Essay winners tackle global health challenges
THE importance of access to healthy food in health outcomes for children was the main theme of the two winning essays in this year’s MJA, MDA National, Nossal Global Health Prize. Essays submitted for the prize use a story or example from personal experience of working in a resource-poor setting to illuminate a topic of global health importance. Dr Costa Boyages, a rural GP registrar currently completing his residency term at the Shoalhaven District Memorial Hospital in Nowra, NSW, won the medical practitioner category with his essay about the devastating impacts of malnutrition in Timor-Leste, where he worked as a volunteer while he was a medical student. Dr Costa previously had hospital placements in Sweden, Vietnam and Cambodia while he was a student. Before doing medicine he worked as an Australian diplomat with the Department of Foreign Affairs and Trade with overseas assignments in the Asia-Pacific focusing on international trade, climate change and nation building. He told MJA InSight that when he started doing medicine he found that aid work provided “an opportunity to make a modest contribution to the meagre and overstretched resources of our tireless colleagues elsewhere”. “The worst part about any aid work is being confronted with the staggering inequities between the global haves and have-nots”, he said. Victoria Smith, a final year postgraduate medical student at Monash University, Melbourne, won in the medical student category for her essay about the children she encountered during a 6-week placement at the Alice Springs Hospital and the confronting health issues they face due to the lack of good food, clean water and adequate facilities. Ms Smith told MJA InSight it was her first time in the Northern Territory but she had completed a previous a placement in Walgett, which introduced her to Indigenous health and opened her eyes “to the vast complexity of the issues facing Indigenous Australia”. She said the best aspect of her time in Alice Springs was working with the health and allied health professionals who were “passionate about their job and eager to transmit knowledge”. “The worst aspect was feeling so helpless.” Ms Smith is “strongly attracted” to a career in general practice.
Shared decision making cuts antibiotic scripts
A COCHRANE review of randomised controlled trials (RCTs) has found that when doctors and patients are encouraged to discuss the need for antibiotics to treat an acute respiratory infection (ARI), fewer drugs are prescribed. The review included 10 published reports of nine original RCTs (one was a long-term follow-up of an original trial) that included more than 1100 primary care doctors and about 492 000 patients. The Australian authors of the review wrote that interventions aimed at promoting shared decision making in primary care as a core component of multifaceted interventions significantly reduced antibiotic prescribing for ARIs by almost 40% compared with usual care in the short term. However, they found insufficient evidence for sustained reductions in antibiotic prescribing over the longer term. No significant differences were found between those receiving the intervention or usual care in clinical complications such as the need for a second consultation for the same illness, or patient satisfaction with the consultation. However, there was insufficient evidence to assess intervention effects on other clinically adverse or patient and/or caregiver shared decision process outcomes. The quality of evidence for the review was assessed as moderate or low quality for all outcomes. “The variety in the interventions and training components studied has important implications for knowing which intervention components should be used in clinical practice, or how best to adapt successful programmes to other primary care environments with different practice characteristics or access to financial and core support resources”, the authors wrote.
Aim for systolic BP below 120 mm Hg to cut cardiac risks
LOWERING systolic blood pressure (BP) to a target goal of less than 120 mmHg resulted in significantly lower rates of fatal and non-fatal cardiovascular events and death from any cause compared with a target of 140 mmHg or less, according to a randomised controlled trial published in the New England Journal of Medicine. The 9361 study participants were aged at least 50 years, had a systolic BP of 130‒180 mmHg at baseline and an increased cardiovascular risk, but did not have diabetes. They were randomly assigned to a systolic BP target of less than 120 mmHg (intensive treatment) or a target of less than 140 mmHg (standard treatment). The treatment protocol encouraged, but did not mandate, the use of drug classes with the strongest evidence for reduction in cardiovascular outcomes, including thiazide-type diuretics (encouraged as the first-line agent), loop diuretics (for participants with advanced chronic kidney disease) and beta-adrenergic blockers (for those with coronary artery disease). Compared with participants in the standard treatment group, those assigned to intensive-treatment had a 25% lower relative risk of myocardial infarction (the primary outcome) and lower rates of several other important outcomes, including heart failure (38% lower relative risk), death from cardiovascular causes (43% lower) and death from any cause (27% lower). However, serious adverse events, including hypotension, syncope, electrolyte abnormalities and acute kidney injury or failure, were higher in the intensive-treatment group, but there were no falls causing injury or bradycardia. The researchers wrote that the study results “add substantially to the evidence of benefits of lowering systolic blood pressure, especially in older patients with hypertension”. An accompanying editorial said the study “will change practice”, saying the journal was “proud to publish it and to defend the importance of the expedited peer-review and publication process that it has undergone”.
Central obesity mortality risk greater than high BMI
HAVING excessive fat distribution around the waist poses a greater mortality risk than being overweight or obese based on body mass index (BMI), particularly in the absence of central fat distribution, according to a study published in the Annals of Internal Medicine. The 14.3-year study of 15 184 men and women aged 18‒90 years examined the risk for total and cardiovascular mortality associated with having normal-weight central obesity, defined as an elevated waist-to-hip ratio, in people with a normal BMI. The study found that men of normal weight, who had central obesity, had an 87% higher mortality risk than men with similar BMI but no central obesity. Their mortality risk was more than twice that of men who were overweight or obese but who were not centrally obese. A similar pattern played out for women with central obesity, although their mortality risk was less (48%) compared to women with no central obesity. They had a 40% higher total mortality risk than a woman who was overweight, and 32% greater risk than those deemed obese, based on BMI. “Cardiovascular mortality showed the same relationship”, the researchers wrote. An accompanying editorial said waist-to-hip ratio was a simple and reliable measure for central obesity that was infrequently used in daily clinical practice. “Although assessing for total fat mass with BMI to identify patients at greater cardiovascular risk is a good start, it is not sufficient”, the editorial said, adding that the numerator in the BMI calculation did not distinguish between lean and fat mass.
Mindfulness interventions have potential in primary care
MINDFULNESS-based interventions (MBI) show promise in improving the mental health and quality of life of primary care patients, according to research published in the Annals of Family Medicine. The meta-analysis of six randomised controlled trials included three that focused on mindfulness-based stress reduction and three on mindfulness-based cognitive therapy. The trials included 553 participants, aged from 43‒69 years, whose conditions included chronic musculoskeletal pain, mood disturbance, chronic stress, chronic illness and medically unexplained symptoms. The trials used control conditions including waiting lists, usual care,massage, spirituality programs, pharmacotherapy or placebo. “MBIs were efficacious for improving mental health, with a high heterogeneity, and for improving quality of life, with a low heterogeneity”, the researchers wrote. However, in terms of improving general health, only a moderate effect was seen. The researchers said although there was insufficient evidence to draw conclusions about the effect of mindfulness interventions, they showed potential. “Although the number of randomized controlled trials applying MBIs in primary care is still limited, our results suggest that these interventions are promising for the mental health and quality of life of primary care patients.” The researchers said given that common chronic conditions were addressed in primary care, “an effective MBI designed for this setting could benefit countless people worldwide”.
Radial access best in cardiac catheterisation
A SYSTEMATIC review and meta-analysis involving more than 17 000 patients has found that radial access in invasively managed adults with acute coronary syndrome (ACS) reduced all-cause mortality by 28% compared with femoral access. The study, published in Annals of Internal Medicine, pooled data from four high-quality, multicentre trials to show radial access reduced death (relative risk [RR], 0.73), major adverse coronary events (RR, 0.86) and major bleeding (RR, 0.57), although the procedures lasted slightly longer (standardised mean difference, 0.11 minute) and had a higher risk of access-site crossover (6.3% v 1.7%) than for femoral procedures. There were no notable effects on myocardial infarction or stroke outcomes. The researchers wrote that their findings applied to patients “across the broad spectrum of ACS undergoing invasive management and consolidate the role of transradial intervention as a life-saving procedure”. They said the findings supported the use of radial access as the default strategy for cardiac catheterisation in patients with ACS and warranted an upgrade of current guidelines recommendations. An accompanying editorial said the meta-analysis “should be ‘a call to arms’ for U.S. cardiologists to increase their utilization of this approach”.

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