Queries on lung-function trajectories in COPD
RESEARCHERS have found that the classic trajectory of an accelerated decline in forced expiratory volume in 1 second (FEV1) from a normal level is not a necessary feature of COPD, and that a substantial proportion of people who develop the disease have a low FEV1 level in early adulthood. The research, published in the New England Journal of Medicine, stratified participants from three independent cohorts according to lung function —FEV1 ≥ 80% or < 80% of the predicted value — at cohort inception and the presence or absence of COPD at the last study visit to determine the rate of decline in FEV1 over time and COPD status. Among the 657 study participants who had an FEV1 of less than 80% of the predicted value before 40 years of age, 174 (26%) had COPD after 22 years of observation. Of the 2207 participants who had a baseline FEV1 of at least 80% of the predicted value before 40 years of age, 158 (7%) had COPD after 22 years. The researchers found about half the 332 participants with COPD at the end of the observation period had a normal FEV1 before 40 years of age, followed by a rapid decline in FEV1, with a mean decline of 53 ± 21 mL per year. The other half had had a low FEV1 in early adulthood and a subsequent mean decline in FEV1 of 27 ± 18 mL per year, despite similar smoking exposure The authors acknowledged that there was a “wide range of individual trajectories, such that both low maximally attained lung function in early adulthood and a subsequent rapid decline may contribute to COPD”. They wrote that even though they could not precisely estimate the contribution of the trajectory of low maximally attained lung function to COPD, their “results suggest that this contribution may be substantial”. An accompanying editorial raised questions about the analysis but said two messages remained clear — spirometric measurements continued to provide the best predictive measure of both the risk of developing COPD and disease severity in those with obstruction, and that it was important to continue to focus on cigarette smoking as the major risk factor for developing COPD. “Stopping smoking or, better yet, never starting continues to be the major determinant of lung health”, the editorial said.
 
Research needed on hospital “weekend effect” 
AN international comparison of 30-day inhospital mortality by day of the week for emergency admissions shows a “weekend effect” in the countries studied, except for Australia. The research, published in BMJ Quality & Safety, included data from nearly 3 million hospital records in England, Australia, the US and the Netherlands over a 4-year period from 2009. The main finding was that mortality outcomes from the sample of metropolitan teaching hospitals varied within each country and by day of the week. A total of 73 636 inhospital deaths were recorded following emergency admission and within 30 days, giving an overall crude 30-day mortality rate of 3.9%. The researchers wrote that when examined by day of the week, crude mortality rates were higher for a weekend emergency admission compared with a weekday admission for all countries except for the six Australian hospitals, which showed an almost constant rate throughout the week. “Interestingly, these Australian hospitals had the largest proportion of emergency admissions, while having one of the lowest 30-day crude mortality rates after an emergency admission with little or no variation throughout the week”, the researchers wrote. However, when inhospital mortality for emergency patients was calculated 7 days after admission, the Australian hospitals showed significant higher odds of death on a Saturday and Sunday compared with a Monday admission. Lack of power due to the small sample size from Australia could have contributed to the lack of weekend effect at 30 days post-admission, the researchers wrote. They also found the adjusted odds of 30-day death following elective surgery in all countries remained significantly high when surgery took place on a Friday, Saturday and/or Sunday compared with a Monday procedure. “This suggests that other processes involved in the care of these patients were not accounted for in our analysis”, they wrote. An accompanying editorial said attention should now turn to in-depth studies on the cause of the weekend effect or on how it might be mitigated.
 
Pregnant women with epilepsy have high delivery risks
PREGNANT women with epilepsy are at a considerably higher risk for adverse complications and death during delivery at hospitals, according to a retrospective study published in JAMA Neurology. The research was based on a cohort of pregnant women identified through a national inpatient database of more than 4 million delivery-related hospital discharges. The authors used hospitalisation records to examine the obstetrical outcomes associated with each delivery, including maternal death, caesarean delivery, length of stay in hospital, pre-eclampsia, preterm labour and stillbirth. Women with epilepsy had a maternal mortality rate of 80 deaths per 100 000 pregnancies compared with six deaths for women without epilepsy – a greater than 10-fold risk. Women with epilepsy were at a heightened risk for other adverse outcomes, including pre-eclampsia, preterm labour and stillbirth. They also had increased health care utilisation, including a greater risk of caesarean delivery and a prolonged length of hospital stay. The authors wrote that despite the heightened risk of complications, they did not observe evidence that women with epilepsy were routinely triaged to high-risk medical centres. They said these high-risk patients might be best cared for in the medical centres with subspecialty expertise in neurology, maternal–fetal medicine and critical care. “With approximately half a million women with epilepsy of reproductive age in the United States and 25 000 offspring born to these women annually, there is considerable need to understand the risks of pregnancy in this population”, they wrote. An accompanying editorial said that while the research provided new information about the risks associated with pregnancy in women with epilepsy, it raised more questions than it answered. “We need to understand the mechanisms underlying these risks, including death, so that we can identify the specific population at risk and devise interventions to reduce these risks”, the authors wrote.
 
CBT shows promise in treating insomnia
COGNITIVE behaviour therapy (CBT) may help patients with comorbid insomnia improve their symptoms and sleep parameters, research published in JAMA Internal Medicine has found. The authors conducted a meta-analysis of 37 randomised controlled trials involving 2189 paients examining the effectiveness of CBT for insomnia (CBT-I) among patients with a psychiatric and/or medical comorbid condition, including alcohol dependence, depression, post-traumatic stress disorder, chronic pain, cancer and fibromyalgia. The authors said that overall their findings indicated that CBT-I had positive effects on reducing insomnia symptoms and sleep disturbances in comorbid insomnia. At post-treatment evaluation, 36.6% of patients who received CBT-I were in remission from insomnia compared with 16.9% of those in control or comparison groups. The authors wrote that pre- and post-treatment controlled effect sizes were medium to large for most sleep parameters, including sleep onset latency, wake after sleep onset and sleep quality. A small to medium effect was also found across comorbid conditions, with larger effects on psychiatric conditions compared with medical conditions. They said given that insomnia disorders were highly prevalent in primary care, health care professionals should regularly assess for sleep disturbances in the context of comorbid conditions, and efforts should be directed at implementing CBT-I. An accompanying commentary said the study demonstrated that CBT-I was an effective treatment for insomnia, even in the context of medical and psychiatric conditions, and that more research was needed to better understand the treatment response to CBT-I.
 
Doctors frequently work while sick despite risks
HOSPITAL doctors and other health care colleagues frequently work while sick, despite recognising this could put patients at risk, according to research published in JAMA Pediatrics. The study, conducted in 2014 at a large US children’s hospital, was based on responses to an anonymous survey by of 280 attending physicians and 256 advanced practice clinicians (APCs), including nurse practitioners, physician assistants, clinical nurse specialist, and certified nurse midwives. The authors found that 504 (95.3%) of respondents reported working while sick at least once in the past year, and 50 reported working while sick at least five times. Respondents worked with significant symptoms, including diarrhoea, fever and acute onset of significant respiratory symptoms. Physicians were more likely than APCs to report working with each of these symptoms. Reasons deemed important in deciding to work while sick included not wanting to let colleagues and patients down, staffing concerns, fear of ostracism from colleagues, and concerns about continuity of care. Additional reasons given for working while sick included extreme difficulty finding coverage, a strong cultural norm to come to work unless remarkably ill, and ambiguity about what constituted “too sick to work”. The authors said their results highlighted the complex social and logistic factors that caused attending health care workers to work while sick. “These results may inform efforts to design systems at our hospital to provide support for attending physicians and ACPs and help them make the right choice to keep their patients and colleagues safe while caring for themselves”, they wrote. An accompanying editorial said that strong administrative and physician leadership was essential to support appropriate sick leave and ensure adequate staffing. “Also essential is clarity from occupational health and infection control departments to identify what constitutes being too sick to work”, the editorial said.
 
Study identifies suicide risk for soldiers
ENLISTED soldiers on their first tour of duty account for most medically documented suicide attempts by members of the US Army, according to a longitudinal, retrospective cohort study into suicide attempts during the wars in Afghanistan and Iraq. The research, published in JAMA Psychiatry, found the risk was particularly high among soldiers with a recent mental health diagnosis. An analysis of data from 9791 suicide attempts and a control group examined sociodemographic, service-related and mental health predictors of medically documented suicide attempts among active-duty regular Army soldiers from January 2004 to December 2009. Enlisted soldiers accounted for 98.6% of all suicide attempts (9650 attempters; overall rate, 377.0 per 100 000 person-years). In multivariate models, suicide attempts among enlisted soldiers were predicted by female sex, entering Army service at 25 years or older, current age 29 years or younger, white race, educational level less than high school, in the first 4 years of service, having never or previously been deployed, and a mental health diagnosis during the previous month. Attempts among officers (overall rate, 27.9 per 100 000 person-years) were predicted by female sex, entering service at 25 years or older, current age of 40 years or older and a mental health diagnosis during the previous month. The researchers wrote that their findings suggested that enlisted soldiers and officers required unique considerations in research and suicide prevention. “For clinicians assessing individual risk, distinguishing between who they are likely to see in practice vs who is at highest risk in the population is important”, they wrote.
 

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