International move to control scabies
A DIVERSE group of physicians, policymakers and researchers from five continents have formed the International Alliance for the Control of Scabies, describing infection with the parasite as one of the world’s most neglected diseases. The objectives of the alliance, which includes Australian experts, were outlined in a Viewpoint article published in PLOS Neglected Tropical Diseases. The authors of the article said that scabies affected people in all countries, but particularly those in the most vulnerable societies. “Children in developing countries are most susceptible, with an average prevalence of 5–10%”, they wrote. “The highest incidence is in tropical climates, with rates of up to 25% overall and up to 50% in some communities in the South Pacific and northern Australia.” The authors described the huge public health burden caused by the complications and secondary effects of scabies. “Infestation is frequently complicated by bacterial skin infection, including impetigo, cellulitis, and abscess due to Streptococcus pyogenes and Staphylococcus aureus. Such bacterial skin infections predispose to serious suppurative and nonsuppurative sequelae”, they wrote. Members of the new alliance have exchanged ideas on what they consider to be the priority areas of advocacy, epidemiology, control strategies and biological research, with working groups established to plan progress on those themes. “There are many obstacles on the road toward control of human scabies, but the effects on children, families, and communities worldwide, particularly the underappreciated downstream effects, are a strong impetus for us to embark on the campaign”, the authors wrote.

Probiotic benefits in doubt
RESEARCHERS have recommended against probiotic preparations for elderly people to reduce the incidence of antibiotic-associated diarrhoea (AAD) after finding they make little difference. The multicentre randomised controlled trial, published in The Lancet, included nearly 3000 inpatients aged 65 years and older, with about half assigned to receive a multistrain preparation of lactobacilli and bifidobacteria, and half to receive placebo. The researchers found similar primary outcomes — the occurrence of AAD within 8 weeks and Clostridium difficile diarrhoea (CDD) within 12 weeks of recruitment — in both groups. In the group receiving the probiotic, ADD (including CDD) occurred in 10.8% of participants versus 10.4% in the placebo group (P = 0.71). “Analysis of secondary outcomes including diarrhoea severity, frequency of abdominal symptoms, length of hospital stay, and quality of life showed no evidence of a beneficial effect attributable to the microbial preparation”, the researchers wrote. They said there had been problems obtaining stool samples for testing in about 40% of participants with diarrhoea, a problem that had been reported in previous trials. An accompanying commentary said the study, described as “large and rigorous”, did raise questions about the cost-effectiveness of probiotics.

Big variations in natural gestation length
THE length of gestation after natural conception varies considerably, even when measured exactly, according to research published in Human Reproduction. Even after excluding preterm births and women with pregnancy-related medical conditions, researchers have found that gestational length varied by 37 days. They wrote that this suggested much of the variability observed reflected natural variation. The prospective cohort study followed 125 singleton pregnancies from unassisted conception to birth, with detailed hormonal measurements through the conception cycle. Ovulation, implantation and corpus luteum rescue pattern were identified with urinary hormone measurements. The median time from ovulation to birth was 268 days (38 weeks, 2 days). The researchers found the coefficient of variation was higher when measured by last menstrual period (4.9%) than by ovulation (3.7%), reflecting the variability of time of ovulation. “We are not aware of previous data on length of human pregnancy based on precise measures of ovulation in naturally conceiving women”, the researchers wrote. They said in pregnant women a due date was based on 280 days from the last menstrual period. However, they suggested a more evidence-based approach might be to assign a range of due dates, such as the interquartile range in which half of women will deliver, or to describe the due date as a median of when women would deliver. “Clinical prediction of dates might also consider the lengths of a woman’s other pregnancies”, they wrote. “In our data, the average length of a woman’s other pregnancies was strongly related to gestational length in her study pregnancy.”

Arthritis a risk for DVT
A LARGE cohort study involving the entire population of Taiwan from 1998 to 2008 has found a significant increased risk of venous thromboembolism (VTE) in patients with rheumatoid arthritis (RA). From a cohort of 23.74 million people, the research, published in the Annals of Rheumatic Diseases, was based on 29 238 RA patients (77% women, mean age 52.4 years) and 116 952 controls, who were followed for 193 753 and 792 941 person-years, respectively. The researchers found the risk of developing deep vein thrombosis (DVT) was 3.36-fold and of developing pulmonary embolism (PE) was 2.07-fold in patients with RA compared with controls, after adjusting for age, sex and comorbidities. “Although the patients with RA in this study had a higher prevalence of comorbidities and coexistent conditions associated with the development of VTE than the comparison cohort, RA remains an independent risk factor for developing DVT and PE after adjusting for covariates”, the researchers wrote. “These findings highlight the importance of a multidisciplinary team adopting an integrated approach to the intervention of potential risk factors among patients with RA.”

High glucose levels linked to dementia
HIGH glucose levels are associated with an increased risk of dementia, according to research published in the New England Journal of Medicine. Researchers used clinical measurements of glucose and glycated haemoglobin levels from 2967 study participants. They found that among participants without diabetes, higher average glucose levels of 115 mg/dL (6.4 mmol/L) compared with 100 mg/dL (5.5 mmol/L) in the preceding 5 years were related to an increased risk of dementia, with an adjusted hazard ratio (AHR) for dementia of 1.18 (95% confidence interval [CI], 1.04–1.33). In participants with diabetes, higher average glucose levels of 190 mg/dL (10.5 mmol/L) compared with 160 mg/dL (8.9 mmol/L) were also related to an increased risk of dementia, with an AHR of 1.40. The researchers said the findings were consistent across a variety of sensitivity analyses. “These data suggest that higher levels of glucose may have deleterious effects on the aging brain”, they wrote. “Our findings underscore the potential consequences of temporal trends in obesity and diabetes and suggest the need for interventions that reduce glucose levels.” The authors concluded that the underlying mechanisms of the association between elevated glucose levels and dementia “need to be clarified”.

Health coaching no help
A TELEPHONE health coaching service designed to reduce hospital use and associated costs has been shown to increase emergency admissions, outpatient attendances and secondary care costs, according to research in the BMJ. The Birmingham OwnHealth service was set up in 2006 to “improve self care strategies, improve clinical indicators, and reduce health service use” in patients with heart failure, coronary heart disease, diabetes or chronic obstructive pulmonary disease. The study was based on 2703 patients enrolled in the service from general practice who were assigned a care manager who made regular 15-minute telephone calls to the patients, usually at monthly intervals, with a minority receiving calls more frequently based on disease severity, social isolation or severe weather. The 2698 controls received usual care. The researchers found emergency admissions increased by 0.05 per head more among the intervention group than matched controls, a relative increase of 13.6%. Outpatient attendances rose by 0.37 per head more among intervention patients, and secondary care costs increased by £175 per head more among intervention patients. “There was no evidence of reductions in hospital admissions, and no savings were detected from which to offset the cost of the intervention”, the researchers wrote. “The study serves as a warning that efficacy as demonstrated by randomised controlled trials might not imply effectiveness in routine practice.”


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