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Interventions effective in cutting antibiotic prescribing
A COCHRANE update on the effectiveness of interventions to reduce antibiotic prescribing for hospital inpatients has found that interventions can reduce antimicrobial resistance or hospital-acquired infections, and improve clinical outcome. The review also found that restrictive interventions work faster than persuasive interventions. The updated meta-analysis and review, first published in 2005, included 89 studies that reported 95 interventions. Most (84%) interventions targeted antibiotic prescribing (choice of antibiotic, timing of first dose and route of administration) and the remainder aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. It found four interventions intended to increase effective prescribing for pneumonia were associated with a significant reduction in mortality, and nine interventions intended to decrease excessive prescribing were not associated with a significant increase in mortality. The authors wrote that complex, multifaceted interventions were not necessarily more effective than simpler interventions. However, they said only 10 of 89 studies provided information on the cost of intervention. “The paucity of evidence about the cost effectiveness of guideline implementation in general is inexcusable”, they wrote.
Young adult obesity major risk for adverse events
A POPULATION-based study that followed a cohort of young men for 33 years has found that 48% of those who were obese were diagnosed with type 2 diabetes, hypertension, myocardial infarction, stroke or venous thromboembolism (VTE) or died before reaching 55 years of age. The study, published in BMJ Open, followed 6502 men born in Denmark in 1955 from 22 years of age. The cohort include 5407 (83%) men of normal weight as young adults, 353 (5%) underweight, 639 (10%) overweight and 97 (1.5%) obese. The researchers found that obesity was associated with an event rate that, compared with normal weight, was increased more than eightfold for type 2 diabetes, fourfold for VTE and double for hypertension, myocardial infarction and premature death. “The strong association between young adulthood obesity and [VTE] was of particular importance because it, to our knowledge, has not previously been reported”, the authors wrote. “The magnitude of the relative and absolute risk estimates emphasise the major clinical and public health implications associated with obesity in young adulthood.”
Penicillin helps in cellulitis recurrence
PATIENTS given prophylactic penicillin for 12 months after two or more episodes of leg cellulitis have fewer recurrences than those given placebo, without any increase in adverse effects, according to research published in the New England Journal of Medicine. The double-blind, randomised, controlled trial included 274 patients with two or more episodes of cellulitis of the leg, followed for 3 years. The treated group received 250 mg of penicillin twice a day for 12 months. During the prophylaxis phase, 30 of 136 participants in the penicillin group (22%) had a recurrence compared with 51 of 138 in the placebo group (37%). Overall, participants in the penicillin group had fewer repeat episodes than those in the placebo group (119 v 164) but the recurrence rates in the two groups were similar after penicillin prophylaxis was ceased. “Although some level of protection appeared to be sustained for several months after the end of prophylactic therapy, this effect was lost by 36 months, a finding that suggests that longer-term prophylaxis may be required”, the authors wrote. Patients with a high body mass index, pre-existing oedema, or at least three episodes of previous cellulitis were less likely to have a response to prophylaxis.
GI bleed may signal unrelated disease
A NON-VARICEAL upper gastrointestinal (GI) bleed may be a marker of disease or an indicator of a deterioration in non-GI comorbidity, according to a population-based cohort study of more than 16 000 patients and more than 81 000 controls published in PLOS Medicine. The researchers found a cumulative excess risk of death in the 5 years following a non-variceal upper GI bleed. The total 5-year risk of death due to GI causes (malignant or non-malignant) ranged from 3.6% to 15.2%, representing an excess over controls of between 3.6% (3.0%–4.2%) and 13.4% (12.4%–14.5%), respectively. In contrast, the total 5-year risk of death due to non-GI causes ranged from 4.1% to 46.6%, representing an excess over controls of between 3.8% (3.1%–4.5%) and 19.0% (17.5%–20.6%), respectively. “This analysis showed that although there was an excess risk of death from gastrointestinal causes, more than half the total excess risk of death was from unrelated non-gastrointestinal causes”, they wrote. The largest increases were from neoplastic and cardiovascular disease, but half of those who died from these two causes were not diagnosed before the upper GI bleed. “This finding suggests that, in addition to indicating upper gastrointestinal pathology, an upper gastrointestinal bleed is either a cause of non-gastrointestinal co-morbidity or an indicator of existing co-morbidity (whether diagnosed or undiagnosed)”, they wrote, suggesting that for patients who have a non-variceal upper GI bleed, reassessment of comorbidity should be considered in the follow-up period.
More risks with cosmetic breast implants
RESEARCHERS have called for further investigations into the long-term effects of cosmetic breast implants on the detection and prognosis of breast cancer after finding reduced survival among women with implants who develop the disease. The systematic review, published in the BMJ, involving nearly 47 000 women suggested that women with cosmetic breast implants had later stage tumours at diagnosis and a higher risk of breast cancer-specific mortality compared with women without implants. The authors warned that the results should be treated with caution because of gaps and limitations in the available literature. However, they said the accumulating evidence suggested women with cosmetic breast implants who developed breast cancer were at increased risk of being diagnosed with non-localised breast tumours than women with breast cancer who did not have implants. “Moreover, current evidence also suggests that cosmetic breast implants adversely affect breast cancer specific survival following the diagnosis of such disease”, they wrote.
Gene predicts weight-loss surgery success
RESEARCHERS have identified a genetic locus associated with weight loss after gastric bypass surgery. The research, published in the American Journal of Human Genetics, involved an exploratory genome-wide association study of 693 genetically unrelated individuals undergoing Roux-en-Y gastric bypass (RYGB) to identify a genetic locus that was reproducibly associated with weight loss after the procedure. The researchers said the study provided evidence for the use of genomics to identify the potential response of individuals to surgical procedures. They said knowledge of additional genetic contributors to weight loss, comorbidity resolution and adverse outcomes after RYGB and their use as clinical predictors of outcome could help to more precisely identify those who would obtain the greatest benefit from RYGB and other types of weight-loss surgery. “Furthermore, future identification of predictors of long-term weight stabilization would provide important information that would complement the identified predictors of initial weight loss”, they wrote. “Together, these approaches could facilitate identification of individuals who would benefit most from RYGB and thereby improve the overall utility of this highly effective yet invasive treatment.”