Are the economically active more deserving?

OBJECTIVE--To investigate the possibility of an association between the duration of medical treatment before coronary angiography and demographic and non-clinical factors. DESIGN--A systematic review of a random sample of 500 patients undergoing their first angiographic assessment. SUBJECTS--500 cases were selected randomly from patients investigated in 1991 at the two catheterisation centres in Northern Ireland. MAIN OUTCOME MEASURES--The duration of medical management before angiography. RESULTS--346 had elective and 154 urgent catheterisation. The duration of medical management was adjusted for both case mix (age at onset, body mass index, angina grade, history of myocardial infarction, history of hypertension, diabetes or hyperlipidaemia, treatment intensity) and other demographic variables (sex, smoking status, an indicator of "deprivation", and distance of the patient's area of residence from the hospital). After this adjustment the mean duration of medical management before angiography was twice as long for economically inactive patients as for those who were economically active. In a multiple regression, the relevant beta coefficient was 0.44 (95% confidence interval 0.33 to 0.58, P < 0.0001). CONCLUSIONS--These results suggest that, in making discretionary decisions about when to refer patients with angina for revascularisation assessment, doctors may be influenced by non-clinical factors unrelated to disease severity

Optimal designs for active controlled dose finding trials with efficacy-toxicity outcomes

Nonlinear regression models addressing both efficacy and toxicity outcomes are increasingly used in dose-finding trials, such as in pharmaceutical drug development. However, research on related experimental design problems for corresponding active controlled trials is still scarce. In this paper we derive optimal designs to estimate efficacy and toxicity in an active controlled clinical dose finding trial when the bivariate continuous outcomes are modeled either by polynomials up to degree 2, the Michaelis- Menten model, the Emax model, or a combination thereof. We determine upper bounds on the number of different doses levels required for the optimal design and provide conditions under which the boundary points of the design space are included in the optimal design. We also provide an analytical description of the minimally supported $D$-optimal designs and show that they do not depend on the correlation between the bivariate outcomes. We illustrate the proposed methods with numerical examples and demonstrate the advantages of the $D$-optimal design for a trial, which has recently been considered in the literature.Comment: Keywords and Phrases: Active controlled trials, dose finding, optimal design, admissible design, Emax model, Equivalence theorem, Particle swarm optimization, Tchebycheff syste

Precision public health-the Emperor's new clothes

Recently the Centre for Disease Control suggested that ‘precision public health’ presents significant opportunities to improve the health of the population,1 but what does this concept add and does it live up to the hype? The promise is that by harnessing the power of Big Data, particularly genomic data, we may indeed see early gains in public health as a result of ‘more-accurate methods for measuring disease, pathogens, exposures, behaviors, and susceptibility’ to guide targeted prevention strategies.2 However, the term ‘precision public health’ is susceptible to misinterpretation. Long before Big Data in the form of personalized genetic and epigenetic profiling arrived, much public health screening and prevention strategy was premised on varying degrees of targeting and stratification, so this is nothing new. Nevertheless, others in the UK have used analogous terms such as ‘personalized prevention’ or ‘personalized public health’, representing them as part of an urgent agenda in which we must ‘reap the benefits of the genomic revolution’.3 The purpose of this article is therefore to highlight some of the evidentiary and philosophical challenges for the concept of ‘precision public health’ which have not been exposed to sufficient scrutiny. It is also to argue for a more considered focus beyond the genome, lest we career headlong towards a diversion of resources, away from what really matters, to the detriment of population health. To do this, we structure our critique by aligning it with the so-called population perspective on precision medicine (i.e. the ‘P4 approach’), namely that precision public health should aim to be Predictive, Preventive, Personalized and Participatory.4 The advantage of taking this approach is that whereas it focuses on the key dimensions and parameters of the decisions that could help improve care both for individuals and populations, it has gained traction among precision medicine proponents themselves. Thereafter we return to the more philosophical and ethical arguments that should remind us of a bigger picture and the trade-offs that we might be making by investing in ‘precision public health’

Cardiovascular risk factors-using repeated cross-sectional surveys to assess time trends in socioeconomic inequalities in neighbouring countries

OBJECTIVES: This study compares trends in socioeconomic inequalities related to key cardiovascular risk factors in neighbouring countries Northern Ireland (NI) and the Republic of Ireland (RoI).DESIGN: Repeated cross-sectional studies.SETTING: Population based.PARTICIPANTS: 3500-4000 in national surveys in NI and 5000-9000 in RoI, aged 20-69 years.MEASURES: Educational attainment was used as a socioeconomic indicator by which the magnitude and direction of trends in inequalities for smoking, diabetes, obesity and physical inactivity in NI and RoI were examined between 1997/1998 and 2007/2011. Gender-specific relative and absolute inequalities were calculated using the Relative Index of Inequality (RII) and Slope Index of Inequality (SII) for both countries.RESULTS: In both countries, the prevalence of diabetes and obesity increased whereas levels of smoking and physical inactivity decreased over time. In NI relative inequalities increased for obesity (RII 1.1 in males and 2.1 in females in 2010/2011) and smoking (RII 4.5 in males and 4.2 in females in 2010/2011) for both genders and absolute inequalities increased for all risk factors in men and increased for diabetes and obesity in women. In RoI greater inequality was observed in women, particularly for smoking (RII 2.8 in 2007) and obesity (RII 8.2 in 2002) and in men for diabetes (RII 3.2 in 2002).CONCLUSIONS: Interventions to reduce inequalities in risk factors, particularly smoking, obesity and diabetes are encouraged across both countries.</p

Turning to art as a positive way of living with cancer: A qualitative study of personal motives and contextual influences

Why do some women turn to creative art-making after a diagnosis of cancer? Eleven women provided qualitative accounts that were analyzed following guidelines for interpretative phenomenological analysis (IPA). Some described taking up artistic leisure activities initially in order to manage emotional distress. Others emphasized their need for positive well-being, taking up art to experience achievement and satisfaction, to regain a positive identity, and to normalize family dynamics in the context of living with cancer. Participants’ turn to art-making was facilitated by biographical and contextual factors, including pre-existing craft skills, long-standing personal values and coping philosophies, family role models for managing adversity, and the supportive encouragement of family and friends. Other research has acknowledged that positive lifestyle change and post-traumatic growth can occur after a cancer diagnosis, and this study reveals a multi-faceted process. The findings suggest a need for further research into the experiences that facilitate positive lifestyle change and subjective well-being among people who are living with cancer

Systematic review of rehabilitation programmes initiated within 90 days of a transient ischaemic attack or 'minor' stroke: a protocol.

Introduction Transient ischaemic attacks (TIAs) and strokes are highly prevalent conditions. Stroke killed 5.7 million people worldwide in 2005 and is estimated to cause 6.5 million deaths globally in 2015. Stroke survivors are often left with considerable disability. Many strokes are preceded by a TIA/‘minor’ stroke in the previous 90 days and therefore the immediate period after a TIA/minor’ stroke is a crucial time to intervene to tackle known vascular risk factors. Although rehabilitation following a TIA/minor stroke is widely recommended, there is a paucity of research that offers an evidence base on which the development or optimisation of interventions can be based, particularly for home-based approaches and non-pharmacological interventions in the acute period following the initial TIA/‘minor’ stroke. This systematic review will investigate the effect of rehabilitation programmes initiated within 90 days of the diagnosis of a TIA or ‘minor’ stroke aimed at reducing the subsequent risk of stroke. Methods/design This systematic review will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses(PRISMA) guidance. Randomised and quasi-randomised controlled trials of rehabilitation programmes initiated within 90 days of a TIA or ‘minor’ stroke will be included. Articles will be identified through a comprehensive search of the following databases, guided by a medical librarian: the Cochrane Library, Web of Science, MEDLINE, Embase, CINAHL and PsycINFO. Two review authors will independently screen articles retrieved from the search for eligibility and extract relevant data on methodological issues. A narrative synthesis will be completed when there is insufficient data to permit a formal meta-analysis. Discussion This review will be of value to clinicians and healthcare professionals working in TIA and stroke services as well as to general practitioners/family physicians who care for these patients in the community and to researchers involved in designing and evaluating rehabilitation interventions