Surgical audit details improvements
THE fifth annual national report of the Australian and New Zealand Audits of Surgical Mortality (ANZASM) has revealed a significant jump in the participation rate of surgeons and hospitals. The report’s executive summary said surgeon participation had risen from 60% in 2009 to 96% at the end of 2013. The public hospital participation rate was 100% while private hospitals were at 89%, up from 73% in 2011. Most of the patients in the 2013 audit were emergency admissions with at least one comorbidity. Most patients who were expected to benefit from critical care support received it, with 3% of patients not treated in a critical care unit most likely to have benefited from it. A delay in implementing definitive treatment was the most frequent clinical management issue. The reasons for delay included geographical issues, diagnostic problems in the emergency department, inappropriate diagnosis, need for transfer, availability of theatre and communication issues. The proportion of cases identified with an adverse event (unintended injury or event caused by medical management) decreased from 6% in 2009 to 3% in 2013. The report’s conclusion said that as the audit continued to grow and develop, “the ability to identify trends across Australia will further add to the ongoing knowledge of the participants, potentially leading to better outcomes for all surgical patients”.

Recommendations on nail psoriasis “challenge”
THE Medical Board of the National Psoriasis Foundation in the US has developed treatment recommendations for nail psoriasis, a condition the authors describe as a “clinical challenge”. The recommendations, published in JAMA Dermatology, were based on a review of research on nail psoriasis treatments published between 1947 and May 2014. The authors found clinical trial data were limited, and results were reported inconsistently, “making comparisons among treatment options difficult”. They wrote that treatment of nail psoriasis should balance consideration of the extent of skin disease, psoriatic arthritis, and severity of nail disease with concomitant impairment of quality of life. “All patients should be evaluated for onychomycosis because this may complicate psoriatic nail disease”, they wrote. Treatment recommendations for four clinical nail psoriasis scenarios were developed based on the evidence review and on expert opinion from members of the medical board. Recommendations ranged from high-potency topical corticosteroids with or without calcipotriol for patients with disease limited to the nails, to methotrexate, tumour necrosis factor inhibitors and other biological agents for those with significant nail, skin, and joint disease. “Nail psoriasis poses a significant burden to our patients with psoriasis”, the authors wrote. “Even when psoriasis and psoriatic arthritis are controlled, nail disease may persist.”

Nurturing intervention reduces stress in at-risk children
A RANDOMISED trial of an experimental 10-week attachment-based parenting program has shown it can normalise diurnal cortisol production among at-risk children. The research, published in JAMA Pediatrics, examined the effects of the Attachment and Biobehavioral Catch-up (ABC) intervention, designed to enhance behavioural and biological regulation in young children at risk for parental neglect by helping parents become more synchronous and nurturing as well as less frightening. The research included 115 US children who had been involved with Child Protective Services before the age of 2 years, following allegations of neglect in infancy. The children, randomly assigned to the ABC intervention or a control intervention, were followed up when aged 46.5‒69.6 months, about 3 years after the intervention. The authors wrote that the analyses revealed that children who had been involved in the ABC intervention showed a more typical pattern of cortisol production, with higher morning levels and a steeper decline across the day, than children in the control group. They said blunted cortisol levels, often termed “hypocortisolism”, were being increasingly recognised as a biomarker of chronic stress.  “The results suggest that the intervention led to persistent, long-term effects on the functioning of the [hypothalamic–pituitary–adrenal] stress system, which may have implications for preventing child psychological and physical health problems given previous reports linking cortisol disruptions to these deleterious child outcomes”, the authors wrote.
Mediterranean diet may slow ageing
ADHERENCE to a Mediterranean diet has been associated with longer telomeres, further supporting the claim that the diet promotes health and longevity, according to US researchers. The prospective cohort study, published in The BMJ, assessed the blood samples and self-reported dietary data of a sub-cohort of 4676 middle-aged, disease-free women in the Nurses’ Health Study. Participants, aged 42–70 years, completed food questionnaires, and genomic DNA was extracted from the peripheral blood leukocytes to measure telomere length. The researchers found a statistically significant inverse correlation between age at blood draw and telomere length: younger women had longer telomeres. A diet score was calculated for each participant, with a higher score representing a closer resemblance to the Mediterranean diet. The researchers found that greater adherence to the Mediterranean diet was significantly associated with longer telomeres, with each one point change in diet score corresponding to an average 1.5 years of telomere ageing. Telomere length was considered a biomarker of ageing, with shorter telomeres associated with a decreased life expectancy and increased rates of developing age-related chronic diseases, the researchers wrote.  “The established protective effects of the Mediterranean diet on oxidative stress and chronic inflammation may explain the favorable influence of the Mediterranean diet on telomere length”, they wrote. An accompanying editorial said similar data on the effects of the Mediterranean diet for men was required, and suggested that “studies measuring the attrition or shortening of telomeres over time would add important new information to cross sectional analyses”.

Prematurity “strong” risk factor for flu complications
PREMATURITY is a strong risk factor for influenza-related complications in children, according to a systematic review published in The Lancet Respiratory Medicine. The authors wrote that unlike other risk factors identified in the systematic review — neurological disorders, sickle cell disease, immunosuppression, diabetes and age younger than 2 years— prematurity was not defined as a risk factor in any existing guidelines. The review included 28 articles reporting data from 27 studies with a total of 14 086 children. Strong risk factors for hospital admission were neurological disorders (univariable odds ratio [OR], 4.62), prematurity (OR, 4.33), sickle cell disease (OR, 3.46), immunosuppression (OR, 2.39), diabetes (OR, 2.34) and younger than 2 years (OR, 2.51). Reactive airways disease including asthma (OR, 1.36) and obesity (OR, 0.99) were not found to be risk factors. The presence of more than one coexisting condition significantly increased the risk of hospital admission, from 52% (one condition only) to 74% (more than one condition) when age younger than 2 years was included as a risk factor. The researchers wrote that although consideration of at-risk disorders was already recommended in the clinical management of children presenting with influenza or influenza-like illness, the estimate of the level of risk associated with different disorders still relied on the subjective judgement of individual doctors. They called for their findings to be used to update definitions of patients regarded as at risk of influenza-related complications and to specifically define at-risk groups of children in guidelines. An accompanying commentary said although the results of the study should be treated with some caution, if they were confirmed in future research the finding of prematurity as a risk factor “could have major policy implications, since 11% (15 million) of the world’s babies are born preterm, and prematurity is the leading cause of child mortality in children younger than 5 years”.

Maternal overweight increases mortality risk for babies
MATERNAL overweight as well as obesity has been associated with increased risks of infant mortality, and the risk rises with increasing body mass index (BMI), a study published in The BMJ has found. Researchers assessed the relationship between maternal body mass and infant mortality outcomes in more than 1.8 million live single births in Sweden during 1992‒2010. The authors categorised the BMI of mothers as underweight (BMI ≤ 18.4), normal (18.5‒24.9), overweight (25.0‒29.9), obese grade 1 (30.0‒34.9), obese grade 2 (35.0‒39.9), or obese grade 3 (≥ 40.0). “Compared with infants of normal weight mothers, infant mortality risks were modestly increased in overweight and mildly obese mothers, while obesity grade 2 or 3 was associated with more than doubled risks of infant mortality”, the authors wrote. They found that maternal BMI was linked with risks of infant mortality primarily in term births (delivery at 37 weeks or later), where risks of deaths due to birth asphyxia and other neonatal morbidities increased with maternal overweight and obesity. Obesity grades 2 and 3 were also associated with increased infant mortality due to congenital anomalies and sudden infant death syndrome. The authors said the study results needed to be replicated in other populations and the reasons behind the association between maternal overweight and obesity and risk of infant mortality explored. However, they wrote that their results provided enough evidence “for public health officials to act against the obesity epidemic to promote infant health”. An accompanying editorial said while there was little information on the direct effect of physical activity and diet on infant mortality, doctors “should counsel women about the risks associated with overweight and obesity, and help them set targets for gestational weight gain informed by pre-pregnancy body mass index”.  

Later neuroimaging benefits very preterm infants
NEW research has confirmed the relative prognostic value of later neuroimaging of extremely preterm infants compared with the use of early cranial ultrasound (CUS) 4‒14 days following birth. In a prospective study published in Pediatrics, researchers found that adverse near-term CUS and magnetic resonance imaging (MRI) findings among these infants were associated with adverse neurodevelopmental outcomes. The researchers used masked readers to interpret early and late CUS and brain MRI in 480 infants who were born at less than 28 weeks’ gestation and survived to near term. MRI white matter abnormality (WMA), cerebellar lesions and serial CUS adverse findings were evaluated as predictors of neurodevelopmental outcomes at 18‒22 months of age. Late CUS and MRI findings that reflected white matter injury or significant cerebellar lesions were each associated with neurodevelopmental impairment or death in preterm infants, the authors said. “In models that did not include late CUS, MRI findings of both moderate-to-severe WMA and significant cerebellar lesions were independently associated with adverse outcomes”, they wrote. The results highlighted the need to “understand the evolution of brain injury over time in outcomes prediction rather than to rely upon early findings only”. They also suggested that recommendations for neuroimaging in preterm infants should be revisited to recognise the limitations of using early CUS alone to predict neurological outcomes. An accompanying commentary said the study added valuable information about the prognostic value of neuroimaging in infants and reinforced “the importance of long-term follow-up of at-risk infants at school age and beyond”.

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