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Cardiac screening not advised for low-risk patients
THE American College of Physicians has advised doctors not to use resting or stress electrocardiography (ECG), stress echocardiography, or stress myocardial perfusion imaging to screen for cardiac disease in asymptomatic, low-risk adults. In an article published in the Annals of Internal Medicine the college’s High Value Care Task Force wrote that cardiac screening had not been shown to improve patient outcomes and was associated with potential harms due to false-positive results that could lead to potentially unnecessary tests and procedures. The advice was based on a systematic review and recommendations from the US Preventive Services Task Force on screening with ECG; guidelines and standards developed by the American College of Cardiology in conjunction with other professional societies; and articles on the yield, benefits and harms of cardiac screening. The taskforce said cardiovascular risk assessment should start with a global risk score combining individual risk factor measurements into a single quantitative estimate of risk. However, it said recommendations for cardiac screening in higher risk patients were less clear-cut. “Implementing recommendations that focus on initial cardiovascular risk assessment based on traditional cardiovascular risk factors and using a global risk score, addressing modifiable risk factors, and not performing additional cardiac screening in low-risk patients would improve patient care while avoiding unnecessary harms and costs”, the taskforce wrote. “To be most effective, efforts to reduce the use of imaging should be multifocal and should address clinician behaviors, patient expectations, direct-to-consumer screening programs, and financial incentives.”
Better longer-term outcomes from CABG
A RANDOMISED controlled trial has found that in patients with multivessel coronary artery disease, coronary artery bypass grafting (CABG) is associated with a lower risk of major adverse cardiovascular events in the longer term than percutaneous coronary intervention (PCI) with everolimus-eluting stents. The research, published in the New England Journal of Medicine, included 880 patients from East Asia with a mean age of 64 years, with 438 randomly assigned to the PCI group and 442 to the CABG group. The researchers had planned to enrol 1776 patients but terminated enrolments early because of a slow enrolment rate. In the PCI group patients received an average of 3.4 stents, with intravascular ultrasonography used in 71.8% of patients during PCI. In the CABG group, 64.3% of patients had off-pump surgery and 99.3% had revascularisation of the left anterior descending coronary artery with the left internal thoracic artery. Complete revascularisation occurred in 71.5% of the CABG group compared with 50.9% in the PCI group. During follow-up patients in the PCI group were significantly more likely to receive medications such as antiplatelet agents, beta-blockers, angiotensin-converting-enzyme inhibitors or angiotensin II-receptor blockers and calcium-channel blockers. At 2 years, the primary end point of death, myocardial infarction or target-vessel revascularisation occurred in 11.0% of the PCI group and 7.9% of the CABG group. At longer-term follow-up the primary end point had occurred in 15.3% of the PCI group and 10.6% of the CABG group. The researchers found no significant difference in the rate of stroke between the two groups.
Data lacking on insulin pump risks and benefits
A JOINT statement by European and US diabetes groups has raised concerns about the lack of data available about the risk and benefits of insulin pumps. The statement, published in Diabetologia, said that even with modern insulin pumps, errors of insulin infusion could occur due to pump failure, blockage, infusion site problems, insulin stability issues or user error, or a combination of these, exposing users to significant and potentially fatal hazards from both hyperglycaemia and hypoglycaemia. The statement, from the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group, said clinical studies required by regulators before marketing of the pumps were small and over-reliant on bench testing. “Once a pump is available on the market, insufficient data are made publicly available on its long-term use in a real-world setting; such data could provide vital information to help healthcare teams to educate and support users, and thereby prevent [adverse events]”, it said. The statement called for public funding of more observation studies and clinical trials to address clinically important questions in relation to pump therapy. Five recommendations in the statement included the need for more “harmonised” standards for pump manufacturers, greater transparency, international evidence-based guidelines, more research of “real-world” conditions, and better support from health care teams.
Diet soft drink raises cardiometabolic risks in older adults
RESEARCHERS have described their finding that diet soft drink is associated with escalating abdominal obesity as a “striking dose–response relationship”, saying it is a “potential pathway for cardiometabolic risk” in adults aged 65 years and over. In a prospective study of 749 Mexican-Americans and European-Americans aged 65 years at baseline, published in the Journal of the American Geriatrics Society, the positive dose–response relationship was observed between initial diet soda intake (DSI) and subsequent long-term increases in waist circumference (WC) over a mean total follow-up of almost 10 years. The mean interval WC gain in all diet soft drink users during follow-up — including daily and occasional users — was almost three times that of non-users. “For daily users, interval [WC change] was almost four times that of nonusers”, the researchers wrote. The differences were adjusted for demographic and socioeconomic factors and initial WC, diabetes mellitus status, leisure-time physical activity, smoking status and length of follow-up The researchers wrote that adult WCs had increased substantially in the US in the past 25 years, and if “frequent DS consumption is causally related to the increasing central obesity observed in daily users in the current study, the clinical relevance of this association could be substantial”. “Together with emerging reports from other animal and human studies, these results raise concerns about the safety of chronic DSI by older individuals, especially those already at high cardiometabolic risk”, they concluded.
Earning ability linked to length of breastfeeding
BREASTFEEDING is associated with increased intelligence in adulthood, as well as higher educational attainment and earning ability, according to research published in The Lancet Global Health. The authors used data from a prospective birth cohort study of infants born in Brazil in 1982. Breastfeeding information was recorded in early childhood. When 3493 participants were aged 30 years, data on intelligence quotient (IQ), educational attainment and income were collected The authors divided participants into five groups based on the length of time they were breastfed, and controlled for variables that could contribute to an increased IQ, including family income, parental schooling, genomic ancestry, maternal age and birth weight. The authors found durations of total breastfeeding and where breastfeeding was the main form of nutrition were positively associated with IQ, educational attainment and income. Participants who were breastfed for 12 months or more had higher IQ scores, more years of education and higher monthly incomes compared with those who were breastfed for less than 1 month. The authors wrote that IQ was responsible for 72% of the effect on income, saying it was the first study to report a direct association between breastfeeding and earning potential. “Our results suggest that breastfeeding not only improves intelligence up to adulthood, but also has an effect at both the individual and societal level, by increasing educational attainment and earning ability”, the authors wrote. An accompanying comment said the findings suggested that breastfeeding might have long-term effects on intelligence in a population without strong social patterns of breastfeeding, and that this effect might mediate effects on life outcomes.
Shingles risk with combination treatment for psoriasis
A LARGE study with more than 520 000 person-years of follow-up has observed an increased risk for herpes zoster (HZ) in patients with psoriasis treated by a combination of methotrexate and a biologic medication. The study, published in JAMA Dermatology, included 95 941 patients who were followed up for about 11 years. Using a multivariate analysis, the researchers observed that treatment with phototherapy, methotrexate, cyclosporine and biologic medications (tumour necrosis factor inhibitors [infliximab, adalimumab, etanercept], ustekinumab, alefacept and efalizumab) as a single agent was not associated with HZ. However, combination treatment with biologic medications and methotrexate showed a significant association with an increased incidence of HZ, while acitritin was associated with decreased incidence. The increased risk for HZ was also associated with age at baseline, female sex, use of corticosteroids, high and intermediate socioeconomic status, and psoriasis severity. The researchers wrote that the present study used data regarding all underlying diagnoses and all prescriptions, as well as primary care, inpatient and outpatient visits with their respective diagnoses, and compared patients treated with different systemic modalities for psoriasis with patients free of systemic treatment. “This enables differentiation of the effect of the disease per se from the treatment modality effect.” They wrote that patients treated with biological medications and methotrexate could be offered preventive HZ vaccination but, “at a minimum”, should be made aware of the risk of HZ. “Because early treatment of HZ may decrease the severity of symptoms and the incidence of complications (eg, postherpetic neuralgia), it is important to alert patients about the hazard of developing HZ.”
Antipsychotics warning in elderly patients with dementia
THE absolute effect of antipsychotics on mortality in elderly patients with dementia may be higher than previously thought and increases with dose, a US study published in JAMA Psychiatry has found. The research was based on a retrospective case–control study of 90 786 patients aged 65 years or older diagnosed with dementia, including 46 008 patients who had a new prescription for an antipsychotic (haloperidol), atypical antipsychotic (olanzapine, quetiapine, and risperidone), valproic acid and its derivatives, or an antidepressant. The authors measured the absolute change in mortality risk and the number needed to harm (NNH) of patients who received treatment that would be associated with one death over 180 days of follow-up among medication users compared with non-users. Patients who received haloperidol had the highest overall increased mortality risk at 3.8% with an NNH of 26 compared with non-medication patients, the authors wrote. They found that risperidone had the greatest increased mortality risk among the atypical antipsychotic medications. Compared with antidepressant users, the increase in mortality risk for risperidone users ranged from 12.3% with an NNH of 8 for haloperidol, to 3.2% with an NNH of 31 for quetiapine. The authors said that as a group, the atypical antipsychotics showed a dose–response increase in mortality risk, with 3.5% greater mortality in the high-dose subgroup relative to the low-dose group. The authors said the prescription of antipsychotic medication that increased mortality risk “seems contrary to the tenet ‘first, do no harm,’ yet for patients who pose a danger to themselves and others and are in profound distress, use of such medications may still be appropriate”. The results of the study could help physicians minimise the potential harm associated with antipsychotic treatment, the authors wrote.
Measles outbreak blamed on “substandard” vax rates
SUBSTANDARD vaccination compliance is likely to blame for the 2015 measles outbreak linked to Disneyland in the US, according to a research letter published in JAMA Pediatrics. The authors used publicly available incidence data and Health Map media alerts to determine the potential role of suboptimal vaccination coverage. They estimated that the measles, mumps and rubella (MMR) vaccination rates among an exposed population in which secondary cases had occurred could be as low as 50% and was likely to be no higher than 86%. “Given the highly contagious nature of measles, vaccination rates of 96% to 99% are necessary to preserve herd immunity and prevent future outbreaks”, the authors wrote. They said that even the highest estimation of vaccination rates fell well below this threshold. While data on MMR vaccination rates were available, coverage was often calculated at the state or country level and might not be granular enough to assess risk in an outbreak situation, the authors wrote. This was especially the case for outbreaks at a tourist destination such as Disneyland, where vaccination coverage among visitors was highly heterogeneous. “Clearly, MMR vaccination rates in many of the communities affected by this outbreak fall below the necessary threshold to sustain herd immunity, thus placing the greater population at risk as well”, the authors wrote.