, EMBASE, Scopus, and Cochrane Central Register of Controlled Trials to identify eligible reports of sevelamer-associated gastrointestinal tract injuries. The bibliographies of identified articles, Goggle scholars, and websites of relevant professional associations were also searched for relevant studies. Two independent reviewers identified eligible studies and data were extracted in Excel. Only studies that had sevelamer crystals seen in the histopathological exams were included. (Table) Results: We included 58 studies describing a total of 77 patients with a mean age of 58.8 years. Diabetes was present in 27% of cases and at least one risk factor to have slow GIT motility was identified in 63.3% of patients. Both sevelamer carbonate and sevelamer hydrochloride were reported to be associated with GIT injury. Gastrointestinal bleeding (44.2 %) and abdominal pain (37.7 %) were the most common presenting symptoms. The large intestines were the most common area of involvement (74 %), especially in the rectosigmoid area (36.4 %). Ulceration (52 %) and inflammation (48.1 %) were the most common histopathological findings. Stopping sevelamer was the most common pharmacological intervention. 20.8% of patients required surgical intervention, while 6.5% had an endoscopic intervention. Full recovery was reported in 45.5% while 6.5% of patients died. Conclusion: While sevelamer crystals can be found incidentally in the mucosa of the GIT, there is growing evidence that sevelamer use can be associated with GIT injury. Slow GIT motility can be an important risk factor to develop sevelamer-associated GIT injury. If a GIT injury was found during endoscopy and sevelamer crystals were identified on histopathological exam, discontinuing sevelamer and using an alternative phosphate binder should be considered. Further studies are needed to identify risk factors and the best approaches for primary and secondary prevention. Table 1. - Characteristics of included studies GIT: gastrointestinal tract, GIB: Gastrointestinal bleeding Demographics Age (years)Malesfemales 58.88 ± 10.934 (44.2 %)35 (44.5 %) Comorbidities DiabetesConstipationPrevious abdominal surgeryBlood thinnersPossible Slow GIT motility 27 (35.5 %)4 (5.2 %)15 (19.5 %)16 (20.8 %)49 (63.3%) Sevelamer treatment Sevelamer carbonateSevelamer hydrochlorideBothAverage doseMedian doseDuration 16 (20.8 %)12 (15.6 %)1 (1.3%)4,176.29 mg3,200.00 mg5 days – 7 years Symptoms GIBAbdominal painDiarrheaNausea/vomitingEsophageal dysphagia 34 (44.2 %)29 (37.7 %)12 (15.6 %)10 (13%)1 (1.3%) Location of GIT injury EsophagusStomachSmall IntestinesIleocecal valveLarge intestinesCecum and/or ascending colonTransverse ColonDescending colonRectosigmoidDiffuse colonic or unspecifiedAppendix 8 (10.4 %)8 (10.4 %)3 (3.9 %)3 (3.9 %)57 (74 %)8 (10.4 %)7 (9.1 %)1 (1.3%)28 (36.4 %)15 (19.5 %)2 (2.6 %) Histopathological abnormalities* UlcerationInflammationPerforationNecrosisIschemiaStrictureInflammatory polyp 40 (52 %)37 (48.1 %)14 (18.2 %)11 (14.3 %)6 (7.8 %)3 (3.9 %)3 (3.9 %) Pharmacological interventions Stopped SevelamerDecreased sevelamer doseContinued Sevelamer 35 (45.5 %)1 (1.3 %)1 (1.3 %) Procedural interventions Surgical interventionEndoscopic treatmentEndovascular intervention 16 (20.8)5 (6.5 %)1 (1.3 %) Outcomes RecoveredDeathNot reported 35 (45.5 %)5 (6.5 %)37 (48.1 %) *Includes both microscopic and macroscopic findings.

COVID-19 in patients with B cell immune deficiency

This article aims to describe the clinical manifestations and management of COVID-19 in patients with primary and secondary B cell deficient states. We describe the epidemiologic and clinical features as well as unique management paradigm including isolation precautions with COVID-19. We then focus upon primary and secondary preventive approaches including vaccination and pre- as well as post-exposure prophylaxis. Further, we elaborate upon the important disease specific risk factors in these patients and the need to conduct prospective clinical trials to develop individualized management strategies in this population.

Pharmacological Strategies for Suicide Prevention Based on the Social Pain Model: A Scoping Review

Suicidal behaviour is a public health problem whose magnitude is both substantial and increasing. Since many individuals seek medical treatment following a suicide attempt, strategies aimed at reducing further attempts in this population are a valid and feasible secondary prevention approach. An evaluation of the available evidence suggests that existing treatment approaches have a limited efficacy in this setting, highlighting the need for innovative approaches to suicide prevention. Existing research on the neurobiology of social pain has highlighted the importance of this phenomenon as a risk factor for suicide, and has also yielded several attractive targets for pharmacological strategies that could reduce suicidality in patients with suicidal ideation or a recent attempt. In this paper, the evidence related to these targets is synthesized and critically evaluated. The way in which social pain is related to the “anti-suicidal” properties of recently approved treatments, such as ketamine and psilocybin, is examined. Such strategies may be effective for the short-term reduction in suicidal ideation and behaviour, particularly in cases where social pain is identified as a contributory factor. These pharmacological approaches may be effective regardless of the presence or absence of a specific psychiatric diagnosis, but they require careful evaluation.

Polypill for atherosclerotic cardiovascular disease prevention in Haiti: Eligibility estimates in a low-income country.

Multidrug therapy is a World Health Organization "best buy" for the prevention and control of noncommunicable diseases. CVD polypills, including ≥2 blood pressure medications, and a statin with or without aspirin, are an effective, scalable strategy to close the treatment gap that exists in many low- and middle-income countries, including Haiti. We estimated the number of Haitian adults eligible for an atherosclerotic CVD (ASCVD) polypill, and the number of potentially preventable CVD events if polypills were implemented nationally. We used cross-sectional data from the Haiti CVD Cohort, a population-based cohort of 3,005 adults ≥18 years in Port-au-Prince, to compare two polypill implementation strategies: high-risk primary prevention and secondary prevention. High-risk primary prevention included three scenarios: (a) age ≥40 years, (b) hypertension, or (c) predicted 10-year ASCVD risk ≥7.5%. Secondary prevention eligibility included history of stroke or myocardial infarction. We then used the 2019 Global Burden of Disease database and published polypill trials to estimate preventable CVD events, defined as nonfatal MI, nonfatal stroke, and cardiovascular death over a 5-year timeline. Among 2,880 participants, the proportion of eligible adults for primary prevention were: 51.6% for age, 32.5% for hypertension, 19.3% for high ASCVD risk, and 5.8% for secondary prevention. Based on current trends, an estimated 462,509 CVD events (95% CI: 369,089-578,475) would occur among adults ≥40 years in Haiti from 2019-2024. Compared with no polypill therapy, we found 32% or 148,003 CVD events (95% CI: 70,126-248,744) could be prevented by a combined primary and secondary prevention approach in Haiti if polypills were fully implemented over 5 years. These modeling estimates underscore the potential magnitude of preventable CVD events in low-income settings like Haiti. Model calibration using observed CVD events, costs, and implementation assumptions are future directions. clinicaltrials.gov, identifier: NCT03892265.

American College of Preventive Medicine: Addressing the Opioid Epidemic Through a Prevention Framework

The opioid epidemic has resulted in significant morbidity and mortality in the U.S. Health systems, policymakers, payers, and public health have enacted numerous strategies to reduce the harms of opioids, including opioid use disorder (OUD). Much of this implementation has occurred before the development of OUD‒related comparative effectiveness evidence, which would enable an understanding of the benefits and harms of different approaches. This article from the American College of Preventive Medicine (ACPM) uses a prevention framework to identify the current approaches and make recommendations for addressing the opioid epidemic, encompassing strategies across a primordial, primary, secondary, and tertiary prevention approach. Key primordial prevention strategies include addressing social determinants of health and reducing adverse childhood events. Key primary prevention strategies include supporting the implementation of evidence-based prescribing guidelines, expanding school-based prevention programs, and improving access to behavioral health supports. Key secondary prevention strategies include expanding access to evidence-based medications for opioid use disorder, especially for high-risk populations, including pregnant women, hospitalized patients, and people transitioning out of carceral settings. Key tertiary prevention strategies include the expansion of harm reduction services, including expanding naloxone availability and syringe exchange programs. The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in which historical and current practices may be ineffective or causing harm. De-implementation strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all policies; eliminating barriers to medications for OUD, debunking the myth of detoxification as a primary solo treatment for opioid use disorder; and destigmatizing care practices and policies to better treat people with OUD.

Implementation of fixed-dose combination therapy for secondary prevention of atherosclerotic cardiovascular disease among Syrian refugees in Lebanon: a qualitative evaluation

BackgroundWe report findings of a qualitative evaluation of fixed-dose combination therapy for patients with established atherosclerotic cardiovascular disease (ASCVD) attending Médecins Sans Frontières (MSF) clinics in Lebanon. Cardiovascular disease is a leading cause of death and disability worldwide, and humanitarian actors are increasingly faced with the challenge of providing care for chronic diseases such as ASCVD in settings where health systems are disrupted. Secondary prevention strategies, involving 3–5 medications, are known to be effective for patients at risk of heart attack or stroke, but supply and adherence are challenging in humanitarian settings. Fixed dose combination therapy, combining two or more medications in one tablet, may be a strategy to address this.MethodsThe evaluation was nested within a prospective mixed-methods study in which eligible ASCVD patients were followed for 1 year during (i) 6 months of usual care then (ii) 6 months of fixed dose combination (FDC) therapy. After 1 year, we conducted in-depth interviews with a purposive sample of patients, MSF staff and external stakeholders. Interviews focused on acceptability and sustainability of the fixed dose therapy intervention. Interview data were analysed thematically, informed by thea Theoretical Framework of Acceptability. Additional attention was paid to non-typical cases in order to test and strengthen analysis.ResultsPatients and health care providers were positive about the FDC intervention. For patients, acceptability was related to ease of treatment and trust in MSF staff, while, for staff, it was related to perceived improvements in adherence, having a good understanding of the medication and its use, and fitting well with their priorities for patient’s wellbeing. External stakeholders were less familiar with FDC therapy. While external clinicals expressed concerns about treatment inflexibility, non-clinician stakeholder interviews suggested that cost-effectiveness would have a major influence on FDC therapy acceptability. Sustainability was tied to the future role of MSF care provision and coherence with the local health system.ConclusionsFor patients and clinic staff, FDC was an acceptable treatment approach for secondary prevention of ASCVD disease in two MSF clinics in Lebanon. Sustainability is more complex and calls for better alignment of care with public systems.

Fracture Liaison Service (FLS) for secondary prevention of fragility fractures: the Italian IMPACT Project

Osteoporosis and subsequent fragility fractures are an important public health issue since this is a common disease that leads to disability, and increased mortality, and therefore has a significant social and economic impact. Several studies have highlighted a dramatic diagnostic-therapeutic gap. A coordinated multidisciplinary system, known as the fracture liaison service (FLS) model, is the most appropriate approach for osteoporosis management and secondary prevention. Developed by the International Osteoporosis Foundation (IOF) through its Capture the Fracture campaign, the FLS model aims to avoid fragmentation of the care pathway by facilitating communication and coordination between primary care and medical specialists. The approach also involves patient identification and education, risk evaluation, the approval of treatments, and long-term follow up. The development of FLS programs has been strongly supported by the IOF. In Italy’s case, the primary recommendations made by the IOF in order to improve the management of patients with fragility fractures, and reverse the expected increase in the number of such fractures and their relative cost over the next 10 years, include the development of dedicated multidisciplinary care pathways, based on the FLS model. In order to make an effective contribution to the organizational needs in this regard, the primary objective of the IMPACT Project is to support the implementation and customization, in selected pilot centers in Italy, of an FLS model in line with the IOF recommendations and coherent with the Italian National Health Service (SNN), and to identify connection points with the territory, the activities of new healthcare professionals, and digital touchpoints in the care pathway.

Secondary Prevention in Radiologically Isolated Syndromes and Prodromal Stages of Multiple Sclerosis.

Following the extraordinary progress in the treatment of multiple sclerosis (MS), two major unmet needs remain: understanding the etiology of the disease and, hence, designing definitive cures (this perspective is neither at hand, nor it can be taken for granted that the etiologic targets will be readily treatable); the prevention of an overt and disabling disease, which seems to be a more realistic and pragmatic perspective, as the integration of genetic data with endophenotypes, MRI, and other biomarkers ameliorates our ability to identify early neuroinflammation. Radiologically isolated syndrome (RIS; diagnosed when the unanticipated MRI finding of brain spatial dissemination of focal white matter lesions highly suggestive of MS occurs in subjects without symptoms of MS, and with normal neurological examinations) and the recently focused “prodromal MS” are conditions at risk of conversion toward overt disease. Here, we explore the possibility of secondary prevention approaches in these early stages of neuroinflammation. RIS and prodromal MS are rare conditions, which suggest the importance of Study Groups and Disease Registry to implement informative clinical trials. We summarize ongoing preventive approaches in the early stages of the demyelinating process, especially in RIS conditions. Moreover, we highlight the importance of the biomarkers and the predictors of evolution to overt disease, which may be useful to select the individuals at risk of conversion to clinically isolated syndrome (CIS) and/or clinically definite MS. Finally, we illustrate the importance of the endophenotypes to test the frontline immunomodulatory approach for preventive strategies. Future investigations, especially in relatives of patients, based on MRI techniques and biological studies (better with integrated approaches) may provide opportunities to understand the MS early causal cascade and may help to identify a “therapeutic window” to potentially reverse early disease processes.