Study reveals Indigenous cancer disparity
ABORIGINAL people in NSW are more likely than non-Aboriginal people to be diagnosed with cancer at a more advanced stage of disease, but the delays in diagnosis are more pronounced in some cancer types than others, according to Australian research. The research, published in the MJA, involved a cross-sectional study of cancer cases, excluding lymphohaematopoietic cancers and cancers of unknown primary site, diagnosed in NSW between 2001 and 2007. Overall, 40.3% of 2039 cancers in Aboriginal people and 46.6% of 191 954 cancers in non-Aboriginal people were localised at diagnosis, the authors found. After adjusting for age, sex, year of diagnosis, area of residence and socioeconomic status, Aboriginal people had significantly higher risks of regional or distant spread for head and neck cancer, relative to localised spread, than non-Aboriginal people. The authors said that for breast, cervical and prostate cancers and melanoma, the risks of regional or distant spread were higher for Aboriginal people, but these differences were not statistically significant. For lung, colorectal, upper gastrointestinal tract, other gynaecological, and eye, brain and central nervous system cancers, the risks of regional, distant and unknown spread of disease were similar for Aboriginal and non-Aboriginal people. “Individuals, communities and health professionals need to be vigilant in detecting cancer in Aboriginal people as early as possible and ensuring that they receive the best available treatment”, the authors said.

GPs “central” to bowel cancer screening success
GENERAL practice must be made more central to the National Bowel Cancer Screening Program (NBCSP) if the program is to succeed, according to a letter published in the MJA. The authors wrote that while the NBCSP identified GPs as critical partners, it did not adequately include and support GPs, who had personal frequent contact with a large proportion of the NBCSP’s target population. They said the current practice of returning the patient’s faecal occult blood test (FOBT) results and samples to GPs on paper created extra work of scanning results into patients’ electronic clinical records and, more importantly, prevented GPs’ clinical software from automatically generating appropriate reminders. The uptake of bowel cancer screening was likely to be greater if “general practice is a true partner in the process, as occurs in the cervical screening program”. By following this model, the NBCSP would perform a back-up function to notify the patient’s usual GP if an FOBT result was received within 3‒ 6 months of it becoming due. The authors said it would become increasingly important to consult closely with the primary sector and provide support to GPs to facilitate their role in the expanded NBCSP.

Striking differences in access to stem cell transplants
A WOLRDWIDE retrospective observational study has found striking disparities between countries, in absolute transplant numbers, frequency of transplant and spread of haemopoietic stem cell transplantation (HSCT). The study, published in The Lancet Haematology, showed the different patterns across countries were affected mainly by availability of resources and infrastructure, The Worldwide Network for Blood and Marrow Transplantation, which includes the Australasian Bone Marrow Transplant Recipient Registry, collected data for the evolution of HSCT activity and volunteer donors in the 194 WHO member states. It found 953 651 HSCTs (58% autologous and 42% allogeneic) were reported by 1516 transplant centres from 75 countries. The use of HSCT had increased from the first transplant in 1957 to almost 10 000 by 1985 and an estimated 1 million by December 2012. The highest number of HSCTs were reported from Europe (52%), followed by the Americas (31%), South-East Asia and the western Pacific (15%) and eastern Mediterranean and Africa (2%). The authors wrote that the data “show the effect of intensive global collaboration and data sharing on donors and patient outcome” “Competent authorities are challenged to provide adequate infrastructure for patients and donors and to change the present situation in which access remains restricted to countries and people with sufficient resources”, they wrote. “Professional organisations will have to define the evidence-based but economically adapted indications for HSCT as an efficient and cost-effective approach for patients with life-threatening, potentially curable diseases.” An accompanying commentary described HSCT as “an expensive procedure requiring upfront investment, complex care, and substantial expertise”.

Risks of shorter stay for hip fracture patients
A SHORT hospital stay of 10 days or less after hip fracture has been associated with an increased risk of death after discharge in a large Swedish study published in The BMJ. The study included more than 116 000 patients aged 50 years and older with hip fracture between 2006 and 2012. During the study period the mean length of stay for patients reduced from 14.2 days to 11.6 days The researchers found that for patients whose length of stay was 10 days or less (n = 59 154), each 1-day reduction in length of stay increased the odds of death within 30 days of discharge by 8% in 2006 (odds ratio 1.08), increasing to16% by 2012 (odds ratio 1.16). For patients with a length of stay of 11 days or more (n = 56 957), a 1-day reduction in length of stay was not associated with an increased risk of death after discharge. “Strategies to reduce length of stay include early discharge to rehabilitation in community settings, which results in patients’ exposure to fewer care providers with adequate education in the early postoperative period”, the researchers wrote. Shorter length of stay also reduced the time available for a comprehensive evaluation of the patient’s medical conditions during hospitalisation, they wrote, saying their study confirmed that elderly patients with hip fracture often have multiple comorbidities and high risks of complications. An accompanying editorial said doctors should carefully consider rapid discharge of patients. “For some patients, early discharge is likely beneficial and for others perhaps not”, the editorial said. “As policy makers, we should be aware that, while we have the tools to reduce length of stay, the potential for unintended consequences should not be forgotten.”

Pros and cons of bariatric surgery before pregnancy
WOMEN who become pregnant after bariatric surgery have a decreased risk of gestational diabetes and excessive fetal growth, compared with similar women who do not have surgery, a Swedish study has found. However, the research, published in the New England Journal of Medicine also linked bariatric surgery with an increased risk of the infant being small-for-gestational-age. The authors compared 670 pregnancies in 616 women who had previously undergone bariatric surgery with a control group of pregnancies matched for the mother’s presurgery body mass index, age, parity, smoking history, educational level and delivery year. Gestational diabetes was diagnosed in 1.9% of the postsurgery pregnancies, and in 6.8% of the control pregnancies, the authors wrote. Postsurgery pregnancies were associated with 15.6% of small-for-gestational age infants, compared with 7.6% in the control group. The authors said although pregnancies after bariatric surgery had a shorter gestation than the control pregnancies, the risk of preterm birth did not differ significantly between the groups. The risk of the combined outcome of stillbirth or neonatal death was 1.7% in the postsurgery group and 0.7% in the control group, with the difference not reaching statistical significance. They found no significant difference between the groups in the frequency of congenital malformations. The authors said their results highlighted the need for increased surveillance during pregnancy and neonatal period among women with a history of bariatric surgery. An accompanying editorial said that considering these risks, “decisions regarding bariatric surgery in women of reproductive age should take into account the benefits and risks associated with this not inconsequential procedure in terms of both pregnancy and long-term health”.
NSAIDs a risk for MI patients on antithrombolytics
THE concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs) and antithrombolytics by patients following myocardial infarction (MI) has been associated with an increased risk of bleeding and excess thrombotic events, even after short-term treatment. A Danish study published in JAMA included 61 971 patients aged 30 years and older (mean age 67.7 years) admitted to hospital with first-time MI between 2002 and 2011. The researchers found the distribution of antithrombotic treatment at study inception among prescription NSAID users and non-NSAID users were equal. At least one prescription claim for NSAID treatment after discharge was identified for 20 931 patients (33.8%). There were 18 105 (29.2%) deaths during the median follow-up of 3.5 years, and 5288 bleeding events (8.5%) including 799 (15.0%) fatal bleeds. A total of 18 568 patients (30.0%) experienced cardiovascular events. The researchers wrote that evaluation of different groups of NSAIDs, COX-2 inhibitors, non-selective NSAIDs and other NSAIDs showed all were associated with both increased crude and adjusted risks compared with no NSAID use. An accompanying editorial said the cumulative evidence now available was an “important reminder that the while NSAIDs can be helpful and at times necessary medications for satisfactory quality of life, use of these medications among patients with a history of a recent MI is likely to be associated with clinically meaningful bleeding and ischemic risks”.

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