Consanguineous marriage risks confirmed
NEW UK research has found that consanguineous marriage can more than double the risk of giving birth to a baby with a congenital anomaly, although the absolute risk is low. The research, published in The Lancet, also found a similar but expected increased risk in white British mothers aged over 34 years. The researchers said the high level of consanguineous marriage within the large Pakistani community in the study accounted for 31% of birth defects in babies of Pakistani origin. They investigated the influence of various maternal lifestyle and clinical risk factors in children with one or more anomalies from the Born in Bradford (BiB) study, which is tracking the health of 13 500 babies born between 2007 and 2011. Overall rates of congenital anomalies in the BiB babies (305.74 per 10 000 live births) were almost double national rates (165.90 per 10 000). Socioeconomic status did not explain the increased rates of birth defects in offspring of blood relatives and, in contrast with previous research, maternal smoking, alcohol consumption and obesity were not identified as risk factors in this cohort. A high level of maternal education was protective irrespective of ethnic origin, roughly halving the risk of having a baby with a congenital anomaly. The authors wrote that risks associated with consanguinity should be added to routine antenatal counselling about congenital anomaly risks associated with advanced maternal age, medication and alcohol consumption. An accompanying commentary, by Professor Alan Bittles of the Centre for Comparative Genomics at Murdoch University in Perth, said caution was needed in describing the effect of consanguineous marriage on congenital anomalies, “with a perceived doubling of risk as likely to alarm as inform unless accompanied by the baseline disease prevalence”.

New anticoagulant “effective” in VTE
APIXABAN provided “a simple, effective, and safe regimen for the initial and long-term treatment of venous thromboembolism” (VTE), according to the authors of a randomised double-blind study published in the New England Journal of Medicine. The researchers compared apixaban (10 mg twice daily for 7 days, then 5 mg twice daily for 6 months) with conventional therapy (subcutaneous enoxaparin followed by warfarin) in 5395 patients with acute VTE. They found the fixed-dose oral apixaban therapy was as effective as the conventional treatment but with a 69% reduction in major bleeding. “These findings add to the evidence that the new oral anticoagulants are simple alternatives to conventional therapy for patients with acute venous thromboembolism and address some lingering clinical questions”, the authors wrote. An accompanying editorial said new anticoagulants were not for every patient and more information was needed on reversal strategies, monitoring, approaches to treatment failure, adherence compared with warfarin and cost-effectiveness. “Shifting with care to new treatments is essential to safe and effective practice”, it said.

“Less is more” in psychosis therapy
A SMALL randomised controlled trial has identified “major advantages” of using a dose reduction/discontinuation (DR) strategy compared with maintenance treatment (MT) in patients with remission of first-episode psychosis. The research, published in JAMA Psychiatry, included 128 patients in the original trial in 2001–2002. For the long-term follow-up of 7 years, 103 patients remained in the study. The follow-up assessment included symptom severity and level of social functioning during the previous 6 months, relapses during the whole follow-up period, and the type and dose of antipsychotics used during the initial 2-year trial. The assessed recovery and functional remission rates for those assigned to a DR strategy were more than twice those of patients who were assigned to MT (40.4% v 17.6% and 46.2% v 19.6%, respectively), and there was no significant difference in the symptom remission rate (69.2% v 66.7%) between the groups. “Additional studies are necessary before these results are incorporated into general practice”, the researchers wrote. An accompanying editorial said that for most patients with psychosis “we need to determine which medication, for how long, in what minimal dose, and what range of intensive psychosocial interventions will be needed to help them get well, stay well, and lead fulfilling and productive lives”.

Control of CHD risks still low
AN analysis of US National Health and Nutrition Examination Surveys from 1988 to 2010 has found that despite progress, opportunities for improving concomitant hypertension and hypercholesterolaemia control persist. The analysis, published in Circulation, found that although concomitant hypertension and hypercholesterolaemia control improved over time, it remained low, with fewer than one in three patients attaining control of both risk factors. The researchers said prescribing antihypertensive and antihyperlipidaemic medications to achieve treatment goals, especially for older, minority, diabetic and cardiovascular disease patients, and accessing health care at least biannually, could improve concurrent risk factor control and coronary heart disease (CHD) prevention. They wrote that various strategies to reduce residual CHD risk in hypertensive patients, including treating blood pressure to lower goals and using different classes of antihypertensive medications, had limited impact. “However, treating moderate cholesterol elevations with low-dose statins reduced CHD 35% to 40%”, they wrote. “Significant opportunities remain for attaining national CHD prevention goals by improving concomitant hypertension and hypercholesterolemia control.”

Placebo OK for most patients
A US survey has found patients are open to the idea of placebo treatments, with up to 84% saying it is acceptable for doctors to recommend placebo treatments under certain conditions. The research, published in the BMJ, involved a telephone survey of 853 members of Kaiser Permanente Northern California, aged 18–75 years and seen by a primary care provider for a chronic health problem at least once in the previous 6 months. Less than 21% of respondents stated that it was never acceptable for doctors to recommend placebo treatments. The conditions under which patients said it was acceptable to recommend a placebo varied according to the doctor’s level of certainty about the benefits of the treatment, the purpose of the treatment and the transparency with which the treatment was described to patients. “Our findings also underscore the importance of honesty and trust in the prescription of placebo treatments”, the authors wrote. “Respondents indicated that the use of placebo treatments could have a negative impact on the doctor-patient relationship if patients learnt that a doctor had recommended a placebo to placate patient’s expectations for treatment — especially if it did not work.”

Home-based walking a winner
IN patients with peripheral artery disease (PAD) with and without classic claudication symptoms, a home-based walking exercise program significantly improved walking endurance, physical activity and patient-perceived walking endurance and speed, according to research published in JAMA. The randomised controlled trial of 194 participants with PAD involved a 6-month home-based group-mediated cognitive behavioural exercise intervention. The intervention consisted of a 1-hour instruction session at baseline and two exercise sessions, which included feedback on walking exercise and group interaction. The participants were encouraged to attend a group exercise session each week and walk at home for at least 45 minutes three times a week. The researchers found the program significantly improved the 6-minute walk performance, by an average of 53.5 m, compared with a control group. “The home-based walking exercise program did not require physician supervision and was safe for patients with PAD meeting inclusion criteria including passing a baseline exercise stress test”, the authors wrote. “Based on these findings, clinical practice guidelines should advise clinicians to recommend home-based walking programs with a weekly group-mediated cognitive behavioral intervention component for patients with PAD who do not have access to supervised exercise.”


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