NSAIDs don’t increase miscarriage risk
THE use of nonsteroidal anti-inflammatory drugs (NSAIDs) during pregnancy does not increase the risk of spontaneous abortion, according to research published in CMAJ. The research included 65 457 women who conceived during a 7-year period and were admitted to an Israeli hospital for a birth or spontaneous abortion (9.9%), and included 4495 (6.9%) who had been exposed to NSAIDs. The researchers found no important associations between exposure to NSAIDs and the risk of spontaneous abortion with the exception of a significant association found for indomethacin. “We believe that this result is possibly due to reverse causation bias”, they wrote. “Indomethacin is a well-known tocolytic drug indicated to treat preterm labour.” They wrote that because many women needed to take NSAIDs and because half of all pregnancies were unplanned, “the conflicting findings from past research have caused confusion and fear among pregnant women and their health care providers”. They called for further research to assess the risk following exposure to selective cyclooxygenase-2 inhibitors.

Cognitive therapy shows promise for schizophrenia
COGNITIVE therapy (CT) was a viable alternative for patients with schizophrenia who refused or discontinued antipsychotic drug treatment for at least 6 months, according to the results of a small single-blind randomised trial published in The Lancet. The study included 74 patients aged 16–65 years with schizophrenia spectrum disorders who had chosen not to take antipsychotic medication. Participants were randomly assigned to CT plus usual treatment or usual treatment alone. They were assessed based on positive and negative syndrome scale (PANSS) scores, with low scores considered preferable. The researchers found PANSS scores were consistently lower in the CT group compared with the usual therapy alone group. The researchers found the proportion of participants achieving good clinical outcomes in each disorder (defined as an improvement of > 50% in adjusted PANSS total scores) at 9 months were seven (32%) of 22 participants in the CT group, and three (13%) of 23 from the usual treatment alone group. At 18 months seven (41%) of 17 receiving CT and three (18%) of 17 receiving usual treatment had achieved good clinical outcomes. They found that CT significantly improved personal and social functioning and some dimensions of delusional beliefs (cognitive) and voice hearing (cognitive and physical) but did not significantly affect the amount of distress associated with delusional beliefs or voice hearing, or levels of depression, social anxiety, and self-rated recovery. “Our findings suggest that cognitive therapy is an acceptable, safe, and effective treatment alternative for people who choose not to take antipsychotics.”, they wrote, calling for a larger, definitive trial. An accompanying commentary said the findings were impressive but urged caution because the study did not have a placebo intervention.

Animal products not declared in drugs
MOST common medications in the UK contain animal products that could make them unsuitable for vegetarians and vegans, an analysis published in the BMJ reports. The report authors wrote that labelling of animal content in medication was poor, variably applied and patients with dietary restrictions were likely to be consuming animal products unwittingly. They identified the 100 most commonly prescribed drugs in primary care in the UK in January 2013 and found 74 contained one or more of lactose (commonly extracted from cow’s milk using bovine rennet; n = 59), gelatine (sourced from bovine or porcine skin, hide or bone, and fish; n = 20) or magnesium stearate (from the rendered fat of cows, pigs and sheep; n = 49). They also found that accompanying literature did not always declare the presence of animal products and if it did, the information was often incomplete or inaccurate. “Contact with manufacturers … also revealed uncertainty about whether medications were suitable for vegetarians”, the authors wrote. “It is likely that patients are unwittingly ingesting medications containing animal products with neither prescriber nor dispenser aware.” They warned that patients who discontinued medications without medical consultations to avoid animal products were at risk of adverse outcomes. Improved labelling, “mirroring those standards advised for food”, and small changes to legislation would help, but the “ultimate solution would be to eliminate animal derived products where possible from medications”, they concluded.

Colorectal cancer tests get thumbs up
FAECAL immunochemical tests (FITs) have high overall accuracy for diagnosing colorectal cancer (CRC), according to a systematic review published in Annals of Internal Medicine. The review, which included 19 studies, found FITs were moderately sensitive and highly specific, with an overall diagnostic accuracy of 95%. Sensitivity for CRC increased, but specificity decreased when lower assay cut-off values were used to indicate a positive test result  “Although our study could not identify the optimal cutoff value for CRC screening, a FIT cutoff value less than 20 µg/g had the best combination of sensitivity and specificity”, the authors wrote. They also found that it might be possible for FIT type to be customised to different sized care settings without significant variability in accuracy. However, they wrote that balancing increased sensitivity with the resulting increased numbers of positive results was a trade-off health systems would need to assess as it would impact on colonoscopy resources.

Energy expenditure increases with obesity
THE use of the metabolic equivalent (MET) of 3.5 mL O2/kg/minute to quantify the physical activity and exercise performance needed to lose weight overestimates values in overweight to severely obese patients by up to 38%, according to research published in the International Journal of Obesity. The researchers wrote that MET values calculated using this equation “markedly underestimate” oxygen taken up. They measured resting oxygen uptake (VO2-REE) in 1131 patients with a body mass index (BMI) above 25 kg/m² by indirect calorimetry and calculated VO2-REE related to body weight. The cohort included 72.0% women, the mean age was 42.5 years and mean BMI was 42.5 kg/m². The mean MET-REE (MET related to body weight) was 2.47 mL O2/kg/min in women and 2.62 mL O2/kg/min in men, markedly lower than the expected 3.5 mL O2/kg/min. The researchers found that the current MET formula, which systematically underestimated cardiopulmonary fitness, became more biased the more the patient’s BMI increased. The authors developed BMI-dependent MET correction factors that they said should reduce error and could be used for different classes of obesity. “Our data may help to develop more accurate questionnaires and devices for the assessment of physical activity in overweight to severely obese subjects”, they wrote.

Call to defer start of renal dialysis
EARLY initiation of renal dialysis may have little benefit for the patient and places a burden on the health care system, according to new guidelines from the Canadian Society of Nephrology published in the CMAJ. The guidelines recommended an “intent-to-defer” dialysis strategy emphasising quality of life and the high value of resources while placing a low value on surrogate markers such as serum albumin, body nitrogen levels and estimated glomerular filtration rate (eGFR). “Traditional criteria for initiation of dialysis have limitations because they are based on creatinine-based measures of kidney function”, the guidelines stated. They recommended that adult patients (over 18 years) with an eGFR below 15 mL/min/1.73 m² be closely monitored by a nephrologist, with dialysis initiated when clinical indications emerged or the eGFR was 6 mL/min/1.73 m² or less, whichever occurred first. “Our recommendation places a high value on the avoidance of a burdensome and resource-intensive therapy that does not provide measurable benefit when started before the development of a clinical indication, such as uremic symptoms”, the guideline authors wrote. “Adherence to this recommendation requires timely follow-up with a nephrologist to closely monitor clinical indications for dialysis initiation.” They based their recommendation on a systematic review of 26 reports of 23 studies, including one review, which reported a pooled estimate of survival with early versus late initiation of dialysis.

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