Project aims to reduce CT scans in children
THE launch of an Australian project last week to reduce radiation exposure from computed tomography (CT) scans in children and young people has coincided with a new US study showing a drop in the use of CT scans on children between 2004 and 2012. The multicentre cross-sectional study of children admitted to 33 US paediatric tertiary-care hospitals, published in Pediatrics, found a decline in CT use in 10 of the most common diagnostic groups, including concussion, seizure, ventricular shunt procedures, upper respiratory tract infections and appendicectomy. There was a concomitant increase in alternate imaging modalities in eight of the studied diagnostic groups. The research included rates of CT, ultrasound and magnetic resonance imaging (MRI) based on billing data for 66 433 patients in 2004 and 85 745 patients in 2012. The study authors said they believed the decrease in CT use was multifactorial. They wrote that there had been concerted efforts to assess and increase awareness of imaging-related radiation exposure among ordering physicians, medical students and families. “In addition to less overall imaging for some conditions, we hypothesize that concerns over ionizing radiation may be influencing providers’ choice in imaging, which may affect lifetime cancer risks for pediatric patients”, they wrote. In Australia, the federal government’s Healthdirect Australia announced it had partnered with the Australian Commission on Safety and Quality in Health Care to develop “a one-stop-shop for information and resources about CT scans for children and young people”. The government’s “CT scans and radiation exposure in children and young people” webpage includes links to clinical decision support tools, online education modules, protocols, guidelines and downloadable resources from a range of agencies, medical colleges, professional bodies and peak groups that work in the area of child health.
Life expectancy up but disability not declining
AN analysis of the Global Burden of Disease Study 2013, published in The Lancet, has found that while life expectancy has increased by 6.2 years since 1990, these gains have not being accompanied by commensurate declines in age-standardised rates of disability, especially from major musculoskeletal disorders, mental and substance use disorders, neurological disorders and diabetes. The data showed that Japan had the highest healthy life expectancy (HALE) at 73.4 years and Lesotho in southern Africa had the lowest at 42 years. Australia’s HALE was 68.43 years for men and 70.63 years for women, up from 64.14 and 67.93 years, respectively, in 1990. The study authors wrote that while HALE at birth had increased by 5·4 years between 1990 and 2013, worldwide, age-standardised disability-adjusted life-year (DALY) rates fell by 27%. “Global progress has accelerated since 2005 because of major reductions in HIV/AIDS and malaria, in addition to continued progress against other major communicable, maternal, neonatal, and nutritional disorders”, they wrote. Although the total volume of DALYs was down by only 3·6% during the study period, the authors said this was largely due to population growth and ageing driving up numbers of DALYs, with demands on health systems remaining high. They said improved data and monitoring could help decisionmakers to reduce DALYs from a wide range of causes through prevention, treatment and rehabilitation. An accompanying commentary said the world needed its “fourth quartile countries to catch up in terms of epidemiological transition, and to catch up fast. The question that remains is whether the world has the collective will to make that happen?”
Environment and genetics equally contribute to rosacea
GENETICS and environmental factors equally contribute to rosacea scores, with correlations found between rosacea and ultraviolet (UV) radiation exposure, alcohol and smoking, according to a US study of twins published in JAMA Dermatology. The cohort-based survey included 275 twin pairs who completed questionnaires and were examined by a dermatologist to determine a rosacea score for each twin according to the National Rosacea Society (NRS) grading system. The cohort included 233 identical twin pairs with a mean rosacea score of 2.46 and 42 fraternal twin pairs with a mean rosacea score of 0.75. The researchers said the higher association of NRS scores between identical twins compared with fraternal twins indicated a genetic influence. They calculated that the genetic contribution was 46%. A higher NRS score was also significantly associated with age and lifetime UV radiation exposure. Other correlated variables included body mass index (BMI), smoking, alcohol consumption, cardiovascular comorbidity and skin cancer comorbidity. The authors wrote that their results confirmed UV radiation as the single most important environmental variable, and also revealed the unexpected association between rosacea and high BMI. “We do not know whether this association is the result of unique behavior patterns in individuals with a high BMI. However, this finding provides a starting point for addressing this unexpected association”, they wrote. The study could “serve as a foundation to confirm and pursue the mechanism for specific genetic and environmental contributions to rosacea”.
Delivery outcomes similar with obstetricians and GPs
A LARGE Canadian retrospective population-based cohort study has found no difference in the risk of perinatal mortality or maternal morbidity and mortality between deliveries by family physicians and those by obstetricians. The research, published in the CMAJ, was based on 799 823 neonatal records, which included 72.7% delivered by obstetricians and 27.3% by family physicians, and 793 053 maternal records at 390 hospitals. Infants with a birthweight of less than 500 g or gestational age less than 20 weeks at delivery were excluded. The researchers identified 3600 (0.45%) perinatal deaths and 14 394 (1.82%) cases of maternal morbidity and mortality during the study period from 2006 to 2009. The researchers admitted that, because of the limitations of their statistical method, the confidence intervals around the risk ratios in the results were wide. However, they said the findings build on previous research that supported the safety of obstetric delivery by family physicians. “The current study is among the largest on this topic to date and strengthens these earlier findings by including an adjustment for unmeasured selection bias”, they wrote.
Fertility concerns of younger women with breast cancer
YOUNGER women with breast cancer are less likely to initiate tamoxifen therapy and more likely to discontinue its use due to fertility concerns, according to US research published in JNCI. The study included 515 patients aged younger than 45 years with stage 0 to III hormone receptor-positive breast cancer, for whom tamoxifen was recommended. Clinical and pathologic tumour characteristics, treatment regimens and fertility concerns were recorded, clinical factors associated with tamoxifen non-initiation and discontinuation identified and patient reasons for not starting tamoxifen or discontinuing use documented. Based on multivariable analysis, fertility concerns were statistically associated with both non-initiation and early discontinuation of tamoxifen. Other independent predictors of non-initiation included a diagnosis of ductal carcinoma in situ, declining radiation therapy and not receiving chemotherapy. Smoking and not receiving radiation therapy were also statistically significant predictors of early withdrawal from therapy. The authors said that young survivors of breast cancer were a unique population contending with issues that were distinct from the more routinely studied postmenopausal population. Future research should focus on designing targeted clinical tools to maximise outcomes for this cohort of young survivors, they wrote. An accompanying editorial said that adherence to endocrine treatment was especially critical for young women, as they were at a higher risk for recurrence and death from breast cancer. “In turn, accounting for their concerns and identifying effective strategies to manage them may enhance quality of care, quality of life, and survival,” the editorial authors wrote.
Study emphases importance of maternal diet
NEW research shows improved maternal diet quality in the year before conception is associated with a reduction in some congenital heart defects (CHDs) in children. The research, published in the Archives of Diseases in Childhood: Fetal & Neonatal Edition, was based on a multicentre population-based case–control study of modifiable risk factors for major birth defects, and included 9885 mothers of babies with major non-syndromic CHDs and 9468 mothers with unaffected babies. A better quality diet was based on common recommended dietary guidelines based around a Mediterranean Diet Score, with positive scores for legumes, grains, fruits and nuts, vegetables, fish and the ratio of monounsaturated to saturated fatty acid intake, and negative scores for dairy, meat and sweets. Better maternal diet quality during the year before pregnancy was associated with a reduced risk for selected non-syndromic CHD, which were mostly specific subgroups of conotruncal and septal defects. No clear risk reduction was observed for several other CHDs. “These results add to the accumulating evidence of the importance of diet quality for many health outcomes”, the researchers wrote. “There are very few known protective factors for CHDs; if better diet could help reduce the risk, it would represent a further benefit of the recommendations about optimal nutrition that are part of many preconception care initiatives.”
Long-term impacts of newborn hypoglycaemia
EARLY transient newborn hypoglycaemia is associated with lower academic test scores at 10 years of age, according to US research published in JAMA Pediatrics. The population-based study included all infants born in 1998 at the University of Arkansas for Medical Sciences who had a least one recorded glucose concentration. The authors matched the medical record data of 1395 newborns with normoglycaemia or transient hypoglycaemia with their student achievement tests in 2008. Most of the newborns included were full term and late preterm, and 50.3% were male. Transient hypoglycaemia glucose levels of <35, <40 and <45 mg/dL (<2, <2.2 <2.5 mmol/L) were observed in 6.4%, 10.3% and 19.3% of newborns, respectively. The authors found that, in general, infants with hypoglycaemia were smaller, less mature, less commonly full term and more frequently from multifetal gestations. After controlling for gestational age, race, sex, insurance status, maternal education level and socioeconomic status, transient hypoglycaemia was associated with decreased probability of proficiency in fourth grade literacy and mathematics achievement tests. The authors found that the mean fourth-grade literacy test score and proficiency rate were 544 and 32%, respectively, among children who had neonatal hypoglycaemia, compared with 583 and 57% among children who were normoglycaemic as newborns. The mean mathematics test score and proficiency rate were 562 and 46%, respectively, for those who had hypoglycaemia, compared with 589 and 64% for those who were normoglycaemic. “While our study did not prove that transient newborn hypoglycemia causes poor academic performance, we believe that the findings raise legitimate concerns that need to be further investigated in other newborn cohorts”, the authors wrote. An accompanying editorial said there were many challenges and unanswered questions surrounding the glycaemic management of newborn infants, and that well designed randomised controlled trials with detailed follow-up were needed to provide direction.