Doctor burnout getting worse in US
BURNOUT and satisfaction with work–life balance (WLB) is getting worse for US physicians, according to research published in the Mayo Clinic Proceedings. The study authors said American medicine “appears to be at a tipping point with more than half of US physicians experiencing professional burnout”. The research was based on a survey of US physicians and a probability-based sample of the general US population in 2014, using the methods and measures employed in a 2011 survey by the same authors. Of the 6880 physicians who completed the 2014 survey, 54.4% reported at least one symptom of burnout in 2014 compared with 45.5% in 2011. Satisfaction with WLB was 40.9% in 2014 compared with 48.5% in 2011. The researchers wrote that minimal changes in burnout or satisfaction with WLB were observed between 2011 and 2014 in the probability-based samples of working US adults, resulting in an increasing disparity between physicians and general workers. They found “substantial differences” in rates of burnout and satisfaction with WLB by specialty. The prevalence of burnout was higher for all specialties in 2014 compared with 2011, including family medicine (51.3% in 2011 v 63.0% in 2014), general paediatrics (35.3% v 46.3%), urology (41.2% v 63.6%), orthopaedic surgery (48.3% v 59.6%), dermatology (31.8% v 56.5%), physical medicine and rehabilitation (47.4% v 63.3%), pathology (37.6% v 52.5%), radiology (47.7% v 61.4%) and general surgery subspecialties (42.4% v 52.7%). Satisfaction with WLB was lower in 2014 for all specialty disciplines except obstetrics and gynaecology and general surgery. The authors wrote that despite the “substantial erosion” in satisfaction with WLB in the past 3 years, there had been no increase in the median number of hours worked per week. “Given the extensive evidence that burnout among physicians has effects on quality of care, patient satisfaction, turnover, and patient safety, these findings have important implications for society at large”, they wrote.
No evidence for metformin in type 1 diabetes
RESEARCH assessing the efficacy and safety of metformin as an adjunct to insulin for overweight adolescents with type 1 diabetes has found no evidence to support prescribing the oral glucose-lowering agent. The 6-month, multi-centre, placebo-controlled randomised trial, published in JAMA, assessed the effect of adding 2000 mg of metformin each day to basal–bolus insulin treatment in 140 adolescents with type 1 diabetes. Participants had a mean body mass index in the 94th percentile, a mean total daily insulin dose of 1.1 U/kg and mean HbA1c of 8.8%. Each participant’s height, weight, blood pressure and waist circumference were measured at baseline, 13 weeks and 26 weeks. Fasting blood was analysed for serum lipids, liver enzymes, creatinine and C-peptide at the same testing intervals. Participants also wore a blinded continuous glucose monitor sensor for 3‒7 days at the same intervals and recorded insulin use for 1 week before each interval. “Despite a small decrease in HbA1c favoring the metformin group at 13 weeks, mean HbA1c levels increased by ~0.2% from baseline values of 8.8% in each treatment group at 26 weeks”, the authors wrote. “Among overweight adolescents with type 1 diabetes, the addition of metformin to insulin did not improve glycemic control after 6 months”, they said, noting that the use of metformin was associated with an increased risk of gastrointestinal adverse events. Similarly, there were no concomitant improvements in cardiovascular risk factors. However, the researchers said the study may have been too short to show beneficial effects on surrogate markers of future cardiovascular disease.
Too much TV affects cognitive function in adults
LOW levels of physical activity and high levels of television viewing during young-to-mid-adulthood are associated with worse cognitive performance and slower processing speed in midlife, but not verbal memory, according to the results of a 25-year study published in JAMA Psychiatry. The prospective study of 3247 adults assessed television viewing and physical activity at repeated visits (three or more assessments) between 1985 and 2011. High television viewing was based on more than 3 hours a day. At baseline, the mean age of the participants was 25.1 years, 56.5% were female, 54.5% were white and 92.9% had completed at least high school. The researchers found that the 10.9% of participants who had high television viewing were more likely to have poor cognitive performance compared with those with low television viewing. Low physical activity, found in 16.3% of participants, was significantly associated with poor cognitive function performance. The odds of poor performance were almost two times higher for adults with both high television viewing and low physical activity compared with those with low television viewing and high physical activity. The researchers wrote that their findings indicated that early adulthood could be a “critical period to promote physical activity for healthy cognitive aging, especially as physical activity levels during this life stage track with activity levels in later life”. They said the effect of sedentary behaviour “may be especially consequential because the use of screen-based technologies for work and leisure has increased in the past several decades”. 
HIV-1 prophylaxis protects high-risk men 
A DOUBLE-blind, randomised controlled trial of antiretroviral therapy for pre-exposure to HIV-1 prophylaxis among men who have unprotected anal sex with men has found using the therapy before and after sexual activity provides protection against infection. The study, published in the New England Journal of Medicine, included 400 participants who were randomly assigned to take a combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) or placebo. All participants received risk-reduction counselling and condoms, and were regularly tested for HIV-1 and HIV-2 and other sexually transmitted infections. A total of 16 HIV-1 infections occurred during the median 9.3 months of follow-up — two in the therapy group and 14 in the placebo group, indicating a relative reduction of 86% in the risk of HIV-1 infection in the therapy group. The rates of serious adverse events were similar in both groups, but those in the therapy group had higher rates of gastrointestinal (14% v 5%) and renal (18% v 10%) adverse events. The researchers wrote that their findings were among the highest risk reductions reported to date, but acknowledged that the short follow-up period could have increased the likelihood of an exaggerated estimate of efficacy due, in part, to high initial adherence. “While we wait for an effective vaccine against HIV, the use of such preexposure prophylaxis with TDF-FTC among high-risk men could contribute to a reduced incidence of HIV infection”, they wrote. The study was presented in part at the 20th International AIDS Conference held in Melbourne last year. An accompanying perspective said political will “must be mobilized to match the scientific evidence and provide the financial and human resources necessary to dramatically scale up HIV testing and treatment around the world”. 
Costs of cancer drugs vary across countries
A CROSS-country price comparison has found that prices for cancer drugs vary across Europe, Australia and New Zealand, contradicting earlier comparative studies that showed Australian prices (presented as a price index) were low. The study, published in The Lancet Oncology, was based on comparability in terms of the economic situation and of the pharmaceutical system in 16 European countries, Australia and New Zealand. It included the official list prices per unit at ex-factory price level of 31 originator cancer drugs at June 2013. Of the countries studied, New Zealand had the lowest data availability (missing data for 65% of the 31 drugs), followed by Portugal (61%) and Australia (32%). The difference between the highest and lowest priced countries varied between 28% and 388%. Within the sample, the price of gemcitabine had the highest price range between the highest (New Zealand) and lowest (Australia) priced countries. Zoledronic acid also had a large price difference, with New Zealand the highest priced country and Greece the lowest. The researchers wrote that the existence of generics on the market might have affected prices in some countries. They said that due to the large effects new cancer drugs had on budgets, public payers were considering managed-entry agreements (ie, arrangements between a manufacturer and payer or provider to enable access to medicines), with such agreements increasingly used in Australia and several European countries, and just starting to be introduced in New Zealand. They concluded that public payers “risk overpaying” for cancer drugs. In an accompanying commentary said that the “societal challenge is to combine the development and availability of promising new drugs with the sustainability of our system”.
Keep it simple best for asthma action plans
LOW-LITERACY asthma action plans that include illustrations and photographs improve the quality of asthma counselling, according to a randomised controlled trial published in Pediatrics. Researchers randomly assigned 119 physicians at two US academic centres to use a low-literacy or standard action plan to counsel the hypothetical parent of child with moderate persistent asthma. None of the physicians had received training in how to use the plan. Of the physicians who used the low-literacy plan, 96.7% recommended a time of day for taking daily medications compared with 51.7% using the standard plan. Similarly, 93.4% of those using the low-literacy plans reinforced the need for daily medications when sick, compared with 34.5% using the standard plan. The use of a spacer was recommended by 83.6% of physicians using the low-literacy plan, compared with 43.1% using a standard plan. After completing the questionnaire, all physicians were shown the action plan they had not been assigned and more than 90% in both groups preferred the low-literacy version. The researchers wrote that given that there was no standard, universal asthma action plan available, implementing the low-literacy plan could reduce variability in the way instructions were provided to parents of children with asthma. “A move to having a nationally available, evidence-based low-literacy asthma action plan could help improve parent and patient understanding, adherence, and, ultimately, asthma outcomes”, they wrote.

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