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Cardiac risk factors still too high despite preventive guidelines
DESPITE improved adherence to secondary preventive guidelines by patients who survive an acute myocardial infarction (AMI), a Swedish study measuring risk factor control post-AMI shows only some factors have improved over time. The research, published in the European Journal of Preventive Cardiology, also found gender differences in lipid control and blood pressure control, despite guideline recommendations being gender neutral. Readmission rates for cardiac and non-cardiac reasons were reduced over time, but were higher in women than men. The registry study included 51 620 patients — more than half of all patients who survived an AMI in 2005–2014 — who were examined 2 and/or 12 months post-AMI. Risk factor control and readmissions at 1 year were compared between 2005 and 2012 cohorts. The researchers found lipid control (low density lipoprotein cholesterol < 2.5 mmol/L) improved from 67.9% to 71.1% over time, achieved by 67.9% of men and 63.3% of women. Blood pressure control (< 140 mmHg systolic) increased over time from 59.1% to 69.5% and was better in men than women (66.4% v 61.9%). The smoking cessation rate of 55.6% was no different between genders or over time. Cardiac readmissions occurred in 18.2% of women and 15.5% of men, dropping from 2005 to 2012 (20.8% v 14.9%). The adjusted odds ratio was 1.22 for women versus men and 0.94 for the 2012 versus the 2005 cohort. The authors wrote that the use of secondary preventive drugs during the first year after an AMI was high in study participants but long-term risk factor control during that first year was suboptimal regarding blood pressure, cholesterol levels and smoking habits. They speculated that failure to recognise the importance of risk factor control in women, by physicians or patients, could contribute to higher risk factors in women, as well as more drug side effects being experienced by women. The authors said their study revealed substantial preventive potential. “Effective strategies should be developed to provide high quality and equal care for all aspects of the prevention of recurrent disease”, they wrote.
Cold weather causes more deaths than heat
A LARGE international study, which analysed more than 74 million deaths in 13 countries including Australia, has found that cold weather kills 20 times as many people as hot weather. The research, published in The Lancet, included deaths during various periods between 1985 and 2012, finding 7.71% of mortality was attributable to non-optimum temperature, with substantial differences between countries, ranging from 3.37% in Thailand to 11.00% in China. The temperature percentile of minimum mortality varied from roughly the 60th percentile in tropical areas to about the 80–90th percentile in temperate regions. More temperature-attributable deaths were caused by cold (7.29%) than by heat (0.42). In Australia, 6.50% of deaths were attributed to the cold and 0.45% to heat. The study found extreme cold and hot temperatures were responsible for 0·86% of total mortality. The authors wrote that research to date on the association between human health and ambient temperature had focused mainly on the effects of extreme heat, with public health plans designed almost exclusively for heatwave periods. “Our results suggest that public-health policies and adaptation measures should be extended and refocused to take account of the whole range of effects associated with temperature, although further research is needed to clarify how much of the excess mortality related to each component is preventable”, they wrote. An accompanying editorial said that despite the study’s limitations, it highlighted the need for in-depth studies because high or low temperatures affect susceptible groups such as unwell, young and elderly people the most.
Walking intervention reduces PAD mobility loss
UNSUPERVISED walking exercise supported by a cognitive behavioural intervention can prevent mobility loss and improve functioning in people with peripheral artery disease (PAD), according to research published in the Journal of the American Heart Association. The study included 194 patients with PAD randomly assigned to receive a group-mediated cognitive behavioural intervention (GMCB) or a control intervention. In the first 6 months of the trial, those in the GMCB group attended weekly meetings led by a facilitator at an exercise centre, and were instructed to walk for exercise a minimum of 5 days a week. Group support and self-regulatory skill instructions were used to help participants adhere to unsupervised home-based walking exercise. Those in the control group attended weekly group meetings at a medical centre where they received educational lectures on health topics unrelated to exercise. For the following 6 months, each group received telephone contact only. At the 6-month follow up, fewer participants receiving the GMCB intervention had experienced mobility loss compared with the control group (6.3% v 26.5%). At 12 months, 5.2% of people in the GMCB group experienced mobility loss compared with 18.5% in the control group. Compared with the control group, the intervention also improved fast-paced 4 m walking velocity at 6 months, and the Short Physical Performance Battery at 12 month follow-up. “Older people who lose mobility have higher rates of nursing home placement, morbidity, mortality, depression, hospitalizations, chronic disease, and cognitive impairment”, the authors wrote. Maintaining mobility was also integral to preserving functional independence, social interactions, and activities of daily living for patients with PAD. Additional study was needed to “determine whether interventions designed to increase home-based exercise and that have fewer on-site visits improve walking performance and prevent mobility loss in people with PAD”, the authors said.
Concussion history in footballers raises cognitive risks
A HISTORY of concussion resulting in a loss of consciousness is a risk factor for increased hippocampal atrophy and mild cognitive impairment (MCI), according to a US study of retired athletes. The research, published in JAMA Neurology, included 28 former National Football League (NFL) players and a control group of 21 cognitively healthy adults with no history of concussion or past football experience. The study also included six control participants with MCI but no history of concussion. The mean age for the former athletes was 58.1 years, and 59.0 years for the control participants. Among the retired players, 17 had reported a grade 3 (G3) concussion with loss of consciousness. Former athletes with a concussion history but without cognitive impairment had normal but significantly lower learning test scores compared with the control group. Athletes with a concussion history and MCI performed worse compared with both control participants and athletes without memory impairment. Older retired players with at least one G3 concussion had significantly smaller bilateral hippocampal volumes compared with control participants at the 40th, 60th and 80th age percentiles. All retired athletes aged over 63 years with a history of G3 concussion were diagnosed with MCI. “Our findings suggest that a remote history of concussion with loss of consciousness is associated with both later-in-life decreased in hippocampal volume and memory performance in retired NFL players”, the authors wrote. The number of games played was also negatively associated with hippocampal size, but not as strongly as a history of G3 concussion because these changes in anatomical structure and cognitive function only became evident with ageing, the authors wrote. They recommended that “prospective longitudinal studies after a G3 concussion would add further insight to the mechanism of MCI development in these populations”.
Oral steroids little help in acute sciatica
AMONG patients with acute radiculopathy due to a herniated lumbar disk, a short course of oral steroids resulted in modestly improved function compared with placebo, but no improvement in pain, research published in JAMA has found. The randomised clinical trial was conducted in a large US integrated health care delivery system, and included 269 adults who had radicular pain for 3 months or less, a herniated disk and a score of 30 or higher on the Oswestry Disability Index (ODI) (range, 0–100; higher scores indicate greater dysfunction). Patients were randomised to receive either a tapering 15-day course of oral prednisone or placebo. The primary outcome was ODI change at 3 weeks, with secondary measures including ODI scores at 1 year, lower extremity pain (measured on a 0–10 scale; higher scores indicate more pain) and spinal surgery. The authors found a small, statistically significant improvement in function measured by the ODI at both 3 weeks and 52 weeks in the prednisone-treated group, but no difference in lower extremity pain scores at any point in time. Several secondary outcomes showed small but inconsistent improvements with prednisone relative to placebo, and there were no serious adverse events related to treatment. The authors said that pain could limit function, so as pain decreased, function would increase until pain limited functional capacity again. “This may explain the improved function without measurable improvement in pain”, they wrote, saying that, to date, no study had examined the effectiveness of a full course of oral steroids in addition to usual care in a well powered clinical trial. They said an important rationale for using oral steroids was the potential to decrease the need for more invasive treatments, but the use of prednisone did not decrease the likelihood of undergoing surgery in this trial. The authors said the generalisability of their results might be limited by the requirement for a positive magnetic resonance imaging finding, and a baseline ODI score of 30 points or higher.
Family history not a risk for breast cancer spread
A POSITIVE family history of breast or ovarian cancer does not provide a significant independent contribution to the risk of distant disease recurrence in young patients with breast cancer, according to research published in the British Journal of Surgery. The multicentre prospective observational cohort study of young women diagnosed with breast cancer at age 40 years or younger in the UK found in multivariable analyses that there were no significant differences in distant disease-free intervals for patients with versus those without a family history. The findings applied to the whole cohort and when stratified by oestrogen receptor status. The cohort included 2850 patients, with no family history reported by 65.9% and breast/ovarian cancer in at least one first- or second-degree relative reported by 34.1%. Those with a family history were more likely to have grade 3 tumours (63.3% v 58.9%) and less likely to have human epidermal growth factor receptor 2-positive tumours (24.7% v 28.8%) than those with no family history. The researchers wrote that patients with an affected close relative (first-degree v second-degree relative and first-degree relative v no family history) had significantly smaller tumours, which probably reflected earlier self-presentation to medical services. “Earlier presentation may be offset by the high-grade tumours in the [family history] group, particularly the subgroup with affected first-degree relatives, negating any outcome difference”, they wrote. Patients with a family history of breast cancer who presented with the disease might seek reassurance from their surgeon that they were at no higher risk from recurrence or death than similar patients with no family history. “This study demonstrates that family history per se is not an independent prognostic feature for recurrence in young-onset breast cancer treated in the modern era”, the researchers wrote.
Abdominal sepsis responds to shorter antibiotic course
A RANDOMISED controlled trial involving patients with complicated intra-abdominal infections who had undergone adequate source control has found a fixed 4-day course of antibiotic treatment resulted in similar outcomes to those of a traditional, longer antibiotic course for approximately 8 days. The research, published in the New England Journal of Medicine, included 518 patients with a mean age of 52.2 years randomised to receive antibiotics until 2 days after the resolution of fever, leucocytosis and ileus, with a maximum 10 days of therapy (control group), or to receive a fixed course of antibiotics for 4±1 days. Surgical-site infection, recurrent intra-abdominal infection or death occurred in 56 of 257 patients (21.8%) in the experimental group and 58 of 260 patients (22.3%) in the control group. All patients in the study had complicated intra-abdominal infection with fever (temperature ≥38.0°C), leucocytosis (≥11,000 peripheral white cells per cubic mm) or gastrointestinal dysfunction due to peritonitis. Source control was defined as procedures to eliminate infectious foci, control factors that promote ongoing infection, and correction or control anatomical derangements to restore normal physiological function. The researchers wrote that their data provided support for the concept that after patients had an adequate source-control procedure, the beneficial effects of systemic antimicrobial therapy were limited to the first few days after intervention. An accompanying editorial said a “nagging question” from the study was why more than 20% of patients in both groups had complications after treatment, saying “it seems likely that source control remains a considerable problem in treating abdominal sepsis”.
Activity strongly linked to survival in ICD patients
A STUDY using physical activity data collected automatically by implantable cardioverter-defibrillators (ICDs) has shown that activity is strongly correlated with survival in patients, even after adjustment for age, sex and device type. The research, published in the Journal of the American Heart Association, found that patient physical activity in just the first 30‒60 days after implantation yielded a 40% absolute difference in survival at 4 years between the most and least active quintiles (90.8% v 50.0%). “This marked inverse relationship between activity and mortality was similar regardless of whether baseline activity or longitudinal activity is considered, with a similarly increased hazard for death for incremental difference of activity of only 30 minutes [per day] after adjustment for demographic and clinical covariates”, the researchers wrote. The study was based on 98 437 patients with a mean age of 67.7 years and 71.7% male. Of the cohort 43.4% had a cardiac resynchronisation therapy (CRT) device and 56.6% an ICD (single or dual chamber). Baseline physical activity for the entire cohort in the 30‒60-day window post-ICD implantation averaged 107.5 minutes of activity a day, ranging from a mean of 32.5 minutes in the lowest quintile to 207.7 minutes in the most active quintile. Compared with the most active quintile, patients in the least active quintile were older (mean age 74.6 years v 59.3 years), female (35.6% v 21.1%) and more commonly received a CRT device (53.2% v 30.4%). The researchers wrote that despite the limitations of their study the findings suggested that evaluating activity in an ICD patient before undergoing an ICD replacement procedure may provide additional prognostic information.