Breastfeeding may reduce leukaemia risk
BREASTFEEDING for 6 months is associated with a lower incidence of childhood leukaemia compared with children were never breastfed or breastfed for a shorter time, a meta-analysis published in JAMA Pediatrics has found. The authors reviewed 18 case-controlled studies that included breastfeeding as a measured exposure and leukaemia as a measured outcome, and which provided data on breastfeeding duration. The analysis, which included data on 10 292 leukaemia cases and 17 517 control individuals, indicated that breastfeeding for 6 months or longer was associated with a 19% lower risk for childhood leukaemia. A separate meta-analysis of 15 studies indicated that children who had ever been breastfed compared with those who were never breastfed had an 11% lower risk for childhood leukaemia, although the definition of “never breastfed” differed between studies. The authors wrote that, based on current results, 14%‒19% of all childhood leukaemia cases might be prevented by breastfeeding for 6 months or more. They said several biological features of breast milk might explain their findings, including its many immunologically active components that influence the development of the immune system of the breastfed infant, and its involvement in the development of a healthy intestinal microbiome . They said that breastfeeding was a highly accessible and low-cost public health measure, and that health care providers should be given tools to assist mothers with breastfeeding. “The many potential preventive health benefits of breastfeeding should also be communicated openly to the general public, not only to mothers, so breastfeeding can be more socially accepted and facilitated.” The authors also highlighted the need for more high-quality studies to clarify the biological mechanisms underlying the link between breastfeeding and lower childhood leukaemia morbidity.

Too much pre-surgery testing for low-risk procedures
DESPITE guideline recommendations to limit testing before low-risk surgeries, preoperative electrocardiography (ECG) and chest radiography are performed too frequently, according to a study published in CMAJ. The researchers used data from Canadian health care databases on more than 1.5 million patients aged over 18 years who underwent more than two million low-risk procedures across 137 institutions between 2008 and 2013.  The authors assessed patient and institutional-level factors associated with ECG, transthoracic echocardiography, cardiac stress test or chest radiographic in the 60 days before the procedure. Endoscopy, ophthalmologic surgery and other low-risk procedures accounted for 40.1%, 34.2% and 25.7% of procedures, respectively. The authors found that ECG and chest radiography were conducted before 31.0% and 10.8% of procedures, respectively, whereas the rates of preoperative echocardiography and stress testing were 2.9% and 2.1%, respectively. There was significant variation between institutions, with the frequency of preoperative ECG ranging from 3.4% to 88.8%. ECG and radiography were undertaken significantly more frequently in patients who were older, and were also associated with preoperative medical and anaesthesia consultations. The authors said their results contributed substantially to the literature on health care overuse, and highlighted the need for improved alignment with guidelines in the use of preoperative testing before low-risk surgical procedures. The results were also important for public policy, including the Choosing Wisely initiative, which aimed to reduce unnecessary low-value practices by changing the attitudes of both physicians and patients. “More study is needed to determine the underlying causes of this variation and to develop care pathways to reduce low-value preoperative testing”, the authors wrote.

Weekend discharge does not increase readmissions
A RETROSPECTIVE review of data for patients who had undergone abdominal aortic aneurysm repair, colectomy, total hip arthroplasty and pancreatectomy has found that weekend discharge from hospital is not associated with higher 30-day or 90-day readmission rates. The research, published in JAMA Surgery, included data for 128 057 patients who underwent major surgery in Californian hospitals in 2012, including  29 883 (23.3%) who were discharged on a weekend. The researchers found that, contrary to their hypothesis, weekend discharge was not associated with an increased risk for hospital readmission. “In fact, weekend discharge was inversely associated with readmission after colectomy”, the researchers wrote. After controlling for confounding variables, they found that patients with any complication were almost four times more likely to be readmitted. Patients who had unplanned admissions for surgery were up to 12 times more likely to be readmitted compared with elective surgery patients. “One explanation for why weekend discharge was not associated with higher readmission rates in our study may be that current systems in place already do an effective job”, the researchers wrote. “For example, those patients considered at high risk for readmission may already be selected for weekday discharge.” They said that, anecdotally, it was not uncommon for doctors to defer discharging high-risk patients until after the weekend. They also speculated that despite fears of reduced staffing on the weekend, family members could be more available to help with the transition home. An accompanying commentary advised caution in interpreting the study, saying “continued efforts to improve the discharge process are essential — for weekday and weekend discharges alike”.

Concerns over prevalence of sexual violence against children
THE US Centers for Disease Control and Prevention (CDC) has found a disturbing level of sexual violence against children in low- and middle-income countries, with the prevalence for females at 25% or higher in five of seven countries it surveyed. In a report published in the Morbidity and Mortality Weekly Report, the CDC wrote that, as a member of a global public-private partnership known as Together for Girls, it had collaborated with host country governments, communities, and academic institutions in Cambodia, Haiti, Kenya, Malawi, Swaziland, Tanzania, and Zimbabwe to conduct national household surveys of children and young adults aged 13–24 years to assess the extent of violence. The surveys found the lifetime prevalence of experiencing any form of sexual violence in childhood ranged from 4.4% among females in Cambodia to 37.6% among females in Swaziland. The surveys also found that in most countries the proportion of victims who received relevant assistance, including health and child protective services, was at most 10%. The report said the first step in addressing violence against children was to establish comparable international estimates of the magnitude of the problem. “Accurately quantifying and then addressing sexual violence is integral to achieving several major global health aims, including HIV prevention”, it said. “The prevention of sexual violence and the promotion of safe, stable, and nurturing relationships and environments for children need more research, as does the assessment of other social, structural/environmental, or clinical approaches.”

Doubts on supplement benefits for menopause symptoms
RESEARCHERS have found no evidence that calcium and vitamin D supplementation influences menopause-related symptoms, such as vasomotor, mood or sleep complaints, in women in their 60s. The research, published in Maturitas, was part of the Women’s Health Initiative Calcium/Vitamin D Supplementation Trial (CaD) , in which 17 101 women at 40 clinical sites were randomised to elemental calcium carbonate (1000 mg) and vitamin D (400 IU) daily, or placebo. During a mean follow-up of 5.7 years, participants provided data on menopause-related symptoms via questionnaires. The researchers found that the women in the CaD arm did not have a different number of symptoms at follow-up to those of women taking placebo. There were also no differences between the levels of sleep disturbance, emotional wellbeing or energy/fatigue between the two groups. “Our results do not suggest that menopausal women should take calcium plus vitamin D at these doses to improve vasomotor, mood, or sleep complaints… to improve well-being among postmenopausal women with an average of 64 years”, the researchers wrote. Limitations of the study included the fact that women with menopausal symptoms so severe that they disrupted their lives had been discouraged from participating, that the average age of the population was 64 years and that the study did not assess changes in symptom severity.

History of lesions determines sun protection levels
PEOPLE exposed to high levels of ambient solar radiation and who either have a history of treatment for skin lesions or have sun-sensitive skin types are more likely to practise sun protection and examine their skin, Australian research has found. The cross-sectional analysis, published in JAMA Dermatology, was based on a random sample of 40 172 Queensland adults aged 40‒69 years in 2011. The authors also obtained data on all melanoma diagnoses during 2009 from the Queensland Cancer Registry. At baseline, study participants reported information about their pigmentary characteristics, sun protection and whole-body skin examination practices, and skin cancer history in a questionnaire. The participants were divided into three groups: those with previously confirmed melanoma, with a self-reported history of only actinic skin lesions, or with no self-reported history of any skin lesion. The authors found that people with a previously confirmed melanoma and/or treated actinic lesions were more likely than those without a history to report sun protection practices, including regular use of sunscreen and wearing of hats. People with a history of skin lesions also had an almost two-fold higher prevalence of skin examinations by a physician in the previous 3 years. Within all three groups, the strongest association with sun protection practices was with having a sun-sensitive skin type. Among those without a history of treated skin lesions, the strongest factor associated with clinical examinations was self-reported nevus density at 21 years of age. The authors said that people with an interest in skin cancer or prevention were probably overrepresented in their sample, so that, “although our findings are likely to have high internal validity, they may not be generalizable to other populations”.


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