News in brief

AN “impressive reduction” in HIV incidence in people taking daily oral pre-exposure prophylaxis (PrEP) without a measurable increase in other sexually transmitted infections “strongly” supported adding PrEP to the current standard of prevention for men who have sex with men at risk of HIV infection, according to the authors of new research published in The Lancet. PROUD, an open-label randomised trial conducted at 13 sexual health clinics in England, included HIV-negative gay and other men who had sex with men who had had anal intercourse without a condom in the previous 90 days. Participants were randomly assigned to receive daily combined tenofovir disoproxil fumarate (245 mg) and emtricitabine (200 mg) either immediately or after a 1-year deferral. Of the 544 participants, 275 were in the immediate group and 269 in the deferred group. The researchers wrote that, based on evidence of effectiveness before the trail ended, the trial steering committee recommended all deferred participants be offered PrEP. Follow-up for HIV incidence was complete for 94% in the immediate group and 90% in the deferred group. Three HIV infections occurred in the immediate group and 20 in the deferred group. The researchers said the reduction in HIV incidence exceeded any placebo-controlled trial results, As well, the proportion of sexually transmitted infections, including rectal gonorrhoea or chlamydia, did not differ significantly between the groups. However, they wrote that a potential disadvantage of PrEP was the generation of drug-resistant viruses and the resulting loss of treatment options. An accompanying commentary said the results from PROUD “suggest that pragmatic deployment of PrEP must be part of any relevant primary HIV prevention strategy. Identifying and offering treatment to all people with HIV must also be a priority for their personal health, and to decrease HIV transmission”.

 

THE most common source of transmission of pertussis infection to infants has changed from mothers to siblings, a US study has found. The research, published in Pediatrics, included 1306 infants aged less than 1 year who were identified at pertussis surveillance sites between 2006 and 2013. Data on source of infection (SOI) were collected during interviews with each patient’s parent or guardian. The authors defined SOI as a person with cough illness consistent with pertussis who had contact with the infant within the 7–20 day period before the infant’s cough onset. A total of 24.2% of cases occurred in infants aged less than 2 months. An SOI was identified in 569 cases. More than 66% of SOIs were immediate family members, most commonly siblings (35.5%), followed by mothers (20.6%) and fathers (10.0%). Mothers had been the predominant SOI until a shift to siblings began in 2008, the authors wrote. Overall, the SOI median age was 14 years, and the median age for sibling SOIs was 8 years. The authors said their results highlighted the changing nature of pertussis epidemiology and that continued monitoring of the source of infant infection through surveillance was important. “With evidence of waning immunity and possible transmission of pertussis through subclinical infections, the current cocooning strategy is unlikely to offer sufficient protection of vulnerable infants”, the authors wrote. Prevention efforts should focus on increasing Tdap vaccination coverage during pregnancy, they wrote, saying “this is currently our best strategy for providing direct protection to the infant, regardless of the changing source of infant infection”.

 

NEW guidelines for the care of patients who survive colorectal cancer (CRC), from the American Cancer Society, have been published in the CA: A Cancer Journal for Clinicians. The guidelines were based on a review of studies, meta-analyses and clinical practice recommendations from the US and other countries, including Australia. They were developed for primary care doctors and identify the essential components of CRC survivorship care — from managing side effects to screening for recurrence or new cancers, encouraging healthy lifestyle changes and improving communication between all care providers. The guideline authors wrote that given the potential impact of CRC and its treatment on the health of patients, “it is imperative that cancer survivors receive high-quality, comprehensive, coordinated follow-up care”. They said that, historically, the focus of clinical follow-up care had been on surveillance for recurrent or new cancers, but it was now clear that the physical and psychosocial effects of CRC must also be managed. “Moreover, cancer survivors need to be counselled on health promotion strategies to help minimise or mitigate these impacts.” A key recommendation in the new guidelines was that patients and primary care doctors should have a survivorship care plan, which included a concise summary of treatment. “Despite gaps in the evidence base regarding critical components of clinical follow-up care, enough evidence exists to provide consensus-based guidelines to improve post-treatment care until additional evidence can be generated”, the authors wrote.

 

LOW resting heart rate (RHR) in late adolescence has been associated with an increased risk for violent and non-violent criminality among men in adulthood in a Swedish study published in JAMA Psychiatry. The researchers used data from several national registers on 710 264 men born between 1958 and 1991. RHR and blood pressure were measured as part of mandatory military conscription assessment at a mean age of 18.2 years. The men were followed up for up to 35.7 years. The outcomes measured were violent and non-violent criminal convictions, and medical treatments or deaths owing to assault and unintentional injuries. The authors found that 40 093 men were convicted of a violent crime during nearly 12.9 million person-years of follow-up. Compared with men with the highest RHR (greater than or equal to 83 beats per minute), those with the lowest RHR (less than or equal to 60 beats per minute) had a 39% higher chance of being convicted of violent crimes and a 25% higher chance of being convicted of non-violent crimes. The authors said their results were “compatible with the theoretical interpretations of low RHR reflecting low arousal or low response to fear”. Further investigation was needed to understand the genetic and environmental mechanisms linking low RHR with the risk for antisocial behaviour, they wrote. An accompanying editorial questioned whether the criminal justice system could continue to ignore the growing body of evidence that established an association between RHR and antisocial behaviour in men, women, children and adults.

 

THE global mortality rate for children under 5 years old has fallen by 53% in the past 25 years, from 90·6 deaths per 1000 livebirths in 1990 to 42·5 in 2015, according to a study by the United Nations Inter-agency Group for Child Mortality Estimation published in The Lancet. The annual number of under-5 deaths worldwide dropped from 12·7 million to 5·9 million. However, only 62 of 195 countries with available data met the Millennium Development Goal (MDG) target for 1990‒2015 to reduce under-5 mortality by two-thirds. Two regions — east Asia and the Pacific, and Latin America and the Caribbean — and 62 countries, including 24 low-income and lower-middle income countries, achieved the MDG target. “Remarkable progress has been made worldwide to improve child survival over the past 25 years”, the authors wrote. Even in sub-Saharan Africa, the region with the highest under-5 mortality rate in the world, the annual rate of reduction in deaths increased from 1·6% in the 1990s to 4·1% in 2000–2015. However, the authors wrote that the toll of the past 25 years was large, with an estimated 236·3 million children worldwide dying before their fifth birthday. The authors called on countries and the international community to take “immediate action to accelerate further the pace of progress to fulfil children’s rights to health and development”. An accompanying commentary said that the world had the necessary means to save the lives of infants, providing “a moral imperative to implement the efficacious child survival interventions that are now available”.

 

AN analysis published in the CMAJ has called for continued medical research into psychedelic drugs, saying they might offer new ways to treat mental illness and addiction in patients who do not benefit from currently available treatments. The authors, from the Multidisciplinary Association for Psychedelic Studies — Canada, wrote that since the 1970s most psychedelic substances had been classified as “drugs of abuse” with no recognised medical value. “However, controlled clinical studies have recently been conducted to assess the basic psychopharmacological properties and therapeutic efficacy of these drugs as adjuncts to existing psychotherapeutic approaches”, they wrote. These studies included psychedelic-assisted treatments for mental health disorders such as anxiety, addiction and post-traumatic stress disorder, although the authors admitted that results were mostly from small-scale pilot studies with relatively few participants. They also acknowledged potential health risks of these substances, such as precipitation of psychotic breaks in patients with psychotic disorders or a predisposition to these disorders. However, they predicted that if further scientific evidence accumulated on the therapeutic value of psychedelic medicines, specialised clinical training for physicians, nurses, psychologists and other health professionals would be needed to meet an increased demand for such treatments, saying medical school curricula might need to be updated to include the latest knowledge about psychedelic drugs “The re-emerging paradigm of psychedelic medicine may open clinical and therapeutic doors long closed”, they wrote.

 

US researchers have raised concerns about an increasing number of high school students using e-cigarettes to vaporise cannabis. Their research, published in Pediatrics, was based on anonymous surveys completed by 3847 Connecticut high school students in 2014 about their use of e-cigarettes and cannabis. It found using e-cigarettes to vaporise cannabis was common among the students, especially those who reported lifetime dual use of e-cigarettes and cannabis. The researchers wrote that 5.4% of the total sample used e-cigarettes to vaporise cannabis, 18.0% of lifetime e-cigarette users, 18.4% of lifetime cannabis users and 26.5% of lifetime dual users. The students used e-cigarettes to vaporise hash oil and wax infused with delta-9-tetrahydrocannabinol and other portable electronic vaporisers to vaporise dried cannabis leaves. The researchers said that despite its limitations, their study provided important insight into the ways adolescents were vaporising cannabis. “In addition to potential negative health outcomes, the fact that adolescents are vaporizing cannabis may have other consequences”, they wrote.