News in brief

TWO meta-analyses published in The Lancet show aromatase inhibitors (AIs) and bisphosphonates improve outcomes for postmenopausal women with early breast cancer. The first meta-analysis of randomised trials of AIs or tamoxifen as endocrine treatment for early breast cancer included 31 920 postmenopausal women with oestrogen-receptor-positive cancer. A comparison of 5 years of AIs versus 5 years of tamoxifen showed recurrence rate ratios (RRs) favoured AIs significantly during the first year (RR, 0.64). In years 2–4, there was also a significant reduction (RR, 0.80), but no significant difference was found thereafter. The analysis also found 10-year breast cancer mortality was lower with AIs than tamoxifen (12.1% v 14.2%). The researchers wrote that a review of guidelines seemed appropriate, as it was currently recommended that endocrine treatment of postmenopausal women with early breast cancer start with tamoxifen in three of four options. An accompanying editorial said the meta-analysis did not take into account the patient experience due to side effects. “Ultimately, the best choice for adjuvant endocrine therapy is a treatment the patient is willing to take”, it said. The second meta-analysis  included individual patient data on 18 766 women who took part in randomised controlled trials of bisphosphonate treatment, mostly for 2–5 years, with median follow-up of 5.6 woman-years. The analysis included 3453 first recurrences of breast cancer and 2106 subsequent deaths. It found that, overall, the reductions in recurrence (RR, 0.94), distant recurrence (RR, 0.92) and breast cancer mortality (RR, 0.91) were of borderline significance, but the reduction in bone recurrence (RR, 0.83) was more definite. In premenopausal women, treatment had no apparent effect on any outcome, but among 11 767 postmenopausal women it produced highly significant reductions in recurrence (RR, 0.86), distant recurrence (RR, 0.82), bone recurrence (RR, 0.72) and breast cancer mortality (RR, 0.82). An accompanying comment described the analysis as a “landmark report on breast cancer treatment” that should “lead to widespread adoption of bisphosphonates as a standard of care for the adjuvant therapy of early-stage breast cancer in postmenopausal women”.

 

AN observational study of almost 80 000 people who had undergone either open or endovascular repair of abdominal aortic aneurysm has found endovascular repair was associated with a substantial early survival advantage that gradually decreased over 8 years of follow-up. The research, published in the New England Journal of Medicine, found that overall perioperative mortality was 1.6% with endovascular repair and 5.2% with open repair. Through the 8 years of follow-up, perioperative mortality decreased by 0.8 percentage points among patients who underwent endovascular repair and 0.6 percentage points for open repair. Interventions related to the management of the aneurysm or its complications were more common after endovascular repair, while interventions for complications related to laparotomy were more common after open repair. Aneurysm rupture occurred in 5.4% of patients after endovascular repair versus 1.4% of patients after open repair. The researchers wrote that a decline in reinterventions after endovascular repair over the follow-up period “seemed to be driven by a decrease in the number of minor reinterventions, primarily coil embolization, which probably represents a more conservative attitude toward the management of type 2 (side branch) endoleak”. They said the decline in perioperative mortality was most likely due to operators’ increased familiarity with the procedure and improvements in endografts over time. “It is unlikely, however, that this reduction in perioperative mortality is driven by improved patient selection, because most patients are now being treated with the use of endovascular repair, and mortality after open repair was reduced over this period as well”, they wrote.

 

SURVIVAL odds for people who have an out-of-hospital cardiac arrest have increased following interventions to improve bystander and first-responder resuscitation efforts, according to US research. The study, published in JAMA, included 4961 patients who had out-of-hospital cardiac arrests between 2010 and 2013, with resuscitation attempted. The authors examined patient outcomes and changes in the number of resuscitation attempts after several educational initiatives were introduced in North Carolina. The interventions included training for the general population in cardiopulmonary resuscitation (CPR) and in the use of automated external defibrillators (AEDs), training first responders (including police and firefighters) in team-based CPR including AED use and high-performance CPR before emergency medical services arrived, and training dispatchers to recognise cardiac arrest. The authors found that the combination of bystander CPR and first-responder defibrillation increased from 14% in 2010 to 23% in 2013. Survival with favourable neurological outcomes also increased, from 7% in 2010 to 10% in 2013, and was associated with bystander-initiated CPR. Bystander and first-responder interventions were also associated with higher survival to hospital discharge. Survival following emergency medical services-initiated CPR and defibrillation was 15%, compared with 34% following bystander-initiated CPR and defibrillation. The authors said their results highlighted the potential of strengthening first-responder programs, in addition to increasing the number of bystanders who could provide CPR, particularly in residential areas and in areas with a long emergency services response time. Another JAMA study from Japan found rates of bystander chest compression and defibrillation increased between 2005 and 2012, and were associated with increased odds of neurologically intact survival. An accompanying editorial said that despite increased knowledge and use of bystander CPR and improved survival over time, ongoing efforts were needed to improve outcomes after out-of-hospital cardiac arrest. 

 

CHILDREN from low-income households have atypical structural development in areas of the brain associated with school readiness skills, according to a longitudinal study published in JAMA Pediatrics. The US authors analysed magnetic resonance imaging scans of 389 typically developing children, adolescents and young adults aged 4‒22 years, with complete sociodemographic and neuroimaging data collected between 2001 and 2007. The authors calculated each child’s scores on cognitive and academic achievement tests and measured brain tissue, including grey matter of the total brain, frontal lobe, temporal lobe and hippocampus. The authors found that the regional grey matter volumes of children living below 1.5 times the federal US poverty line were on average 3%‒4% below the developmental norm. A larger developmental gap of 8%‒10% was observed among children from the poorest households. The authors said these developmental differences had consequences for a child’s academic achievement. On average, children from low-income households scored 4‒7 points lower on standardised tests, and as much as 20% of the gap in test scores could be explained by developmental lags in the frontal and temporal lobes of the brain. To avoid long-term costs of impaired academic functioning, households below 150% of the federal poverty level should be targeted for additional resources aimed at remediating early childhood environments, they wrote. An accompanying editorial said this research was part of an “unassailable” body of evidence that highlighted the need for public policy and early parenting interventions to preserve the developing brain. 

 

PROVIDING families of young overweight children with regular low-intensity support can make small but significant differences to body weight and lifestyle behaviour over 2 years, the results of a randomised controlled trial published in Pediatrics show. The trial was based on 206 overweight and obese children aged 4‒8 years who were randomly assigned to usual care (UC) or tailored package (TP) sessions. The UC families received personalised feedback and generalised advice about healthy lifestyles at baseline and at 6 months. The TP families attended a single multidisciplinary session to develop specific goals suitable for each family, then met with a mentor each month for 12 months, and then every 3 months for another 12 months to discuss progress and for support. After 2 years, children in the TP group had smaller gains in body mass index, were more physically active, had improved diets and reported fewer non-core foods available in the home compared with children in the UC group. The researchers wrote that smaller but still positive outcomes in the UC group suggested screening for overweight in young children, followed by a minimal two-session intervention, might lead to small but sustained changes to relative weight. “This alternative approach is considerably less involved and could feasibly be incorporated into the primary care environment with relatively little effort”, they wrote. 

 

LOW birthweight and an unhealthy lifestyle in adulthood are both associated with a significantly higher risk of type 2 diabetes, and the combination has synergistic effects, according to a study published in The BMJ. The findings were based on data for nearly 150 000 men and women included in three large cohorts of health professionals and nurses. At baseline, all participants were free from diabetes, cardiovascular disease and cancer, and provided information on birthweight. Five lifestyle factors (diet, smoking, physical activity, body mass index [BMI] and alcohol consumption) were used to calculate an unhealthy lifestyle score. Incident cases of type 2 diabetes were identified through self-report and validated by a supplementary questionnaire. During 20–30 years of follow-up, 11 709 new cases of type 2 diabetes were documented. Across the three study cohorts, low birthweight and an unhealthy adulthood lifestyle were jointly associated with an increased risk of type 2 diabetes. Compared with people in the middle category of birthweight (3.18‒3.82 kg), the multivariate adjusted relative risk of type 2 diabetes among those with the lowest birthweight (< 2.5 kg) was 1.49. Further adjustment for current BMI amplified the association between low birthweight and type 2 diabetes, with a pooled relative risk of 1.55. The joint effect could be broken down to 22% for a low birthweight alone, 59% for an unhealthy lifestyle alone, and 18% for an additive interaction between low birthweight and unhealthy lifestyle. The authors said the significant additive interaction suggested public health consequences of unhealthy lifestyles would be larger in low birthweight populations. They said their findings highlighted that “most cases of type 2 diabetes cases could be prevented by the adoption of a healthier lifestyle, but simultaneous improvement of both prenatal and postnatal factors could further prevent additional cases”. 

 

FORMER professional rugby players have decreased neck mobility and significantly greater prevalence of neck pain compared with men who have never played the game competitively, according to research published in the Journal of Neurosurgery: Spine. The research included 101 former rugby players (all men, mean age of 40.3 years) and a control group of 85 men (mean age of 41.6 years). The former rugby players were evaluated an average of 5.8 years after retirement, and the groups were matched by age, job, current sports training and smoking habits. Each participant received a complete neurological evaluation. The researchers found that significantly more former rugby players than controls complained of chronic neck pain (51% v 32%) and had significant reductions of neck mobility. However, among those complaining of pain, there was no statistically significant difference between groups based on a visual analogue scale and the Neck Disability Index. The researchers wrote that a narrower cervical canal and more foraminal stenosis seen on magnetic resonance imaging in the rugby group suggested that participation in this sport might promote the development of degenerative lesions in young, retired rugby players. They also found that although only one case of neurological disease was noted in the 101 former rugby players, they had more often undergone surgery for a degenerative problem. Longer evaluation of more than 10 years after retiring from the sport was needed to determine if the findings persisted over time, the researchers wrote.