New recommendations on cervical cancer screening
NEW US guidelines, published in the Annals of Internal Medicine, recommend cervical cancer screening with cytology in average-risk, asymptomatic women no more than once every 3 years. The recommendations, from the clinical guidelines committee of the American College of Physicians, also advise doctors not to screen average-risk women younger than 21 years or those older than 65 years who have had three consecutive negative cytology test results or two consecutive negative cytology plus human papillomavirus (HPV) test results within 10 years, with the most recent test performed within 5 years. A combination of cytology and HPV testing is recommended once every 5 years in average-risk women aged 30 years or older. “As clinicians adhere more strongly to guidelines, it is anticipated that the harms and costs of cervical cancer screening will be minimized and the benefits will be maximized”, the guidelines authors wrote. The guidelines differ from those in Australia, which still recommend cytology every 2 years for women aged from 18‒20 years to 69 years. The Medical Services Advisory Committee has recommended to the Australian Government that the HPV screening test should replace the current cytology test, with testing every 5 years in women aged 25 years to 70‒74 years.
ED-initiated treatment helps opioid-dependent patients
A RANDOMISED controlled trial to test the efficacy of three emergency department (ED)-initiated interventions for opioid-dependent patients has found buprenorphine treatment with referral to primary care significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use and decreased use of inpatient addiction treatment services. However, the research, published in JAMA, also found the treatment did not significantly decrease the rates of urine samples that tested positive for opioids or of HIV risk. The interventions involved 329 opioid-dependent patients who were randomly allocated to screening and referral to treatment (referral group); screening, brief intervention and facilitated referral to community-based treatment services (brief intervention group); or screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone and referral to primary care for 10 weeks of follow-up (buprenorphine group). Of the participants, 25% reported using only prescription opioids and 53% reported intravenous drug use. The researchers wrote that the diverse group of opioid-dependent participants had substantial psychiatric and substance use-related comorbidity. They found that ED-initiated buprenorphine with primary care office-based follow up for ongoing treatment resulted in a greater percentage of individuals engaging in treatment and fewer days of self-reported illicit opioid use than those in the referral or brief intervention groups. “The majority of patients who were provided a referral, with or without facilitation, were not engaged in addiction treatment at 30 days”, they wrote. “Although this single-site study supports this ED-initiated treatment strategy, these findings require replication in other centers before widespread adoption”, they concluded.
Adolescent self-poisoning a long-term suicide predictor
SELF poisoning in adolescence is a strong predictor of suicide and premature death in the following decade, according to a study published in The Lancet Psychiatry. Researchers used health care databases in Ontario, Canada, to identify 20 471 adolescents aged 10–19 years who attended an emergency department or were admitted to hospital for a first self-poisoning episode between 2001 and 2012. All surviving individuals were followed up from the date of hospital discharge until death or the end of the study period. Each adolescent was matched with 50 population-based reference individuals without this history, matched for age, sex and year of cohort entry. The authors found that the median age of teens discharged from hospital after the first self-poisoning episode was 16 years and 69% were female. Acetaminophen was the most common agent ingested, followed by antidepressants and non-steroidal anti-inflammatory drugs. Over the median follow-up period of 7.2 years, 248 of the adolescents in the self-poisoning group died, more than half by suicide. The risk of suicide among these adolescents was more than 30 times higher at 1 year compared with the matched population, the authors wrote. They said the risk attenuated over time, but remained significantly greater than the matched cohort at 10 years. Factors associated with suicide included recurrent self-poisoning, male sex and psychiatric care in the preceding year. Adolescents admitted to hospital for self-poisoning were also more likely to die from accidents and from all causes during follow-up. The authors said their results highlighted the need for sustained, focused prevention efforts in this susceptible population. “An appropriate psychiatric follow-up plan should be implemented before hospital discharge for all such adolescents, including those who are discharged from the emergency department”, the authors wrote.
High CPR rates for dialysis patients
INHOSPITAL cardiopulmonary resuscitation (CPR) use was 20 times more common in patients receiving maintenance dialysis compared with a representative sample of the general population (6.3% v 0.3%), according to research published in JAMA Internal Medicine. The retrospective cohort study included 663 734 patients aged 18 years or older on a national registry for end-stage renal disease who initiated maintenance dialysis between 2000 and 2010. Patients who received inhospital CPR from 91 days after dialysis initiation through to the time of death, first kidney transplantation or end of the follow-up period in 2011 were included. The researchers found that although the proportion of CPR recipients in their cohort surviving to hospital discharge (21.9%) was comparable to other hospitalised patients (17.0%‒23.0%), median survival after discharge “was considerably worse”. “Members of this cohort survived a median of 5 months after hospital discharge compared with almost 3 years for other hospitalized patients”, the researchers wrote. “Differences with prior reports in other populations were even more striking after accounting for differences in age.” They said their findings emphasised the need to improve advance care planning in this population group. “Information on population-level outcomes after CPR may be useful background for supporting discussions among patients, families, and health care professionals about desired treatment intensity and preferences for resuscitation.” An accompanying commentary asked why advance care planning was not documented, or worse, not adequately discussed in the dialysis setting. “Rational, evidence-based, and compassionate advance care planning for patients receiving dialysis should be among the highest-priority services provided within the [end-stage renal disease] program.”
Cardio risks for patients after Hodgkin lymphoma
SURVIVORS of Hodgkin lymphoma (HL) have an increased risk of cardiovascular disease for the rest of their lives, according to research published in JAMA Internal Medicine. The retrospective cohort study included 2524 Dutch patients diagnosed with HL before the age of 51 years. Study participants were treated between 1965 and 1995 and had survived at least 5 years following diagnosis. The authors used data from medical records and GPs to compare the prevalence of cardiovascular disease among HL survivors up to 40 years after treatment, with the general population. After a median follow up of 20 years, 1713 cardiovascular events were identified in 797 patients. The authors found that patients still had a four- to seven-fold increased risk of developing coronary heart disease (CHD) or heart failure (HF) in the 35 years or more following treatment, compared with the general population. The highest relative risks were seen in patients treated before the age of 25 years, but substantial absolute excess risks were also observed for patients treated at older ages. Within the cohort, the 40-year cumulative incidence of any type of cardiovascular disease was 50%. Patients who received mediastinal radiotherapy experienced an increased risk of CHD, valvular heart disease (VHD) and HF. Anthracycline-containing chemotherapy was also associated with increased HF and VHD risk. A total of 51% of patients with cardiovascular disease experienced multiple cardiovascular events. The authors said their results highlighted that survivors of HL remained at substantially higher risk of various cardiovascular diseases for at least 40 years after their diagnosis. “Treating physicians and patients should be aware of the persistently increased risk of cardiovascular diseases throughout life, and the results of our study may direct guidelines for follow-up of patients with HL”, the authors wrote. An accompanying commentary said the research could help physicians identify high-risk patients, including “those with a history of HL who were treated at a young age and those who are the longest from treatment”.
“Complex” intervention reduces caesarean rates
A CLUSTER randomised controlled trial of an intervention to reduce caesarean rates in Canadian hospitals has found the program resulted in a significant but small reduction in the rate of caesarean deliveries without increasing neonatal and maternal morbidity and mortality. The research, published in the New England Journal of Medicine, found that while the intervention significantly reduced the caesarean rate among women with low-risk pregnancies it did not reduce rates among those with high-risk pregnancies. The intervention involved randomisation of hospitals to receive audits of indications for caesarean delivery, feedback provided to health professionals and implementation of best practices, or not. The primary outcome was the caesarean delivery rate in the 1 year after the intervention period. The trial included 184 952 women in 32 hospitals — 53 086 who delivered in the year before the intervention and 52 265 after. The researchers found the rate of caesareans in the pre-intervention period to the post-intervention period in the intervention group changed from 22.5% to 21.8% compared with 23.2% to 23.5% in the control group. The intervention group also had a reduction in major neonatal morbidity compared with the control group. The researchers wrote that because they had tested a complex, multifaceted intervention, “it is not possible to determine which of its components were primarily responsible for the observed effect”.
Psychosomatic impacts on children after separation
A LARGE cross-sectional study, based on a national classroom survey of psychosomatic symptoms in children aged 12‒15 years, has found that children of separated parents who do not live together experience more psychosomatic problems than those in nuclear families. However, the research, published in the Journal of Epidemiology and Community Health, also found that children in joint physical custody (JCP) arrangements reported better psychosomatic health than children living mostly or only with one parent. The research included nearly 150 000 children in Sweden and showed children in JPC were in an intermediate position between children in nuclear families, who had the least psychosomatic problems, and those in single care, who had the most problems. The authors wrote that their findings were consistent with previous findings and the pattern had been established in relation to other outcomes such as satisfaction with life, risk behaviour, parent–child relationships, school achievement, wellbeing and mental health. “Psychosomatic symptoms are related to stress, but despite the fact that two homes require adaptation to different neighbourhoods and family climates, our results show lower risks for psychosomatic symptoms for children in JPC than in single care residency”, they wrote. Satisfaction for children in JPC with their material resources and parent–child relationships was important for their psychosomatic health “but cannot explain the differences between children in different living arrangements”, they wrote, saying longitudinal studies on family factors before and after the separation were needed.