News in brief

Global plan needed for antibiotic resistance
POOR understanding of the unique features and risks of antibiotic resistance has been cited as an important cause of global complacency about the decreasing effectiveness of antibiotics in treating common infections, according to a multinational report published in The Lancet Infectious Diseases Commission. The report, published ahead of European Antibiotic Awareness Day today and the start of the US Centers for Disease Control and Prevention “Get smart about antibiotics” week, said that although antibiotic resistance was undermining the effective treatment of many important bacterial diseases with high mortality, it lacked the high profile of HIV, tuberculosis and malaria. The authors said the paucity of new antibiotic drugs in recent decades had resulted from a combination of significant scientific challenges, low financial returns for pharmaceutical companies compared with many other medicines such as those for chronic diseases, and the regulatory environment. “Clear information on the health and economic burden of antibiotic resistance is urgently needed to make this complex problem tangible to policy makers”, the report authors wrote. They said the serious threat to public health caused by the rapid loss of antibiotic effectiveness called for global actions and recommended “a health systems thinking approach in the efforts to contain antibiotic resistance”. “We call for a coalition of governments with a strong representation from [low- and middle-income countries] that will work with WHO, UNICEF, UN Development Programme, other UN agencies, other international bodies, science academies, development aid agencies, philanthropists, and civil society organisations to develop a global plan to tackle the antibiotic crisis and share responsibilities for its implementation”, they wrote.

Prostate cancer rates up, deaths down
THE first comprehensive report on prostate cancer, released by the Australian Institute of Health and Welfare, shows the age-standardised incidence of prostate cancer has increased significantly from 79 new cases per 100 000 males in 1982 to 194 in 2009. The report said the increase in incidence was due to the rise in the number of men presenting for testing, changes in diagnostic practices and the ageing population. In 2011, 3294 deaths from prostate cancer were recorded, making it the fourth leading cause of death among Australian males after coronary heart disease, lung cancer and cerebrovascular disease. The report also found that despite the rise in incidence, the age-standardised mortality rate had decreased from 34 deaths per 100 000 males in 1982 to 31 deaths per 100 000 in 2011. “In 2006–2010, around 9 in 10 (92%) males diagnosed with prostate cancer survived 5 years from diagnosis. This is higher than for all cancers among males (65%), as well as other leading cancers among males, including melanoma of the skin (89%) and lung cancer (13%)”, the report said. Aboriginal and Torres Strait Islander males were less likely to be diagnosed with prostate cancer despite being as likely to die from it as non-Indigenous males. The information provided in the report would help “to inform service planning, resource allocation and the evaluation of prostate cancer-related programs and policies”, the authors said.

Midstream testing for cystitis questioned
MANAGING women with cystitis according to cultures from voided midstream urine samples may lead to undertreatment of low-quantity or mixed Escherichia coli infections, or inappropriate treatment, according to research in the New England Journal of Medicine. Women aged 18‒49 years with symptoms of cystitis provided midstream and catheter urine cultures, which were compared for microbial species and colony counts. The researchers found that “colony counts of E. coli as low as 10 to 10² CFU [colony-forming units] per millilitre in midstream urine were sensitive and specific for the presence of E. coli in catheter urine in symptomatic women”. However, the presence of enterococci (in 10% of cultures) and group B streptococci (in 12% of cultures) in midstream urine was not predictive of bladder bacteriuria at any colony count. “The positive predictive values for enterococci and group B streptococci in midstream urine cultures were very low, even at high colony counts, in contrast to the high positive predictive values for E. coli”, the authors wrote. “These data suggest that enterococci and group B streptococci only rarely cause acute uncomplicated cystitis.” An accompanying editorial concluded that “it seems that a vast number of patients are currently receiving unnecessary treatment, causing avoidable adverse effects and contributing to the loss of efficacy of the remaining antimicrobial agents in our dwindling arsenal”.

Recurrent melanomas and nevi differences
A STUDY designed to determine the significance of dermoscopic features of pigmented lesions that recur in scars, published in JAMA Dermatology, has found that, as well as being strongly associated with older age and a longer time to recurrence, dermoscopic features associated with melanoma include circles, especially if the lesion is on the head and neck area, eccentric hyperpigmentation at the periphery, chaotic and non-continuous growth pattern, and pigment traversing the scar’s edge. The retrospective, observational study analysed data from 98 recurrent nevi and 62 recurrent melanomas collected from 15 clinics across 12 countries. Patients with recurrent melanomas were significantly older than those with recurrent nevi (63.1 years vs 30.2). Recurrent melanomas were more frequently located on the head and neck than recurrent nevi (46.8% vs 3.1%); contained circles more often (33.9% vs 7.1%); were more asymmetrical; had more eccentric pigmentation (37.1% vs 21.4%) and had a more chaotic growth pattern (59.7% vs 22.4%). Most significantly, pigmentation traversing the scar’s edge was more often found in recurrent melanoma than recurrent nevi (87.1% vs 42.9%). The researchers said differentiating between recurrent melanomas and recurrent nevi was difficult in a clinical setting and that use of the original pathology slides was preferable. “An excision biopsy of any doubtful recurrent lesion in dermoscopy is the gold standard treatment at present”, the researchers wrote.

Ageing “timebomb” may be furphy
CURRENT measures of population ageing are inaccurate and the concept of the so-called ageing population “timebomb” may be misleading, according to research in the BMJ. The standard indicator of population ageing — the old age dependency ratio — takes the number of people who have reached state pension age and divides it by the number of working age (16‒64 years) adults in order to estimate the proportion of older people relative to those who pay for them. By this count there were 7‒8 adults of working age for every person aged 65 years and over in 1910, a ratio which decreased to just under four adults of working age for every older person in 1980. The researchers argued that the age of a population comprises two components: the years lived by its members (their ages) and their years left (remaining life expectancies). So “although the median age of 24 in 1900 carried a life expectancy of 39 more years, those at the median age of 40 in 2009 could expect to live a further 42 years”, they said. Using a definition of the dependent older population as people with a remaining life expectancy of 15 or less years, they found that “dependency has fallen by one third over the past four decades”. “We should not assume that population ageing itself will strain health and social care systems”, they concluded.

Big drop in digoxin use
RESEARCHERS have found a huge reduction in the use of digoxin since 1997 in the US, despite a trial demonstrating a significant decrease in hospital admissions for heart failure (HF) in patients receiving digoxin therapy. In a research letter, published in JAMA Internal Medicine, the authors wrote that since the publication of the Digitalis Investigation Group (DIG) trial in 1997 digoxin treatment visits dropped by 86%, with the biggest decline between 1997 and 2001, especially for patients with HF. “An increasing number of evidence-based therapies for HF, the perceived toxic effects and challenges of digoxin dosing, and the negative results of the DIG trial with respect to its primary end point of all-cause mortality, may all have contributed to reductions in digoxin use”, the authors wrote. “However, the DIG trial demonstrated a significant decrease in hospital admissions for HF in ambulatory patients receiving digoxin therapy. These changes may be particularly salient to contemporary clinical practice in clinical and policy efforts to reduce inpatient health care utilization for HF.” The authors wrote that the prospect of new prospective randomised trials of digoxin were unlikely, “leaving its fate as an integral part of HF therapy in contemporary practice uncertain”.