Flu vax may protect hearts
AN Australian study, published in Heart, has shown that influenza vaccination is significantly protective against acute myocardial infarction (AMI), with study participants who had an AMI (cases) being almost twice as likely to be unvaccinated as those who did not (controls). Of the 559 participants, who were patients in a Sydney tertiary hospital, 34 of the 275 cases (12.4%) and 19 of 284 controls (6.7%) had influenza and half were vaccinated. The researchers found influenza infection was not a significant predictor of recent AMI. However, influenza vaccination was significantly protective (odds ratio 0.55; 95% CI, 0.35‒0.85), with a vaccine effectiveness of 45% (95% CI, 15%‒65%). “Cardiovascular disease is the second largest contributor to disease burden in Australia, accounting for 18% of the total disability-adjusted life years lost”, the researchers wrote. “As such, even a small effect of influenza vaccination in preventing AMI may have significant population health gains.” They suggested the role of an expanded vaccination program for adults aged over 50 years — a significant proportion of those at risk of AMI — should be explored by further research. “At the least, clinicians should be aware of influenza and infection as an underlying and poorly diagnosed precipitant or comorbidity in hospitalised patients and of the preventive benefit of influenza vaccine for patients at risk for AMI”, the researchers wrote.

Midwife care gives best outcomes
A COCHRANE review has found that women who received continued care throughout pregnancy and birth from a small group of midwives were less likely to give birth preterm and required fewer interventions during labour and birth than when care was shared between different obstetricians, GPs and midwives. The researchers reviewed data from 13 trials involving a total of 16 242 women, with women at low risk of complications included in eight trials and high-risk women in five trials. They found that when midwives were the main providers of care throughout, women were less likely to give birth before 37 weeks or lose their babies before 24 weeks. They were also happier with the care they received, and consistently received fewer of some interventions, specifically amniotomy, use of regional analgesia, episiotomy and instrumental delivery. Women experiencing midwife-led care were on average more likely to experience spontaneous vaginal birth, a longer mean length of labour and be attended at birth by a known midwife. There were no differences in caesarean birth rates and stillbirth was not reported specifically. “Policy makers who wish to achieve clinically important improvements in maternity care, particularly around normalising and humanising birth, and preventing preterm birth should consider midwife-led continuity models of care and consider how financing of midwife-led services can be reviewed to support this”, the researchers wrote.

“Ideal” BP may not be best in CKD
QUESTIONS about optimal blood pressure (BP) targets in patients with chronic kidney disease (CKD) have been raised by a study showing that CKD patients with BP in the range of 130 to 159/70 to 89 mmHg had the lowest mortality rates. The study, published in Annals of Internal Medicine, included more than 650 000 US veterans with CKD and a mean age of 73 years. The researchers found that patients considered to have “ideal” BP (< 130/80 mmHg) had increased mortality rates because of the inclusion of persons with low systolic BP and diastolic BP. “Patients with stage 1 hypertension actually had the lowest mortality rates”, the researchers wrote. “These associations were consistent in patients with or without diabetes mellitus and in those with or without microalbuminuria.” An accompanying editorial said translating the findings into practice “is challenging”. However, the editorial said a “seemingly acceptable SBP combined with a low DBP may be a cause for concern, especially in older patients with CKD and comorbid conditions”.

Confront hand hygiene practices
THE success of translating the WHO’s recommendations for hand hygiene into health care practice has been shown in a quasi-experimental study in 43 hospitals in Costa Rica, Italy, Mali, Pakistan and Saudi Arabia. The study, published in The Lancet Infectious Diseases, used a step-wise approach in four 3–6 month phases to implement the WHO’s strategy. The researchers, including from Australia, assessed the hand-hygiene compliance of health care workers and their knowledge of microbial transmission and hand-hygiene principles. Overall compliance increased from 51.0% before the intervention to 67.2% after. “Compliance levels varied greatly between hospitals and were lowest in low-income and middle-income countries”, they wrote. The highest rates of compliance involved indications that protected health care workers from microbial contamination and infection. However, compliance with indications that would specifically protect patients was significantly lower before the intervention. The researchers said the success of the intervention showed that real-life observations of practices “are fundamental to confront health-care workers with their actual behaviour and responsibilities and to call for accountability with regard to patient safety”. They said their findings represented “powerful support for decision and policy makers to enforce implementation of WHO’s strategy”, already recommended by the US Centers for Disease Control and Prevention, the European Centre for Disease Prevention and Control, and by 50 national hand-hygiene campaigns, including in Australia.

Wedge insoles no good for knee OA
THE findings of a meta-analysis, published in JAMA, do not support the use of lateral wedge insoles for medial knee osteoarthritis. The meta-analysis of 12 trials involving 885 participants, including 502 using lateral wedge treatments, found that among trials comparing wedge insoles with neutral insoles, there were no significant or clinically important effects of laterally wedged insoles on knee pain. The researchers wrote that it was possible that lateral wedges “are no more efficacious than neutral inserts for pain reduction because their effect on medial loading of the knee does not affect pain”. “Although meta-analytic pooling of all the studies showed a statistically significant association between use of lateral wedges and lower pain in medial knee osteoarthritis, restriction of studies to those using a neutral insole comparator did not show a significant or clinically important association”, the researchers wrote.

Diabetes risk for young users of antipsychotics
CHILDREN and youth recently started on antipsychotic medication had a threefold greater risk of newly diagnosed type 2 diabetes than matched controls, according to a study published in JAMA Psychiatry. The retrospective cohort study included 28 858 young people aged between 6 and 24 years who had recently been prescribed antipsychotic drugs and 14 429 controls. Users of antipsychotics had a threefold increased risk for type 2 diabetes (hazard ratio [HR], 3.03; 95% CI, 1.73–5.32), which was apparent within the first year of follow-up (HR, 2.49; 95% CI, 1.27–4.88). The risk remained elevated for up to 1 year following discontinuation of antipsychotic use (HR, 2.57; 95% CI, 1.34–4.91). The researchers found 106 incident cases of type 2 diabetes (18.9 cases per 10 000 person-years). They wrote that 87% of antipsychotic users received atypical drugs. “Study findings were largely unchanged when the cohort was restricted to this group or to risperidone, the most frequently prescribed individual drug”, they wrote. “Olanzapine, quetiapine, ziprasidone, and aripiprazole were used less frequently, but each had a significantly elevated HR.”


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