Similar outcomes from varicose vein treatment options
A MULTICENTRE trial, published in the NEJM, comparing the clinical effectiveness of endovenous laser ablation, foam sclerotherapy and surgery for the treatment of varicose veins has shown no clinically substantial differences in quality of life between the groups. However, the randomised trial of 798 patients from 11 vascular surgery departments in the UK, whose outcomes were assessed at baseline and at 6 weeks and 6 months after treatment, did find that patients treated with foam had moderately worse outcomes on a measure of disease-specific quality of life than those who underwent surgery. “These differences were small, and their clinical importance is uncertain”, the researchers wrote. All treatments had similar clinical efficacy, but there were fewer complications such as lumpiness, skin staining and numbness after laser treatment, and successful ablation rates of the main trunks of the saphenous vein were lower after treatment with foam.

Informed women have fewer prenatal tests
A RANDOMISED clinical trial has shown that a free computerised interactive decision-support guide can help women make informed decisions about prenatal genetic testing. The trial, published in JAMA, included 710 women who had not undergone screening or diagnostic testing and remained pregnant at 11 weeks’ gestation. They were randomised to the computerised decision-support guide plus access to prenatal testing with no out-of-pocket expense, or usual care with no special financial arrangements. The researchers found that significantly fewer women in the intervention group underwent invasive diagnostic testing compared with women in the control group (5.9% v 12.3%). Women in the intervention group were more likely to have no testing (25.6% v 20.4%) or screening alone (68.5% v 67.3%). They also had significantly higher knowledge scores (9.4 v 8.6 on a 15-point scale), and were more likely to correctly report both the miscarriage risk of amniocentesis (73.8% v 59.0% correct), and their age-adjusted likelihood of carrying a fetus with trisomy 21 (58.7% v 46.1% correct) “In a diverse population of women receiving care in a variety of settings, these findings show that after receiving complete prenatal testing information and the opportunity to explicitly consider their values and preferences via an interactive decision-support tool and having financial barriers to testing removed, participants were less likely to opt for invasive testing and more likely to forgo testing for aneuploidy altogether”, the researchers wrote. Having such a decision guide available in clinical settings could provide a consistent and accurate message on the risks and benefits of testing, they wrote, saying their trial results added support to the contention that women may not be currently receiving adequate counselling about their options. An accompanying editorial warned that prenatal genetic testing “in the era of personalized genomic medicine” was not a “one size fits all” proposition and that it would continue to present challenges and require research on the optimal way to translate it to clinical practice.

Opt-out consent increases organ donations
AN internal comparison has shown that opt-out consent to organ donation leads to a relative increase in the total number of liver and kidney transplants. The study, published in BMC Medicine used statistics on the International Registry of Organ Donation and Transplantation to compare organ donor and transplant rates across 48 countries, including Australia, operating either opt-in or opt-out consent legislation. The researchers found between 2002 and 2012, deceased donor rates (per million population) were higher in opt-out countries, but the number of living donors was greater in countries with opt-in consent. However, when the living and deceased donor figures were combined, liver and kidney donation rates were both shown to be higher in opt-out systems. The study also found that the total number of deceased and living donors rose over the 13-year study period. The researchers attributed this to a variety of factors including “not only an increase in the number of people willing to donate, but also improved criteria for identifying and selecting donors, improved transplantations procedures, and an increase in transplantation capacity”. Although the study results supported existing research on the higher rates of opt-out consent, the researchers argued the introduction of opt-out legislation alone was unlikely to solve a country’s donor shortage. They found opt-out consent countries still had significant transplant waiting lists and an organ donor shortage. The researchers proposed that in opt-out countries it might be possible to reduce the number of people on waiting lists by developing living organ donation infrastructure and by presenting this option to relatives.

Metformin risk in patients with hypothyroidism
A LONGITUDINAL study, published in CMAJ, has confirmed there is an increased risk of low thyroid-stimulating hormone (TSH) in patients being treated for hypothyroidism who take metformin. The highest risk was observed in the first 180 days after metformin was initiated. However, the researchers found that metformin appeared to have no effect on TSH levels in euthyroid patients. The research included 74 300 patients in the base cohort, who began receiving metformin or sulfonylurea monotherapy during the study period between 1988 and 2012. The cohort included 5689 patients with treated hypothyroidism, and 59 937 who were euthyroid. The mean duration of antidiabetic treatment was 0.6 years among patients with treated hypothyroidism and 1.1 years for euthyroid patients. There were 495 events of low TSH during follow up of patients with treated hypothyroidism, an overall incidence rate of 119.7/1000 person-years. Among euthyroid patients, there were 322 low TSH events during follow-up, with an overall incidence rate of 4.5/1000 person-years. The researchers wrote that, when compared with sulfonylurea monotherapy, the use of metformin monotherapy was associated with a 55% increased risk of low TSH levels in patients with treated hypothyroidism. In the first 90 days of use, the hazard ratio (HR) was elevated but not significant (adjusted HR 1.73), followed by an increased risk after 90–180 days of use (adjusted HR 2.30), which returned closer to normal after more than 180 days of use. In euthyroid patients, the adjusted HR was 0.97, with no clear pattern with duration of use. “Given the relatively high incidence of low TSH levels observed in our study in patients receiving metformin (125.2/1000 person-years), there is a need for further research to determine the short- and long-term clinical consequences of this biochemical event, the necessity of monitoring TSH levels when starting metformin, and the appropriateness of adapting levothyroxine doses when low TSH levels are observed in patients starting metformin”, the researchers wrote.

Sick children resilient about quality of life
A SYSTEMATIC review has found seeking the perspectives of both children and their parents is essential to understanding the impact of a congenital or chronic condition on a child’s quality of life (QoL). The research, published in Pediatrics, reviewed 37 studies (including Australian-based research) of self-reported QoL in children under 12 years of age with a congenital health condition. The studies were evaluated using a variety of generic and condition-specific instruments, including the Pediatric Quality Of Life Inventory. Regardless of the child’s condition, the research found children reported QoL scores similar to age-matched controls. However, the review did find that a child’s perspective on QoL differed from their parents’ in the more subjective emotional domains. When disagreement occurred between a child and parent report of QoL, the researchers stressed the importance of identifying other factors. In the cases of children with cerebral palsy, factors such as “parental stress, mental health and wellbeing also contributed to a parental underestimation of QoL in children”. The review also discovered that children as young as 4 years of age were able to report their QoL if assisted by specifically designed questionnaires with simplified response scales or interviews. The researchers concluded that it was vital to consider both child and parent perspectives even for younger children when assessing the impact of a condition on QoL. They wrote that the main strength of their review was that it addressed the previous “lack of consistency” in assessing self-reported QoL in young children by applying a systematic review method, which included a pre-specified criteria checklist. However, they said none of the studies had measured self-reported QoL over time in the same individual, and suggested a longitudinal approach to evaluating QoL would be useful.

Acute glaucoma risk for long-haul flyers
ANGLE-closure glaucoma (ACG) may be linked to long-haul airline flights, according to British ophthalmologists writing in JAMA Ophthalmology. They presented three cases of women airline passengers requiring specialist ophthalmic care for ACG on arrival at their destination, including a 53-year-old woman on a flight from London to Sydney. They warned that the care the women received might not be possible for at-risk passengers flying to areas with less advanced health care or language barriers. “Although we cannot exclude the possibility of coincidence, these cases suggest an increased risk of ACG in susceptible individuals on long-haul flights”, they wrote, saying the risk could relate to extended periods of sitting upright in low-light conditions, which could cause pupil block. “Individuals with risk factors for ACG should be advised of the symptoms and the appropriate course of action should the symptoms occur.” They also warned that airline personnel were not trained to recognise acute glaucoma or administer treatment. “Airline staff should be aware of ACG and consider the value of training cabin crews and having medications, such as pilocarpine, 2%, eye drops and acetazolamide, 250-mg tablets, in cabin first-aid kits”, they wrote. In the meantime, a safe first aid measure was for affected passengers to be in a supine rather than an upright position to help reduce pupil block.

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