[Correspondence] Should the cutoff for hypertension in older adults be different from younger adults?

The American College of Cardiology and American Heart Association has modified the definition of hypertension in adults.1 In this definition, blood pressure is divided into four groups, including normal blood pressure, elevated blood pressure, stage 1 hypertension, and stage 2 hypertension. These cutoffs were chosen on the basis of the relationship between systolic blood pressure (SBP) and diastolic blood pressure (DBP) with the incidence of cardiovascular diseases.1

[Comment] Intergenerational burden and risks of NCDs: need to promote maternal and child health

The 2018 Political Declaration adopted at the third UN High-Level Meeting on the Prevention and Control of Non-communicable Diseases (NCDs)1 states that investment and progress towards the NCD reduction target set out in Sustainable Development Goal 3.4 have been insufficient. Meanwhile, the Global Burden of Disease Study 20172 showed no countries projected to meet the reduction in mortality from NCDs by 2030.

[Correspondence] Yellow fever: the Pacific should be prepared

We can anticipate the emergences of arboviruses, even if predicting them with high accuracy is impossible.1 Countries infested with Aedes (Stegomyia) aegypti mosquitoes should be prepared for detection, prevention, surveillance, and clinical management of disease transmitted by A aegypti,1 especially those diseases causing severe and fatal infections and for which effective preventive measures exist, such as safe and affordable vaccines.

Preventing heart disease – a continuing story

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

Public Health England (PHE) is the organisation responsible for the oversight of all preventive activity in England. This ranges from vigilance for infectious disease outbreaks and epidemics, through immunisation programs, to advice and support for prevention in general practice – including that relating to non-communicable diseases, especially circulatory disorders.

With the increased prevalence of cardiovascular disease in an ageing population, PHE has been reviewing investment in its prevention strategy. (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/749866/CVD_ROI_tool_final_report.pdf)

As in Australia, since the mid-1960s, deaths in middle age from heart attack have decreased in England by well over 50 per cent. This is attributable, almost equally as best we can tell, to improvements due to primary prevention, most notably dramatic downturns in smoking, and to improved treatment.

Falls in the rate of ‘sudden death’, which are substantial, are an obvious place where primary prevention is working. But the evidence is difficult to collect and assess. As Earl Ford, an American epidemiologist, and Simon Capewell, a clinical epidemiologist from Liverpool University in the UK, wrote in 2011 (www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031210-101211), “Changes in risk factors may explain approximately from 44 per cent to 76 per cent of declining CHD mortality and treatments may explain approximately from 23 per cent to 47 per cent. Thus, both prevention and treatments have contributed immensely to the decline in CHD mortality.”

Nevertheless, despite these advances, cardiovascular disease remains a major problem. This year, according to calculations from the Australian Heart Foundation, based on data from the Bureau of Statistics, about 8,000 Australians will die from a heart attack.

Heart attack death was previously restricted to economically advanced societies, but it now spread widely through economically developing, and even the poorest, nations. Here, death from heart disease follows the pattern we saw in Australia before the decline in mortality began in the 1960s, namely, middle-aged men and women, rather than the elderly, being at serious risk. Our effectiveness in managing infectious disease in those less affluent countries means that those people are now more prone to the degenerative diseases familiar to us.

What is the scope for prevention in clinical practice? A survey this year by the Heart Foundation found: “One in two Australians who have had a heart attack [and there are about 40,000 of them under 55] continue to smoke. Of these, close to 40 per cent did not even attempt to quit … almost one in four have failed to regularly monitor their blood pressure levels. More than a quarter are not having regular cholesterol checks. Around one in three tried to increase their physical activity levels or lose weight, however failed to maintain the changes.”

In clinical practice, prevention of death – and disability – from cardiovascular disease is a deep concern –a frequent reason for consultation and prescription and a major consumer of time in general practice.

Despite the lack of information about outcomes, Public Health England, with help from the University of Sheffield, examined the available evidence for what works and how much it costs (including general practitioners’ time). PHE settled on five interventions – detection and treatment which had merit both in terms of medical outcome and cost for:

Hypertension
Atrial fibrillation (anticoagulation)
Hypercholesterolaemia
Diabetes
Non-diabetic hyperglycaemia (‘pre-diabetes’)
Chronic kidney disease.

Based on a 2014 health survey in England, the prevalence of individuals aged 16+ with one or more of these high risk conditions was 49 per cent.

The best evidence concerning effective interventions for each condition was then assembled, along with data on the cost of the most effective interventions and the duration of likely effect following the interventions. This information was combined into a package which allows individual practitioners to calculate the local costs and benefits of these interventions in their practice.

“The single intervention with the highest net total savings in the short term (years 2-5) is to optimise the proportion of people taking statins… a saving of £700 million in England [total population: 45 million] by year five. However, in the long term (20 years), optimising antihypertensive treatment is the single intervention predicted to save the most money (over £2 billion)… but most of the lifestyle interventions are not cost-saving over 20 years.”

What may we conclude for Australia? Among the preventive interventions for managing cardiovascular disease in general, and heart disease in particular, we are committed to long-term care for optimal effect. This may not become obvious for 20 years, but this is not to gainsay it.

Preventive treatment requires a philosophy of long-term care and support to be effective.

[Perspectives] How much should we be worried?

Global health is in the midst of an uncertain, confusing, and uncomfortable passage. Donor financing for infectious disease control has plateaued and is in decline, while low-income national governments are loath to pick up the slack and state leaders, especially in Africa, have largely exited the stage. Expensive and competing priorities spotlighted in the Sustainable Development Goals—non-communicable diseases, universal health coverage—are capturing the headlines at glossy global summits and stand at the centre of the WHO Director-General’s vision for revitalising WHO, at a suggested price tag exceeding US$10 billion in new funds.

[World Report] US CDC task force to investigate acute flaccid myelitis cases

Over 100 cases of acute flaccid myelitis, an infectious disease that is still poorly understood, have been detected in the USA so far this year. Sharmila Devi reports.

Smoking fathers, low sperm sons

A new study has linked low sperm count in some men to the fact that their fathers smoked while their mothers were pregnant.

Research has long shown the link between maternal smoking during pregnancy and reduced sperm count in male offspring, but Sweden’s Lund University has now made a link to smoking fathers.

The research team has found that men whose fathers smoked at the time of pregnancy had half as many sperm as those with non-smoking fathers.

This is independent of nicotine exposure from the mother.

News Medical reports that the study was conducted on 104 Swedish men aged between 17 and 20.

“Once the researchers had adjusted for the mother’s own exposure to nicotine, socioeconomic factors, and the sons’ own smoking, men with fathers who smoked had a 41 per cent lower sperm concentration and 51 per cent fewer sperm than men with non-smoking fathers,” the report states.

The research team at Lund University claim discovery of this point and is the first to publish.

Researcher Jonatan Axelsson, specialist physician in occupational and environmental medicine, said he was “very surprised” that, regardless of the mother’s level of exposure to nicotine, the sperm count of the men whose fathers smoked was so much lower.

“Unlike the maternal ovum, the father’s gametes divide continuously throughout life and mutations often occur at the precise moment of cell division,” he said.

“We know that tobacco smoke contains many substances that cause mutations so one can imagine that, at the time of conception, the gametes have undergone mutations and thereby pass on genes that result in reduced sperm quality in the male offspring.

“We know there is a link between sperm count and chances of pregnancy, so that could affect the possibility for these men to have children in future. The father’s smoking is also linked to a shorter reproductive lifespan in daughters, so the notion that everything depends on whether the mother smokes or not doesn’t seem convincing. Future research could perhaps move us closer to a causal link.”

News Medical states: The biomarker cotinine is a metabolite from nicotine which can be measured in the blood. By measuring the level of cotinine, researchers can see whether the parents themselves smoke or whether they have been exposed to passive smoking. Many previous studies have shown that it is harmful to the fetus if the mother smokes but, in this study, the link between the father’s smoking habit and the son’s sperm count is even clearer.

Most newly occurring mutations (known as de novo mutations) come via the father and there are also links between the father’s age and a number of complex diseases. In addition, researchers have observed that smoking is linked to DNA damage in sperm and that smokers have more breaks in the DNA strand. Children of fathers who smoke have been reported to have up to four times as many mutations in a certain repetitive part of the DNA as children of non-smoking fathers.

Brain mapper finds hidden region

World-renowned cartographer of the brain, Scientia Professor George Paxinos AO from Neuroscience Research Australia (NeuRA), has discovered a hidden region of the human brain.

The region is found near the brain-spinal cord junction and Professor Paxinos has named it the Endorestiform Nucleus.

Professor Paxinos suspected the existence of the Endorestiform Nucleus 30 years ago but has only now been able to see it with better staining and imaging techniques. Commenting on this discovery, Professor Paxinos said it’s like finding a new star.

“There is nothing more pleasant for a neuroscientist than identifying a hitherto unknown area of the human brain. In this case, there is also the intrigue that this area is absent in monkeys and other animals,” said Professor Paxinos, adding, “there have to be some things that are unique about the human brain besides its larger size, and this may be one of them.”

The discovery of new brain regions helps researchers to explore cures for diseases including Alzheimer’s, Parkinson’s disease and motor neuron disease.The Endorestiform Nucleus was noticed when Professor Paxinos introduced the use of chemical stains, combined with imaging techniques, in the production of his latest atlas.

The Endorestiform Nucleus is located within the inferior cerebellar peduncle, an area that integrates sensory and motor information to refine our posture, balance and fine movements.

“I can only guess as to its function, but given the part of the brain where it has been found, it might be involved in fine motor control,” said Professor Paxinos.

Many neuroscientists researching neurological or psychiatric diseases, in humans or animal models, use Professor Paxinos’ maps as guides for their work.

An increasingly detailed understanding of the architecture and connectivity of the nervous system has been central to most major discoveries in neuroscience in the past 100 years.

“Professor Paxinos’ atlases, showing detailed morphology and connections of the human brain and spinal cord, provide a critical framework for researchers to test hypotheses from synaptic function to treatments for diseases of the brain,” said Professor Peter Schofield, CEO at NeuRA.

“It is truly an honour for Elsevier to be continuing Professor Paxinos’ legacy of publishing with us,” said Natalie Farra, Senior Editor at Elsevier. “His books are world-renowned for their expertise and utility for brain mapping, and for their contributions to our understanding of the structure, function and development of the brain.”

Professor Paxinos is the author of the most cited publication in neuroscience and another 52 books of highly detailed maps of the brain. The maps chart the course for neurosurgery and neuroscience research, enabling exploration, discovery and the development of treatments for diseases and disorders of the brain.

The discovery of the Endorestiform Nucleus, is detailed in Professor Paxinos latest book titled Human Brainstem: Cytoarchitecture, Chemoarchitecture, Myeloarchitecture.

[Comment] Transforming the landscape of liver disease in the UK

In 2014, The Lancet published the inaugural report of the Lancet Commission on Liver Disease in the UK.1 With mortality from liver diseases having risen four-fold over the previous four decades, the report was timely and urgently needed. Led by Roger Williams of the UK’s Foundation for Liver Research, Institute of Hepatology, King’s College London, the Commission provided a comprehensive analysis of the disease burden in the UK and carefully examined access to, and quality of, care for patients with liver disease.

First ever multi-drug Ebola trial for the Congo

The Ministry of Health of the Democratic Republic of the Congo (DRC) has announced that a randomised control trial has begun to evaluate the effectiveness and safety of drugs used in the treatment of Ebola patients.

The trial is the first-ever multi drug trial for an Ebola treatment. It will form part of a multi-outbreak, multi-country study that was agreed to by partners under a World Health Organisation (WHO) initiative.

Until now, more than 160 patients have been treated with investigational therapeutics under an ethical framework developed by WHO, in consultation with experts in the field and the DRC, called the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI).

The MEURI protocol was not designed to evaluate the drugs. Now that protocols for trials are in place, patients will be offered treatments under that framework in the facilities where the trial has started. In others, compassionate use will continue up to the time when they join the randomisation. Patients will not be treated noticeably differently from before, though the treatment they receive will be decided by random allocation. The data gathered will become standardised and will be useful for drawing conclusions about the safety and efficacy of the drugs.

“Our country is struck with Ebola outbreaks too often, which also means we have unique expertise in combatting it,” said Dr Olly Ilunga, Minister of Health of the DRC.

“These trials will contribute to building that knowledge, while we continue to respond on every front to bring the current outbreak to an end.”

In October, WHO convened a meeting of international organisations, United Nations partners, countries at risk of Ebola, drug manufacturers and others to agree on a framework to continue trials in the next Ebola outbreak, whenever and wherever that is. Over time, this will lead to an accumulation of evidence that will help to draw robust conclusions across outbreaks about the currently available drugs, and any new ones that may come along.

At the heart of the long-term plan and the current trial is always the goal to ensure that patients with Ebola and their communities are treated with respect and fairness. All patients should be provided with the highest level of care and have access to the most promising medications.

The current trial is coordinated by WHO, and led and sponsored by the DRC’s National Institute for Biomedical Research (INRB), in partnership with the DRC Ministry of Health, the National Institute of Allergy and Infectious Diseases (NIAID) which is part of the United States’ National Institutes of Health, The Alliance for International Medical Action (ALIMA) and other organisations.