Discrimination queried in GP exams
RESEARCHERS in the UK have found significant differences in outcomes for black and minority ethnic candidates and white candidates in some parts of the postgraduate examinations of the Royal College of General Practitioners (MRCGP). The research, published in the BMJ, included a cohort of 5095 candidates sitting the applied knowledge and clinical skills assessment tests in 2010–2012 and another 1175 candidates not trained in the UK, who sat an English language capability test (IELTS) and the Professional and Linguistic Assessment Board (PLAB) examination, required for registration. The researchers found significant differences persisted between white UK graduates and other candidate groups. UK-trained black and minority ethnic graduates were more likely to fail the clinical skills assessment at their first attempt than their white UK colleagues (17% v 4.5%), and those trained outside the UK were also more likely to fail the clinical skills assessment than white UK candidates (65% v 4.5%), but this difference was no longer significant after controlling for scores in the applied knowledge test, IELTS and PLAB examinations. “Previous training experience and cultural factors (which include physician-patient relationships, and communication and proficiency in spoken English) could help explain these differences between UK candidates and international medical graduates”, the researchers wrote. “However, these cultural factors cannot explain differences between white candidates and black and minority ethnic candidates who have trained in the UK, and who would have had similar training experiences and language proficiency.”

Details lacking on cosmetic surgery outcomes
DESPITE a dramatic increase in demand for cosmetic procedures in the past decade, there is limited high-quality evidence available about the psychosocial outcomes for patients, according to research published in JAMA Dermatology. The authors reviewed the literature to investigate the impact of facial cosmetic surgery and minimally invasive procedures on psychosocial variables to guide clinical practice and set norms for clinical performance. The analysis of 16 studies, including 11 that investigated rhinoplasty as an individual procedure or as part of other procedures, included 1021 people. The authors wrote that their aim was to determine if patient-reported psychological variables improved after surgical and minimally invasive facial cosmetic procedures. “Based on this systematic review of the literature, the evidence suggests that a number of psychosocial domains improve following facial cosmetic procedures, although the quality of this evidence is limited …”, they wrote, saying “the medical community must determine if these cosmetic interventions have a positive impact on patients beyond aesthetic rejuvenation”. The authors said there were potential positive psychosocial gains from cosmetic procedures and it was important to identify patients most likely to benefit to allow for preoperative screening. They said there were “numerous ethical challenges in cosmetic practice [that] may be better addressed with this information”.

Health costs rise to 9.5% of GDP
THE latest health expenditure report from the Australian Institute of Health and Welfare shows expenditure has increased from 8.4% of gross domestic product (GDP) in 2001–2002 to 9.5% in 2011–2012. The report said most of the increase coincided with the Global Financial Crisis. It also showed that the ratio of government health expenditure to taxation revenue remained stable between 2001–2002 and 2007–2008, increasing by less than 1% to 20.8%, but then jumped to 26.2% in 2009–2010 before declining to 25.6% in 2011–2012. “Over the decade to 2011–12, the Australian Government ratio of health expenditure to taxation revenue rose by 4.0 percentage points to 26.4%, while the state and territory governments ratio rose by 8.1 percentage points to 24.5%”, the report said. “Growth in health expenditure has largely been driven by increases in the volume of health goods and services purchased, rather than price.” The report said the estimated national average level of recurrent expenditure on health in 2011–2012 was $5881 per person, ranging from $5711 in NSW to $8512 in the NT. Governments funded 69.7% of total health expenditure during 2011–2012, while non-government funding of 30.3% was down from 32.8% in 2001–2002.

Dramatic drop in hip replacement mortality
A LARGE retrospective analysis of postoperative mortality after hip joint replacement in the UK has found it has fallen substantially since 2003. The analysis, published in The Lancet, included 409 096 primary hip replacements to treat osteoarthritis which were listed on the National Joint Registry between 2003 and 2011, described by the researchers as the largest arthroplasty register in the world. It found 1743 patients died within 90 days of surgery during the 8 years, with a substantial secular decrease in mortality from 0.56% in 2003 to 0.29% in 2011 after adjustment for age, sex, and comorbidity. The researchers wrote that several modifiable clinical factors were associated with decreased mortality — posterior surgical approach, mechanical thromboprophylaxis, chemical thromboprophylaxis with heparin (with or without aspirin), and spinal versus general anaesthetic. They suggested that widespread adoption of these four simple clinical management strategies “could, if causally related, further reduce mortality”. They also found that the type of prosthesis was unrelated to mortality, and that being overweight was associated with lower mortality. “The data are observational, so causality cannot be proven, but testing these findings with a randomised controlled trial is unfeasible and unethical”, the researchers wrote.

Sensor insulin pump reduces hypos
AUSTRALIAN researchers have shown patients with type 1 diabetes have fewer episodes of moderate to severe hypoglycaemia if they use a sensor-augmented insulin pump which automates insulin suspension when glucose levels fall too low. The research, published in JAMA, included 95 patients randomly allocated to use either a standard insulin pump or a sensor-augmented pump. Patients had a mean age of 18.6 years, mean duration of diabetes of 11 years and mean duration of pump therapy of 4.1 years. The baseline rate of severe and moderate hypoglycaemic events was much lower in the pump-only group than in the low-glucose suspension group (20.7 v 129.6 per 100 patient-months). However after 6 months, the adjusted incidence rate per 100 patient-months was 34.2 events for the pump-only group and 9.5 for the low-glucose suspension group. The researchers wrote that “it is notable” that the intervention group had no seizure or coma episodes, while these continued at the same rate in the control group. “These findings suggest that automated insulin suspension can reduce the incidence of hypoglycemic events in those most at risk, that is, those with impaired awareness of hypoglycemia”, they wrote.

Echo increases rheumatic heart disease detection
ECHOCARDIOGRAPHY is increasing detection rates of rheumatic heart disease (RHD), according to the authors of a review article published in Global Heart, the journal of the World Heart Federation (WHF). The WHF introduced new guidelines in 2012 on using echocardiography for the diagnosis of RHD. In the review, data from New Zealand, India and Africa showed echocardiography increased detection rates of both definite RHD cases and borderline cases (abnormal echocardiograms without clinical symptoms). In NZ, where echocardiographic screening has been used since 2008, the WHF criteria found a definite RHD case rate of 10 per 1000 in schoolchildren aged 10–13 years, and a borderline RHD rate of 24 per 1000. However, the review authors said the acceptability of long-term secondary prophylaxis for those with echocardiographically detected RHD had not been established or researched. “In most regions, children with an episode of acute [rheumatic fever] are admitted to hospital with the acute illness, often with painful arthritis. This allows families to understand well and accept, usually, the importance of secondary prophylaxis”, they wrote. “In contrast, the logic for secondary prophylaxis may not be understood by the family of an otherwise healthy child who is found to have echocardiographic RHD.” They called on cardiologists and cardiac surgeons to advocate for improvements in secondary prophylaxis programs, as this was pivotal for RHD control. “Portable echocardiography is a relatively new screening tool for RHD, which has raised awareness of the high prevalence of RHD in many countries”, they wrote, saying the natural history of subclinical echocardiographically detected RHD was the “most important research question to be answered before more widespread screening is endorsed”.

Bone density tests don’t reduce fractures
RESEARCHERS say the current clinical practice of repeating a bone mineral density (BMD) test every 2 years to improve fracture risk classification may not be necessary in those aged 75 years or older with untreated osteoporosis. The population-based cohort study, published in JAMA, included 310 men and 492 women from the Framingham Osteoporosis Study, who had two measures of femoral neck BMD taken between 1987 and 1999, and were assessed for risk of hip or major osteoporotic fracture for about 12 years following the second measure. During follow up, 113 participants (14.1%) experienced one or more major osteoporotic fractures (88 hip, 24 spine, five shoulder and 33 forearm). They were more likely to have reported a prior fracture, and to have a lower body mass index and baseline BMD than participants without a major osteoporotic fracture. On average, participants who experienced a major osteoporotic fracture lost BMD of 0.006 g/cm2 or 0.9% per year compared with 0.005 g/cm2 or 0.6% per year in participants without a fracture. “BMD change provided little additional information beyond baseline BMD for the clinical management of osteoporosis”, the authors wrote. “The second BMD measure resulted in a small proportion of individuals reclassified as high risk of hip or major osteoporotic fracture, and it is unclear whether this reclassification justifies the current US practice of performing serial BMD tests at 2.2-year intervals.”

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