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A new study led by researchers at Boston Medical Center, in collaboration with Harvard Pilgrim Health Care Institute, shows that value-based incentive programs aimed at reducing health care-associated infections did not improve infection rates in either safety-net or non-safety-net hospitals. Published in JAMA Network Open, these results also demonstrate persistent disparities between infection rates at safety-net and non-safety net hospitals, with higher rates of health care-associated infections in safety-net hospitals.

"While these value-based programs intend to use financial incentives and penalties to encourage hospitals to improve patient outcomes, our data demonstrate that the programs aren't actually resulting in any benefits for patients. In addition, because infection rates remain higher at safety-net hospitals compared to non-safety net hospitals, more safety-net hospitals are required to pay financial penalties," said Heather Hsu, MD, MPH, the study's first author who is a pediatrician at Boston Medical Center. "This may have unintended consequences on the financial stability of safety-net hospitals and health care systems, and the services they are able to provide for their patients."

In 2001, safety-net hospitals were defined by the Institute of Medicine as hospitals that provide care to a large share of uninsured or Medicaid patients, regardless of their ability to pay. As a result, many safety-net hospitals are under more financial stress than non-safety-net hospitals and rely on supplemental funding from both the state and the federal government to remain operational. According to America's Essential Hospitals, the average operating margin for its national membership of safety-net hospitals was 1.6 percent in 2017; for all hospitals nationwide, that rate was 7.8 percent.

Reducing health care-associated infections is a main target of quality improvement efforts across all health care systems. The Affordable Care Act established two value-based incentive programs to target health care-associated infections that were put in place in 2014: the Hospital Value-Based Purchasing (HVBP) program, which rewards or penalizes the highest and lowest performing hospitals by up to two percent of total inpatient payments received, and the Health Care-Acquired Conditions Reduction Program (HACRP), which reduces payments by up to one percent for the lowest performing hospitals. These programs compare hospital performance for specific health care-associated infections based on data that hospitals and health care systems publicly report to the Centers for Disease Control and Prevention National Healthcare Safety Network against national benchmarks.

For this study, the researchers analyzed data from 618 acute care facilities (including 145 safety-net hospitals) across the country that reported data to the National Healthcare Safety Network and had implemented HACRP and HBVP between 2013 and 2018. The specific health care-associated infections investigated in this study were: central line-associated bloodstream infections; catheter-associated urinary tract infections; and surgical site infections after colon surgery and abdominal hysterectomy.

The results showed that neither safety-net nor non-safety-net hospitals showed improvements in the four infections analyzed during the study period, including after the value-based programs were implemented. Safety-net hospitals had higher rates of central line-associated bloodstream infections, catheter-associated urinary tract infections and surgical site infections after colon surgery compared with non-safety-net hospitals both before and after value-based program implementation.

Insurance coverage provided through Medicaid and Medicare, while critical, does not typically cover the actual cost of care. This results in safety-net hospitals relying on supplemental government funding to continue to provide necessary health care services to patients. At the present time, the availability of these uncompensated care funds is decreasing, and could be eliminated, which would have a detrimental impact on safety-net hospitals and other health care systems.

"Right now, the programs are not leading to any meaningful improvements in patient safety and are contributing to inequity in our health care system by disproportionately penalizing safety-net hospitals," added Hsu, assistant professor of pediatrics at Boston University School of Medicine. "We hope that these results can serve as a starting point to re-evaluate and re-design value-based incentive programs."

The researchers note that adding in a social risk factor adjustment before assessing penalties based on reported outcomes data may help avoid systematic penalization of safety-net hospitals without setting lower quality standards in these institutions.

Scientists at Vanderbilt University Medical Center (VUMC) and the Translational Genomics Research Institute (TGen) in Phoenix, Arizona, have discovered previously unreported genetic and cellular changes that occur in the lungs of people with pulmonary fibrosis (PF).

Their findings, reported Wednesday, July 8, in the journal Science Advances, should aid the search for new ways to treat or prevent this devastating lung-scarring disease, they said.

PF can be triggered by inhaling coal or asbestos, exposure to radiation and certain drugs and hypersensitivity and autoimmune reactions. In addition, "idiopathic" PF, a subset of the disease with no known cause, kills up to 40,000 Americans each year, according to the Pulmonary Fibrosis Foundation.

Anti-fibrotic and anti-inflammatory drugs can slow disease progression, but they are not without serious side effects. Lung transplantation is another option, but due to the severe shortage of donor organs few people with PF or IPF obtain new, healthy lungs.

"Our understanding of the cellular and molecular mechanisms actively driving disease in the lungs of pulmonary fibrosis patients has been limited," said Jonathan Kropski, MD, who led the study with TGen's Nicholas Banovich, PhD. "We have not yet been able to answer very basic questions, such as 'Which cells are the ones that make the fibrosis?'"

Kropski is assistant professor of Medicine and Cell and Developmental Biology in the Division of Allergy, Pulmonary and Critical Care Medicine at VUMC.

The researchers used advanced microfluidic techniques and single-cell RNA sequencing to identify variations in the transcriptome, or gene-expression profile, in more than 100,000 individual lung cells from 20 patients with PF and 10 controls who did not have the disease.

They identified multiple previously undescribed types of cells from patients with PF that expressed high levels of collagen and other components of the extracellular matrix (ECM) that accumulates in PF lungs.

Normally the ECM provides the structural and biochemical support between cells that are organized into tissues. But in PF and IPF, the progressive accumulation of ECM destroys the alveoli, the tiny air sacs in the lungs that allow for the exchange of oxygen and carbon dioxide.

Using another technique, RNA in situ hybridization, the researchers mapped the distribution of various cell populations in PF lungs compared to control lungs. Taken together, these findings "provide remarkable insights into the cellular architecture of the human lung and the fundamental mechanisms driving disease pathology in PF," they conclude.

The German Institute for Quality and Efficiency in Health Care (IQWiG) used an evidence map to investigate to what extent informative evidence exists on the benefit and harm of the diagnostic procedures "non-invasive computed tomography angiography" (CTA) and "stress MRI" in people with suspected coronary heart disease (CHD).

Focused searches provided extensive and informative evidence for the diagnosis of CHD using non-invasive procedures: Randomized controlled trials (RCTs) and evidence-based guidelines contain suitable data on the advantages and disadvantages of both procedures.

Coronary heart disease: leading cause of death in adults

Coronary heart disease (CHD) is the most frequent cause of death in adulthood in Germany, both in men and women: Plaques in the coronary vessels (arteriosclerosis) lead to narrowing of blood vessels (stenosis) and thus to reduced blood flow in the heart muscle (myocardial ischaemia). Typical symptoms are pain and tightness in the chest with difficulties breathing (angina pectoris).

However, symptoms of chronic CHD can also be atypical. An accurate diagnosis is therefore essential for the proper care of patients with CHD. Which diagnostic procedure is used in the individual case depends mainly on the individual risk of CHD - depending on age, sex, symptoms, intolerances - as well as on the risks of the procedure applied (e.g. radiation exposure for CT), the devices available, and the on-site expertise.

Detection of stenosis or its consequences

Various imaging techniques can be applied to detect chronic CHD: In addition to invasive coronary angiography (ICA) using left heart catheters, some non-invasive methods, such as computed tomography angiography (CTA) or stress tests using magnetic resonance imaging (MRI), are available. ICA and CTA are morphological procedures and although they directly detect stenosis, they do not necessarily indicate ischaemia. CTA is currently the only available non-invasive morphological procedure for the diagnosis of CHD.

In contrast, functional diagnostic procedures such as non-invasive stress MRI investigate the consequences of stenosis for the blood flow in the heart muscle: For instance, stress MRI examines how the heart functions under stimulated stress.

Systematic reviews based on RCTs and guidelines

The search for current systematic reviews identified 24 relevant reviews for the evidence map. Aggregated results for selected outcomes (all-cause mortality, myocardial infarction, etc.) from 9 RCT-based systematic reviews were compared with the respective standard care (including non-invasive functional procedures). Although insufficient data (one systemic review) were available for stress MRI, this could change with the results of studies published in the meantime (since March 2020).

The results showed that myocardial infarctions occurred less frequently after a CTA-based diagnosis. It remains to be seen whether more effective treatment planning after a CTA plays a role here. However, an ICA was often still performed after a CTA, without the reasons for this being clear. After an MRI, fewer ICAs were performed. But the detailed evaluation and interpretation of these results was not a topic of the search for evidence; only a benefit assessment can investigate this issue

Three evidence-based guidelines, including the German National Health Care Guideline (NVL), unanimously recommend non-invasive procedures as the first test for the diagnosis of chronic CHD.

Procedure of report production

The present report was prepared in the form of a working paper within the framework of the general commission, which was awarded to IQWiG by the Federal Joint Committee (G-BA) in December 2004 in order to strengthen the Institute's scientific independence. This general commission enables IQWiG to select and investigate topics independently. In contrast to other report types, there are no deadlines for the publication of working papers. The working paper was sent to the G-BA on 2 June 2020.

An English summary of this working paper will be available soon. If you wish to be informed when it is published, please contact info@iqwig.de.

Asian longhorned ticks outside the U.S. can carry debilitating diseases. In the United States and elsewhere they can threaten livestock and pets. The new study, published in the journal Zoonoses and Public Health, sheds new light on the origin of these exotic ticks and how they are spreading across the United States.“While additional samples from the tick’s native range are needed to pinpoint more exactly the source of the U.S. introduction, our data suggest that they came from one or more locations in northeastern Asia – either through a single introduction of at least three ticks or as multiple introductions from different populations,” said lead author Andrea M. Egizi, a visiting professor in the Department of Entomology at Rutgers University–New Brunswick and a research scientist with the Monmouth County Tick-borne Diseases Laboratory hosted by the Rutgers Center for Vector Biology. In 2017, Rutgers Center for Vector Biology and other researchers detected an infestation of the Asian longhorned tick (Haemaphysalis longicornis), which is native to East Asia, in New Jersey. It was the first time established populations of this species had been detected in the United States. Subsequent investigations found the tick to be widespread in the eastern U.S. Rutgers researchers discovered it has been present in New Jersey since at least 2013.
Although this species transmits serious illnesses to people and animals in other countries, experts don’t know whether the tick populations in the United States will make people sick, according to the U.S. Centers for Disease Control and Prevention.The species has two forms: one with males and females, and one with self-cloning females that lay eggs without needing to mate, a process called “parthenogenesis.” The self-cloning form, free from the need to look for mates, are especially likely to thrive and spread. A single female can establish a fast-growing population. This type entered Australia and New Zealand in the early 1900s, and now causes significant losses in the cattle industry.
Rutgers Center for Vector Biology researchers enlisted about 25 collaborators at 20 institutions to get samples of Asian longhorned ticks across the United States and internationally, and used gene sequencing to detect genetic similarities and differences between various populations.

Their findings indicate that at least three individual ticks, from self-cloning populations, were brought to the United States, which explains why all adult Asian longhorned ticks found in the U.S. so far have been female. Overall, U.S. ticks are more likely to have come from an East Asian country (or countries) than from Australia and New Zealand.
As part of the study, the U.S. Department of Agriculture Animal and Plant Health Inspection Service, Veterinary Services found evidence that these ticks traveled within the United States on wildlife as well as through the transport of pets or livestock.“One thing we uncovered is the ease with which pets, especially dogs, can accidentally help ticks cross international borders and state lines,” said senior author Dina M. Fonseca, a professor and director of the Center for Vector Biology in the Department of Entomology in the School of Environmental and Biological Sciences. “Many countries require dogs to be treated for ticks and other parasites before entering the country, but the United States does not. We urge greater awareness of this issue to prevent future exotic tick introductions.”

Rutgers-affiliated coauthors include Matthew Bickerton and James L. Occi, both entomology doctoral students.

Journal

Zoonoses and Public Health

DOI

10.1111/zph.12743

An important line of defence in the fight against the new corona virus SARS-CoV-2 is the formation of neutralising antibodies. These can eliminate the intruders and have great potential to be used for prevention and treatment of SARS-CoV-2 infection. A team of researchers led by Prof. Florian Klein (Cologne University Hospital) and the German Center for Infection Research (DZIF) has further elucidated how these antibodies develop and has isolated potent SARS-CoV-2 neutralizing antibodies. Together with Boehringer Ingelheim, these antibodies are currently being further characterized and developed. It is expected that they will enter the stage of clinical development later this year. The results were published today (July 07, 2020) in the journal Cell.

"Our goal was to better understand the immune response to SARS-CoV-2 and to identify highly potent antibodies that could be used to prevent and treat COVID-19," explained Prof. Klein, Director of the Institute of Virology at the Cologne University Hospital and Principal Investigator at the DZIF. "We assume that such antibodies are effective for several weeks and may protect against COVID-19 during this period," added Dr. Christoph Kreer, who conducted the work together with Dr. Matthias Zehner in Cologne.

In close collaboration with scientists from Marburg, Frankfurt, Munich, Tübingen and Israel, the researchers investigated the SARS-CoV-2 antibody response in twelve individuals recovered from COVID-19. They examined more than 4000 SARS-CoV-2-specific B cells on a single cell level and were able to partly decode the humoral immune response to SARS-CoV-2. They reconstructed 255 antibodies in the laboratory, which were examined by Prof. Stephan Becker's laboratory in Marburg for their ability to neutralise the novel coronavirus SARS-CoV-2. In total, 28 neutralising antibodies were found.

"Interestingly, many antibodies showed only a small number of mutations. This means that only minor changes were necessary to effectively recognise and neutralise the virus" says Dr. Zehner. In fact, in blood samples collected before the pandemic, the scientists found B cells carrying similar antibody characteristics to those of SARS-CoV-2 neutralising antibodies. This may suggest that SARS-CoV-2 antibodies can be readily formed and that an active vaccine may provide rapid protection.

The antibodies have been developed for protecting against and treating COVID-19. In addition, these antibodies could be used for 'post-exposure prophylaxis. Here antibodies would be applied after contact with an infected individual. "This form of intervention could be of particularly interest for stopping localised outbreaks and for preventing disease progression in people at risk," said Prof. Klein. The scientists expect that first clinical trials will be performed at the end of 2020.

The Great Chinese Famine (1959-1962) was probably the greatest man-made disaster in history resulting in tens of millions of deaths. The responses to the famine and that to COVID-19 are all to similar, characterized by false claims, misinformation and, most of all, political posturing at the expense of public health. The importation of Russian sparrows helped lead to ending the great famine. We await the arrival of the sparrows in the the form of a vaccine. There is no guarantee that a safe and effective vaccine is forthcoming, but even if one or more are developed it will be 12 or more months before it can be given to enough people to end the pandemic. In the absence of a vaccine an infectious disease will only burn itself out as a result of Herd Immunity. We need to understand that Herd Immunity is not an intervention we choose, it is a natural phenomenon that is evolving case by case.

A discussion of how we inappropriately continue to define a "case" is also given and an argument made to utilize daily COVID hospital admissions as a much more valid measure of the medical impact of COVID-19.

BOSTON- New research from Boston Medical Center shows that routine Hepatitis C (HCV) testing at federally qualified health centers (FQHC) improves diagnosis rates and health outcomes for people with HCV infections in the United States, and is cost-effective. The formerly recommended targeted testing approach was shown to provide worse outcomes at a higher cost when compared to routine testing.

Published in the American Journal of Medicine, results show that these health care facilities can provide opportunities to enhance HCV testing and treatment, where care is typically provided to an underserved and diverse patient population with a high proportion of both injection drug use and HCV. This comes at a time when there has been an increase in HCV infections due to the opioid epidemic, and as recent data show that the United States is not on the list of high-income nations expected to achieve the World Health Organization's goal of eliminating HCV by 2030.

"Routine testing at federally qualified health centers is shown to provide better health outcomes and reduced financial burden compared to targeted testing," said Sabrina Assoumou, MD, MPH, an infectious diseases physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine. "Federally qualified health centers can serve as venues to enhance testing and treatment, reducing the impact of HCV in the country."

Counselor-initiated routine rapid-testing with follow-up RNA testing identified 75 percent of cases at the FQHC compared to only seven percent identified by risk-based targeted testing by a clinician. By having a dedicated counselor initiate and perform testing, there was an increase in the percentage of cases identified by 41 percent compared to alternative approaches where clinicians were offering testing. In addition, targeted testing missed patients with no identified substance use. For example, risk-based laboratory-based targeted testing by a clinician only identified seven percent of HCV infections in the first month of the intervention whereas clinician-initiated phlebotomist-performed routine laboratory-based testing identified 25 percent of infections.

The Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF) have recently updated recommendations to include one-time HCV testing screening for adults 18 years and older. This new research provides data on the cost-effectiveness of alternative testing approaches to expand testing and treatment in high prevalence clinical settings, specifically evaluating the relative costs and comparative outcomes of various implementation models for HCV testing. Using simulation modeling, routine rapid HCV testing is shown to be cost-effective when compared to risk-based laboratory testing at US FQHC. Compared to risk-based laboratory testing, routine rapid testing performed by a counselor identified 68 percent more cases in the first month and resulted in a 22 percent reduction in liver deaths among patients with liver cirrhosis. This intensive approach to testing in FQHCs shifts the timing of cure to early disease stage, preventing liver-related morbidity and reducing HCV-attributable deaths, even when there is substantial ongoing hepatitis C testing at venues elsewhere.

Individual-level data was used from 57 FQHCs to model 9 strategies, including permutations of HCV antibody testing modality, person initiating testing and testing approach. The outcomes included life expectancy, quality adjusted life years (QALY), hepatitis C cases identified, treated and cured, and incremental cost-effectiveness ratios (ICERs).
 

One of the biggest social media sites -- Facebook -- has allowed "anti-vaxxers" to gain a stronger voice against the use of the human papillomavirus, or HPV, vaccine, according to a new study from a media expert at the University of Missouri.

Monique Luisi, an assistant professor in the Missouri School of Journalism, studied more than 6,500 public HPV vaccine-related posts on Facebook over the first 10 years since the vaccine was approved by the U.S. Food and Drug Administration in 2006. The Centers for Disease Control and Prevention estimates that approximately 80 million Americans are infected with HPV, and 14 million new cases occur annually. HPV is also associated with genital warts and six types of cancer in men and women, including cervical and throat cancer.

Despite the vaccine's reported benefits of preventing multiple cancers and genital warts, Luisi said 45% of the posts she identified displayed a negative tone toward people getting the vaccine. In addition, over the course of a decade, Luisi identified a negative trend occurring on Facebook toward how people perceive the vaccine -- including its safety, effectiveness and whether its use leads to the encouragement of sexual behavior.

"The representation of the HPV vaccine has not only worsened, but negative posts toward the HPV vaccine have received more public engagement, and evidence shows that these negative posts have generated momentum for other related negative posts," Luisi said. "It would be one thing if we only saw just the negative information out there. But there's also negative momentum carried by these posts, and if negative posts are encouraging more people to post other negative content, then we can predict how the conversation is going to go and that people are also being influenced by the messages they see."

Luisi said her next step for this research will be to study the implications this content has on parents and guardians as decision-makers. She said it's important for people to recognize the power of sharing content on social media.

"People talk about a lot of things on social media," she said. "While someone might not be directly involved in a conversation on a particular topic, they still might see that conversation while scrolling through their social media. Therefore, I think it's important to think about intent when sharing content. Even the simple act of sharing -- intentional or unintentional -- can influence others."

Differences in lung physiology and immune function in children could be why they are more often spared from severe illness associated with COVID-19 than adults, according to pediatric and adult physicians at The University of Texas Health Science Center at Houston (UTHealth) and Baylor College of Medicine, who teamed up to investigate the disparity.

The perspectives paper was recently published in American Journal of Physiology-Lung Cellular and Molecular Physiology.

According to the paper, only about 1.7% of the first 149,082 cases in the U.S. were infants, children, and adolescents younger than 18 years old. Authors noted that children under 18 make up 22% of the U.S. population. Only three pediatric deaths were identified by the Centers for Disease Control and Prevention (CDC) as of April 2020.

"These profoundly decreased rates of symptomatic infection, hospitalization, and death are well beyond statistical significance, require further examination, and may hold the key to identifying therapeutic agents," the authors wrote.

Angiotensin-converting enzyme 2s, called ACE2, are the doors that allow SARS-CoV-2, the novel coronavirus that causes COVID-19, to enter the body's cells. Children naturally have less ACE2 in the lungs than adults.

"ACE2 are important for viral entry and there seems to be less of them in children, because they increase with age," said Matthew Harting, MD, MS, assistant professor in the Department of Pediatric Surgery at McGovern Medical School at UTHealth, pediatric surgeon with UT Physicians, and senior author of the paper. Harting is also director of the pediatric ECMO program providing advanced cardiac and respiratory support at Children's Memorial Hermann Hospital.

In addition to fewer ACE2 receptors, the authors note the immune system in children responds to viruses differently than that of adults, leaving less opportunity for severe illness in pediatric patients. There are several different mechanisms behind the differences, including the retention of T-cells in children, which are able to fight off or limit inflammation.

"T-cells have a viral response and also an immune modulator response. In severe cases of adult COVID-19 patients, we've seen that those T-cells are reduced, so the ability to fight the virus is also reduced. In kids, those T-cells seem to be maintained, so they are still able to prevent the virus," said Harry Karmouty-Quintana, PhD, an assistant professor in the Department of Biochemistry and Molecular Biology at McGovern Medical School, and a co-author of the paper.

Lung tissue in children naturally has a higher concentration of regulator T-cells. Patients with higher levels of T-cells also have higher levels of Interleukin 10 (IL-10), also known as human cytokine synthesis inhibitory factor, an anti-inflammatory cytokine.

"IL-10 inhibits the inflammation of other components like IL-6 that are detrimental. Adults tend to experience hyperinflammatory state, where kids do not," Karmouty-Quintana said. "In preclinical studies in mice, IL-10 has also shown to decrease with age."

The paper's findings were made possible through collaboration in a multidisciplinary group made up of pediatric and adult physicians and scientists in pediatric surgery, adult critical care, neonatology, and molecular biology.

"We, as physicians, have been challenged with the question of how to treat COVID-19 and we're learning in real time," said Bindu Akkanti, MD, associate professor of critical care medicine with McGovern Medical School, attending physician in critical care with Memorial Hermann-Texas Medical Center, and a study co-author. "I knew that to figure out the best way to treat adults, we needed to get a team together to get to the bottom of why children were being spared from severe illness related to the virus. So, I reached out to Dr. Karmouty-Quintana and we teamed up with Dr. Harting and two other physicians in the Texas Medical Center to start investigating." Akkanti also sees pulmonary patients at UT Physicians.

"Collaborations like this between adult and pediatric providers are really important and this disease highlights where we can learn a lot when we compare the way it behaves in younger kids with older people," Harting said. "Even now as we're learning about effective treatments, we're seeing younger people handle this disease better than older people. Moving forward, physicians and scientists need multidisciplinary collaboration to continue learning - this is just another step in the right direction to attack this virus."

Krithika Lingappan, MBBS, was the first author of the paper and Jonathan Davies, MD, was a co-author. Both Lingappan and Davies are assistant professors of pediatrics at Baylor College of Medicine and neonatologists with Texas Children's Hospital.

As a result of the collaboration, the team has begun a new study using blood samples from patients in different stages of COVID-19 to continue to understand how to treat the virus and the disparities in disease progression between children and adults.

July 8, 2020 - "Nurse-initiated and managed antiretroviral therapy" (NIMART) is an innovative approach to making effective medications more accessible to people living with HIV (PLWH) in low-resource countries. A new study identifies challenges and opportunities to promoting nurse- and midwife-led HIV services in eastern and southern Africa, reports the July/August issue of The Journal of the Association of Nurses in AIDS Care (JANAC). The official journal of the Association of Nurses in AIDS Care, JANAC is published in the Lippincott portfolio by Wolters Kluwer.

Improved training, supportive supervision, and formal mentorship programs are key steps toward establishing or strengthening NIMART care, suggests the new research by Rebecca E. MacKay, MPH, of Rollins School of Public Health at Emory University, Atlanta, and colleagues. They write, "Health facilities have important opportunities to advance NIMART practice through strengthening these aspects of in-service support."

Nurses/ Midwives Need Support and Education to Meet NIMART Goals

Eastern and southern Africa accounts for more than half of the PLWH globally - however, the region has also shown remarkable progress toward eliminating HIV. From 2010 to 2018, new HIV/AIDS cases declined by 28 percent in eastern and southern Africa, compared to a global decline of 16 percent.

Increasing access to effective antiretroviral therapy (ART) is a major part of the Fast-Track Strategy of the Joint United Nations Program on HIV/AIDS (UNAIDS), which aims to end the AIDS epidemic by 2030. Designed to make ART more accessible, NIMART is a "task-sharing" approach that enables nurses, midwives, and nurse-midwives - professionals who are far more available than physicians in sub-Saharan African - to provide advanced clinical services, including HIV testing and prescribing of ART for PLWH.

The study included a questionnaire completed by 200 nurses, midwives, and nurse-midwives at 30 healthcare facilities in 11 eastern and southern African countries. Up to 80 percent of nurses/midwives responded that they had "sufficient authority" to provide NIMART care. Sixty percent or more agreed that their pre-service education and in-service training had effectively prepared them to offer HIV treatment.

However, the nurses/midwives expressed more concerns about their level of supervision and mentorship. More than one-third of respondents felt they did not receive adequate supportive supervision or feedback on care provided. Nurses, midwives, and nurse-midwives providing pediatric HIV care tended to have less-positive responses than those providing prevention of mother-to-child transmission services for pregnant and breastfeeding women or HIV-exposed infants.

Interviews with 62 clinical supervisors at the same facilities identified several barriers to effective NIMART care: deficiencies in training, staff shortages, inadequate supplies or space, high workloads, and challenges in managing children with HIV. But the supervisors interpreted many of these barriers and challenges as potential opportunities for improving NIMART services: strengthening in-service training, increasing staffing, providing adequate supplies and space, and increasing capacity for pediatric services.

In a triangulation step, the issues identified in the nurse/midwife questionnaires and supervisor interviews were consistent with each other. "Although the nurses, midwives, and nurse midwives in the facilities assessed clearly had the authority to provide NIMART services, a substantial proportion did not feel that they were well prepared or well supported to deliver this care," Ms. MacKay and coauthors write.

The researchers believe their findings have implications for efforts to promote effective provision of NIMART care in southern and eastern Africa. Steps facilities can take to improve NIMART services include standardized in-service training, formal clinical mentorship programs in prevention, and specific protocols for ongoing supportive supervision. Ms. MacKay and colleagues conclude: "Taking advantage of these opportunities may be a critically important step toward meeting the Fast Track Strategy to the AIDS epidemic by 2030."

8 July 2020: A follow-up study of almost 20,000 young women who had a first cycle of IVF in Denmark between 1995 and 2014 indicates that those who responded poorly to treatment, with few eggs collected, are at a significantly increased risk of later age-related diseases. The findings, says investigator Mette Wulf Christensen from Aarhus University in Denmark, suggest an "association with early ovarian ageing and an accelerated ageing process in general".(1)

The results, she explains, are consistent with what we know so far about early menopause, which has been shown in several studies to be associated with an increased risk of cardiovascular diseases, osteoporosis and mortality. "Identifying women at risk of early menopause may thus allow early preventive health initiatives in terms of a healthy lifestyle," says Christensen.

This is the first time that the yield of eggs in IVF as a measure of ovarian ageing - and thus as a risk predictor of age-related ill-health and mortality - has been investigated in a large-scale cohort study. The results will be presented online today by Ms Christensen, a PhD student, at the virtual Annual Meeting of ESHRE.

The study was based on the national registries of Denmark in which each individual has their own identifying number, thus allowing cross-linkage between various registries of health outcomes and treatments. In this case women below the age of 37 who had a first cycle of IVF or ICSI in Denmark between 1995 and 2014 were divided into one of two groups according to their response to ovarian stimulation: those who had produced five or fewer eggs for collection, defined as "early ovarian ageing"; and those who responded normally with at least eight eggs. The number of eggs harvested was thus used as a marker of ovarian reserve. There were 1,234 women in the former group, and 18,614 in the latter.

During the six-year average period of follow-up, the incidence of chronic disease in the two groups was analysed from the cross-linked registry data, providing a real-life estimate of risk for cardiovascular disease, osteoporosis, type-2 diabetes, cancer, and all-cause mortality. Results showed that women in the early ovarian ageing group had an increased overall risk (by 26%) of all-cause disease when compared to those with a normal ovarian response. This higher risk was statistically significant, and evident in cardiovascular diseases (39% higher) and osteoporosis (more than double). The two groups were also cross-checked with the "early retirement benefit" register, in which the early ovarian ageing group were also more likely to be listed.

The risk of cancer, other age-related diseases and all-cause death was not significantly different.

Commenting on the implications of the results, Ms Christensen said that, although the common biological mechanisms behind ovarian and general ageing are "somewhat obscure", the data from this study demonstrate that young women with early ovarian ageing - defined as low oocyte output after FSH stimulation - have an increased risk of age-related morbidity and possibly mortality, "and strongly support the hypothesis that low ovarian reserve may be a useful marker of later health problems". Counselling this group of patients at fertility clinics, she added, "may therefore be important for introducing preventive measures such as lifestyle changes or the use of HRT to reduce the adverse health risks which follow an earlier menopause".

The American Cancer Society (ACS) has updated its guideline for HPV vaccination, adapting a 2019 update from the Federal Advisory Committee on Immunization Practices (ACIP). The ACS first issued a guideline for routine use of the HPV vaccine in 2007, with an update issued in 2016. This third version of the guideline is published in CA: A Cancer Journal for Clinicians, the ACS's flagship medical journal.

For the update, members of the ACS's Guideline Development Group (GDG) participated in content review of two new 2019 ACIP recommendations, and were charged to propose any modification or adaptation after reviewing the evidence evaluated by ACIP and its interpretation, as well as some recent studies and considerations related to implementation efforts to increase rates of population coverage and on-time vaccination. While there was broad general agreement, there were also some areas of difference between the ACIP recommendations and judgments of the GDG in the context of cancer prevention aims and nationwide efforts to increase vaccine utilization.

The ACS's update addresses three key issues: The ACS adaptation emphasizes that vaccination may be routinely offered at age 9-12; it endorses harmonization of catch-up vaccination for all individuals through age 26 while continuing to include a qualifying statement about reduced effectiveness of vaccination at older ages (i.e. young adults as compared to teens and pre-teens); and does not endorse the recommendation for shared clinical decision-making about vaccination for adults aged 27-45 years.

Age to begin vaccination

Girls and boys should get 2 doses of the HPV vaccine at ages 9 to 12 years.

Qualifying Statement: Routine HPV vaccination between ages 9-12 years is expected to achieve higher on-time vaccination rates, resulting in increased numbers of cancers prevented. Health care providers are encouraged to start offering the HPV vaccine at age 9 or 10 years.

Catch-up vaccination

Children and young adults up to age 26 years who have not received the HPV vaccine should get vaccinated. Vaccination of young adults will not prevent as many cancers as vaccination of children and teens.

Qualifying Statement: Providers should inform individuals aged 22-26 that vaccination may be less effective in lowering their cancer risk.

Adult vaccination

The ACS does not recommend HPV vaccination for persons older than 26 years.

Qualifying statement: ACS does not endorse shared clinical decision-making for adults ages 27-45 due to the low effectiveness and low cancer prevention potential of vaccination in this age group, the burden of decision-making on patients and clinicians, and the lack of sufficient guidance on selection of individuals who might benefit.

"We're seeing evidence that starting vaccination at age 9 or 10 has potential benefits that are expected to lead to higher vaccination rates, resulting in increased numbers of cancers prevented compared to starting at ages age 11 and 12," said Debbie Saslow, PhD, managing director, HPV & GYN Cancers. "It's for that reason we felt it was important to say that starting at age 9 or 10 is more than OK; it's preferable to achieve the full cancer-preventing potential of this vaccine."

The ACS decision not to endorse shared clinical decision-making for vaccination between ages 27 and 45 was based primarily on the minimal cancer prevention benefit expected from vaccination of individuals in that age range. In addition, there has been a global shortage of HPV vaccine that is expected to continue for the next several years.

"The combination of HPV vaccination and cervical cancer screening has the potential to prevent tens of thousands of cancers caused by HPV each year in this country and to eliminate cervical cancer as a public health problem in the coming decades," conclude the authors. "Vaccination of all children between ages 9 and 12 years will prevent >90% of the cervical, oropharyngeal, anal, vaginal, vulvar, and penile cancers that are caused by HPV and, combined with screening and the treatment of cervical precancers, can lead to the first elimination of a cancer in history."

In a clinical trial of patients with rheumatoid arthritis, treatment with a drug called upadacitinib provided greater benefits than methotrexate, the most commonly used initial therapy for rheumatoid arthritis.

Upadacitinib inhibits certain proteins called Janus kinase enzymes that are involved in inflammation. It's approved for treating patients with rheumatoid arthritis, but only after they've tried methotrexate.

In the study published in Arthritis & Rheumatology, 947 patients who had not previously taken methotrexate were randomized to receive once-daily upadacitinib (15 mg or 30 mg) or weekly methotrexate for 24 weeks. Both doses of upadacitinib lessened clinical signs of arthritis and improved patient-reported symptoms to a greater extent than methotrexate. Importantly, both doses prevented further joint damage in 88% to 89% of patients, compared with 78% of patients taking methotrexate.

Treatment with the 30 mg dose provided minimal additional efficacy compared with the 15 mg dose, but it was linked with a higher rate of side effects.

"This trial convincingly demonstrates the efficacy of the JAK inhibitor upadacitinib as monotherapy in early rheumatoid arthritis. It works faster and better than methotrexate alone," said lead author Ronald van Vollenhoven, MD, of the Amsterdam University Medical Centers, in The Netherlands. "The latter drug can be combined with corticosteroids to obtain a more rapid effect, and future studies will perhaps use that comparison."

Children who are relatively tall for their age have a higher risk of developing obesity, according to a new study published in Obesity.

In the study, investigators examined the health records of 2.8 million children who were initially examined between 2 and 13 years of age. When they were re-examined an average of 4 years later (but up to 13 years later), taller children were more likely to have a higher body mass index than shorter children.

For example, among the thinnest children at the start, the prevalence of obesity at the second exam was 5-fold higher in the tallest children than in the shortest children (3.1% versus 0.6%). Among the heaviest children at the start, the respective prevalence rates of obesity were 89.5% versus 53.4%.

The association between taller height and obesity at the second exam was strongest in children who were initially examined when they were younger than 7 years old.

"As about half of this association is independent of the initial body mass index of the child, the use of height may be a simple way to more accurately classify which children will become obese," said lead author David S. Freedman, PhD, of the Centers for Disease Control and Prevention.

Pancreatic cancer carries a poor prognosis, and it often goes undetected until advanced stages. A new BJS (British Journal of Surgery) study indicates that a certain cocktail of chemotherapy drugs may be a safe and effective treatment option for patients with a metastatic form of the disease.

The study, which was an early-phase 46-patient trial intended to provide preliminary results regarding safety and efficacy, tested a strategy involving injections of paclitaxel into the abdomen and injections of gemcitabine and nab-paclitaxel (a combination of paclitaxel and a protein called albumin) into the blood.

The treatment had acceptable toxicities, and patients had a median survival time of 14.5 months, with a 1-year survival rate of 60.9%.

"Now, a phase 3 study to compare survival outcomes between this therapy and standard chemotherapy has been launched," said senior author Sohei Satoi, MD, of Kansai Medical University, in Japan.