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BMJ 2011; 343 doi: (Published 17 August 2011) Cite this as: BMJ 2011;343:d5239

Violence against women is strongly linked with common mental disorders

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More than a quarter of Australian women experience at least one type of gender based violence at some time in their life. In a nationally representative survey of 4451 women, aged 16-85 years, this included intimate partner physical violence, rape, other forms of sexual assault, and stalking. The survey also used structured interviews that had been validated for diagnosing common mental disorders. The overall lifetime prevalence of such disorders among these women was estimated at 38%, with a prevalence of 25% for anxiety, 18% for mood disorders, 14% for substance use disorders, and 10% for post-traumatic stress disorder (PTSD).

Only 28% of women who had not been exposed to any of the four types of gender based violence had ever had one of these mental disorders, compared with 57% of women exposed to one form of violence and 89% of women exposed to three or four forms. Risk of any mental disorder, as well as all disorders individually, consistently increased with the number of forms of gender based violence to which women were exposed.

The link was particularly strong for PTSD. Compared with women who had not been exposed to gender based violence, those who had been exposed to one form were almost three times as likely to experience PTSD (odds ratio 2.82, 95% CI 2.01 to 3.95). These figures were 6.04 (3.87 to 9.42) and 15.90 (8.32 to 30.20) for exposure to two and three or four types of violence, respectively. Analyses were adjusted for a wide range of demographic, social, and economic factors, as well as personal and family medical history.

Rivaroxaban seems non-inferior to warfarin in atrial fibrillation

Rivaroxaban, a factor Xa inhibitor that is taken orally, may offer an alternative to warfarin for the prevention of clotting in patients with atrial fibrillation. In a recent trial, 14 264 patients with non-valvular atrial fibrillation were randomly assigned to 20 mg of rivaroxaban once a day or warfarin. All had a moderate to high risk of stroke because of a previous stroke or transient ischaemic attack, systemic embolism, or presence of risk factors such as heart failure, hypertension, old age, or diabetes. Participants and doctors were blinded to allocation, and median follow-up was just under two years.

Both in the per protocol analysis, prespecified as primary, and in the intention to treat analysis, rivaroxaban was non-inferior to warfarin for the primary outcome—a composite of stroke or systemic embolism. In the intention to treat analysis, the primary outcome occurred in 269 patients allocated to rivaroxaban (2.1% a year) and in 306 patients allocated to warfarin (2.4% a year) (hazard ratio 0.88, 95% CI 0.74 to 1.03; P<0.001 for non-inferiority; P=0.12 for superiority). Overall rates of bleeding did not differ between the groups, although intracranial bleeding was less common with rivaroxaban (0.5% v 0.7% with warfarin), as was bleeding that ended with death (0.2% v 0.5%).

The editorialists (doi:10.1056/NEJMe1107516) think that oral alternatives to warfarin have finally arrived for patients with atrial fibrillation. These alternatives include rivaroxaban, as well as dabigatran—a direct thrombin inhibitor also shown in a previous trial not to be inferior to warfarin. However, they note the lack of antidotes for these new agents that would enable rapid reversal of anticoagulation in case of life threatening bleeding or surgery.

Drug combo may help in infection of the pleura

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About a third of patients with infection of the pleura need surgery, and up to one in five die, despite treatment with antibiotics and drainage through a chest tube. A previous trial showed no benefit of streptokinase applied intraplurally in these patients, although it has been hypothesised that application of fibrinolytic drugs might break up intrapleural fibrinous divides and thus improve chest tube drainage and possibly other outcomes, such as hospital stay.

A new factorial two by two trial tested a different fibrinolytic—tissue plasminogen activator, alone or combined with recombinant human DNase—against placebo. It was hoped that DNase might decrease viscosity and reduce biofilm formation, also improving drainage. However, none of the measured outcomes improved when each drug was given on its own. On the contrary, when given alone, DNase increased the odds of surgical referral at three months by about 3.5-fold compared with placebo. Treatment with DNase alone should therefore be avoided, despite previous encouraging results from small case series.

However, in combination, tissue plasminogen activator and DNase reduced pleural effusions at day seven, decreased referrals for surgery at three months, and shortened hospital stay by nearly seven days. No differences were seen between the groups for measures of inflammation (white cell count, C reactive protein, or fever), deaths, or adverse events.

A total of 210 patients were included in the trial. The authors call for confirmation of these results in further studies; for now, the new combination treatment might be considered for patients in whom standard drug treatment has failed and surgery is not an option.

Life expectancy is shorter in young black people on dialysis in the US than for their white peers

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Black people have been thought to live longer on dialysis than white people. A study scratched beneath the surface of this finding and showed a different picture once effect modification by age and the competing risk of kidney transplantation were taken into account. The study included all 1.3 million people with newly diagnosed end stage kidney disease in the US between 1995 and 2009.

It turns out that the favourable results for survival of black people with end stage kidney disease who receive dialysis are driven by older age groups; most patients are older than 65 years. But in younger age groups (up to 50 years), black people are up to twice as likely to die while on dialysis as a result of end stage kidney disease. The results were extensively adjusted for comorbidities and socioeconomic factors.

Things are aggravated by the fact that black people receive fewer transplants. For example, about one in five black people in their 30s received a transplant, compared with nearly half of white people in this age group. This should not be the case, because transplantation increases life expectancy in all patients, regardless of age and ethnicity.

Young black people are less likely to have private insurance and more likely to have no insurance than their white peers. But this doesn’t account for all the differences; young black people are more likely to die while on dialysis even if they have private insurance, and even if they have been treated with erythropoietin, a proxy for good quality care.

As little as 15 minutes of exercise each day may prolong life

A study from Taiwan examined the association between physical activity and mortality. In this study, people who did as little as 90 minutes of exercise each week, who would ordinarily be considered physically inactive, were looked at as a separate group. Around 12.5% (28 311/226 493) of those who exercised at all did so for about 15 minutes on six days a week. It turns out that even such low levels of exercise improve survival. The study followed up for an average of eight years more than 400 000 people who underwent regular health check-ups.

Compared with people who exercised very little, those who did not exercise at all had a 17% higher risk of dying from any cause, and an 11% higher risk of dying from cancer. Each extra 15 minutes of daily exercise was linked with a 4% reduction in the risk of dying from any cause, and a 1% lower risk of cancer related death. The results held in both sexes, regardless of age, smoking and drinking habits, and overall risk of cardiovascular disease.

At age 30, men who exercised for 15 minutes each day on average could expect to live 2.6 years longer than their peers who did not exercise at all. This was 3.1 years for women. Among 30 year olds who met the recommendations for physical activity—30 minutes’ exercise on five days a week—men could expect to live 4.2 years longer and women 3.7 years longer, compared with their physically inactive peers.

Linaclotide shows promise for chronic constipation


Two phase III trials tested 145 μg or 290 μg of linaclotide each day against placebo for the relief of chronic constipation. In both trials, linaclotide improved the primary outcome, which was defined as three or more complete spontaneous bowel movements each week and an increase of one or more complete spontaneous bowel movements from baseline during at least nine of the 12 weeks of treatment. This was achieved in about one in five participants allocated to linaclotide, compared with up to 6% of patients receiving placebo. Secondary outcomes—including stool frequency, stool consistency, severity of straining, abdominal discomfort, bloating, and severity of constipation—also improved.

Adverse events were recorded in 60.5% (260/430) of people allocated to 145 μg of linaclotide, 55.7% (235/422) of those who took the 290 μg dose, and 52.1% (221/424) of those allocated to placebo. Diarrhoea was seen in up to 16% of people who took linaclotide compared with 4.7% of those taking placebo. Severe diarrhoea occurred in 1.5% (13/852) of people taking linaclotide compared with 0.2% (1/424) of those allocated to placebo.

Linaclotide is a synthetic peptide that binds to and activates the guanylate cyclase C receptor in the intestinal epithelium. This causes secretion of chloride and bicarbonate into the lumen; fluids follow and this speeds up intestinal transit.

Smoking is linked with more CHD in women than in men

We know that women who smoke have about double the risk of lung cancer compared with men with similar characteristics, but what about coronary heart disease (CHD)? A systematic review combined 86 prospective studies that allowed for comparisons between the sexes.

In an analysis of 2.4 million people, smoking conferred a 1.25-fold higher risk of coronary heart disease in women compared with men. The results were adjusted for the intensity of smoking as well as other cardiovascular risk factors such as serum cholesterol, diabetes, systolic blood pressure, and body mass index.

Women have been shown to be less likely to quit smoking than men, and in some countries they are more likely to take up smoking. A linked editorial (doi:10.1016/S0140-6736(11)61035-0) says that the tobacco industry seems to view women as its growth market, so it is imperative that prevention and cessation interventions are targeted at both sexes.


Cite this as: BMJ 2011;343:d5239

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