Evidence-based practice could reduce caesarean births
REDUCING variation in the clinical practice of caesarean section (CS) for risk-based groups of women would lower the overall rate of CS, according to research published in the MJA. Researchers analysed 183 310 births at 81 NSW hospitals in the population-based record linkage study, including 56 696 by CS, giving an overall CS rate of 30.9%. They found hospital CS rates varied from 11.8% to 47.4%. “Compared with women who had a vaginal birth, women who had a CS were more likely to be older, Asian-born and nulliparous”, the researchers wrote. “Having had a previous CS, diabetes, hypertension, private maternity care and preterm birth were also associated with an increased likelihood of CS.” They wrote that understanding hospital heterogeneity in performing CS and implementing evidence-based practices “may result in improved maternity care”. The researchers suggested nulliparous women at term and women with previous CS, multifetal pregnancies or preterm birth could be priority targets for achieving clinical practice changes. The three groups of women who contributed most to the overall CS rate were all made up of women with a single cephalic pregnancy who gave birth at term, including those who had had a previous CS (36.4% of all CSs); nulliparous women with an elective delivery (pre-labour CS or labour induction, 23.4%); and nulliparous women with spontaneous labour (11.1%).

Whole fruit reduces diabetes risk
RECOMMENDING to patients that they increase consumption of a variety of whole fruits, especially blueberries, grapes and apples, could be a prevention measure for type 2 diabetes, according to research published in the BMJ. The researchers performed a prospective study of three cohorts of US men and women, finding that the associations with risk of type 2 diabetes differed significantly among individual fruits, with greater consumption of blueberries, grapes, apples, bananas and grapefruit significantly associated with a reduced risk. The researchers said the differences in glycaemic index/glycaemic load values of fruits did not account for the association of specific fruits with risk of type 2 diabetes. “Moreover, greater fruit juice consumption was associated with an increased risk, and substitution of whole fruits for fruit juice was associated with a lower risk, except for strawberries and cantaloupe [rockmelon]”, they wrote. They found that 12 198 of the 187 382 study participants developed type 2 diabetes. The overall risk in the populations studied over nearly 3.5 million person-years of follow-up was 6.5%. Among those who had three servings per week of individual whole fruits rather than fruit juice the overall risk was reduced by 7%. The researchers found that for every three servings of whole fruit a week, the pooled hazard ratios (95% confidence intervals) of risk for type 2 diabetes was 0.74 (0.66–0.83) for blueberries, 0.88 (0.83‒0.93) for grapes and raisins, 0.93 (0.90‒0.96) for apples and pears, 0.95 (0.91‒0.98) for bananas, and 0.95 (0.91‒0.99) for grapefruit. In contrast, the hazard ratio of risk for type 2 diabetes for rockmelon consumption was 1.10 (1.02‒1.18).

Alcohol still most common drug of concern
THE latest data released by the Australian Institute of Health and Welfare shows that 659 publicly funded alcohol and other drug treatment agencies provided 153 668 treatment episodes in 2011‒2012. The most common principal drug of concern was alcohol (46%), followed by cannabis (22%), amphetamines (11%) and heroin (9%). Alcohol was the principal drug of concern in all states and territories, with cannabis second in all states and territories except SA, where amphetamines were more common. Counselling was a main or additional treatment used in 49% of the treatment episodes and was the main treatment type in 43% of episodes. Withdrawal management (18%) and assessment-only (14%) were also common treatment types. The report authors wrote that licit and illicit drug use was a significant problem in Australia, costing an estimated $56 billion in 2004–05. They note that many types of treatment were available in Australia. “Most aim to reduce the harm of drug use, while some use a structured drug-free setting with abstinence-oriented interventions to help prevent relapse and develop skills and attitudes that assist clients to make changes leading to drug-free lifestyles”, they wrote.

Overconfidence in diagnoses
US researchers have found that diagnostic accuracy decreases when physicians are faced with more difficult cases — but diagnostic confidence does not. In a study published in JAMA Internal Medicine, the researchers also found that the level of overconfidence increased with the difficult cases, contrary to their hypothesis that both accuracy and confidence would decrease when physicians were faced with such cases. The researchers analysed responses to four case vignettes by 118 general internists from across the US. They found diagnostic accuracy (scored as 0 or 1) was 55.3% for two easier cases and 5.8% for two more difficult cases. Despite the large difference in diagnostic accuracy, they found the difference in confidence (scored by the participants on a scale of 1 to 10) was relatively small (7.2 vs 6.4, for easier and more difficult cases, respectively). Higher confidence was related to decreased requests for additional diagnostic tests and higher case difficulty was related to more requests for additional reference materials. “These findings might imply that overconfidence, which increased with both case difficulty and as diagnostic processes evolved, might impede recognition of faulty reasoning”, the researchers wrote. “Our findings could have important implications for continuing physician education, where little emphasis is placed on diagnostic calibration.”

Lower drug dose reduces fetal abnormalities
USING valproate in the lowest dose that controls severe seizures in pregnant women with epilepsy may reduce the hazard of one of the most devastating of fetal malformations, according to Australian research published in Neurology. The analysis of data in the Australian Register of Antiepileptic Drugs in Pregnancy found that the mean dose of valproate taken during the first trimester was higher in mothers whose offspring had spina bifida (2000 ± 707 mg/day vs 1257 ± 918 mg/day) and hypospadias (2417 ± 1320 mg/day vs 1235 ± 715 mg/day). The researchers said the overall mean maternal valproate dosage taken by women decreased over the last 5 years of the study period from 1999 to 2012, and this was paralleled by a statistically significant decrease in the rate of occurrence of spina bifida and hypospadias, but not other malformations. They found valproate was the only significant teratogen used by women on the register, “although this in itself does not exclude the possibility that other [antiepileptic drugs] may possess a lesser degree of teratogenic potential that has not been detected”. They said that although there was no valproate dosage that was free from the hazard of fetal malformation, minimising the drug’s use and dosage was likely to have “greater dividends in relation to spina bifida than in other, less handicapping fetal maldevelopments”.


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