Lifestyle, not birthweight, key in Aboriginal health
IN a surprise outcome, researchers have found that the high-risk combination for type 2 diabetes of low birthweight (LBW) or fetal growth restriction (FGR) with later overweight or obesity was rare in a cohort of Aboriginal adolescents. The research, published in the MJA, found no associations between LBW and FGR with higher fasting adolescent insulin and glucose levels, contrary to the International Society for Developmental Origins of Health and Disease hypothesis. The researchers said this suggested that the adverse effects of poor fetal nutrition might be concealed by the persistent undernutrition found in the Aboriginal adolescent cohort. The longitudinal prospective study of 686 Aboriginal babies born at the Royal Darwin Hospital between 1987 and 1990 and followed up between 2006 and 2008 involved 134 adolescents with complete data. It found those with LBW or FGR were not overweight at age 18 years. “In this adolescent cohort, there were no negatively directed associations between birthweight and either fasting glucose, insulin concentrations or the insulin-resistance measure, with no evidence of the U-shaped associations described for populations with similar high rates of type 2 diabetes in adult life”, the researchers wrote. “A positively directed association occurred for birthweight with fasting glucose levels.” They predicted that the growth trajectory for the cohort would positively change and “the high-risk combination for chronic disease of LBW or FGR followed by overweight or obesity will become more common over the next decade. Then the relationships of LBW or FGR with chronic biomarkers may become apparent”. High rates of type 2 diabetes observed in the adult Aboriginal population were more likely to decrease by using strategies targeted at improving lifestyle factors in childhood and adolescence, rather than focusing on improving birthweight alone, the researchers said.
HRT scare linked to thousands of deaths
US researchers have concluded that the widespread rejection of oestrogen therapy such as postmenopausal hormone replacement therapy (HRT) after the 2002 Women’s Health Initiative (WHI) study had most likely led to almost 50 000 unnecessary deaths in the US, mainly from heart disease, among women aged 50–69 years who had had a hysterectomy. The research, published in the American Journal of Public Health, analysed US census data, hysterectomy rates and estimates of decline in hormone use in women between 2002 and 2011. It found that the use of oral oestrogen-only in women aged 50–59 years had declined by almost by 79% between 2001 and 2011. The researchers blamed the decline on one part of the WHI, which related to women with a uterus who took combined oestrogen–progesterone, which found an increased risk of adverse events including cancer. Despite mostly positive health outcomes from the second part of the WHI study, which showed a mortality benefit among women who had no uterus and who took oestrogen-only compared with placebo, an “aversion to hormone replacement therapy of all kinds” had continued “among doctors and patients alike”. The researchers said women, health practitioners and the media should be offered “clear and accurate information about the positive effects of estrogen alone therapy” in women who had had a hysterectomy. “Our analysis suggests that failure to differentiate among populations of women and preparations of [hormone therapy] has cost thousands of lives”, they wrote.
Aspirin lowers colorectal cancer risk
LONG-term, low-dose aspirin taken on alternate days may reduce the incidence of colorectal cancer (CRC) in healthy women but does increase the risk of non-fatal gastrointestinal bleeding, according to research published in the Annals of Internal Medicine. Researchers followed nearly 40 000 women aged 45 years and older enrolled in the Women’s Health Study who took a low dose (100 mg) of aspirin or placebo every other day for 18 years until the study ended in 2004. The researchers found the incidence of CRC was 20% lower in the aspirin group than in the placebo group. Researchers continued to follow a cohort of 33 682 women, who kept taking aspirin after the trial ended until 2012, who had the greatest reduction in CRC risk. However, there were no differences between groups in incidence of other cancer types or in overall cancer risk or death. Compared with women who took placebo, those who took aspirin had more gastrointestinal bleeding (8.3% v 7.3%) and peptic ulcers (7.3% v 6.2%). “Whether new results about long-term benefits for cancer will tip the balance in favor of [recommending] aspirin [for primary prevention] remains to be determined”, the researchers wrote. An accompanying editorial said that the lack of a reduction in all-cause mortality, or even in the risk for all cancer, with aspirin in the study “should temper any recommendations for widespread use of aspirin in healthy middle-aged women”.
Legal claims against GPs on the rise
A SYSTEMATIC review of malpractice claims in primary care across five countries, including Australia, has found that failure or delay in diagnosis and medication errors were the most common reasons for claims. Of the 7152 studies considered for the review, published in BMJ Open, 34 were eligible for analysis, including 15 based in the US, nine in the UK, seven in Australia, two in France and one in Canada. The review found that, when compared with other specialties, general practice was consistently ranked in the top five most sued specialties on US medical indemnity databases. In the UK and Australia, malpractice claims against GPs were rising. Among adults, cancer and heart attack were the most common source of claims of missed diagnoses, with appendicitis, ectopic pregnancy and fractures also frequently cited in missed diagnosis claims. Among children, the most frequent claims related to meningitis and cancers. “Importantly, the majority of malpractice claims are successfully defended”, the researchers wrote, also noting: “For doctors, facing a malpractice claim can have serious implications”. One such implication was the subsequent practice of defensive medicine, which could result in increased diagnostic testing, increased referral rates, prescription of unnecessary medication and avoiding treating certain conditions or performing certain procedures. “This practice can improve patient care but must be balanced with the potential negative consequences both for patients, in terms of undergoing unnecessary investigations, and for the health service, in terms of increased healthcare expenditure”, they wrote.
Dangers of multiple hospitalisations
REPEATED hospitalisations of elderly nursing home residents with dementia for the same infections or dehydration resulted in poor survival, according to research published in JAMA. The researchers identified 1.3 million elderly (mean age 84.5 years) nursing home residents with advanced cognitive impairment in the US. They found there had been two or more hospitalisations for pneumonia in 1.78% of the residents, for urinary tract infections in 4.33%, for septicaemia in 1.58% and for dehydration in 3.49%. Compared with overall survival of 476 days, the adjusted survival for those with multiple hospitalisations was significantly lower — 95 days for pneumonia; 146 days for UTI, 111 days for dehydration or malnutrition, and 89 days for septicaemia. The researchers said prior research suggested that these common complications of dementia could be treated with the same efficacy in the nursing home as in the hospital. “Future research is needed to understand whether these transitions are based on financial incentives, poor communication, or a lack of resources needed to diagnose and treat a [nursing home] resident”, they wrote.
Mutation causes urinary tract malformations
RESEARCHERS have identified a genetic mutation that causes congenital malformations of the kidney and urinary tract. The study, published in the New England Journal of Medicine, involved a Sardinian family with congenital malformations of the kidney and urinary tract, with several family members experiencing kidney failure at a young age. Using exome gene sequencing, the researchers identified a mutation of the dual serine–threonine and tyrosine protein kinase (DSTYK) gene in all of the affected family members. The researchers then screened 311 unrelated individuals with urinary tract defects and found seven other patients with DSTYK mutations. The researchers said the identification of the mutation suggested haploinsufficiency as a potential genetic mechanism, “underscoring a critical role of DSTYK gene dosage in the development of the human urinary tract”. “These findings show the effectiveness of exome sequencing for the elucidation of heterogeneous developmental traits with modest-sized pedigrees”, they wrote.