Underuse of beta-blockers following myocardial infarction: a tale of two cities

Aims: To measure factors associated with underuse of beta-blocker therapy after myocardial infarction (MI). Methods: The Newcastle and Perth collaborating centres of the World Health Organization (WHO) MONICA project (to MONItor trends and determinants of Cardiovascular disease) systematically evaluated all patients admitted to hospital in their respective regions with possible MI. A total of 1766 patients in Newcastle and 4503 patients in Perth, discharged from hospital after confirmed MI from 1985 to 1993, were studied, Rates of beta-blocker use before and after hospital discharge were evaluated and correlates of beta-blocker use determined. Results: Beta-blocker use was similar in Newcastle and Perth before MI (21% of patients in each centre). During hospital admission, beta-blocker therapy was initiated nearly twice as frequently in Perth compared with Newcastle (66 vs 36%, respectively) and more patients were discharged from hospital on beta-blockers in Perth (68%) than in Newcastle (45%). The main factors associated with underuse of beta-blockers in multivariate analysis were geographical centre (odds ratio (OR) for Newcastle compared with Perth 0.3 95% confidence interval (CI) 0.3-0.3), a history of previous MI (OR 0.6, 95% CI 0.5-0.7), admission to hospital in earlier years (OR 0.4, 95% CI 0.3-0.4 for years 1985-87 compared with years 1991-93), diabetes (OR 0.6, 95% CI 0.5-0.8) and the concomitant use of diuretics (OR 0.5, 95% CI 0.4-0.6) and calcium antagonists (OR 0.6, 95% CI 0.5-0.8). Conclusions: Underuse of beta-blockers after MI was strongly related to hospital prescribing patterns and not to community use of beta-blockers. Underuse occurred in patients with diabetes and in patients with left ventricular dysfunction, patients who stand to benefit most from beta-blocker use following MI.

Enhancing emancipatory systems methodologies for sustainable development

Our interest lies in applying the principles of critical systems thinking to human activity systems in developing countries in situations where issues of natural resource sustainability constrain the feasible set of long-term strategies. The concept of sustainable development provides an expanded domain for critical systems thinking. The fundamental values underpinning sustainable development are that both intragenerational and intergenerational equity are important. As a consequence, key stakeholders are often excluded from power-sharing within current social systems. Addressing these issues requires renewed focus on emancipatory commitment and methodologies. To date, Ulrich's critical systems heuristics is the only critical systems methodology that offers practicable tools for emancipation. A case study analysis in Tigray, northern Ethiopia, provides insights in relation to the application of critical system heuristics to issues of sustainable development and highlights the need to extend the use of critical systems heuristics beyond the design and monitoring of structured interventions.

The Winnipeg principles, WTO and sustainable development: Proposed policies for reconciling trade and the environment

There is, a widespread belief that the WTO has made virtually no concessions to environmentalists about their concerns arising from free trade and the process of globalization. There are concerns that these processes may undermine prospects for sustainable development. Following, the United Nations Conference on Environment and Development held in Rio de Janeiro in 1992, the International Institute for Sustainable Development was established to advocate policies to support sustainable development within Canada and globally. In 1994, it proposed the Winnipeg Principles as. a means for reconciling international trade and development so as to: achieve sustainable development (ISD, 1994a,b). These seven principles are outlined in this article and assessed:. Although the International Institute for Sustainable Development had hoped: through these principles to influence the work programme of the Environment and Trade Committee of WTO, it seems to have little effect. Probably if these principles had been seriously considered by WTO, the serious social conflicts which emerged globally at the beginning of this century would have been avoided, and we would be in a better position to understand the complex links between trade, environment and sustainable development and adopt relevant policies. Copyright (C) 2001 John Wiley & Sons, Ltd and ERP Environment.

Overcrowding and Infant Mortality: A Tale of Two Cities

Using detailed historical data for the cities of Glasgow and Edinhurgh, evidence is found in support of the hypothesis that overcrowding is a significant cause of infant mortality. We distinguish between voluntary overcrowding (due to the budgetary choices of poor families) and involuntary overcrowding (due to market failure in the provision of an adequate supply of appropriate housing). We found that, over the fifty year period, 1911-1961, Glasgow's infant mortality rate was significantly higher than that of Edinburgh, despite their close geographical proximity, and that a large part of the difference can he attributed to involuntary overcrowding in the first half of the twentieth century. We argue that this was due to the distinctly different housing policies adopted by the two cities, with important lessons for present day public authorities.