[MUSIC] Dear students, I will now present the third case study of this module about the screening of cardiovascular conditions. And for this case study, we will speak about the screening of cardiovascular disease risk factor in children. As you will see, this is a very complex issue, compared to screening of hypertension and diabetes in adults. For these presentations, I will use the same structure that you know quite well now. Which is about, I would begin to speak about the burden of disease, the benefits and harms of treatments of cardiovascular disease factor in children. Evidence and issue, and you will see there is very few evidence and many issues about the screening of those risk factors in children. And finally, should we screen, or should we not screen? I will finish with some recommendations about the screening of cardiovascular disease risk factor in children. We have seen previously that cardiovascular disease is the leading cause of deaths worldwide. The rate is frequent in elderly, typically, cardiovascular disease risk factors, and these disease are occurs in adults. You don't thinks about children when we speaks about cardiovascular disease. Nevertheless, there is ample evidence now that the process causing cardiovascular disease begins in childhood, very early in life. And this is evidenced from the last 30 years, which have shown that this process begins very early in life. Therefore, if the process begins early in life, well you could imagine it's interesting to trying to screen for these conditions. For the risk factor for these conditions, early in life, during childhood and adolescence, and this is what I will speak about. That today about the issue about this kinds of way of dealings with the early pathogenesis of cardiovascular diseases early in lives. There is four main cardiovascular diseases risk factors I would like to consider for the presentations, which is elevated blood pressure. The second ones will be abnormal blood lipids, or what we call hypercholesterolemia, this is also elevated blood glucose, or diabetes. And finally, I will mentions about the screenings for smoking at that age, is that useful or is that not useful. All these conditions, there is now evidence can be detected in children and adolescents. So it's possible to screen for these conditions at that age, but is that justified? Let's speaks about the impact of benefits of harms and treatments of these conditions when we begin during childhood. For instance, for elevated blood pressure, or hypertensions, there is evidence that if the level of blood pressure is very high in children, there is benefits to treat. Children will benefit having those kind of treatments. What is not known is that if the level of blood pressure is relatively elevated, not so high, there is no evidence that you have any benefits to make any treatments, so this is one issue. About abnormal blood lipids, this is the same issue. There is evidence that if you screen and you treat people with what we call, familial hypercholesterolemia, you could have some benefits to treat those persons which are at very high risk of having a disease due to these conditions. But this is a very special case, for instance, children with familial hypercholesterolemia, they have a risk of getting a heart disease at the age of 30 or 40 if we do nothing. So it's the very special cases, it doesn't mean that we have a benefit to screens for any type of hypercholesterolemia, but it's very specific about that. About type 2 diabetes, there is also the possibility that if you screen for those conditions too, very early in life to implement lifestyle modifications. But as you will see, evidence of benefits are very low. Finally, about the smokings, for sure it seems evident that preventing children from smoking is useful. For sure it's useful, but should we screen for smokings? And there is little evidence that screening To try to identify if the child smokes and make some interventions, are very useful to prevent them from smoking. Much more useful, are what we call structural preventions, choose low, avoiding the children to have access to smokings. But screening is probably a not so efficient a strategy for the preventions of smoking in children and adolescents. Evidence and issue are also related to the discriminative power of the risk factors. And I will mention that this is also true in children's, but I think it's more in adults. But I think it's also very important to understand that quite well in children. On the slide, this is what I want to show here. On the upper part of the slides, you see that you have here on the left the distributions of blood pressure among the individuals, we didn't do cardiovascular disease. And here, you've got on the right of the figures, the people who get the cardiovascular disease. And ideally, we would like to have a situation like that, in the sense of those who get the disease have on average, a much higher blood pressure. So you can discriminate on the right, the people who have high blood pressure, and indeed the disease. And the one on the left who doesn't have a high blood pressure, right, they didn't get cardiovascular disease. This would be ideal, but the reality is more like the B situations. In the sense that you have a slight difference in the distributions among those who get the disease, and those who didn't get the disease. So, as you can see, those who didn't get the disease have a blood pressure like that, and those who get it have a blood pressure like that. So you have a small difference, but there is no big difference. So blood pressure is not a really powerful discriminative risk factors among those who will get the disease and those who get the disease. This is true in adults, but it becomes much more important also in children. Because in children, you have also to expect that you will not get the disease before 40 or 50 years from this age. So it's become much more important to have a good discriminative power, and in general, cardiovascular risk factor have a low discriminative power. It's rather technical, but I think it's important to get that in mind. Further issue, and I come also to these slides, which is very important to understand. Here on the upper part of the slides, you see that if you look at the childhood times in gray, and in white the adult times. And here you get individuals who in adulthood gets the disease. If you do nothing, you will have the disease at a given age during adulthood. If you screen during adulthood, you will tend to delay or to prevent the event, you will get the event later in life. So you are successful, so you are happy with your screening and treatments for disease if you screen during childhood and you treat during childhood. If you delay from the same amount of time, they are the same, if you can see. There is no benefit to screening here at that age, because you can wait during adulthood, and you will get the disease later on, so it's good, but you don't have any gains. What you have to be sure, that if you screen at that age, because you will begin treatment earlier, and so on. You have to be sure, do we delay much at a later age, the evidence compared to a screen and treatment during adulthood. And this is a general truth about the screening for cardiovascular risk factor in childhood. If you want to recommend that, you have to be sure that it's more powerful than making the screening and treatments during adulthood, otherwise it's useless. It just costs money and you have no real benefits about that. So, and to finish this presentation, should we screen, or should we not screens? And here are recommendations quite complex, and I think it's important to take some time to look at these tables. On the left you have the conditions I've mentioned, blood pressure The dyslipidemia, diabetes, smoking. You have US recommendations from the National Heart, Lung, and Blood Institute Wish is a famous institute with very wise people making good recommendations, and what they say in the recommendations in 2011, they say we should screens in children for every of this conditions. Blood pressure, annual blood pressure measurements in kids, universal lipid screening at the age of nine, and later on also, at the age of 17. Targeted screenings for diabetes and smoking, we should assess smoking regularly from the age 9 to 11 years old. What is interesting is, if you look at other bodies which are more scientific, more evidence based recommendations, they say we should not do that. And you see here, for example, the US Preventive Services Task Force recommendations, they say evidence are insufficient to recommend screening for hypertension. Evidence is insufficient to recommend screening for dyslipidemia, there is no specific recommendations for diabetes. And recommendations for screening for smoking is a little bit complex. Maybe for primary care conditions should do that, but the evidence is relatively weak about that. And there is no strong recommendations to screen for tobacco use. And here also, on the tables you see the recommendations from UK, from the UK National Screening Committee, which is also saying there is no systematic population screening to be recommend. The screenings for dyslipidemia is not recommended, no recommendations for diabetes. And no specific recommendations for smoking during childhood and adolescence. With these tables, this finish this presentations about the screenings for cardiovascular risk factors in children, thank you for your interests. [MUSIC]
