News in brief

GPs working in small communities and those who have worked in a rural location for less than 3 years are most at risk of leaving rural practice, research has found. The study, published in the MJA, was based on a survey of Australian GPs between 2008 and 2012, which assessed work location, frequency of mobility and the characteristics of those who moved. Data were derived from a national longitudinal survey that collects data in annual waves from mostly the same panel of doctors. There were 3906 participants in 2008, which represented 19% of Australia’s GP workforce, and 3502, 3514, 3287 and 3361 participants in subsequent years. GP registrars were excluded from the study as many did not have autonomy over their work location during their fellowship training. The authors found that 133 GPs moved from rural to metropolitan areas, while 103 GPs moved from metropolitan to rural locations. Of the 271 GPs who moved within non-metropolitan Australia, 77 moved to regional centres, but only 24 GPs left regional centres for a smaller rural or remote location. Annual location retention rates were 95% in regional centres, 90% in small rural towns and 82% in very remote areas. The authors wrote that GPs in small towns of less than 5000 residents had the highest risk of leaving rural practice. Mobility rates were significantly higher for GPs who had worked in a location for less than 3 years and for those who worked as either contracted or salaried employees. Mobility rates were also higher among international medical graduates. Younger age was a small predictor of increased mobility, while sex and family status had no association with mobility. The authors wrote that increasing workforce supply and maintaining the existing rural medical workforce remained a key issue in improving rural health in Australia. They said their results would be “useful in guiding more effective targeting of rural health policies and workforce planning and incentives”.

 

AUSTRALIAN research has found that exposure to fine particulate matter (PM_2.5) in bushfire smoke is associated with an increased risk of acute coronary events, particularly among older adults. The research, published in the Journal of the American Heart Association, was based on air pollution modelling and health registry data to determine the impact of PM_2.5 concentrations on the number of out-of-hospital cardiac arrests, hospital admissions and emergency department visits for ischaemic heart disease (IHD), acute myocardial infarction and angina during the 2006‒2007 Victorian bushfires. During the 2-month study period, 457 out-of-hospital cardiac arrests, 2106 emergency department visits and 3274 hospital admissions for IHD were recorded. The authors found that an increase in bushfire smoke PM_2.5 was associated with an increase in risk for out-of-hospital cardiac arrests of 6.98% after adjusting for temperature and relative humidity. There was also an increase in risk of hospital admissions for IHD by 1.86% and for AMI by 2.34%. This association was observed mainly in adults aged over 65 years. Men had a higher risk of out-of-hospital cardiac arrests events, while women showed a higher risk of IHD-related hospital admissions. The authors said their results indicated that PM_2.5 exposure could be an important determinant of acute coronary events during bushfire periods, and that susceptible people such as older adults may be at higher risk. “Given the increased incidence and frequency of wildfires recently and the increased number of people at risk of smoke exposure, future research is required to investigate the role of fine particulate matter exposure from wildfire smoke in triggering acute coronary events”, they wrote. Such research would inform policy and practice, and help build capacity in the management of adverse cardiovascular health impacts in vulnerable communities during bushfires.

 

PATIENTS aged 50 years and older with ulcerative colitis (UC) who chose colectomy had better survival outcomes than those who took medicine, according to a retrospective matched cohort study published in the Annals of Internal Medicine. Among patients younger than 50 years, no survival benefit was for surgery was found above medical therapy. The US research included patients with advanced UC defined as at least one of the following: hospitalisation with a primary diagnosis of UC, two or more oral corticosteroid prescriptions within a 90-day period, or any prescription for immunosuppressant therapy. The cohort included 830 patients undergoing elective colectomy and 7541 matched patients who had medical therapy. They were followed up until they died or the study ended. Data analysis showed mortality rates associated with elective colectomy and medical therapy in the overall cohort were 34 and 54 deaths per 1000 person-years, respectively. The researchers wrote that a post hoc analysis suggested the survival benefit was most evident in patients aged 50 years or older, although it was not evident in the subgroup of older patients treated with immunosuppressants for their advanced UC. “These findings warrant discussion with patients when one is weighing the risks and benefits of different medical therapies and total colectomy”, they wrote. An accompanying editorial cautioned interpretation of the study for a number of reasons, including lack of randomisation, and the population only comprising Medicare and Medicaid patients. However, with a 5-year mortality rate about 30% lower among surgically treated patients 50 years or older, it said the study demonstrated that “simply keeping a patient’s colon intact” was not a sufficient long-term measure of therapeutic “success”. The goal of therapy should be less about avoiding surgery and more about making the patient well.

 

AUSTRALIAN and New Zealand research suggests that although extremely preterm infants of multiple gestation births are at increased risk of mortality compared with singletons, the difference may be diminishing. The retrospective study, published in Pediatrics, included 15 402 infants born at ≤27 weeks’ gestation admitted to neonatal intensive care units between 1995 and 2009, with mortality and major morbidities compared between singletons and multiples across three 5-year epochs (1995‒1999, 2000‒2004, 2005‒2009). Extreme preterm multiples were more likely to have lower birthweight, higher maternal age and higher rates of assisted conception, antenatal steroid use and caesarean delivery compared with singletons. However, rates of major morbidities or composite adverse outcomes were not different between the two groups across all epochs. Over the 15-year period, the mortality rate for multiples was significantly higher compared with singletons (24.7% vs 21.9%). However, there was an overall reduction in the mortality rate of extremely preterm infants from epoch 1 to epoch 3, falling from 27.5% to 19.2%, compared with singletons (24.5% to 18.9%). The authors wrote that the regionalisation of neonatal care in Australia and New Zealand “makes this a good representation of the extremely preterm population”. They wrote that the study findings had important implications in the risk assessment of outcomes in extremely preterm infants and the antenatal counselling of parents with multiple gestation pregnancies. They called for further studies to determine the impact of multiple gestation and assisted reproductive technology techniques on long-term neurodevelopmental outcomes.

 

LONG-term survivors of young adult cancers have an increased rate of hospitalisation, which does not return to baseline after 20 years, according to research published in the Journal of Clinical Oncology. The Canadian research included 20 275 cancer survivors who lived at least 5 years recurrence-free and were diagnosed between the ages of 20 and 44 years, and 101 344 non-cancer controls. During the study period, 6948 (34.3%) of the cancer survivors were admitted to hospital, with an adjusted relative rate of hospitalisations in survivors compared with controls of 1.51. The rate of hospitalisation was highest for survivors of upper gastrointestinal, leukaemia and urological malignancies. The hospitalisation rate (per 100 person years) between survivors and controls significantly decreased from 0.22 in the 5–8 years post-diagnosis to 0.15 in the 18–20 years post-diagnosis. The researchers wrote that in all time periods, survivors were more likely to be hospitalised than controls, indicating a substantial and persistent burden for patients. They also found survivors and controls were hospitalised for mental health disorders at equivalent rates. “Our study identifies populations of survivors at particular risk of hospitalization as well as the affected organ or tissue systems relating to the hospital admission”, the researchers wrote. “This information would be useful for developers of recommendations or guidelines to counsel survivors of young adult cancers on their future quality of life.”

 

COMBINED use of antidepressants and non-steroid anti-inflammatory drugs (NSAIDs) is associated with an increased risk of intracranial haemorrhage within 30 days of taking the medications compared with taking antidepressants alone, research has found. The study, published in The BMJ, included more than 4 million people drawn from a Korean health insurance database between 2009 and 2013. Participants were included in the study if they were new users of antidepressants and had received a prescription for at least one antidepressant during the study period. Patients who had been diagnosed with cerebrovascular diseases in the previous year were excluded. The authors identified the time to first admission to hospital with intracranial haemorrhage within 30 days of drug use, using regression models to compare the risk of bleeding among those who had taken antidepressants with and without NSAIDs. The authors found that the 30-day risk of intracranial haemorrhage was higher for combined use of antidepressants and NSAIDs than for use of antidepressants without NSAIDs. Compared with women, men had a higher risk for intracranial haemorrhage when taking both medications. Comorbidities and co-medications did not appear to increase the risk of bleeding with combined use of antidepressants and NSAIDs, the authors found. No statistically meaningful differences in haemorrhage risk between the different drug types were observed. The authors said their results confirmed existing research on the increased risk of combining antidepressants and NSAIDs, and that “special attention is needed when patients use both these drugs together”. An accompanying editorial said that useful information to help practitioners with decision making was still lacking but given the availability of over-the-counter analgesics, it was important doctors considered interactions from non-prescribed drugs. “Further research is needed to extend the findings over longer time periods and to quantify risks in different populations”, it said.