Aspirin for CV prevention -- for which patients?

Put your patient on aspirin? Take him off? Here's what you need to know to get it right.     

The search for new risk factors for coronary heart disease: occupational therapy for epidemiologists?

The identification of the proximal causes of coronary heart disease (CHD) during the second half of the 20th century contributed to the prevention of premature CHD and the extension of life expectancy in middle-aged and older people in many wealthy countries. These major CHD risk factors-high blood cholesterol, high blood pressure, cigarette smoking and physical inactivity-satisfy public health criteria of causality. Strong epidemiological evidence suggests that they explain at least 75% of new cases of CHD. However, the search for 'new' or 'emerging' CHD risk factors continues, partly justified by a myth that minimizes the contribution of the major risk factors. The public health criteria of causality were applied to the following proposed new risk factors: thrombotic factors and serum homocysteine levels; infectious agents; early life exposures including prenatal factors; genetic influences; oestrogen deficiency; and the role of the psychosocial environment. None of these factors are as important as the established risk factors for epidemic CHD and their potential contribution for improving population health is limited or unclear. Research into unexplained variations in the occurrence of CHD and into life course influences and socioeconomic inequalities may provide extra leads to effective public health action. Especially important is research on the upstream social and economic determinants of CHD and its major risk factors, on the spread of the CHD epidemic to poorer populations, and into prevention policy and programme effectiveness. Available evidence supports the feasibility and effectiveness of population-wide prevention directed towards increasing the proportion of people at low risk of CHD. The vast majority of the public health effort should be directed to this approach rather than to the high risk individual approach. There is still a major gap between knowledge and action in preventing the CHD epidemics.     

Medline for Medical Students? Searching for the Right Answer

Objective: Does MEDLINE use, when added to more traditional sources of information, improve the accuracy of medical students' clinical decisions when compared to those obtained using traditional sources only? Design: Randomized control trial. Setting: McMaster University Faculty of Medicine, Undergraduate Program. Participants: The entire class of 101 medical students, class of 1998. Overall response rate on 9 items was 56% (510/909), with 35% (35/101) completing all 9 items. Intervention: All participants were randomized on each of the nine clincal scenarios for which the student could choose to apply, or refrain from applying, a proferred intervention. When randomized to the control arm, the student used traditional sources of information for decision-making. When randomized to the experimental arm, the student used MEDLINE searching in addition to more traditional sources of information, for decision-making. Main Outcome Measures: Prior to, and subsequent to the information search, the students indicated their comfort in using the proffered intervention on a seven point Likert scale. Results: Analyzed with one-way ANOVA, the mean rating post-search of the control non- MEDLINE arm was 2.94 (SD = 1.80) (where 1 = correct, 7 = incorrect) and of the experimental MEDLINE arm was 2.71 (SD = 1.81), (F(1,522) = 2.03, p = 0.15 n.s). The mean change of the control arm was 0.97 (SD = 2.04) and of the experimental arm was 1.008 (SD = 1.92), (F(1,511) = 0.04, p = 0.84n.s.). Conclusions: The addition of MEDLINE to more traditional answer-seeking behaviors by medical students does not translate into a beneficial impact on clinical decision-making.     

IT standards for PHRs. Are PHRs ready for standards? Are standards ready for PHRs?

The personal health record market looks like a blur, but organizing around common technical standards will help PHRs gain traction with providers, payers, and consumers.     

Does Universal Testing for COVID-19 Work for Everyone?

The Coronavirus disease 2019 (COVID-19) pandemic has been especially devastating among nursing home residents, with both the health circumstances of individual residents as well as communal living settings contributing to increased morbidity and mortality. Preventing the spread of COVID-19 infection requires a multipronged approach that includes early identification of infected residents and health care personnel, compliance with infection prevention and control measures, cohorting infected residents, and furlough of infected staff. Strategies to address COVID-19 infections among nursing home residents vary based on the availability for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests, the incorporation of tests into broader surveillance efforts, and using results to help mitigate the spread of COVID-19 by identifying asymptomatic and presymptomatic infections. We review the tests available to diagnose COVID-19 infections, the implications of universal testing for nursing home staff and residents, interpretation of test results, issues around repeat testing, and incorporation of test results as part of a long-term response to the COVID-19 pandemic. We propose a structured approach for facility-wide testing of residents and staff and provide alternatives if testing capacity is limited, emphasizing contact tracing. Nursing homes with strong screening protocols for residents and staff, that engage in contact tracing for new cases, and that continue to remain vigilant about infection prevent and control practices, may better serve their residents and staff by thoughtful use of symptom- and risk-based testing strategies.     

Caring for the infirm: a task for the individual or for a social insurance programme?

In West Germany, seventy per cent of all nursing home patients receive only a pocket-money, for social health insurances are responsible only for the care of "sick" people, but not of those needing only "care". The infirm individual, however, rarely can pay for the costs of nursing homes out of his own revenue. Despite general agreement that guarding against the financial risks of becoming dependent on nursing is insufficient there is little consensus on what a new concept should look like. Some proposals are more concerned with avoiding cost-expansion than with effective health care. On the one hand, the implementation of a new branch in the social insurance system, called "nursing insurance", is demanded, which would pay for the stay in nursing homes. On the other hand, it is emphasized that the capacity for voluntary individual provision should be strengthened as well as the families' means to care for their bedridden members. This paper presents the discussion and outlines implications for health care of the various proposals.     

Best for Britain?

Work in Oregon to develop a system for explicit rationing of healthcare has attracted worldwide attention. But, say Morton Warner and colleagues, it isn't a model the UK should follow.