Children at risk from clandestine drug labs
AUSTRALIAN doctors have been urged to familiarise themselves with the dangers faced by children whose carers are involved in clandestine drug laboratories by authors of a letter in the MJA. There was a 50% increase in the number of clandestine laboratories detected in WA between 2009-2010 and 2010-2011, with children at risk in about 40% of these laboratories. The authors wrote that despite this, many doctors remained unaware of the dangers. Children are at risk of physical injury due to explosions, booby traps or firearms; exposure to methamphetamine deposited during manufacture; and to toxic chemicals used in the process. Symptoms of exposure can include respiratory and neurological problems. There is also a high risk that children living in these conditions will have been exposed to child abuse and neglect. “A child who has been discovered [in such a situation] must undergo decontamination … and a full medical assessment, with particular attention to neurodevelopment”, the authors wrote. “We would urge all health professionals in Australia who are involved in the care of children and adolescents to familiarise themselves with this emerging public health concern.”

Support for doctors to help those tired of living to die
A SUBSTANTIAL minority of the Dutch general public supports physician assistance in dying for older people who are tired of living, according to research published in the Journal of Medical Ethics. The researchers said the findings implied that “this topic should be taken seriously in the debate about end-of-life care and decision-making”. The cross-sectional survey of 1960 people was conducted among a random sample of the Dutch public, using statements and vignettes. The researchers found 26% of people agreed with a vignette in which a physician honours a request for physician-assisted suicide of an older person tired of living but without a serious medical condition. Twenty-one percent agreed with the statement: “In my opinion euthanasia should be allowed for persons who are tired of living without having a serious disease”. The researchers found that those who supported assistance in dying for those tired of living were not necessarily the same people who were the subject of the debate. “This suggests that society needs to protect the vulnerable from public opinions such as these”, the researchers wrote. They found that those in favour of assistance in dying for older people were more likely to be more highly educated, non-religious, have less trust in their physician to comply with their wishes, and more often preferred to make their own health decisions rather than allowing physicians to make them. “A shared theme seems to be that those who support assistance in dying value control”, they wrote.

Statins for kidney disease patients
THE new guideline from the Kidney Disease: Improving Global Outcomes organisation recommends wider statin use among patients with chronic kidney disease (CKD). The synopsis of eight key recommendations regarding lipid management and monitoring in adults with CKD, including those receiving chronic dialysis or who have had kidney transplants, was published in the Annals of Internal Medicine. The key recommendation was for treatment with a statin or statin with ezetimibe in adults aged 50 years or older with an estimated glomerular filtration rate (eGFR) of less than 60 mL/minute per 1.73 m2 who are not treated with chronic dialysis or kidney transplantation. Other recommendations included that adults with established dialysis-dependent CKD should not begin treatment with statins or statin/ezetimibe; patients taking a statin at the time of starting dialysis should continue to do so; kidney transplant patients should receive statin treatment because of their increased risk for coronary events; and adults aged 18‒49 years at risk of heart disease with an eGFR of less than 60 mL/minute per 1.73 m2  and not treated with dialysis or kidney transplantation should be treated with statins. The guideline authors wrote that they were optimistic that the guideline emphasised “the high cardiovascular risk associated with CKD (regardless of [low density lipoprotein] cholesterol levels) while also reducing complexity for practitioners and enhancing implementation”.

Acid suppression impacts B12
RESEARCH published in JAMA shows an association between the use of acid-inhibiting medications — proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs) — for 2 or more years and a subsequent diagnosis of vitamin B12 deficiency. The researchers compared 25 956 patients with an incident diagnosis of vitamin B12 deficiency between 1997 and 2011 with 184 199 patients without a deficiency. Exposures and outcomes were available from electronic pharmacy, laboratory and diagnostic databases. They found that in patients with vitamin B12 deficiency, 3120 (12.0%) were dispensed 2 or more years’ supply of PPIs, 1087 (4.2%) were given 2 or more years’ supply of H2RAs (without PPI use), and 21 749 (83.8%) did not receive prescriptions for either PPIs or H2RAs. In patients without vitamin B12 deficiency, 13 210 (7.2%) received 2 or more years’ supply of PPIs, 5897 (3.2%) were given H2RAs (without PPIs), and 165 092 (89.6%) were not prescribed either PPIs or H2RAs. Doses of more than 1.5 PPI pills a day were more strongly associated with vitamin B12 deficiency than doses of less than 0.75 pills a day. “The magnitude of the association was stronger in women and younger age groups with more potent acid suppression (PPIs vs H2RAs) and decreased after discontinuation of use”, the researchers wrote. “There was no significant trend with increasing duration of use and no strong evidence for confounding by utilization of medical care.” The researchers wrote that their findings “do not recommend against acid suppression for persons with clear indications for treatment, but clinicians should exercise appropriate vigilance when prescribing these medications and use the lowest possible effective dose”.

Tight glycaemic control dangers in the elderly
A NEW cross-sectional study of US veterans has added to increasing evidence from randomised clinical studies and observational studies showing the magnitude and risk of serious hypoglycaemia in patients under intensive glycaemic treatment. The study, published in JAMA Internal Medicine, included 652 378 patients who received insulin and/or a sulfonylurea, with 205 857 (31.5%) identified as having intensive treatment based on their HbA1c result — 11.3% had a last HbA1c value less than 6.0%; 28.6% less than 6.5%; and 50.0% less than 7.0%. “Our study provides confirmation that intensive glycemic control, representing possible overtreatment, is common among older veterans”, the researchers wrote, saying a substantial proportion of largely elderly veteran patients had significant comorbid conditions. They wrote that the veterans were potentially being overtreated based on the most recent guidelines. “Of individuals who were either 75 years or older or had renal insufficiency and/or cognitive impairment, 1 in 10 patients had a last HbA1c value below 6.0% and approximately half had values below 7.0%.” The researchers suggested HbA1c closer to 8% or even higher may be appropriate for most higher-risk patients. They also identified about 20% of patients who might benefit from a re-evaluation of therapy. “While being 75 years or older does not necessarily contraindicate tight control, for most persons the marginal lifetime benefit compared with 8.0% HbA1c is minimal, and the harms (known and unknown) of medications are potentially greater.”

Music’s powers a myth
ENROLLING your preschoolers in music classes might make them appreciate music but it won’t make them smarter — at least not in the short term, according to new research. US researchers who conducted two randomised control trials involving young children say they have confirmed that music education improves the musical skills, repertoire and appreciation of music, but does not improve cognitive development. The research, published in PLOS One, involved one trial of 29 children in Boston assigned to 6 weeks of weekly music or visual arts classes and another involving 46 families assigned to music classes or a control group. The researchers found there was no consistent evidence for cognitive transfer from music training. The preschool music classes did not cause detectable skill increases in the cognitive domains of spatial, linguistic or numerical reasoning. “Of course, these negative findings do not imply that preschool arts instruction does not engender nonmusical cognitive benefits to preschool children”, the researchers wrote, acknowledging the training duration in their trials was substantially shorter than previous trials. “Whether or not future studies uncover reliable relations between music education and extra-musical aspects of cognitive development, instruction in the arts likely will thrive for its intrinsic value”, they wrote.

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