When Does Primary Prevention Encroach on Secondary Prevention?

PURPOSE OF REVIEW: The risk of incident atherosclerotic cardiovascular disease (ASCVD) in primary prevention is typically lower than in secondary prevention. However, there is a spectrum of risk among individuals undergoing primary prevention with the risk in some individuals approaching those of secondary prevention. We review the clinical conditions wherein the risk in primary prevention is similar to that observed in secondary prevention. RECENT FINDINGS: Among individuals without established ASCVD, coronary artery calcium (CAC) scores ≥ 300 AU are associated with ASCVD event rates similar to secondary prevention populations. CAC score ≥ 1,000 AU are associated with an ASCVD risk seen in very high-risk secondary prevention populations. Interpretation of these observations must however consider differences in the risk reduction strategies. Current guidelines dichotomize ASCVD prevention into primary and secondary prevention, but certain primary prevention patients have an ASCVD risk equivalent to that of secondary prevention populations. Identifying higher risk primary prevention populations will allow for better risk mitigation strategies.

Ideational factors associated with consistent use of insecticide-treated nets: a multi-country, multilevel analysis.

BACKGROUND: Malaria remains a major cause of morbidity and mortality in sub-Saharan Africa. Using insecticide-treated nets (ITNs) every night, year-round is critical to maximize protection against malaria. This study describes sociodemographic, psychosocial, and household factors associated with consistent ITN use in Cameroon, Côte d'Ivoire and Sierra Leone. METHODS: Cross-sectional household surveys employed similar sampling procedures, data collection tools, and methods in three countries. The survey sample was nationally representative in Côte d'Ivoire, representative of the North and Far North regions in Cameroon, and representative of Bo and Port Loko districts in Sierra Leone. Analysis used multilevel logistic regression and sociodemographic, ideational, and household independent variables among households with at least one ITN to identify correlates of consistent ITN use, defined as sleeping under an ITN every night the preceding week. FINDINGS: Consistent ITN use in Côte d'Ivoire was 65.4%, 72.6% in Cameroon, and 77.1% in Sierra Leone. While several sociodemographic and ideational variables were correlated with consistent ITN use, these varied across countries. Multilevel logistic regression results showed perceived self-efficacy to use ITNs and positive attitudes towards ITN use were variables associated with consistent use in all three countries. The perception of ITN use as a community norm was positively linked with consistent use in Cameroon and Côte d'Ivoire but was not significant in Sierra Leone. Perceived vulnerability to malaria was positively linked with consistent use in Cameroon and Sierra Leone but negatively correlated with the outcome in Côte d'Ivoire. Household net sufficiency was strongly and positively associated with consistent use in all three countries. Finally, the findings revealed strong clustering at the household and enumeration area (EA) levels, suggesting similarities in net use among respondents of the same EA and in the same household. CONCLUSIONS: There are similarities and differences in the variables associated with consistent ITN use across the three countries and several ideational variables are significant. The findings suggest that a social and behaviour change strategy based on the ideation model is relevant for increasing consistent ITN use and can inform specific strategies for each context. Finally, ensuring household net sufficiency is essential.

Association between cannabis use and complications related to ulcerative colitis in hospitalized patients: A propensity matched retrospective cohort study.

Ulcerative colitis (UC) is a chronic inflammatory process that is occasionally associated with complications that cause significant morbidity and mortality. Studies in experimental animal models have demonstrated a beneficial effect of cannabis on intestinal inflammation. It is however unknown if this corresponds to fewer complications for patients with Ulcerative Colitis.We aimed to compare the prevalence of UC related complications and certain key clinical endpoints among cannabis users and nonusers hospitalized with a primary diagnosis of UC, or primary diagnosis of a UC-related complication with a secondary diagnosis of UC.Using data from the Healthcare Cost and Utilization Project-National Inpatient Sample (NIS) during 2010-2014, a total of 298 cannabis users with UC were compared to a propensity score matched group of nonusers with UC. We evaluated several UC-related complications and clinical endpoints.Within our matched cohort, prevalence of partial or total colectomy was lower in cannabis users compared to nonusers (4.4% vs 9.7%, P = .010) and there was a trend toward a lower prevalence of bowel obstruction (6.4% vs 10.7%, P = .057). Cannabis users had shorter hospital length-of-stay (4.5 vs 5.7 days P < .007) compared to their nonuser counterparts.Cannabis use may mitigate some of the well described complications of UC among hospitalized patients. Our findings need further evaluation, ideally through more rigorous clinical trials.

Efficacy of a Digital Health Tool on Contraceptive Ideation and Use in Nigeria: Results of a Cluster-Randomized Control Trial.

BACKGROUND: Contraceptive prevalence in Nigeria remains among the lowest in the world, which substantially contributes to the country's high maternal and child mortality. Mobile phone technology penetration has increased considerably in Nigeria, opening opportunities for programs to use this medium for reaching their intended audience with health-protective information. METHODS: In 2017, the Health Communication Capacity Collaborative conducted a cluster-randomized control trial in Kaduna City to assess the efficacy of the digital health tool Smart Client on ideational and behavioral variables related to family planning. Twelve wards in the city were randomly assigned to intervention (6 wards) and control (6 wards) arms of the study. A total of 565 women aged 18-35 years were randomly selected from study wards and consented to participate in the study. At recruitment, the women completed a baseline survey. The women in the intervention group were registered to receive 1 welcome call, 13 program calls, and 3 quiz calls on their mobile phones. Each of the program calls had several segments, including introduction, drama episode, and friend-to-friend chat. The last quiz call included evaluation questions. Women in the control arm received no intervention. The efficacy of the intervention was assessed using both per-protocol and intent-to-treat differences-in-differences techniques. RESULTS: The intervention and control arms were equivalent in terms of key sociodemographic characteristics, with the exception of religion. Attrition was a major challenge in the study. On average, participants receiving the intervention listened to 7.2 drama episodes but only 2.6 personal stories and 1.1 sample dialogues. The results of both per-protocol and intent-to-treat analyses show that the intervention was efficacious in improving relevant ideational and behavioral outcomes. For example, the intent-to-treat results show that the intervention increased women's perceived level of confidence to discuss family planning with a provider by 27.7 percentage points and modern contraceptive prevalence by 14.8 percentage points. CONCLUSION: This efficacy assessment showed that using an interactive voice response-based digital tool that includes drama is a viable option for promoting positive ideation about family planning and increasing contraceptive use in Nigeria. Significant lessons learned from this efficacy trial include informing participants at the time of recruitment of what the opening segment of the calls will sound like to avoid the calls being mistaken for telemarketing calls and intensive testing prior to scale-up to avoid potential attrition due to technical issues.

Factors affecting the achievement of fertility intentions in urban Nigeria: analysis of longitudinal data.

BACKGROUND: Maternal mortality ratio in Nigeria is among the highest in the world with an estimated 160 women dying every day of complications related to pregnancy and childbirth. In addition to appropriate management of complications related to pregnancy and childbirth, preventing unwanted pregnancies is an effective way to reduce maternal deaths. Identifying potentially modifiable factors associated with the achievement of fertility intentions is critical for developing behavior change interventions that will contribute to reducing maternal mortality. METHODS: The data analyzed came from a longitudinal design with data collected in 2010/2011 and 2014 from the same group of women of reproductive age in six Nigerian cities. The data were collected as part of efforts to evaluate the effects of the Nigerian Urban Reproductive Health Initiative (NURHI). A total of 10,672 women were interviewed at the two points in time but the analyses in this manuscript were limited to 1921 in-union women who reported that they desired no more children at baseline in 2010/2011. The principal analytic method was multivariable regression adjusted for clustering at the enumeration area level. The analysis controlled for socio-demographic and household variables, ideational characteristics, and contraceptive use at baseline. RESULTS: About two thirds of the women who desired no more children at baseline have neither had any children nor were pregnant at endline. The strongest predictors of the achievement of fertility intentions include parity, age, religion, residence, spousal communication about family size, perceived severity of another pregnancy, and spousal agreement about family size. CONCLUSION: A comprehensive strategy to help women avoid unwanted pregnancies should include efforts to increase women's understanding about effective ways to prevent unplanned pregnancies and strengthen self-efficacy for contraceptive use. Promoting spousal communication about reproductive issues, engaging men, promoting smaller family sizes and changing pronatalist attitudes should also be part of such a strategy.