Advance directive uptake remains low
SOCIOECOMONIC factors, including marital and employment status, contribute to people not completing health care advance directives (ADs), according to research published in the MJA. The researchers contacted 3055 households in South Australia and surveyed a single member over the age of 15 years. The study found that nearly half of participants had not completed any AD document or a will, and that respondents were more likely to have completed financial documents than health care documents. Analysis showed that the odds of not having completed any AD was higher among those aged 15–24 years compared with those aged over 65 years. However, the authors wrote that although completion rates were highest in the 65 years and older age group, “there is still a significant proportion of older people not completing health care ADs”. People living in rural and regional areas and those who were not married or not working had reduced odds of completing ADs. The authors suggested that GPs who worked in the country or areas with a high proportion of people who were not married or not working should “promote the role of ADs and the value of identifying a trusted substitute decisionmaker to help with future decisions”. They said that although the completion of ADs was low, the use of these documents among younger age groups was encouraging and indicated that a broadened GP discussion about ADs to include younger people would “be important in meeting patient goals of future care”. Identifying the demographic characteristics of those who did not complete ADs “could help GPs provide these groups with targeted health promotion using relevant community health services”, the authors wrote.
Warning on HIV diagnoses in older patients
A CASE report has highlighted the increasing number of older Australians being diagnosed with HIV. The report, published in the MJA, described the case of a 66-year-old male patient who received an HIV diagnosis more than 9 months after his symptoms were first investigated at a regional hospital. Once diagnosed, the patient started daily treatment and 6 weeks later his symptoms, including weight loss, diarrhoea and profound lethargy, had ceased. The authors said this case reflected the growing issue of late HIV diagnoses, and that while the numbers of older people with HIV were still small compared to other age groups, they experienced significant HIV-associated morbidity and mortality. Health care providers were consistently under-recognising the possibility of HIV in older patients because “specific HIV or opportunistic infection symptoms can mimic other diseases frequently associated with older age”, the authors wrote. The patient presented with a syndrome compatible with stage IV HIV, yet testing was only initiated after a low CD4+ cell count was indirectly identified in an investigation into suspected malignancy. The authors wrote that in 2013, more than 88% of new HIV diagnoses were made in metropolitan centres, meaning rural clinicians were relatively underexposed to patients with HIV. They said there needed to be a greater “awareness of HIV across all medical specialties, including in rural and remote centres”.
Poor oral health identified in elite athletes
A CONSENSUS statement has highlighted the poor oral health of elite athletes and identified key preventive strategies. The authors of the statement, published in the British Journal of Sports Medicine, conducted a systematic review of 39 studies on the oral health of elite athletes and its effect on athletic performance. Oral health was found to be consistently poor in elite athletes across these studies, and dental caries, periodontal disease, dental erosion and impacted molars were widely reported. The authors found that disease incidence was not clearly differentiated by socioeconomic status, and that the standards of oral health in elite athletes were similar to those of non-athletes in disadvantaged populations. Poor oral health in athletes was attributed to several factors, including a high consumption of acidic drinks and carbohydrate-containing gels, which led to erosion and decay. Dehydration and drying of the mouth during intensive sporting activity also caused dental caries as it led to a reduction in saliva and its protective properties. The authors said that better health promotion, education and behaviour change was needed across all levels of sport, and suggested that “regular assessments of oral health by a dental professional, especially preseason, will allow for personalisation of prevention plans and early treatment of any disease”.
Link between psoriasis and uncontrolled hypertension
IN patients with hypertension, psoriasis was associated with a greater likelihood of uncontrolled hypertension in a dose-dependent manner, a study has found. The research, published in JAMA Dermatology, showed that moderate to severe psoriasis, where 3% or more of the body surface area was affected, was most strongly linked with uncontrolled hypertension. The study analysed the electronic medical records of a random sample of UK general practice patients with previously diagnosed hypertension, which included 1322 patients aged 25–64 years with psoriasis, and an age-matched control group of 11 977 patients without psoriasis. Uncontrolled hypertension was defined as a systolic blood pressure (BP) of 140 mmHg or higher, or a diastolic BP of 90 mmHg or higher. The authors said the association between psoriasis severity and uncontrolled hypertension was independent of other risks factors for poor BP control such as age, body mass index, smoking status, alcohol use and the presence of comorbid diseases. They wrote that the biological pathway that linked hypertension and psoriasis was unknown, but supported the theory that an overexpression of endothelin 1 was a contributing factor. The findings had important clinical implications for patients with hypertension, the authors wrote, suggesting “the need for more effective blood pressure management, particularly among patients with more severe psoriasis”. Further research was required on the effect of chronic inflammatory diseases on hypertension and whether improved hypertension management has an impact on psoriasis severity.
Impacts of physical activity and depressive symptoms
PHYSICAL activity and depressive symptoms have a bidirectional relationship across multiple decades of adulthood, a study has found. The prospective cohort study of about 11 000 British people followed for three decades was published in JAMA Psychiatry. Each participant was born in the same week in 1958, and information on their depressive symptoms and frequency of physical activity was collected at 23, 33, 42 and 50 years of age in a questionnaire. At most ages, analysis showed that a greater frequency of activity predicted a lower number of depressive symptoms. Participants who increased activity during the longitudinal analysis from zero to three times a week reduced their odds of depression by 19%, the authors said. The data also found that higher levels of depressive symptoms predicted less frequent physical activity, and this association was strongest in young adulthood and diminished significantly as the participants aged. The authors said the bidirectional relationship emphasised “the potential importance of activity to prevent and alleviate depressive symptoms in adulthood and, in turn, depressive symptoms before midlife could be a barrier to activity”. The authors said that strategies to maintain and promote physical activity across all age groups were warranted. From a clinical perspective, practitioners who treated patients with depression should address activity as part of any treatment plan, they wrote.