News in brief

Statin users are eating up
THE importance of dietary modification by people taking statins has been highlighted in a US study that found caloric and fat intake among statin users in 2009˗2010 was significantly greater than in 1999˗2000. In a repeated cross-sectional study of more than 27 800 US adults, published in JAMA Internal Medicine, researchers found the increased caloric and fat intake by statin users between 1999 and 2010 was not mirrored in non-users. They also found the proportion of statin users in the study population more than doubled from 7.5% to 16.5% over the decade. Among statin users, caloric intake increased by 9.6% in the study period, but there was not a significant increase among non-users. Similar patterns were found with fat, with intake increasing by 14.4% among statin users compared with a 2.3% decrease in non-users. The mean body mass index of statin users also increased over the study period. The researchers said the study results showed that “it may be appropriate to reevaluate and discuss dietary recommendations in the time of statins”. “We believe that the goal of statin treatment, as with any pharmacotherapy, should be to allow patients to decrease risks that cannot be decreased without medication, not to empower them to put butter on their steaks”, they wrote. An accompanying editor’s note said the study raised concerns of a potential “moral hazard of statin use” in addition to known adverse effects. “Focusing on cholesterol levels can be distracting from the more beneficial focus on healthy lifestyle to reduce heart disease risk”, it said.

Coeliac disease a risk in kids with IBS
COELIAC disease is four times more prevalent in children with irritable bowel syndrome (IBS) than among children with recurrent abdominal pain from other causes, according to research published in JAMA Pediatrics. The 6-year prospective cohort study included 782 children with a median age of 6.8 years who had been referred to a tertiary referral centre for recurrent abdominal pain. Using the Rome III criteria, children were classified as having IBS, functional dyspepsia, functional abdominal pain, or another functional or organic disorder. Serological testing found 15 patients who tested positive for coeliac disease — 12 of 270 patients with IBS (4.4%), two of 201 patients with functional dyspepsia (1%), and one of 311 patients with functional abdominal pain (0.3%). The researchers wrote that the identification of IBS as a high-risk condition for coeliac disease might help in paediatric primary care because, rather than routinely testing for coeliac disease indiscriminately in all children with recurrent abdominal pain, screening could be restricted to children with IBS. “This new approach might have important implications for the cost of care because it has been estimated that in children with FGIDs [functional gastrointestinal disorders], screening tests are common, costs are substantial, and the yield is minimal”, they wrote. “Considering that, in our series, 1 in 23 children with IBS has celiac disease, the immediate testing for celiac disease would result in a significant reduction in the cost of diagnostic procedures.” An accompanying editorial said selective screening for coeliac disease was warranted for children with IBS but not for children with other FGIDs. “However, the lines distinguishing IBS from alternative FGIDs are often blurred. It is within this reality that pediatric health care providers should examine the evidence, evaluate the patient and family, weigh the likelihood of a false-positive test result, and make the decision that they believe will benefit the patient most”, it said.

Child abuse–mental disorders link “robust”
A LARGE Canadian study shows 32% of the adult population has experienced child abuse — physical abuse, sexual abuse and/or exposure to intimate partner violence (IPV) — which has “robust associations” with mental conditions. The research, published in CMAJ, found all three types of child abuse were associated with mental disorders, self-reported mental conditions, suicidal ideation and suicide attempts. It also found the “least severe” type of physical abuse (being slapped on the face, head or ears, or hit or spanked with something hard) showed a strong association with mental conditions, including suicidal ideation and suicide attempts. The researchers used data from the 2012 Canadian Community Health Survey: Mental Health, with a representative sample of 25 113 respondents aged 15 years and older. Most respondents were interviewed (87%) in person by trained lay interviewers. The researchers found the prevalence of any of the three types of child abuse was 32.1%, with physical abuse the most common (26.1%), followed by sexual abuse (10.1%) and exposure to IPV (7.9%). They wrote that the strongest findings for mental conditions were for drug abuse/dependence, suicidal ideation and suicide attempts. “We found a dose–response relation, with a trend of more types of child abuse corresponding with greater odds of mental conditions”, they wrote. They said although several mental conditions were assessed in the survey, many important disorders (eg, personality disorders) were not included, and several disorders were assessed using self-reported diagnoses. “Clinicians working in the mental health field should be skilled in assessing patients for exposure to abuse and should understand the implications for treatment”, the researchers wrote.

Fetal growth predicts stillbirth
BOTH restricted and excessive fetal growth have been linked to stillbirth in a study published in PLOS Medicine. The researchers identified abnormal fetal growth in 25% of stillbirths using population norms. However, by using a new approach to estimate gestational age based on ultrasound and individualised norms they found abnormal fetal growth accounted for almost 60% of stillbirths. The research included analyses of 527 singleton stillbirths and 1821 singleton live births. The researchers found that, based on the new approach a fetus that was small for gestational age (SGA) was associated with a three- to four-fold increased risk of stillbirth compared with a fetus with an “appropriate” weight for gestational age. Large for gestational age (LGA) was associated with an increased risk of stillbirth based on the ultrasound and individualised norms but not the population norms. The more severely SGA or LGA (below the 5th percentile or above the 95th percentile) was associated with an increased risk of stillbirth. “Our results suggest that, contrary to current practices and recommendations, the most effective approach to identifying fetal growth abnormalities for prediction and prevention of stillbirth would focus on both severe SGA and LGA (<5th an >95th percentile) pregnancies and would use norms developed from normal pregnancies, rather than population norms, for fetal growth surveillance”, the researchers wrote. “This strategy would identify as at risk almost half of the pregnancies that would result in stillbirth.”

Mental health impacts of conflicts
AUSTRALIAN researchers have shown the need for a multitiered approach to advancing recovery and reconstruction in communities in the aftermath of war and conflict. The research, published in The Lancet Global Health, found that communities that continued to experience repeated violence after a war could have a major escalation in rates of post-traumatic stress disorder (PTSD) and severe distress. The 6-year longitudinal study in Timor-Leste assessed 1022 adults exposed to ongoing internal conflict following the Indonesian occupation after independence. The participants were first assessed in 2004 and again in 2010–2011. The researchers found the prevalence of PTSD increased from 23 of 1022 (2.3%) in 2004, to 171 of 1022 (16.7%) in 2010, while the prevalence of severe distress increased from 57 of 1022 (5.6%) to 162 of 1022 (15.9%). Both these outcomes were associated with disability at follow-up. “Our findings are novel in showing that a period of internal violence was associated with a major escalation in the prevalence of post-traumatic stress disorder and severe distress among a population previously exposed to prolonged conflict”, the researchers wrote. “Recurrent internal conflict is common in post-conflict countries and hampers socioeconomic development. Our study is the first to show its specific adverse effect on the mental health of the population.” An accompanying commentary said that by “recognising the moral, legal, and political links between trauma, perpetrators, and social context, the adverse effects can be better linked to means of personal and social recovery and resilience”.

Breast screening anxiety “transient”
WOMEN who have false-positive mammogram results have an initial significant increase in personal anxiety but these effects are transient, according to research published in JAMA Internal Medicine. The researchers also found that women were motivated to avoid false-positive mammograms, with a large proportion of women prepared to travel for 4 hours to have a hypothetical test that would reduce the chance of a false-positive result. Most women would also choose a mammography with reduced false positives over one with reduced breast compression. The quality-of-life telephone survey included 1028 women who were questioned shortly after breast screening and again at 1-year follow-up. Anxiety was initially significantly higher for women with false-positive mammograms compared with women with negative results, but health utility scores did not differ and there were no significant differences between groups at 1 year. Future screening intentions differed by group (25.7% v 14.2% more likely in false-positive than in negative groups) but willingness to travel and stay overnight did not (9.9% v 10.5% in false-positive v negative groups). Future screening intention was significantly increased among women with false-positive mammograms, younger age and poorer health. The researchers wrote that the results provided useful information for health care providers who counsel individual women on whether to initiate breast cancer screening and for policymakers assessing the clinical effectiveness of mammographic screening. An accompanying commentary said that given the controversy concerning the risks and benefits of mammography, “it is critical to enhance patients’ understanding of screening, to engage patients in shared decision making, and to communicate and reconcile abnormal results in a patient-centered and efficient fashion”.