Issue 1 / 19 January 2015

TEN risk with contrast medium
THE first Australian case of toxic epidermal necrolysis associated with the iodinated contrast medium iopamidol has been reported in the MJA, with researchers warning about the use of contrast medium (CM) in imaging and cardiac catheterisation. The authors reported the case of a 44-year-old woman who presented to the emergency department meeting the diagnostic criteria for toxic epidermal necrolysis (TEN), which included bullae and desquamation, buccal and vaginal ulceration, a positive Nikolsky sign, tachycardia, fever and hypotension. She required admission to the burns unit, and was discharged home on Day 15. The patient had undergone a computed tomography (CT) scan of the neck with the CM iopamidol about 4 weeks before the development of symptoms. Her only recent exposure to medications was thyroxine sodium daily for 19 years, and indapamide daily for 6 months. The patient reported having had a previous CT scan of the neck; however, information on the CM used was unavailable. The authors said that cases of TEN caused by CM had been reported in the literature, and most commonly involved repeated exposure or sensitisation to the CM in the cardiac catheter laboratory. Only two published cases were attributed to the administration of iopamidol. “Although it is difficult to be sure that iopamidol was responsible for the development of TEN in our patient, it is highly likely to be the cause”, they wrote. The authors said it was important to be aware of the risk of CM and “although rare, life-threatening adverse effects such as TEN should lead to reconsideration of contrast dyes”.

Case against immigration detention is “irrefutable”
IMMIGRATION detention fails every standard of medicine — science, ethics, health, economics, pragmatics and human rights — according to a letter published in the MJA. The authors were writing on behalf of J’Accuse (a group of prominent doctors, lawyers, academics and refugee advocates) and Doctors for Refugees, in response to a recent MJA article that examined ethical dilemmas for doctors working in immigration detention. The authors wrote that despite accumulated evidence and established opposition from national and professional bodies, including medicine, paediatrics and psychiatry, “successive governments deny or rationalise inveterate harms, arguably implicate professionals in legitimating abuses the professionals cannot prevent, and deflect needed policy change”. As immigration detention’s damages were unmitigated by any (mental) health intervention, and immigration detention rendered clinicians ineffectual, there was a strong clinical and ethical argument for withdrawing services, the authors wrote. They said that rather than health care for asylum seekers and detainees remaining with the Department of Immigration and Border Protection or being outsourced, “federal or state health departments should provide and manage services and monitor standards independently”. While this would not resolve the problem of immigration detention, “it may attenuate some of its worst effects”, the authors wrote.

Nicotine metabolite ratio could help smokers quit
THE success of different smoking cessation treatments could be predicted by the rate at which smokers metabolise nicotine, researchers have found. The study, published in The Lancet Respiratory Medicine, tested whether the nicotine metabolite ratio (NMR), a genetically informed biomarker of nicotine clearance, predicted response to nicotine patch or varenicline. The authors randomly assigned 1246 smokers, classified as slow or normal metabolisers, to 11 weeks of the nicotine patch (plus a placebo pill), varenicline (plus placebo patch), or a placebo pill and patch. All participants also received behavioural counselling and were followed for 12 months after their quit date. Analysis showed that at the end of treatment, varenicline was more effective than nicotine patch in normal metabolisers, not for slow metabolisers. The authors found that slow metabolisers also reported greater overall side effect severity with varenicline versus placebo. Matching treatment choice based on the NMR “could provide a viable clinical strategy for optimising quit rates for all smokers, whilst minimising side-effects for slow metabolisers”, the authors wrote. They suggested that normal metabolisers be treated with varenicline, and slow metabolisers with nicotine patch. However, the use of NMR to individualise treatment would incur additional cost and time, the authors said. “Our findings also underscore the notion that tobacco dependence is a heterogeneous condition and pharmacotherapies are not equally effective for all smokers.”

Long work hours linked to risky alcohol use
PEOPLE working long hours are more likely than those working standard hours to increase their alcohol consumption to levels that pose a health risk, according to research published in The BMJ. The systematic review and meta-analysis was based on published studies and unpublished individual participant data. In a cross sectional analysis of 333 693 people in 14 countries, including Australia, longer working hours were associated with a 1.11-fold likelihood of higher levels of alcohol use, the authors said. A prospective analysis showed a similar association for new onset, risky alcohol use in 100 602 people from nine countries. The authors found the odds ratios of new onset risky alcohol use for those working 49–54 hours and ≥55 hours a week were 1.13 and 1.12, respectively, compared with working standard 35–40 hours. They said one possible explanation for this association was that alcohol could be used by employees to alleviate the added stress caused by these working longer hours. The authors highlighted that risky alcohol use was an issue in the workplace because it had adverse and serious effects on employees, including absenteeism, inefficiency, poor performance, impaired decision making and injuries at work. “Further research is needed to assess whether preventive interventions against risky alcohol use could benefit from information on working hours.”

Diabetes overtreated in older patients
A SUBSTANTIAL proportion of older people with diabetes in the US may be overtreated, with insulin and sulfonylureas, risking severe hypoglycaemia, research published in JAMA Internal Medicine has found. The authors studied 1288 adults with diabetes aged 65 years and over, who were drawn from the National Health and Nutrition Examination Survey (NHANES) between 2001 and 2010. The patients were divided into three groups based on health status: very complex/poor (difficulty with two or more activities of daily living or being dependent on dialysis); complex/intermediate (difficulty with two or more instrumental activities of daily living or having three or more chronic conditions; and relatively healthy (if criteria for the other two groups were not met). Overall, 61.5% of the adults had an HbA1c level less than 7%, indicating tight glycaemic control, and this proportion did not differ across health status categories. Of the adults with an HbA1c level less than 7%, 54.9% were treated with either insulin or sulfonylureas and this proportion was similar across health status categories. The authors found that nearly two-thirds of older adults with diabetes who had complex/intermediate or very complex/poor health attained tight glycaemic control. “These vulnerable adults are unlikely to experience the benefits of intensive glycemic control and instead are likely to experience harms from treatment, such as hypoglycemia and other adverse effects”, they said. The authors wrote that recognition of both the harms and benefits of glycaemic control was critical for patients and physicians, and other health care professionals, to make informed decisions about glucose-lowering treatment.

Melanoma risk for airline pilots and cabin crew
A SYSTEMATIC review and meta-analysis has confirmed the higher rates of melanoma among aviation workers, estimating that both pilots and flight crews have approximately twice the general population risk of melanoma. The review, published in JAMA Dermatology, included 19 studies with more than 266 431 participants. The authors used primary random-effect meta-analyses to establish standardised incidence ratio (SIR) and standardised mortality ratio (SMR) for melanoma in any flight-based occupation. The overall summary SIR of participants in any flight-based occupation was 2.21, (2.22 and 2.09 for pilots and cabin crew, respectively), the authors said. They also found the overall summary SMR of participants in any flight-based occupation was 1.42, and the summary SMR for pilots and cabin crew was 1.83 and 0.90, respectively. The authors said the increased risk could be due to greater occupation-related exposure to ultraviolet radiation. They suggested that further research was needed on mechanisms and optimal occupational protection needed for aviation workers.

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