Volume 210 Issue 9

Using genetic profiles to predict obesity risk at birthUS researchers have devised a scoring system based on genetic markers that predicts an individual's inborn risk for obesity. Based upon data from the largest genome‐wide study of obesity, they applied new algorithms to integrate information from more than 2 million genetic variants affecting body mass index (BMI). The resulting score accurately predicted BMI and obesity in more than 300 000 individuals from birth to middle age. The study, published in Cell, also revealed that some people are much more susceptible to obesity than others: those scoring in the top 10% were more than 13 kg heavier on average than those in the lowest 10%, and were 25 times as likely to develop severe obesity. The impact of the score was discernable from about the age of 3 years. While the score is not a perfect predictor — some people with a genetic predisposition never become obese — the researchers contend that genetic profiles can help identify high risk individuals and help doctors recommend approaches to avoiding health risks associated with a high BMI. The microarray genetic test, costing $US50 per person tested, detects variations and mutations among millions of genetic markers. The authors believe their scoring approach will eventually be useful for predicting genetic risks for a range of health conditions, such as heart disease, breast cancer, and atrial fibrillation. Interventions might include prescribing preventive cholesterol‐lowering medication, lifestyle counselling, or using wearable technology to detect irregular heartbeat. https://www.cell.com/cell/fulltext/S0092-8674(19)30290-9 Oxytocin could help treat alcohol use disorderThe neuropeptide oxytocin blocks increased drinking in alcohol‐dependent rats, according to a US study published in PLOS Biology. Targeting the oxytocin system, the authors noted, may provide novel pharmaceutical interventions for treating alcohol use disorder. Oxytocin can reduce consumption, withdrawal symptoms, and drug‐seeking behaviour associated with several drugs of misuse, and showed promise as a pharmacological approach to treating drug addiction. In order to understand how oxytocin achieves these effects, the investigators tested the hypothesis that oxytocin would reverse the maladaptive brain changes that develop in alcohol dependence and thereby reduce alcohol drinking in an established rat model of alcohol dependence. The authors investigated the effects of oxytocin on dependence‐induced alcohol consumption and on signaling by the inhibitory neurotransmitter γ‐aminobutyric acid (GABA) in the central nucleus of the amygdala (CeA), a key brain region in the network affected by alcohol dependence. Their results indicated that oxytocin administered systemically, intranasally, or directly into the brain reduced drinking in alcohol‐dependent but not in non‐alcohol‐dependent rats, and also blocked GABA signaling in the CeA, suggesting that oxytocin blocks increased drinking by altering CeA GABA transmission. These results provide evidence that anomalies in the oxytocin system may underlie alcohol use disorder and that targeting this system, possibly by intranasal administration of oxytocin, could be a useful therapy for people who misuse alcohol. https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.2006421

Cate Swannell

Prison-based antiviral treatment for chronic hepatitis C is a critical element of the national elimination goal

Timothy Papaluca · Margaret E Hellard · Alexander J V Thompson · Andrew R Lloyd

Tailored guidelines are needed to support strategies for dementia risk reduction

Emily You · Kathryn A Ellis · Kay Cox · Nicola T Lautenschlager

The gait, arms, legs and spine (GALS) screen improves confidence and competence in the examination of the joints

Jane Dacre

A 77-year-old woman with a background of hypertension, diet-controlled type 2 diabetes and bilateral cataract surgery was referred by her GP to the emergency department

Stuart Campbell · Emma Hack · Babu Philip

Differences in life expectancy within countries are as important as international comparisons

Adrian E Bauman

Personal contact is crucial for encouraging patients to participate

Pardeep S Jhund

Improving control of health risk factors will be required for further substantial life expectancy increases

Alan D Lopez · Tim Adair

Novel, multifaceted recruitment methods are needed to obtain adequate participation in Australian randomised controlled trials

Roseanne Peel · Shu Ren · Alexis Hure · Tiffany‐Jane Evans · Catherine A D'Este · Walter P Abhayaratna · Andrew M Tonkin · Ingrid Hopper · Amanda G Thrift · Christopher R Levi · Jonathan Sturm · David Durrheim · Joseph Hung · Tom G Briffa · Derek P Chew · Phil Anderson · Lynelle Moon · Mark McEvoy · Philip M Hansbro · David A Newby · John R Attia

Correct swabbing technique and caution when interpreting negative results are needed

Daniel P O'Brien · Maria Globan · Janet M Fyfe · Caroline J Lavender · Adrian Murrie · Damian Flanagan · Peter Meggyesy · Jonathan T Priestley · David Leslie

A low threshold for investigation and treatment of CVD in COPD and COPD in CVD is essential

Paul Leong · Martin I Macdonald · Brian S Ko · Phil G Bardin

With the advent of better biomarkers and disease-modifying therapeutics in the near future, the era of precision health is coming of age in COPD

Ma'en Obeidat · Mohsen Sadatsafavi · Don D Sin

To the Editor: Patients may require long term anticoagulation for reasons that commonly include deep vein thrombosis, pulmonary embolism or atrial fibrillation.1 In these circumstances, heparin is commonly used for bridging and is discontinued after the effects of warfarin result in a therapeutic international normalisation ratio. It takes approximately 5 days for this to occur because warfarin inhibits the production of vitamin K‐dependent clotting factors II, VII, IX and X.2 The time to therapeutic anticoagulation is a reflection of the half‐lives of the circulating clotting factors and the time for them to diminish from the plasma. This has been our mindset for decades from the perspective of warfarin use. The introduction of direct‐acting oral anticoagulants (DOACs), such as apixaban, dabigatran and rivaroxaban, has resulted in important logistical and clinical benefits in patients admitted to hospital. For example, bridging with heparin is no longer needed3 because DOACs directly inhibit circulating clotting factors resulting in a relatively quick onset of anticoagulation. The maximum concentration in the plasma is achieved within a few hours, which also mirrors its anticoagulant effect.4 Unfortunately, based on internal audits at our institution, our medication safety committee has identified cases in which DOACs were combined with heparin or low molecular weight heparin. During a 38‐day audit period, there were 14 cases involving such duplication. Based on anecdotal discussions, this duplication is partly related to the prescribers’ lack of knowledge with regards to DOACs. Nurses or pharmacists usually intercepted these events such that the overlap occurred for a few doses and no patients were harmed. In the shift from warfarin to DOACs, inadvertent and unnecessary duplicate anticoagulation due to bridging increases the risk of bleeding. Although we seldom use absolutes, we can confidently endorse that there are no circumstances in which DOACs should be combined with another anticoagulant. Prescriber education and clear institutional guidelines may help deal with this issue. In addition, institutions with electronic medical records could optimise clinical decision support systems to prevent such duplication. The combination of DOACs with heparin is a bridge to nowhere.

Mark A Sheppard · Russell Levy · Asad E Patanwala

To the Editor: Recent Australian surveys of gluten content in gluten‐free labelled foods purchased from supermarkets or restaurants are reminders of the difficulties faced by patients with coeliac disease.1,2,3 Despite trying to adhere to a gluten‐free diet, significant inadvertent gluten exposure is common, leaving about 30% of patients with incomplete intestinal mucosal healing.4,5 In Australia, a “no detectable gluten” standard applies to food labelled gluten‐free. However, surveys published in the Journal reported detectable gluten in 14% of imported gluten‐free foods (0.5–1.1 parts per million [ppm]),2 in 9% of gluten‐free marketed restaurant foods in Melbourne (5.2 to > 80 ppm),3 and in 2.7% of “commonly purchased” gluten‐free foods (5–49 ppm), including foods manufactured in dedicated gluten‐free factories.1 The governance of the compliance with the gluten‐free food code is unsatisfactory; the testing of gluten‐free foods is done by the food industry. Despite a multilayered food code bureaucracy, there is no federal or state oversight of testing, and test results are not published. State authorities have not investigated the non‐compliance reported for imported gluten‐free foods in 2016.2 Local governments are responsible for implementing state food laws, yet, they cannot coordinate oversight of gluten testing nationally. The federal Department of Agriculture and Water Resources is responsible for imported foods, but there is no evidence they test gluten‐free foods imported from jurisdictions that permit up to 20 ppm gluten. The Australian Competition and Consumer Commission is responsible for the Australian Consumer Law, and Food Standards Australia and New Zealand establishes the food code standard; however, there has been no indication by either agency that they consider the problems with the gluten‐free standard or its governance a sufficient public health issue to warrant changes to current practices. Inadvertent gluten exposure may occur by cross‐contamination from known gluten‐containing foods, or from foods considered free of gluten by listed ingredients but not labelled gluten‐free. The very least that patients with coeliac disease should expect is negligible additional contamination from foods that are labelled gluten‐free. Transparent testing of gluten‐free labelled foods is therefore critical. It is unlikely that the government will implement regular testing programs in place of the current ad hoc and unreported industry‐based testing. However, mandating the regular publication of laboratory test results is a simple measure to reassure consumers with coeliac disease, and would likely be a positive initiative for local gluten‐free food exporters seeking to take international advantage of the tight Australian gluten‐free standard.

Geoffrey M Forbes

To the Editor: Bateson and Black1 do a great service in encouraging clinicians to discuss pre‐conception care with women of reproductive age.1 However, in relation to infection prevention, one area not discussed was cytomegalovirus (CMV) infection, which is the most common infectious cause and the second most common aetiology of all causes of severe congenital malformations.2 Mother to child transmission of CMV can result in prematurity, stillbirth, cerebral palsy and neurodevelopmental delay and is the most common infectious cause of hearing loss.2 Discussions about CMV prevention should ideally commence before pregnancy, as maternal CMV infection in the first trimester poses the greatest risk of harm to the fetus if mother to child transmission occurs. Such discussions should continue throughout pregnancy, as secondary maternal infection with a different strain of CMV can also result in mother to child transmission of virus,2 although the risk per infectious event is lower. Women can adopt simple hygiene strategies to reduce risk of CMV infection and thus reduce mother to child transmission of virus during pregnancy. These recommendations have been published3 and referenced in consensus recommendations2 and other sources.4 Strategies preventing women acquiring CMV (usually from children)3 are acceptable and inexpensive — handwashing, not sharing food or objects covered with children's saliva, not kissing children on the lips and wearing disposable gloves during nappy changes. These strategies reduce the risk of infection before pregnancy and of mother to child transmission during pregnancy;2 they do not affect reactivation of latent virus, although this is associated with lower mother to child transmission. Universal serological screening with CMV IgG to determine previous immunity is not recommended, as congenital CMV can still occur as a result of non‐primary maternal infection and reactivation during pregnancy. Women should be advised to use hygiene strategies regardless of their serological status.2 In Australia, only one in six women who are pregnant know about CMV,5 and only one in ten maternity clinicians routinely discuss CMV prevention with pregnant women.6 It is likely fewer discuss CMV prevention before conception. We encourage clinicians, women considering pregnancy and parents to increase their knowledge about CMV and its prevention.4

Antonia Shand · Pamela Palasanthiran · William D Rawlinson

In reply

Deborah J Bateson · Kirsten I Black