From intervention to prevention

True primary prevention of disease or its complications now seems an attainable goal in many situations. The success of vaccination against various infections is the model—prevention before any hint of disease. Thus, the push is on to treat patients with minimal hyperlipidemia before target-organ symptoms develop, to treat hyperglycemia aggressively before complications become evident, and to treat rheumatoid arthritis with potent biologics early in the course of disease, even before we establish that the disease is running a destructive course. We often have only clinical gestalt to guide us in these choices. But we must remember that interventional trials of primary prevention are often difficult to conduct. By the very nature of primary prevention, the events of interest are fewer during the trials than during secondary prevention trials. Sample size and trial duration often must be substantial. In the current issue, three sets of authors alert us to the issues of prevention in three totally different conditions: ischemic stroke (page 433), diabetic retinopathy (page 447), and intimate partner violence (page 406). In all three, symptoms of the problem may not be recognized early, although risk factors can be identified. The challenge is to show that addressing and treating the risk factors improves the clinical outcome. The data are coming. In the meantime, the authors present a few suggestions for prevention (and recognition) of three disparate and common clinical problems.