Trickle-down climate risk regulation.

Climate change impacts-including flooding, wildfires, and crop failures-are destroying ecosystems, homes, infrastructure, farms, and businesses. Regulators around the globe are paying increasing attention to what these events mean for banks and the financial system, with several attending not only to bank impacts from, but also bank contributions to, climate change. The European Central Bank, for example, is signaling to banks that they must plan and make their transition away from financing of fossil fuels-to respond not only to their own risks but also to the science pointing to the necessity of this transition for the planet and financial system. Yet in the US, the primary regulators of national and community banks are narrowly zeroing in on risks posed to the largest banks-those with over $100 billion in total consolidated assets-without attention to these banks' role in financing greenhouse gas-emitting activities and what they mean for other important financial actors. Such a "trickle-down" approach to regulation-assuming that protecting big banks will protect other, smaller financial entities and the financial system more broadly-obscures the financial crisis that is already underway and inadequately responds to scientific evidence on distinctive features of climate risk and impacts.

Do continuing medical education articles foster shared decision making?

INTRODUCTION: Defined as reviews of clinical aspects of a specific health problem published in peer-reviewed and non-peer-reviewed medical journals, offered without charge, continuing medical education (CME) articles form a key strategy for translating knowledge into practice. This study assessed CME articles for mention of evidence-based information on benefits and harms of available treatment and/or preventive options that are deemed essential for shared decision making (SDM) to occur in clinical practice. METHODS: Articles were selected from 5 medical journals that publish CME articles and are provided free of charge to primary-care physicians of the Province of Quebec, Canada. Two individuals independently scored each article with the use of a 10-item checklist based on the International Patient Decision Aid Standards. In case of discrepancy, the item score was established by team consensus. Scores were added to produce a total article score ranging from 0 (no item present) to 10 (all items present). RESULTS: Thirty articles (6 articles per journal) were selected. Total article scores ranged from 1 to 9, with a mean (+/- SD) of 3.1 +/- 2.0 (95% confidence interval 2.8-4.3). Health conditions and treatment options were the items most frequently discussed in the articles; next came treatment benefits. Possible harms, the use of the same denominators for benefits and harms, and methods to facilitate the communication of benefits and harms to patients were almost never described. No significant differences between journals were observed. DISCUSSION: The CME articles evaluated did not include the evidence-based information necessary to foster SDM in clinical practice. Peer-reviewed and non-peer-reviewed medical journals should require CME articles to include this type of information.

Delirium in older emergency department patients discharged home: effect on survival.

OBJECTIVES: To determine whether prevalent delirium is an independent predictor of mortality in older patients seen in emergency departments (EDs) and discharged home without admission. DESIGN: Prospective study with 18 months of follow-up. SETTING: EDs in two Montreal hospitals. PARTICIPANTS: From a cohort study of prognosis for delirium (107 delirious and 161 nondelirious subjects), 30 delirious and 77 nondelirious subjects aged 66 and older who were discharged home without admission were identified. MEASUREMENTS: Detailed interviews with patients and their proxies and review of medical charts were performed at enrollment. Trained lay interviewers determined delirium status using the Confusion Assessment Method. Subjects were followed up at 6-month intervals for a total of 18 months. Dates of death were obtained from the Ministère de la Santé et des Service Sociaux (Ministry of Health and Social Services). Survival analysis was performed using the Cox proportional hazards modeling adjusting for potential confounding variables. RESULTS: The analysis revealed a statistically significant association between delirium and mortality after adjustments for age, sex, functional level, cognitive status, comorbidity, and number of medications for the first 6 months of follow-up (hazard ratio = 7.24; 95% confidence interval = 1.62-32.35). The subjects whose delirium was not detected by the ED physician or nurse had the highest mortality over 6 months (30.8%). The mortality of delirious subjects detected in the ED was similar to that of the nondelirious subjects (11.8 vs 14.3%). CONCLUSION: The results of this study suggests that nondetection of delirium in the ED may be associated with increased mortality within 6 months after discharge. Further research is necessary to examine the effectiveness of improving detection on subsequent prognosis of older patients with delirium.

Prognostic factors for functional independence in older adults with mild dementia: results from the canadian study of health and aging.

We investigated the prevalence of and prognostic factors for functional independence in personal activities of daily living in a population-based sample of 90 seniors with mild dementia from the Canadian Study of Health and Aging. Personal activities of daily living were assessed from the report of proxy respondents at baseline and at the 5-year follow-up (or retrospectively if death had occurred). Sixteen (17.8% of the total group of 90) subjects maintained their personal activities of daily living independence over the full 5-year period or up to 3 months before death (15.1% if the four subjects reclassified as not demented at the second wave are excluded). An age of 75-84 years (vs. those 65-74 years of age and 85+ years of age; odds ratio 12.9, 95% confidence interval 2.7, 112.7), the absence of gait-balance-movement problems (odds ratio 5.2, 95% confidence interval 1.3, 25.8), the presence of extrapyramidal signs (odds ratio 9.5), and fewer years of formal education (odds ratio 3.6) were favorable prognostic factors in our multivariate modeling. An absence of sensory problems was a statistically significant favorable prognostic factor in bivariate analysis. Prior studies on the time required for patients with dementia to progress to functional milestones used clinic-based samples. Our findings, which have potential public health implications, need to be confirmed and expanded upon.

Donepezil and rivastigmine in the treatment of Alzheimer's disease: a best-evidence synthesis of the published data on their efficacy and cost-effectiveness.

BACKGROUND: Various drugs have been approved for the treatment of Alzheimer's disease (AD) in the United States and Canada, including donepezil and rivastigmine, although questions remain as to their efficacy, effectiveness, and long-term benefits. OBJECTIVE: The goal of this study was to conduct a best-evidence synthesis of data on the efficacy and cost-effectiveness of donepezil and rivastigmine in the treatment of AD. METHODS: Relevant published randomized controlled trials (RCTs) and Phase IV open-label extension studies (excluding abstracts) were identified through searches of MEDLINE, HealthSTAR, and PsycINFO for the period January 1984 to October 2001. The bibliographies of retrieved articles were searched for additional publications. For inclusion in the best-evidence synthesis, clinical trials had to pass a blinded quality assessment (score > or =5 on the Jadad scale) and use National Institute of Neurological and Communicative Disease and Stroke-Alzheimer's Disease and Related Disorders Association diagnostic criteria. Economic studies were selected using National Health Service Centre for Reviews and Dissemination criteria for reporting critical summaries of economic evaluations. RESULTS: Nine RCTs of donepezil and 2 of rivastigmine were identified and met inclusion criteria for the best-evidence synthesis. Eight donepezil trials and both rivastigmine trials included patients with mild AD (Mini-Mental State Examination [MMSE] score, 15-27) or moderate AD (MMSE score, 8-14); 1 donepezil trial included patients with moderate or severe AD (MMSE score, 0-7). In the RCTs of donepezil, the mean decrease in scores on the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) was greater with active treatment than with placebo (lower scores indicate less cognitive deterioration). In the RCTs of rivastigmine, ADAS-cog scores decreased over the follow-up period with both active treatment and placebo; however, scores decreased more with active treatment. Three Phase IV studies of donepezil and I Phase IV study of rivastigmine were identified. Their results were consistent with those of the RCTs. Ten economic studies (7 donepezil, 3 rivastigmine) were identified and reviewed. In 4 of the donepezil studies and all 3 rivastigmine studies, use of the drug cost less than a no-drug strategy. CONCLUSIONS: The efficacy data indicate that both donepezil and rivastigmine can delay cognitive impairment and deterioration in global health for at least 6 months in patients with mild to moderate AD. Patients receiving active treatment will have more favorable ADAS-cog scores for at least 6 months, after which their scores will begin to converge with those of patients receiving placebo. Differences in methodology, types of direct or indirect costs included, and sources of cost data made it difficult to compare and synthesize findings of the economic studies; therefore, the cost-effectiveness data are inconclusive.