News in brief

CMV disease in adults a “diagnostic challenge”
THE prevalence and risks associated with cytomegalovirus (CMV) in adults with a normal immune response appears to be greater than previously understood, according to the authors of a Clinical focus article in the MJA. Based on the findings of previous studies, the authors identified CMV as a well recognised pathogen in neonates and immunocompromised adults, but said its incidence in healthy adults was less understood and often asymptomatic. They wrote that case reports demonstrated CMV infection was capable of producing severe disease and a range of potential clinical manifestations, commonly including colitis, in immunocompetent adults. The incidence of severe CMV disease in immunocompetent adults was possibly due to a milder degree of immune dysfunction related to comorbidities such as kidney disease or diabetes mellitus. The authors wrote that there was potential for numerous adverse outcomes if diagnosis of CMV disease in immunocompetent adults was delayed. “Delay in initiation of targeted therapy leads to increasing morbidity and mortality as a result of disease progression”, they said. “Severe CMV disease in immunocompetent adults is likely to remain a diagnostic challenge in many circumstances. However, earlier consideration of CMV as a potential aetiological agent in individuals with atypical or refractory disease, regardless of immune status, may facilitate early non-invasive diagnosis and the initiation of appropriate directed antiviral therapy”, the authors said.

Designer drug dangers exposed
THE dangers of emerging “designer” psychoactive recreational drugs have been revealed in a case report published in the MJA. The authors reported the case of a 44-year-old man who died following intravenous use of α-pyrrolidinopentiophenone (α-PVP) — a type of synthetic cathinone — believed to be the first reported death associated with the drug in Australia. The patient arrived at the intensive care unit with cardiac arrest and later developed cerebral oedema and multiple cerebral infarctions. The authors believed their patient most likely died from complications of exposure to α-PVP. Commonly referred to as “bath salts” or “legal highs”, the drugs were misused for their stimulant and psychoactive effects, the authors wrote. “Clinical features of synthetic cathinone intoxication include cardiovascular, autonomic, neuromuscular and neuropsychiatric symptoms and signs.” They said the single biggest factor influencing this patient’s death from α-PVP was the route of exposure to the drug by intravenous injection. “From toxic kinetic first principles, this results in faster and higher blood concentrations compared with ingestion and nasal insufflation.” The patient tested negative for amphetamines when a urine drug screen was performed, which highlighted that “medical professionals in Australia need to be aware of the limitations of commonly available drug screens, which might not detect new psychoactive substances”, the authors said.

Smoker support for plain packaging surges
AUSTRALIAN researchers have found a surge in support among smokers for the plain packaging (PP) of tobacco products, saying it is prospectively associated with higher levels of quitting. The population-based study, published in Tobacco Control, analysed surveys of Australian smokers on their attitudes towards PP at four time points — four before and one after its implementation in December 2012. The authors found a slight rise in opposition to PP in the lead up to implementation, but no change in support. However, following implementation, support for PP increased significantly from 28.2% to 49%. Only a minority of smokers remained against PP and opposition mainly came from those who smoked heavily or underestimated the health risks, the authors said. Analysis showed that support before and after implementation was predicted by a belief in the greater adverse health impacts of smoking, desire to quit and lower addiction. Smokers who supported the policy were also more interested in quitting and more likely to make attempts to quit in the months following implementation, the authors wrote. However, they were unable to assess whether the increase in support was due to the PP rules, the changes to the warnings, or a response to the total standardised packaging initiative. The authors said their results highlighted that PP implementation had been broadly accepted by smokers in Australia, which increased the likelihood that PP would also be accepted by smokers in other countries.

Good news on chronic hep C survival
PATIENTS with chronic hepatitis C virus (HCV) infection and bridging fibrosis or cirrhosis can have survival rates comparable to the general population if a sustained virological response (SVR) can be attained, researchers have found. A research letter, published in JAMA, compared the survival rate of 530 patients with chronic HCV and advanced hepatic fibrosis against age- and sex-matched controls in the general population. In the study group there were 13 patients with SVR who died, resulting in a cumulative 10-year overall survival rate of 91.1%, which did not differ greatly from the matched controls. In contrast, 100 patients who did not attain SVR died —a survival rate of 74%, which was significantly lower than the general population. The authors said the excellent survival among patients with advanced liver disease and SVR might be explained by the associations between SVR and regression of hepatic inflammation and fibrosis, along with a reduction in diabetes mellitus occurrence, end-stage renal disease and cardiovascular events. “Even though patients with cirrhosis and SVR remain at risk for hepatocellular carcinoma, the annual hepatocellular carcinoma incidence is low and survival is substantially better compared with those without SVR”, the authors wrote. They said a limitation of the study was that all patients received interferon-based therapy, and recommended the results be confirmed when interferon-free therapy is widely used.

Mental illness risks with military deployment
MILITARY personnel who are deployed for more than 13 months over a 3-year period are at increased risk of developing mental illnesses, post-traumatic stress disorder (PTSD) and problems at home, according to research published in The Lancet Psychiatry. The population-based study was based on the results of a questionnaire completed by 3982 UK military personnel between 2007 and 2009, who had been deployed in the previous 3 years. Analysis showed an association between cumulative time deployed and mental illness outcomes, which included a score of 40 or more on the PTSD checklist, psychological distress, problems at home, and multiple physical symptoms. The authors said this link was stronger for participants who had been deployed for more than 13 months, particularly in the categories of PTSD, physical symptoms, and problems with family and relationships compared with those deployed for shorter time periods. However, they found the number of deployments was not associated with worse mental health or problems at home. The authors recommended that cumulative deployments be monitored to “prevent an increase in levels of stress and mental illness in the UK military”. They said their results supported UK guidelines for tour length, known as the Harmony Guidelines, which aimed to limit the maximum period of deployment during a set period of time. An accompanying commentary highlighted the importance of greater “dwell times” between deployments and said the mental health impacts of deployment on other personnel, including humanitarian and disaster relief workers, needed to be investigated. Another study published in JAMA Psychiatry found a high concentration of suicide risk and other adverse outcomes in the 12 months after hospital discharge among active US soldiers who had been hospitalised with psychiatric disorders.

Extreme longevity quest to continue
THE quest to find the secret to living longer will continue after researchers failed to find a link between genetics and extreme human longevity. The study, published in PLOS One involved whole-genome sequencing of 17 supercentenarians (people aged 110 years or older) to explore if there was a genetic basis for why some individuals live longer. The authors found no significant evidence of enrichment for a single rare protein-altering variant or for a gene harbouring different rare protein-altering variants among supercentenarians compared with control genomes. The gene which showed the most enrichment was the TSHZ3 transcription-factor gene and although it did carry protein-altering variants in more of the long-lived subjects than the controls, this difference was not statistically significant, the authors wrote. The genome of one supercentenarian was also found to have a pathogenic mutation in DSC2, known to predispose individuals to arrhythmogenic right ventricular cardiomyopathy. However, even with this pathogenic mutation, the supercentenarian still lived for more than 110 years, the authors wrote. “Supercentenarians are extremely rare and their genomes could hold secrets for the genetic basis of extreme longevity”, they said. The authors made the full DNA sequences of all 17 supercentenarian genomes available as a resource to assist future genetic analyses.