Is an Ounce of Prevention Worth an Ounce of Cure? Explaining the Decline in Cardiovascular Mortality, 1964-2010

Mortality from coronary heart disease in the United States has fallen 60% from its peak. Cardiologists and epidemiologists have debated whether this decline reflects risk factor control or the power of medical therapeutics. Attempts to resolve this debate and guide health policy have generated sophisticated datasets and techniques for modeling cardiovascular mortality. Neither effort, however, has provided specific guidance for health policy. Historical analysis of the decline debate and the development of cardiovascular modeling offers valuable lessons for policymakers about tensions between medical and public health strategies, the changing meanings of disease prevention, and ability of evidence-based research and models to guide health policy. Policymakers must learn to open up the black box of epidemiological models -- and of their own decision making processes -- to produce the best evidence-informed policy.History of Scienc

The Decline and Rise of Coronary Heart Disease: Understanding Public Health Catastrophism

The decline of coronary heart disease mortality in the United States and Western Europe is one of the great accomplishments of modern public health and medicine. Cardiologists and cardiovascular epidemiologists have devoted significant effort to disease surveillance and epidemiological modeling to understand its causes. One unanticipated outcome of these efforts has been the detection of early warnings that the decline had slowed, plateaued, or even reversed. These subtle signs have been interpreted as evidence of an impending public health catastrophe. This article traces the history of research on coronary heart disease decline and resurgence and situates it in broader narratives of public health catastrophism. Juxtaposing the coronary heart disease literature alongside the narratives of emerging and reemerging infectious disease helps to identify patterns in how public health researchers create data and craft them into powerful narratives of progress or pessimism. These narratives, in turn, shape public health policy.History of ScienceOther Research Uni

The Burden of Disease and the Changing Task of Medicine

History of Scienc

Making the Case for History in Medical Education

Historians of medicine have struggled for centuries to make the case for history in medical education. They have developed many arguments about the value of historical perspective, but their efforts have faced persistent obstacles, from limited resources to curricular time constraints and skepticism about whether history actually is essential for physicians. Recent proposals have suggested that history should ally itself with the other medical humanities and make the case that together they can foster medical professionalism. We articulate a different approach and make the case for history as an essential component of medical knowledge, reasoning, and practice. History offers essential insights about the causes of disease (e.g., the non-reductionistic mechanisms needed to account for changes in the burden of disease over time), the nature of efficacy (e.g., why doctors think that their treatments work, and how have their assessments changed over time), and the contingency of medical knowledge and practice amid the social, economic, and political contexts of medicine. These are all things that physicians must know in order to be effective diagnosticians and caregivers, just as they must learn anatomy or pathophysiology. The specific arguments we make can be fit, as needed, into the prevailing language of competencies in medical education.History of Scienc

Prevalence and architecture of de novo mutations in developmental disorders.

The genomes of individuals with severe, undiagnosed developmental disorders are enriched in damaging de novo mutations (DNMs) in developmentally important genes. Here we have sequenced the exomes of 4,293 families containing individuals with developmental disorders, and meta-analysed these data with data from another 3,287 individuals with similar disorders. We show that the most important factors influencing the diagnostic yield of DNMs are the sex of the affected individual, the relatedness of their parents, whether close relatives are affected and the parental ages. We identified 94 genes enriched in damaging DNMs, including 14 that previously lacked compelling evidence of involvement in developmental disorders. We have also characterized the phenotypic diversity among these disorders. We estimate that 42% of our cohort carry pathogenic DNMs in coding sequences; approximately half of these DNMs disrupt gene function and the remainder result in altered protein function. We estimate that developmental disorders caused by DNMs have an average prevalence of 1 in 213 to 1 in 448 births, depending on parental age. Given current global demographics, this equates to almost 400,000 children born per year

International genome-wide meta-analysis identifies new primary biliary cirrhosis risk loci and targetable pathogenic pathways.

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist

Penilaian Kinerja Keuangan Koperasi di Kabupaten Pelalawan

This paper describe development and financial performance of cooperative in District Pelalawan among 2007 - 2008. Studies on primary and secondary cooperative in 12 sub-districts. Method in this stady use performance measuring of productivity, efficiency, growth, liquidity, and solvability of cooperative. Productivity of cooperative in Pelalawan was highly but efficiency still low. Profit and income were highly, even liquidity of cooperative very high, and solvability was good

Juxtaposing BTE and ATE – on the role of the European insurance industry in funding civil litigation

One of the ways in which legal services are financed, and indeed shaped, is through private insurance arrangement. Two contrasting types of legal expenses insurance contracts (LEI) seem to dominate in Europe: before the event (BTE) and after the event (ATE) legal expenses insurance. Notwithstanding institutional differences between different legal systems, BTE and ATE insurance arrangements may be instrumental if government policy is geared towards strengthening a market-oriented system of financing access to justice for individuals and business. At the same time, emphasizing the role of a private industry as a keeper of the gates to justice raises issues of accountability and transparency, not readily reconcilable with demands of competition. Moreover, multiple actors (clients, lawyers, courts, insurers) are involved, causing behavioural dynamics which are not easily predicted or influenced. Against this background, this paper looks into BTE and ATE arrangements by analysing the particularities of BTE and ATE arrangements currently available in some European jurisdictions and by painting a picture of their respective markets and legal contexts. This allows for some reflection on the performance of BTE and ATE providers as both financiers and keepers. Two issues emerge from the analysis that are worthy of some further reflection. Firstly, there is the problematic long-term sustainability of some ATE products. Secondly, the challenges faced by policymakers that would like to nudge consumers into voluntarily taking out BTE LEI