Comprehensive Evidence-based Health Maintenance.

The potential of primary prevention to prevent, delay, or ameliorate disease is immense. However, the total spending on preventive services in the US remains astoundingly small and represents a meager 3.5% of total health care spending. Moreover, training focused on prevention in medical schools is often neglected, and time-constrained primary providers frequently omit effective preventive and early detection measures, or perform them perfunctorily. Indeed, preventable conditions of serious consequences including 'premature' mortality, cardiovascular events, and major organ failure are ubiquitous with the global obesity and diabetes epidemics, and the ongoing high prevalence of noxious habits and drug abuse. Although each aspect has been the subject of extensive research, a succinct evidence-base summary is scarce. We have conducted a review of high-quality evidence (systematic reviews, meta-analyses, and practice guidelines) over the last 20 years to extract the best updated recommendations on comprehensive disease prevention and approved screening, briefly citing significant risk reductions by lifestyle interventions, pharmacological prevention, cancer screening, other endorsed screening, immunizations, and issues in the patient-provider interface.

In RA, use of systemic glucocorticoids ≥5 mg/d (prednisolone-equivalent) was linked to MACE at 8.7 y.

SOURCE CITATION: So H, Lam TO, Meng H, et al. Time and dose-dependent effect of systemic glucocorticoids on major adverse cardiovascular event in patients with rheumatoid arthritis: a population-based study. Ann Rheum Dis. 2023;82:1387-1393.37487608.

The Cardiovascular Burden of Rheumatoid Arthritis - Implications for Treatment.

Mortality in rheumatoid arthritis is increased, about twice vs controls, and cardiovascular diseases are a major cause. The pathogenesis is primarily accelerated atherosclerosis of the coronary, cervical, and cerebral arteries, which is premature, pervasive, and progressive, but often occult, under-recognized, and under-treated. It is mostly driven by the chronic, systemic autoimmune inflammation, but increased prevalence of traditional risk factors and adverse effects of treatments are also very important. Inflammatory markers, disease severity, and duration are major determinants of the cardiovascular risk in rheumatoid arthritis, which is underestimated by usual methods. Cardiovascular protection is best achieved by suppressing inflammation and disease activity as early as possible ("treat-to-target"), and striving to achieve and maintain remission or lowest disease activity. Secondly, identifying and addressing the whole spectrum of traditional risk factors, currently often neglected, is necessary. Because long-term glucocorticoid exposure ≥5 mg/d may be associated with cardiovascular events and other harm, more intensive treatment, especially useful for bridging with methotrexate at the outset of treatment, needs to be limited in time and dosage. A multipronged approach may improve cardiovascular outcomes of RA patients in future studies.

In RA, new use of JAK inhibitors was associated with nonmelanoma skin cancer vs. TNF inhibitors at 2 y.

SOURCE CITATION: Huss V, Bower H, Hellgren K, et al; ARTIS group. Cancer risks with JAKi and biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis or psoriatic arthritis: a national real-world cohort study. Ann Rheum Dis. 2023;82:911-919. 36868796.

The spectrum of hospitalization-associated harm in the elderly.

Acutely ill patients are not infrequently referred to the hospital and admitted, when they could be diagnosed and managed in the ambulatory setting or by hospital-level care at home. Avoidable admissions are particularly regrettable when the wide spectrum of hospitalization-associated patient harm is considered. It includes acute discomfort to the patient due to multiple disturbing hospital stressors; an emotional trauma; the burden of multiple redundant tests begetting false-positive and incidental findings triggering further testing and cascades; highly prevalent adverse events and serious harm associated with medical care, such as nosocomial infections, delirium, falls, and adverse drug events; and a complex array of post-discharge complications including significant physical and functional decline; cognitive decline; flawed transitions of care; common post-discharge adverse events; and a substantial risk of readmission, restarting the vicious cycle and compromising patient well-being, safety, and outcomes. Elderly patients are especially vulnerable, but in-hospital patient harm is not limited to older adults and is associated with increased length of stay, escalating costs, and mortality. The myriad types of harm that often accompany hospital admission is often not fully appreciated. Better awareness may result in better preventive strategies, in finding alternatives to hospital admission in some cases, and may contribute towards an improved patient experience and safety when hospitalization is mandatory, and the provision of enhanced care in the vulnerable post-discharge period.

Six attitudes to promote personal, patient-centred care in an era of addictive technology.

In contrast with the rapid advances in medical knowledge and technology, the clinical encounter may often appear as perfunctory, impersonal, and unworthy to both patient and practitioner who is often immersed in the computer screen rather than the patient, stressed by improbable time constraints, and often finds deceptive relief in inappropriate test-ordering, prescriptions, and referrals. We suggest routinely adopting six attitudes to achieve a more balanced, personal, and patient-centred encounter: conducting a curiosity-driven encounter; emphasizing humanistic values; performing a complete physical examination; increasing patients' face time; addressing the patient's health as a whole; and rational test-ordering and judicious prescribing.