Tributes to AIDS delegates on MH17
THE opening session of the 20th International AIDS Conference in Melbourne last night included tributes to the six delegates who died when the Malaysian Airlines MH17 flight was shot down over the Ukraine. In a media release, the conference organisers said a 1 minute “global moment of remembrance was held in their honour” at the session. Those taking part in the tribute included 11 former, present and future presidents of the International AIDS Society with representatives from the organisations who lost colleagues — the WHO, AIDS Fonds, Stop AIDS Now, The Female Health Company, the Amsterdam Institute for Global Health and Development and members of the Dutch HIV research community. The conference begins today with 12 000 delegates taking part. The conference theme, “Stepping up the pace”, will include discussions on the latest research developments and the status of the epidemic throughout the world. Two Toowoomba doctors — pathologist Dr Roger Guard and his wife, Dr Jill Guard, a retired GP — were also killed in the airline tragedy.

Severe eye injury warnings
TWO letters published in the MJA have highlighted two different, but devastating, modes of eye injury. In one letter ophthalmologists reported on severe alkali burns to the face and eyes of two young workers injured while cleaning beer lines. One patient was a 23-year-old man whose face (60%–80% of facial skin) and both eyes (grade IV 1) were injured while he was using a commercially available beer line cleaner (potassium hydroxide; pH, 14). He was treated according to burns protocol, but a non-healing right corneal ulcer developed, requiring multiple operations. The authors wrote that bilateral reconstructive eyelid surgery was also needed and further surgery was required to preserve his remaining vision (light perception in the right eye and no light perception in the left), as well as ongoing psychological and social support.. The second patient received a grade IV injury to her left eye and underwent multiple operations to heal the ocular surface. After 4 years of treatment, her final visual acuity was light perception. “Alkali injuries to the eye are devastating as they cause liquefactive necrosis and pass rapidly through the cornea to the eye’s internal structures”, the authors wrote. They found there were no mandatory safety guidelines in Australia, and recommended non-vented safety goggles to provide adequate protection be worn throughout the cleaning procedure, from set-up to clean-up. A second letter describes the considerable hazard to eyes from the barbs in tasers, used by police throughout Australia. The authors wrote that TASER International warned that “serious injury, including permanent vision loss” could result from barb contact with the eye. In a literature search the authors found seven case reports and one review of ocular damage relating to taser use. Ocular damage associated with taser use included mydriasis, iritis, macular cysts, lid lacerations, cataracts, retinal detachment, optic neuritis, vitreous haemorrhage and globe penetration, in some cases resulting in total vision loss. The authors wrote that as in the “management of a barbed fish hook penetrating the eye or ocular area, a taser barb should not be removed at the scene but should be immobilised (eg, by covering it with a foam or paper cup) until appropriate ophthalmic surgical removal is possible”.

Familial link found for cerebral palsy
NEW research suggests cerebral palsy includes a genetic component, providing additional evidence that the underlying causes of cerebral palsy extend beyond the clinical management of delivery. The population-based cohort study, published in the BMJ, included more than two million Norwegians born between 1967 and 2002, using national registries and linkages among families to identify 3649 cases of cerebral palsy. The researchers found a 15-fold increased risk of cerebral palsy among co-twins of cerebral palsy cases, a six- to ninefold increased risk among first degree relatives of a person with cerebral palsy, an up to threefold increased risk among second degree relatives, and a 1.5-fold increased risk among third degree relatives. “The pattern of stronger associations in more closely related family members points to a genetic cause, but this is not the only possible interpretation”, the researchers wrote. They speculated that aggregation of conditions within families could also reflect a shared environment or shared interactions between genes and environment. “The ‘dose-response’ relation, from a 15-fold increased risk among twins to a 1.5-fold increased risk among third degree relatives, is compatible with multifactorial inheritance, in which several genes act in concert with each other and with the environment to produce the phenotype”, they wrote. However, they warned that their measures of familial risk might not be generalisable to genetically different populations. “In pursuing the enigma of cerebral palsy, future aetiological studies should consider the possibility of genetic causes as well as genetic susceptibility to environmental causes”, they wrote. An accompanying editorial said the “excellent study” illustrated that the “elusive search for the causes of neurodisabilities such as cerebral palsy is far from over. While we wait, however, we must remember that cerebral palsy remains a relatively infrequent occurrence at about 2 per 1000 live births in developed countries”.

Niacin therapy risks too high in CVD
AN editorial published in the New England Journal of Medicine says niacin (nicotinic acid) “must be considered to have an unacceptable toxicity profile for the majority of patients, and it should not be used routinely” to raise HDL cholesterol levels. The editorial, commenting on two studies published in the NEJM, said consistent findings of a lack of benefit from raising high-density lipoprotein (HDL) cholesterol levels with the use of niacin added to low-density lipoprotein cholesterol–lowering therapy with statins “seriously undermine the hypothesis that HDL cholesterol is a causal risk factor” in cardiovascular disease despite the fact that higher HDL cholesterol levels are associated with better cardiovascular outcomes. In the Heart Protection Study 2–Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2-THRIVE) study published in the NEJM, researchers randomly assigned 25 673 adults with vascular disease to receive daily treatment with either a combination of 2 g of extended-release niacin and 40 mg of laropiprant, or a matching placebo and followed them for a median of 3.9 years. Although participants on the active treatment achieved lower mean LDL cholesterol levels and higher HDL cholesterol levels than those on placebo, there was no significant effect on the incidence of major vascular events (13.2% for active treatment v 13.7% for controls). Additionally, the niacin–laropiprant group had an increased incidence of serious diabetes diagnoses and of disturbances in diabetes control. They also had increased rates of serious adverse events associated with the gastrointestinal and musculoskeletal systems, skin and “unexpectedly”, infection and bleeding. The second report was based on the Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes (AIM-HIGH) trial, whose main results were reported in 2011 and showed no incremental clinical benefit from the addition of high-dose extended-release niacin to statin therapy during a 36-month mean follow-up in 3414 patients with stable atherosclerotic disease, low baseline levels of HDL cholesterol and elevated triglyceride levels. In a letter to the NEJM, the authors elaborated on the rates of serious adverse events in the AIM-HIGH study population. Overall, they found 34.2% of patients who received extended-release niacin and 32.5% of patients who received placebo had serious adverse events during follow-up. They wrote that there were significant between-group differences in the numbers of serious adverse events in gastrointestinal disorders, and infections and infestations which required further exploration.

Doctors best at signing up as donors
CANADIAN researchers have found that organ donor registration is more likely among doctors than the general public. The research, published in JAMA, also found that younger physicians and women were more likely to register, which was also reflected in general populations. The population-based cross-sectional study included 15 233 physicians, 60 932 matched citizens and 10 866 752 Ontario citizens. A total of 6596 physicians (43.3%) were registered donors compared with 17 975 matched citizens (29.5%) and 2 596 766 of the general public (23.9%). “Physicians were 47% more likely to be registered for organ and tissue donation than matched citizens”, the authors wrote. Among those registered for organ donation, 11.7% of physicians, 14.3% of matched citizens and 16.8% of the general public excluded at least one organ or tissue from donation. The researchers found that half of all physicians were not registered, saying they had no information on the reasons why some physicians did not register.

Pregnancy loss linked to CHD    
RESEARCH published in Annals of Family Medicine suggests that women with a history of miscarriage or stillbirth have a slightly increased risk of total coronary heart disease (CHD) after adjusting for traditional cardiovascular disease (CVD) risk factors and the number of pregnancies. The prospective study found the association between pregnancy loss and CHD appeared to be independent of hypertension, body mass index, waist-to-hip ratio, and white blood cell count. “Moreover, the risk appears greater among women with a history of stillbirth than among women with a history of miscarriage”, they wrote. The research included 77 701 women, with 23 538 (30.3%) reporting a history of miscarriage; 1670 (2.2%) a history of stillbirth and 1673 (2.2%) a history of both miscarriage and stillbirth. The researchers found the multivariable-adjusted odds ratio for CHD for one or more stillbirths was 1.27 compared with no stillbirth; and was 1.19 for women with a history of one miscarriage and 1.18 for two or more miscarriages compared with no miscarriage. For ischaemic stroke, the multivariable odds ratio for stillbirths and miscarriages was not significant. The researchers wrote that although they could not determine the mechanism of the associations, there was a suggestion of a shared cause for pregnancy loss and CHD that required further investigation to better understand the pathophysiologic mechanisms behind the increased risk, such as changes in endothelial function, insulin resistance, inflammation and hypercoagulable states. “Our findings, although not conclusive, suggest that women with a history of miscarriage or a single stillbirth may be at increased CVD risk and should be considered candidates for closer surveillance and/or early intervention by their primary care physician so that risk factors can be carefully monitored and controlled (including monitoring of CVD risk factors — diabetes, hypertension, cholesterol, obesity, smoking, and diet)”, they wrote.

Inhaled steroids can slow growth in kids with asthma
A COCHRANE review has shown that regular use of inhaled corticosteroids (ICS) at low or medium daily doses is associated with statistically significant suppression of children’s growth in the first year of treatment for asthma. The systematic review included 25 trials with 8471 children (5128 ICS-treated and 3343 control) with mild to moderate persistent asthma up to 18 years old, and involved all available ICS except triamcinolone. Six molecules (beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone and mometasone) given at low or medium daily doses were used during a period from 3 months to 4‒6 years. The review showed that ICS as a group suppressed growth rates when compared to placebos or non-steroidal drugs. In 14 of the trials, involving 5717 children, the average growth rate was about 6‒9 cm per year in control groups, but was reduced by about 0.5 cm in the treatment groups. The authors wrote that subgroup analysis indicated that the effect size of ICS on linear growth velocity appeared to be associated more strongly with the ICS molecule than with the device or dose. ICS-induced growth suppression seemed to be maximal during the first year of therapy and less pronounced during subsequent years of treatment. “Although catchup growth up to 12 months after ICS cessation has been documented, limited evidence suggests that ICS-induced growth suppression in children of prepubertal age may persist until they reach adult height”, the authors wrote. “Growth suppression appears neither progressive nor regressive, and it is not cumulative beyond the first year of therapy. Although the well-established benefits of regular use of ICS may outweigh the potential risks of a relatively small and non-cumulative suppression in linear growth in children with persistent asthma, one would suggest that ICS should be prescribed at the lowest effective dose. Moreover, it is prudent to monitor linear growth in children treated with ICS, given that individual susceptibility to these drugs may vary considerably”, they wrote.

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