No benefit from nurse-led hospital intervention
CARE Navigation (CN), a nurse-led hospital-based coordinated care intervention, does not improve quality of life or reduce unplanned hospital presentations or admissions for patients with chronic illness, according to a study published in the MJA
. The study included 500 emergency department (ED) patients at one NSW hospital between May 2010 and February 2011 randomised to receive CN or standard care. The intervention included two nurses to conduct CN through the recruitment period and for 24 months of follow-up. One nurse managed patients at ED presentation by assessing current health status and risk of readmission, and directing patients to the best method of care in the hospital or community. The second nurse monitored the progress of patients’ care, minimised delays to discharge from the hospital ward and reviewed patients’ hospital stay, assessing the need for out-of-hospital care facilities and arranging ongoing care after hospital discharge. The CN nurses used an electronic assessment form to identify medical and psychosocial risks of readmission, and to identify ED patients who might not require hospital admission if community-based care was available. The researchers found the CN group received more community health services (rate ratio, 1.94) than the standard care group, but this did not result in statistically significant differences in the number of re-presentations, number of readmissions, quality of life at 24 months or other measures. The study authors wrote that although no intervention effect was detected, CN did have an impact on the processes of care following discharge. “Patients in the intervention group received more services from community health agencies, mainly nursing services”, they wrote. “Future service development should explore the potential benefits of linking navigated intrahospital care to ongoing, proactive care planning and delivery in the community.”
Urinary incontinence surgery for women “effective”
MID-URETHRAL sling (MUS) operations for the treatment of stress urinary incontinence (SUI) in women are highly effective in the short and medium term, with accruing evidence demonstrating their effectiveness in the long term, according to the results of a Cochrane review
. The review, which included 81 mainly randomised controlled trials and a total of 12 113 women, showed that more than 80% of women with SUI were cured or had significant improvement in their symptoms up to 5 years after having surgery either via the transobturator route (TOR) or retropubic (RPR) route, and irrespective of the type of tapes used. MUS procedures using the RPR had higher morbidity compared to TOR, though the overall rate of adverse events remained low. The TOR had lower rates of bladder perforation (0.6% v 4.5%), major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay. Postoperative voiding dysfunction was less frequent following TOR. Overall rates of groin pain were higher in the TOR group (6.4% v 1.3%) but suprapubic pain was lower (0.8% v 2.9%). The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups, with 24/1000 instances with TOR and 21/1000 for RPR. “This review illustrates [the procedures’] positive impact on improving the quality of life of women with SUI”, the authors wrote. They called for more trials in the review to publish the results of longer-term follow up “to increase the robustness of evidence” supporting the use of MUS, to provide answers about long-term adverse events, including whether there is a significant decline in effectiveness over time, and to identify the point at which decline becomes significant enough to require women to need repeat procedures.
Research confirms melanoma thickness impact on survival
A RETROSPECTIVE review of cases of cutaneous melanoma reported to the Victorian Cancer Registry has found thickness trends differ between nodular and non-nodular primary cutaneous melanoma. The research, published in a letter to the MJA
, was based on four 1-year cohorts in 1989, 1994, 1999 and 2004, which included 5775 cases of primary invasive melanoma and 3649 cases of in situ melanoma. Mortality data were collected to 2013. To understand the trends associated with nodular melanoma (NM) over time, all melanomas other than NM were grouped together and classified as non-NM, and compared with NM cases. The incidence of all types of melanoma increased over time, with the proportion of in situ melanoma rising from 33% in 1989 to 43% in 2004. As previously reported, NMs were thicker at the time of diagnosis. The authors found that the thickness of invasive non-NM decreased over time, while the thickness of NM did not change. For all melanomas there was a significant association between increasing thickness and decreasing survival. The authors found that survival among patients with non-NM improved over time, which was explained by the decreasing trend in thickness. For NM cases, there was no evidence of a change in survival over time. The authors said their analysis highlighted that although patients with non-NM were being diagnosed earlier, when lesions were thinner with improved survival outcomes, this was not true for patients with NM. While much progress had been made in the treatment of metastatic melanoma, including targeted therapies and checkpoint inhibitors, the best opportunity to reduce melanoma and mortality was in early detection, the authors wrote. They said that public health education and improved screening had been effective in achieving earlier diagnoses; however, “greater awareness of the clinical features of NM (which are often distinct and differ from the [asymmetry, border, colour, diameter] diagnostic criteria) is still required to reduce overall melanoma mortality”.
Menopausal women have lower risk of CHD than men
A US population-based study has found that menopausal women have a lower risk of coronary heart disease (CHD) events than men, even after considering an extensive list of potential confounders. The research, published in the Journal of the American Heart Association
, found that the advantage was particularly pronounced for fatal CHD events, regardless of menopause type, and in both white and black participants. The 23 086 participants were enrolled in a study examining geographic and racial differences in stroke. The researchers used Cox regression models to calculate the hazard of incident non-fatal CHD (definite or probable myocardial infarction) and acute CHD death, adjusting for age, age at last menstrual period <45 years, region, education level, income, diabetes, smoking, systolic blood pressure, lipid levels, albumin-creatinine ratio, physical activity, C-reactive protein, body mass index, waist circumference and medication use. The researchers found white women in natural menopause and surgical menopause had a reduced hazard of non-fatal events, compared with white men, while black women in natural menopause but not surgical menopause had a marginally reduced hazard of non-fatal events, compared with black men. “Our results confirm that the risk of having any incident CHD event in women is lower than in men”, they wrote, noting that this low risk persisted despite the postmenopausal state, regardless of menopause type and despite comprehensive adjustment for traditional and unconventional CHD risk factors. “This suggests that other factors besides menopause status and CHD risk factors are driving sex differences in mid-life.”.
PTSD associated with cardiac risks in women
WOMEN who experience traumatic events or have elevated post-traumatic stress disorder (PTSD) symptoms have an increased risk for cardiovascular disease (CVD) compared to women not exposed to traumatic events, US research has found. The study, published in Circulation
, was based on 49 978 women enrolled in the Nurses’ Health Study II, aged 25‒42 years at baseline in 1989, who were followed biennially to 2008. The authors confirmed the incidence of CVD events with additional information or medical record review, and trauma exposure and PSTD symptoms were assessed via questionnaire and PTSD screen. In comparison with no trauma exposure, four or more PTSD symptoms were associated with increased CVD risk (hazard ratio, 1.60) after adjusting for age, family history and childhood factors. The authors also found that exposure to trauma but no PTSD symptoms was associated with elevated CVD risk, but exposure to trauma and less than four PTSD symptoms was not. The authors wrote that health behaviours and medical risk factors were found to account for an estimated 14% of the CVD risk associated with trauma exposure and no PTSD symptoms. “Our findings suggest that elevated PTSD symptoms and trauma exposure may each be associated with poor cardiovascular health”, the researchers wrote. Trauma exposure and PTSD were associated with dysregulation of the autonomic nervous system, hypothalamic-pituitary-adrenal axis and inflammatory response, and subsequent changes in catecholamines, cortisol and inflammatory cytokines could possibly increase CVD risk, they wrote. If studies continued to demonstrate this relationship, “then assessing and monitoring cardiovascular function in trauma-exposed individuals and those with PTSD may have a positive public health impact and help to detect preclinical markers of cardiovascular dysfunction”.
Neighbourhoods dictate diabetes risk
NEIGHBOURHOOD resources that support greater physical activity (PA) and healthy diets are associated with a lower incidence of type 2 diabetes, a US study has found. The research, published in JAMA Internal Medicine
, included data on a multi-ethnic cohort of 5124 adults aged 45‒84 years who were free of type 2 diabetes mellitus (T2DM) at baseline. They underwent five clinical follow-up examinations from 2000 to 2012. The authors assessed neighbourhood PA and health food resources using geographic information systems (GIS) and survey-based methods combined into a summary score. During a median 8.9 years of follow-up, 12.0% of participants developed T2DM. Compared with those who did not develop T2DM, they were more likely to have lower baseline household income, fewer years of education, less healthy diets, lower levels of moderate and vigorous PA, a higher body mass index and a family history of T2DM. The authors wrote that long-term exposure to residential environments with greater resources to support PA and to a lesser extent healthy diets was associated with a lower incidence of T2DM during the study period. “The associations were generally robust to adjustment for other risk factors and model specifications although associations were primarily found with survey-based, but not GIS-based, exposures”, they wrote. The research indicated that modifying specific features of neighbourhood environments, including increasing the availability of healthy foods and PA resources, might help mitigate the risk for T2DM. An accompanying commentary
said the study highlighted that “the risk for T2DM is a combination of both person and place, and our national strategies need to understand and intervene across these levels”.