Paediatric burn injuries have long-term impacts
CHILDREN who have been hospitalised with burns have a higher risk of long-term all-cause mortality than children with no injury, according to Australian research published in Pediatrics. The authors conducted a population-based cohort study of 10 426 children aged under 15 years who were hospitalised for burn injury in WA between 1980 and 2012. The medical and death records of this group were compared with a cohort of matched, uninjured children. The median follow-up time for the paediatric burn cohort was 18.1 years after discharge from hospital. Of the burn cohort, 0.1% of children died in hospital and an additional 1.5% died during long-term follow-up, compared with 0.6% mortality overall in the non-injured cohort. After adjusting for measurable sociodemographic and pre-existing health conditions, children who sustained burn injury had a 1.6 times greater rate of all-cause mortality than those without injury, the authors found. Burn injury accounted for 38% of all-cause deaths that occurred in the burns cohort during follow-up but there was also an excess of other causes. The authors wrote that burn injury caused significant depression of humoral and cell-mediated immunity, sustained high levels of oxidative stress, and prolonged elevation of stress hormones. These effects could induce a spectrum of medical issues, including insulin resistance, increased fracture risk, increased risk of sepsis, liver enlargement, cardiac dysfunction and hormonal abnormality. They said that “an estimate of the mortality burden from burn injury based on in-hospital deaths alone underestimates the total mortality burden”. The authors wrote that their results could have implications for clinical management and burn prevention.
Immunity wanes after meningococcal B vax
CHILDREN who received the multicomponent serogroup B meningococcal vaccine (4CMenB) in infancy had waning immunity by the age of 5 years, even if they had an additional booster at 40 months, researchers have found. The UK study, published in CMAJ aimed to test the persistence of the immunity conferred by the vaccine, which is registered for use in Australia but is not currently funded by the National Immunisation Program. The study was based on an assessment of 163 5-year-old children who had either received the vaccine in a previous randomised trial, or were part of a vaccine-naive control group. Each child in the control group was given two doses of the vaccine at 60 and 62 months of age. Serum bactericidal antibody titres were measured against four indicator strains of serogroup B meningococcuss matched to each individual vaccine component, and against four mismatched strains. The authors found that in children who received the vaccine at ages 2, 4, 6, 12 and 40 months, 44%‒88% still had protective antibody titres against matched strains, and 13%‒81% against mismatched strains. For children who received the vaccine later at 12, 40 and 42 months, the percentage with protective antibody titres against matched strains was 80%‒100%, and 60%‒100% against mismatched strains. Administering the vaccine to the control group yielded protective titres against matched strains in 92%‒100% of children, the authors found. Children in the control group reported pain at the site of vaccination, but rates of fever were low. The authors wrote that their results highlighted the need for more information about the effects of the 4CMenB vaccine on nasopharyngeal carriage, the likely breadth of strain coverage and long-term persistence. “Introduction of the 4CMenB vaccine into the UK’s routine immunization schedule provides an ideal opportunity to assess the effect of this vaccine in a real-world setting and will guide the implementation of 4CMenB vaccination in Canada and worldwide”, the authors said.
GP education reassuring for patients with low back pain
A SYSTEMATIC review by Australian researchers of clinical trials on the benefits of education in primary care for patients with acute or subacute low back pain (LBP), has found moderate- to high-quality evidence that it increases reassurance more than usual care/control education. The review, published in JAMA Internal Medicine, of 14 trials of education interventions, which included instructions on the benign nature of LBP, advice to stay active and promoting self-management, included 4872 patients. The trials assessed reassurance with questionnaires about fear, worry, anxiety, “catastrophization” and health care use. The researchers wrote that interventions delivered by doctors “were significantly more reassuring” than those delivered by other health care professionals such as physiotherapists or nurses, and reduced LBP-related primary care visits. They wrote that a survey of Australian general practice activity had found that only 20% of GPs report giving advice and education in the treatment of LBP. “When the goal of communication is to persuade a concerned patient to change their beliefs or behavior, the authority and credibility of the source is critical”, they wrote. “Thus, within primary care, physicians may be best placed to provide education with the utmost authority and conviction.” The researchers said future research was needed to determine if physical interventions, such as exercise programs, would enhance treatment effects. An accompanying commentary said interpreting the findings of the review was a challenge because there was no standardised measure for reassurance. “Nonetheless, the results of this systematic review are encouraging in suggesting that simple education interventions may have a positive impact on concerns or worries about low back pain”, the author wrote.
Genetic component to coronary dissection
US researchers have identified a familial association in spontaneous coronary artery dissection (SCAD), a major cause of acute coronary syndrome in young women, suggesting it has a genetic predisposition. A case series, published in JAMA Internal Medicine, by researchers at the Mayo Clinic SCAD Registry, used “novel research methods, patient champions, and social media” to better characterise the condition, which the authors said was considered to be rare. Of 412 women on the registry they identified five cases in which SCAD occurred in familial pairs — mother–daughter, identical twin sisters, sisters, aunt–niece, and first-cousins — implicating both recessive and dominant modes of inheritance. “Although previously published series on patients with SCAD have identified female sex, fibromuscular dysplasia, hormonal influences, and connective tissue diseases as possible risk factors, the present study identifies a probable genetic predisposition in some individuals as well as familial occurrence of fibromuscular dysplasia”, the authors wrote, saying that in their clinical experience, many patients who had SCAD reported a family history of early, unexpected or peripartum death or premature cardiovascular events in young or low-risk relatives. “Recognition of SCAD as a heritable disorder has implications for at-risk family members and furthers our understanding of the pathogenesis of this complex disease”, they wrote. “Novel research methods that leverage the enthusiasm and motivation of patients and families, the growth of online patient communities, and the power of social media have the potential to transform the study and our understanding of uncommon conditions.”
Caution advised on using e-cigarettes to quit smoking
THE NHMRC has released a public statement saying there is currently not enough evidence to conclude that e-cigarettes can benefit smokers in quitting, or about the extent of potential harms. The statement, from the NHMRC CEO Professor Warwick Anderson, recommended health authorities act to minimise harm from e-cigarettes until evidence of safety, quality and efficacy was available. It said experts had raised concerns that e-cigarettes were being promoted as a safer option for smokers when long-term health effects were not unknown. “They are also concerned that the potential benefits to smokers are outweighed by the risks posed by widespread e-cigarette use within the community, including the possibility that they may make smoking socially acceptable again”, the statement said. “Experts also disagree about whether e-cigarettes may help smokers to quit, or whether they will become ‘dual users’ of both e-cigarettes and tobacco cigarettes instead”, it said, noting that e-cigarettes had not been approved by the Therapeutic Goods Administration for this purpose. The NHMRC is funding research into the safety and efficacy of e-cigarettes for smoking cessation.
Sustained weight loss reduces AF burden
AMONG obese patients with atrial fibrillation (AF), sustained weight loss is associated with a significant reduction in AF burden and maintenance of sinus rhythm, according to Australian research published in the Journal of the American College of Cardiology. The study included 355 patients with symptomatic AF who had a body mass index of 27 kg/m2 or more. All patients were counselled on the importance of weight and risk factor management, and were able to participate in a physician-led weight management clinic or a self-managed weight loss program. Weight loss and fluctuation were measured, and AF burden was determined using the AF Severity Scale questionnaire. Dose–response was determined by dividing the participants into three groups based on weight loss: greater than 10% (group 1), 3%‒9% (group 2) and less than 3% (group 3). At follow-up, which was for a mean of about 4 years, AF burden and symptom severity decreased more in group 1 than in groups 2 and 3. Arrhythmia-free survival both with and without rhythm control strategies (medication or ablation) was also greatest in group 1. The authors wrote that weight loss of greater than 10% resulted in a sixfold greater probability of arrhythmia-free survival compared with the other two groups. However, a weight fluctuation of more than 5% partially offset this benefit, with a twofold increased risk of arrhythmia recurrence. Beneficial effects of weight loss on blood pressure, diabetic control, lipid profile and inflammation were also observed, which might have contributed to the reduction in AF burden. The authors wrote that weight loss and avoidance of weight fluctuation were important strategies for reducing the rising burden of AF. “These findings underscore the importance of treating underlying causative conditions when attempting to maintain sinus rhythm in obese AF patients”.