eMJA: In Other Journals, 4 May 2009

Offspring of older fathers appear to be more likely to have impaired neurocognitive outcomes in early childhood, according to results of a large US study. Using a sample of over 33 000 child participants from the US Collaborative Perinatal Project, researchers assessed the relationship between paternal or maternal age and outcome measures at 8 months, 4 years and 7 years. A range of neurocognitive tests was used and the data were analysed using two models, one taking into account the parents’ ages, and the other included the parents’ level of education and income. Advanced paternal age was significantly associated with lower scores on all but one of the neurocognitive measures. Near-linear decline with increasing paternal age was noted in most of the measures, and the association was independent of social factors. The authors comment that whether the children of older fathers “catch up” during later childhood is unknown, and that the mechanism of action may be related to genetic mutations in the male germ cell line or epigenetic mechanisms.

Larvae for leg ulcers

Larval therapy has become popular for the treatment of leg ulcers, based on the premise that their use stimulates healing, reduces bacterial load, and eradicates methicillin-resistant Staphylococcus aureus (MRSA). To formally test these hypotheses, researchers conducted a randomised controlled trial involving 267 patients with sloughy or necrotic leg ulcers. They set out to compare the effectiveness of larval therapy using either loose or bagged larvae with hydrogel — a standard ulcer dressing used for debridement. Although larval therapy resulted in more pain, did not increase healing rates or reduce bacterial load when compared with hydrogel, it significantly reduced the time to debridement of necrotic ulcers. The authors comment that there is much to learn about the role of debridement in ulcer healing.

BMJ 2009; 338: b773

I’m going home . . .

Why patients leave hospital against medical advice (AMA) is a difficult question, and one that researchers have attempted to answer in a US-based review, along with an analysis of predictors of such discharges and potential associated health care costs. Predictors of AMA discharge included younger age, lack of medical insurance, and a history of substance or alcohol misuse. Some studies had novel findings, including one that found that patients without a primary care doctor were more likely to discharge themselves AMA. The authors comment that the literature is limited to medical record reviews and retrospective analyses, but offer possible strategies for preventing AMA discharges, which include addressing substance misuse, recognising and managing psychological factors such as anxiety and anger, and using motivational interviewing, which aims to uncover the unspoken motivations behind patients’ behaviours.

Mayo Clin Proc 2009; 84: 255-260

Prostate cancer: screening and mortality

The controversy surrounding prostate-specific antigen (PSA) testing for prostate cancer has deepened, following the publication of two randomised controlled trials: one from the US, and the other a European collaboration.1,2 In both studies, researchers analysed the effect of regular PSA testing on mortality rates from prostate cancer. In the US study of 76 693 men over 9 years, mortality from prostate cancer was low and did not differ significantly between the tested and untested groups. The authors of this study concluded that the risks of over-screening, diagnosis and treatment are high. In the European study of 182 000 men, the absolute risk difference between the screened and unscreened group was 0.71 deaths per 1000 men. Despite the apparent reduction in rate of death by 20% in the screened group, the researchers comment that the results reflect combined data from a number of trials, the findings are an interim analysis, and the number needed to be screened to prevent one death (1410 men) is high.

1. N Engl J Med 2009; 360: 1310-1319

2. N Engl J Med 2009; 360: 1320-1328

Religion and the end of life

Patients who use religious faith to cope with cancer appear to be more likely to receive life-prolonging care in the last days of life, according to US researchers, who conducted a prospective, longitudinal study of 345 patients with advanced cancer. Main outcome measures were intensive life-prolonging care in the form of mechanical ventilation or resuscitation in the last week of life. Patients were initially assessed for the use of positive religious coping, psychological and spiritual measures, advance care planning, and end-of-life treatment preferences. Intensive life-prolonging measures in the last week of life were significantly associated with a high level of religious coping at baseline, even after controlling for advance care planning and other psychosocial confounders. The authors discuss the possible meaning of these findings at length, concluding that clear associations in religiousness and spirituality research are elusive, and that clinicians need to be aware of religious methods of coping when they discuss options with terminally ill cancer patients.

JAMA 2009; 301: 1140-1147

Dr Tanya Grassi, MJA

mja.com.au | The Medical Journal of Australia

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