https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00516-4.pdf

The World report on ageing and health: a policy framework for healthy ageing.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)62229-1.pdf

How to increase value and reduce waste when research priorities are set

This article reviews the scientific research that indicates that despite marked declines in public support for negative racial attitudes in the United States, racism, in its multiple forms, remains embedded in American society. The focus of the article is on the review of empirical research that suggests that racism adversely affects the health of nondominant racial populations in multiple ways. First, institutional racism developed policies and procedures that have reduced access to housing, neighborhood and educational quality, employment opportunities, and other desirable resources in society. Second, cultural racism, at the societal and individual level, negatively affects economic status and health by creating a policy environment hostile to egalitarian policies, triggering negative stereotypes and discrimination that are pathogenic and fostering health-damaging psychological responses, such as stereotype threat and internalized racism. Finally, a large and growing body of evidence indicates that experiences of racial discrimination are an important type of psychosocial stressor that can lead to adverse changes in health status and altered behavioral patterns that increase health risks.

/pdf/racism-and-health-i-pathways-and-scientific-evidence-uvsdsykho9.pdf

Racism and Health I: Pathways and Scientific Evidence

Under physiological conditions, the number and function of microglia--the resident macrophages of the CNS--is tightly controlled by the local microenvironment. In response to neurodegeneration and the accumulation of abnormally folded proteins, however, microglia multiply and adopt an activated state--a process referred to as priming. Studies using preclinical animal models have shown that priming of microglia is driven by changes in their microenvironment and the release of molecules that drive their proliferation. Priming makes the microglia susceptible to a secondary inflammatory stimulus, which can then trigger an exaggerated inflammatory response. The secondary stimulus can arise within the CNS, but in elderly individuals, the secondary stimulus most commonly arises from a systemic disease with an inflammatory component. The concept of microglial priming, and the subsequent exaggerated response of these cells to secondary systemic inflammation, opens the way to treat neurodegenerative diseases by targeting systemic disease or interrupting the signalling pathways that mediate the CNS response to systemic inflammation. Both lifestyle changes and pharmacological therapies could, therefore, provide efficient means to slow down or halt neurodegeneration.

Microglial priming in neurodegenerative disease.

Introduction 
Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care.


Methods 
Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa = 0.86).


Results 
We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions.


Conclusions 
Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step.

/pdf/prevalence-determinants-and-patterns-of-multimorbidity-in-4gqa2ewt19.pdf

Prevalence, Determinants and Patterns of Multimorbidity in Primary Care: A Systematic Review of Observational Studies

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)60240-2.pdf

Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

Health inequalities are systematic, socially produced and unfair: systematic because the differences in health outcomes are not randomly distributed but rather show a consistent pattern across the socioeconomic spectrum; socially produced because no Law of Nature decrees that the poor should endure greater ill health and premature mortality than the rich, and unfair because they are maintained by unjust social arrangements—arrangements which mean, for instance, that the chances of survival for many children are determined by the socio-economic position into which they are born. 1

/pdf/time-to-care-tackling-health-inequalities-through-primary-4fj6ddz3id.pdf

Time to care: tackling health inequalities through primary care

Background Influenza immunisation is recommended for all people aged ≥65 years and younger people with particular chronic diseases. The Quality and Outcomes Framework (QOF) has provided new financial incentives for influenza immunisation since 2004.

Aim To determine the impact of the 2004 UK General Medical Services contract on the overall uptake of, and socioeconomic inequalities associated with, influenza immunisation.

Design and setting Retrospective general-practice population database analysis in 15 general practices in Scotland, UK.

Method Changes in influenza-immunisation uptake for those in at-risk groups between 2003–2004 and 2006–2007 were measured, and variation in uptake examined using multilevel modelling.

Results Uptake rose from 67.9% in 2003–2004 to 71.4% in 2006–2007. The largest increases were seen in those aged <65 years with chronic disease, with uptake rising from 49.6% to 58.4%, but rates remained considerably lower than in those aged ≥65 years. Differences between practices narrowed (median odds ratio [OR] for two patients randomly selected from different practices: 2.13 (95% confidence interval [CI] = 2.00 to 2.26) in 2003–2004 versus 1.44 (95% CI = 1.40 to 1.49) in 2006–2007. However, inequalities in uptake by patient socioeconomic status did not change: adjusted OR for most deprived versus most affluent was 0.75 (95% CI = 0.70 to 0.80) in 2003–2004 versus 0.72 (95% CI = 0.68 to 0.76) in 2006–2007.

Conclusion Overall uptake rose significantly and differences between practices narrowed considerably. However, socioeconomic and age inequalities in influenza immunisation persisted in the first 3 years of the QOF. This contrasts with other ecological analyses, which have concluded that the QOF has reduced inequalities. The impact of financial incentives on inequalities is likely to vary, and some kinds of care may require more targeted improvement activity and support.

Impact of the GP contract on inequalities associated with influenza immunisation: a retrospective population-database analysis.

This is a bold attempt to master and summarise a vast body of knowledge. The authors have chosen to focus on several acute and chronic problems encoun-tered on a day-to-day basis by primary care physicians, namely: sore throat, UTI, congestive heart failure and diabetes. This allows them to describe characteristics and weaknesses of studies within this research domain, with which researchers working in primary health care will be able to readily identify. In taking this approach, the authors have been able to establish a clear direction of travel for the future of primary care research, both in identifying areas of need, and in making recom-mendations on appropriate research methodologies. The chapter provides a well constructed snapshot, as well as a wealth of references, for those interested in exploring problem solving skills in primary care in greater depth. From students and early-career research-ers, to more experienced researchers seeking a birds-eye perspective of experiences to-date, this summary reinforces the need for General Practice research to maintain a key strategic position, as outlined earlier in the introduction to this document.

The research agenda for general practice/family medicine and primary health care in Europe. Part 4. Specifi c problem solving skills

This is a bold attempt to master and summarise a vast body of knowledge. The authors have chosen to focus on several acute and chronic problems encountered on a day-to-day basis by primary care physicians, namely: sore throat, UTI, congestive heart failure and diabetes. This allows them to describe characteristics and weaknesses of studies within this research domain, with which researchers working in primary health care will be able to readily identify. In taking this approach, the authors have been able to establish a clear direction of travel for the future of primary care research, both in identifying areas of need, and in making recommendations on appropriate research methodologies. The chapter provides a well constructed snapshot, as well as a wealth of references, for those interested in exploring problem solving skills in primary care in greater depth. From students and early-career researchers, to more experienced researchers seeking a birdseye perspective of experiences to-date, this summary reinforces the need for General Practice research to maintain a key strategic position, as outlined earlier in the introduction to this document.

Michael Norbury

Papers

Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

Time to care: tackling health inequalities through primary care

Impact of the GP contract on inequalities associated with influenza immunisation: a retrospective population-database analysis.

The research agenda for general practice/family medicine and primary health care in Europe. Part 4. Specifi c problem solving skills

'Commentary on: The research agenda for general practice/family medicine and primary health care in Europe. Part 4. Specific problem solving skills'.