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Mindfulness equal to antidepressants to prevent depressive relapse
A RANDOMISED controlled trial has found that mindfulness-based cognitive therapy with support to taper or discontinue antidepressant treatment (MBCT-TS) and maintenance antidepressant treatment to prevent depressive relapse are both associated with positive outcomes for patients, with similar relapse rates. The single-blind, parallel-group randomised control PREVENT trial, published in The Lancet, included 424 adult patients with three or more previous major depressive episodes who were receiving a therapeutic dose of maintenance antidepressants. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants. The researchers found the time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over the 24-month study period. There was also no difference in the number of serious adverse events. Ten adverse events were reported in the study period, including two deaths in each group. A cost-effectiveness analysis showed MBCT-TS was not more cost-effective than maintenance antidepressants in terms of either relapse or recurrence or quality of life years. “This largest trial of any mindfulness-based approach to date answered an important clinical question of high relevance to GPs and patients at risk for depressive relapse or recurrence”, the authors wrote, saying that when combined with previous studies, it provided important evidence that MBCT-TS might confer ongoing protection for patients who would like an alternative to maintenance antidepressant medication. “The results further suggest that psychosocial treatments such as MBCT and [cognitive behavioural therapy] offer added value for patients who need them most (ie, those at highest risk of depressive relapse or recurrence).” An accompanying commentary said MBCT-TS was a “promising new treatment that is reasonably cost effective and applicable to the large group of patients with recurrent depression”.
CPAP for sleep apnoea also reduces AF
A META-ANALYSIS to evaluate the cumulative effect of treating obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) has found it is associated with a significant reduction in atrial fibrillation (AF) recurrence. The research, published in the Journal of the American College of Cardiology: Clinical Electrophysiology, found that in seven prospective cohort studies with 1087 patients, those who used CPAP had a significant reduction in AF recurrence rate compared with non-users (n = 186 of 557 [33.3%] v 308 of 530 [58.1%]; relative risk: 0.58; 95% CI: 0.51 to 0.67; p < 0.001). The beneficial effect of CPAP use was found in patients who underwent catheter ablation with pulmonary vein isolation and those who were managed medically. The authors wrote that the lack of any significant association between patient and study covariates known to affect arrhythmia outcomes and AF recurrence “suggests that CPAP use may be primarily responsible for these results and that these findings are not due to a chance effect”. “These study findings are important as they provide the most conclusive evidence available and give the clinician an additional means to reduce AF recurrence in patients with OSA”, they wrote. “Given the 42% relative risk reduction seen in the present study, which may now evolve to be a third major treatment option (in addition to medical therapy and ablation), revision of the current AF guidelines may be in order.”
Medical student loans highlight gender disparities
UK medical graduates on a full-time salary are unlikely to pay off their student loan debt because of high university fees and the debt being written off after 30 years, a study published in BMJ Open has found. The study authors generated a loan repayment model based on the data from 4286 doctors working 30 hours or more a week who participated in national workforce surveys between 1997 and 2014. When additional loans for living costs were factored in, the initial graduate debt could be as high as £81 916 (AUS$152 200), the authors wrote. The average woman would repay £75 786 ($140 800), while the average man would repay £110 644 ($205 600). The authors found that full-time male graduates earned on average 35% more than their female counterparts by the age of 55 years, which they said confirmed that medical graduate salaries were correlated with gender. This salary gap started at age 30 years, with several explanations cited including discrimination, career breaks, career choices, part-time work and motherhood. The gender difference had an impact on the repayment of potential graduate debt. For those graduates who were able to repay the debt within 30 years, a higher yearly salary was advantageous because early repayment meant fewer interest charges were accrued. However, for those who did not repay their total debt within 30 years of graduation, which was the case for the average female medical graduate, a lower salary was advantageous because of lower yearly repayments and the residual debt being written off. The authors said it was reasonable that similar repayment variations might exist across many graduate careers in the UK. “It is also apparent that at the current level of fees, even small changes in the student loan contract will have substantial implications for lifetime wealth across different income groups, across male and female graduates, and on the sustainability of the student loans system”, the authors wrote.
PET helps decisions on radiotherapy for Hodgkin’s lymphoma
A RANDOMISED trial to assess whether patients with early-stage Hodgkin’s lymphoma who respond well to three cycles of combined chemotherapy will benefit from radiotherapy has found patients had a very good prognosis with or without radiotherapy. However, the research, published in the New England Journal of Medicine, did show a slight benefit from radiotherapy on progression-free survival. The phase 3 trial included 571 patients with newly diagnosed stage IA or stage IIA Hodgkin’s lymphoma who had three cycles of chemotherapy with doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) and then underwent positron emission tomography (PET) scanning. PET findings were negative in 426 of patients (74.6%), with 420 randomly assigned to study groups (209 to radiotherapy and 211 to no further therapy). At a median 60 months’ follow-up, there were eight instances of disease progression in the radiotherapy group and eight patients had died (five who received no radiotherapy and three with disease progression, including one from Hodgkin’s lymphoma). In the no further therapy group at a median 60 months of follow up, there were 20 instances of disease progression and four patients had died (two with disease progression and none from Hodgkin’s lymphoma). The 3-year progression-free survival rate was 94.6% in the radiotherapy group and 90.8% in the no further therapy group. The authors wrote that longer follow-up was needed to determine whether the response-adapted approach (assessing response using PET before offering radiotherapy) would lead to fewer long-term toxic effects such as fewer second cancers, less cardiovascular disease and improved overall survival compared with a strategy incorporating radiotherapy for all patients. An accompanying editorial said that as both strategies worked, patients should be involved in deciding which strategy to use after being fully informed of the risks and the benefits.
More data needed on sport for long QT syndrome patients
RESEARCHERS have called for prospective registries of long QT syndrome (LQTS) patients who play sport be established to quantify the risks and assist doctors and patients to make informed decisions on sports participation. A retrospective review, published in the Journal of the American College of Cardiology: Clinical Electrophysiology, included 212 children with genotype-positive LQTS, including 103 who participated in competitive or recreational sport. The review found there were no cardiac events and no deaths observed in treatment-compliant LQTS children in up to 15 years of follow-up. The study participants had a mean age at diagnosis of about 8 years. The researchers identified a total of 105 LQTS disease-causing mutations. All patients were treated with a beta-blockade, with non-compliance in one patient and intolerance in another. Of the patients who participated in sport, 26 were in competitive sports and 77 in recreational sports, and none had LQTS symptoms during sports participation. The researchers wrote that sports disqualification for patients with LQTS, in accordance with current guidelines, was commonly adopted by physicians, despite recent literature demonstrating a significant risk reduction in patients compliant with beta-blocker therapy. “Decisions regarding whether children with LQTS should engage in sports participation, both competitive and recreational, are difficult”, they wrote, saying prospective registries were required to examine the risk of arrhythmia and sudden cardiac death in treated patients with LQTS. An accompanying editorial warned that when suggesting sports and LQTS might be acceptable, “it is absolutely critical that a complacent and cavalier attitude be resisted”.
Study supports hep B prophylaxis for infants
A LARGE prospective US study into the outcomes of infants born to mothers with hepatitis B has found perinatal infection occurred in 1% of these infants; most of whom received the recommended immunoprophylaxis with hepatitis B immunoglobulin and vaccination. The research, published in Pediatrics, included data from 17 951 mother-infant pairs, with hepatitis B surface antigen testing results available for 9252 (51.5%) infants. Of these, 100 (1.1%) acquired perinatal hepatitis infection. The highest risk of perinatal hepatitis B infection was associated with younger maternal age, Asian or Pacific Islander race, maternal hepatitis B e-antigen positivity, maternal antibody to hepatitis B e-antigen negativity, maternal viral load of 2000 IU/mL or more and infant receipt of less than three hepatitis B vaccine doses. “Timely immunoprophylaxis and completion of the [US Advisory Committee on Immunization Practices] recommended 3-dose HepB vaccine series is the cornerstone of perinatal hepatitis B prevention”, the study authors wrote. They said their research demonstrated that the number of hepatitis B vaccine doses was associated with risk of infant infection, with infection occurring in 6.7% of infants who received less than three doses, compared with 1.1% of infants who received three or more doses. An accompanying commentary said pregnant women who were at high risk of transmitting the virus to their babies might benefit from antiviral therapy, but that further studies were important “because there are tangible downstream risks to using antiviral agents during pregnancy”.
Question patients about their pets
ALTHOUGH pets play a small role in the overall transmission of pathogens, disease risk is increased in pregnant women, young children and people who are immunocompromised, according to the authors of a review published in the CMAJ. The authors said more research was needed to quantify the disease risks. The review was based on literature searches, reviews and consensus guidelines, and limited to pet species typically owned by the general public (dogs, cats, fish, birds, amphibians, reptiles, rabbits and other rodents). The authors found that all pets could transmit diseases to people, including Salmonella, multidrug-resistant bacteria and parasites, such as hookworm, roundworm and Toxoplasma. Infection could be contracted from bites, scratches, salvia or contact with faeces, and reptiles and amphibians might also transmit disease indirectly through contaminated surfaces. The authors said studies indicated physicians did not regularly ask their patients about pet contact, or discuss the risks of zoonotic diseases. They said that given the health benefits of animal ownership and the reluctance of people to give up their pets, doctors should focus on advising patients on ways to reduce their risk of acquiring pet-associated disease. These measures included wearing protective gloves to clean aquariums and cages, proper handwashing after pet contact, discouraging pets from face licking, keeping litter boxes away from areas where food was prepared, and regularly scheduling veterinary visits for all pets. The authors said that existing pet contact recommendations were based on limited data, and future studies should focus on identifying the proportion of human infectious disease for which pet contact was responsible and assessing the effectiveness of prevention methods.