Latest list of low value medical tests released

Genetic testing for coeliac disease, repeat colonoscopies, whole breast radiation therapy, management of low risk prostate cancer and bone metastases, brain radiation therapy, locoregional therapy, and the inappropriate use of anti-fungal drugs are among a raft of tests, treatments and procedures recently highlighted in the latest recommendations released under the Choosing Wisely Australia program. The Human Genetics Society of Australasia (HGSA), the Gastroenterological Society of Australia (GESA), the Royal Australian and New Zealand College of Radiologists’ (RANZCR) Faculty of Radiation Oncology, and the Australasian Chapter of Sexual Health Medicine (AChSHM) released new recommendations last week, as additions to existing recommendations from other medical societies and colleges under the Choosing Wisely program. The full list of recommendations is available here. Clinical Professor Jack Goldblatt from HGSA said: “Releasing our lists of recommendations today raises awareness of how unnecessary genetic testing can lead to further unnecessary investigations, worry, ethical, social and legal (such as insurance) issues … Of increasing concern is the ‘direct to consumer’ genetic testing for MTHFR and APOE genes. MTHFR is an enzyme that converts folate. MTHFR variants are very common in the general population and folic acid supplementation has been shown to increase folate levels, regardless of MTHFR status. Having a variant in the gene does not generally cause health problems. APOE is considered a risk or susceptibility factor for Alzheimer’s disease, but having a test only shows a probability, so people undertaking a test for APOE can also risk being falsely reassured”. New recommendations from GESA include not undertaking genetic testing for coeliac disease due to the fact that a coeliac gene can be found in one third of the population and a positive result does not make coeliac disease a certainty, and not repeating colonoscopies more often than recommended by the National Health and Medical Research Council guidelines due to the invasive nature of the procedure and risk of complications. Similarly, RANZCR have recommended that management of low risk prostate cancer should always involve a discussion on active surveillance prior to initiating surgical or radiation treatment. Dr Graham Neilsen, President of AChSHM, says: “Many of our Choosing Wisely recommendations focus on screening and testing which is not generally helpful for people who have not experienced symptoms … our recommendations today point to the importance of good conversations between clinicians and patients on appropriate care”.

Indoor tanning associated with outdoor UV risk

Adults who frequently tanned indoors – a practice associated with an increased risk for melanoma – also showed poor outdoor sun protection practices and were less likely to undergo skin cancer screening, according to a new study published online by JAMA Dermatology. Researchers from Johns Hopkins University School of Medicine used 2015 National Health Interview Survey data for a study population of 10 262 non-Hispanic white adults aged 18–60 years without a history of skin cancer. The analysis was limited to non-Hispanic white adults because of their high prevalence of indoor tanning and high incidence of skin cancer. Among the 10 262 adults (49% female), 787 (7.0%) reported having tanned indoors within the past year, 3.6% reported moderately frequent indoor tanning (one to nine times in the past year) and 3.4% reported frequent indoor tanning (10 times or more in the past year). More frequent tanning bed use was associated with poor use of sunscreen, protective clothing and shade, and with having had multiple sunburns in the past year. Among people aged 18–34 years, those who had tanned indoors 10 times or more in past year were more likely to report rarely or never wearing protective clothing and rarely or never seeking shade on a warm sunny day compared with those who had not tanned indoors. Women who frequently tanned indoors were more likely to report rarely or never applying sunscreen, rarely or never wearing protective clothing, rarely or never seeking shade and multiple sunburns in the past year compared with women who did not tan indoors. Men who had tanned indoors more than 10 times in the past year were more likely to rarely or never seek shade, and men who had tanned indoors less than ten times in the past year were more likely to rarely or never use protective clothing and to report multiple sunburns in the past year compared with men who did not tan indoors. People who tanned indoors were not more likely to have undergone a full-body skin examination compared with those adults who do not tan indoors.

Wrist-worn heart rate monitors skipping a beat

In a study published online by JAMA Cardiology, US researchers assessed the accuracy of four popular wrist-worn heart rate (HR) monitors under conditions of varying physical exertion. The study included 50 healthy adults; average age, 37 years; 28 participants (56%) were women. Participants wore standard electrocardiographic limb leads and a Polar H7 chest strap monitor. Each participant was randomly assigned to wear two different wrist-worn HR monitors. Four wrist-worn monitors were assessed: Fitbit Charge HR (Fitbit), Apple Watch (Apple), Mio Alpha (Mio Global), and Basis Peak (Basis). Heart rate was assessed with the participant on a treadmill at rest and at 2, 3, 4, 5 and 6 mph. Participants exercised at each setting for 3 minutes to achieve a steady state; HR was recorded instantaneously at the 3-minute point. After completion of the treadmill protocol, HR was recorded at 30, 60, and 90 seconds’ recovery. Across all devices, 1773 HR values were recorded. When compared with electrocardiogram, the HR monitors had variable accuracy. The authors state that two of the four wrist monitors had suboptimal accuracy during moderate exercise; while the Basis Peak overestimated HR during moderate exercise, the Fitbit Charge HR underestimated HR during more vigorous exercise. Analysis showed that variability occurred across the spectrum of mid-range HRs during exercise. The Apple Watch and Mio Alpha had 95% of differences fall within -27 beats per minute (bpm) and +29 bpm of the electrocardiogram, while Fitbit Charge HR had 95% of values within -34 bpm and +39 bpm and the corresponding values for the Basis Peak were within -39 bpm and +33 bpm. “We found variable accuracy among wrist-worn HR monitors; none achieved the accuracy of a chest strap-based monitor. In general, accuracy of wrist-worn monitors was best at rest and diminished with exercise,” the authors wrote. “Electrode-containing chest monitors should be used when accurate HR measurement is imperative.”

SSRIs during pregnancy may increase risk of speech disorders

The children of mothers who had depression-related psychiatric disorders and purchased selective serotonin reuptake inhibitors (SSRIs) at least twice when they were pregnant had an increased risk for speech and language disorders, according to an article published online by JAMA Psychiatry, but further studies are needed before conclusions can be drawn about possible clinical implications. US researchers used registry data in Finland from 1996 to 2010, and the final study group included 56 340 infants (about 51% male). The offspring were divided into three groups: 15 596 were in the SSRI-exposed group because their mothers were diagnosed as having depression-related psychiatric disorders with a history of purchasing SSRIs during pregnancy; 9537 were in the unmedicated group because their mothers were diagnosed as having depression-related psychiatric disorders or other psychiatric disorders associated with SSRI use but had no history of purchasing SSRIs during pregnancy; 31 207 were in the unexposed group because they were unexposed prenatally to an SSRI or had mothers without a psychiatric diagnosis. The average ages of children at diagnosis were 4.4 years old for speech and language disorders, 3.5 years for scholastic disorders and 7.7 years for motor disorders. The children of mothers who purchased SSRIs at least twice during pregnancy had a 37% increased risk of speech and language disorders compared with offspring in the unmedicated group and a 63% increased risk compared with children in the unexposed group.

Exercise confirmed to have positive impacts on pregnancy and labour

Strenuous exercise during pregnancy is unlikely to prolong labour or boost the risk of premature birth, says a consensus statement from the International Olympic Committee (IOC), published online in the British Journal of Sports Medicine. But the overall quality of the available evidence on the impact of intense exercise is not strong, with few studies carried out in elite athletes, the statement warns. The statement is the second in a series of five issued by the IOC on exercise and pregnancy, including in elite athletes. It draws on a systematic review of the available published evidence, presented by an international panel of experts in Lausanne, Switzerland, in September 2016. In summary, there is strong evidence that exercise during pregnancy reduces excessive birthweight, without boosting the risk of underweight at birth. There is also moderately good evidence that it neither boosts the risk of premature birth nor reduces Apgar score, and there is moderately strong evidence that exercise during pregnancy does not increase the rates of induced labour, the need for episiotomy or epidural. Similarly, there is moderately good evidence that physical activity does not prolong labour, and some research suggests that regular exercise may even shorten it. The impact of exercise on delivery method is still unclear, with some research suggesting that it lowers the risk of a caesarian section birth, although this may be a consequence of reduced obesity in pregnant women who exercise. While strenuous exercise speeds up fetal heart rate, this is only temporary, with the heart rate returning to normal once exercise is stopped. Some evidence suggests that high impact training routines and repetitive weight training may be linked to a heightened risk of miscarriage, thus elite athletes planning pregnancy might want to consider reducing or refraining from these activities during the first 3 months of pregnancy. It should be noted that there are very few studies of the effects of exercise on pregnancy carried out in elite athletes.


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