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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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A Proven, Practical Alternative For Pain

There has been a lot of noise around opioid use lately. In particular, in the States where it’s been declared a public health emergency. While concerted efforts are being made to ensure that patients who are experiencing chronic pain are not also in a position where they also have to deal with opioid addiction, in the cases of severe, acute pain most doctors would consider pain relief the priority and opioids the gold standard. Well it seems that too may need a rethink. According to a new randomised controlled trial just published in JAMA, an oral ibuprofen/paracetamol combination works just as well at reducing pain, such as that felt with a suspected fractured arm as a range of other oral opioid combinations including oxycodone and paracetamol. The US researchers randomly selected over 400 patients who presented to emergency with moderate to severe arm or leg pain, severe enough to warrant investigation by imaging to receive an oral paracetamol/ibuprofen combination pain relief or one of three other opioid combination analgesics including oxycodone/paracetamol, hydrocodone/paracetamol or codeine/paracetamol. Two hours after ingestion there were no statistically significant or clinically important difference in pain reduction between the four groups. A limitation of the study was that it didn’t compare adverse effects, however the study authors said their findings support the use of the paracetamol/ibuprofen combination as an alternative to oral opioid analgesics, at least in cases of severe arm or leg pain. Their findings also contradict the long-held idea that non-opioid pain killers are less effective than opioids, an idea that has been underpinned by the WHO pain ladder that has guided clinicians managing both cancer and non-cancer pain since 1986. Even though most scripts for opioids are written out in the community, previous research has showed that long-term opiate use is higher among those patients who were initially treated in hospital. “Typically, treatment regimens that provide adequate pain reduction in the ED setting are used for pain management at home,” an accompanying editorial stated. “[This trial] provides important evidence that nonopioid analgesia can provide similar pain reduction as opioid analgesia for selected patients in the ED setting.” What’s more, the effectiveness of this paracetamol and ibuprofen combination for moderate to severe pain may also translate to its more widespread use for acute pain in other clinical conditions traditionally treated with opioid medication, however this would need further investigation, the editorial author concluded. Ref: JAMA 2017; 318(17): 1661-1667. Doi:10.1001/jama.2017.16190 JAMA 2017; 318(17) 1655-1656

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Antibiotics Still Best For Suspected UTI

At a time when there is increasing pressure on GPs not to prescribe antibiotics, a new primary care study endorsing their role in the early treatment of uncomplicated UTI makes a welcome change. The trial, recently published in the BMJ showed that not only did early antibiotic treatment for a lower UTI significantly shorten the duration of symptoms, it also reduced the risk of the patient developing pyelonephritis. However, the researchers stopped short of recommending all women with lower UTI symptoms commence antibiotics at first presentation. In deference to the rising rates of antibiotic resistance against UTI-causing bacteria, and the fact that little harm came to the women who were originally in the NSAID group but were eventually put on antibiotics, they effectively suggest a ‘just in case’ script. “[A] strategy of selectively deferring rather than completely withholding antibiotic treatment may be preferable for uncomplicated lower UTI,” they said. The only caveat they suggested to this strategy, was for women who had lower UTI symptoms and a CRP greater than 10mg/L who appeared, in post hoc analysis to have a greater likelihood of developing pyelonephritis and might therefore benefit from immediate antibiotics. But this would need further research they suggested. The Swiss study, a randomised, double blind trial involved more than 250 women who presented to their GP with symptoms of an uncomplicated lower UTI, and were found to have either leucocytes or nitrite or both on a urine dipstick test. The women were randomised to receive either norfloxacin or the NSAID, diclofenac. The choice of norfloxacin as the antibiotic, which does seem a little like using a hammer to crack a nut, was based on pre-determined high susceptibility rates in this Swiss population and diclofenac was the NSAID chosen because it had the same dosing regimen as the norfloxacin. Overall, symptoms were gone after a median of two days in the antibiotic group but lasted twice as long in the NSAID group, with the majority of NSAID women eventually needing antibiotics. Also of note was that 5% of women in the NSAID group developed pyelonephritis compared with none in the antibiotic group. So even though research suggests we can safely withhold antibiotics in a number of self-limiting bacterial diseases such as acute otitis media, sinusitis and traveller’s diarrhoea – we should perhaps reconsider that strategy for treating UTIs, the study authors suggest. BMJ 2017; 359: j4784. http://dx.doi.org/10.1136/bmj.j4784

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Pressure increased on hypertension treatment

New US guidelines are the most aggressive yet in terms of targets for blood pressure control. Put out by the American College of Cardiology and the American Heart Association, and published in JAMA, the guidelines recommend we now consider anyone with a BP of 120/80 mmHg or above as having abnormal blood pressure. People who have a systolic between 120 and 130 mmHg but whose diastolic is still below 80 mmHg are to be considered to have elevated BP. But those who have both a systolic up to 10mmHg above target (120-130mmHg) and a diastolic between 80 and 90 mmHg should now be classified as having stage 1 hypertension. An accompanying editorial estimates that this reclassification will result in a 14% increase in the US population who should be recognised as having hypertension. But before clinicians start reaching for the script pad, the guidelines recommend this stage 1 hypertension be initially treated with non-pharmacological therapies – basically addressing the factors that most likely pushed their blood pressure up to start with – lose weight, exercise more, reduce salt intake, cut down on alcohol. The exception to this, is that group of patients whose absolute 10 year CVD risk predictor has them with a 10% or more chance of having a major CV event. In these cases, it’s gloves off. The less than 130/80 target for high risk patients is very similar to Australian guidelines. What’s different is that this is now a recommended target for everyone. The new US guidelines recommend everyone with a BP over 140/90 mmHg be treated with medication (preferably two agents) regardless of their absolute CV risk. Our Heart Foundation says try other lifestyle changes in people with a very low CV risk and no other comorbidities until we reach the 160/100 mmHg mark. The other new development in the US guidelines is the recommendation to use BP measurements from ambulatory or home BP monitoring to both confirm a diagnosis of hypertension and titrate therapy. This is in keeping with Australian recommended practice. The US guidelines were developed by an expert committee after examining all the current evidence and conducting a series of systematic reviews looking at some key clinical questions. “From a public health perspective, considering the high population-attributable risk of CVD associated with hypertension, the potential benefits of tighter control of hypertension are substantial,” the guideline authors wrote. However, they do acknowledge that such an aggressive approach does carry risks, especially in the elderly. “Although studies do suggest that lower BP is better for most patients, including those older than 75 years, the balance of the potential benefits of hypertension management and medication costs, adverse effects, and polypharmacy must be considered for each individual patient,” they said. Ref: JAMA. Published online November 20, 2017. doi:10.1001/jama.2017.18706

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Unprecedented Rise In Scarlet Fever In England And Asia

Scarlet fever is on the rise. According to the latest issue of The Lancet Infectious Diseases, cases of scarlet fever in the UK reached a 50 year high last year with a seven fold increase in new cases in the last five years. In addition, similar increases having been reported in a number of Asian countries including Vietnam, China, South Korea and Hong Kong. But public health authorities remain perplexed as to why the disease appears to be making a comeback. Detailed analysis of the causative organism shows different strains of the strep bacteria have been responsible for the UK and Asian outbreaks, so they are unsure if they are linked at all or whether the resurgence has to do with external factors such as the immune status of the population or environmental factors. So far it would seem that Australia is yet to be affected by this increased incidence however experts are warning we should not be complacent. Unlike in England, scarlet fever is not a notifiable disease in this country except in WA. And even in the UK, data suggests marked under-reporting. Scarlet fever is highly contagious and usually affects children under the age of 10, although it can occur in adults as well. While the bacterial infection, caused by Streptococcus pyogenes or group A Streptococcus (GAS) was a common cause of death in the 1800s, these days it is readily treated with antibiotics usually penicillin. However, failure to recognise the condition and treat it appropriately can lead to complications such as pneumonia, and liver and kidney damage. Children with the infection typically experience sore throat, headache and fever along with the characteristic popular pink-red rash that feels like sandpaper and the so-called strawberry tongue. Diagnosis is usually made via a throat swab. In an accompanying comment, Australian infectious diseases researchers Professor Mark Walker and Stephan Brouwer from the University of Queensland said, “Scarlet fever epidemics have yet to abate in the UK and northeast Asia. Thus, heightened global surveillance for the dissemination of scarlet fever is warranted.” In other words, be alert, people! Ref: Lancet Infect Dis 2017 Published Online November 27, 2017 http://dx.doi.org/10.1016/ S1473-3099(17)30693-X Online/Comment http://dx.doi.org/10.1016/ S1473-3099(17)30694-1

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Don’t hold back on giving patches to pregnant smokers

All pregnant women who are smokers should be offered nicotine replacement therapy (NRT) as an option to help them quit, Australian researchers say. In a review published in the MJA, authors said that even though there was a general acknowledgement that there was no firm evidence that proved NRT was safe or effective in pregnancy, all the current guidelines recommend its use for women who couldn’t quit without medication. In a nutshell, NRT is safer than smoking, and smoking during pregnancy is the most important preventable risk factor for poor maternal and infant health outcomes, they said. Despite this, there appears a reluctance among doctors, both here and around the world to prescribe the therapy to pregnant women. The researchers cited a recent survey of Australian GPs and obstetricians that found one in four said they never prescribed NRT in pregnancy. One possible reason for this reluctance, they suggest is the caveats and cautions included in many of the guidelines. Phrases such as ‘only if women are motivated’, ‘only give out two weeks’ supply’ and ‘under close supervision’ hardly inspire confidence in the safety of the therapy. “Ambiguous messages may be contributing to the low NRT prescribing rates and, therefore, it is important to provide a clear practical message to health practitioners and women,” they said. After analysing the various guidelines, the researchers suggest using the strength of the urge to smoke as well as how frequently the urge to smoke occurs to help assess when a woman needs to start or increase the dose of their NRT. “The most important guidance for NRT in pregnancy is to use the lowest possible dose that is effective. However, to be effective, women should be instructed to use as much as needed to deal with cravings,” they advised. They also recommend women be encouraged to use NRT for at least 12 weeks or longer if required to ensure they don’t relapse. All smokers who are pregnant should be told “There is nothing better for you and your baby’s health than to quit smoking.” Ref: MJA  Online first 4.12.17 doi:10.5694/mja17.00446

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New hope for kids with severe food allergies

One of the new class of biologics may have a pivotal role in desensitising children with severe food allergies, US researchers say. That was the conclusion after their placebo-controlled study showed that a preliminary short course of the monoclonal antibody, omalizumab (Xolair) improved the safety and efficacy of oral immunotherapy in children with multiple severe Ig-E mediated food allergies. Admittedly the study was small, involving only 48 children aged 4-15 years, and only looked at children with Ig-E mediated allergies to multiple foods but the implications, the study authors say are important. These patients are a highly atopic population who are at risk of near-fatal or fatal food allergic reactions to multiple foods. There is plenty of evidence that oral immunotherapy is effective for single food desensitisation. However there has been little proof that immunotherapy works in children with allergies to multiple foods, and these are the ones more likely to accidentally ingest a food that may trigger anaphylaxis. Children with multiple food allergies are also far more likely to be unable to tolerate the oral immunotherapy. So in this phase 2 trial, those children in the treatment group were given omalizumab for eight weeks before commencing oral immunotherapy against a range of allergens including peanuts, cows milk and several different tree nuts. Outcomes were assessed by a food challenge at week 36 that looked at the ability to tolerate 2g of the trigger food. At the 36 week mark, 83% of children could now tolerate the allergenic food in the omalizumab-primed group compared with only 33% in the placebo group.  It also appeared that omalizumab was well-tolerated with no serious or severe adverse events occurring in those who received it. The impact of these findings on the lives of affected children should not be underestimated, the researchers suggest in The Lancet Gastroenterology and Hepatology. “[The] ability to increase an individual’s threshold of food ingestion to a serving of protein [for example] is important for their nutrition and overall quality of life,” they wrote. The study had its limitations, namely it remains unknown if the desensitisation was sustained but the finding that the anti-IgE cover made the oral immunotherapy more tolerable and therefore more effective is a major though incremental advance in the management of this increasingly prevalent condition. Ref: Lancet Gastroenterology and Hepatology. Published Online Dec 11, 2017 http://dx.doi.org/10.1016/52468-1253(17)30392-8

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Green light for ginkgo

Ischaemic stroke patients are less likely to deteriorate mentally if they take ginkgo biloba extract in addition to low-dose aspirin in the acute phase, a new study suggests. “Cognitive decline after stroke can result in vascular cognitive impairment and Alzheimer’s disease,” the study authors wrote. Importantly then, this randomised controlled trial showed stroke patients who took ginkgo as well as aspirin had better memory function, executive functions, neurological function and daily life in the six months after experiencing their stroke than those patients who took aspirin alone. The Chinese study also showed that taking ginkgo was not associated with an increased incidence of adverse events. The results of the study, published in the journal, Stroke and Vascular Neurology support the long-held hypothesis that ginkgo protects against neuronal death caused by ischaemia, which had been demonstrated in animal stroke models. It has been suggested that the possible mechanism of ginkgo’s effectiveness may include anti-apoptosis and increasing cerebral blood flow. In the study, researchers randomised over 340 patients, from five hospitals who had had an ischaemic stroke in the previous seven days to receive either 450mg of ginkgo biloba extract with 100mg aspirin daily or only the 100mg of aspirin daily. Both groups were treated for six months and were various intervals over that period. From the very early assessments (at 12 days) and through until 180 days, the difference in the assessments of cognitive and executive function was statistically significant. Similarly neurological and global function was significantly better in the group that took ginkgo. “These data suggest that [ginkgo biloba extract] is effective and could be recommended in the treatment of acute ischaemic stroke,” the study authors concluded. Ref: Li S, et al. Stroke and Vascular Neurology 2017; 0:000104. doi:10.1136 /svn-2017-000104

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Menopausal hormonal therapy prevents depression

Sometimes evidence proves what was long-suspected to be true. A new study, just published in JAMA Psychiatry shows women who took hormone replacement therapy early in the menopausal transition had almost half the risk of developing clinically significant depressive symptoms compared to women who took a placebo. The study also confirmed that women of this age and stage are at high risk of significant depression, with almost one third of women in the placebo group developing symptoms and signs of the condition over the 12 month study period. Previous research had suggested that hormone therapy could help manage existing depression in menopausal women, however according to the Canadian researchers, this study, conducted among initially euthymic women was the first to show hormone therapy’s role in preventing the affective disorder. More than 170 perimenopausal and early post-menopausal women were randomly assigned to receive transdermal oestradiol (0.1mg/day) and intermittent oral micronized progesterone or placebo patches and tablets for 12 months. They were assessed regularly for depression using a validated depression scale (CES-D). Women on placebo were more likely to record a score that equated with significant depression at least once over the study period (32.3%) compared with women taking the hormone therapy (17.3%). Interestingly, women who had had what the researchers called ‘stressful life events’ in the six months prior to enrolment in the trial actually had greater benefit from the hormone therapy. Whereas other possible confounders such as baseline vasomotor symptoms, a history of depression, and baseline oestradiol levels did not appear to affect the protective benefit of the therapy. The progesterone was given for 12 days every three months, to induce vaginal bleeding so the finding that this adverse effect was more common in the hormone therapy group was hardly surprising but of note the two groups did not differ in other adverse effects including headaches, bloating, breast tenderness, weight gain and GI symptoms. An accompanying editorial sounded a few warnings about the study including the fact that the oestrogen dose was higher than currently recommended for treating women with hot flushes and the progestin dose was less than that recommended to protect the endometrium. The two editorial authors, including Dr Martha Hickey, from the University of Melbourne also cautioned that using hormone therapy to prevent depression might result in prolonged hormone exposure with the known risks associated with this, and is not currently recommended for this indication. However, the study authors were cautiously enthusiastic about their findings saying, “If confirmed in a larger sample of early perimenopausal women, the findings of this study…suggest that hormone therapy may also be indicated for the prevention and/or treatment of depressive symptoms appearing in the early menopause transition, regardless of whether menopausal symptoms are present.” Ref: JAMA Psychiatry. doi:10.1001/jamapsychiatry.2017.3998

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Surviving breast cancer not the end of the story

Breast cancer survival has improved dramatically over the last few decades. Courtesy of earlier diagnosis and better treatments, five year survival has increased from 70% in the 1980s to 90%, says Melbourne medical oncologist, Dr Jacqueline Chirgwin in the latest issue of the MJA. It is little wonder then that there is now increased focus on the ongoing general health in this ever-growing population of breast cancer survivors. “Although breast cancer is worldwide the most common cancer in women, many, perhaps most patients die from other causes,” she says. Dr Chirgwin’s comments are in relation to an Australian study, published in the same issue of the journal which showed comorbid conditions are more likely to develop in women who have been diagnosed with hormone-dependent breast cancer than in women without cancer. The South Australian researchers reached this conclusion after analysing a random sample of PBS data from a cohort of women who commenced endocrine therapy at some time in the eight years from 2004 and compared that with age and sex matched controls who weren’t taking anti-cancer treatment. Conditions significantly more likely to develop in the breast cancer women included depression, pain or pain-inflammation, osteoporosis, diabetes, cardiovascular disorders and gastric acid disorders. As the study authors point out there are a number of very logical reasons why these conditions are more likely in this particular group of women. For example it is hardly surprising that someone given a diagnosis of breast cancer might subsequently develop depression and be prescribed antidepressants. Similarly a number of the cancer medications may contribute to comorbidities such as cardiovascular disease, osteoporosis and musculoskeletal pain, in addition menopausal hormone therapy is contraindicated. In addition some risk factors for breast cancer are the same risk factors for other chronic conditions such as heart disease and diabetes, namely excessive alcohol consumption, obesity and physical inactivity. And while the findings might not be all that surprising, the researchers suggest that we are missing a major opportunity to target this at-risk group in a manner which will ultimately improve their health outcome, independent of the breast cancer. “As most women diagnosed with breast cancer in Australia can now be cured, the burden of non-cancer comorbidities is becoming a major health concern for these patients, but this is still largely unrecognised. Future breast cancer research should focus on strategies that effectively respond to the burden imposed by these comorbidities,” they concluded. Ref: MJA doi:10.5694/mja17.00006 doi:10.5694/mja17.00938

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Risk of post-op pneumonia halved

A single 30minute educational session with a physio about post-op breathing exercises prior to elective upper abdo surgery, halves that patient’s risk of respiratory complications compared with usual care, Australian research shows. The randomised study conducted among 441 patients across three hospitals in Australia and New Zealand showed the pre-op intervention reduced the risk of post-operative pulmonary complications from 27% in the control group to 12% in the physio-taught group. In fact, the number need to treat to prevent one such complication was only seven. The effect was greatest in men, those undergoing colorectal surgery, those aged under 65 and those educated by an experienced physiotherapist. So what did this all-important physio session involve? Well, as they say in the classics – it wasn’t rocket science. The physiotherapists had a standard script which included educating the patient about the high likelihood of a pulmonary complication following this type of surgery (10 to 50% according to the literature) and the importance of early ambulation as well as breathing exercises in preventing these. Many patients are unlikely to up and about in the first couple of days following major upper abdominal surgery but at least the breathing exercises can be done from the moment the patient regains consciousness – two sets of 10 slow, deep breaths followed by three coughs, using an abdominal support pillow to reduce pain. And this is to be repeated hourly. This was emphasised in the education session which was conducted at some stage in the six weeks prior to surgery. The physio session also included a practice run through of these exercises. However, interestingly the control group also received pre-op written information about these same facts and exercises, and were reminded of them post-op as part of standard care. What then made the difference? “One explanation for the effectiveness of pre-operative physiotherapy to reduce [post-operative pulmonary complications] is that the preparation, motivation and training of the patient before surgery brings the timing of breathing exercise initiation to immediately after regaining consciousness after surgery,” the study authors suggested. A degree of atelectasis is common with this type of surgery and general anaesthetic. The immediate commencement of these exercises could facilitate the re-inflation of the lungs, and prevent the progression of this atelectasis. The primary end point of this study was the development of one or more of seven respiratory symptoms or signs in the 14 days post op including chest xray evidence of consolidation or collapse, cough with coloured sputum or a respiratory-related high white cell count. One of the secondary endpoints was pneumonia, the relative risk of which was reduced by 52% courtesy of the intervention. In essence, the study showed how the right education and motivation given at the right time can dramatically improve health outcomes with results that are directly applicable to tens of millions of patients awaiting surgery such as this worldwide. “[P]atients reported that pre-operative physiotherapy empowered them to treat themselves and placed high value on its role in improving their post-operative recovery,” the researchers said. Ref: BMJ 2018;360:j5916 doi:10.1136/bmj.j5916

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Omega-3 fatty acids do not prevent heart attacks

Taking fish oil supplements to prevent a heart attack has always been somewhat controversial. However, a new meta-analysis, involving almost 78,000 high risk individuals has provided the best evidence to date that the practice is not worthwhile. (1) The UK researchers analysed the data from 10 trials which had investigated whether taking omega-3 fatty acid supplementation reduced the risk of fatal and non-fatal coronary heart disease as well as other vascular events including stroke. According to the study findings, published in JAMA Cardiology, those individuals randomised to omega-3 fatty acid supplementation for a mean of 4.4 years experienced no significant benefit in terms of preventing adverse vascular outcomes compared with those who did not receive supplementation. “Importantly, this meta-analysis also demonstrated no significant effect on major vascular events in any particular sub-groups, including prior vascular disease, diabetes, lipid levels, or statin use,” the study authors wrote. They suggest that the results of this study provide no support for the recommendations to use approximately 1g/d of omega-3 fatty acids in patients with a history of coronary heart disease to prevent heart attacks or any other vascular disease, which is the current advice from American Heart Association. Our own Australian Heart Foundation guidelines have been a little more circumspect with regard omega-3 fatty acids. While they do suggest supplementation for people whose diet is lacking in fish sources of EPA and DHA, they do say the cardioprotective benefit may be only for some high-risk groups. “There is evidence omega-3 supplements can play a beneficial role in the treatment of patients with high triglyceride levels and patients with existing heart disease, specifically heart failure,” according to their website. (2) Whether this advice is set to change remains to be seen. However, while this latest study might seem like the nail in the coffin for the fish oil business there is an important caveat to consider. The trials included in the meta-analysis involved various doses of omega-3 fatty acid supplementation. All but one trial included combinations of EPA and DHA, with the one exception being a trial of EPA supplementation alone. Daily doses of EPA ranged from 226 to 1800 mg/day and DHA doses varied from 0 to 1700mg/day. Several large randomised controlled trials, involving over 50,000 participants are currently underway investigating whether much higher doses of omega-3 fatty acids will reduce the risk of major cardiovascular events. Even the authors of this latest meta-analysis concede “The results of the ongoing trials are needed to assess if higher doses of omega-3 fatty acids (3-4g/d) may have significant effects on risk of major vascular events.” Ref: 1. JAMA Cardiol. doi: 10.1001/jamacardio.2017.5205 2. https://www.heartfoundation.org.au/images/uploads/main/Programs/Health_Professional_QA_Fish_Omega3_Cardiovascular_Health.pdf

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Long-term dangers of postnatal depression

There is no debate – postpartum depression can be a devastating disease for a new mother. However, what is probably less well-recognised is the long-term consequences of that illness on the child. The latest findings from an ongoing longitudinal UK study of parents and infants shows that children whose mother was assessed as having moderate to severe depression at both two and eight months after delivery had a substantially increased risk of adverse outcomes across a number of child measures from behaviour and learning to mental health up to 18 years later. The observational study known as the British Avon Longitudinal Study of Parents and Children(ALSPAC) has followed over 9800 women who were pregnant in the early 1990s. In the latest findings, published in JAMA psychiatry, the researchers noted that women who still had moderate to severe depression at eight months postpartum, were likely to still have depression 11 years later. And the children of these women had a four- fold increased risk of behaviour problems as a pre-schooler, twice the risk of being poor at maths in high school and a seven fold increased risk of depression as an adult. Conversely, if the postpartum depression was not persistent at either the moderate or severe level there appeared to be no increased risk of behaviour and learning problems or depression in the offspring, which is reassuring. The study findings published in JAMA psychiatry raise a number of interesting questions. “Having established a highly vulnerable group of mothers still does not answer the question of what to do about interventions, or who, when, or how to treat,” the author of an accompanying editorial says. The design of the study meant the researchers were unable to determine the effects of maternal treatment on reducing postpartum depression and improving child outcomes. As the editorial author also points out, there is also considerable debate whether treatment should focus mainly on the mother and her illness or be directed at the mother-infant relationship. Nonetheless, it is clear that, as a first step at least, these mothers with persistent severe depression need to be identified. Screening for depression which now focuses on pregnancy and the immediate postpartum period needs to be extended to a year after delivery. “Screening both early and late in the first postpartum year will enable the identification of women with persistent [postnatal depression] and thus the offer of appropriate treatment,” the study authors concluded. Ref: JAMA Psychiatry doi:10.1001/jamapsychiatry.2017.4363 doi:10.1001/jamapsychiatry.2017.4265

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A Proven, Practical Alternative For Pain

There has been a lot of noise around opioid use lately. In particular, in the States where it’s been declared a public health emergency. While concerted efforts are being made to ensure that patients who are experiencing chronic pain are not also in a position where they also have to deal with opioid addiction, in the cases of severe, acute pain most doctors would consider pain relief the priority and opioids the gold standard. Well it seems that too may need a rethink. According to a new randomised controlled trial just published in JAMA, an oral ibuprofen/paracetamol combination works just as well at reducing pain, such as that felt with a suspected fractured arm as a range of other oral opioid combinations including oxycodone and paracetamol. The US researchers randomly selected over 400 patients who presented to emergency with moderate to severe arm or leg pain, severe enough to warrant investigation by imaging to receive an oral paracetamol/ibuprofen combination pain relief or one of three other opioid combination analgesics including oxycodone/paracetamol, hydrocodone/paracetamol or codeine/paracetamol. Two hours after ingestion there were no statistically significant or clinically important difference in pain reduction between the four groups. A limitation of the study was that it didn’t compare adverse effects, however the study authors said their findings support the use of the paracetamol/ibuprofen combination as an alternative to oral opioid analgesics, at least in cases of severe arm or leg pain. Their findings also contradict the long-held idea that non-opioid pain killers are less effective than opioids, an idea that has been underpinned by the WHO pain ladder that has guided clinicians managing both cancer and non-cancer pain since 1986. Even though most scripts for opioids are written out in the community, previous research has showed that long-term opiate use is higher among those patients who were initially treated in hospital. “Typically, treatment regimens that provide adequate pain reduction in the ED setting are used for pain management at home,” an accompanying editorial stated. “[This trial] provides important evidence that nonopioid analgesia can provide similar pain reduction as opioid analgesia for selected patients in the ED setting.” What’s more, the effectiveness of this paracetamol and ibuprofen combination for moderate to severe pain may also translate to its more widespread use for acute pain in other clinical conditions traditionally treated with opioid medication, however this would need further investigation, the editorial author concluded. Ref: JAMA 2017; 318(17): 1661-1667. Doi:10.1001/jama.2017.16190 JAMA 2017; 318(17) 1655-1656

By Dr Linda Calabresi
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Antibiotics Still Best For Suspected UTI

At a time when there is increasing pressure on GPs not to prescribe antibiotics, a new primary care study endorsing their role in the early treatment of uncomplicated UTI makes a welcome change. The trial, recently published in the BMJ showed that not only did early antibiotic treatment for a lower UTI significantly shorten the duration of symptoms, it also reduced the risk of the patient developing pyelonephritis. However, the researchers stopped short of recommending all women with lower UTI symptoms commence antibiotics at first presentation. In deference to the rising rates of antibiotic resistance against UTI-causing bacteria, and the fact that little harm came to the women who were originally in the NSAID group but were eventually put on antibiotics, they effectively suggest a ‘just in case’ script. “[A] strategy of selectively deferring rather than completely withholding antibiotic treatment may be preferable for uncomplicated lower UTI,” they said. The only caveat they suggested to this strategy, was for women who had lower UTI symptoms and a CRP greater than 10mg/L who appeared, in post hoc analysis to have a greater likelihood of developing pyelonephritis and might therefore benefit from immediate antibiotics. But this would need further research they suggested. The Swiss study, a randomised, double blind trial involved more than 250 women who presented to their GP with symptoms of an uncomplicated lower UTI, and were found to have either leucocytes or nitrite or both on a urine dipstick test. The women were randomised to receive either norfloxacin or the NSAID, diclofenac. The choice of norfloxacin as the antibiotic, which does seem a little like using a hammer to crack a nut, was based on pre-determined high susceptibility rates in this Swiss population and diclofenac was the NSAID chosen because it had the same dosing regimen as the norfloxacin. Overall, symptoms were gone after a median of two days in the antibiotic group but lasted twice as long in the NSAID group, with the majority of NSAID women eventually needing antibiotics. Also of note was that 5% of women in the NSAID group developed pyelonephritis compared with none in the antibiotic group. So even though research suggests we can safely withhold antibiotics in a number of self-limiting bacterial diseases such as acute otitis media, sinusitis and traveller’s diarrhoea – we should perhaps reconsider that strategy for treating UTIs, the study authors suggest. BMJ 2017; 359: j4784. http://dx.doi.org/10.1136/bmj.j4784

By Dr Linda Calabresi
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Pressure increased on hypertension treatment

New US guidelines are the most aggressive yet in terms of targets for blood pressure control. Put out by the American College of Cardiology and the American Heart Association, and published in JAMA, the guidelines recommend we now consider anyone with a BP of 120/80 mmHg or above as having abnormal blood pressure. People who have a systolic between 120 and 130 mmHg but whose diastolic is still below 80 mmHg are to be considered to have elevated BP. But those who have both a systolic up to 10mmHg above target (120-130mmHg) and a diastolic between 80 and 90 mmHg should now be classified as having stage 1 hypertension. An accompanying editorial estimates that this reclassification will result in a 14% increase in the US population who should be recognised as having hypertension. But before clinicians start reaching for the script pad, the guidelines recommend this stage 1 hypertension be initially treated with non-pharmacological therapies – basically addressing the factors that most likely pushed their blood pressure up to start with – lose weight, exercise more, reduce salt intake, cut down on alcohol. The exception to this, is that group of patients whose absolute 10 year CVD risk predictor has them with a 10% or more chance of having a major CV event. In these cases, it’s gloves off. The less than 130/80 target for high risk patients is very similar to Australian guidelines. What’s different is that this is now a recommended target for everyone. The new US guidelines recommend everyone with a BP over 140/90 mmHg be treated with medication (preferably two agents) regardless of their absolute CV risk. Our Heart Foundation says try other lifestyle changes in people with a very low CV risk and no other comorbidities until we reach the 160/100 mmHg mark. The other new development in the US guidelines is the recommendation to use BP measurements from ambulatory or home BP monitoring to both confirm a diagnosis of hypertension and titrate therapy. This is in keeping with Australian recommended practice. The US guidelines were developed by an expert committee after examining all the current evidence and conducting a series of systematic reviews looking at some key clinical questions. “From a public health perspective, considering the high population-attributable risk of CVD associated with hypertension, the potential benefits of tighter control of hypertension are substantial,” the guideline authors wrote. However, they do acknowledge that such an aggressive approach does carry risks, especially in the elderly. “Although studies do suggest that lower BP is better for most patients, including those older than 75 years, the balance of the potential benefits of hypertension management and medication costs, adverse effects, and polypharmacy must be considered for each individual patient,” they said. Ref: JAMA. Published online November 20, 2017. doi:10.1001/jama.2017.18706

By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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Unprecedented Rise In Scarlet Fever In England And Asia

Scarlet fever is on the rise. According to the latest issue of The Lancet Infectious Diseases, cases of scarlet fever in the UK reached a 50 year high last year with a seven fold increase in new cases in the last five years. In addition, similar increases having been reported in a number of Asian countries including Vietnam, China, South Korea and Hong Kong. But public health authorities remain perplexed as to why the disease appears to be making a comeback. Detailed analysis of the causative organism shows different strains of the strep bacteria have been responsible for the UK and Asian outbreaks, so they are unsure if they are linked at all or whether the resurgence has to do with external factors such as the immune status of the population or environmental factors. So far it would seem that Australia is yet to be affected by this increased incidence however experts are warning we should not be complacent. Unlike in England, scarlet fever is not a notifiable disease in this country except in WA. And even in the UK, data suggests marked under-reporting. Scarlet fever is highly contagious and usually affects children under the age of 10, although it can occur in adults as well. While the bacterial infection, caused by Streptococcus pyogenes or group A Streptococcus (GAS) was a common cause of death in the 1800s, these days it is readily treated with antibiotics usually penicillin. However, failure to recognise the condition and treat it appropriately can lead to complications such as pneumonia, and liver and kidney damage. Children with the infection typically experience sore throat, headache and fever along with the characteristic popular pink-red rash that feels like sandpaper and the so-called strawberry tongue. Diagnosis is usually made via a throat swab. In an accompanying comment, Australian infectious diseases researchers Professor Mark Walker and Stephan Brouwer from the University of Queensland said, “Scarlet fever epidemics have yet to abate in the UK and northeast Asia. Thus, heightened global surveillance for the dissemination of scarlet fever is warranted.” In other words, be alert, people! Ref: Lancet Infect Dis 2017 Published Online November 27, 2017 http://dx.doi.org/10.1016/ S1473-3099(17)30693-X Online/Comment http://dx.doi.org/10.1016/ S1473-3099(17)30694-1

By Dr Linda Calabresi
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Don’t hold back on giving patches to pregnant smokers

All pregnant women who are smokers should be offered nicotine replacement therapy (NRT) as an option to help them quit, Australian researchers say. In a review published in the MJA, authors said that even though there was a general acknowledgement that there was no firm evidence that proved NRT was safe or effective in pregnancy, all the current guidelines recommend its use for women who couldn’t quit without medication. In a nutshell, NRT is safer than smoking, and smoking during pregnancy is the most important preventable risk factor for poor maternal and infant health outcomes, they said. Despite this, there appears a reluctance among doctors, both here and around the world to prescribe the therapy to pregnant women. The researchers cited a recent survey of Australian GPs and obstetricians that found one in four said they never prescribed NRT in pregnancy. One possible reason for this reluctance, they suggest is the caveats and cautions included in many of the guidelines. Phrases such as ‘only if women are motivated’, ‘only give out two weeks’ supply’ and ‘under close supervision’ hardly inspire confidence in the safety of the therapy. “Ambiguous messages may be contributing to the low NRT prescribing rates and, therefore, it is important to provide a clear practical message to health practitioners and women,” they said. After analysing the various guidelines, the researchers suggest using the strength of the urge to smoke as well as how frequently the urge to smoke occurs to help assess when a woman needs to start or increase the dose of their NRT. “The most important guidance for NRT in pregnancy is to use the lowest possible dose that is effective. However, to be effective, women should be instructed to use as much as needed to deal with cravings,” they advised. They also recommend women be encouraged to use NRT for at least 12 weeks or longer if required to ensure they don’t relapse. All smokers who are pregnant should be told “There is nothing better for you and your baby’s health than to quit smoking.” Ref: MJA  Online first 4.12.17 doi:10.5694/mja17.00446

By Dr Linda Calabresi
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New hope for kids with severe food allergies

One of the new class of biologics may have a pivotal role in desensitising children with severe food allergies, US researchers say. That was the conclusion after their placebo-controlled study showed that a preliminary short course of the monoclonal antibody, omalizumab (Xolair) improved the safety and efficacy of oral immunotherapy in children with multiple severe Ig-E mediated food allergies. Admittedly the study was small, involving only 48 children aged 4-15 years, and only looked at children with Ig-E mediated allergies to multiple foods but the implications, the study authors say are important. These patients are a highly atopic population who are at risk of near-fatal or fatal food allergic reactions to multiple foods. There is plenty of evidence that oral immunotherapy is effective for single food desensitisation. However there has been little proof that immunotherapy works in children with allergies to multiple foods, and these are the ones more likely to accidentally ingest a food that may trigger anaphylaxis. Children with multiple food allergies are also far more likely to be unable to tolerate the oral immunotherapy. So in this phase 2 trial, those children in the treatment group were given omalizumab for eight weeks before commencing oral immunotherapy against a range of allergens including peanuts, cows milk and several different tree nuts. Outcomes were assessed by a food challenge at week 36 that looked at the ability to tolerate 2g of the trigger food. At the 36 week mark, 83% of children could now tolerate the allergenic food in the omalizumab-primed group compared with only 33% in the placebo group.  It also appeared that omalizumab was well-tolerated with no serious or severe adverse events occurring in those who received it. The impact of these findings on the lives of affected children should not be underestimated, the researchers suggest in The Lancet Gastroenterology and Hepatology. “[The] ability to increase an individual’s threshold of food ingestion to a serving of protein [for example] is important for their nutrition and overall quality of life,” they wrote. The study had its limitations, namely it remains unknown if the desensitisation was sustained but the finding that the anti-IgE cover made the oral immunotherapy more tolerable and therefore more effective is a major though incremental advance in the management of this increasingly prevalent condition. Ref: Lancet Gastroenterology and Hepatology. Published Online Dec 11, 2017 http://dx.doi.org/10.1016/52468-1253(17)30392-8

By Dr Linda Calabresi
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Green light for ginkgo

Ischaemic stroke patients are less likely to deteriorate mentally if they take ginkgo biloba extract in addition to low-dose aspirin in the acute phase, a new study suggests. “Cognitive decline after stroke can result in vascular cognitive impairment and Alzheimer’s disease,” the study authors wrote. Importantly then, this randomised controlled trial showed stroke patients who took ginkgo as well as aspirin had better memory function, executive functions, neurological function and daily life in the six months after experiencing their stroke than those patients who took aspirin alone. The Chinese study also showed that taking ginkgo was not associated with an increased incidence of adverse events. The results of the study, published in the journal, Stroke and Vascular Neurology support the long-held hypothesis that ginkgo protects against neuronal death caused by ischaemia, which had been demonstrated in animal stroke models. It has been suggested that the possible mechanism of ginkgo’s effectiveness may include anti-apoptosis and increasing cerebral blood flow. In the study, researchers randomised over 340 patients, from five hospitals who had had an ischaemic stroke in the previous seven days to receive either 450mg of ginkgo biloba extract with 100mg aspirin daily or only the 100mg of aspirin daily. Both groups were treated for six months and were various intervals over that period. From the very early assessments (at 12 days) and through until 180 days, the difference in the assessments of cognitive and executive function was statistically significant. Similarly neurological and global function was significantly better in the group that took ginkgo. “These data suggest that [ginkgo biloba extract] is effective and could be recommended in the treatment of acute ischaemic stroke,” the study authors concluded. Ref: Li S, et al. Stroke and Vascular Neurology 2017; 0:000104. doi:10.1136 /svn-2017-000104

By Dr Linda Calabresi
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Menopausal hormonal therapy prevents depression

Sometimes evidence proves what was long-suspected to be true. A new study, just published in JAMA Psychiatry shows women who took hormone replacement therapy early in the menopausal transition had almost half the risk of developing clinically significant depressive symptoms compared to women who took a placebo. The study also confirmed that women of this age and stage are at high risk of significant depression, with almost one third of women in the placebo group developing symptoms and signs of the condition over the 12 month study period. Previous research had suggested that hormone therapy could help manage existing depression in menopausal women, however according to the Canadian researchers, this study, conducted among initially euthymic women was the first to show hormone therapy’s role in preventing the affective disorder. More than 170 perimenopausal and early post-menopausal women were randomly assigned to receive transdermal oestradiol (0.1mg/day) and intermittent oral micronized progesterone or placebo patches and tablets for 12 months. They were assessed regularly for depression using a validated depression scale (CES-D). Women on placebo were more likely to record a score that equated with significant depression at least once over the study period (32.3%) compared with women taking the hormone therapy (17.3%). Interestingly, women who had had what the researchers called ‘stressful life events’ in the six months prior to enrolment in the trial actually had greater benefit from the hormone therapy. Whereas other possible confounders such as baseline vasomotor symptoms, a history of depression, and baseline oestradiol levels did not appear to affect the protective benefit of the therapy. The progesterone was given for 12 days every three months, to induce vaginal bleeding so the finding that this adverse effect was more common in the hormone therapy group was hardly surprising but of note the two groups did not differ in other adverse effects including headaches, bloating, breast tenderness, weight gain and GI symptoms. An accompanying editorial sounded a few warnings about the study including the fact that the oestrogen dose was higher than currently recommended for treating women with hot flushes and the progestin dose was less than that recommended to protect the endometrium. The two editorial authors, including Dr Martha Hickey, from the University of Melbourne also cautioned that using hormone therapy to prevent depression might result in prolonged hormone exposure with the known risks associated with this, and is not currently recommended for this indication. However, the study authors were cautiously enthusiastic about their findings saying, “If confirmed in a larger sample of early perimenopausal women, the findings of this study…suggest that hormone therapy may also be indicated for the prevention and/or treatment of depressive symptoms appearing in the early menopause transition, regardless of whether menopausal symptoms are present.” Ref: JAMA Psychiatry. doi:10.1001/jamapsychiatry.2017.3998

By Dr Linda Calabresi
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Surviving breast cancer not the end of the story

Breast cancer survival has improved dramatically over the last few decades. Courtesy of earlier diagnosis and better treatments, five year survival has increased from 70% in the 1980s to 90%, says Melbourne medical oncologist, Dr Jacqueline Chirgwin in the latest issue of the MJA. It is little wonder then that there is now increased focus on the ongoing general health in this ever-growing population of breast cancer survivors. “Although breast cancer is worldwide the most common cancer in women, many, perhaps most patients die from other causes,” she says. Dr Chirgwin’s comments are in relation to an Australian study, published in the same issue of the journal which showed comorbid conditions are more likely to develop in women who have been diagnosed with hormone-dependent breast cancer than in women without cancer. The South Australian researchers reached this conclusion after analysing a random sample of PBS data from a cohort of women who commenced endocrine therapy at some time in the eight years from 2004 and compared that with age and sex matched controls who weren’t taking anti-cancer treatment. Conditions significantly more likely to develop in the breast cancer women included depression, pain or pain-inflammation, osteoporosis, diabetes, cardiovascular disorders and gastric acid disorders. As the study authors point out there are a number of very logical reasons why these conditions are more likely in this particular group of women. For example it is hardly surprising that someone given a diagnosis of breast cancer might subsequently develop depression and be prescribed antidepressants. Similarly a number of the cancer medications may contribute to comorbidities such as cardiovascular disease, osteoporosis and musculoskeletal pain, in addition menopausal hormone therapy is contraindicated. In addition some risk factors for breast cancer are the same risk factors for other chronic conditions such as heart disease and diabetes, namely excessive alcohol consumption, obesity and physical inactivity. And while the findings might not be all that surprising, the researchers suggest that we are missing a major opportunity to target this at-risk group in a manner which will ultimately improve their health outcome, independent of the breast cancer. “As most women diagnosed with breast cancer in Australia can now be cured, the burden of non-cancer comorbidities is becoming a major health concern for these patients, but this is still largely unrecognised. Future breast cancer research should focus on strategies that effectively respond to the burden imposed by these comorbidities,” they concluded. Ref: MJA doi:10.5694/mja17.00006 doi:10.5694/mja17.00938

By Dr Linda Calabresi
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Risk of post-op pneumonia halved

A single 30minute educational session with a physio about post-op breathing exercises prior to elective upper abdo surgery, halves that patient’s risk of respiratory complications compared with usual care, Australian research shows. The randomised study conducted among 441 patients across three hospitals in Australia and New Zealand showed the pre-op intervention reduced the risk of post-operative pulmonary complications from 27% in the control group to 12% in the physio-taught group. In fact, the number need to treat to prevent one such complication was only seven. The effect was greatest in men, those undergoing colorectal surgery, those aged under 65 and those educated by an experienced physiotherapist. So what did this all-important physio session involve? Well, as they say in the classics – it wasn’t rocket science. The physiotherapists had a standard script which included educating the patient about the high likelihood of a pulmonary complication following this type of surgery (10 to 50% according to the literature) and the importance of early ambulation as well as breathing exercises in preventing these. Many patients are unlikely to up and about in the first couple of days following major upper abdominal surgery but at least the breathing exercises can be done from the moment the patient regains consciousness – two sets of 10 slow, deep breaths followed by three coughs, using an abdominal support pillow to reduce pain. And this is to be repeated hourly. This was emphasised in the education session which was conducted at some stage in the six weeks prior to surgery. The physio session also included a practice run through of these exercises. However, interestingly the control group also received pre-op written information about these same facts and exercises, and were reminded of them post-op as part of standard care. What then made the difference? “One explanation for the effectiveness of pre-operative physiotherapy to reduce [post-operative pulmonary complications] is that the preparation, motivation and training of the patient before surgery brings the timing of breathing exercise initiation to immediately after regaining consciousness after surgery,” the study authors suggested. A degree of atelectasis is common with this type of surgery and general anaesthetic. The immediate commencement of these exercises could facilitate the re-inflation of the lungs, and prevent the progression of this atelectasis. The primary end point of this study was the development of one or more of seven respiratory symptoms or signs in the 14 days post op including chest xray evidence of consolidation or collapse, cough with coloured sputum or a respiratory-related high white cell count. One of the secondary endpoints was pneumonia, the relative risk of which was reduced by 52% courtesy of the intervention. In essence, the study showed how the right education and motivation given at the right time can dramatically improve health outcomes with results that are directly applicable to tens of millions of patients awaiting surgery such as this worldwide. “[P]atients reported that pre-operative physiotherapy empowered them to treat themselves and placed high value on its role in improving their post-operative recovery,” the researchers said. Ref: BMJ 2018;360:j5916 doi:10.1136/bmj.j5916

By Dr Linda Calabresi
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Omega-3 fatty acids do not prevent heart attacks

Taking fish oil supplements to prevent a heart attack has always been somewhat controversial. However, a new meta-analysis, involving almost 78,000 high risk individuals has provided the best evidence to date that the practice is not worthwhile. (1) The UK researchers analysed the data from 10 trials which had investigated whether taking omega-3 fatty acid supplementation reduced the risk of fatal and non-fatal coronary heart disease as well as other vascular events including stroke. According to the study findings, published in JAMA Cardiology, those individuals randomised to omega-3 fatty acid supplementation for a mean of 4.4 years experienced no significant benefit in terms of preventing adverse vascular outcomes compared with those who did not receive supplementation. “Importantly, this meta-analysis also demonstrated no significant effect on major vascular events in any particular sub-groups, including prior vascular disease, diabetes, lipid levels, or statin use,” the study authors wrote. They suggest that the results of this study provide no support for the recommendations to use approximately 1g/d of omega-3 fatty acids in patients with a history of coronary heart disease to prevent heart attacks or any other vascular disease, which is the current advice from American Heart Association. Our own Australian Heart Foundation guidelines have been a little more circumspect with regard omega-3 fatty acids. While they do suggest supplementation for people whose diet is lacking in fish sources of EPA and DHA, they do say the cardioprotective benefit may be only for some high-risk groups. “There is evidence omega-3 supplements can play a beneficial role in the treatment of patients with high triglyceride levels and patients with existing heart disease, specifically heart failure,” according to their website. (2) Whether this advice is set to change remains to be seen. However, while this latest study might seem like the nail in the coffin for the fish oil business there is an important caveat to consider. The trials included in the meta-analysis involved various doses of omega-3 fatty acid supplementation. All but one trial included combinations of EPA and DHA, with the one exception being a trial of EPA supplementation alone. Daily doses of EPA ranged from 226 to 1800 mg/day and DHA doses varied from 0 to 1700mg/day. Several large randomised controlled trials, involving over 50,000 participants are currently underway investigating whether much higher doses of omega-3 fatty acids will reduce the risk of major cardiovascular events. Even the authors of this latest meta-analysis concede “The results of the ongoing trials are needed to assess if higher doses of omega-3 fatty acids (3-4g/d) may have significant effects on risk of major vascular events.” Ref: 1. JAMA Cardiol. doi: 10.1001/jamacardio.2017.5205 2. https://www.heartfoundation.org.au/images/uploads/main/Programs/Health_Professional_QA_Fish_Omega3_Cardiovascular_Health.pdf

By Dr Linda Calabresi
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Long-term dangers of postnatal depression

There is no debate – postpartum depression can be a devastating disease for a new mother. However, what is probably less well-recognised is the long-term consequences of that illness on the child. The latest findings from an ongoing longitudinal UK study of parents and infants shows that children whose mother was assessed as having moderate to severe depression at both two and eight months after delivery had a substantially increased risk of adverse outcomes across a number of child measures from behaviour and learning to mental health up to 18 years later. The observational study known as the British Avon Longitudinal Study of Parents and Children(ALSPAC) has followed over 9800 women who were pregnant in the early 1990s. In the latest findings, published in JAMA psychiatry, the researchers noted that women who still had moderate to severe depression at eight months postpartum, were likely to still have depression 11 years later. And the children of these women had a four- fold increased risk of behaviour problems as a pre-schooler, twice the risk of being poor at maths in high school and a seven fold increased risk of depression as an adult. Conversely, if the postpartum depression was not persistent at either the moderate or severe level there appeared to be no increased risk of behaviour and learning problems or depression in the offspring, which is reassuring. The study findings published in JAMA psychiatry raise a number of interesting questions. “Having established a highly vulnerable group of mothers still does not answer the question of what to do about interventions, or who, when, or how to treat,” the author of an accompanying editorial says. The design of the study meant the researchers were unable to determine the effects of maternal treatment on reducing postpartum depression and improving child outcomes. As the editorial author also points out, there is also considerable debate whether treatment should focus mainly on the mother and her illness or be directed at the mother-infant relationship. Nonetheless, it is clear that, as a first step at least, these mothers with persistent severe depression need to be identified. Screening for depression which now focuses on pregnancy and the immediate postpartum period needs to be extended to a year after delivery. “Screening both early and late in the first postpartum year will enable the identification of women with persistent [postnatal depression] and thus the offer of appropriate treatment,” the study authors concluded. Ref: JAMA Psychiatry doi:10.1001/jamapsychiatry.2017.4363 doi:10.1001/jamapsychiatry.2017.4265

By Dr Linda Calabresi
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