Treatment with misoprostol by midwives is safe and eff ective

Because a test can only aff ect outcomes by changing care, the failure to follow best practices, or the ineff ectiveness of treatments, can be falsely attributed to the test. Indeed in the PARR-2 trial, 9 although performance of a cardiac PET viability scan did not change outcomes in patients with heart failure overall, patients who received PET-guided care (and not just a scan) had fewer events. SCOT-HEART bypassed this issue by using the upstream outcome of diagnostic certainty, but clinical events remain the preferred evidentiary standard. Third, if intermediate outcomes are used, what outcomes are most important to both patients and clinicians in guiding test selection? Diagnostic thinking is important, and might change processes of care, as shown in SCOT-HEART, but other unexamined parameters such as effi ciency, safety, and avoidance of unnecessary invasive procedures might be equally, if not more, salient. Finally, although the very low rate of clinical events in SCOT-HEART (ie, cardiovascular death or myocardial infarction were reported in just 68 [1·6%] participants in 1·7 years of follow-up) is encouraging in documenting an excellent prognosis for patients with new-onset stable chest pain receiving contemporary care, to show a diff erence in patient outcomes with diff erent testing strategies in view of this excellent prognosis would need a large incremental test eff ect driving diff erences in downstream care, an extremely large study sample, prolonged follow-up, or a combination of these factors. SCOT-HEART 7 provides important data regarding the eff ect of the addition of a new technology to usual care, and explores new methods for the theory and