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Dr Linda Calabresi

Dr Linda Calabresi

GP; Medical Editor, Healthed
Dr Linda Calabresi is an Australian-based health professional. Linda is trained as a GP (General Practitioner) and has practices located in North Ryde, Artarmon.

More from this expert

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Do Not Order These Tests On Pregnant Women

Hot on the heels of the Choosing Wisely campaign of “do nots” for GPs, the Royal Australasian College of Physicians has released a new list of tests doctors should avoid ordering on pregnant women. The recommendations come from the Society of Obstetric Medicine in Australia and New Zealand (SOMANZ), and include the advice that the D-dimer test should not be used to diagnose venous thromboembolism in pregnant women as it is unreliable. Even though women are five times more likely to develop venous thromboembolism in pregnancy, other investigative tests should be used if a clot is suspected as D-dimer concentrations normally rise in pregnancy regardless of whether thrombosis has occurred, making abnormal results ‘incredibly unreliable’. Another recommendation included in the RACP’s top five low value practices and interventions is to not test for inherited thrombophilia in women who have a history of placenta-mediated complications of pregnancy such as stillbirth, recurrent miscarriages or placental abruption. The rationale behind the recommendation is that while some older, retrospective studies had suggested there might be an association with an inherited clotting disorder and these complications, more recent and more robust evidence has shown there is no link and what’s more, taking low molecular weight heparin is not useful as a preventive measure. The experts also advise not to do repeat tests for proteinuria in women with established  pre-eclampsia. Even though proteinuria is an important diagnostic marker for pre-eclampsia it is has no prognostic value. The level of the proteinuria does not correlate with the severity of the maternal complications, so repeated testing does not help management. MTHFR testing has become popular in certain, mainly allied health circles and is controversial. SOMANZ has made a strong recommendation to not undertake MTHFR polymorphism tests as part of a routine evaluation for thrombophilia in pregnancy. “Patients with the thermolabile variant of the methylenetetrahydrofolate reductase (MTHFR) polymorphism are at higher risk of hyperhomocysteinaemia which has been associated with venous thrombosis. However, these associations appear to hold only in countries lacking grain products nutritionally fortified as a public health measure.” They also say testing may lead to many anxiety-provoking false positives, as up to 15% of the population have homozygous variants, which in most instances appear to have no deleterious effects. The final test on the list is the erythrocyte sedimentation rate. The experts advise do not measure ESR in pregnancy as the levels can vary widely depending on factors such as gestational age and haemoglobin concentrations and therefore the test cannot reliably distinguish between healthy and unhealthy women in pregnancy. The list is the latest publication put out as part of the physician-led Evolve initiative run by the RACP. The aim of the initiative is to help ensure high quality patient care by identifying those practices and interventions that represent poor value to patients in terms of improving their clinical outcome and may even cause harm. According to the media release there are now 17 Evolve lists that have been published across a range of medical specialties, and there are another 15 in development. Ref: https://evolve.edu.au/published-lists/society-of-obstetric-medicine-of-australia-and-new-zealand

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Poo Transplants Beat Antibiotics

Faecal transplantation has been gaining momentum as a mainstream treatment over recent years, but now a systematic review published in the MJA puts it ahead of antibiotics in effectiveness against Clostridium difficile-associated diarrhoea. The literature search examined all the randomised controlled trials on the topic up until February this year, including some recently published studies, and concluded there was moderate quality evidence that faecal microbiota transplantation is more effective in patients with Clostridium difficile-associated diarrhoea than either vancomycin or placebo. The review also found that samples that had been frozen and then thawed prior to transplantation were as effective as fresh samples. “Our systematic review also highlights the fact that frozen/thawed transplants – a more convenient approach that reduces the burden on a donor to supply a sample on the day it is needed – is as effective as fresh [faecal microbiota transplant],” the authors said. However, there was less clarity about the optimal method of administering the transplanted microbiota. “Our analysis indicates that naso-duodenal and colonoscopic application may be more effective than retention enemas, but this conclusion relies on indirect comparisons of subgroups,” they concluded suggesting that further research was needed to determine the best route of administration. There also needs to be more evidence into the most appropriate donor – whether they should be related, unrelated or anonymous, or whether ‘pooling stool from several donors’ would be the best way to go. “Over the past 20 years the worldwide incidence of [Clostridium difficile-associated diarrhoea] has more than doubled, and outbreaks have been associated with greater morbidity and mortality, although to a lesser extent in Australia,” the study authors said. Even though recent guidelines from Europe and North America now recommend these transplants to treat antibiotic-resistant Clostridium difficile-associated diarrhoea, the international authors of the review said these recommendations were based on relatively poor evidence. It is expected this systematic review that includes more scientifically robust clinical trials will inform future guidelines on the topic, particularly in Australia and New Zealand whose guidelines on treating Clostridium difficile-associated diarrhoea currently need updating. Ref: doi: 10.5694/mja17.00295

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Rectal Exams Still Important – Sorry

Most GPs of a certain vintage would have heard the old adage “if you don’t put your finger in, you put your foot in.” It refers of course to the digital rectal examination and its importance as part of a thorough physical examination especially when symptoms indicate some potential pathology in that area. However it would be fair to say that most doctors, let alone patients are not particularly enthusiastic about this particular test. Indeed you could almost hear the collective sigh of relief when the authoritative guidelines suggested regular DRE was not useful as a means of screening for prostate cancer. The downside of this change in recommendation and general avoidance behaviour is that one can become deskilled in this examination, potentially missing an opportunity to diagnose a variety of conditions from prostate abnormalities to cancer. In the latest MJA, Dr Christopher Pokorny from the South Western Sydney Medical School at UNSW gives a synopsis of indications for DRE and a run through of the appropriate technique. “About 25% of colorectal cancers occur in the rectum and up to half can be palpated, but accuracy depends on training, experience, examination technique and the length of the examining finger,” Dr Pokorny writes. His list of indications for the procedure include the more obvious symptoms such as PR bleeding or mucus, change in bowel habit and prostatic symptoms but also a history of faecal urgency, difficult defaecation, faecal incontinence and anorectal pain (with the caveat that DRE should be avoided if there is an obvious anal fissure). Placing the patient in the left lateral position for the procedure is recommended with the patient drawing their knees to their chest and assuming that the patient is safe from falling off the examination couch. Assessment is made of the skin around the anus – looking for fissures, fistulae, skin tags, skin diseases such as warts or psoriasis, abscesses and haemorrhoids. The well-lubricated, gloved finger is then gently inserted, rotated in a clockwise direction into the rectum. Dr Pokorny suggests a systematic examination of the rectal mucosa anteriorly, posteriorly and laterally for masses that should be described as soft, hard, irregular or smooth. Prostatic abnormalities in men and ovarian or uterine abnormalities in women may be noted being careful not to confuse a palpable cervix in a woman with a mass. Finally, the doctor needs to check for any blood, including malaena on the glove. Dr Pokorny does concede the value of this examination is limited by the body habitus of the patient, and the length of the examiner’s fingers. Nonetheless, it is unwise to miss this diagnostic opportunity in general practice. “DRE is an often neglected but important part of the physical examination and should be performed whenever symptoms suggest anorectal or prostatic pathology,” he concludes. MJA doi:10.5694/mja17.00373

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Zika Now In Fiji

In what could represent a major blow to tourism in the region, the US Centers for Disease Control have, this week, issued a level 2 warning that mosquitoes in Fiji have been found to be infected with Zika virus and have transmitted the infection to humans. Because of the strong link between Zika virus infection and severe birth defects, the CDC is strongly advising against women who are pregnant or who are even planning on becoming pregnant travelling to the area. And as the virus can also be transmitted through the sex, the advice for pregnant women whose partner has travelled to Fiji is to use condoms or refrain from sex for the duration of the pregnancy. The warning also signals an alert for Australian doctors to consider Zika virus in patients who present with symptoms such as fever, rash and headache following travel to Fiji. However, one of the major problems in curtailing the spread of this virus has been the fact that infected adults may display very few if any symptoms and maybe unaware that have contracted the disease. What’s more an infected male can harbour the Zika virus in his semen for much longer than in other bodily fluids, so the CDC recommends that men travelling to a Zika-prone country, that now includes Fiji, avoid conceiving a child for six months after leaving the area or from the time they develop symptoms if they indeed do develop symptoms. Women clear the virus more quickly and therefore the recommendation from the CDC is that they avoid falling pregnant two months after potential exposure or from when symptoms appear, assuming their partner did not travel. For those people, including pregnant women who can’t avoid travel Fiji or other Zika-prone area, the CDC advises they take precautions to avoid mosquito bites and continue these precautions for three weeks after returning home. These include the use of specific insect repellents and the wearing of long-sleeved clothing. Ref: https://wwwnc.cdc.gov/travel/notices/alert/zika-virus-fiji

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Could It Be Endometriosis?

Endometriosis, or more particularly diagnosis of endometriosis is often a challenge in general practice. When should you start investigating a young girl with painful periods? Is it worth investigating or should we just put them on the Pill? At what point should these young women be referred? Consequently, the most recent NICE guidelines on the diagnosis and management of endometriosis, published in the BMJ will be of interest to any GP who manages young women. According to the UK guidelines, there is commonly a delay of up to 10 years between the development of symptoms and the diagnosis of endometriosis, despite the condition affecting an estimated 10% of women in the reproductive age group. Endometriosis should be suspected in women who have one or more of the following symptoms:
  • chronic pelvic pain
  • period pain that is severe enough to affect their activities
  • deep pain associated with or just after sex
  • period-related bowel symptoms such as painful bowel movements
  • period-related urinary symptoms such as dysuria or even haematuria
Sometimes it can be worthwhile to get the patient to keep a symptom diary especially if they are unsure if their symptoms are indeed cyclical. Women who present with infertility and a history of one or more of these symptoms should also be suspected as having endometriosis.

Investigations

With regard investigations, the guidelines importantly state that endometriosis cannot be ruled out by a normal examination and pelvic ultrasound. Nonetheless after abdominal and pelvic examination, transvaginal ultrasound should be the first investigation to identify endometriomas and deep endometriosis that has affected other organs such as the bowel or bladder. Transabdominal ultrasounds are a worthwhile alternative in women for whom a transvaginal ultrasound is not appropriate. MRI might be appropriate as a second line investigation but only to determine the extent of the disease. It should not be used for initial diagnosis. Similarly, the serum CA-125 is an inappropriate and unreliable diagnostic test. Diagnostic laparoscopy is reserved for women with suspected endometriosis who have a normal ultrasound.

Treatment

If the symptoms of endometriosis can’t be adequately controlled with analgesia, the guidelines recommend hormonal treatment with either the combined oral contraceptive pill or progestogen. Women need to be aware that this will reduce pain and will have no permanent negative effect on fertility. Surgical options to treat endometriosis need to be considered in women whose symptoms remain intolerable despite hormonal treatment, if the endometriosis is extensive involving other organs or if fertility is a priority and it is suspected that the endometriosis might be affecting the woman’s ability to fall pregnant. All in all, these guidelines from the Royal College of Obstetricians and Gynaecologists don’t offer much in the way of new treatments but they do provide a framework to help GPs manage suspected cases of endometriosis and hopefully reduce that time delay between symptom-onset and diagnosis. BMJ 2017; 358: j3935 doi: 10.1136/bmj.j3935
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How long do anxiety patients need medication?

It is well-known that when a patient with depression is commenced on antidepressants and they are effective, they should continue them for at least a year to lower their risk of relapse. The guidelines are pretty consistent on that point. But what about anxiety disorders? Along with cognitive behavioural therapy, antidepressants are considered a first-line option for treating anxiety conditions such as generalised anxiety disorder, obsessive-compulsive disorder and post-traumatic disorder. Antidepressants have been shown to generally effective and well-tolerated in treating these illnesses. But how long should they be used in order to improve long-term prognosis? Internationally, guidelines vary in their recommendations. If the treatment is effective the advice has been to continue treatment for variable durations (six to 24 months) and then taper the antidepressant, but this has been based on scant evidence. To clarify this recommendation, Dutch researchers conducted a meta-analysis of 28 relapse prevention trials in patients with remitted anxiety disorders. Their findings, recently published in the BMJ, support the continuation of pharmacotherapy. “We have shown a clear benefit of continuing treatment compared with discontinuation for both relapse… and time to relapse”, the authors stated. In addition, the researchers found the relapse risk was not significantly influenced by the type of anxiety disorder, whether the antidepressant was tapered or stopped abruptly or whether the patient was receiving concurrent psychotherapy However, because of the duration of the studies included in the meta-analysis, only the advice to continue antidepressants for at least a year could be supported by evidence. After this, the researchers said there was no evidence-based advice that could be given. “[However] the lack of evidence after this period should not be interpreted as explicit advice to discontinue antidepressants after one year,” they said. The researchers suggested that those guidelines that advise antidepressant should be tapered after the patient has achieved a sustained remission should be revised. In fact, they said, there were both advantages and disadvantages to continuing treatment beyond a year, and more research was needed to help clinicians assess an individual’s risk of relapse. This is especially important as anxiety disorders are generally chronic and there have been indications that in some patients, the antidepressant therapy is less effective when reinstated after a relapse. “When deciding to continue or discontinue antidepressants in individual patients, the relapse risk should be considered in relation to side effects and the patient’s preferences,” they concluded. Ref: BMJ 2017;358:j392 doi:10.1136/bmj:j3927

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Obesity Surgery – Worth The Money

For most patients in Australia, obesity surgery is an expensive exercise. The surgery alone is likely to see you out of pocket to the tune of several thousand at least. And then there’s the time off work, specialist appointments, follow-up etc etc. So you can understand patients being hesitant about the prospect. And then there’s the worry about effectiveness. Will it work? And if so for how long? Well, new research, published in The New England Journal of Medicine goes a long way to alleviating those fears. The prospective US study, showed that not only did more than 400 severely obese patients who underwent gastric bypass surgery lose a significant amount of weight but that weight loss and the health benefits obtained because of it, were sustained 12 years later. Two years after undergoing the Roux-en-Y surgery, these patients had lost an average of 45kg. Over the following decade there was some weight gain, but at the end of the 12 years the average weight loss from baseline was still a massive 35kg. The impressiveness of this statistic is put into perspective by researchers who compared this cohort with a similar number of severely obese people who had sought but did not undergo gastric bypass. Over the duration of the study this group lost an average of only 2.9kg. And another group, also obese patients who had not sought surgery lost no weight at all on average over this time period. What is even more significant is the difference in morbidity associated with the surgery. The researchers found that of the patients who had type 2 diabetes at baseline, 75% no longer had the disease at two years. And despite the progressive nature of type 2 diabetes, 51% were still diabetes-free at 12 years. In addition, the surgery group had higher remission rates and lower incidence rates of hypertension and lipid disorders. “This study showed long-term durability of weight loss and effective remission and prevention of type 2 diabetes, hypertension and dyslipidaemia after Roux-en-Y gastric bypass,” the study authors concluded. Even though this surgery is done less commonly in Australia than laparoscopic procedures, the reality is that bariatric surgery, for the most part represents enormous value for severely obese patients. The dramatic results and the significant health benefits will no doubt increase pressure on the government and private health insurers to improve access to what could well be described as life-changing surgery. Ref: NEJM 2017; 377: 1143-1155. DOI: 10.1056/NEJMoa1700459

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PPIs for infant reflux a risk

It seemed such a godsend, didn’t it? Omeprazole for severe infant reflux. A massive improvement on the previous advice to elevate the head of the cot and nurse upright. But since it first appeared in guidelines, there have been studies, reports and opinions cautioning against the overuse of PPIs citing everything from them being ineffectual to their potential to predispose the child to allergy. Now it looks like there is yet another reason why we need to think again before prescribing a PPI for the distressed infant with reflux and their exhausted parents. According to an article recently appearing in a JAMA network publication, recent study findings cast more doubt on the safety of this treatment option, suggesting that giving PPIs to infants less than six months of age is associated with a higher risk of bone fractures later in childhood. The US researchers analysed data, including pharmacy outpatient data from over 850,000 children born within the Military Health Care System over a 12 year period. According to findings presented at a Pediatric Academic Societies Meeting earlier this year, children given a PPI in the first six months of their life had a 22% increased risk of fracture in the following 5-6 years. And if, for some reason they were also given a H2 blocker the risk jumped to 31%. Interestingly if they only received the H2 blocker there was no significant increase in fracture risk. The study also showed the longer the duration of PPI use the greater the risk of fracture. It is thought that the mechanism behind the increased fracture risk relates to the PPI-induced decrease in gastric acid causing a reduction in calcium absorption. While the study is still going through the process of peer-review and is yet to be published, the study’s lead author, US Air Force Capt Laura Malchodi (MD) said the findings suggest increased caution should be exercised with regard these drugs. “Our study adds to the growing body of evidence suggesting [acid-reducing] medications are not safe for children, especially very young children,” she told delegates. “[PPIs] should only be prescribed to treat confirmed serious cases of more severe, symptomatic, gastroesophageal reflux disease (GERD), and for the shortest length of time needed.” Ref: JAMA published online Sept 29, 2017. Doi:10.1001/jama.2017.12160

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If In Doubt Cut It Out

New guidelines suggest excising a changing skin lesion after one month As with facing an exam where you haven’t studied, or finding yourself naked in a public place – missing a melanoma diagnosis is the stuff of nightmares for most GPs. In a condition where the prognosis can vary dramatically according to a fraction of a millimetre, the importance of early detection is well-known and keenly felt by clinicians. According to new guidelines published in the MJA, Australian doctors’ ability to detect classical melanomas early has been improving as evidenced by both the average thickness of the tumour when it is excised and the improved mortality rates associated with these types of tumours. Unfortunately, however the atypical melanomas are still proving a challenge. Whether they be nodular, occurring in an unusual site or lacking the classic pigmentation, atypical melanomas are still not being excised until they are significantly more advanced and consequently the prognosis associated with these lesions remains poor. As a result, a Cancer Council working group have revised the clinical guidelines on melanoma, in particular focusing on atypical presentations. The upshot of their advice? If a patient presents with any skin lesion that has been changing or growing over the course of a month, that lesion should be excised. The Australian guideline authors suggest that in addition to assessing lesions according to the ABCD criteria (asymmetry, border irregularity, colour variegation, and diameter >6mm) we should add EFG (elevated, firm and growing) as independent indicators of possible melanoma. “Any lesion that is elevated, firm and growing over a period of more than one month should be excised or referred for prompt expert opinion,” they wrote. In their article, the working group do acknowledge that it is not always a delayed diagnosis that is to blame for atypical melanomas being commonly more advanced when excised. Some of these tumours, such as the nodular and desmoplastic subtypes can grow very rapidly. “These subtypes are more common on chronically sun-damaged skin, typically on the head and neck and predominantly in older men,” the authors said. However, the most important common denominator with melanomas is that they are changing, they concluded. A history of change, preferably with some documentation of that change such as photographic evidence should be enough to raise the treating doctor’s index of suspicion. “Suspicious raised lesions should be excised rather than monitored,” they concluded. Ref: MJA Online 9.10.17 doi:10.5694/mja17.00123

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Would You Pick This Diagnosis?

A case history recently published in the BMJ highlights one of those uncommon but very diagnoseable conditions if you just spot the clues. According to the French authors, the 62 year old man presented with a history of recurrent oral ulcers sometimes accompanied by laryngitis and conjunctivitis. During one of these episodes he had developed an acute fever, a sore throat when swallowing and laryngitis – he had sought medical attention and was prescribed ibuprofen and clarithromycin. Two days after this, the man developed conjunctivitis, erosions in the mucosal membrane in the mouth and skin lesions. Not unsurprisingly, the man’s attending doctors though he had Stevens-Johnson syndrome and sent him to hospital. Full examination showed painful diffuse erosions of mucous membranes not only of the oral cavity but also of the nose, the epiglottis and the glans. The skin lesions were noted to be target lesions involving three raised concentric red rings and they were found on the trunk, lower limbs and scrotum. He was febrile, fatigued and eating was painful. Diagnostic tests showed a raised CRP but little else. The skin biopsy showed a dense lichenoid lymphocytic infiltrate. So did he have Stevens-Johnson syndrome? Apparently not. The target lesions with their three concentric rings and the widespread oral, ocular and genital mucous membrane erosions are in fact suggestive of erythema multiforme, and specifically because of the fact more than one mucous membrane was involved, the more severe type of erythema multiforme – erythema multiforme major. The authors did concede that erythema multiforme is frequently confused with Stevens-Johnson syndrome, and even toxic epidermal necrolysis (TEN), which are life-threatening conditions. The features that helped distinguish this as a case of erythema multiforme rather than the other more serious alternatives were:
    • the previous episodes of oral ulcers, sometimes with laryngitis and conjunctivitis. Even though erythema multiforme is rare, of the people who do get it some 40% experience multiple recurrences often triggered by the herpes simplex virus.
    • erythema multiforme is generally a post-infectious disease most commonly herpes simplex (which was tricky in this case as viral cultures from the patient’s mouth were negative) whereas 85% of Stevens-Johnson syndrome and toxic epidermal necrolysis cases are drug-induced.
    • erythema multiforme usually begins with systemic symptoms such as fever and then mucosal involvement. The skin lesions typically appear later. In Stevens-Johnson syndrome and toxic epidermal necrolysis the severe cutaneous reaction is usually the first sign of the condition occurring four to 28 days after taking the offending drug.
    • finally the skin lesions are different. As in this case, the typical skin lesions of erythema multiforme are three raised concentric rings that usually respond to topical steroids and oral antihistamines. In Stevens-Johnson syndrome and toxic epidermal necrolysis the lesions are ‘atypical targets with two concentric rings and purpuric macules that evolve into blisters and skin that detaches with finger friction (Nikolsky sign).’
And what happened to this patient? According to the case report, he wound up staying eight days in hospital treated with enteral nutrition, topical steroids and steroid mouthwashes. All the skin and mucosal membrane lesions healed and he fully recovered. Interestingly, he did have minor relapses annually for a number of years but these weren’t severe enough to warrant any further treatment. Ref: BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j3817

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Self-Harm On The Increase Among Young Girls

Self-harm among teenagers is on the increase, a new study confirms and frighteningly it’s our younger girls that appear most at risk. According to a population-based, UK study the annual incidence of self-harm increased by an incredible 68% between 2011 and 2014 among girls aged 13-16, from 46 per 10000 to 77 per 10000. The research, based on analysis of electronic health records from over 670 general practices, also found that girls were three times more likely to self-harm than boys among the almost 17,000 young people (aged 10-19 years) studied. The importance of identifying these patients and implementing effective interventions was highlighted by the other major finding of this study. “Children and adolescents who harmed themselves were approximately nine times more likely to die unnaturally during follow-up, with especially noticeable increases in risks of suicide…, and fatal acute alcohol and drug poisoning,” the BMJ study authors said. And if you were to think this might be a problem unique to the UK, the researchers, in their article actually referred to an Australian population based cohort study published five years ago that found that 8% of adolescents aged less than 20 years reported harming themselves at some time. The UK study also showed that the likelihood of referral was lowest in areas that were the most deprived, even though these were the areas where the incidence was highest, an example of the ‘inverse care law’ where the people in most need get the least care. While the link between social deprivation and self-harm might be understandable, researchers were at a loss to explain the recent sharp increase in incidence among the young 13-16 year old girls in particular. What they could say is that by analysing general practice data rather than inpatient hospital data, an additional 50% of self-harm episodes in children and adolescents were identified. In short, it is much more likely a self-harming teenager will engage with their GP rather than appear at a hospital service. And even though, as the study authors concede there is little evidence to guide the most effective way to manage these children and adolescents, the need for GPs to identify these patients and intervene early is imperative. “The increased risks of all cause and cause-specific mortality observed emphasise the urgent need for integrated care involving families, schools, and healthcare provision to enhance safety among these distressed young people in the short term, and to help secure their future mental health and wellbeing,” they concluded. BMJ 2017; 359:j4351 doi: 10.1136/bmj.j4351

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PPIs Increase Risk Of Stomach Cancer

Looks like there is yet another reason to rethink the long-term use of proton pump inhibitors. And this one is a doozy. According to a new study, recently published in the BMJ journal, Gut, the long-term use of PPIs is linked to a more than doubling of the risk of developing stomach cancer. And before you jump to the reasonable conclusion that these patients might have had untreated Helicobacter Pylori, this 2.4 fold increase in gastric cancer risk occurred in patients who had had H.pylori but had been successfully treated more than 12 months previously. What’s more, the risk increased proportionally with the duration of PPI use and the dose, which the Hong Kong authors said suggested a cause-effect relationship. No such increased risk was found among those patients who took H2 receptor antagonists. While the study was observational, the large sample size (more than 63,000 patients with a history of effective H.pylori treatment) and the relatively long duration of follow-up (median 7.6 years) lent validity to the findings. The link between H.pylori and gastric cancer, has been known for decades. It has been shown that eradicating H.pylori reduces the risk of developing gastric cancer by 33-47%. However, the study authors said, it is also known that a considerable proportion of these individuals go on to develop gastric cancer even after they have successfully eradicated the bacteria. “To our knowledge, this is the first study to demonstrate that long-term PPI use, even after H. pylori eradication therapy, is still associated with an increased risk of gastric cancer,” they said. By way of explanation, the researchers note that gastric atrophy is considered a precursor to gastric cancer. And while gastric atrophy is a known sequela of chronic H. pylori infection, it could also be worsened and maintained by the profound acid suppression associated with PPI use and this could be why the risk persisted even after the infection had been treated. Bottom line? According to the study authors, doctors need to ‘exercise caution when prescribing long-term PPIs to these patients even after successful eradication of H. pylori.’ Ref: Gut 2017; 0:1-8. Doi:10.1136/gutjnl-2017-314605

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Do Not Order These Tests On Pregnant Women

Hot on the heels of the Choosing Wisely campaign of “do nots” for GPs, the Royal Australasian College of Physicians has released a new list of tests doctors should avoid ordering on pregnant women. The recommendations come from the Society of Obstetric Medicine in Australia and New Zealand (SOMANZ), and include the advice that the D-dimer test should not be used to diagnose venous thromboembolism in pregnant women as it is unreliable. Even though women are five times more likely to develop venous thromboembolism in pregnancy, other investigative tests should be used if a clot is suspected as D-dimer concentrations normally rise in pregnancy regardless of whether thrombosis has occurred, making abnormal results ‘incredibly unreliable’. Another recommendation included in the RACP’s top five low value practices and interventions is to not test for inherited thrombophilia in women who have a history of placenta-mediated complications of pregnancy such as stillbirth, recurrent miscarriages or placental abruption. The rationale behind the recommendation is that while some older, retrospective studies had suggested there might be an association with an inherited clotting disorder and these complications, more recent and more robust evidence has shown there is no link and what’s more, taking low molecular weight heparin is not useful as a preventive measure. The experts also advise not to do repeat tests for proteinuria in women with established  pre-eclampsia. Even though proteinuria is an important diagnostic marker for pre-eclampsia it is has no prognostic value. The level of the proteinuria does not correlate with the severity of the maternal complications, so repeated testing does not help management. MTHFR testing has become popular in certain, mainly allied health circles and is controversial. SOMANZ has made a strong recommendation to not undertake MTHFR polymorphism tests as part of a routine evaluation for thrombophilia in pregnancy. “Patients with the thermolabile variant of the methylenetetrahydrofolate reductase (MTHFR) polymorphism are at higher risk of hyperhomocysteinaemia which has been associated with venous thrombosis. However, these associations appear to hold only in countries lacking grain products nutritionally fortified as a public health measure.” They also say testing may lead to many anxiety-provoking false positives, as up to 15% of the population have homozygous variants, which in most instances appear to have no deleterious effects. The final test on the list is the erythrocyte sedimentation rate. The experts advise do not measure ESR in pregnancy as the levels can vary widely depending on factors such as gestational age and haemoglobin concentrations and therefore the test cannot reliably distinguish between healthy and unhealthy women in pregnancy. The list is the latest publication put out as part of the physician-led Evolve initiative run by the RACP. The aim of the initiative is to help ensure high quality patient care by identifying those practices and interventions that represent poor value to patients in terms of improving their clinical outcome and may even cause harm. According to the media release there are now 17 Evolve lists that have been published across a range of medical specialties, and there are another 15 in development. Ref: https://evolve.edu.au/published-lists/society-of-obstetric-medicine-of-australia-and-new-zealand

By Dr Linda Calabresi
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Poo Transplants Beat Antibiotics

Faecal transplantation has been gaining momentum as a mainstream treatment over recent years, but now a systematic review published in the MJA puts it ahead of antibiotics in effectiveness against Clostridium difficile-associated diarrhoea. The literature search examined all the randomised controlled trials on the topic up until February this year, including some recently published studies, and concluded there was moderate quality evidence that faecal microbiota transplantation is more effective in patients with Clostridium difficile-associated diarrhoea than either vancomycin or placebo. The review also found that samples that had been frozen and then thawed prior to transplantation were as effective as fresh samples. “Our systematic review also highlights the fact that frozen/thawed transplants – a more convenient approach that reduces the burden on a donor to supply a sample on the day it is needed – is as effective as fresh [faecal microbiota transplant],” the authors said. However, there was less clarity about the optimal method of administering the transplanted microbiota. “Our analysis indicates that naso-duodenal and colonoscopic application may be more effective than retention enemas, but this conclusion relies on indirect comparisons of subgroups,” they concluded suggesting that further research was needed to determine the best route of administration. There also needs to be more evidence into the most appropriate donor – whether they should be related, unrelated or anonymous, or whether ‘pooling stool from several donors’ would be the best way to go. “Over the past 20 years the worldwide incidence of [Clostridium difficile-associated diarrhoea] has more than doubled, and outbreaks have been associated with greater morbidity and mortality, although to a lesser extent in Australia,” the study authors said. Even though recent guidelines from Europe and North America now recommend these transplants to treat antibiotic-resistant Clostridium difficile-associated diarrhoea, the international authors of the review said these recommendations were based on relatively poor evidence. It is expected this systematic review that includes more scientifically robust clinical trials will inform future guidelines on the topic, particularly in Australia and New Zealand whose guidelines on treating Clostridium difficile-associated diarrhoea currently need updating. Ref: doi: 10.5694/mja17.00295

By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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Rectal Exams Still Important – Sorry

Most GPs of a certain vintage would have heard the old adage “if you don’t put your finger in, you put your foot in.” It refers of course to the digital rectal examination and its importance as part of a thorough physical examination especially when symptoms indicate some potential pathology in that area. However it would be fair to say that most doctors, let alone patients are not particularly enthusiastic about this particular test. Indeed you could almost hear the collective sigh of relief when the authoritative guidelines suggested regular DRE was not useful as a means of screening for prostate cancer. The downside of this change in recommendation and general avoidance behaviour is that one can become deskilled in this examination, potentially missing an opportunity to diagnose a variety of conditions from prostate abnormalities to cancer. In the latest MJA, Dr Christopher Pokorny from the South Western Sydney Medical School at UNSW gives a synopsis of indications for DRE and a run through of the appropriate technique. “About 25% of colorectal cancers occur in the rectum and up to half can be palpated, but accuracy depends on training, experience, examination technique and the length of the examining finger,” Dr Pokorny writes. His list of indications for the procedure include the more obvious symptoms such as PR bleeding or mucus, change in bowel habit and prostatic symptoms but also a history of faecal urgency, difficult defaecation, faecal incontinence and anorectal pain (with the caveat that DRE should be avoided if there is an obvious anal fissure). Placing the patient in the left lateral position for the procedure is recommended with the patient drawing their knees to their chest and assuming that the patient is safe from falling off the examination couch. Assessment is made of the skin around the anus – looking for fissures, fistulae, skin tags, skin diseases such as warts or psoriasis, abscesses and haemorrhoids. The well-lubricated, gloved finger is then gently inserted, rotated in a clockwise direction into the rectum. Dr Pokorny suggests a systematic examination of the rectal mucosa anteriorly, posteriorly and laterally for masses that should be described as soft, hard, irregular or smooth. Prostatic abnormalities in men and ovarian or uterine abnormalities in women may be noted being careful not to confuse a palpable cervix in a woman with a mass. Finally, the doctor needs to check for any blood, including malaena on the glove. Dr Pokorny does concede the value of this examination is limited by the body habitus of the patient, and the length of the examiner’s fingers. Nonetheless, it is unwise to miss this diagnostic opportunity in general practice. “DRE is an often neglected but important part of the physical examination and should be performed whenever symptoms suggest anorectal or prostatic pathology,” he concludes. MJA doi:10.5694/mja17.00373

By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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Zika Now In Fiji

In what could represent a major blow to tourism in the region, the US Centers for Disease Control have, this week, issued a level 2 warning that mosquitoes in Fiji have been found to be infected with Zika virus and have transmitted the infection to humans. Because of the strong link between Zika virus infection and severe birth defects, the CDC is strongly advising against women who are pregnant or who are even planning on becoming pregnant travelling to the area. And as the virus can also be transmitted through the sex, the advice for pregnant women whose partner has travelled to Fiji is to use condoms or refrain from sex for the duration of the pregnancy. The warning also signals an alert for Australian doctors to consider Zika virus in patients who present with symptoms such as fever, rash and headache following travel to Fiji. However, one of the major problems in curtailing the spread of this virus has been the fact that infected adults may display very few if any symptoms and maybe unaware that have contracted the disease. What’s more an infected male can harbour the Zika virus in his semen for much longer than in other bodily fluids, so the CDC recommends that men travelling to a Zika-prone country, that now includes Fiji, avoid conceiving a child for six months after leaving the area or from the time they develop symptoms if they indeed do develop symptoms. Women clear the virus more quickly and therefore the recommendation from the CDC is that they avoid falling pregnant two months after potential exposure or from when symptoms appear, assuming their partner did not travel. For those people, including pregnant women who can’t avoid travel Fiji or other Zika-prone area, the CDC advises they take precautions to avoid mosquito bites and continue these precautions for three weeks after returning home. These include the use of specific insect repellents and the wearing of long-sleeved clothing. Ref: https://wwwnc.cdc.gov/travel/notices/alert/zika-virus-fiji

By Dr Linda Calabresi
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Could It Be Endometriosis?

Endometriosis, or more particularly diagnosis of endometriosis is often a challenge in general practice. When should you start investigating a young girl with painful periods? Is it worth investigating or should we just put them on the Pill? At what point should these young women be referred? Consequently, the most recent NICE guidelines on the diagnosis and management of endometriosis, published in the BMJ will be of interest to any GP who manages young women. According to the UK guidelines, there is commonly a delay of up to 10 years between the development of symptoms and the diagnosis of endometriosis, despite the condition affecting an estimated 10% of women in the reproductive age group. Endometriosis should be suspected in women who have one or more of the following symptoms:
  • chronic pelvic pain
  • period pain that is severe enough to affect their activities
  • deep pain associated with or just after sex
  • period-related bowel symptoms such as painful bowel movements
  • period-related urinary symptoms such as dysuria or even haematuria
Sometimes it can be worthwhile to get the patient to keep a symptom diary especially if they are unsure if their symptoms are indeed cyclical. Women who present with infertility and a history of one or more of these symptoms should also be suspected as having endometriosis.

Investigations

With regard investigations, the guidelines importantly state that endometriosis cannot be ruled out by a normal examination and pelvic ultrasound. Nonetheless after abdominal and pelvic examination, transvaginal ultrasound should be the first investigation to identify endometriomas and deep endometriosis that has affected other organs such as the bowel or bladder. Transabdominal ultrasounds are a worthwhile alternative in women for whom a transvaginal ultrasound is not appropriate. MRI might be appropriate as a second line investigation but only to determine the extent of the disease. It should not be used for initial diagnosis. Similarly, the serum CA-125 is an inappropriate and unreliable diagnostic test. Diagnostic laparoscopy is reserved for women with suspected endometriosis who have a normal ultrasound.

Treatment

If the symptoms of endometriosis can’t be adequately controlled with analgesia, the guidelines recommend hormonal treatment with either the combined oral contraceptive pill or progestogen. Women need to be aware that this will reduce pain and will have no permanent negative effect on fertility. Surgical options to treat endometriosis need to be considered in women whose symptoms remain intolerable despite hormonal treatment, if the endometriosis is extensive involving other organs or if fertility is a priority and it is suspected that the endometriosis might be affecting the woman’s ability to fall pregnant. All in all, these guidelines from the Royal College of Obstetricians and Gynaecologists don’t offer much in the way of new treatments but they do provide a framework to help GPs manage suspected cases of endometriosis and hopefully reduce that time delay between symptom-onset and diagnosis. BMJ 2017; 358: j3935 doi: 10.1136/bmj.j3935
By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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How long do anxiety patients need medication?

It is well-known that when a patient with depression is commenced on antidepressants and they are effective, they should continue them for at least a year to lower their risk of relapse. The guidelines are pretty consistent on that point. But what about anxiety disorders? Along with cognitive behavioural therapy, antidepressants are considered a first-line option for treating anxiety conditions such as generalised anxiety disorder, obsessive-compulsive disorder and post-traumatic disorder. Antidepressants have been shown to generally effective and well-tolerated in treating these illnesses. But how long should they be used in order to improve long-term prognosis? Internationally, guidelines vary in their recommendations. If the treatment is effective the advice has been to continue treatment for variable durations (six to 24 months) and then taper the antidepressant, but this has been based on scant evidence. To clarify this recommendation, Dutch researchers conducted a meta-analysis of 28 relapse prevention trials in patients with remitted anxiety disorders. Their findings, recently published in the BMJ, support the continuation of pharmacotherapy. “We have shown a clear benefit of continuing treatment compared with discontinuation for both relapse… and time to relapse”, the authors stated. In addition, the researchers found the relapse risk was not significantly influenced by the type of anxiety disorder, whether the antidepressant was tapered or stopped abruptly or whether the patient was receiving concurrent psychotherapy However, because of the duration of the studies included in the meta-analysis, only the advice to continue antidepressants for at least a year could be supported by evidence. After this, the researchers said there was no evidence-based advice that could be given. “[However] the lack of evidence after this period should not be interpreted as explicit advice to discontinue antidepressants after one year,” they said. The researchers suggested that those guidelines that advise antidepressant should be tapered after the patient has achieved a sustained remission should be revised. In fact, they said, there were both advantages and disadvantages to continuing treatment beyond a year, and more research was needed to help clinicians assess an individual’s risk of relapse. This is especially important as anxiety disorders are generally chronic and there have been indications that in some patients, the antidepressant therapy is less effective when reinstated after a relapse. “When deciding to continue or discontinue antidepressants in individual patients, the relapse risk should be considered in relation to side effects and the patient’s preferences,” they concluded. Ref: BMJ 2017;358:j392 doi:10.1136/bmj:j3927

By Dr Linda Calabresi
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Obesity Surgery – Worth The Money

For most patients in Australia, obesity surgery is an expensive exercise. The surgery alone is likely to see you out of pocket to the tune of several thousand at least. And then there’s the time off work, specialist appointments, follow-up etc etc. So you can understand patients being hesitant about the prospect. And then there’s the worry about effectiveness. Will it work? And if so for how long? Well, new research, published in The New England Journal of Medicine goes a long way to alleviating those fears. The prospective US study, showed that not only did more than 400 severely obese patients who underwent gastric bypass surgery lose a significant amount of weight but that weight loss and the health benefits obtained because of it, were sustained 12 years later. Two years after undergoing the Roux-en-Y surgery, these patients had lost an average of 45kg. Over the following decade there was some weight gain, but at the end of the 12 years the average weight loss from baseline was still a massive 35kg. The impressiveness of this statistic is put into perspective by researchers who compared this cohort with a similar number of severely obese people who had sought but did not undergo gastric bypass. Over the duration of the study this group lost an average of only 2.9kg. And another group, also obese patients who had not sought surgery lost no weight at all on average over this time period. What is even more significant is the difference in morbidity associated with the surgery. The researchers found that of the patients who had type 2 diabetes at baseline, 75% no longer had the disease at two years. And despite the progressive nature of type 2 diabetes, 51% were still diabetes-free at 12 years. In addition, the surgery group had higher remission rates and lower incidence rates of hypertension and lipid disorders. “This study showed long-term durability of weight loss and effective remission and prevention of type 2 diabetes, hypertension and dyslipidaemia after Roux-en-Y gastric bypass,” the study authors concluded. Even though this surgery is done less commonly in Australia than laparoscopic procedures, the reality is that bariatric surgery, for the most part represents enormous value for severely obese patients. The dramatic results and the significant health benefits will no doubt increase pressure on the government and private health insurers to improve access to what could well be described as life-changing surgery. Ref: NEJM 2017; 377: 1143-1155. DOI: 10.1056/NEJMoa1700459

By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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PPIs for infant reflux a risk

It seemed such a godsend, didn’t it? Omeprazole for severe infant reflux. A massive improvement on the previous advice to elevate the head of the cot and nurse upright. But since it first appeared in guidelines, there have been studies, reports and opinions cautioning against the overuse of PPIs citing everything from them being ineffectual to their potential to predispose the child to allergy. Now it looks like there is yet another reason why we need to think again before prescribing a PPI for the distressed infant with reflux and their exhausted parents. According to an article recently appearing in a JAMA network publication, recent study findings cast more doubt on the safety of this treatment option, suggesting that giving PPIs to infants less than six months of age is associated with a higher risk of bone fractures later in childhood. The US researchers analysed data, including pharmacy outpatient data from over 850,000 children born within the Military Health Care System over a 12 year period. According to findings presented at a Pediatric Academic Societies Meeting earlier this year, children given a PPI in the first six months of their life had a 22% increased risk of fracture in the following 5-6 years. And if, for some reason they were also given a H2 blocker the risk jumped to 31%. Interestingly if they only received the H2 blocker there was no significant increase in fracture risk. The study also showed the longer the duration of PPI use the greater the risk of fracture. It is thought that the mechanism behind the increased fracture risk relates to the PPI-induced decrease in gastric acid causing a reduction in calcium absorption. While the study is still going through the process of peer-review and is yet to be published, the study’s lead author, US Air Force Capt Laura Malchodi (MD) said the findings suggest increased caution should be exercised with regard these drugs. “Our study adds to the growing body of evidence suggesting [acid-reducing] medications are not safe for children, especially very young children,” she told delegates. “[PPIs] should only be prescribed to treat confirmed serious cases of more severe, symptomatic, gastroesophageal reflux disease (GERD), and for the shortest length of time needed.” Ref: JAMA published online Sept 29, 2017. Doi:10.1001/jama.2017.12160

By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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If In Doubt Cut It Out

New guidelines suggest excising a changing skin lesion after one month As with facing an exam where you haven’t studied, or finding yourself naked in a public place – missing a melanoma diagnosis is the stuff of nightmares for most GPs. In a condition where the prognosis can vary dramatically according to a fraction of a millimetre, the importance of early detection is well-known and keenly felt by clinicians. According to new guidelines published in the MJA, Australian doctors’ ability to detect classical melanomas early has been improving as evidenced by both the average thickness of the tumour when it is excised and the improved mortality rates associated with these types of tumours. Unfortunately, however the atypical melanomas are still proving a challenge. Whether they be nodular, occurring in an unusual site or lacking the classic pigmentation, atypical melanomas are still not being excised until they are significantly more advanced and consequently the prognosis associated with these lesions remains poor. As a result, a Cancer Council working group have revised the clinical guidelines on melanoma, in particular focusing on atypical presentations. The upshot of their advice? If a patient presents with any skin lesion that has been changing or growing over the course of a month, that lesion should be excised. The Australian guideline authors suggest that in addition to assessing lesions according to the ABCD criteria (asymmetry, border irregularity, colour variegation, and diameter >6mm) we should add EFG (elevated, firm and growing) as independent indicators of possible melanoma. “Any lesion that is elevated, firm and growing over a period of more than one month should be excised or referred for prompt expert opinion,” they wrote. In their article, the working group do acknowledge that it is not always a delayed diagnosis that is to blame for atypical melanomas being commonly more advanced when excised. Some of these tumours, such as the nodular and desmoplastic subtypes can grow very rapidly. “These subtypes are more common on chronically sun-damaged skin, typically on the head and neck and predominantly in older men,” the authors said. However, the most important common denominator with melanomas is that they are changing, they concluded. A history of change, preferably with some documentation of that change such as photographic evidence should be enough to raise the treating doctor’s index of suspicion. “Suspicious raised lesions should be excised rather than monitored,” they concluded. Ref: MJA Online 9.10.17 doi:10.5694/mja17.00123

By Dr Linda Calabresi
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Would You Pick This Diagnosis?

A case history recently published in the BMJ highlights one of those uncommon but very diagnoseable conditions if you just spot the clues. According to the French authors, the 62 year old man presented with a history of recurrent oral ulcers sometimes accompanied by laryngitis and conjunctivitis. During one of these episodes he had developed an acute fever, a sore throat when swallowing and laryngitis – he had sought medical attention and was prescribed ibuprofen and clarithromycin. Two days after this, the man developed conjunctivitis, erosions in the mucosal membrane in the mouth and skin lesions. Not unsurprisingly, the man’s attending doctors though he had Stevens-Johnson syndrome and sent him to hospital. Full examination showed painful diffuse erosions of mucous membranes not only of the oral cavity but also of the nose, the epiglottis and the glans. The skin lesions were noted to be target lesions involving three raised concentric red rings and they were found on the trunk, lower limbs and scrotum. He was febrile, fatigued and eating was painful. Diagnostic tests showed a raised CRP but little else. The skin biopsy showed a dense lichenoid lymphocytic infiltrate. So did he have Stevens-Johnson syndrome? Apparently not. The target lesions with their three concentric rings and the widespread oral, ocular and genital mucous membrane erosions are in fact suggestive of erythema multiforme, and specifically because of the fact more than one mucous membrane was involved, the more severe type of erythema multiforme – erythema multiforme major. The authors did concede that erythema multiforme is frequently confused with Stevens-Johnson syndrome, and even toxic epidermal necrolysis (TEN), which are life-threatening conditions. The features that helped distinguish this as a case of erythema multiforme rather than the other more serious alternatives were:
    • the previous episodes of oral ulcers, sometimes with laryngitis and conjunctivitis. Even though erythema multiforme is rare, of the people who do get it some 40% experience multiple recurrences often triggered by the herpes simplex virus.
    • erythema multiforme is generally a post-infectious disease most commonly herpes simplex (which was tricky in this case as viral cultures from the patient’s mouth were negative) whereas 85% of Stevens-Johnson syndrome and toxic epidermal necrolysis cases are drug-induced.
    • erythema multiforme usually begins with systemic symptoms such as fever and then mucosal involvement. The skin lesions typically appear later. In Stevens-Johnson syndrome and toxic epidermal necrolysis the severe cutaneous reaction is usually the first sign of the condition occurring four to 28 days after taking the offending drug.
    • finally the skin lesions are different. As in this case, the typical skin lesions of erythema multiforme are three raised concentric rings that usually respond to topical steroids and oral antihistamines. In Stevens-Johnson syndrome and toxic epidermal necrolysis the lesions are ‘atypical targets with two concentric rings and purpuric macules that evolve into blisters and skin that detaches with finger friction (Nikolsky sign).’
And what happened to this patient? According to the case report, he wound up staying eight days in hospital treated with enteral nutrition, topical steroids and steroid mouthwashes. All the skin and mucosal membrane lesions healed and he fully recovered. Interestingly, he did have minor relapses annually for a number of years but these weren’t severe enough to warrant any further treatment. Ref: BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j3817

By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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Self-Harm On The Increase Among Young Girls

Self-harm among teenagers is on the increase, a new study confirms and frighteningly it’s our younger girls that appear most at risk. According to a population-based, UK study the annual incidence of self-harm increased by an incredible 68% between 2011 and 2014 among girls aged 13-16, from 46 per 10000 to 77 per 10000. The research, based on analysis of electronic health records from over 670 general practices, also found that girls were three times more likely to self-harm than boys among the almost 17,000 young people (aged 10-19 years) studied. The importance of identifying these patients and implementing effective interventions was highlighted by the other major finding of this study. “Children and adolescents who harmed themselves were approximately nine times more likely to die unnaturally during follow-up, with especially noticeable increases in risks of suicide…, and fatal acute alcohol and drug poisoning,” the BMJ study authors said. And if you were to think this might be a problem unique to the UK, the researchers, in their article actually referred to an Australian population based cohort study published five years ago that found that 8% of adolescents aged less than 20 years reported harming themselves at some time. The UK study also showed that the likelihood of referral was lowest in areas that were the most deprived, even though these were the areas where the incidence was highest, an example of the ‘inverse care law’ where the people in most need get the least care. While the link between social deprivation and self-harm might be understandable, researchers were at a loss to explain the recent sharp increase in incidence among the young 13-16 year old girls in particular. What they could say is that by analysing general practice data rather than inpatient hospital data, an additional 50% of self-harm episodes in children and adolescents were identified. In short, it is much more likely a self-harming teenager will engage with their GP rather than appear at a hospital service. And even though, as the study authors concede there is little evidence to guide the most effective way to manage these children and adolescents, the need for GPs to identify these patients and intervene early is imperative. “The increased risks of all cause and cause-specific mortality observed emphasise the urgent need for integrated care involving families, schools, and healthcare provision to enhance safety among these distressed young people in the short term, and to help secure their future mental health and wellbeing,” they concluded. BMJ 2017; 359:j4351 doi: 10.1136/bmj.j4351

By Dr Linda Calabresi
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PPIs Increase Risk Of Stomach Cancer

Looks like there is yet another reason to rethink the long-term use of proton pump inhibitors. And this one is a doozy. According to a new study, recently published in the BMJ journal, Gut, the long-term use of PPIs is linked to a more than doubling of the risk of developing stomach cancer. And before you jump to the reasonable conclusion that these patients might have had untreated Helicobacter Pylori, this 2.4 fold increase in gastric cancer risk occurred in patients who had had H.pylori but had been successfully treated more than 12 months previously. What’s more, the risk increased proportionally with the duration of PPI use and the dose, which the Hong Kong authors said suggested a cause-effect relationship. No such increased risk was found among those patients who took H2 receptor antagonists. While the study was observational, the large sample size (more than 63,000 patients with a history of effective H.pylori treatment) and the relatively long duration of follow-up (median 7.6 years) lent validity to the findings. The link between H.pylori and gastric cancer, has been known for decades. It has been shown that eradicating H.pylori reduces the risk of developing gastric cancer by 33-47%. However, the study authors said, it is also known that a considerable proportion of these individuals go on to develop gastric cancer even after they have successfully eradicated the bacteria. “To our knowledge, this is the first study to demonstrate that long-term PPI use, even after H. pylori eradication therapy, is still associated with an increased risk of gastric cancer,” they said. By way of explanation, the researchers note that gastric atrophy is considered a precursor to gastric cancer. And while gastric atrophy is a known sequela of chronic H. pylori infection, it could also be worsened and maintained by the profound acid suppression associated with PPI use and this could be why the risk persisted even after the infection had been treated. Bottom line? According to the study authors, doctors need to ‘exercise caution when prescribing long-term PPIs to these patients even after successful eradication of H. pylori.’ Ref: Gut 2017; 0:1-8. Doi:10.1136/gutjnl-2017-314605

By Dr Linda Calabresi
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