Molecular testing best for measles, mumps
MOLECULAR testing has an important role to play in diagnosing measles, mumps and rubella in vaccinated populations, according to a WA research letter published in the MJA. The authors said that with far fewer cases of these diseases now being seen, the clinical acumen and the positive predictive value of a clinical diagnosis had diminished, and that this uncertainty made laboratory testing more important. However, the IgM response could take several days to appear or be absent in post-vaccination infection, which necessitated molecular testing methods, such as polymerase chain reaction (PCR). The authors assessed the mode of laboratory confirmation of notified cases of measles, mumps and rubella in vaccinated, partially vaccinated and unvaccinated patients in WA from 2001 to 2010. Modes of laboratory confirmation included serological testing alone, PCR and serological testing, and PCR alone. During the study period, there were 82 cases of measles, 335 of mumps and 38 of rubella confirmed. Overall, when laboratory-confirmed cases were stratified by vaccination status, the proportion confirmed by PCR alone ranged from 18% in unvaccinated to 71% in the fully vaccinated, including from 21% to 63% for measles, and 22% to 74% for mumps, respectively. The authors said that diagnosis by PCR allowed virus genotyping, which was important for epidemiological purposes and could distinguish wild-type measles virus from the vaccine strain when vaccine was used for post-exposure prophylaxis. “We recommend collection of respiratory specimens, whole blood and/or urine for PCR diagnosis, in addition to serological testing, for laboratory diagnosis in suspected cases of measles, mumps and rubella”, the authors wrote.

Healthy Kids Check needs comprehensive evaluation
A MORE comprehensive evaluation of Healthy Kids Check (HKC) outcomes is needed to determine the true impact of the service on childhood health management, according to a letter published in the MJA. The authors were responding to a previous MJA study that assessed identification rates for health and developmental problems in 4-year-old children before and after HKC services administered by GPs as a one-off assessment. The research showed that HKCs were more likely than routine GP visits to detect oral health, vision and behavioural problems. The authors of the letter said the numbers of height, weight and oral health problems found in the study were surprisingly small. They said national prevalence rates of more than 20% for childhood overweight and 40% for untreated dental caries were not matched by the study findings for height and weight problems, and oral health problems of only 3.2% and 1.8% respectively. While it was possible that the communities involved in the study experienced exceptional health status or that only healthy children attended HKCs, they wrote, it was more likely these problems remained undetected. “Such discrepancies in the rates are significant because HKCs were established, in part, to detect early lifestyle risk factors; an aim that cannot be realised if there is incomplete recording of these developmental indicators.” A response to the letter by two coauthors of the original research agreed with the need for long-term follow-up. However, the coauthors said the overall detection rate of 5% for problems related to height and weight might correspond to the 6%-7% of children aged 5-9 years with obesity, rather than to the additional 15% with overweight. “Does the Healthy Kids Checks detect problems that lead to better child outcomes? We do not know. This is a health policy that has been implemented without adherence to evidence-based practice principles”, they wrote.

Patients prefer phone for test results
PATIENT preferences for how they receive skin biopsy results are changing, according to research published in JAMA Dermatology. The research was based on 301 adult patients attending US melanoma clinics who were surveyed on their preferences for receiving biopsy results; these responses were compared with doctors’ preferred practices for notification. The researchers found 67.1% of the patients surveyed preferred to speak directly to their doctors by telephone to receive results, “followed by a distant second choice (19.5%) of being notified in person at a clinic visit”. Voice message and an online patient portal were each nominated by just 5.1% of patients as the preferred method. “The most important consideration for patients was a communication modality that provided test results in the most rapid manner; 51.7% wanted a method that was rapid, and 7.8% preferred a method that was not only speedy but also allowed them an opportunity to ask questions”, the researchers wrote. Of the 47 doctors who responded to the doctors’ survey, the overall preferred method of contacting patients aligned with patient preference for speaking by telephone (56.5%). However, the doctors were uncertain about guidelines regarding communication of test results. An accompanying commentary said inconsistent and poorly understood regulations in the US about electronic patient-physician communication made it difficult to create a universal standard for all dermatologists. “It may be time to adjust curriculums to include updated paradigms of breaking bad news that integrate current technology”, the commentary said.

Glibenclamide concerns for gestational diabetes
US researchers have found newborns of women with gestational diabetes mellitus (GDM) treated with glyburide (known as glibenclamide in Australia) have an elevated risk of adverse outcomes compared with newborns of women treated with insulin. The large retrospective population-based cohort study of 110 879 women with GDM, published in JAMA Pediatrics, included 9173 (8.3%) who had pharmacological treatment — 4982 treated with glyburide and 4191 treated with insulin. The mean age of the women was 33.5 years. The researchers found the proportion of the cohort treated with glyburide increased from 8.5% in 2000 to 64.4% in 2011. Compared with women treated with insulin, newborns whose mothers were treated with glyburide had a higher risk of neonatal intensive care admission (adjusted risk ratio [aRR], 1.41), respiratory distress (aRR, 1.63), neonatal hypoglycaemia (aRR, 1.40), birth injury (aRR, 1.35) and being large for gestational age (aRR, 1.43). However, they were not at increased risk for obstetric trauma (aRR, 0.92), preterm birth (aRR, 1.06) or jaundice (aRR, 0.96). The likelihood of caesarean delivery was 3% lower in the glyburide group. “These results are consistent with findings from prior studies and suggest that women with GDM being treated with glyburide may not be achieving adequate glucose control”, the researchers wrote. They called for further investigation of these differences in pregnancy outcomes as “a public health priority”. An accompanying editorial said that, despite its limitations, the study “heightens residual concerns about the use of glyburide to treat GDM that need to be resolved before this drug should be recommended for continued use in pregnancy”.

Cardiovascular deaths rise with population ageing and growth
POPULATION ageing and growth accounted for an increase in the number of global deaths from cardiovascular disease between 1990 and 2013, according to research published in the New England Journal of Medicine. The researchers said this increase was despite an overall decrease in age-specific death rates in most regions. They found only a few regions where gains in cardiovascular health “offset these demographic forces to a degree sufficient to cause a decline in the number of cardiovascular deaths”. Mortality data from the Global Burden of Disease Study 2013, based on 188 countries grouped into 21 world regions, were used for the research. The researchers found that, in 2013, the number of people who died from cardiovascular disease was more than 17.3 million, representing an increase from 1990 of 40.8%, despite a decrease in deaths attributable to epidemiological changes of 39.3%. For the most common cause of cardiovascular death — ischaemic heart disease— the number of deaths increased by an estimated 41.7% from 1990 to 2013. “Population aging contributed to an estimated 52.5% increase in these deaths, whereas population growth contributed to an estimated 23.6% increase”, the researchers wrote. “On the basis of these estimates, large reductions in the age-specific risk of death from ischemic heart disease have led to almost 2 million fewer deaths than would have been expected had death rates remained unchanged from 1990.”

Metabolic risks from staying up late
EARLY to bed might not only make patients healthy, wealthy and wise — it may also improve their metabolic profile. A study published in the Journal of Clinical Endocrinology and Metabolism, which included 1620 participants aged 47–59 years recruited from the Korean Genome and Epidemiology Study, has found that staying up late is independently associated with metabolic syndrome and diabetes. The researchers classified participants according to chronotype, described as a trait determining individual circadian preference in behavioural and biological rhythm relative to external light-dark cycle. Chronotype was classified as morning in 29.6% of the participants, evening in 5.9%, and neither morning nor evening in 64.5%. The researchers found that, compared with morning chronotype, evening type was significantly associated with diabetes (odds ratio [OR], 1.73), metabolic syndrome (OR, 1.74) and sarcopenia (muscle loss, OR, 3.16) after adjusting for confounding factors. They also found gender differences, with evening type in men associated with diabetes (OR, 2.98) and sarcopenia (OR, 3.89), but only metabolic syndrome associated with evening type in women (OR, 2.22). “One possible explanation is a greater chance of chronic sleep loss in evening type because lack of sleep exerts deleterious effects on metabolic pathways”, the researchers wrote. They said although average sleep duration was no different between evening and other types in the study, “evening persons are known to accumulate sleep debt on weekdays and then have extended catch-up sleep on the weekend”. It was possible that repetitively occurring sleep loss at least during weekdays contributed to poor metabolic profiles in evening types, they wrote.

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