Can we learn health care lessons from Germany?

While Americans are unlikely to import a foreign health care financing system lock, stock and barrel, the country could learn from Germany's checks and balances that maintain fairness, economy and professional freedom, says this well-known congressional adviser.     

Can we still learn from single center experience after PARTNER?

With the publication of the Placement of Aortic Transcatheter Valves (PARTNER) trial, transcatheter aortic valve replacement (TAVR) has undoubtedly become the gold standard for severe aortic stenosis in patients that are not suitable candidate for surgical aortic valve replacement (AVR). The PARTNER trial also showed that TAVR is non-inferior to AVR in high-risk patients. A recent publication by Ben-Dor et al evaluated the outcome of high-risk patients with severe aortic stenosis who were referred to their institution for participation to the PARTNER trial. Only a minority of patients made it in the trial and the majority of patient ended being treated medically. Some patients were also treated with AVR outside the trial. The outcomes of all these patients were stratified by the treatment they received (AVR, TAVR or medical therapy with or without balloon aortic valvuloplasty). The 3 groups were different in their baseline characteristics. Ben-Dor et al found that patients treated medically had greater mortality than patients treated with TAVR or AVR. The survival of patients treated with TAVR was similar to those treated with AVR. Independent predictors of mortality were also found from their analysis. In this commentary, we discuss the finding of this study and compare it withthe current literature.     

Hypersensitivity to Vespula and Polistes: Can we tell the primary sensitization from the clinical history?

ObjectiveTo study the relationship between the primary sensitization to wasp venoms and the geographical and seasonal circumstances of the anaphylaxis-induced sting.MethodsWe performed a retrospective review of 115 patients (age 10-80) who suffered a systemic reaction to a wasp sting. Season and type of locality (urban or rural) at the moment of the sting were recorded. Serum specific IgE levels to venoms from Vespula and Polistes were measured, and a primary sensitization was determined to whichever genus of wasp for which the highest class of specific IgE was observed. The primary sensitization in relation to the type of locality and the season was assessed using the chi-square test.ResultsMost reactions occurred in urban areas (67.8 %), and in the summer season (63.4 %). Most patients were sensitized to Vespula venom (94.8 %). Primary sensitization was to Vespula in 56.5 %, to Polistes in 10.4%, and undetermined in 33 %. The distribution of geographical areas did not show significant differences in relation to primary sensitization (p > 0.05). Most patients with primary sensitization to Vespula suffered the anaphylaxis-induced sting after the spring season, with a statistically significant result (p < 0.05).ConclusionIn our population, the probability of Vespula sting is higher than Polistes sting when the reaction occurs after spring. This finding can help us to identify the responsible vespid when the diagnostic tests do not provide an accurate result.     

What can we learn from Europe?

The European Society of Cardiology has produced guidelines for the treatment of acute myocardial infarction as well as for chronic heart failure and for the use of beta blockers and angiotensin converting enzyme inhibitors. These documents provide clear evidence and strength of recommendations for the secondary prevention of complications after a myocardial infarction. The identification of heart failure and left ventricular systolic dysfunction are important risk factors in this context. The use of secondary prevention treatments in Europe has been evaluated in several surveys. The use of treatments varies across the participating countries and evidence based therapies in general are under-utilised. Various approaches have been taken to disseminate evidence based secondary prevention. Experience from the Italian BRING-UP collaboration illustrates how the use of beta blockers can be increased. Similarly, the Swedish RIKS-HIA registry of acute myocardial infarction has increased the use of secondary preventive treatments.     

Can we afford to eliminate restenosis? Can we afford not to?

Over the past decade, coronary stenting has emerged as the dominant form of percutaneous coronary revascularization. However, bare metal stents remain limited by a high incidence of restenosis, leading to frequent repeat revascularization procedures and substantial economic burden. Antiproliferative drug-eluting stents (DES) have recently demonstrated dramatic reductions in rates of restenosis, compared with conventional stenting, but important concerns about their costs have been raised. In this article, we summarize current evidence on the economic impact of restenosis and explore the potential benefits and economic outcomes of DES. In addition to examining the long-term costs of this promising technology, we consider the potential cost-effectiveness of DES from a health care system perspective and the impact of specific patient, lesion, and provider characteristics on these parameters.     

What do we need to learn to optimize the SLIT alternative?

Allergen-specific immunotherapy (IT) is the only treatment of allergy in adults and children capable of modifying the immune response at early steps. As a consequence, IT improves symptoms, prevents the onset of new sensitizations, reduces the risk of developing asthma and its clinical efficacy lasts many years. The main rationale for administering sublingually IT (SLIT) is to reduce the occurrence of side effects, still yet preserving the immunological effects. SLIT with the most common allergens have been used in many studies with significant clinical effectiveness in both asthma and rhinitis. The pharmacokinetic of allergens administered through non injection routes is complex. Peptide absorption across oral mucosa occurs mainly by passive diffusion but delivery of proteins has some limitations. Moreover, the molecular mechanisms responsible for the efficacy of SLIT are poorly defined. In this review we focus on the anatomy/histology of the oral cavity as well as on the associated immunological structures to envisage what may happen when an allergen is kept in the mouth. Moreover, the induction of immune responses in this particular immunological environment is also discussed.     

Can too much exercise be dangerous: what can we learn from the athlete’s heart?

Exercise prevents and aids treatment of coronary heart disease, hypertension, heart failure, diabetes mellitus, obesity and depression, reduces cardiac events and improves survival. However, evidence suggests that the relationship between exercise and mortality may be curvilinear, with modest additional benefit at higher levels. Intensive exercise has also been associated with increased atrial fibrillation risk, although its clinical implications are not well understood. Other proposed adverse effects of exercise on the heart, including reduced right ventricular function, elevated cardiac biomarkers, myocardial fibrosis and coronary artery calcification, are less substantiated. Current evidence cannot affirm that extreme exercise is dangerous and future studies should combine large cohorts to obtain a statistically reliable limit. Associations between features of the athlete’s heart and cardiovascular morbidity and mortality should also be explored.Key words: arrhythmias, atrial fibrillation, BJCA, exercise, heart diseases, sports, ventricular remodelling     

What can we learn from the Dutch cannabis coffeeshop system?

Aims To examine the empirical consequences of officially tolerated retail sales of cannabis in the Netherlands, and possible implications for the legalization debate. Methods Available Dutch data on the prevalence and patterns of use, treatment, sanctioning, prices and purity for cannabis dating back to the 1970s are compared to similar indicators in Europe and the United States. Results The available evidence suggests that the prevalence of cannabis use among Dutch citizens rose and fell as the number of coffeeshops increased and later declined, but only modestly. The coffeeshops do not appear to encourage escalation into heavier use or lengthier using careers, although treatment rates for cannabis are higher than elsewhere in Europe. Scatterplot analyses suggest that Dutch patterns of use are very typical for Europe, and that the ‘separation of markets’ may indeed have somewhat weakened the link between cannabis use and the use of cocaine or amphetamines. Conclusions Cannabis consumption in the Netherlands is lower than would be expected in an unrestricted market, perhaps because cannabis prices have remained high due to production‐level prohibitions. The Dutch system serves as a nuanced alternative to both full prohibition and full legalization.     

What did we learn from the Shanghai hepatitis A epidemic?

A major outbreak of hepatitis A (HAV), associated with consumption of raw clams, occurred in Shanghai, China in 1988. Over 300 000 cases were reported, of which 47 (0.015%) were fatal. An elevated mortality rate was observed in hepatitis B surface antigen (HBsAg)-positive patients (0.05%). The majority of these patients were also hepatitis B e antigen (HBeAg)-positive, indicating active liver disease and high viral replication rates. The increased mortality in hepatitis B virus (HBV)/HAV coinfected individuals is hypothesized to be the result of T-cell-mediated destruction of HBV-infected hepatocytes, enhanced by acute HAV infection. Following recovery from HAV there is an increase in HBV expression and activated cytotoxic cells and subsequent cytolysis. Patients with chronic HBV infection are clearly at considerable risk of severe disease and increased mortality in the event of HAV infection. The period of greatest risk is during the immunoeliminative phase of HBV infection, which generally occurs in early adulthood. With the prevalence of HBV approaching 10% in this group, there is a clear opportunity for benefit from vaccination.     

Glucose effects on the peritoneum: what can we learn from rodent models?

During long-term peritoneal dialysis (PD) the peritoneal membrane underlies processes of structural and functional reorganization mediated by high glucose and reactive glucose metabolites that are contained in PD solutions; this process is accompanied by increasing fibrosis. Mechanistically, the peritoneal damage is triggered by the interaction of advanced glycation end-products with their receptor; this is true for rodents as well as for humans. With this knowledge interventional strategies can be tested in rodent models, among them are the lipid soluble vitamin B1 analogue benfotiamine (BF) or detoxifying enzymes such as glyoxalase. Of additional interest is the finding that PD fluids do not only cause local but also systemic damage, in particular renal and cardiovascular. In the case of kidney damage, the intervention with BF was also successful. Taken together, PD can be regarded as a local model for long-term diabetes together with systemic aspects of damage.     

Women and hypertension: what did we learn from the Women's Health Initiative?

The Women's Health Initiative (WHI) provides valuable data on blood pressure (BP) and on the prevalence, treatment, and control of hypertension in the largest multiethnic, best characterized cohort of postmenopausal women ever studied, including 98,705 women aged 50 to 79 years. Hypertension prevalence was high (38% overall) and directly related to age. Major determinants of hypertension prevalence included black race, history of cardiovascular disease (CVD), and concomitant CVD risk factors of physical inactivity, overweight/obesity, and excess alcohol consumption. Menopausal hormone treatment had little effect on BP. BP control rates declined dramatically with age. Interestingly, participants who were insured by Medicaid had significantly higher treatment rates and tended to have better BP control than those with Medicare only, perhaps reflecting differences in drug coverage and/or age. Inadequate intensity of antihypertensive treatment contributed to poor BP control: approximately 60% of participants were treated with a single drug; 30% with 2 drugs; <10% with 3 or more drugs, and the number of medications used was similar across age groups despite the age-related increase in the severity of hypertension. This treatment pattern is inconsistent with current treatment guidelines, which stress the need for 2 or more antihypertensive medications to control BP in most older hypertensive patients. The take-home message from WHI is that more effective strategies, including more efficient and cost-effective systems of healthcare delivery, are needed to control BP and prevent CVD morbidity and mortality in older women, a group characterized by severe, treatment-resistant hypertension and high risk for CVD events.     

Defining the future of primary care: what can we learn from patients?

From the earliest definitions of the term primary care to the most recent, all have stressed that primary care is predicated on a sustained relationship between patients and the clinicians who care for them. Primary care differentiates itself from other areas of medicine by attending to the whole person, in the context of the patient's personal and medical history and life circumstances, rather than focusing on a particular disease, organ, or system. Finally, the primary care physician plays a distinctive role in integrating the care that patients receive from within and outside of the primary care setting. Data obtained from patients over the past 15 years demonstrate that most Americans have a physician whom they consider to be their primary physician. This was the case well before the rules of managed care plans required patients to align themselves with a particular primary care physician and to allow that physician to coordinate all of their medical care. However, information from patients indicates that despite primary care relationships that endure over several years, the ideals of whole-person, integrated care are largely unmet in patients' primary care experiences. Moreover, considerable evidence indicates that the quality of primary care relationships has eroded over the past several years. This article highlights the relative strengths and weaknesses of primary care, as experienced and reported by patients, and posits three areas that must be addressed for primary care to live up to the ideals of sustained partnerships providing whole-person, integrated care. These three areas involve the use of teams in medicine, the establishment of meaningful primary care partnerships, and integration of care in a delivery system that patients experience as increasingly fragmented.     

Caloric restriction and human longevity: what can we learn from the Okinawans?

Caloric (or dietary) restriction (CR) extends lifespan and lowers risk for age associated diseases in a phylogenetically diverse group of species. Whether prolonged CR increases average or maximum lifespan or promotes a more youthful physiology in humans at advanced ages is not yet known. However, available epidemiological evidence indicates that CR may already have contributed to an extension of average and maximum life span in one human population and appears to have lowered risk for age associated chronic diseases in other human populations. We review the human studies in the context of a special human population, older Okinawans, who appear to have undergone a mild form of prolonged CR for about half their adult lives.     

What might we learn from climate forecasts?

Most climate models are large dynamical systems involving a million (or more) variables on big computers. Given that they are nonlinear and not perfect, what can we expect to learn from them about the earth's climate? How can we determine which aspects of their output might be useful and which are noise? And how should we distribute resources between making them "better," estimating variables of true social and economic interest, and quantifying how good they are at the moment? Just as "chaos" prevents accurate weather forecasts, so model error precludes accurate forecasts of the distributions that define climate, yielding uncertainty of the second kind. Can we estimate the uncertainty in our uncertainty estimates? These questions are discussed. Ultimately, all uncertainty is quantified within a given modeling paradigm; our forecasts need never reflect the uncertainty in a physical system.