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¿Qué tienen en común los siguientes escenarios? • Después de reinar como uno de los tratamientos médicos más utilizados desde hace más de 3.000 años, la sangría sólo empezó a declinar en el siglo 20 (1), a pesar de que era ineficaz, y responsable de muchas muertes, incluyendo las de George Washington y Carlos II (2). • A pesar de ser una práctica sencilla, altamente eficaz y bien entendida, menos de la mitad de los profesionales de la salud se lavan las manos al entrar en contacto con los pacientes (3), y menos del 20% de las personas en todo el mundo lo hacen, después de defecar (4). La resistencia al cambio fue tan feroz inicialmente, que Ignaz Semmelweis, quien proporcionó la primera evidencia clara de su beneficio en el siglo 19, fue ridiculizado, acosado e incluso obligado a exiliarse por la comunidad médica de Viena, muriendo sin el reconocimiento que merecía, ya que tomaría 50 años más para que sus ideas fueran aceptadas (5). • Durante miles de años, los machos dominantes han excluído a las mujeres, niños y enemigos de la categoría de seres humanos completos, para justificar el sometimiento y terribles actos de violencia. A lo largo de los siglos, los médicos han tolerado y apoyado la creencia de que ciertos grupos de personas son “menos que humanos”, jugando un papel clave en la evaluación del valor de los esclavos, garantizando que la tortura no sea letal, realizando experimentos o manteniendo su aptitud para el trabajo forzado (6-9). • En la asistencia sanitaria del siglo 21, además de algunos ejemplos flagrantes de guías de práctica clínica racistas (9,10), la deshumanización es endémica en relación con las interacciones con los pacientes y los participantes en estudios de investigación, ya que con frecuencia son tratados como máquinas homogeneizadas, seres insensibles, con trozos de órganos enfermos, o como seres incivilizados, irracionales o carentes de sentimientos (11-13).

Chronic pain clinical trials have historically assessed benefit and risk outcomes separately. However, a growing body of research suggests that a composite metric that accounts for benefit and risk in relation to each other can provide valuable insights into the effects of different treatments. Researchers and regulators have developed a variety of benefit-risk composite metrics, although the extent to which these methods apply to randomized clinical trials (RCTs) of chronic pain has not been evaluated in the published literature. This article was motivated by an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting and is based on the expert opinion of those who attended. In addition, a review of the benefit-risk assessment tools used in published chronic pain RCTs or highlighted by key professional organizations (ie, Cochrane, European Medicines Agency, Outcome Measures in Rheumatology, and U.S. Food and Drug Administration) was completed. Overall, the review found that benefit-risk metrics are not commonly used in RCTs of chronic pain despite the availability of published methods. A primary recommendation is that composite metrics of benefit-risk should be combined at the level of the individual patient, when possible, in addition to the benefit-risk assessment at the treatment group level. Both levels of analysis (individual and group) can provide valuable insights into the relationship between benefits and risks associated with specific treatments across different patient subpopulations. The systematic assessment of benefit-risk in clinical trials has the potential to enhance the clinical meaningfulness of RCT results.

Summary The medicalisation of life under the influence of health-care systems, focused on curing diseases, has made dying well challenging. This systematic review identifies common themes from published systematic reviews about the conditions for a good death as a means to guide decisions around this universal event. MEDLINE, Embase, APA PsycInfo, and AMED were searched for citations with “good death” or “dying well” in their titles on Sept 23, 2020, and complemented with backward reference and forward citation screening with Google Scholar. Articles published in peer-reviewed journals in any language were included. Articles that focused on the identification of conditions for a good death and described how primary studies were sought and selected were also included. Data on general characteristics, quality, and themes were extracted independently. 13 of 275 potentially eligible reviews were included. Common themes were dying at the preferred place, relief from pain and psychological distress, emotional support from loved ones, autonomous treatment decision making, avoidance of futile life-prolonging interventions and of being a burden to others, right to assisted suicide or euthanasia, effective communication with professionals, and performance of rituals. No reviews specified the meaning or timing of death, connected themes, or prioritised them. Vague jargon was often used to describe complex concepts. Most conditions for a good death could be offered to most dying people, without costly medical infrastructure or specialised knowledge. Efforts to describe these conditions clearly, to identify whether there are exceptions or missing items, and whether they apply in non-dominant settings (ie, outstide institutional, affluent, anglophone, and Christian settings) are needed.

BackgroundLong COVID—also known as post-acute sequelae of COVID-19 or PASC—is a systemic syndrome affecting a large number of persons in the aftermath of the pandemic. Cognitive dysfunction (or brain fog) is one of its most common manifestations of PACS, and there are no effective interventions to mitigate it. Home-based personalized computerized cognitive training (CCT), which has shown effectiveness to improve other conditions, could offer hope to relieve the cognitive dysfunction in people with a previous history of COVID-19.ObjectiveTo evaluate the feasibility and potential benefit of a personalized CCT intervention to improve cognitive function among people living with PACS.MethodsAdult individuals who self-reported cognitive dysfunction more than 3 months after a diagnosis of COVID-19 were recruited through an online platform designed for the study. Those who were eligible assessed their general cognitive function before completing as many cognitive daily training sessions as they wished during an 8-week period, using a personalized CCT application at home. The sessions included gamified tasks that tapped into five cognitive domains (attention, coordination, memory, perception and reasoning) and were tailored to the specific cognitive strengths and weaknesses detected at each point. At the end of this period, participants repeated the general cognitive function assessment. The differences between the scores at 8 weeks and baseline was the main outcome, complemented with analyses of the changes based on the participants’ age, training time, self-reported health level at baseline and time since the initial COVID-19 infection. Participants’ cognitive assessment scores were also computed in terms of percentiles according to the normative database of the test, considering their corresponding age- and gender-based reference sample.ResultsThe participants had significant cognitive dysfunction at baseline, even though 80% of them had had the initial episode of COVID-19 more than a year before enrolling in the study. Eighty nine percent reported negative levels of self-reported health at baseline. On average, 51 training sessions (range: 10 to 251) were completed over a mean time of 435 minutes (range 78 to 2448). Most of the participants obtained higher scores after CCT in each of the domains as compared with baseline (attention: 81% of the sample; memory: 86%; coordination: 82%; perception: 88%; reasoning: 77%). The magnitude of the score increase at post-test was high across domains (attention: 31% of change; memory: 37%; coordination: 52%; perception: 42%; reasoning: 26%). Following CCT, there were also improvements in the percentile data in all the domains (attention: 14 points; memory: 18 points; coordination: 18 points; perception: 17 points; reasoning: 11 points).ConclusionsThis study suggests that a self-administered CCT based on gamified cognitive tasks could be an effective way to ameliorate cognitive dysfunction in persons with PASC.

The current pilot study was set to evaluate the feasibility and potential benefit of a personalized computerized cognitive training (CCT) intervention to improve cognitive function among people living with post-acute sequelae of COVID-19 (PASC). Seventy three adults who self-reported cognitive dysfunction more than 3 months after a diagnosis of COVID-19 took part in an 8-week training study. Participants’ general cognitive function was assessed before they completed as many cognitive daily training sessions as they wished during an 8-week period, using a personalized CCT application at home. At the end of this period, participants repeated the general cognitive function assessment. The differences between the scores at 8 weeks and baseline in five cognitive domains (attention, memory, coordination, perception, reasoning), complemented with analyses of the changes based on the participants’ age, training time, self-reported health level at baseline and time since the initial COVID-19 infection. Participants had significant cognitive dysfunction and self-reported negative health levels at baseline. Most of the participants obtained higher scores after CCT in each of the domains as compared with baseline. The magnitude of this score increase was high across domains. It is concluded that a self-administered CCT based on gamified cognitive tasks could be an effective way to ameliorate cognitive dysfunction in persons with PASC. The ClinicalTrials.gov identifier is NCT05571852.

BackgroundIn recent years, digital tools have become a viable means for patients to address their health and information needs. Governments and health care organizations are offering digital tools such as self-assessment tools, symptom tracking tools, or chatbots. Other sources of digital tools, such as those offered through patient platforms, are available on the internet free of charge. We define patient platforms as health-specific websites that offer tools to anyone with internet access to engage them in their health care process with peer networks to support their learning. Although numerous social media platforms engage users without up-front charges, patient platforms are specific to health. As little is known about their business model, there is a need to understand what else these platforms are trying to achieve beyond supporting patients so that patients can make informed decisions about the benefits and risks of using the digital tools they offer.ObjectiveThe aim of this study is to explore what patient platforms are trying to achieve beyond supporting patients and how their digital tools can be used to generate income.MethodsTextual and visual data collected from a purposeful selection of 11 patient platforms from September 2013 to August 2014 were analyzed using framework analysis. Data were systematically and rigorously coded and categorized according to key issues and themes by following 5 steps: familiarizing, identifying a thematic framework, indexing, charting, and mapping and interpretation. We used open coding to identify additional concepts not captured in the initial thematic framework. This paper reports on emergent findings on the business models of the platforms and their income-generating processes.ResultsOur analysis revealed that in addition to patients, the platforms support other parties with interests in health and information exchanges. Patient platforms did not charge up-front fees but generated income from other sources, such as advertising, sponsorship, marketing (eg, sending information to users on behalf of sponsors or providing means for sponsors to reach patients directly), supporting other portals, and providing research services.ConclusionsThis study reports on the mechanisms by which some patient platforms generate income to support their operations, gain profit, or both. Although income-generating processes exist elsewhere on social media platforms in general, they pose unique challenges in the health context because digital tools engage patients in health and information exchanges. This study highlights the need to minimize the potential for unintended consequences that can pose health risks to patients or can lead to increased health expenses. By understanding other interests that patient platforms support, our findings point to important policy implications, such as whether (and how) authorities might protect users from processes that may not always be in their best interests and can potentially incur costs to the health system.

Copyright © 2020 International Association for the Study of Pain., Interpreting randomized clinical trials (RCTs) is crucial to making decisions regarding the use of analgesic treatments in clinical practice. In this article, we report on an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, the purpose of which was to recommend approaches that facilitate interpretation of analgesic RCTs. We review issues to consider when drawing conclusions from RCTs, as well as common methods for reporting RCT results and the limitations of each method. These issues include the type of trial, study design, statistical analysis methods, magnitude of the estimated beneficial and harmful effects and associated precision, availability of alternative treatments and their benefit-risk profile, clinical importance of the change from baseline both within and between groups, presentation of the outcome data, and the limitations of the approaches used.

UNSTRUCTURED Author response to peer review for MS#19583

UNSTRUCTURED Real-world drug repurposing—the immediate “off-label” prescribing of drugs to address urgent clinical needs—is an indispensable strategy gaining rapid traction in the current COVID-19 crisis. Although off-label prescribing (ie, for a nonapproved indication) is legal in most countries, it tends to shift the burden of liability and cost to physicians and patients, respectively. Nevertheless, in urgent public health crises, it is often the only realistic source of a meaningful potential solution. To be considered for real-world repurposing, drug candidates should ideally have a track record of safety, affordability, and wide accessibility. Although thousands of such drugs are already available, the absence of a central repository of off-label uses presents a barrier to the immediate identification and selection of the safest, potentially useful interventions. Using the current COVID-19 pandemic as an example, we provide a glimpse at the extensive literature that supports the rationale behind six generic drugs, in four classes, all of which are affordable, supported by decades of safety data, and pleiotropically target the underlying pathophysiology that makes COVID-19 so dangerous. Having previously fast-tracked this paper to publication in summary form, we now expand on why cimetidine/famotidine (histamine type-2 receptor antagonists), dipyridamole (antiplatelet agent), fenofibrate/bezafibrate (cholesterol/triglyceride-lowering agents), and sildenafil (phosphodiesterase-5 inhibitor) are worth considering for patients with COVID-19 based on their antiviral, anti-inflammatory, renoprotective, cardioprotective, and anticoagulation properties. These examples also reveal the unlimited opportunity to future-proof public health by proactively mining, synthesizing, and cataloging the off-label treatment opportunities of thousands of safe, well-established, and affordable generic drugs.

Real-world drug repurposing—the immediate “off-label” prescribing of drugs to address urgent clinical needs—is an indispensable strategy gaining rapid traction in the current COVID-19 crisis. Although off-label prescribing (ie, for a nonapproved indication) is legal in most countries, it tends to shift the burden of liability and cost to physicians and patients, respectively. Nevertheless, in urgent public health crises, it is often the only realistic source of a meaningful potential solution. To be considered for real-world repurposing, drug candidates should ideally have a track record of safety, affordability, and wide accessibility. Although thousands of such drugs are already available, the absence of a central repository of off-label uses presents a barrier to the immediate identification and selection of the safest, potentially useful interventions. Using the current COVID-19 pandemic as an example, we provide a glimpse at the extensive literature that supports the rationale behind six generic drugs, in four classes, all of which are affordable, supported by decades of safety data, and pleiotropically target the underlying pathophysiology that makes COVID-19 so dangerous. Having previously fast-tracked this paper to publication in summary form, we now expand on why cimetidine/famotidine (histamine type-2 receptor antagonists), dipyridamole (antiplatelet agent), fenofibrate/bezafibrate (cholesterol/triglyceride-lowering agents), and sildenafil (phosphodiesterase-5 inhibitor) are worth considering for patients with COVID-19 based on their antiviral, anti-inflammatory, renoprotective, cardioprotective, and anticoagulation properties. These examples also reveal the unlimited opportunity to future-proof public health by proactively mining, synthesizing, and cataloging the off-label treatment opportunities of thousands of safe, well-established, and affordable generic drugs.

UNSTRUCTURED Real-world drug repurposing—the immediate “off-label” prescribing of drugs to address urgent clinical needs—is a widely overlooked opportunity. Off-label prescribing (ie, for a nonapproved indication) is legal in most countries and tends to shift the burden of liability and cost to physicians and patients, respectively. Nevertheless, health crises may mean that real-world repurposing is the only realistic source for solutions. Optimal real-world repurposing requires a track record of safety, affordability, and access for drug candidates. Although thousands of such drugs are already available, there is no central repository of off-label uses to facilitate immediate identification and selection of potentially useful interventions during public health crises. Using the current coronavirus disease (COVID-19) pandemic as an example, we provide a glimpse of the extensive literature that supports the rationale behind six generic drugs, in four classes, all of which are affordable, supported by decades of safety data, and targeted toward the underlying pathophysiology that makes COVID-19 so deadly. This paper briefly summarizes why cimetidine or famotidine, dipyridamole, fenofibrate or bezafibrate, and sildenafil citrate are worth considering for patients with COVID-19. Clinical trials to assess efficacy are already underway for famotidine, dipyridamole, and sildenafil, and further trials of all these agents will be important in due course. These examples also reveal the unlimited opportunity to future-proof our health care systems by proactively mining, synthesizing, cataloging, and evaluating the off-label treatment opportunities of thousands of safe, well-established, and affordable generic drugs.

UNSTRUCTURED Physician–patient collaboration was recognized as a critical core of participatory medicine more than a century ago. However, the subsequent focus on scientific research to enable cures and increased dominance of physicians in health care subordinated patients to a passive role. This paternalistic model weakened in the past 50 years—as women, minorities, and the disabled achieved greater rights, and as incurable chronic diseases and unrelieved pain disorders became more prevalent—promoting a more equitable role for physicians and patients. By 2000, a shared decision-making model became the pinnacle for clinical decisions, despite a dearth of data on health outcomes, or the model’s reliance on single patient or solo practitioner studies, or evidence that no single model could fit all clinical situations. We report about a young woman with intractable epilepsy due to a congenital brain malformation whose family and medical specialists used a collaborative decision-making approach. This model positioned the health professionals as supporters of the proactive family, and enabled them all to explore and co-create knowledge beyond the clinical realm. Together, they involved other members of the community in the decisions, while harnessing diverse relationships to allow all family members to achieve positive levels of health, despite the resistance of the seizures to medical treatment and the incurable nature of the underlying disease.

Chiropractic care is popular for low back pain, but may increase the risk for acute lumbar disc herniation (LDH). Low back pain is a common early (prodromal) symptom of LDH and commonly precedes LDH diagnosis. Our objective was to investigate the association between chiropractic care and acute LDH with early surgical intervention, and contrast this with the association between primary care physician (PCP) care and acute LDH with early surgery. Using a self-controlled case series design and population-based healthcare databases in Ontario, Canada, we investigated all adults with acute LDH requiring emergency department (ED) visit and early surgical intervention from April 1994 to December 2004. The relative incidence of acute LDH with early surgery in exposed periods after chiropractic visits relative to unexposed periods was estimated within individuals, and compared with the relative incidence of acute LDH with early surgery following PCP visits. 195 cases of acute LDH with early surgery (within 8 weeks) were identified in a population of more than 100 million person-years. Strong positive associations were found between acute LDH and both chiropractic and PCP visits. The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits. Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH. We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care.

We are fully aware that we could have wasted our time writing this message, as nobody might read it. Even those who read it might ignore it, and those who read and care about it might be unable to do anything. It may simply be too late. Nevertheless, this message describes the hopes we had back in 1999, imagining how the incredible digital tools whose birth we were witnessing, could change the world for the better. In 2019, when we wrote these words, we were saddened to realize that most of what we had imagined and proposed in the past 20 years could have been written the day before, without losing an iota of relevance. Whoever or whatever you might be, dear reader—a human, a sentient machine, or a hybrid—we would like you to understand that, rather than an attempt to predict the future, which probably continues to be an impossible endeavor, this message was meant to act as an invitation, regardless of when or where it is found, to engage in a conversation that has already transcended time and space, even if the issues it contains have become irrelevant.

UNSTRUCTURED We are fully aware that we could have wasted our time writing this message, as nobody might read it. Even those who read it might ignore it, and those who read and care about it might be unable to do anything. It may simply be too late. Nevertheless, this message describes the hopes we had back in 1999, imagining how the incredible digital tools whose birth we were witnessing, could change the world for the better. In 2019, when we wrote these words, we were saddened to realize that most of what we had imagined and proposed in the past 20 years could have been written the day before, without losing an iota of relevance. Whoever or whatever you might be, dear reader—a human, a sentient machine, or a hybrid—we would like you to understand that, rather than an attempt to predict the future, which probably continues to be an impossible endeavor, this message was meant to act as an invitation, regardless of when or where it is found, to engage in a conversation that has already transcended time and space, even if the issues it contains have become irrelevant.

This paper outlines a framework for identifying and classifying different types of patient engagement tools, available on online patient platforms, according to the flow of information and patient engagement concepts. We demonstrate the application of the framework using data collected from a purposive sample of eleven patient platforms, stratified by various attributes (for-profit/not-for-profit, single/multiple conditions, different conditions). This framework can help health care organizations in better understanding the processes supported by various tools, and thereby determining better ways to engage patients using web-based Platforms.

ObjectivesTo ask all clinical, administrative and support staff affiliated with a large network of healthcare facilities to identify the conditions that they consider as non-negotiable for their own deaths to be regarded as good.MethodsAll 3495 staff of a healthcare network were asked to rank 10 conditions according to how non-negotiable they would be for themselves during their final 3 months or few hours for their own deaths to be considered as good. They were also asked about whether they had thought about their own death in the last 3 months, if they had a will, believed in God, and in the possibility of a good death, and the intensity of their fear of death.Results2971 (85%) completed the survey. Most were female (79%) and clinical staff (65%). 93% believed in God, 60% had thought about their death recently, 33% had an intense fear of death, and 4% had a will. 64% considered a good death possible. Participants ranked dying at a preferred place, emotional support from family and friends and relief from physical symptoms as their top priorities. The lowest ranked conditions were (from the bottom) relief from psychological distress, performance of rituals and the right to terminate life. There were no statistically significant differences across genders or individual occupational groups.ConclusionMost of conditions for a good death of interest to healthcare professionals could be provided without sophisticated medical infrastructure or specialised knowledge, opening the door for new support services to make it possible for everyone, anywhere.

The question that forms the title of this article, "What do we need to protect, at all costs, during the 21st century?," speaks to the sizable changes in health care systems and settings that surround the continuing professional development (CPD) provider, and the need to establish a core set of principles and practices as the field moves forward from both theoretical and practical aspects. It also provided the focus for one of the five keynote lectures presented during the 2016 World Congress on Continuing Professional Development. As the planners of this keynote session, we sought to evoke answers to the question, not from the speaker, but from the audience itself, a process enabled by a highly engaging presentation style and powered by interactive digital technologies. Further, we believed that the session would not directly lead to suggestions to improve the theory and practice of CPD, but rather to create the biopsychosocial context-a sort of platform-on which such discussions can occur.

Physician–patient collaboration was recognized as a critical core of participatory medicine more than a century ago. However, the subsequent focus on scientific research to enable cures and increased dominance of physicians in health care subordinated patients to a passive role. This paternalistic model weakened in the past 50 years—as women, minorities, and the disabled achieved greater rights, and as incurable chronic diseases and unrelieved pain disorders became more prevalent—promoting a more equitable role for physicians and patients. By 2000, a shared decision-making model became the pinnacle for clinical decisions, despite a dearth of data on health outcomes, or the model’s reliance on single patient or solo practitioner studies, or evidence that no single model could fit all clinical situations. We report about a young woman with intractable epilepsy due to a congenital brain malformation whose family and medical specialists used a collaborative decision-making approach. This model positioned the health professionals as supporters of the proactive family, and enabled them all to explore and co-create knowledge beyond the clinical realm. Together, they involved other members of the community in the decisions, while harnessing diverse relationships to allow all family members to achieve positive levels of health, despite the resistance of the seizures to medical treatment and the incurable nature of the underlying disease.

Real-world drug repurposing—the immediate “off-label” prescribing of drugs to address urgent clinical needs—is a widely overlooked opportunity. Off-label prescribing (ie, for a nonapproved indication) is legal in most countries and tends to shift the burden of liability and cost to physicians and patients, respectively. Nevertheless, health crises may mean that real-world repurposing is the only realistic source for solutions. Optimal real-world repurposing requires a track record of safety, affordability, and access for drug candidates. Although thousands of such drugs are already available, there is no central repository of off-label uses to facilitate immediate identification and selection of potentially useful interventions during public health crises. Using the current coronavirus disease (COVID-19) pandemic as an example, we provide a glimpse of the extensive literature that supports the rationale behind six generic drugs, in four classes, all of which are affordable, supported by decades of safety data, and targeted toward the underlying pathophysiology that makes COVID-19 so deadly. This paper briefly summarizes why cimetidine or famotidine, dipyridamole, fenofibrate or bezafibrate, and sildenafil citrate are worth considering for patients with COVID-19. Clinical trials to assess efficacy are already underway for famotidine, dipyridamole, and sildenafil, and further trials of all these agents will be important in due course. These examples also reveal the unlimited opportunity to future-proof our health care systems by proactively mining, synthesizing, cataloging, and evaluating the off-label treatment opportunities of thousands of safe, well-established, and affordable generic drugs.

Public-private partnerships (PPPs) in public health have gained great attention in the global health literature over the last two decades. Evidence suggests that PPPs could contribute to mitigating complex health problems. There is, however, limited knowledge about the process and specific conditions in which PPPs for healthy eating, in particular, can be developed successfully. To address this gap, this article first summarizes the literature, and second, using qualitative content analysis, identifies factors deemed to influence the process of building PPPs for healthy eating. The literature search was undertaken in two stages. The first stage focused on PPPs in public health to understand what constitutes a PPP, and the types and characteristics of PPPs. The second stage sought empirical examples and conceptual papers related to PPPs for healthy eating to identify critical elements that could facilitate or hinder partnerships between the government and the food industry. The search yielded 38 articles on PPPs in public health and 20 on PPPs for healthy eating. The analysis generated 23 individual elements that have the potential to influence a successful process of building PPPs for healthy eating (eg, endorsement from an individual champion, equal representation from partner organizations on board committees). The analysis also yielded five factors that appeared to well-represent the 23 individual elements of PPP formation: motivation, enablers, governance, benefits, and barriers. These results constitute an important step to understand critical factors involved in the formation of PPPs in public health and should inform additional empirical research to validate them.

Objectives To evaluate how the rank probabilities obtained from network meta-analysis (NMA) change with the use of increasingly stringent criteria for the relative effect comparing two treatments which ranks one treatment better than the other. Study Design and Setting Systematic survey and reanalysis of published data. We included all systematic reviews (SRs) with NMA from the field of cardiovascular medicine that had trial-level data available, published in Medline up to February 2015. We reran all the NMAs and determined the probabilities of each treatment being the best. For the best treatment, we examined the effect on these probabilities of varying, what we call the decision threshold, the relative effect required to declare two treatments different. Results We included 14 SRs, having a median of 20 randomized trials and 9 treatments. The best treatments had probabilities of being best that ranged from 38% to 85.3%. The effect of changing the decision thresholds on the probability of a treatment being best varied substantially across reviews, with relatively little decrease (∼20 percentage points) in some settings but a decline to near 0% in others. Conclusion Rank probabilities can be fragile to increases in the decision threshold used to claim that one treatment is more effective than another. Including these thresholds into the calculation of rankings may aid their interpretation and use in clinical practice.

Chiropractic spinal manipulation treatment (SMT) is common for back pain and has been reported to increase the risk for lumbar disc herniation (LDH), but there is no high quality evidence about this. In the absence of good evidence, clinicians can have knowledge and beliefs about the risk. Our purpose was to determine clinicians’ beliefs regarding the risk for acute LDH associated with chiropractic SMT. Using a belief elicitation design, 47 clinicians (16 chiropractors, 15 family physicians and 16 spine surgeons) that treat patients with back pain from primary and tertiary care practices were interviewed. Participants’ elicited incidence estimates of acute LDH among a hypothetical group of patients with acute low back pain treated with and without chiropractic SMT, were used to derive the probability distribution for the relative risk (RR) for acute LDH associated with chiropractic SMT. Chiropractors expressed the most optimistic belief (median RR 0.56; IQR 0.39–1.03); family physicians expressed a neutral belief (median RR 0.97; IQR 0.64–1.21); and spine surgeons expressed a slightly more pessimistic belief (median RR 1.07; IQR 0.95–1.29). Clinicians with the most optimistic views believed that chiropractic SMT reduces the incidence of acute LDH by about 60% (median RR 0.42; IQR 0.29–0.53). Those with the most pessimistic views believed that chiropractic SMT increases the incidence of acute LDH by about 30% (median RR 1.29; IQR 1.11–1.59). Clinicians’ beliefs about the risk for acute LDH associated with chiropractic SMT varied systematically across professions, in spite of a lack of scientific evidence to inform these beliefs. These probability distributions can serve as prior probabilities in future Bayesian analyses of this relationship.

Objective To explore the role of online communities from the perspective of breast cancer survivors who are facilitators of face-to-face support groups. Methods Seventy-three attendees (73% response rate) of a Canadian support group-training program completed a questionnaire examining when and why they used online communities. A purposive sample of 12 respondents was interviewed on how they used them in comparison to traditional supportive care. Survey responses were analyzed using descriptive statistics, and interview transcripts using a descriptive interpretive approach. Results Online communities were used by 31.5%, mostly during treatment (73.9%), daily or weekly (91.3%), primarily for information (91.3%) and symptom management (69.6%) and less for emotional support (47.8%). Reasons for non-use were lack of need (48.0%), self-efficacy (30.0%), trust (24.0%), and awareness (20.0%). Respondents used online communities to address unmet needs during periods of stress and uncertainty. A multi-theory framework helps to explain the conditions influencing their use. Conclusion Online communities have the potential to fill gaps in supportive care by addressing the unmet needs of a subgroup of breast cancer survivors. Further research is required among typical cancer survivors. Practice implications Online communities could play an important role as a supplemental resource for a sub-group of breast cancer survivors.

Support is considered an important factor for realizing the benefits of health information technology (HIT) but there is a dearth of research on the topic of support, especially in primary care. We conducted a qualitative multiple case study of 4 family health teams (FHTs) and one family health organization (FHO) in Ontario, Canada in an attempt to gain insight into users’ expectations and needs, and the realities of end-user support for primary care electronic medical records (EMRs). Data were collected by semi-structured interviews, documents review, and observation of training sessions. The analysis highlights the important role of on-site information technology (IT) staff and super-users in liaising with various stakeholders to solve technical problems and providing hardware and functional (‘how to’) support; the local development of data support practices to ensure consistent documentation; and the gaps that exist in users’ and support personnel’s understanding of each other’s work processes.

Research problem: Tutorials and user manuals are important forms of impersonal support for using software applications, including electronic medical records (EMRs). Differences between user- and vendor-generated documentation may indicate support needs, which are not sufficiently addressed by the official documentation, and reveal new elements that may inform the design of tutorials and user manuals. Research question: What are the differences between user-generated tutorials and manuals for an EMR and the official user manual from the software vendor? Literature review: Effective design of tutorials and user manuals requires careful packaging of information, balance between declarative and procedural texts, an action and task-oriented approach, support for error recognition and recovery, and effective use of visual elements. No previous research compared these elements between formal and informal documents. Methodology: We conducted a mixed-methods study. Seven tutorials and two manuals for an EMR were collected from three family health teams and compared with the official user manual from the software vendor. Documents were qualitatively analyzed using a framework analysis approach in relation to the principles of technical documentation described before. Subsets of the data were quantitatively analyzed using cross-tabulation to compare the types of error information and visual cues in screen captures between user- and vendor-generated manuals. Results and discussion: The user-developed tutorials and manuals differed from the vendor-developed manual in that they contained mostly procedural and not declarative information; were customized to the specific workflow, user roles, and patient characteristics; contained more error information related to work processes than software usage; and used explicit visual cues on screen captures to help users identify window elements. These findings imply that to support EMR implementation, tutorials and manuals need to be customized and adapted to specific organizational contexts and workflows. The main limitation of the study is its generalizability. Future research should address this limitation and may explore alternative approaches to software documentation, such as modular manuals or participatory design.

Background Although access to information on health services is particularly important for recent immigrants, numerous studies have shown that their use of information and referral services is limited. This study explores the role played by 2-1-1 Toronto in supporting recent immigrants. Purpose The study objectives were to (1) understand whether 2-1-1 Toronto is reaching and supporting recent immigrants and (2) gain a better appreciation of the information needs of this population group. Methods A phone survey was conducted in 2005–2006 to collect information on 2-1-1 users' characteristics and levels of satisfaction. Survey data were compared (in 2006) with census data to assess their representativeness. To achieve Objective 2, semistructured qualitative interviews were conducted and analyzed in 2006–2007, with a subset of Spanish-speaking callers. Results Recent immigrants were overrepresented among 2-1-1 callers. However, the survey population was substantially younger and had higher levels of formal education than the general population. Health-related queries represented almost one third of the total. The survey showed very high levels of satisfaction with the service. Many interviewees described their first experiences with the Canadian healthcare system negatively. Most of them had relied on disjointed, low-quality information sources. They trusted 2-1-1 but had discovered it late. Conclusions Results are mixed in terms of 2-1-1's support to immigrants. A significant percentage of users do not take full advantage of the service. The service could become the information “entry point” for recent immigrants if it was able to reach them early in the resettlement process. Proactive, community-oriented work and a more creative use of technology could help.

It has been suggested that the quality of clinical trials should be assessed by blinded raters to limit the risk of introducing bias into meta-analyses and systematic reviews, and into the peer-review process. There is very little evidence in the literature to substantiate this. This study describes the development of an instrument to assess the quality of reports of randomized clinical trials (RCTs) in pain research and its use to determine the effect of rater blinding on the assessments of quality. A multidisciplinary panel of six judges produced an initial version of the instrument. Fourteen raters from three different backgrounds assessed the quality of 36 research reports in pain research, selected from three different samples. Seven were allocated randomly to perform the assessments under blind conditions. The final version of the instrument included three items. These items were scored consistently by all the raters regardless of background and could discriminate between reports from the different samples. Blind assessments produced significantly lower and more consistent scores than open assessments. The implications of this finding for systematic reviews, meta-analytic research and the peer-review process are discussed.

PurposeMany countries around the world have been undertaking initiatives to promote the improvement of care for people with chronic diseases. The purpose of this article is to showcase some of the innovations developed in Spain, with emphasis on the societal burden of chronicity and the emergent challenge of polypathology.MethodsThe database of the Observatory of Innovative Practices on Complex Chronic Disease Management (known in Spanish as OPIMEC and available at www.opimec.org) was used to identify innovations in Spain. Those that met five requirements were selected for this article. The person in charge of each innovation selected was contacted and asked to provide further information. All data gathered were organized in a similar way to facilitate a better understanding.FindingsSix out of 45 potentially eligible innovations were selected. The innovations are related to strategies, predictive tools, case management, home care and patient education.ConclusionThe innovations showed in this artic...

Information and communications technology (ICT) has great potential for helping China achieve a greater level of 'consumer-centered' health services. The objectives of the research were to: (i) explore the availability of ICT infrastructure for health in China; and (ii) develop an approach for Consumer-centered eHealth (CeH) Technology adoption to solve those problems. The approach to evaluating the ICT infrastructure in China involved examining variables of school enrolment, per capita income and governance variables on the number of PCs, fixed telephones, mobile phone subscribers and Internet users. These were evaluated using a double-log regression model and cross-sectional data on various provinces in China. The analysis was based on 31 of the 34 provinces, autonomous regions and municipalities that comprise Hong Kong, Macao and Taiwan. There were a number of main findings: (i) medical literacy and the number of Internet users had a statistically significant positive relationship with the number of PCs in each province; (ii) the combined school enrolment rate and per capita income had a statistically significant direct relationship with the number of fixed telephones and mobile phone subscribers; (iii) the combined school enrolment ratio and the number of fixed telephones had a statistically significant positive relationship with Internet usage; (iv) there were major inequalities in ICT connectivity between upper-middle, lower-middle and low income provinces in China; and (v) the information quality had statistically significant positive effect on all determinants. In order to improve access to health care, especially for remote rural areas and for the elderly in China, there is need to boost the availability and utilization of eHealth services. Each province will need to develop a road map in a strategic CeH plan that will, over time, enable its citizens to realize that vision.

The path to improving healthcare quality for individuals with complex health conditions is complicated by a lack of common understanding of complexity. Modern medicine, together with social and environmental factors, has extended life, leading to a growing population of patients with chronic conditions. In many cases, there are social and psychological factors that impact treatment, health outcomes, and quality of life. This is the face of complexity. Care challenges, burden, and cost have positioned complexity as an important health issue. Complex chronic conditions are now being discussed by clinicians, researchers, and policy-makers around such issues as quantification, payment schemes, transitions, management models, clinical practice, and improved patient experience. We conducted a scoping review of the literature for definitions and descriptions of complexity. We provide an overview of complex chronic conditions, and what is known about complexity, and describe variations in how it is understood. We developed a Complexity Framework from these findings to guide our approach to understanding patient complexity. It is critical to use common vernacular and conceptualization of complexity to improve service and outcomes for patients with complex chronic conditions. Many questions still persist about how to develop this work with a health and social care lens; our framework offers a foundation to structure thinking about complex patients. Further insight into patient complexity can inform treatment models and goals of care, and identify required services and barriers to the management of complexity.

Almost a decade ago, public health initiated a number of innovative ventures to attract investments from multinational drug companies for the development of new drugs and vaccines to tackle neglected diseases (NDs). These ventures - known as product development public-private partnerships (PD PPPs) - represent the participation of the public and private actors toward the discovery and development of essential medicines to reduce the suffering of over one billion people worldwide living with NDs. This systematic review aimed to identify empirical-based descriptive articles to understand critical elements in the partnership process, and propose a framework to shed light on future guidelines to support better planning, design and management of existing and new forms of PPPs for public health. Ten articles met the inclusion criteria and were analyzed and synthesized using qualitative content analysis. The findings show that the development stage of PD PPPs requires a careful initiation and planning process including discussion on values and shared goals, agreement on mutual interests & equality of power relation, exchange of expertise & resources, stakeholder engagement, and assessment of the local health capacity. The management stage of PD PPPs entails transparency, extensive communication and participatory decision-making among partner organizations. This review illustrates the difficulties, challenges and effective responses during the partnering process. This model of collaboration may offer a way to advance population health at present, while creating streams of innovation that can yield future social and financial dividends in enhancing the public's health more widely.

Given the increasing penetration and health care related use of the Internet, we examined the evidence on the impact of Internet-based interventions on pain. A search of Medline, CINAHL, PsycINFO, and the Cochrane Library was conducted for literature published from 1990 to 2010 describing randomized controlled trials that assessed the effects of Internet-based interventions on patients with pain of any kind. Of 6724 citations, 17 articles were included. The studies evaluated the effects of interventions that provided cognitive and behavioral therapy, moderated peer support programs, or clinical visit preparation or follow-up support on 2503 people in pain. Six studies (35.3%) received scores associated with high quality. Most cognitive and behavioral therapy studies showed an improvement in pain (n=7, 77.8%), activity limitation (n=4, 57.1%) and costs associated with treatment (n=3, 100%), whereas effects on depression (n=2, 28.6%) and anxiety (n=2, 50%) were less consistent. There was limited (n=2 from same research group) but promising evidence that Internet-based peer support programs can lead to improvements in pain intensity, activity limitation, health distress and self-efficacy; limited (n=4 from same research group) but promising evidence that social networking programs can reduce pain in children and adolescents; and insufficient evidence on Internet-based clinical support interventions. Internet-based interventions seem promising for people in pain, but it is still unknown what types of patients benefit most. More well-designed studies with diverse patient groups, active control conditions, and a better description of withdrawals are needed to strengthen the evidence concerning the impact of Internet-based interventions on people in pain.

Background Support is often considered an important factor for successful implementation and realising the benefits of health information technology (HIT); however, there is a dearth of research on support and theoretical frameworks to characterise it. Objective To develop and present a comprehensive, holistic, framework for characterising enduser support that can be applied to various settings and types of information systems. Method Scoping review of the medical informatics and information systems literature. Results A theoretical framework of end-user support is presented. It includes the following facets: support source, location of support, support activities, and perceived characteristics of support and support personnel. Conclusion The proposed framework may be a useful tool for describing and characterising enduser support for HIT. it may also be used by decision makers and implementation leaders for planning purposes.

The internet has been used to support and inform the lay person about health and healthcare services almost since its inception. One of the most popular elements of this is the exchange of informat...

From 1978 on, Spain rapidly expanded and strengthened its primary health care system, offering a lesson in how to improve health outcomes in a cost-effective manner. The nation moved to a tax-based system of universal access for the entire population and, at the local level, instituted primary care teams coordinating prevention, health promotion, treatment, and community care. Gains included increases in life expectancy and reductions in infant mortality, with outcomes superior to those in the United States. In 2007 Spain spent $2,671 per person, or 8.5 percent of its gross domestic product on health care, versus 16 percent in the United States. Despite concerns familiar to Americans--about future shortages of primary care physicians and relatively low status and pay for these physicians--the principles underlying the Spanish reforms offer lessons for the United States.

There has been an increase in the number of chronic pain clinical trials in which the treatments being evaluated did not differ significantly from placebo in the primary efficacy analyses despite previous research suggesting that efficacy could be expected. These findings could reflect a true lack of efficacy or methodological and other aspects of these trials that compromise the demonstration of efficacy. There is substantial variability among chronic pain clinical trials with respect to important research design considerations, and identifying and addressing any methodological weaknesses would enhance the likelihood of demonstrating the analgesic effects of new interventions. An IMMPACT consensus meeting was therefore convened to identify the critical research design considerations for confirmatory chronic pain trials and to make recommendations for their conduct. We present recommendations for the major components of confirmatory chronic pain clinical trials, including participant selection, trial phases and duration, treatment groups and dosing regimens, and types of trials. Increased attention to and research on the methodological aspects of confirmatory chronic pain clinical trials has the potential to enhance their assay sensitivity and ultimately provide more meaningful evaluations of treatments for chronic pain.

To explore the questions that community-dwelling individuals with a traumatic spinal cord injury (SCI) have regarding their chronic pain and to identify their preferred methods of acquiring this information.Semi-structured interviews were conducted with 12 individuals experiencing SCI-related chronic pain. Qualitative content analysis was used to identify participants' questions about their pain and to organise them according to emergent themes.Six themes pertaining to chronic pain were identified. These included: (1) cause, (2) communication, (3) expectation, (4) getting information, (5) management and (6) other's experience with chronic pain. Participants described using a variety of sources to obtain information about chronic pain including health care providers, other SCI-consumers and the Internet. Participants preferred to have chronic pain information available to them on an as needed basis.Individuals with SCI have numerous questions about their chronic pain and use a variety of information sources to answer them. Many are dissatisfied with the level of knowledge that family physicians have about SCI-related chronic pain. This study provides valuable information from the consumer's perspective, which can be used to develop interventions to help health care professionals and consumers manage SCI-related chronic pain.

SUMMARY Background Morphine Patient-Controlled Analgesia (PCA) increases the frequency of postoperative nausea and vomiting (PONV) and the effectiveness adding haloperidol is unknown. Methods 145 women scheduled to undergo short-stay surgery under general anaesthesia were randomly assigned in two groups: One group received 2 mg i.v. of haloperidol 30 minutes before the end of surgery plus 2 mg mixed with 50 mg of morphine for administration via PCA (Group H); the other group received the same analgesic scheme for pain management using two comparable i.v. boluses of saline (Group P). Furthermore, both groups received dexamethasone 4 mg during anaesthesia induction. Ondansetron (4 mg i.v.) was used for antiemetic rescue. Participants and outcomes assessors were blinded to group assignment. The primary endpoints were incidence of nausea, vomiting and antiemetic requirements during the first 24 hours after surgery. Secondary endpoints included sedation and morphine requirement. Results Cumulative data at 24 hours showed that the group H had less nausea (71.2% vs. 20.6%; RR 0.29 [95% CI: 0.17-0.46]) and vomiting (47% vs. 11.8%; RR 0.25; [95% CI: 0.12-0.49]), and required less ondansetron (66.7% vs. 17.7%), but had an increased incidence of sedation (NNH: 3.5; 95% CI, 2.3-6.7). The NNT for Total response (no nausea, no vomiting/retching) was 2.5 (0–2 hours) and 2 (2–24 hours). Conclusion A bolus of haloperidol 2 mg prior to the end of surgery followed by 2 mg mixed with 50 mg of Morphine for PCA administration can significantly reduce the frequency of PONV but at a cost of increased sedation.