Phone counselling effective for gene testing
COUNSELLING by telephone before and after gene testing for BRCA1/BRCA2  can be as effective and efficient as in-person counselling, according to US research published in the Journal of Clinical Oncology. Telephone counselling (TC) was also shown to be more cost-effective, costing between US$114.40 and US$321.40 less per patient than usual care (UC) counselling, depending on the location of the patient. The researchers wrote that in-person counselling was recommended by the US Preventative Services Task Force, but this was problematic for people with limited access to trained counsellors and genetic professionals. In the US, an estimated 350 000 women carry the BRCA1/BRCA2 mutation, but fewer that 15% have been identified. The authors found that TC was non-inferior to UC on all outcomes including cancer distress, perceived stress, genetic counselling satisfaction, physical function, and mental function at both 2 weeks and 3 months after counselling. The researchers found that the only measure in which TC was inferior was in the percentage of women who underwent testing after counselling, with 90.1% of UC and 84.2% of TC being tested. This lower testing rate “may be due to the fact that UC participants could provide DNA immediately”, the authors wrote, while TC participants had to travel to a clinic to provide a sample. However, they wrote that TC could “broaden the reach and accessibility” of genetic testing.

Death risk for after hours MI patients
PATIENTS attending hospital with acute myocardial infarction (MI) on weekends or at night are more likely to die than those who present in “regular” hours, according to research published in the BMJ. A systematic review of 48 studies from North America, Europe and elsewhere, involving 1 896 859 patients, found presenting in “off-hours” with acute MI was associated with higher short-term mortality, while those presenting with ST elevation MI (STEMI) off-hours were less likely to receive percutaneous coronary intervention within 90 minutes and had longer “door-to-balloon” time by nearly 15 minutes. The authors wrote that the difference in door-to-balloon times was “likely associated with availability of cardiologists, support staff for the cardiac catheterization laboratory, or both”. They wrote that an alternative explanation was that patients who present during off-hours “tend to be sicker”, often because they have delayed seeking medical attention. The implications of the results at a population level “may be substantial”, they wrote. The research indicated that one in 27 inhospital deaths in patients presenting with MI, or one in 29 deaths within 30 days after admission, would be prevented if the higher mortality during off hours was reduced. An accompanying editorial said hospital managers hoping to improve their performance for MI “should focus on improving their off-hour care, with the goal of providing consistently high quality care 24 hours a day and seven days a week”.

Reducing fever may spread flu
REDUCING fever through the use of antipyretic medications such as aspirin may increase the spread of infections, according to a mathematical modelling study published in the Proceedings of the Royal Society Biological Sciences. The review of published data on the effects of seasonal influenza suggested that fever suppression might increase the expected number of cases and deaths in the US for pandemic influenza by 1% and for seasonal influenza by 5%. The authors said fever suppression was a common strategy for patients with influenza, used by both parents and physicians because it made the patient feel better. However, “an individual whose fever has been reduced is likely to feel better and is therefore more likely to interact with others” by going back to work or school or other gatherings, the authors wrote. Fever suppression could also increase “both the rate and duration of viral shedding” which also increased transmission rates. The knock-on effect was “larger epidemics and hence greater morbidity and mortality”, the authors wrote. They calculated that at least 700 deaths a year could be prevented in the US by avoiding antipyretic medication. They suggested a “non-negligible proportion of the 50–100 million” victims of the 1918 flu epidemic could have survived if aspirin had not been widely used for fever suppression.

URTI interferes with warfarin
ACUTE upper respiratory tract infection (URTI) increases the risk of excessive anticoagulation in patients on warfarin, independent of antibiotic use, research published in JAMA Internal Medicine has found. A cohort of 12 006 patients receiving warfarin for about 6 years were assigned to one of three groups — patients with stable warfarin therapy who bought an antibiotic (antibiotic group; n = 5857); patients with an URTI but not receiving antibiotics (sick controls; n = 570); and patients who bought a warfarin refill (stable controls; n = 5579). The proportion of patients with a follow-up international normalised ratio (INR) of 5.0 or more was 3.2%, 2.6% and 1.2% respectively. The difference between the stable control group and both other groups was significant (P < 0.001 for antibiotic v stable; P < 0.017 for sick v stable), but the difference between the antibiotic and sick control groups was not (P = 0.44). The authors found that antibiotics that interfere with warfarin metabolism (eg, metronidazole and trimethoprim–sulfamethoxazole) posed a greater risk of excessive anticoagulation than those that do not. They also found that “cancer diagnosis, elevated baseline INR and female sex” predicted an INR of 5.0 or more at follow-up. An accompanying editor’s note said that URTI increased follow-up INR even without antibiotics probably because of a combination of “eating less, using acetaminophen [paracetamol]-containing medications, and developing fever”. “Of importance to us as clinicians is that most patients had minimal changes in the INR with antibiotics, indicating that we should not lower warfarin doses preemptively”, the editorial said. However, “patients with respiratory tract illness, especially those receiving an antibiotic that interferes with warfarin metabolism, as well as women, patients with cancer, and those with an elevated baseline INR, are at higher risk for excessive anticoagulation and should have additional INR monitoring”.

Parental age impacts mental health
THE offspring of younger mothers and of older fathers are at increased risk of mental disorders, although the nature of the outcomes varies, according to research published in JAMA Psychiatry. A total of 2 894 688 people born in Denmark between 1955 and 2006, whose parents were also born in Denmark, were followed up from 1995 to 2011. During that time 218 441 had their first psychiatric contact for any psychiatric disorder. Disorders were placed in 10 categories — any psychiatric diagnosis; those due to psychoactive substance abuse; schizophrenia and related disorders; mood disorders; neurotic, stress-related and somatoform disorders; eating disorders; personality disorders; mental retardation; pervasive developmental disorders; and behavioural and emotional disorders with childhood or adolescent onset. Parents aged 25–29 years at the child’s birth were the reference group. The authors found “an increased risk for a set of mental disorders in the offspring appears to be associated with younger mothers and older fathers”. In particular, they noted that young mothers were linked to an “increased risk for hyperkinetic disorder and behavioural and emotional disorders”.  They found several disorders showed little or no association with parental age, such as schizoaffective disorder, bipolar disorder and eating disorders/anorexia. The researchers wrote that given the complicated patterns of association between parental age and mental disorders “recommendations about optimal age of parenthood need to consider a broad range of biologically and psychosocially mediated variables that may be associated with younger and older parents”.

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