Warfarin and atrial fibrillation
Jaime Caro and colleagues conducted a nonrandomized, prospective observational trial to see whether warfarin's benefits in preventing stroke established in randomized trials would be seen in actual practice. A total of 221 patients with atrial fibrillation were assigned to 4 groups: ASA (14%), warfarin (39%), blended treatment (29%) and no treatment (17%). Patients receiving warfarin had a significantly lower risk of stroke and transient ischemic attack (rate ratio [RR] 0.34, 95% confidence interval [CI] 0.12-0.99) and a longer median time to stroke (24.9 v. 18.4 months, p = 0.01) than those who received no treatment. The stroke rates in the ASA and blended treatment groups were lower, but not significantly. In an accompanying editorial Stuart Connolly remarks on the low rate of warfarin use (39%) in practice. Figure 1
Expanding private health insurance
Arguments supporting the expansion of private health insurance toward either a parallel private stream or an expanded supplementary tier have assumed that insurers are eager to enter the market. Raisa Deber and colleagues challenge this. By applying insurance principles to both a parallel and a supplementary tiered system they conclude that economic incentives will lead private insurers to restrict and cap coverage and that risk selection will increase the cost of a publicly funded plan. When 10 insurers and employers were interviewed they agreed that a parallel private system is incompatible with insurance principles and that supplementary insurance would be restricted to certain people and services.
Malnutrition in elderly patients
Nahid Azad and colleagues interviewed 152 elderly patients in an acute care hospital to test the sensitivity of 3 nutritional screening tools. A detailed nutrition assessment was then completed, and the authors discovered that 62 patients (40.8%) were well nourished, 67 (44.1%) were at moderate risk for malnutrition and 23 (15.1%) were malnourished. The 3 screening tools performed poorly, with respective sensitivities of 32%, 54% and 57% and specificities of 85%, 61% and 69%. The authors conclude that further research is needed to devise a validated tool to screen elderly patients in acute care settings.
Opinions on clinical prevention
What do patients and family physicians have to say about the recommendations of the Canadian Task Force on Preventive Health Care? Quite a bit according to Marie-Dominique Beaulieu and colleagues in their report of the results of focus groups involving 35 physicians and 75 patients. Both physicians and patients seem not to want to give up the annual health exam. Both value early diagnosis and see it as a legitimate end regardless of its effect on morbidity. There is a perceived gap between researchers and clinicians, which Richard Goldbloom, in his editorial, aptly portrays as science and ritual.
Calcium-channel blockers and cognitive decline
Colleen Maxwell and colleagues have assessed the risk of cognitive decline in patients taking antihypertensive drugs by analysing data from the Canadian Study of Health and Aging. A total of 205 respondents with hypertension and no history of dementia completed the Modified Mini-Mental State (3MS) examination at baseline and 5 years later. After adjustment for covariates subjects using calcium-channel blockers (CCBs) exhibited a significantly greater risk for cognitive decline than users of other antihypertensive drugs (odds ratio [OR] 2.28). When individual CCBs were assessed relative to beta-blockers, only non-dihydropyridine CCBs (e.g., diltiazem) were associated with a significantly greater risk of cognitive decline (OR 3.72). In an accompanying editorial Henry Dinsdale comments on the need for further investigation and advises adherence to current guidelines. Figure 2