News p 1471 

Twenty years ago the secretary of state for social services of the last Labour government appointed Sir Douglas Black to chair a working group to review information on inequalities in health and suggest policy and research that should follow from this review.1 The report appeared in 1980 and received a cold reception from the new Conservative government.2 The climate for the reception of the Black report's successor—the independent inquiry into inequalities in health, chaired by Sir Donald Acheson and published this week3—is hopefully different. How do its findings and recommendations compare?

For 17 years of Conservative government the Labour party made political capital out of the non-implementation of the recommendations of the Black report. The announcement before the 1997 election that, if elected, Labour would commission an independent review into inequalities in health was therefore welcome.4 When launching the inquiry in July 1997 the minister for public health criticised the health strategy of the previous administration for “its excessive emphasis on lifestyle issues” which “cast the responsibility back on to the individual.”5 Given the history of the Black report—released with no press release and only 260 copies—the commitment to publish the new report was encouraging, as was the statement that “its conclusions, based on evidence, will contribute to the development of a new strategy for health.”3 The review's terms of reference, however, included the stipulation that it must …

https://www.bmj.com/content/bmj/317/7171/1465.full.pdf

The independent inquiry into inequalities in health: Is welcome, but its recommendations are too cautious and vague

2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Objective: To assess whether population screening for impaired vision among older people in the community leads to improvements in vision. Design: Systematic review of randomised controlled trials of population screening in the community that included any assessment of vision or visual function with at least 6 months9 follow up. Subjects: Adults aged 65 or over. Main outcome measure: Proportions with visual impairment in intervention and control groups with any method of assessing visual impairment. Results: There were no trials that primarily assessed visual screening. Outcome data on vision were available for 3494 people in five trials of multiphasic assessment. All the trials used self reported measures for vision impairment, both as screening tools and as outcome measures. The inclusion of a visual screening component in the assessments did not result in improvements in self reported visual problems (pooled odds ratio 1.04: 95% confidence interval 0.89 to 1.22). A small reduction (11%) in the number of older people with self reported visual problems cannot be excluded. Conclusions: Screening of asymptomatic older people in the community is not justified on present evidence. Visual impairment in this age group can usually be reduced with treatment. It is unclear why no benefit was seen. Further work is needed to clarify what interventions are appropriate for older people with unreported impairment of vision. Key messages Impaired vision is common among older people and has a variety of adverse associations General practitioners are currently obliged to offer an annual assessment of vision as part of the 75 and over programme Evidence for effectiveness of visual screening is lacking, but a small beneficial effect cannot be excluded The continued inclusion of screening for impaired vision in screening programmes for older people is not supported by the evidence Further work is needed to clarify appropriate interventions for older people with unreported visual impairment

https://www.bmj.com/content/bmj/316/7132/660.full.pdf

Effectiveness of screening older people for impaired vision in community setting: systematic review of evidence from randomised controlled trials

To evaluate the current visual status and ophthalmic history of a sample of elderly patients with fractured neck of femur and to study the relationship between visual status and demographic factors. A four-centre study of all patients admitted to hospital with fractured neck of femur. The setting was two district (Ayr, Dunfermline) and two teaching (Glasgow, Dundee) hospitals in Scotland. The study examined 537 patients aged 65 years and over admitted with acute fractured neck of femur to hospital. Bilateral visual impairment (binocular visual acuity worse than 6/12) was found in 239 of 518 patients (46%). Of this group, the principal causes for visual deficit were untreated cataract (49%), macular degeneration (21%), uncorrected refractive error (17%), and glaucoma (3%). The visually impaired group were more likely to have symptomatic visual complaints (58 vs 26%), however, were less likely to be under optometric care (71 vs 85%). A higher proportion of the group with visual impairment lived in areas of social deprivation (40 vs 26%). Patients with fractured neck of femur represent a frail elderly group that have poorer vision than that documented in any other elderly population. The visual defect was potentially remediable in the majority of cases but this group of individuals are not generally in touch with the ophthalmic services. Social deprivation appears to be associated with this groups' inability to access ophthalmic care.

/pdf/visual-impairment-in-elderly-patients-with-hip-fracture-1hcit7smeh.pdf

Visual impairment in elderly patients with hip fracture: causes and associations

Optometric and ophthalmic contact in elderly hip fracture patients with visual impairment.

The role of antisecretory drugs for the prevention of upper gastrointestinal bleeding in patients using anticoagulants is unclear. We investigated this question in a systematic review and meta-analysis.We searched Embase, PubMed, Web of Science, Scopus, the Cochrane Library, and clinicaltrials.gov thru April 2021 for controlled randomized trials and observational studies evaluating the association of proton pump inhibitors (PPIs) or H2-receptor antagonists with overt upper gastrointestinal bleeding in patients using anticoagulants. Independent duplicate review, data extraction, and risk of bias assessment were performed. Observational studies were included only if they provided results controlled for at least 2 variables. Meta-analyses were performed using random effects models.Six observational studies and 1 randomized trial were included. All but 1 study had low risk of bias. None of the studies excluded patients with concomitant aspirin or nonsteroidal anti-inflammatory drug use. For PPIs, the pooled relative risk of upper gastrointestinal bleeding was 0.67 (95% confidence interval 0.61, 0.74) with low statistical heterogeneity (I2 = 15%). Individual studies showed greater treatment effect in patients with higher risk for upper gastrointestinal bleeding (eg, nonsteroidal anti-inflammatory drug or aspirin use, elevated bleeding risk score). A single observational study evaluating the association of H2-receptor antagonists with upper gastrointestinal bleeding found a relative risk of 0.69 (95% confidence interval 0.24-2.02).Evidence drawn mostly from observational studies with low risk of bias demonstrate that PPIs reduce upper gastrointestinal bleeding in patients prescribed oral anticoagulants. The benefit appears to be most clearcut and substantial in patients with elevated risk of upper gastrointestinal bleeding. 

Association of Anti-Secretory Drugs with Upper Gastrointestinal Bleeding in Patients Using Oral Anticoagulants: A Systematic Review and Meta-Analysis.

Patients aged 60-75 years registered with one inner city general practice were sent a questionnaire asking when they last received an eye check by an optometrist. Of the 193 (77%) who responded, 110 (59%) had attended in the last 2 years, and 138 (74%) in the last 3 years. Males and those with mobility problems were less likely to have had their eyes checked. Seventy-seven previous non-attenders were offered an appointment with an optometrist and this was accepted by 34 (44%). These individuals showed a high level of ophthalmic morbidity. Discussion of optometric checks should be included in general practice health checks and the elderly surveillance programme.

Eye tests in the elderly: factors associated with attendance and diagnostic yield in non-attenders.

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Association of Anti-Secretory Drugs with Upper Gastrointestinal Bleeding in Patients Using Oral Anticoagulants: A Systematic Review and Meta-Analysis.

Eye tests in the elderly: factors associated with attendance and diagnostic yield in non-attenders.