Clinic assists with genetic cardiac diagnosis
AN assessment of outcomes during the first 6 years of operation of the Cardiac Genetics Clinic (CGC) at the Royal Melbourne Hospital has found it played an important role in assisting doctors and patients by confirming or negating a genetic cardiac diagnosis. The research, published in the MJA, included 1170 individuals, with a median age of 39 years, who attended the clinic either as the proband or as an at-risk family member. The authors used the CGC’s database to determine the referral diagnoses, sex, number of visits and incidence of genetic testing for each patient, with 57.5% of patients attending the clinic only once in the study period. Most visits fell into four broad diagnostic categories — cardiomyopathy, aortopathy, arrhythmia disorders, and resuscitated cardiac arrest and/or family history of sudden cardiac death. Genetic testing was undertaken in 381 individuals, and a pathogenic mutation was identified in 47.6% of tests, representing 15.3% of the total population. The authors said that everyone who attended the clinic had undergone appropriate screening investigations and examination, and when genetic testing was offered it was accompanied by counselling and education. The authors said a major contribution of the clinic was to facilitate the implementation of a personalised management plan for the affected individuals and their family members after receiving a diagnosis. They anticipated that the use of genetic testing at the CGC would increase in the future, reflecting both its potentially decreasing costs as well as the increased utility of multiple gene testing. “The currently recommended care model for genetic medicine, achieved by a multidisciplinary team working together with the genetics laboratory, provides an effective means for translating advances in genomic medicine into clinical practice”, they wrote.
Antidepressant trial reanalysis finds major flaws
A REANALYSIS of trial data from more than 15 years ago has found neither paroxetine nor high-dose imipramine is effective in treating major depression in adolescents, with both drugs associated with an increase in harms. The new study, published in The BMJ, reanalysed the findings of a trial conducted between 1994 and 1998 across 12 psychiatry centres in North America, which included 275 adolescents with major depression of at least 8 weeks’ duration randomly assigned to receive 8 weeks of double-blind treatment with 20–40 mg paroxetine, 200–300 mg imipramine, or placebo. The outcomes measured included changes from baseline in total Hamilton depression scale (HAM-D) score and the proportion of responders at the end of the acute treatment phase. The authors of the original research concluded that paroxetine was a safe and efficacious treatment. The BMJ researchers, including from Australia, examined the trial’s final clinical report, appendices, other publicly available documents, and the individual participant data. They found there was no statistically or clinically significant difference in efficacy between paroxetine and imipramine compared with placebo. HAM-D scores decreased by 10.7, 9.0 and 9.1 points, respectively, for the paroxetine, imipramine and placebo groups. The authors found clinically significant increases in harms, including suicidal ideation, and behaviour and other serious adverse events, in the paroxetine group and cardiovascular problems in the imipramine group. They said their reanalysis showed that access to primary data from trials had important implications for both clinical practice and research, and that regulatory authorities should mandate accessibility of data and protocols. “When the data become accessible to others, it becomes clear that scientific authorship is provisional rather than authoritative”, they wrote. An accompanying editorial said the findings highlighted the need to reactivate dormant trials, saying that adding extra years of follow-up via linked databases “will allow the study of long term outcomes, including those not part of the original protocol”.
Indoor insecticide exposure increases risk of childhood cancer
CHILDREN exposed to indoor residential insecticides have a higher risk of developing childhood haemopoietic cancers, according to a meta-analysis published in Pediatrics. The analysis was based on 16 case-controlled, epidemiologic studies on the association between residential pesticide exposure and childhood brain tumour, haemopoietic malignancies, Wilms tumour, neuroblastoma or multiple malignancies. The sample size of each study ranged from 45 to 1184 cases, and the upper age limits of participants were 9 to 19 years. Overall, the results suggested that cancer risks were related to the type of pesticide and where it was used, the authors said. Exposure to residential indoor insecticides during childhood was significantly associated with an increased risk of childhood cancers, including leukaemia and lymphoma, but not childhood brain tumour. The strongest association observed was between indoor insecticide exposure and acute childhood leukaemia. However, there was no significant association between outdoor insecticides and childhood cancers. The authors said that additional research was needed to confirm the relationship between residential pesticide exposures and childhood cancers, and to understand the underlying mechanisms of this association. In the meantime, preventive measures and policies should be developed to minimise residential pesticide use, especially indoors. “Every effort should be made to limit children’s exposure to pesticides”, the authors wrote.
Study shows diet can lower breast cancer risk
A MEDITERRANEAN diet supplemented with extra virgin olive oil is associated with a relatively lower risk for breast cancer, according to a study published in JAMA Internal Medicine. The randomised trial included 4282 women aged 60–80 years in Spain who were at high risk of cardiovascular disease. The women were allocated to a Mediterranean diet supplemented with extra-virgin olive oil (EVOO, 1 L per week for the participants and their families), a Mediterranean diet supplemented with mixed nuts (15 g of walnuts, 7.5 g of hazelnuts and 7.5 g of almonds a day), or a control diet. The women were recruited through primary care centres, and had an average body mass index of 30.4, with most undergoing menopause before the age of 55 years. They were followed up for a median of 4.8 years, and 35 cases of confirmed breast cancer were identified. Observed rates of breast cancer (per 1000 person-years) were 1.1 for the Mediterranean diet with EVOO group, 1.8 for the Mediterranean diet with nuts group, and 2.9 for the control group. The authors found that women allocated to EVOO had a 62% relatively lower risk of malignant breast cancer than those allocated to the control diet. The Mediterranean diet supplemented with nuts showed a non-significant risk reduction compared with the control group. When both Mediterranean diet groups were merged, a 51% relative risk reduction was observed. The authors wrote that their findings suggested a beneficial effect of the Mediterranean diet with EVOO in reducing the risk for breast cancer. They said the trial provided a useful scenario for breast cancer prevention because it was conducted through primary health centres. “Nevertheless, these results need confirmation by long-term studies with a higher number of incident cases.”
Injury and illness linked to longer emergency shifts
EXTENDING emergency medical service (EMS) workers’ shifts increases their risk of occupational injury and illness, according to research published in Occupational and Environmental Medicine. The research was based on 3 years of shift schedules and injury and illness reports from 14 large EMS agencies in the US. The authors used logistic regression models to test the relationship between shift length and occupational injury and illness, while controlling for relevant shift work and teamwork factors. The study sample included nearly 1 million shifts, 4382 employees and 950 outcome reports. Among the 705 injury reports, the words “sprain” or “strain” were present in 79.2% of descriptions, while contusions or abrasions were reported in 11.9% of descriptions. One in five injuries or illnesses resulted in restrictions of normal work activities, while 12.7% resulted in time away from work. The authors found that compared with shifts >8 hours and ≤12 hours, shifts >12 hours and ≤16 hours increased the risk by 27% (not statistically significant), but shifts greater than 16 hours and as long as 24 hours increased the risk of injury or illness by 60%. Shifts of ≤ 8 hours decreased the risk of occupational injury or illness by 30%. The authors said their data suggested that EMS workers might not arrive to work fully rested if they had only 6 hours of pre-shift sleep on average. They said there were several important limitations of the study, including no information on call volume, rurality or existing fatigue managements systems. Despite this, the results “are early observational evidence of a preventable exposure associated with injury and illness and should be tested further in a randomised design”.
Racial disadvantage amplified by higher socioeconomic status
US researchers have found that that although both black and white patients with low socioeconomic status (SES) are disadvantaged in regards to life expectancy after acute myocardial infarction (AMI), black patients with higher SES have shorter life expectancy than white patients after AMI. The research, published in Circulation, was based on a nationally representative cohort of more than 140 000 older US patients hospitalised with AMI between 1994 and 1996. It included detailed medical record data, demographic information and 17 years of follow-up of each participant. The mean age of participants was 75.9 years and 6.3% were black. The authors found that 26% of black patients lived in low SES areas compared with 5.7% of white patients. Although both black patients and patients in low SES areas were disadvantaged on life expectancy after AMI, for those living in higher SES areas, the gap between the life expectancies of black and white patients was the greatest, suggesting that “racial disparities may be amplified in patients with the most area-level resources”, the authors wrote. The associations also varied by age with the disparities most prominent among patients aged less than 75 years. The authors said their findings highlighted “the need for additional research investigating racial and socioeconomic differences in post-AMI care and practice patterns”. Any future efforts aimed at decreasing health disparities should focus on reducing the cardiovascular risk burden in black patients, and ensuring equitable delivery of guideline-based therapies, they wrote.