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Stress urinary incontinence (SUI) is defined as a complaint of inadvertent loss of urine occurring as a result of an increase in intraabdominal pressure, in the absence of a detrusor muscle contraction [1]. Estimates of the prevalence vary widely in the published literature, due in part to differing terminologies, diagnostic approaches, and populations studied [1–3]. It has been reported that SUI affects up to 14% of premenopausal women and up to 35% of postmenopausal women [4, 5], unfavourably affecting quality of life (QoL), sexual function, and mental health [6, 7]. Pathophysiologically, SUI is caused by urethral deficiency and impairment of supportive structures such as the levator ani muscle, endopelvic fascia, and pubourethral ligament [8]. The beneficial effect of pelvic floor muscle training (PFMT) on female urinary incontinence and pelvic organ prolapse was first described in 1948 by Arnold Kegel, who reported an astonishing success rate of 84% [9]. More recent studies have demonstrated somewhat lower success rates of PFMT than those reported by Kegel, but still in the impressive range from 56 to 75% based on improved clinical outcomes [10]. Strong evidence and grade A recommendations support the use of PFMT as the first-line conservative treatment for SUI [11]. Although alternative exercise regimens for SUI have been investigated, their clinical implementation is not yet recommended [12]. Other conservative therapeutic options for SUI include vaginal cones, bladder training, as well as electrical or magnetic stimulation. Extracorporeal magnetic stimulation (EMS) is a non-invasive, effective, acceptable, and safe therapeutic modality for SUI [6, 7]. In EMS, induction of a changing magnetic field results in a flow of electrons within the field, controlled depolarisation of the adjacent nerves, and subsequent muscular contraction [13]. Although the optimal frequency and duration of treatment are not yet established, findings of a systematic review have suggested that higher frequency and pulse duration provide an adequate modality for achieving treatment efficacy [14]. At our clinic, which is the largest Croatian urogynaecological referral centre, EMS is routinely offered as an alternative to women who are not willing to perform Kegel exercises. Considering that a direct comparison of these two common conservative methods is lacking, we decided to perform a randomized controlled trial comparing the efficacy of PFMT versus EMS for the treatment of SUI. In this paper we describe the protocol of the study.

As the SARS-CoV-2 virus (COVID-19) continues to affect people across the globe, there is limited understanding of the long term implications for infected patients1–3. While some of these patients have documented follow-ups on clinical records, or participate in longitudinal surveys, these datasets are usually designed by clinicians, and not granular enough to understand the natural history or patient experiences of ‘long COVID’. In order to get a complete picture, there is a need to use patient generated data to track the long-term impact of COVID-19 on recovered patients in real time. There is a growing need to meticulously characterize these patients’ experiences, from infection to months post-infection, and with highly granular patient generated data rather than clinician narratives. In this work, we present a longitudinal characterization of post-COVID-19 symptoms using social media data from Twitter. Using a combination of machine learning, natural language processing techniques, and clinician reviews, we mined 296,154 tweets to characterize the post-acute infection course of the disease, creating detailed timelines of symptoms and conditions, and analyzing their symptomatology during a period of over 150 days.

Author(s): Lane, Jennifer CE; Weaver, James; Kostka, Kristin; Duarte-Salles, Talita; Abrahao, Maria Tereza F; Alghoul, Heba; Alser, Osaid; Alshammari, Thamir M; Areia, Carlos; Biedermann, Patricia; Banda, Juan M; Burn, Edward; Casajust, Paula; Fister, Kristina; Hardin, Jill; Hester, Laura; Hripcsak, George; Kaas-Hansen, Benjamin Skov; Khosla, Sajan; Kolovos, Spyros; Lynch, Kristine E; Makadia, Rupa; Mehta, Paras P; Morales, Daniel R; Morgan-Stewart, Henry; Mosseveld, Mees; Newby, Danielle; Nyberg, Fredrik; Ostropolets, Anna; Woong Park, Rae; Prats-Uribe, Albert; Rao, Gowtham A; Reich, Christian; Rijnbeek, Peter; Sena, Anthony G; Shoaibi, Azza; Spotnitz, Matthew; Subbian, Vignesh; Suchard, Marc A; Vizcaya, David; Wen, Haini; Wilde, Marcel de; Xie, Junqing; You, Seng Chan; Zhang, Lin; Lovestone, Simon; Ryan, Patrick; Prieto-Alhambra, Daniel; OHDSI-COVID-19 consortium | Abstract: ObjectivesConcern has been raised in the rheumatology community regarding recent regulatory warnings that HCQ used in the coronavirus disease 2019 pandemic could cause acute psychiatric events. We aimed to study whether there is risk of incident depression, suicidal ideation or psychosis associated with HCQ as used for RA.MethodsWe performed a new-user cohort study using claims and electronic medical records from 10 sources and 3 countries (Germany, UK and USA). RA patients ≥18 years of age and initiating HCQ were compared with those initiating SSZ (active comparator) and followed up in the short (30 days) and long term (on treatment). Study outcomes included depression, suicide/suicidal ideation and hospitalization for psychosis. Propensity score stratification and calibration using negative control outcomes were used to address confounding. Cox models were fitted to estimate database-specific calibrated hazard ratios (HRs), with estimates pooled where I2 l40%.ResultsA total of 918 144 and 290 383 users of HCQ and SSZ, respectively, were included. No consistent risk of psychiatric events was observed with short-term HCQ (compared with SSZ) use, with meta-analytic HRs of 0.96 (95% CI 0.79, 1.16) for depression, 0.94 (95% CI 0.49, 1.77) for suicide/suicidal ideation and 1.03 (95% CI 0.66, 1.60) for psychosis. No consistent long-term risk was seen, with meta-analytic HRs of 0.94 (95% CI 0.71, 1.26) for depression, 0.77 (95% CI 0.56, 1.07) for suicide/suicidal ideation and 0.99 (95% CI 0.72, 1.35) for psychosis.ConclusionHCQ as used to treat RA does not appear to increase the risk of depression, suicide/suicidal ideation or psychosis compared with SSZ. No effects were seen in the short or long term. Use at a higher dose or for different indications needs further investigation.Trial registrationRegistered with EU PAS (reference no. EUPAS34497; http://www.encepp.eu/encepp/viewResource.htm? id=34498). The full study protocol and analysis source code can be found at https://github.com/ohdsi-studies/Covid19EstimationHydroxychloroquine2.

BackgroundHydroxychloroquine has recently received Emergency Use Authorization by the FDA and is currently prescribed in combination with azithromycin for COVID-19 pneumonia. We studied the safety of hydroxychloroquine, alone and in combination with azithromycin.MethodsNew user cohort studies were conducted including 16 severe adverse events (SAEs). Rheumatoid arthritis patients aged 18+ and initiating hydroxychloroquine were compared to those initiating sulfasalazine and followed up over 30 days. Self-controlled case series (SCCS) were conducted to further establish safety in wider populations. Separately, SAEs associated with hydroxychloroquine- azithromycin (compared to hydroxychloroquine-amoxicillin) were studied. Data comprised 14 sources of claims data or electronic medical records from Germany, Japan, Netherlands, Spain, UK, and USA. Propensity score stratification and calibration using negative control outcomes were used to address confounding. Cox models were fitted to estimate calibrated hazard ratios (CalHRs) according to drug use. Estimates were pooled where I2ResultsOverall, 956,374 and 310,350 users of hydroxychloroquine and sulfasalazine, and 323,122 and 351,956 users of hydroxychloroquine-azithromycin and hydroxychloroquine-amoxicillin were included. No excess risk of SAEs was identified when 30-day hydroxychloroquine and sulfasalazine use were compared. SCCS confirmed these findings. However, when azithromycin was added to hydroxychloroquine, we observed an increased risk of 30-day cardiovascular mortality (CalHR2.19 [1.22- 3.94]), chest pain/angina (CalHR 1.15 [95% CI 1.05-1.26]), and heart failure (CalHR 1.22 [95% CI 1.02- 1.45])ConclusionsShort-term hydroxychloroquine treatment is safe, but addition of azithromycin may induce heart failure and cardiovascular mortality, potentially due to synergistic effects on QT length. We call for caution if such combination is to be used in the management of Covid-19.Trial registration numberRegistered with EU PAS; Reference number EUPAS34497 (http://www.encepp.eu/encepp/viewResource.htm?id=34498). The full study protocol and analysis source code can be found at https://github.com/ohdsi-studies/Covid19EstimationHydroxychloroquine.Funding sourcesThis research received partial support from the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC) and Senior Research Fellowship (DPA), US National Institutes of Health, Janssen Research & Development, IQVIA, and by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea [grant number: HI16C0992]. Personal funding included Versus Arthritis [21605] (JL), MRC-DTP [MR/K501256/1] (JL), MRC and FAME (APU). The European Health Data & Evidence Network has received funding from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 806968. The JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA. No funders had a direct role in this study. The views and opinions expressed are those of the authors and do not necessarily reflect those of the Clinician Scientist Award programme, NIHR, NHS or the Department of Health, England.

Background Hydroxychloroquine, a drug commonly used in the treatment of rheumatoid arthritis, has received much negative publicity for adverse events associated with its authorisation for emergency use to treat patients with COVID-19 pneumonia. We studied the safety of hydroxychloroquine, alone and in combination with azithromycin, to determine the risk associated with its use in routine care in patients with rheumatoid arthritis. Methods In this multinational, retrospective study, new user cohort studies in patients with rheumatoid arthritis aged 18 years or older and initiating hydroxychloroquine were compared with those initiating sulfasalazine and followed up over 30 days, with 16 severe adverse events studied. Self-controlled case series were done to further establish safety in wider populations, and included all users of hydroxychloroquine regardless of rheumatoid arthritis status or indication. Separately, severe adverse events associated with hydroxychloroquine plus azithromycin (compared with hydroxychloroquine plus amoxicillin) were studied. Data comprised 14 sources of claims data or electronic medical records from Germany, Japan, the Netherlands, Spain, the UK, and the USA. Propensity score stratification and calibration using negative control outcomes were used to address confounding. Cox models were fitted to estimate calibrated hazard ratios (HRs) according to drug use. Estimates were pooled where the I2 value was less than 0·4. Findings The study included 956 374 users of hydroxychloroquine, 310 350 users of sulfasalazine, 323 122 users of hydroxychloroquine plus azithromycin, and 351 956 users of hydroxychloroquine plus amoxicillin. No excess risk of severe adverse events was identified when 30-day hydroxychloroquine and sulfasalazine use were compared. Self-controlled case series confirmed these findings. However, long-term use of hydroxychloroquine appeared to be associated with increased cardiovascular mortality (calibrated HR 1·65 [95% CI 1·12–2·44]). Addition of azithromycin appeared to be associated with an increased risk of 30-day cardiovascular mortality (calibrated HR 2·19 [95% CI 1·22–3·95]), chest pain or angina (1·15 [1·05–1·26]), and heart failure (1·22 [1·02–1·45]). Interpretation Hydroxychloroquine treatment appears to have no increased risk in the short term among patients with rheumatoid arthritis, but in the long term it appears to be associated with excess cardiovascular mortality. The addition of azithromycin increases the risk of heart failure and cardiovascular mortality even in the short term. We call for careful consideration of the benefit–risk trade-off when counselling those on hydroxychloroquine treatment. Funding National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, NIHR Senior Research Fellowship programme, US National Institutes of Health, US Department of Veterans Affairs, Janssen Research and Development, IQVIA, Korea Health Industry Development Institute through the Ministry of Health and Welfare Republic of Korea, Versus Arthritis, UK Medical Research Council Doctoral Training Partnership, Foundation Alfonso Martin Escudero, Innovation Fund Denmark, Novo Nordisk Foundation, Singapore Ministry of Health's National Medical Research Council Open Fund Large Collaborative Grant, VINCI, Innovative Medicines Initiative 2 Joint Undertaking, EU's Horizon 2020 research and innovation programme, and European Federation of Pharmaceutical Industries and Associations.

U radu se raspravlja infrastruktura za sekundarnu uporabu podataka u zdravstvenom sustavu Republike Hrvatske - kakvo je sadašnje stanje i što bi trebalo razviti kako bi bolje bio ispunjen potencijal sekundarne uporabe za razvoj znanstvenoga rada, kliničke medicine i bolje upravljanje sustavom.

We have identified in the literature variants in 64 genes that may be involved in gene-obesity-behaviour interactions. Personalisation of behaviourally based preventive approaches against obesity seems feasible, however obesity genomics is still in the discovery phase of translational research and abundant replication studies are needed before these largely pioneering findings can be extended to practice and population impact. Automation of search algorithms and development of more efficient tools for knowledge synthesis of genomic research into gene-obesity-behaviour interactions might facilitate the advent of widely available personalised prevention approaches. Our future efforts shall therefore concentrate on developing such tools, as well as a research repository dedicated to the use of public health genomics for obesity control.

The objective of this paper was to evaluate the 5-year incidence of obesity on a sample of 3229 adults and investigate the potential effect of several sociodemographic and lifestyle habits on weight change and obesity incidence in these individuals. The average annual rate of increase in the prevalence of obese adults between 2003 and 2008 was 10.60% for men and 11.08% for women. Analysis showed that development of obesity in 5-year period in women in Croatia is significantly positively associated with frequent consumption of »hidden« fats of animal origin and significantly negative with each higher education level. No significant predictor of obesity has been found in men. Obesity remains a serious health problem for the Croatian population ; the alarming rates of excess body weight continue to increase. Preventive measures should urgently be undertaken.

This study aimed to assess levels of stress in Croatian adult population using PSS, in a population study (Croatian Adult Cohort Health Study - CroHort). Our results show that the levels of stress were 17.46 (SD = 6.73) for men and 18.32 (SD = 6.46) for women in Croatia. The lowest levels of stress experienced men living in urban area while women living in rural area had the highest level. Men and women who had university degree had significantly lower level of stress. The lowest levels of stress experienced participants who had much better financial condition than average. In men, stress was associated to weak heart, lower back pain, poor financial condition of the household and high alcohol consumption. In women, stress was associated to poor mental health, poor social functioning, poorer financial condition of the household, higher age, lower education, low monthly income of the household and poor general health.

The Public Health Surveillance System (PHSS) is defined as the ongoing, systematic collection, analysis, interpretation and dissemination of health-related data essential to the planning, implementation, and evaluation of public health practice. It serves as an early warning system, guides public health policy and strategies, documents the impact of an intervention or progress towards specified public health targets/goals, and understands and monitors the epidemiology of a condition to set priorities and guide public health policy and strategies. For this purpose, the PHSS should: be ICT-based and comprehensive with clearly defined sources, volumes, and standards of data; include all the stakeholders with information they produce, with enough flexibility in the dynamic of constructing indicators; be safe and able to produce information on demand and on time; and be able to act as a risk management system by providing warnings/reminders/alerts to prevent unwanted events.

Objectives: The purpose of this paper is to describe the medical informatics program and training at the University of Zagreb, School of Medicine (Croatia). Methods: We reviewed the medical informatics program, training and research for medical students at the integrated pre-graduate and graduate level, as well as at the postgraduate education and research level. Results: We present three approaches to teaching and training medical students in medical informatics at the integrated pre-graduate and graduate level. These are (1) Basics of medical informatics taught early in the medical curriculum, (2) Medical informatics which uses students’ clinical knowledge and is taught towards the end of the medical curriculum, and (3) individualized research programs. Both Basics of medical informatics and Medical informatics are courses tailored in line with the IMIA Recommendations on Medical Informatics Education for IT users, and adjusted to students’ attitudes to medical informatics issues and the position of the courses in the medical curriculum. Postgraduate studies, as the higher level of education at the School of Medicine, also include several mostly elective medical informatics courses dealing with general medical informatics methodology and health information system management in both clinical medicine and public health. Included are also simulation modeling, methods of machine learning and knowledge discovery in medical domains, as well as medical statistics and methods oriented towards free textual data analysis. The postgraduate level includes in addition telemedicine, electrophysiological methods in research, and evidence based medicine. Conclusions: Medical students are starting to recognize the role of information in their future profession. They require medical informatics applications to support their professional work with patients, as well as their research. In particular they express interest in machine learning, simulation modeling, medical decision making, data security, e-learning, and evaluation of ICT based medical applications.

Despite numerous changes introduced by the new technologies, the role and the meaning of public health within health has remained stable and important. Public health is also expanding from the strictly population-focus to genetics and nano-technology. This means that the fundaments of public health need to be supplemented by the additional expertise in areas such as medical informatics, bioinformatics, genetic epidemiology and public health genomics. The first step in integration is to develop the means of joining these ideas and experts in the solving of multidisciplinary problems, aiming to supplement public health with the emerging new technologies, ideas and concepts.

The healing process can be viewed as a partnership between doctors and patients, nurses and physicians or, more generally, a partnership of health professionals and health care users (Anonymous, 2008, Graham, 2007). A patient-centered approach that empowers patients to participate in decisions about their treatment and health care options asks for active participation of patients themselves, specifically, in health information gathering and exchange of this information with their health or medical records (Bachman, 2007; Stolyar, Lober, Drozd, & Sibley, 2005).

Background: The contribution disclosure forms used by medical journals to assess and confirm authorship are surveys of self-reported behaviour that follow the cognitive rules of psychometric instruments. We sought to analyze how autobiographical memory, defined as memory for events and issues related to oneself, affected the reliability of contribution forms for the judging of authorship of research articles. Methods: We conducted a prospective study, which ultimately included 919 authors of 201 articles submitted to a general medical journal from July 2001 through December 2002. A authorship disclosure form with a checklist of 11 possible contribution choices for all authors was sent first to each article9s corresponding author, who was asked to fill it out for all authors. A blank form was then sent to each author individually to disclose his or her own contribution to that article. The main outcome measure was test– retest differences between the corresponding authors9 self-declarations, expressed in percent as the gross difference rate (GDR) for each article. Results: More than two-thirds of the corresponding authors (69.7%) differed in at least 1 contribution choice between the 2 disclosure statements made about their own contributions. The reliability of their answers was low to moderate (GDRs > 10%), especially for contributions on the provision of study materials or patients or final approval of the article (GDR 22.9%), guarantor of the study (GDR 20.9%) and drafting of the manuscript (GDR 20.4%). As a proxy for their coauthors9 contributions, corresponding authors also differed from them in the perception of noncorresponding authors9 contributions, disagreeing in 69.4% of cases. Of the 718 noncorresponding authors, 204 (28.4%) met all the criteria for authorship set out by the International Committee of Medical Journal Editors according to the statement given by the corresponding author. When they described their own contributions, this prevalence increased to 40.5%. Interpretation: Psychological factors such as autobiographical memory may confound contribution disclosures as an evaluation tool for authorship on scientific articles and affect responsible authorship and publication practices.

Junk food and the advertising that promotes it are a serious threat to the health of young Americans, says a new report from the US Institute of Medicine. The report summarises current evidence on the effect that advertising campaigns have on the food and beverage consumption of young people in the United States. The report was commissioned by the Congress. The diets of young Americans differ substantially from recommended diets: they are too rich in energy, fat, salt, …

In December 2004 we called for papers that would document the impact on population health and on health systems of the transition from communism in Europe and central Asia.w1 Over the past 18 months, a series of events has focused the eyes of the world on this region. May 2004 saw the historic enlargement of the European Union. In Georgia, Ukraine, and Kyrgyzstan, popular uprisings have led to the removal of autocratic regimes; in Uzbekistan, a similar uprising ended in tragedy. Yet, despite coming to the attention of the world's mass media, this vast region characterised by diversity and shared problems has generated surprisingly few publications on health and health care. We hope that this theme issue—most of it contributed by researchers and authors from the region—will fill some of these gaps and will further stimulate much needed monitoring, research, and debate. One of the key themes in this week's BMJ theme issue is the rising prevalence of HIV/AIDS in some countries of the region. For example, one paper focuses on Ukraine, which has the highest prevalence of HIV infection in Europe (estimated at 1.4% of the population) but lacks any systematic approach to prevention, treatment, or care.1 The authors report how information on the scale and nature of the problem is patchy and is not well known within Ukraine. An accompanying commentary emphasises the need for urgent international action to prevent a potential catastrophe.w2 Non-communicable diseases continue to dominate the overall burden of disease in the region.2 Yet some countries have seen marked reductions in mortality,3 and, although precise explanations for this remain a matter for discussion,w3 it is clear that much can be done to tackle the high toll from cardiovascular disease. As Marquez and Suhrcke note, however, continuing improvement will depend on much more evidence and better use of existing evidence4,5 to inform policy, as well as on the creation of systems to collect data regularly on risk factors for chronic disease.

Karol Sikora , dean elect of Britain's first private medical school, thinks the school will widen access to education. Others beg to differ. Deborah Cohen and Kristina Fister report Known for his outspoken views on NHS reform and private medicine, Karol Sikora, professor of cancer medicine and honorary consultant oncologist at Imperial College London's School of Medicine, is now grappling with medical education. After being approached by Buckingham University's vice chancellor, Terence Kealey, himself a doctor, Professor Sikora was appointed dean elect of Britain's first private medical school at Buckingham University, the only UK university not directly funded by the government. He finds the challenge of implementing a new medical course appealing. “There's going to be a shortage of doctors in 20 years' time, and according to the Wanless report it will be about 25 000 [see BMJ 2002;324: 998]. Although medical school entry has doubled over the last 10 years, it's still too small,” he said. “The trouble is that they [existing educational initiatives] all use the same system of education. We want to get away from this dreadful political correctness in medical education that exists now. The main drivers of medical education in British medical schools are not doctors; they are professional medical …

Improving children's eating and exercise habits is central to making Britain a healthier nation, health secretary John Reid said last week. He was announcing details of how the government was going to implement its public health white paper that was published last November ( BMJ 2004;329:1201). The plan gives details about who will do what and when at national, regional, and local level. The Department of Health will be publishing six monthly progress reports of developments. The bulk of the …

An Asia House and Wellcome Trust exhibition at the Brunei Gallery, School of Oriental and African Studies, London, from 13 October to 12 December 2004 (admission free) www.soas.ac.uk/gallery/bodymindspirit/home.html

Live from Brainworks at the Science Museum9s Dana Centre, London NW1 Thursday 28 October www.danacentre.org.uk/

The aim of this study was to examine the association of weight gain and life expectancy at birth in Croatia. Mean body mass index was based on the data from the Croatian Adult Health Survey 2003. Birth rate and mortality data needed for life expectancy calculation were supplied by the Central Bureau of Statistics. The results suggest that the increase in mean body mass index value (1.31 kg m(-2) for women and 1.41 kg m(-2) for men) will shorten life expectancy at birth for one year. Obesity, if unchecked, might have a negative effect on life expectancy in Croatia. Despite widespread knowledge about how to reduce the severity of the problem, observed trends in obesity in Croatia continue to worsen. These trends threaten to diminish the health and life expectancy of current and future generations.

Based on repeated measurement of health behaviors the CroHort Study showed that health behavior explains a great deal more of class inequalities in mortality than observed in previous studies. These include decreasing prevalence of smoking and increase in obesity, hypertension and diabetes mellitus. The lowest prevalence of health risks was recorded among children and adolescents, followed by general adult population from the CroHort Study. Hospitalized coronary heart disease patients had higher risks prevalence than general population, while the highest prevalence of risks was recorded among patients in cardiac rehabilitation program. The higher levels of stress were associated to lower financial conditions, poorer social functioning and poorer mental health for both men and women. Higher levels of stress were also associated with heart problems, higher alcohol consumption in men while in women stress was associated to poorer general health, higher age and lower levels of education.

The aim of this study was to examine the social conditioning of health behaviors of adults in Croatia, based on the data from Croatian Adult Health Survey 2003. This cross-sectional study on a representative random sample of 9070 Croatian adults showed that obesity was significantly and socially conditioned in women, whereas for men the indication of social conditioning has not reached a statistically significant level. Health behaviors were socially conditioned in both sexes. Men’s living habits were more irregular than those of women. Compared with women, men consumed more cured meat products, consumed alcohol excessivelly and smoked cigarettes more often, whereas they ate less fruits and vegetables. Health promotion strategies based on the behavioral correlates of overweight and obesity are needed to prevent excess weight gain in the Croatian population. While for men a unique educational model is applicable, women require more specialized programs, adapted to their social background.

Harm reduction programmes have been criticised for giving a false impression to adolescents that heroin use doesn't have to be associated with as much harm to the individual as is traditionally thought. Switzerland has had a liberal policy towards harm reduction. And a recent study shows that the incidence of heroin misuse has been falling under an extensive harm reduction programme, which includes methadone substitution with low threshold of illicit use. Credit: LANCET The researchers analysed an anonymised treatment register of almost 80% of the heroin addicts treated between 1991 and March 2005 in the canton of Zurich, which included more than 7000 people. Using the conditional lag time distribution, they estimated the proportion of addicts not yet in substitution treatment programmes and modelled the overall prevalence of heroin misuse as a function of incidence and cessation rate. Credit: ANN INT MED After its all time peak in 1990, the incidence of regular heroin use declined fourfold in the next decade, more than in any other country with data permitting such analysis. The data showed a decline, by 4% a year, in the population of problematic heroin addicts, defined as people who sought and entered treatment. However, the rates of cessation (leaving the substitution programme and not re-entering within a decade) in Switzerland are among the lowest recorded. Lancet 2006;367: 1830–4 [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Children who had ventricular fibrillation or tachycardia before the onset of cardiac arrest have better prognosis than children in cardiac arrest who develop ventricular fibrillation or tachycardia during cardiopulmonary resuscitation. This finding is from a multicentre register study of more than 1000 consecutive children with cardiac arrest. It contradicts previous evidence, which was based on studies from single institutions with small sample sizes, and the traditional view that ventricular fibrillation and tachycardia are “good” cardiac arrest rhythms. Children who develop ventricular fibrillation … [1]: {openurl}?query=rft.jtitle%253DLancet%26rft.stitle%253DLancet%26rft.aulast%253DNordt%26rft.auinit1%253DC.%26rft.volume%253D367%26rft.issue%253D9525%26rft.spage%253D1830%26rft.epage%253D1834%26rft.atitle%253DIncidence%2Bof%2Bheroin%2Buse%2Bin%2BZurich%252C%2BSwitzerland%253A%2Ba%2Btreatment%2Bcase%2Bregister%2Banalysis.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0140-6736%252806%252968804-1%26rft_id%253Dinfo%253Apmid%252F16753485%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1016/S0140-6736(06)68804-1&link_type=DOI [3]: /lookup/external-ref?access_num=16753485&link_type=MED&atom=%2Fbmj%2F332%2F7554%2F1383.atom [4]: /lookup/external-ref?access_num=000238194200028&link_type=ISI

A lmost every textbook about evidence based medicine (EBM) starts with its definition, and that is usually when I roll my eyes and quickly turn the page. Of course, I always go back and read the piece, because I love EBM. But why is it that we still need to define it? It is now about 20 years old and by most relevant medical professionals acknowledged as the way to practise and advance in today's …

Evidence started to matter in biomedical publishing soon after it came to matter in medicine— relatively recently. The first international congress on peer review and biomedical publication was held in Chicago in 1989. At the time of the third congress, in 1997, only 146 original scientific articles had been published on peer review, of which 22 were prospective studies and 11 randomised controlled trials.1 Since then, the body of evidence has been growing, with about 200 abstracts indexed in Medline a year.2 We now have plenty of evidence to support the contention that peer review is "expensive, slow, subjective and biased, open to abuse, patchy at detecting important methodological defects, and almost useless at detecting fraud or misconduct."3 The evidence on how to improve the process is scarce. What did the fifth congress add?

Generalised obesity is increasing in prevalence globally, however trends in abdominal obesity are less well known. In 2003, 1,999 women of childbearing age participated in the Croatian Adult Health Survey, of whom 598 (29.9%) participated in the second cycle in 2008. For 2008, the prevalence of abdominal obesity using the International Diabetes Federation (IDF) criterion (waist circumference > or = 80 cm) was estimated at 70.3% (95% CI 61.8% to 75.7%), whereas the prevalence of abdominal obesity using the National Cholesterol Education Program, Adult Treatment Panel III (NCEP ATP III) criterion (waist circumference > or = 88 cm) was estimated at 48.6% (42.6% to 54.7%). The preceding five-year cumulative incidence was 54.3% (44.5% to 64.2%) and 35.2% (28.0% to 42.4%) using the IDF and NCEP ATP III criteria, respectively. The burden of abdominal obesity is high and rapidly increasing in Croatian women of childbearing age, the key population subgroup for obesity control.

In July 2005 the BMJ will devote a theme issue to the medical problems of hundreds of millions of people in post-communist countries geographically located in central, eastern, and southeastern Europe. Communism came to the Soviet Union after the first world war and to the rest of now transitional Europe after the second world war. The fall of the Berlin Wall in 1989 marked the beginning of the end of communism, and the former communist countries entered a phase of transition to democracies and market economies. The arguably common path that these countries started out on branched in many different directions, partly because they all started from different bases. Today the countries in transition are politically and economically as heterogeneous as is the health status of their populations.1 Although for some the first stage of transition ended with their accession to the European Union in May this year, others are still battling the scars left over from recent or possibly newly emerging wars. Healthwise, however, they have certain common features. Life expectancy at birth is now lower in the transition countries than that in western Europe (see bmj.com). Although in the 1960s it was slightly higher in former East Germany than in former West Germany, by the 1970s the numbers reversed and the gap has been widening ever since.2 In 2000, life expectancy at birth was almost 12 years less in the countries of the former Soviet Union than in western Europe, and it is continuing to decline, making the former Soviet Union one of only two regions in the world where life expectancy is declining, the other being sub-Saharan Africa.3 But in other post-communist countries life expectancy is generally improving.4 Health gains are being driven largely by reductions in deaths from cardiovascular disease in some countries, mostly attributable to a combination of improved diet and improved medical care—in particular the treatment of hypertension.5 w1 The high consumption of alcohol, particularly in the former Soviet Union, is a major risk factor affecting cardiovascular diseases and partly also the high number of deaths from injuries and violence. This perhaps reflects the feeling of hopelessness that now confronts many young people who see few prospects of a better future.w2 Additional risk factors include a diet that contains few micronutrients and a healthcare system that has proved unable to tackle chronic diseases.6 w3 Transition has had an impact on health in other ways. Societal changes have in some countries contributed to increases in several communicable diseases, most notably HIV, other sexually transmitted diseases, and tuberculosis.7 Some of the health effects of transition are already apparent, but others—for example, the predictable rise in lung cancer among the young women currently being targeted by Western tobacco companies—will become apparent in the future.8 A few countries, such as Poland, have resisted the tobacco companies and put in place policies that are ahead of many Western countries and have demonstrable benefits.w4 Transition not only involves rediscovering but also redefining the societal classes, which were arbitrarily denied during communism. In some countries, middle classes with lifestyles similar to their Western neighbours almost disappeared during transition, whereas in others they emerged. But almost everywhere a few oligarchs have been able to acquire enormous wealth while many tens of thousands of people are falling through what remains of the social safety net.9 In many of the poorer former Soviet countries, the social safeguards of the past have almost disappeared, so that a serious illness in the family entails the risk of impoverishing the family entirely.w5 Health systems are also in transition. Most countries have adopted some form of health insurance, although almost everywhere a high level of dependence on government subsidies still exists.10 A common goal is the implementation of modern primary care. A few countries have succeeded, but many—Bulgaria, Latvia, and Moldova, for example—have not.11 Overall, the process of transition in this region has provided important insights, shedding light on key determinants of health (such as alcohol and nutrition), on reforms in the health sector, and on the challenges in implementing the concept of evidence based medicine. Remarkably little information from these countries reaches the international community, for several reasons. As with development assistance for health in general,w6 funding for health research in this region is extremely low. Many academic departments have correctly concentrated on training a new generation of researchers and are only now in a position to engage in high quality research into the health of the population. In some places, especially in the former Soviet Union, language remains a barrier to effective international collaboration. Moreover, many colleagues from countries in transition have important knowledge to share but seek training to present that knowledge.12 Our theme issue will seek partially to redress these issues. In particular, we are seeking papers that shed light on the impact of transition on population health, the experience of healthcare reform, the implementation of evidence based health care, and the reconfiguration of medical training programmes. We welcome original papers from any countries that are undergoing transition in central, eastern, and southeastern Europe, and also personal views and experiences of practitioners, especially those in primary care and public health. We hope that this issue will encourage those who have much to say but who so far have felt unable to say it, and that it will serve as a forum for the exchange of information among the countries in the region and our readers. Please submit your papers via http://submit.bmj.com by 31 January 2005.