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[Editorial] A good first step

Ve, 19/10/2018 - 23:00
The UK Government's appointment of Jackie Doyle-Price to the newly created role of Minister for Suicide Prevention marks a welcome development in the approach to an area of some concern. While suicide rates have fallen heavily in the UK since the Office for National Statistics began keeping records in 1981, almost no progress has been made in suicide rate reduction during 2007–17, with the overall suicide rate rising from 10·0 deaths per 100 000 to 10·1 deaths per 100 000.

[Editorial] Patient safety in vaginal mesh surgery

Ve, 19/10/2018 - 23:00
The National Institute for Health and Care Excellence (NICE) has published draft guidelines for the clinical management of pelvic organ prolapse and stress urinary incontinence. The guidelines, which are open for public consultation until Nov 19, recommend that women, first and foremost, be offered lifestyle interventions, physical and behavioural therapies, and medication before surgical options are considered. Women who do choose to have surgery must be fully informed of the risks and referred to a specialist.

[Comment] Primary health care for the 21st century, universal health coverage, and the Sustainable Development Goals

Ve, 19/10/2018 - 23:00
Good health and wellbeing are fundamental to the prosperity of societies. By many measures, modern humanity enjoys better health than earlier generations.1 But the benefits of modern health care are not accessible to all. Even as the incidence of infectious diseases such as HIV, tuberculosis, and malaria are reduced, many countries struggle to cope with the growing burden of non-communicable diseases, and the complex and growing health needs of ageing populations.2,3

[Comment] How primary health care can make universal health coverage a reality, ensure healthy lives, and promote wellbeing for all

Ve, 19/10/2018 - 23:00
40 years on from the Declaration of Alma-Ata in 1978,1 primary health care (PHC) is at a defining moment. Progress in the uptake of PHC across the world has contributed to raising global standards of health care and improving health, including a revolution in child survival and dramatic improvements in life expectancy. However, we are still far from addressing the determinants of health and the growing health needs of the 21st century and from realising a vision for health supported by health systems oriented around PHC.

[Comment] Primary health care and universal health coverage: competing discourses?

Ve, 19/10/2018 - 23:00
In October, 2018, WHO celebrates 40 years since the International Conference on Primary Health Care (PHC) and offers a renewed vision of PHC—building on, but not replacing, the Declaration of Alma-Ata.1 In those four decades, PHC has faced challenges. Undermined early by the divisive selective-comprehensive debate, PHC was marginalised by structural adjustment and sectoral reforms in the 1990s.2 PHC was, however, acknowledged in the World Health Report 2000 Health Systems: Improving Performance as a precursor of the new universalism: “high quality delivery of essential health care, defined mostly by the criterion of cost-effectiveness, for everyone, rather than all possible care for the whole population or only the simplest and most basic care for the poor”.

[Comment] Reform of primary health care in Pakistan

Ve, 19/10/2018 - 23:00
With a neonatal mortality rate exceeding 45 per 1000 livebirths, a UNICEF report ranked Pakistan as the riskiest place to be born on earth.1 Although the recent Demographic and Health Survey indicates that the situation has improved, the neonatal mortality rate in Pakistan is among the highest in the world.2 Other health indicators, particularly those pertaining to maternal and child health and nutrition, are worse than other countries in the region with comparable or lower socioeconomic indicators.

[Comment] Putting nursing and midwifery at the heart of the Alma-Ata vision

Ve, 19/10/2018 - 23:00
The Alma-Ata vision of a health system rooted in primary health care, which is person-centred and multisectoral, is as relevant now as it ever was. Nursing and midwifery can play a more central part in making this vision a reality. The health workforce has always been central to the 1978 Declaration of Alma-Ata that recognised the important role of health workers in achieving this vision.1 More recently, the World Health Assembly adopted resolutions on the Global Strategy on Human Resources for Health in 20162 and the Working for Health 5-year action plan in 20173 that committed countries to develop a primary health care workforce responsive to population needs as part of universal health coverage.

[Comment] Patient education and engagement in treat-to-target gout care

Ve, 19/10/2018 - 23:00
Gout is the most common inflammatory arthritis worldwide, affecting 4·0% of adults in the USA and 2·5% of adults in the UK.1 The pathophysiology of this crystal arthritis is well understood, and inexpensive urate-lowering drugs that address the underlying cause of the disease are widely available. Yet gout remains poorly managed, with 70% of patients experiencing recurrent gout flares2 and substantial burden from tophi and joint damage, which lead to functional limitations and diminished quality of life.

[Comment] No benefit of chlamydia screening in primary care?

Ve, 19/10/2018 - 23:00
Chlamydia trachomatis is the most common sexually transmitted bacterial infection worldwide. Persistent, untreated infection with C trachomatis leads to pelvic inflammatory disease (PID) and other complications, including ectopic pregnancy and tubal factor infertility. Researchers have shown that interventions that shorten the duration of infection through timely detection and treatment decrease PID incidence by 32%.1 On the basis of that and other evidence, many high-income countries support annual screening and treatment programmes for chlamydia in young women, repeated screening of those who are infected, and expedited partner treatment.

[Comment] Steroid injection or wrist splint for first-time carpal tunnel syndrome?

Ve, 19/10/2018 - 23:00
Carpal tunnel syndrome is a common cause of hand pain, sensory disturbance, and weakness affecting daily activities and quality of life.1 It is a frequent reason for medical consultation and up to 40% of patients are managed exclusively in primary care.2 Treatment goals are to relieve symptoms, improve function, and prevent disease progression to nerve damage. The two treatments that constitute standard care for most patients with first-time carpal tunnel syndrome are night splinting and local steroid injections.

[Comment] Offline: The fetishisation of “global”

Ve, 19/10/2018 - 23:00
Last week, the UK Government, WHO, and OECD came together to host the first Global Ministerial Mental Health Summit. The gathering, under the banner of “Equality for mental health in the 21st century”, felt a genuinely momentous event. Matt Hancock, Britain's Conservative Secretary of State for Health and Social Care, spoke about “a bold and ambitious statement of intent”. Mental health was “a defining challenge of our age”. As machines take over what, in the past, have been considered cognitive tasks, human beings will be left to rely ever more on their emotional skills and abilities.

[Perspectives] Yelzhan Birtanov: leading Kazakhstan to universal health coverage

Ve, 19/10/2018 - 23:00
Although only a child at the time, Yelzhan Birtanov, Minister of Healthcare of Kazakhstan, remembers the landmark 1978 Alma-Ata conference. His physician parents were attendees. “I recall doing drawings with the pens that they brought back from the meeting, and looking at a lot of photos of the conference; even as a young child, it was clear that something major was taking place in my country”, he says.

[Perspectives] Picturing health: global primary health care

Ve, 19/10/2018 - 23:00
I started my application to medical school by writing my belief that “every human being should have equal and fair access to adequate health care”. 18 years later and now a primary care academic clinical fellow, I stand by this belief. It was by no coincidence that the 1978 Declaration of Alma-Ata was signed at the International Conference on Primary Health Care. Global primary health care is key to unlocking inequality and inequity—it works not only to achieve the definition of health as physical, mental, and social wellbeing but also works to achieve family, community, and spiritual wellbeing.

[Correspondence] SHERPA: a new model for clinical decision making in patients with multimorbidity

Ve, 19/10/2018 - 23:00
Data on how to improve the care of patients with multimorbidity are lacking.1 Evidence-based medicine and the teaching of consultation skills—two of the cornerstones of modern clinical practice—are not sufficient for making decisions with and for patients with multimorbidity. Therefore, we have developed a new model that supports the translation of population-based, evidence-based medicine and complex consultation models into simpler, natural conversations about care appropriate for and agreed with individual patients.

[Department of Error] Department of Error

Ve, 19/10/2018 - 23:00
Powles T, Durán I, van der Heijden M, et al. Atezolizumab versus chemotherapy in patients with platinum-treated locally advanced or metastatic urothelial carcinoma (IMvigor211): a multicentre, open-label, phase 3 randomised controlled trial. Lancet 2018; 391: 748–57—In the Results section of this Article, in the sentence that reads “For patients receiving chemotherapy, vinflunine outperformed study expectations; unstratified HRs were 0·95 (95% CI 0·62–1·45) and 0·69 (0·44–1·10) in subgroups based on chemotherapy stratification with vinflunine (n=106) and taxanes (n=128), respectively”, the totals for vinflunine and taxanes are the wrong way around.

[Department of Error] Department of Error

Ve, 19/10/2018 - 23:00
Gupta A, Mackay J, Whitehouse A, et al. Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial. Lancet 2018; 392: 1127–37—In this Article, the fourth sentence of the findings section of the summary has been corrected to read “there was no overall difference in cardiovascular mortality between treatments”. This correction has been made to the online version as of Oct 18, 2018.

[Articles] Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial

Ve, 19/10/2018 - 23:00
Nurse-led gout care is efficacious and cost-effective compared with usual care. Our findings illustrate the benefits of educating and engaging patients in gout management and reaffirm the importance of a treat-to-target urate-lowering treatment strategy to improve patient-centred outcomes.

[Articles] Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial

Ve, 19/10/2018 - 23:00
These findings, in conjunction with evidence about the feasibility of sustained uptake of opportunistic testing in primary care, indicate that sizeable reductions in chlamydia prevalence might not be achievable.

[Articles] The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial

Ve, 19/10/2018 - 23:00
A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care.

[Clinical Picture] External left atrium compression by spinal osteophytes

Ve, 19/10/2018 - 23:00
A previously healthy 76-year-old woman was assessed preoperatively prior to hip arthroplasty. Cardiac examination was notable for a mid-diastolic murmur at the apex—appreciable only in the supine position. She had no signs or symptoms of heart failure. The patient's N-terminal-pro-B-type natriuretic peptide blood concentration was normal (71 pg/mL). A transthoracic echocardiogram showed preserved biventricular systolic function, unimpaired diastolic relaxation, normal left atrial dimensions free of any intra-atrial septation, and no valvular abnormalities.