Australian CBT program reduces suicidal thoughts
AN Australian-designed, web-based cognitive behaviour therapy (CBT) program has reduced suicidal ideation among US medical interns by 60%, highlighting its potential as an efficacious public health measure in a country where one physician dies by suicide every day, according to the authors of research published in JAMA Psychiatry. The 199 interns from multiple specialties were randomised to the web-based therapy group — MoodGYM, developed at the Australian National University’s National Institute for Mental Health Research — or an attention-control group, who received emails with general information about depression, suicidal thinking and local mental health professionals. MoodGYM is a free, online interactive CBT- and interpersonal-based therapy program for young people experiencing mild to moderate levels of depression or anxiety. All interns in the study also completed study activities lasting 30 minutes each week for 4 weeks before starting the internship year. Suicidal ideation was assessed 3 months before students started their intern year and then at 3, 6, 9 and 12 months of their intern year. Over the year, 12% of interns in the MoodGYM therapy reported suicidal ideation during at least one follow-up assessment, compared with 21.2% of students in the control group. The researchers wrote that the findings were important, given that suicidal ideation increased 370% over the first 3 months of the internship year. “With approximately 24 000 medical trainees beginning internship each year, dissemination of a pragmatic, no-cost, feasible, and efficacious prevention program could have substantial public health benefits”, they wrote. Further research using a larger sample would be required to determine whether MoodGYM had any impact on suicide rates, they wrote. An accompanying editorial suggested MoodGYM “inoculated” interns at a critical time in their lives, by providing knowledge and skills that would “enable them to be resilient to the stresses of internship, depression, and suicidal ideation”.
Acupuncture reduces chronic neck pain
ACUPUNCTURE sessions and lessons in the Alexander technique (AT) significantly reduce chronic neck pain over 12 months, compared with usual care, a UK randomised controlled trial published in Annals of Internal Medicine has found. The trial’s 517 participants, with a mean age of 53.2 years, had experienced neck pain for at least 3 months, with a median duration of 6 years. They had a score of at least 28% on the Northwick Park Questionnaire (NPQ) for neck pain and associated disability. The trial participants, who all received 600 minutes of intervention, were randomised to 12 acupuncture sessions plus usual care, 20 one-to-one AT lessons plus usual care, or usual care alone. The mean attendance rate was 10 acupuncture sessions and 14 AT lessons. The study authors found that over 12 months there was a 32% reduction in NPQ scores among those undergoing acupuncture treatment and 31% reduction for AT lessons, both of which exceed the defined threshold of 25% for clinical relevance. “These results compare favorably with findings for physical therapy and exercise, which have typical reductions of up to 8 to 9 percentage points”, the researchers wrote. “The maintenance of benefit from 6 months (when the interventions ended) to 12 months is notable given that the median duration of neck pain was 6 years.” They said neck pain was a leading cause of disability globally. While people with the condition often seek complementary health care such as acupuncture and AT lessons, evidence of long-term health outcomes had been lacking. The study also found that acupuncture and the AT had high rates of acceptability and favourable safety profiles, with no serious adverse events reported.
Big spending doctors have lower litigation risk
A US study has found that doctors who use more resources have statistically significantly lower subsequent rates of alleged malpractice incidents. The observational study, published in The BMJ, used data from more than 18 million admissions to acute care hospitals in Florida in 2000‒2009 and linked them to the malpractice history of attending physicians from seven specialties, which included internal medicine, paediatrics, family medicine, general surgery and obstetrics and gynaecology. Of the 24 637 physicians and 154 725 physician-years included in the research, 4342 malpractice claims were made (2.8% per physician-year). The researchers found that greater average spending by physicians was associated with a reduced risk of incurring a malpractice claim. “For example, among internists, the probability of experiencing an alleged malpractice incident in the following year ranged from 1.5% … in the bottom spending fifth ($19 725 [AUS$27 525]) per hospital admission) to 0.3% … in the top fifth ($39 379 [AUS$54 950] per hospital admission)”, they wrote. The authors acknowledged limitations of the study, including that information on illness severity was lacking and there was no information on whether higher spending was defensively motivated. “A comparison of the costs of additional resource use and the value of reduced errors would be needed to determine whether this defensively motivated care was socially wasteful (that is, classified as defensive medicine) or instead reflects socially beneficial deterrence (that is, the costs of additional resource use are outweighed by the value of reduced errors)”, the authors wrote. An accompanying editorial said that while it might be tempting for doctors to use the study results to justify ordering unnecessary tests and procedures to reduce their risk of malpractice claims, it should be considered as a contribution to the understanding of the risk of claims.
Thrombectomy improves stroke outcomes
ENDOVASCULAR intervention with mechanical thrombectomy in patients with acute ischaemic stroke is associated with improved functional outcomes and higher rates of functional independence at 90 days compared with standard medical management combined with intravenous tissue plasminogen activator (tPA), according to a meta-analysis published in JAMA. The research included eight trials involving 2423 patients (1313 had endovascular thrombectomy and 1110 had standard medical care with tPA) with a mean age of 67.4 years. It also found that endovascular intervention was associated with higher rates of angiographically demonstrated revascularisation at 24 hours. However, it found no significant differences in symptomatic intracranial haemorrhage or all-cause mortality at 90 days. Sensitivity analyses suggested the presence of proximal arterial occlusion on angiographic imaging, intravenous tPA combined with endovascular intervention, and use of stent retriever devices for mechanical thrombectomy were important factors associated with improved functional outcomes with endovascular thrombectomy. The authors wrote that future studies should evaluate the cost-effectiveness of endovascular therapy for the treatment of ischaemic stroke. “In addition, it may be beneficial for medical personnel involved in the early care of patients with acute ischemic stroke, such as paramedics and emergency physicians, to be trained to identify candidate patients who may benefit from endovascular therapy, and for communication to appropriate neurointerventional staff to be streamlined to mobilize neurointerventional resources and reduce the time from stroke onset to recanalization and reperfusion”, they wrote. An accompanying editorial warned that clinicians should realise thrombectomy was not necessarily safer than standard medical care, with similar risks of symptomatic intracranial haemorrhage and all-cause mortality reported in the study, as well as potential procedural risks. The editorial said additional research was needed to see which patients benefited from thrombectomy.
More evidence on animal exposure and asthma
NEW research supports the hypothesis that exposure to dogs and farm animals during the first year of life reduces the risk of asthma in children. The cohort study, published in JAMA Pediatrics, was based on 1 011 051 children born in Sweden between 2001 and 2010, with 376 638 preschool-aged children (14.2% exposed to dogs and 0.5% exposed to farm animals) and 276 298 school-aged children (8.2% exposed to dogs and 0.3% exposed to farm animals) included in the analyses. The researchers found that 18 799 (5.0%) of children in the preschool cohort experienced an asthmatic event before baseline, with 28 511 cases of asthma and 906 071 years at risk recorded during follow-up (incidence rate, 3.1 cases per 1000 years at risk). In the school-aged cohort, 11 585 children (4.2%) experienced an asthmatic event during the seventh year of life. Dog exposure during the first year of life was associated with a decreased risk of asthma in school-aged children and in preschool-aged children 3 years or older, but not in children younger than 3 years. Farm animal exposure was associated with a reduced risk of asthma in both groups. The researchers described the study results as “robust and independent of parental asthma or whether the child was firstborn”. “This information might be helpful in decision making for families and physicians on the appropriateness and timing of early animal exposure”, they wrote.