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Dr Linda Calabresi
Clinical Articles iconClinical Articles

Baby Boozers

While it appears the message about risky drinking is getting through to younger Australians, baby boomers are as bad as ever. According to a research letter appearing in the latest edition of the MJA, the proportion of 55-70-year-olds who could be classed as high-risk drinkers has risen over the last 15 or so years. The South Australian researchers say this is in ‘stark contrast to the significant decrease in risky drinking among people aged between 12-24 years during the same period.’ And while they do emphasise that by far the majority of older Australians (over 80%) are abstainers or drink at low risk levels, the proportional increase of those now in the high-risk category (from 2.1% in 2004 to 3.1% in 2016) represents an additional 400,000 at-risk individuals – significant in anyone’s language. The findings were based on secondary analyses of data from National drug Strategy Household Surveys conducted in 2004, 2007, 2010, 2013 and 2016. Interestingly the researchers defined the risk categories on the basis of the maximum number of standard alcoholic drinks drunk on a single occasion over the course of a month. So low-risk were those individuals who never consumed more than four drinks in a single session, risky drinkers drank 5-10 drinks in one session at least once a month and high-risk drinkers needed to have drunk 11 or more drinks at least once a month. It’s a slightly different means of assessment to the more common approach of asking about average daily alcohol intake and appears more likely to detect the binge drinker – or your classic ‘social drinker.’ As the letter authors point out, detecting problem drinking in this age group is especially important as this cohort is particularly vulnerable to a range of alcohol-related adverse events from falls to diabetes. Once again, the researchers are looking to GPs to detect those at-risk from drinking among our baby boomer patient population and initiate evidence-based interventions, such as short, opportunistic counselling and information sessions. But they recognise this isn’t always easy. “To facilitate early identification of problem drinking and early intervention, educating health care professionals about patterns and drivers of alcohol consumption by older people should be a priority,” the authors said. Perhaps using the study’s categorisation technique of the maximum number of drinks consumed in a single session might go some way to detecting those at risk.  

Referernce:

Roche AM, Kostadinov V. Baby boomers and booze: we should be worried about how older Australians are drinking. Med J Aust. 2019; 210(1): 38-9. DOI: 10.5694/mja2.12025. Available from: https://www.mja.com.au/journal/2019/210/1/baby-boomers-and-booze-we-should-be-worried-about-how-older-australians-are
Expert/s: Dr Linda Calabresi
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Martyn Lloyd Jones
Clinical Articles iconClinical Articles

Here’s why Doctors are Backing Pill Testing at Music Festivals Across Australia

For many years experts in the field of drug policy in Australia have known existing policies are failing. Crude messages (calls for total abstinence: “just say no to drugs”) and even cruder enforcement strategies (harsher penalties, criminalisation of drug users) have had no impact on the use of drugs or the extent of their harmful effects on the community. Whether we like it or not, drug use is common in our society, especially among young people. In 2016 43% of people aged 14 and older reported they had used an illicit drug at some point in their lifetime. And 28% of people in their twenties said they had used illicit drugs in the past year. The use of MDMA (the active ingredient in ecstasy) is common and increasing among young people. In the last three months alone five people have died as a result of using illicit drugs at music festivals and many more have been taken to hospital. The rigid and inflexible attitudes of current policy-makers contrast dramatically with the innovative approaches to public health policy for which Australia was once renowned. Since the 1970s many highly successful campaigns have improved road safety, increased immunisation rates in children and helped prevent the spread of blood-borne virus infections. The wearing of seatbelts was made compulsory throughout Australia in the early 1970s. Randomised breath testing and the wearing of helmets by bike riders were introduced in the 1980s. These measures alone have saved many thousands of lives. The introduction of needle exchange and methadone treatment programs in the late 1980s and, more recently, widespread access to effective treatments for hepatitis C have dramatically reduced the health burden from devastating infections such as HIV and the incidence of serious liver disease. Each of these programs had to overcome vigorous and sustained hostility from opponents who argued they would do more harm than good. But in all cases the pessimists were proved wrong. Safety measures on the roads did not cause car drivers and bike riders to behave more recklessly. The availability of clean needles did not increase intravenous drug use. Easier access to condoms did not lead to greater risk taking and more cases of AIDS. We believe — along with many other experts in the field — that as was the case for these earlier programs, the evidence presently available is sufficient to justify the careful introduction of trials of pill testing around Australia. Specifically, we support the availability of facilities to allow young people at venues or events where drug taking is acknowledged to be likely to seek advice about the substances they’re considering ingesting. These facilities should include tests for the presence of known toxins or contaminants to help avert the dangerous effects they may produce. Such a program should be undertaken in addition to, and not instead of, other strategies to discourage or deter young people from taking illicit drugs. Although pill testing has been widely and successfully applied in many European countries over a twenty year period, it has to be admitted the evidence about the degree of its effectiveness remains incomplete. That’s why any program in Australia should be linked to a rigorously designed data collection process to assess its impact and consequences. However, we do know that the argument that pill testing programs will increase drug use and its associated harms is very unlikely to be true. Most people seeking advice about the constituents of their drugs will not take them if they are advised that they contain dangerous contaminants. And it’s easy to avoid false reassurances about safety by careful explanations and detailed information. The opportunity to provide face-to-face advice to young people about the risks of drug taking is one of the great strengths of pill testing programs. Over the last half century we have learnt public health programs have to utilise multiple strategies and provide messages carefully and tailored for different audiences. What works to combat the harms associated with drug-taking in prisons is different from what works for specific cultural groups or for young people attending music festivals. The available evidence suggests pill testing is an effective and useful approach to harm minimisation in this last group. We believe it has the capacity to decrease ambulance calls to festival-goers, help change behaviour and save lives. It has taken until now for pill testing techniques to be developed to a level where they are able to identify the constituents in analysed samples with sufficient precision, reliability and speed. These techniques, and the range of substances for which they can test, will continue to improve over time. On the basis of experience gained in the UK, Europe and Australia it’s clear pill testing is now feasible and practicable. The members of the Australasian Chapter of Addiction Medicine within the Royal Australasian College of Physicians are the main clinical experts in the field of addiction medicine in this country. Together with the Australian Medical Association and many prominent members of the community with experience in this area we feel this is the time for pill testing to be introduced, albeit in careful and controlled circumstances. We believe this position is also supported by peer users, concerned families, and past and present members of police forces across Australia. The fact the “War on Drugs” has failed does not mean we should give up. There are many new weapons available to us, as we have learnt from the successful public health campaigns of the past. Pill testing will not abolish all the harms associated with drug taking, but if handled carefully, carries the likelihood of reducing them significantly. Martyn Lloyd Jones, Honorary Senior Lecturer, University of Melbourne and Paul Komesaroff, Professor of Medicine, Monash University This article is republished from The Conversation under a Creative Commons license. Read the original article.

Expert/s: Martyn Lloyd Jones, Prof Paul Komesaroff
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Loubaba Mamluk
Clinical Articles iconClinical Articles

Health Risks of Light Drinking in Pregnancy Confirms that Abstention is the Safest Approach

While heavy drinking is clearly harmful to the unborn baby, often leading to miscarriage, premature birth and foetal alcohol syndrome, the possible effects of light drinking have been less clear. High quality data on this issue is lacking due to ethical and methodological issues. On the one hand, experiments (clinical trials) in this area are impossible to conduct. Clinical trials would include randomising a group of pregnant women to drinking alcohol, which is clearly unethical. On the other hand, in observational studies we can never be sure whether the results are due to alcohol or other factors, such as wealth or education.

‘One glass is OK, isn’t it?’

Women often ask about “safe” levels of drinking during pregnancy. The distinction between light drinking and abstinence is indeed the point of most tension and confusion for health professionals and pregnant women, and public health guidance varies worldwide. Our new review of the evidence, published in BMJ Open, shows that this specific question is not being researched thoroughly enough. As there can be no clinical trial research carried out on this topic, we systematically reviewed all the data from a wide range of high quality observational studies. These studies involved pregnant women, or women trying to conceive, who reported on their alcohol use before the baby was born. The researchers assessed the impact of light drinking, compared with no alcohol at all.   >> Read More Source: The Conversation
Expert/s: Loubaba Mamluk, Luisa Zuccolo
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Dr Linda Calabresi
Clinical Articles iconClinical Articles

A Missed Opportunity

Patients are still not consistently being prescribed exercise despite the wealth of evidence that shows its health benefit, according to an editorial in the latest issue of the MJA. The authors, all sports medicine specialists point to statistics showing physical inactivity being the fourth leading cause of morbidity and mortality worldwide. And they reiterate the well-proven benefits of exercise in helping to manage a wide array of chronic diseases from diabetes to depression. Even though physicians have a good track record of influencing lifestyle factors as evidenced by smoking cessation rates, it appears when it comes to exercise GPs are dropping the ball. “Most physicians do not regularly assess or prescribe physical activity or specific exercises,” said the editorial authors who included GP, Dr Anita Green, Chief Medical Officer of the Gold Coast Commonwealth Games. “Even when exercise is advised by physicians, the advice is often not specific or in depth, and simple evidence-based behaviour modification techniques are not routinely used.” But why is this advice, which is also recommended in the RACGP Handbook of non-drug interventions not being given to patients as a matter of routine? One of the greatest barriers to the dispensing of this advice, according to the editorial, is the clinician not practising what he or she should be preaching. “It has been consistently shown that physically active clinicians are more likely to provide physical activity counselling to their patients,” the authors said. And apparently the medical profession could do better in terms of regular exercise. Physical activity levels have been shown to decline during medical training and through residency, perhaps unsurprisingly. More emphasis needs to be placed on the importance of physical activity and exercise prescription as part of both undergraduate and postgraduate training, not only to help clinicians to help their patients but also to help clinicians help themselves. According to the editorial, the current Gold Coast 2018 Commonwealth Games are likely to inspire the next generation of elite athletes to commit to specialised exercise regimens and dedicated training rituals. However, for the vast majority of the sports-viewing population, the spectacle is unlikely to prove sufficiently inspirational to prize them off the couch. If the medical profession really wants to achieve better health outcomes for their inactive patients, it appears they need to lead by example. “Physicians should unequivocally incorporate physical activity into their own daily routine, for their own health benefit, and to become an exercise role model, more confident in prescribing exercise to their patients,” the authors concluded. Ref: MJA doi: 10.5694/mja18.00033

Expert/s: Dr Linda Calabresi
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Dr Linda Calabresi
Clinical Articles iconClinical Articles

Advice for shift workers

We know night shift work is not good for your health. Evidence shows night shift work is associated with an increased risk of sleep loss, occupational accidents, obesity and weight gain, type 2 diabetes, coronary heart disease, and breast, prostate and colorectal cancers, according to a review in the BMJ by two intensive care specialists. But what of strategies to help night shift workers mitigate these risks? What does the research say we should be advising these patients to do to optimise their health, remembering that many health professionals will be involved in this type of shift work? According to the review, there is a ‘paucity of adequately powered, well designed, randomised controlled trials’ on the subject however from what there was and with the addition of expert opinion the review authors recommended the following.
  • Try and make sure you’re not sleep-deprived before a night shift. Try and wake the morning before naturally (without an alarm) and, if possible have a daytime nap maybe taking advantage of that ‘circadian dip’ between 2 and 6pm the afternoon before you front up for night duty.
  • If you get the opportunity to nap during the night shift, try to limit the duration of these to less than 30 minutes, “to avoid slow wave sleep followed by grogginess on waking, known as ‘sleep inertia’”, the authors advise.
  • Caffeine reduces sleepiness and improves performance 20-45 minutes after taking it, with the effect lasting up to five hours.
  • There is evidence that drugs such as modafinil are effective in reducing sleepiness in night shift workers compared with placebo but these drugs have been associated with skin reactions and their long-term safety is yet to be established. Similarly, exposure to bright light has been proposed as a possible means of inhibiting melatonin, reducing sleepiness and perhaps reducing the cancer risk associated with shift work but neither these drugs nor bright light exposure is supported by sufficient evidence to be conclusively recommended.
  • Hunger and digestion are both affected by circadian rhythm. There is some evidence to suggest if you don’t eat you’ll perform better over the duration of the night shift than if you eat, however it is likely you will experience hunger and will be more likely to get GI symptoms leading the authors to recommend a main meal immediately before the shift and then small snacks as required to stave off hunger overnight.
  • And the big one. How to optimise sleep between night shifts? Well- the recommendations are fairly predictable – avoid bright light on the way home (wear sunglasses), employ blue screens on your computer and phone, use eye masks and ear plugs and develop a predictable pre-bed routine. Avoid caffeine for at least six hours before sleep time and perhaps consider taking melatonin the morning after a night shift –some evidence suggests that this increases sleep duration by up to 24 minutes.
“A meta-analysis of 66 studies concluded that regular exercise leads to improvement in sleep quantity and quality, but the optimum timing, duration, and type of exercise for sleep promotion have yet to be determined,” they said. In addition, the review authors didn’t recommend any other sleeping tablets due to a lack of quality evidence of their effectiveness and the risk of dependency. Finally, the researchers advised night shift workers to be aware their performance is likely to be reduced especially in that particularly vulnerable time between 3 and 5am and therefore they should seek support when required to do critical tasks at this time. They also warned workers to be aware of their vulnerability when driving home after night shift and referred to a patient, the inspiration for this review, who experienced the life-changing consequences of being involved in a road traffic accident while on a set of night shifts in 2005. Ref: BMJ 2018; 360:j5637 doi: 10.1136/bmj.j5637

Expert/s: Dr Linda Calabresi
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Emeritus Prof Simon Chapman AO
Clinical Articles iconClinical Articles

Depressing news for smokers

Using prescription drugs or over-the-counter products like gums, mints or patches won’t increase your chances of quitting smoking a year later, according to a new study. The US researchers followed two groups of people 2002/03 and 2010/11 and found at the end of the 12-month period, those using varenicline (sold in Australia as Champix), bupropion (Zyban), or nicotine-replacement therapy (gums, mints or patches) were no more likely to have quit smoking for 30 days or more than those who didn’t use these drugs.
Read more – Weekly Dose: Champix’s effectiveness is questionable and safety record is concerning

Evidence based smoking cessation?

We’re told the best way to quit smoking is to use an “evidence-based” method: a strategy supported by high-quality research evidence. And for the last 30 or so years, this has been nicotine-replacement therapy, bupropion (Zyban) and varenicline (Champix), which claim to increase (and sometimes double) your chance of success. In the hierarchy of evidence, the lowest form is anecdote or case studies (“I smoked for 20 years, then an alternative therapist sprinkled magic powder on me, and the next day I stopped smoking!”). These cannot withstand the most elementary critical appraisal, starting with the basic question of how many similar smokers sprinkled with the powder kept smoking and how many who went nowhere it also stopped smoking. Far higher up the evidence pyramid is the double-blinded, randomised controlled trial (RCTs). In these, both the person taking the treatment and those delivering it are unware of who is taking the active drug and who is taking the comparison placebo or comparison drug. All enrolled in RCTs are randomly allocated to the active or placebo/comparison groups. The numbers of participants are sufficiently large enough to allow for an outcome to be declared statistically significant (or not) above a chance finding.
Read more – Randomised control trials: what makes them the gold standard in medical research?
Some have tried to dismiss earlier findings about the poor performance of nicotine-replacement therapy by emphasising “indication bias”. In the real world, those who opt to use medications to try to quit are likely to be more intractable smokers, more highly addicted to nicotine, and with histories of failure at quitting unaided. No one should therefore be surprised if they fail more often than those who try to quit on their own. In this new study, this issue was anticipated and all smokers were assessed by what the study authors called a “propensity to quit” score. This score accounts for factors such as smoking intensity, nicotine dependence, their quitting history, self-efficacy to quit, and whether they lived in a smoke-free home where quitting would likely be more supported. In the analysis, those who tried to quit with drugs and those who didn’t were matched on this propensity score, so “like with like” could be compared in the analysis. The findings held even when these “propensity” to quit factors were taken into account.

RCTs are very different to real world use

Critics have long pointed out that RCTs have many features which make them a pale shadow of how drugs are used in the real world. RCTs often exclude people with mental illness, poor English, and no fixed address. Excluding hard-to-reach and treat participants is likely to produce more flattering results. In the real world, people are not paid or otherwise incentivised to keep taking the drugs across the full period of the trial, so compliance is almost always far lower. In the real world, people do not get reminder calls, texts or visits from researchers highly motivated to minimise trial drop-out. There is no “Hawthorne effect”: when trial involvement and the attention paid to participants alters the outcomes. Nicotine-addicted people generally know very quickly if they have been allocated to the placebo arm in NRT trials because their brains feel deprived of nicotine. They invariably experience unpleasant symptoms. Knowing they have been allocated to the placebo undermines the integrity of the trial because it is important participants believe the drug might be effective. Large, real world studies like the one just published, which assess long-term success, not just end-of-treatment or short-term results, are therefore of most importance in assessing effectiveness. These new data ought to cause such rhetoric to cool right down. As for the evidence on e-cigarettes in quitting, neither the US Preventive Health Services Task Force, nor the UK’s National Institute for Health and Care Excellence or Australia’s National Health and Medical Research Council, have endorsed e-cigarettes as an effective way of quitting smoking.
Read more: Want to quit smoking? Switching to e-cigarettes no advantage
Quitting smoking is the single most important thing anyone can do to reduce the likelihood they will get heart or lung disease, and a whole string of cancers. It has been in the clear interests of the pharmaceutical and, more recently, the vaping (e-cigarette) industries, to promote the notion that anyone who tries to quit alone is the equivalent of someone with pneumonia refusing antibiotics. Hundreds of millions around the world have quit smoking without using any pharmaceutical intervention. Before nicotine-replacement therapies became available in the 1980s, many millions of smokers successfully quit smoking without using any drug or nicotine substitute. The same still happens today: most ex-smokers quit by going cold turkey. The ConversationThe problem is, in recent years, the government has moth-balled the national quit campaign, the megaphone for promoting this very positive message. Commercial interests are now commodifying something millions have always done for themselves. Simon Chapman, Emeritus Professor in Public Health, University of Sydney This article was originally published on The Conversation. Read the original article.
Expert/s: Emeritus Prof Simon Chapman AO
pregnancy
Dr Linda Calabresi
Clinical Articles iconClinical Articles

Don’t hold back on giving patches to pregnant smokers

All pregnant women who are smokers should be offered nicotine replacement therapy (NRT) as an option to help them quit, Australian researchers say. In a review published in the MJA, authors said that even though there was a general acknowledgement that there was no firm evidence that proved NRT was safe or effective in pregnancy, all the current guidelines recommend its use for women who couldn’t quit without medication. In a nutshell, NRT is safer than smoking, and smoking during pregnancy is the most important preventable risk factor for poor maternal and infant health outcomes, they said. Despite this, there appears a reluctance among doctors, both here and around the world to prescribe the therapy to pregnant women. The researchers cited a recent survey of Australian GPs and obstetricians that found one in four said they never prescribed NRT in pregnancy. One possible reason for this reluctance, they suggest is the caveats and cautions included in many of the guidelines. Phrases such as ‘only if women are motivated’, ‘only give out two weeks’ supply’ and ‘under close supervision’ hardly inspire confidence in the safety of the therapy. “Ambiguous messages may be contributing to the low NRT prescribing rates and, therefore, it is important to provide a clear practical message to health practitioners and women,” they said. After analysing the various guidelines, the researchers suggest using the strength of the urge to smoke as well as how frequently the urge to smoke occurs to help assess when a woman needs to start or increase the dose of their NRT. “The most important guidance for NRT in pregnancy is to use the lowest possible dose that is effective. However, to be effective, women should be instructed to use as much as needed to deal with cravings,” they advised. They also recommend women be encouraged to use NRT for at least 12 weeks or longer if required to ensure they don’t relapse. All smokers who are pregnant should be told “There is nothing better for you and your baby’s health than to quit smoking.” Ref: MJA  Online first 4.12.17 doi:10.5694/mja17.00446

Expert/s: Dr Linda Calabresi
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Diana Lucia
Clinical Articles iconClinical Articles

Alcohol A Risk For Fathers-To-Be

Abstaining from alcohol during preconception and pregnancy is usually considered to be the woman’s responsibility. The main concern surrounding alcohol exposure during pregnancy often relates to well-established evidence of newborns developing a range of behavioural, physical and cognitive disabilities later in life. But recent research is also pointing to a link between alcohol and poor sperm development, meaning the onus is on expectant fathers too. A myriad of studies are showing biological fathers who drink alcohol may have a significant role in causing health problems in their children. Studies are showing paternal alcohol consumption has negative effects at all levels of the male reproductive system. This is as well as altered neurological, behavioural and biochemical outcomes in subsequent generations.
Read more: Hey dad, your health affects your baby’s well-being too

Men and risky drinking

In Australia, men consume alcohol at high or risky levels on a regular basis. National health guidelines recommend no more than two standard drinks on any day. According to the National Alcohol and Drug Knowledgebase, Australian men usually drink more alcohol than women. Data has shown males are twice more likely than females to consume more than two standard drinks per day on average over a 12-month period (24% compared with 9.8%). And about a third of males said they exceeded the guideline not to drink more than five standard drinks on a single occasion on a monthly basis.

Booze and swimmers

These figures are alarming given the compelling evidence about the impact of excessive, chronic or binge alcohol consumption on sperm, semen quality, fertility and child health.
Read more: Dads get postnatal depression too
Animal studies have shown a single dose of ethanol into the stomach lining (equivalent to a human binge drinking) induces damage to the testis, damaging the cells essential for sperm formation. In another experimental study, sperm health and fertility was assessed in male rats after administration of alcohol into the stomach for ten weeks. The results confirmed alcohol significantly reduced sperm concentration and the ability of the sperm to move properly. And none of the rats exposed to alcohol fertilised the females, despite confirmation of successful mating. A myriad of other non-human studies have also shown similar results, suggesting ethanol has the ability to damage sperm and fertility. Studies in humans have also supported these findings. A recent study of 1,221 young Danish men (18-28 years of age) tracked alcohol consumption in the week preceding the study to determine its effects on semen quality (volume, concentration, total count, and shape). The results showed sperm concentration, total sperm count and percentage of sperm with normal shape got worse the more the men drank. This association was observed in men reporting at least five units of alcohol in a typical week, but was most pronounced for men with a typical intake of more than 25 units a week. This suggests even modest habitual alcohol consumption of more than five units a week can negatively affect semen quality.
Read more: Mother knows best? Fathers missing in research about kids
A recent review of studies and meta-analysis of population data replicated many of these findings. The main results showed daily alcohol intake at moderate to high levels had a detrimental effect on semen volume and normal shape.

The effects on children

Limited studies have tracked the drinking patterns of fathers around the time of conception and subsequent health outcomes of the child. But rodent models have shown changes in offspring weight and development, learning and activity, anxiety related behaviours and molecular and physiological effects. A study also reported the women whose partners consumed ten or more drinks per week prior to conception had two to five times increased risk of miscarriage compared to those whose partners did not drink during preconception. Other studies provide some preliminary evidence that paternal preconception alcohol use is associated with acute leukemia at high-level use, heart malformation with daily use, microcephaly with low to moderate use, and effects in relation to fetal growth and mild cognitive impairments.

How can alcohol affect kids before they’re born?

The exact mechanism of how alcohol alters developing sperm and the later health outcomes of the foetus is still not yet fully understood. It’s been suggested alcohol can change the micro-environment within the testes, altering the development and maturation of the sperm. It’s also been suggested alcohol can influence sperm by creating genetic alterations and epigenetic marks. This means changes to gene expression occur without changes to the underlying DNA sequence. These epigenetic marks can be transferred at the time of fertilisation. This can subsequently alter the molecular makeup of the early embryo, leading to alterations in foetal development and the potential to impair offspring health. The biggest hurdle for researchers now is continuing to translate findings from the basic sciences to more sophisticated research in humans. The next stage is to identify patterns of alcohol use by men during the preconception period on foetal and childhood outcomes in the Australian context. The ConversationBut most importantly we need to realise decisions about alcohol use during the preconception period are not the sole responsibility of women. We need to be talking to men about these issues to ensure healthy outcomes for the baby. Diana Lucia, PhD candidate, Neuroscience, School of Biomedical Sciences, The University of Queensland and Karen Moritz, Professor, The Univeristy of Queensland, The University of Queensland This article was originally published on The Conversation. Read the original article.
Expert/s: Diana Lucia, Prof Karen Moritz

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