Call for rheumatic heart disease screening
THE prevalence of rheumatic heart disease (RHD) is significant in remote Indigenous Australian children, with a substantial level of the disease undetected, according to research published in the MJA. The study included a cross-sectional screening survey of 3946 Aboriginal or Torres Strait Islander children aged 5–15 years between 2008 and 2010. Portable echocardiography was performed by cardiac sonographers in 32 remote communities in northern and central Australia, and echocardiograms were recorded and reported offsite by cardiologists. RHD was diagnosed according to 2012 World Heart Federation criteria. The authors found that the prevalence of definite RHD differed between regions, from 4.7 per 1000 Indigenous children in Far North Queensland, to 15.0 per 1000 in the Top End of the Northern Territory. Of the definite cases of RHD detected, 53% had no previous history of acute rheumatic fever or RHD. The prevalence of new cases of definite RHD was 4.6 per 1000 for the entire sample, and 7.0 per 1000 in the Top End. The authors wrote that the evaluation of socioeconomic data suggested that the Top End group was the most disadvantaged in the study population, which was a plausible explanation for the higher prevalence of RHD in that area. An estimated 4–8 per 1000 Indigenous children in remote communities had undetected RHD which could be identified by echocardiographic screening. “Whether such screening should be recommended will require further and careful consideration of its cost-effectiveness, feasibility, sustainability and impact on primary and specialist health care services”, the authors wrote. They said they were currently preparing a cost-effectiveness analysis “that will allow us to make informed recommendations regarding RHD screening to national policymakers”.
 
Colouring in warfarin tablets may cause allergy
A DYE used in a warfarin tablet has been blamed for an allergic skin reaction in a 57-year-old patient. In a short report, published in the MJA, doctors and pathologists based in Perth said the patient, who had a history of paroxysmal atrial fibrillation (AF), previous stroke, coronary artery disease and severe mitral regurgitation, was referred for surgical ablation of AF, coronary revascularisation and mitral valve surgery. During the work-up for surgery, she developed recurrent, pruritic maculopapular rashes on her trunk and upper limbs on two occasions within 3 days of starting oral anticoagulation with warfarin. She was referred to a clinical immunologist for assessment. The report authors said that as allergic reactions to warfarin were rare, a reaction to one of the dyes in the tablet was considered. The patient was started on a different brand of warfarin that did not contain any shared excipients with the original brand. She remained symptom-free and reached a therapeutic international normalised ratio, and later underwent surgery. The authors wrote that the patient remained rate-controlled at 7 months follow-up with the different brand of warfarin. They said “warfarin allergy” could be due to the structure of the different brand of tablet or the excipients introduced for colouring and safety. “While this has previously been documented, excipients are rarely considered as a possible cause of allergic reaction in common practice”, they wrote. Although there was no confirmation, the authors said they strongly suspected indigo carmine (FD&C Blue No. 2) caused the reaction. “With this in mind, we suggest that excipient allergy should be considered in patients with a reaction to warfarin, and dye-free preparations can be administered as a therapeutic alternative.”
 
Psychotropic drugs used for challenging behaviours
A UK study has found that adults with intellectual disability are treated with psychotropic drugs at a rate far exceeding that of recorded mental illness, with certain subgroups such as those with challenging behaviour significantly more likely to receive the drugs. The research, published in The BMJ, included data on more than 33 000 adults with intellectual disability contributed by 571 general practices between 1999 and 2013. The researchers found that 21% of the cohort had a record of mental illness at study entry, including 7% with a record of severe mental illness (schizophrenia 4%, bipolar disorder 1%, other psychosis 2%) and 25% had a record of challenging behaviour By the end of the study period, the proportion of people with a record of mental illness (not including those with only challenging behaviour) at any point in their primary care notes was 34%, and the proportion with a record of severe mental illness was 9%. A history of psychotropic drugs prescription was present in 49% of the cohort at study entry and 63% by the end of data collection. The most common class of drugs prescribed was anxiolytics/hypnotics, followed by antidepressants, antipsychotics and mood stabilisers. New prescriptions for antipsychotics were significantly more common in older people and in those with a record of challenging behaviour, severe mental illness, depression, anxiety, autism, dementia and epilepsy. “We need to understand why most antipsychotics are prescribed to people without a record of severe mental illness and why so many people with challenging behaviour receive antipsychotics”, the authors wrote. They said although the prescription of antipsychotic drugs had declined over the 15-year study period, “more work is clearly needed as prescribing often seems to be contrary to the evidence base and clinical guidelines of good practice”.
 
Youths with chronic illness turn to alcohol, drugs
ALCOHOL and marijuana use is common among young people with chronic medical conditions, with alcohol use associated with non-adherence to treatment, according to research published in Pediatrics. The study included 403 US youths aged 9‒18 years who were receiving care for asthma, cystic fibrosis, type 1 diabetes, arthritis or inflammatory bowel disease. Approximately half the cohort was female, 75.1% were white and the average age was 15.6 years. The participants completed a self-administered questionnaire during a routine subspecialty care visit. The authors found that one-third of the cohort had reported alcohol use in the previous year. Among high school aged youths, 36.5% and 12.7% reported alcohol use and binge drinking in the previous year, respectively, while 20.6% reported marijuana use. Older age was associated with alcohol use, but drinking patterns did not differ by sex, ethnicity, condition or mental health status. In high school-aged youth, 53.1% and 37.2% answered correctly that alcohol could interfere with their medications and laboratory tests, respectively. Youths who answered incorrectly were 8.53 and 4.46 times more likely to drink and binge drink, respectively. The authors found that 32% and 8.3% of high school aged youth reported regularly forgetting or skipping their medications in the previous 30 days. Youth who reported drinking in the previous year were 1.79 and 1.61 times as likely to report regularly missing or skipping medications compared with non-drinkers. The authors said their findings raised significant concerns about the potential for substance use to undermine the health status of young people with chronic medical conditions. “Education and screening of medically vulnerable youth are warranted to ameliorate risk”, they wrote.
 
Breastfeeding fine for women with MS
WOMEN with multiple sclerosis (MS) should be supported if they choose to breastfeed exclusively, as it does not increase the risk of postpartum relapse, a study published in JAMA Neurology has found. The research, based on prospective data collected from a nationwide MS pregnancy registry in Germany, included 201 women with relapsing-remitting MS who were followed up for 1 year post-partum. Participants completed questionnaires on MS history, state of pregnancy, type of delivery, outcome of pregnancy, intention to breastfeed, relapses and medications. Exclusive breastfeeding, defined as at least 2 months of breastfeeding without regular supplemental feeding, was intended by 120 women, but four women stopped exclusive breastfeeding due to a relapse. A total of 39 women did not breastfeed and 42 women combined breastfeeding with supplemental feedings within the first 2 months postpartum. The authors found that 38.3% of the women who did not breastfeed exclusively had a relapse within the first 6 months postpartum compared with the 24.2% who breastfed exclusively for at least 2 months. The time to postpartum relapse after the introduction of supplemental feedings did not differ significantly between women who previously breastfed exclusively and those who did not. The authors said the results indicated that exclusive breastfeeding was a modestly effective MS treatment with a natural end date. “The effect of exclusive breastfeeding seems to be plausible, since disease activity returned in the second half of the postpartum year in exclusively breastfeeding women, corresponding to the introduction of supplemental feedings and the return of menses”, they wrote. The authors said their findings were important for clinical practice “since breastfeeding is highly promoted for the first 6 months of life owing to various well-known beneficial effects for the mother and child”.
 

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