Exercise programs no benefit after ankle fracture
AUSTRALIAN researchers have found that supervised exercise programs do not offer additional benefits to advice alone for patients with isolated and uncomplicated ankle fracture. The pragmatic randomised clinical trial, published in JAMA, included 214 patients with isolated ankle fracture presenting to fracture clinics in seven Australian hospitals. They were randomised to a supervised exercise program and advice about self-management (rehabilitation) that was individually tailored, prescribed, monitored and progressed, or to advice alone, with both interventions delivered by a physical therapist. The researchers followed up 194 (91%) patients at 1 month, 173 (81%) at 3 months and 170 (79%) at 6 months. The participants were mostly middle-aged, with more women than men, and most had less severe fractures. At baseline, participants had significant activity limitation and low quality of life. The primary analyses showed that rehabilitation did not provide a significant benefit over advice, with little difference in outcomes between the groups in activity limitation and quality of life. The researchers wrote that the trial showed treatment effects were not associated with fracture severity or age and sex. “Rehabilitation was more costly to the health care system but did not influence out-of-pocket costs to the individual or total costs”, they wrote. The findings “suggest that routine care for patients after isolated ankle fracture should include self-management advice at the time of removal of immobilization but not a supervised exercise program”.
Troponin levels identity patients at low risk of heart attack
A STUDY involving more than 6000 patients with suspected acute coronary syndrome has defined a cardiac troponin threshold that identifies almost two-thirds of presenting patients as being at very low risk of myocardial infarction (MI) or cardiac death who potentially could be safely discharged from the emergency department. The prospective cohort study, published in The Lancet, included a derivation cohort of 4870 consecutively enrolled patients with acute coronary syndrome presenting to hospitals in Scotland, whose plasma troponin concentrations was measured using a high-sensitivity cardiac troponin I assay, and two validation cohorts of 1434 patients. The researchers found 782 (16%) of patients in the derivation cohort had index MI, with a further 32 (1%) re-presenting with MI and 75 (2%) had cardiac deaths at 30 days. In patients presenting without MI, troponin concentrations were less than 5 ng/L in 2311 (61%) of 3799 patients, with a negative predictive value of 99·6% for the primary outcome. In the validation cohorts, troponin concentrations were less than 5 ng/L in 594 (56%) of 1061 patients, with an overall negative predictive value of 99·4%. At 1 year, these patients had a lower risk of MI and cardiac death than those with a troponin concentration of 5 ng/L or more. The researchers wrote that the “use of cardiac troponin I at our threshold identifies two-to-three-times more low-risk patients than do previous approaches, which would avoid the need for repeat testing in most patients”. Implementation of this approach would reduce avoidable hospital admission and have major benefits for both patients and health care providers, they said. An accompanying commentary by Australian and New Zealand experts said the study was a “huge advance in the assessment of patients with possible acute coronary syndrome in emergency departments. We strongly urge close collaboration between front-line clinicians and their laboratory colleagues to identify optimum assessment strategies, including consideration of troponin assay availability and reliability, before local implementation”.
Occupational bladder cancer persists in some jobs
BLADDER cancer persists in some occupations, where the incidence seems to be increasing and occurring faster in women than men, according to a meta-analysis published in JAMA Oncology. The research included 263 articles that reported bladder cancer risk in 1254 occupations. It showed that while there had been reductions in occupational bladder cancer incidence and mortality, there were still many occupations with an elevated incidence or mortality, despite improvements in workplace hygiene. Incidence was highest in occupations where workers were exposed to aromatic amines, namely rubber, plastic and dye workers, hairdressers and painters. The highest individual reported incidence risks were for factory workers (risk ratio [RR], 16.6), hairdressers (RR, 13.4) and aircraft/ship officers (RR, 11.8). For mortality, the highest reported rates were for workers using chemicals (RR, 27.1) and dyes (RR, 8.3). The researchers said the rising risk among women could be due to an increase in the number of women in the workforce or emerging use of occult carcinogens in occupations dominated by women “Efforts to reduce the impact of [bladder cancer] on workers should be targeted to occupations at risk of mortality”, they wrote. An accompanying commentary said: “Workers around the world have the right to demand and get a safe and carcinogen-free workplace”.
Suicide risk increases after bariatric surgery
RESEARCHERS say screening for suicide risk should be part of bariatric surgery follow-up after finding that self-harm emergencies increased significantly in patients after having surgery. The Canadian population-based, self-matched, longitudinal cohort analysis, published in JAMA Surgery, included 8815 adults who were followed up for 3 years before and 3 years after bariatric surgery. The majority of the cohort were treated with gastric bypass surgery, most were women and most were aged 35 years or older. A total of 111 patients had 158 self-harm emergencies during follow-up. Self-harm emergencies significantly increased after surgery (3.63 per 1000 patient-years) compared with before (2.33 per 1000 patient-years). The most common type of self-harm was intentional overdose. The researchers said almost all self-harm events occurred in patients who had a history of mental health disorder. “These events carried significant risk to the patient, with 85 (53.8%) requiring ambulance transport to a hospital, 147 (93.0%) classified as urgent, and 85 (53.8%) leading to a hospital admission”, they wrote. The clinical implications of the findings included active postoperative screening for self-harm risk among patients who had undergone bariatric surgery and were presenting for follow up, the researchers said. An accompanying commentary said the study underscored the “unique vulnerability of patients undergoing bariatric surgery and forces us to look closely at why suicide rates are more than 4 times higher in these patients than the general population”.
β-blockers linked to major cardiovascular events
A LARGE US study of patients with uncomplicated hypertension has found that treatment with a two-drug regimen that includes a β-blocker is associated with a statistically significant increase in the rate of major adverse cardiovascular events (MACE) and death within 30 days of non-cardiac surgery. The Danish research, published in JAMA Internal Medicine, compared 14 644 patients who received β-blockers (65% female, mean age, 66.1 years) with a similar group of 40 676 patients who received other antihypertensive drugs (57% female, mean age, 65.9 years). The researchers found that 30-day MACEs occurred in 1.3% of patients in the β-blockers group compared with 0.8% of patients in the other group. β-blocker use was associated with increased risks of MACEs in two-drug combinations with renin-angiotensin system (RAS) inhibitors (odds ratio [OR], 2.16), calcium antagonists (OR, 2.17) and thiazides (OR, 1.56), compared with the reference combination of RAS inhibitors and thiazides. Results were similar for all-cause mortality. The risk of MACEs associated with β-blocker use seemed especially pronounced for patients aged at least 70 years, for men and for patients undergoing acute surgery. The researchers wrote that although the study was not randomised, the clinical characteristics of patients who received either β-blockers or an alternative hypertensive medication were similar, and statistical adjustments controlled for differences between patients receiving different drugs. They wrote that their findings suggested that “perioperative management of patients with hypertension should receive specific attention in clinical practice and future guidelines, but additional randomized clinical trials on this question may be warranted”.

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