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PubMed2002

Rationale and design of a clinical trial of a low-molecular-weight heparin in preventing clinically important venous thromboembolism in medical patients: the prospective evaluation of dalteparin efficacy for prevention of venous thromboembolism in immobilized patients trial (the PREVENT study).

The utility of low-molecular-weight heparin (LMWH) in the prophylaxis of venous thromboembolic disease has been examined using the surrogate endpoint of venographically identified thrombi. The largest portion of these thrombi were asymptomatic calf-vein thrombi. The clinical relevance of this observation is a matter of debate. The present study is designed to evaluate the impact of an LMWH on clinically important endpoints. The current study is a randomized, prospective, double-blinded, multicenter, multinational, controlled clinical trial comparing dalteparin with placebo in moderately high-risk hospitalized medical patients. A total of 3300 patients will be randomized to receive either 5,000 IU per day of dalteparin or placebo for 14 days. Patients will undergo appropriate evaluation for any symptomatic episodes and all patients will undergo a bilateral compression ultrasound (CUS) on day 21 to search for asymptomatic proximal thrombi. The primary endpoint is the combination of objectively confirmed symptomatic deep vein thrombi (DVT), fatal or non-fatal pulmonary emboli, all proximal DVT, and sudden death. This study will be the first study to examine clinically important endpoints in evaluating the effect of a LMWH in hospitalized medical patients. This study also is the first study to use CUS rather than venography in concordance with contemporary medical practice. This trial is thus designed to address this important question in a clinically relevant manner.

Adult↗
PubMed2001

Population-based prevention of eating disorders: an application of the Rose prevention model.

BACKGROUND: Several decades of concerted research on eating disorders have generated a broad range of proposed causal influences, but much of this etiologic research does not elucidate practical avenues for preventive interventions. Translating etiologic theory into community health interventions depends on the identification of key leverage points, factors that are amenable to public health intervention and provide an opportunity to maximize impact on the outcome of interest. Population-based preventive strategies, elaborated by epidemiologist Geoffrey Rose, can maximize the impact of public health interventions. In the case of eating disorders, Rose's model is instructive: Dieting stands out as risk behavior that may both fit Rose's model well and be a key leverage point for preventive intervention. METHODS: Grounded in Rose's work, this article lodges a theoretical argument for the population-based prevention of eating disorders. In the introductory section, existing research on the epidemiology of dieting is reviewed, showing that it is extremely common among adolescent girls and women and that the behavior has been implicated as a causal factor for disordered eating. Next, new evidence is offered to build a case for how a population-wide reduction in dieting may be an effective strategy for prevention of eating pathology. Finally Rose's prevention framework is used to introduce a unique and provocative perspective on the prevention of eating disorders. RESULTS: Dieting is a normative behavior in our culture with psychological and physiological effects in the causal chain leading to eating pathology. This behavior may represent an ideal target for population-based prevention. CONCLUSIONS: Theoretical and empirical evidence suggests that a population-wide reduction in dieting may be a justifiable and effective strategy for prevention of eating pathology.

Adolescent↗
PubMed1995

Improving residents' knowledge of cancer prevention: are physicians prepared for prevention?

BACKGROUND: Primary care physicians recognize the goal of integrating cancer-prevention strategies into clinical practice. However, there is little formal training in cancer prevention and early detection. This study describes the effectiveness of a cancer-prevention curriculum called "Recommendations for Cancer Prevention (ReCaP) for Residents" for primary care residency programs. METHODS: The ReCaP for Residents curriculum was organized into eight instructional modules by organ site-specific areas for which there are established primary and secondary cancer-prevention recommendations. The modules include content outlines, learning objectives, slides, and case studies. In-house faculty and 21 residents of two family practice programs participated in an intervention comprising seven one-hour modular presentations during their regular summer teaching program. An established cancer-prevention knowledge test with 100 test items was used to test the residents' knowledge before and after the intervention; the data were analyzed by factor analysis with principal-component extraction and varimax rotation. RESULTS: The residents knew significantly more about cancer prevention after the ReCaP for Residents program. The mean overall prevention knowledge increased significantly (p < .05), and the scores of six of eight specific organ-site areas also increased. CONCLUSION: This study provided evidence that ReCaP for Residents was an effective curriculum for increasing residents' knowledge of cancer prevention. The authors recommend that more extensive programs of this type be implemented.

Curriculum↗
PubMed1992

Inter-rater reliability of preventable death judgments. The Preventable Death Study Group.

This study examined the inter-rater reliability of preventable death judgments for trauma. A total of 130 deaths were reviewed for potential preventability by multiple panels of nationally chosen experts. Deaths involving a central nervous system (CNS) injury were reviewed by three panels, each consisting of a trauma surgeon, a neurosurgeon, and an emergency physician. Deaths not involving the CNS were reviewed by three panels, each consisting of two trauma surgeons and an emergency physician. Cases for review were sampled from all hospital trauma deaths occurring in Maryland during 1986. Panels were given prehospital and hospital records, medical examiner reports, and autopsy reports, and asked to independently classify deaths as not preventable (NP), possibly preventable (POSS), probably preventable (PROB), or definitely preventable (DEF). Cases in which there was disagreement about preventability were discussed by the panel as a group (via conference call). Results indicated that overall reliability was low. All three panels reviewing non-CNS deaths agreed in only 36% of the cases (kappa = 0.21). Agreement among panels reviewing CNS deaths was somewhat higher at 56% (kappa = 0.40). Most of the disagreements, however, were in judging whether deaths were NP or POSS. Agreement was higher for early deaths and less severely injured patients. For non-CNS deaths agreement was also higher for younger patients. When both autopsy results and prehospital care reports were available reliability increased across panels. A variety of approaches have been used to elicit judgments of preventability. This study provides information to guide recommendations for future studies involving implicit judgments of preventable death.

Central Nervous System↗
PubMed1999

How good is the Prevent model for estimating the health benefits of prevention?

STUDY OBJECTIVE: Prevent is a public health model for estimating the effect on mortality of changes in exposure to risk factors. When the model is tested by simulating a development that has already taken place, the results may differ considerably from the actual situation. The purpose of this study is to test the Prevent model by applying it to a synthetic cohort in which the development is unaffected by concealed factors. DESIGN: A micro-simulation model was developed to create basic data for Prevent and give "exact" results as to changes in risk factor prevalences and mortality. The estimates of Prevent simulations were compared with the "exact" results. MAIN RESULTS: Modelling one risk factor related to a cause specific mortality gave fairly similar results by the two methods. Including two risk factors Prevent tends slightly to overestimate the health benefits of prevention. CONCLUSIONS: The differences between the "exact" mortality and the Prevent estimates will be small for realistic scenarios and Prevent provide reasonable estimates of the health benefits of prevention.

Cause of Death↗
PubMed1999

Tuberculosis vaccination versus isoniazid preventive therapy: a decision analysis to determine the preferred strategy of tuberculosis prevention in HIV-infected adults in the developing world.

SETTING: The developing world. OBJECTIVE: To compare the strategy of TB vaccination with that of tuberculin skin-testing in conjunction with isoniazid (INH) in preventing tuberculosis in HIV-infected persons. For any clinical scenarios in which immunization would be more effective than INH preventive therapy, to determine the minimum necessary vaccine safety and effectiveness required. DESIGN: Decision analysis. A hypothetical cohort of 10000 HIV-infected persons, 65% of whom were tuberculin positive, living in the developing world, was studied. Probability estimates were based on BCG vaccine for the baseline analysis, and it was assumed that the vaccine cannot protect if given after infection. RESULTS: Under the probability estimates and assumptions of the analysis, tuberculin skin testing/INH preventive therapy would prevent 458 more cases of TB and 45 more deaths due to TB than TB vaccination. One- and two-way sensitivity analyses revealed no thresholds at which TB vaccination would be the preferred strategy. Vaccine safety did not impact the outcome of the analysis. Three-way sensitivity analysis revealed that if the prevalence of anergy were 35% and the risk of progression to active TB among anergic persons 12.2 cases per 100 person-years, a vaccine would have to be at least 87% effective to be preferred over INH preventive therapy. CONCLUSIONS: Under the conditions of the analysis, which did not account for cost or logistics, tuberculin skin testing/INH preventive therapy would be more effective than TB vaccination in preventing TB among HIV-infected persons. The hypothesized TB vaccine would prevent more TB than INH preventive therapy only in areas where the prevalence of anergy and risk of active TB if anergic were high, and vaccine effectiveness exceeded 87%.

Adult↗
PubMedDate not supplied

Medical students' improved attitudes toward prevention of cardiovascular diseases from entry to graduation. Preventive Cardiology Academic Cooperative Research Group of the National Heart, Lung, and Blood Institute.

First-year medical students have been previously reported to have positive attitudes about disease prevention, in general, and about cardiovascular disease prevention, in particular. Whether medical school experiences exert a positive, negative, or neutral effect on prevention-oriented attitudes in medical students is not known. We assessed attitudes toward heart disease prevention in 770 entering medical students enrolled at six selected American medical schools, each having some curricular emphasis on preventive cardiology, and repeated the attitude survey near graduation in the 750 fourth-year students enrolled in the six schools. Response rates were similar at each of the schools for each administration and averaged 88% in entering students and 74% in the graduating students. We used two mean attitude scores, ranging from 1.0 to 5.0 on a Likert scale, 5.0 representing the most positive attitude. The score treating the importance of primary prevention increased from 4.08 +/- 0.39 to 4.35 +/- 0.41. The attitude score concerning the importance of research in preventive cardiology also increased from 3.65 +/- 0.56 to 3.90 +/- 0.64 (P less than .0001 for both comparisons of first-year to fourth-year students). Analyses by school revealed similar increases, as did analyses for men, women, whites, and nonwhites. The results indicate that positive attitudes toward heart disease prevention can become even more positive during medical school. The perpetuation of positive attitudes should contribute to improved clinical prevention behaviors when these graduates embark on careers in medicine.

Adult↗
PubMed2006

[Comparison of the efficacy of different methods for the prevention of anti-D allo-immunization during pregnancy: targeted strategy limited to risk situations or associated with systematic prevention in the 3rd trimester].

BACKGROUND: In France, anti-Rh prophylaxis is currently based on systematic postnatal prevention which has validated efficacy (relative risk=0.04 versus placebo), associated with targeted antenatal prevention in the event of situations raising a risk of fetomaternal hemorrhage. In most industrialized countries, a systematic prevention policy is applied with immunoglobulin injections for the above cited situations and during the third trimester to cover the risk of spontaneous occult fetomaternal hemorrhage occurring at the end of pregnancy. OBJECTIVE: Compare the efficacy of two strategies for antenatal prevention. MATERIAL AND METHODS: Review of the literature of published comparative studies. Eleven studies were retained (two randomized trials, seven comparative studies, one before-after study, one population-based study) including more than 30,000 treated patients. RESULTS: Globally, immunization rate was to the order of 1.5% (1.2-1.9%) for targeted prevention limited to situations at risk and to the order of 0.2% (0-0.9%), all parities included, for systematic antenatal prevention. Comparative analyses have reported significant odds ratios of 0.20 and 0.37 in all subgroups. CONCLUSION: Despite the heterogeneous nature of the published studies, available data are in favor of systematic prevention: either with a 300g dose at 28GW or 100g at 28GW and 34GW complementary to the postnatal prevention. Few data are available on the real perinatal benefit of systematic prevention.

Female↗
PubMed1997

Guidelines for prevention of nosocomial pneumonia. Centers for Disease Control and Prevention.

This document updates and replaces CDC's previously published "Guideline for Prevention of Nosocomial Pneumonia" (Infect Control 1982;3:327-33, Respir Care 1983;28:221-32, and Am J Infect Control 1983;11:230-44). This revised guideline is designed to reduce the incidence of nosocomial pneumonia and is intended for use by personnel who are responsible for surveillance and control of infections in acute-care hospitals; the information may not be applicable in long-term-care facilities because of the unique characteristics of such settings. This revised guideline addresses common problems encountered by infection-control practitioners regarding the prevention and control of nosocomial pneumonia in U.S. hospitals. Sections on the prevention of bacterial pneumonia in mechanically ventilated and/or critically ill patients, care of respiratory-therapy devices, prevention of cross-contamination, and prevention of viral lower respiratory tract infections (e.g., respiratory syncytial virus [RSV] and influenza infections) have been expanded and updated. New sections on Legionnaires disease and pneumonia caused by Aspergillus sp. have been included. Lower respiratory tract infection caused by Mycobacterium tuberculosis is not addressed in this document. Part I, "An Overview of the Prevention of Nosocomial Pneumonia, 1994, provides the background information for the consensus recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC) in Part II, Recommendations for Prevention of Nosocomial Pneumonia." Pneumonia is the second most common nosocomial infection in the United States and is associated with substantial morbidity and mortality. Most patients who have nosocomial pneumonia are infants, young children, and persons > 65 years of age; persons who have severe underlying disease, immunosuppression, depressed sensorium, and/or cardiopulmonary disease and persons who have had thoracoabdominal surgery. Although patients receiving mechanically assisted ventilation do not represent a major proportion of patients who have nosocomial pneumonia, they are at highest risk for acquiring the infection. Most bacterial nosocomial pneumonias occur by aspiration of bacteria colonizing the oropharynx or upper gastrointestinal tract of the patient. Because intubation and mechanical ventilation alter first-line patient defenses, they greatly increase the risk for nosocomial bacterial pneumonia. Pneumonias caused by Legionella sp., Aspergillus sp., and influenza virus are often caused by inhalation of contaminated aerosols. RSV infection usually occurs after viral inoculation of the conjunctivae or nasal mucosa by contaminated hands. Traditional preventive measures for nosocomial pneumonia include decreasing aspiration by the patient, preventing cross-contamination or colonization via hands of personnel, appropriate disinfection or sterilization of respiratory-therapy devices, use of available vaccines to protect against particular infections, and education of hospital staff and patients. New measures being investigated involve reducing oropharyngeal and gastric colonization by pathogenic microorganisms.

Aspergillosis↗
PubMed2006

Evidence-based HIV behavioral prevention from the perspective of the CDC's HIV/AIDS Prevention Research Synthesis Team.

The evidence-based approach to health promotion and disease prevention is growing in many public health sectors, including HIV behavioral prevention. This approach is based on utilizing relevant and rigorous scientific evidence, most appropriately identified through a systematic research synthesis process. With regard to HIV behavioral prevention, this research synthesis process provides decision makers and prevention planners with the evidence base and recommendations they need to translate proven scientific research into practice. The Center for Disease Control and Prevention's HIV/AIDS Prevention Research Synthesis Team conducts such research synthesis activities to help improve HIV behavioral prevention efforts. The team's recent systematic review of the literature during 2000 to 2004 identified HIV behavioral interventions with the best scientific evidence of efficacy, called best-evidence behavioral interventions. Challenges still exist, however, for determining which of these interventions should be disseminated and implemented. Once translated into practice, if these best-evidence behavioral interventions are further evaluated for effectiveness, these findings and, perhaps, the synthesis of such findings can be used to further improve HIV behavioral prevention in the field.

Centers for Disease Control and Prevention, U.S.↗
PubMed2000

Clinical preventive medicine in primary care: background and practice: 1. Rationale and current preventive practices.

Impressive evidence supports the value of clinical preventive medicine, defined as the maintenance and promotion of health and the reduction of risk factors that result in injury and disease. Primary prevention activities deter the occurrence of a disease or adverse event, e.g., smoking cessation. Secondary prevention (screening) is early detection of a disease or condition in an asymptomatic stage so treatment delays or blocks occurrence of symptoms, e.g., mammographic detection of breast cancer. Tertiary prevention attempts to not allow adverse consequences of existing clinical disease, e.g., cardiac rehabilitation to prevent the recurrence of a myocardial infarction. Preventive services have decreased morbidity and mortality from both acute and chronic conditions. However, these services are underutilized for numerous reasons. Barriers to their use include physician, patient, and health system factors. The traditional disease/treatment model should be modified to incorporate more preventive services. The subsequent 2 parts of this review will discuss suggestions for integrating primary preventive services and screening into primary care practice.

Cause of Death↗
PubMed1991

Preventive care guidelines: 1991. American College of Physicians. Canadian Task Force on the Periodic Health Examination. United States Preventive Services Task Force.

Clinicians increasingly are urged to integrate preventive services into their clinical practices. To facilitate this process, several groups have developed practice guidelines for preventing disease in asymptomatic patients. In this paper, we compare and contrast preventive guidelines from the American College of Physicians (ACP), the Canadian Task Force on the Periodic Health Examination (CTF), the United States Preventive Services Task Force (USPSTF), and other well-known authorities. We chose these groups because they based their recommendations on explicit methods that include critical appraisal of the pertinent literature. Recommendations from these authorities usually are consistent with each other. Moreover, the ACP, CTF, and USPSTF all favor a shift away from the relatively simple classification of patients by age and sex for general preventive interventions to the more complex stratification of patients by additional risk factors and the formulation of a selective prevention strategy that is specific to each risk profile. Some guidelines, particularly the criteria used to define patients who are at increased risk for preventable disease and who should have more intensive surveillance, are difficult to interpret. Further research is needed to address some areas of disagreement and ambiguity. In addition, new tools must be developed to help physicians apply preventive guidelines, particularly those that require noting many patient-specific characteristics.

Canada↗
PubMed2001

Prevention: developing a framework for conceptualizing and evaluating outcomes of preventive services for older people.

There is growing preoccupation among policy makers and commissioners in developing preventive strategies and services. There is simultaneous concern with evidence-based purchasing and provision, within health and social care. In social care the evidence base regarding prevention is neither extensive nor robust. As the review of recent policy documents indicates, the concept of prevention is extremely slippery. What preventive services are and whether they are effective depends on the specific policy context, the overall service objectives and the perspective on outcomes adopted (user, carer, professional, service). Focusing on older people, the paper seeks a way through the confusion, locating prevention within a theoretical model of successful ageing. This conceptualizes ageing as involving adaptation to the changing balance between gains and losses over the life course. Successful ageing is perceived as the attainment of valued goals, the minimisation of losses and maximization of gains through the linked processes of selective compensation and optimisation. The paper then identifies necessary elaborations of the model to take into account the wider cultural and socio-economic context. This shapes and constrains the goals pursued and the resources available in adopting particular adaptation strategies. Within this model, preventive services may be conceived as resources to be drawn upon to support compensatory strategies. Similarly, outcomes and effectiveness of services may be evaluated in terms of whether they facilitate/allow older people to achieve valued goals. In developing and evaluating preventive services in social care the question of interest is reformulated: what contribution do specific services make in optimising gains and compensating for the losses that accompany ageing? This framework is explored in respect of two substantive areas ripe for secondary prevention services and strategies - bereavement and instrumental support in the home.

Adaptation, Psychological↗
PubMed2004

Suicide-preventive activities in psychiatric care: evaluation of an educational programme in suicide prevention.

To promote implementation of suicide-preventive activities, the Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) introduced a 200-h academic, postgraduate educational programme (based on the training-of-trainers model) in suicide prevention. This programme was provided at Karolinska Institute, Stockholm, for key persons in psychiatric care. Twenty-nine key persons from 11 psychiatric intervention clinics in Stockholm County attended the first course. Preconditions for implementing suicide-preventive activities were assessed by means of semi-structured interviews with all course participants still working in the intervention clinics (n=10). In all but one of these 10 clinics, a wide range of suicide-preventive activities had been implemented as a result of the NASP course. Activities varied in scope, but the key persons seemed to have succeeded in pinpointing the key elements in suicide prevention - the need for specific knowledge about the suicidal process and for well-defined suicide-preventive routines. However, organizational factors and staff turnover were obstacles to maintaining and making the activities routine. There is a need to strengthen the course participants' formal roles as implementers and encourage the clinical management in their continuous implementation of suicide-preventive activities.

Adult↗