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Articles

Read the latest articles relevant to your clinical practice, including exclusive insights from Healthed surveys and polls.

By reading selected clinical articles, you earn CPD in the Educational Activities (EA) category whenever you click the “Claim CPD” button and follow the prompts. 

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Megan Lee & Joanne Bradbury
  • Clinical Articles

Five Types of Food to Increase Your Psychological Well-Being

We all know eating “healthy” food is good for our physical health and can decrease our risk of developing diabetes, cancer, obesity and heart disease. What is not as well known is that eating healthy food is also good for our mental health and can decrease our risk of depression and anxiety. Mental health disorders are increasing at an alarming rate and therapies and medications cost $US2.5 trillion dollars a year globally. There is now evidence dietary changes can decrease the development of mental health issues and alleviate this growing burden. Australia’s clinical guidelines recommend addressing diet when treating depression. Recently there have been major advances addressing the influence certain foods have on psychological well-being. Increasing these nutrients could not only increase personal well-being but could also decrease the cost of mental health issues all around the world. 1. Complex carbohydrates One way to increase psychological well-being is by fuelling brain cells correctly through the carbohydrates in our food. Complex carbohydrates are sugars made up of large molecules contained within fibre and starch. They are found in fruit, vegetables, and wholegrains and are beneficial for brain health as they release glucose slowly into our system. This helps stabilise our mood. Simple carbohydrates found in sugary snacks and drinks create sugar highs and lows that rapidly increase and decrease feelings of happiness and produce a negative effect on our psychological well-being. We often use these types of sugary foods to comfort us when we’re feeling down. But this can create an addiction-like response in the brain, similar to illicit drugs that increase mood for the short term but have negative long-term effects. Increasing intake of complex carbohydrates and decreasing sugary drinks and snacks could be the first step in increased happiness and well-being. 2. Antioxidants Oxidation is a normal process our cells carry out to function. Oxidation produces energy for our body and brain. Unfortunately, this process also creates oxidative stress and more of this happens in the brain than any other part of the body. Chemicals that promote happiness in the brain such as dopamine and serotonin are reduced due to oxidation and this can contribute to a decrease in mental health. Antioxidants found in brightly coloured foods such as fruit and vegetables act as a defence against oxidative stress and inflammation in the brain and body. Antioxidants also repair oxidative damage and scavenge free radicals that cause cell damage in the brain. Eating more antioxidant-rich foods can increase the feel-good chemicals in our brain and heighten mood. Antioxidants can help restore the happy chemicals in the brain. www.shutterstock.com.au 3. Omega 3 Omega 3 are polyunsaturated fatty acids that are involved in the process of converting food into energy. They are important for the health of the brain and the communication of its feel-good chemicals dopamine, serotonin and norepinephrine. Omega 3 fatty acids are commonly found in oily fish, nuts, seeds, leafy vegetables, eggs, and in grass fed meats. Omega 3 has been found to increase brain functioning, can slow down the progression of dementia and may improve symptoms of depression. Omega 3 are essential nutrients that are not readily produced by the body and can only be found in the foods we eat, so it’s imperative we include more foods high in omega 3 in our everyday diet. 4. B vitamins B vitamins play a large role in the production of our brain’s happiness chemicals serotonin and dopamine and can be found in green vegetables, beans, bananas, and beetroot. High amounts of vitamins B6, B12, and folate in the diet have been known to protect against depression and too low amounts to increase the severity of symptoms. Vitamin B deficiency can result in a reduced production of happiness chemicals in our brain and can lead to the onset of low mood that could lead to mental health issues over a long period. Increasing B vitamins in our diet could increase the production of the feel good chemicals in our brain which promote happiness and well-being. 5. Prebiotics and probiotics The trillions of good and bad bacteria living in our tummies also influence our mood, behaviour and brain health. Chemical messengers produced in our stomach influence our emotions, appetite and our reactions to stressful situations. Prebiotics and probiotics found in yoghurt, cheese and fermented foods such as kombucha, sauerkraut and kimchi work on the same pathways in the brain as antidepressant medications and studies have found they might have similar effects. Prebiotics and Probiotics have been found to suppress immune reactions in the body, reduce inflammation in the brain, decrease depressed and anxious states and elevate happy emotions. Incorporating these foods into our diet will not only increase our physical health but will have beneficial effects on our mental health, including reducing our risk of disorders such as depression and anxiety.   Disclosure Statement Megan Lee receives funding from Southern Cross University and Santos Organics Joanne Bradbury receives funding from the Australian Traditional-Medicinal Society (ATMS), Santos Organics, and Metagenics to support academic research

By Megan Lee & Joanne Bradbury
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Kevin Davies, Jessica Eccles & Neil Harrison
  • Clinical Articles

What Causes Fibromyalgia?

Fibromyalgia is something of a mystery. It can’t be detected with scans or blood tests, yet it causes lifelong pain for millions of people. The disease mainly affects women (about 75-90% of cases), causing pain all over the body. Because not all healthcare professionals are adept at identifying and diagnosing fibromyalgia, reported rates of the condition vary greatly from country to country. In China, it affects only 0.8% of people, in France around 1.5%, in Canada 3.3%, and in Turkey 8.8%. Estimates in the US range from 2.2% to 6.4%, and in Russia, about 2% of the population is affected. People with the condition are often diagnosed if they have longstanding muscle pain, bone or joint pain and fatigue. Fibromyalgia can also cause insomnia, “brain fog”, some symptoms of depression or anxiety, as well as a range of other complaints, including irritable bowel syndrome and headache. Many patients are also hypermobile (“double-jointed”), and there is some overlap with chronic fatigue syndrome (also known as ME). Guidelines from the American College of Rheumatology make it clear that the diagnosis should be made using defined criteria based on the “widespread pain index” (which scores the number of painful regions out of 19) coupled with a symptom severity scale. The diagnosis also takes fatigue, generalised pain, unrefreshing sleep and cognitive symptoms into account. It doesn’t matter if the patient has another rheumatic disease, they can still be diagnosed with fibromyalgia. The scoring system, recommended by the American College of Rheumatology, is often used in clinical trials, but in the clinic, most doctors rely on detecting tender points in specific places and on excluding other medical conditions, including rheumatic conditions. Unlike say, rheumatoid arthritis or lupus, the tests do not show clear evidence of inflammation or autoimmunity (when the body’s immune system attacks itself) and scans are normal. The lack of inflammation or structural abnormality in muscles or joints – aside from making diagnosis difficult – is the main reason there are no widely accepted or effective treatments. In rheumatic diseases, where we understand the mechanisms that underlie the condition, we have the most effective treatments. In rheumatoid arthritis, for example, we know that much of the inflammation is caused by a cell-signalling protein (cytokine) called tumour necrosis factor and that blocking the activity of this protein switches off the disease in most patients. A number of possible mechanisms have been proposed in fibromyalgia, including abnormal muscle metabolism, reduced levels of steroid hormones such as cortisol, or abnormal small nerve fibres. But these abnormalities aren’t found in all patients with the condition. As such, they can’t be used as part of a diagnostic test, nor can they help develop treatments. Some experts have suggested that fibromyalgia may be related to abnormalities in the autonomic nervous system – the part of the nervous system that controls bodily functions, such as heart rate and blood pressure – and how the brain responds to pain signals and reacts to external stressors (such as infections). But there is currently no hard evidence to back up this theory. Looking for clues To fill in some of the gaps in our knowledge about this devastating condition, our research team at Brighton and Sussex Medical School is investigating the potential role of the autonomic nervous system and inflammation in fibromyalgia and chronic fatigue syndrome. For our study, we have two groups of patients: one with pain as the main symptom and the other with fatigue as the main symptom. We also have matched controls – people without the disease, but otherwise similar characteristics – to make meaningful comparisons. The study is in two parts. First, we will test the patients’ autonomic nervous system using a tilt-table. This involves tilting the person head downwards to see how well their body adapts to this change in posture by changing heart rate and blood pressure (both of which are monitored during the test).Second, we will stimulate patients’ immune systems with a typhoid vaccine (the normal type used in travellers) and perform magnetic resonance brain scans to look for changes in blood flow and also measure the levels of “inflammatory mediators” (the chemicals the body produces in response to stimuli of this type), to see whether these are higher in the fibromyalgia patients. Our study should, for the first time, help us to address the question of whether there really is an abnormal brain response to inflammation or infection in these patient groups and enable us to explore the relationship between the abnormal functioning of the autonomic nervous system and fibromyalgia and chronic fatigue syndrome. Fibromyalgia rarely goes away and treatment options are limited. Only by developing a proper understanding of the disease processes underlying this condition will doctors be able to make a clear, positive diagnosis, and most importantly, offer effective therapy.   Disclosure Statement Kevin Davies receives funding from AR-UK. Jessica Eccles receives funding from Academy of Medical Sciences, National Institute of Health Research, MQ Neil Harrison receives funding from the Wellcome Trust, Medical Research Council (MRC), Arthritis Research UK, and Janssen Pharmaceuticals.

By Kevin Davies, Jessica Eccles & Neil Harrison
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Dr Linda Calabresi
  • Clinical Articles

Vaccinating the Immunosuppressed – Who, What and When

Vaccination in immunosuppressed adult patients has many facets and can be challenging for GPs who don’t deal with these cases regularly. But there are a few key considerations that can help guide clinicians, says Associate Professor Michael Woodward, Melbourne-based geriatrician, writer, researcher and passionate advocate for health promotion. Firstly, not all immunosuppression is equal. It is important to ascertain the degree of immunosuppression, as some people may be being unnecessarily denied vaccines because they are taking medication that can suppress the immune system but only at higher doses or in different formulations. “For instance, someone who is on inhaled corticosteroids for their asthma or on low dose (less than 20mg) prednisolone daily for just a few weeks is not significantly immunosuppressed and can be vaccinated in the same way as other people,” said Professor Woodward in an interview following his presentation at Healthed’s recent Annual Women's and Children’s Health Update in Perth. However, those on higher doses of steroids or on steroids more long-term, as well as those people who have conditions associated with immunosuppression such as haematological malignancy do need special consideration when it comes to vaccination. Most importantly, live vaccines are not to be given to this group. This includes the new herpes zoster vaccine (Zostavax), which absolutely contraindicated in severely immunocompromised patients. The consequences of inadvertently administering this vaccine to an immunosuppressed patient hit the headlines some months ago, highlighting the importance of this guideline. The other question often asked is whether patients who are known to be immunosuppressed, and therefore at greater risk of significant infections actually need more or stronger doses of the vaccines they are able to have. In some cases that is a very real and worthwhile consideration if you want to achieve the objective of immunoprotection, Professor Woodward said. For example, you might consider giving an immunosuppressed patient the pneumococcal vaccine (Prevenar 13) as opposed to the polysaccharide pneumococcal vaccine (Pneumovax 23). “The conjugate vaccine is generally slightly more likely to produce an immune response [than the polysaccharide vaccine],” he said. The other scenario where GPs might need to be considering vaccination in association with immunosuppression, is in patients who are scheduled for an elective splenectomy. The lack of a spleen is known to be associated with a reduction of the body’s ability to respond to a vaccine, so it is currently recommended that people who are about to undergo a splenectomy have the influenza, pneumococcal and the newer zoster vaccine. In addition, they should be vaccinated against H. influenza B and receive the two meningococcal vaccines currently available. All these are detailed as part of the pre-splenectomy recommendations on the spleen.org.au website, with the exception of the zoster vaccine, as the guidelines have yet to be updated. However, Professor Woodward says most health professionals in this area are advocating the inclusion of the zoster vaccine. Some of these vaccinations may also be given shortly after the removal of the spleen in cases where the splenectomy has been urgent, but this is generally not the remit of the GP. In general, the question of vaccination in the immunosuppressed patient can be complicated. It is a highly specialised area and Professor Woodward suggested, if in doubt GPs might want to seek input from a specialist in this area such as an immunologist or a rheumatologist.

By Dr Linda Calabresi
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Victorian Assisted Reproductive Treatment Authority (VARTA)
  • Clinical Articles

The Importance of Preconception Health for Fertility and a Child’s Future

Fertility Week 2018 starts on October 15. This year’s message, Healthy You, Healthy Baby encourages men and women to consider their health before conception to improve their chance of conceiving, and to do their best for their baby’s future health. It has been known for some time that the general environment of a uterus can cause epigenetic changes to a fetus, but there is now growing evidence that the health of both parents before and at the time of conception influences their chance of conceiving and the short and long-term health of their child. The environment where eggs and sperm mature and the composition of the fluid in the fallopian tube when fertilisation takes place are affected by parents’ general health. So, in addition to the genetic material parents contribute to their children, the health of their eggs and sperm health at the time of maturation and conception has lasting effects on the expression of the genes and the health of the future child. Obesity, smoking, environmental toxins, alcohol, drugs, lack of physical activity and poor nutrition all pose risks to the health of egg and sperm and consequently to the health of a future child. Chronic health conditions such as diabetes and hypertension can also adversely affect gamete health.

Why promoting preconception health in primary health care is important

Whether they are actively trying for a baby or not, people of reproductive age can potentially conceive any time. This is why preconception health messages need to be integrated into primary health care and discussed opportunistically with women and men of reproductive age whenever possible.

Screening for pregnancy intention

A condition for preconception health optimisation is that the pregnancy is planned. To reduce the risk of unintended pregnancy, the ‘Guidelines for preventive activities in general practice’ recommend screening for pregnancy intention in primary health care settings. A promising method for assessing the risk of unintended pregnancy and giving prospective parents the opportunity to optimise their preconception health is the One Key Question® (OKQ) initiative developed by the Oregon Foundation for Reproductive Health. It proposes that women are asked ‘Would you like to become pregnant in the next year?’ as a routine part of primary health care to identify the reproductive health services they need to either avoid pregnancy or increase the chances of a successful one. This non-judgemental approach allows practitioners to provide advice about reliable contraception if the answer is ‘no’ and information about preconception health if the answer is ‘yes’ or ‘maybe’.

Providing preconception health information and care

While a 15-minute consultation will not allow in depth discussions about contraception or preconception health, directing women to reliable sources of information and inviting them to make a time to come back to discuss their reproductive health needs in light of their pregnancy intentions might increase awareness of the importance of preconception health optimisation. Considering the mounting evidence about the role of paternal preconception health for fertility and the health of offspring, men also need to be made aware of the importance of being in the best possible shape in preparation for fatherhood. Directing men to accessible and reliable sources of information about male reproductive health can improve awareness about how they can contribute to the long-term health of their children.

Quality resources

Your Fertility is the Commonwealth Government funded national fertility health promotion program that improves awareness among people of reproductive age and health and education professionals about potentially modifiable factors that affect fertility and reproductive outcomes. A media campaign planned for Fertility Week will encourage men and women to seek the information they need from their GP. The Your Fertility website, www.yourfertility.org.au is designed to assist time-poor practitioners to direct their patients through evidence-based, up-to-date, accessible information about all aspects of female and male reproductive health. Resources on the Fertility Week page include videos from fertility experts, facts sheets and messages tailored for both men and women. Short videos produced for health professionals feature Dr Magdalena Simonis, GP, and Associate Professor Kate Stern, fertility specialist, who both describe their approaches to raising lifestyle issues and fertility with male and female patients of reproductive age. The RACGP’s preconception care checklist for practitioners is available from www.racgp.org.au/AJGP/2018/July/Preconception-care Visit the Your Fertility website content, fact sheets for health professionals and patients help promote the important messages about how healthy parents make heathy babies.   Visit the Your Fertility Website View the Preconception Care Checklist    
By Victorian Assisted Reproductive Treatment Authority (VARTA)
pregnancy
Allison Sigmund
  • Clinical Articles

The Risks Associated with Gestational Diabetes Don’t End After Pregnancy

In Australia 12-14% of pregnancies are affected by gestational diabetes. Despite its prevalence, most people aren’t aware the risks don’t end when the pregnancy does. Diabetes occurs when the level of glucose (sugar) in the blood is higher than normal. Cells in the pancreas control blood glucose levels by producing insulin. When these cells are destroyed, type 1 diabetes results. When the body becomes resistant to the action of insulin and not enough insulin can be made, this is known as type 2 diabetes. Resistance to insulin action occurs for many reasons, including increasing age and body fat, low physical activity, hormone changes, and genetic makeup. Gestational diabetes occurs when high blood glucose levels are detected for the first time during pregnancy. Infrequently, this is due to previously undiagnosed diabetes. More commonly, the diabetes is only related to pregnancy. Pregnancy hormones reduce insulin action and increase insulin demand, in a similar way to type 2 diabetes, but usually after the baby is born, hormones and blood glucose levels go back to normal. Read more: Weight gain during pregnancy: how much is too much?

Who gets gestational diabetes?

Factors that increase the risk of gestational diabetes include:
  • a strong family history of diabetes
  • weight above the healthy range
  • non Anglo-European ethnicity
  • being an older mum.
Weight is the major risk factor that can be changed. But in some cases, gestational diabetes may develop without any of these risk factors. Rates of gestational diabetes in Australia have approximately doubled in the last decade. Increased testing for gestational diabetes, changing population characteristics, and higher rates of overweight and obesity may have contributed to this. There are likely to be other factors we do not fully understand.   >> Read More Source: The Conversation
By Allison Sigmund, Sue Lynn Lau, Susan Hendon
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Dr Nelson Chong
  • Clinical Articles

Not Everyone Recovers from Broken Heart Syndrome

A stressful event, such as the death of a loved one, really can break your heart. In medicine, the condition is known as broken heart syndrome or takotsubo syndrome. It is characterised by a temporary disruption of the heart’s normal pumping function, which puts the sufferer at increased risk of death. It’s believed to be the reason many elderly couples die within a short time of each other. Broken heart syndrome has similar symptoms to a heart attack, including chest pain and difficulty breathing. During an attack, which can be triggered by a bereavement, divorce, surgery or other stressful event, the heart muscle weakens to the extent that it can no longer pump blood effectively. In about one in ten cases, people with broken heart syndrome develop a condition called cardiogenic shock where the heart can’t pump enough blood to meet the body’s needs. This can result in death.

Physical damage

It has long been thought that, unlike a heart attack, damage caused by broken heart syndrome was temporary, lasting days or weeks, but recent research suggest that this is not the case. A study by researchers at the University of Aberdeen provided the first evidence that broken heart syndrome results in permanent physiological changes to the heart. The researchers followed 52 patients with the condition for four months, using ultrasound and cardiac imaging scans to look at how the patients’ hearts were functioning in minute detail. They discovered that the disease permanently affected the heart’s pumping motion. They also found that parts of the heart muscle were replaced by fine scars, which reduced the elasticity of the heart and prevented it from contracting properly. In a recent follow-up study, the same research team reported that people with the broken heart syndrome have persistent impaired heart function and reduced exercise capacity, resembling heart failure, for more than 12 months after being discharged from hospital.

Long-term risk

A new study on the condition, published in Circulation, now shows that the risk of death remains high for many years after the initial attack. In this study, researchers in Switzerland compared 198 patients with broken heart syndrome who developed cardiogenic shock with 1,880 patients who did not. They found that patients who experienced cardiogenic shock were more likely to have had the syndrome triggered by physical stress, such as surgery or an asthma attack, and they were also significantly more likely to have died five years after the initial event. People with major heart disease risk factors, such as diabetes and smoking, were also much more likely to experience cardiogenic shock, as were people with atrial fibrillation (a type of heart arrythmia). A second study from Spain found similar results among 711 people with broken heart syndrome, 11% of whom developed cardiogenic shock. Over the course of a year, cardiogenic shock was the strongest predictor of death in this group of patients. These studies show that cardiogenic shock is not an uncommon risk factor in broken heart syndrome patients, and it is a strong predictor of death. They shed light on a condition that was previously thought to be less serious than it is. The evidence now clearly shows that the condition is not temporary and it highlights an urgent need to establish new and more effective treatments and careful monitoring of people with this condition.
By Dr Nelson Chong
pregnancy
Dr Julia Marcello
  • Clinical Articles

Antidepressants in Pregnancy

“Be patient with yourself… nothing in Nature blooms all year.” One of my favourite quotes regarding perinatal depression and anxiety which affects 10-16% of all new parents. The importance of perinatal mental health cannot be overstated. Research has shown that an untreated perinatal mental health condition can lead to substance misuse, poor antenatal attendance as well as poor self-care. There is also a risk of poor attachment to the infant, and a long-term risk of poor child development outcomes through neglect. Suicide is the final risk. The government have recently supported our concerns regarding this important topic by changing the MBS item numbers (16590, 16591, 16407) to include a mental health assessment. We have a duty of care to our patients to know what is safe to prescribe or continue to use in pregnancy- remembering that pregnancy is not protective against mental illness. Did you know that more than half of all women abruptly discontinue antidepressant medication upon confirming a pregnancy? Almost 70% of these women suffer a relapse of depression. Currently the recommendations for a woman on an antidepressant who has been euthymic for at least 12 months include cease the medication in pregnancy, continue the current medication, change to an alternative, safer medication or cease the medication and then reintroduce it if a relapse occurs. Antidepressant medications can cross the placenta, meaning the fetus is exposed. There are also potential pregnancy complications, but the risks to the fetus and the pregnancy are very low. Congenital malformation may occur from exposure to some antidepressants in the first trimester. Growth restriction and neurobehavioural problems may result from exposure in the second trimester. And congenital cardiac defects have been associated with paroxetine use in pregnancy. Postpartum haemorrhage is the only significant potential obstetric complication associated with SSRI and SNRI use. There is also a small increased risk of persistent pulmonary hypertension of the newborn associated with SSRI, SNRI and TCA use in late pregnancy. Antidepressants taken in late pregnancy, may also cause poor neonatal adaptation syndrome (PNAS). This manifests as hypotonia, respiratory distress, hypoglycaemia, seizures and most commonly ‘jittery-ness’ in the infant. Paroxetine has the highest risk of PNAS. Despite this, it is NOT recommended that the dose of medication be reduced in late pregnancy. Because the fetus may not clear the medication in the same way the mother does, lowering the dose might simply risk a relapse of depression in the mother while gaining little or no benefit to the infant. RANZCOG states that SSRIs are generally considered low risk and safe to prescribe in pregnancy and breastfeeding. It is important to know that sertraline has the lowest placental exposure and the lowest excretion into breastmilk. Other medications are listed in the table below as a quick reference guide:

Table 1. ANTIDEPRESSANT CATEGORIES FOR PREGNANCY AND BREASTFEEDING:

Medication Pregnancy Category Breastfeeding
TCAs * avoid doxepin during breastfeeding C Compatible
Citalopram C Compatible
Escitalopram *preferred to citalopram in breastfeeding C Compatible
Fluoxetine C Compatible
Mirtazapine C Compatible
Paroxetine *can cause cardiac defects with high dose first trimester but safest for breastfeeding along with sertraline D Compatible
Sertraline B Compatible
Venlafaxine C Compatible
Compatible- an acceptably low relative infant dose or no significant plasma concentrations or no adverse effects in breastfed infants. When managing perinatal depression is it important to consider potential risk against the known benefits of the medications and the potential detrimental effects of mental illness on the development of the infant and other children in the home.

Key References:

  1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.  Perinatal Depression and Anxiety: C-Obs 48. East Melbourne (AU): RANZCOG; Mar 2015. 16 p. RANZCOG Cat. No.: C-Obs 48. Available from: https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Mental-health-care-in-the-perinatal-period-(C-Obs-48).pdf?ext=.pdf
  2. White L. Antidepressants in Pregnancy. O&G Magazine. 2018; 20(3): 24-25. Available from: https://www.ogmagazine.org.au/20/3-20/antidepressants-in-pregnancy/
  3. Galbally M, Lewis AJ, Snellen M. Introduction Pharmacological management of major depression in pregnancy. In: Gabally M, Snellen M, Lewis AJ, editors. Psychopharmacology and Pregnancy. Berlin: Springer; 2014. p. 67-85.
  Dr Julia Marcello works at Bentley Maternity Unit which provides maternity services to low risk women in WA. The unit is staffed by GP obstetricians, specialist obstetricians and gynaecologists and midwives and offers the option of private care within a public setting. The midwife service is available to low risk women and includes antenatal care, birthing services and postnatal care through the visiting midwifery service and lactation consultant support.  GP shared care services are also available. The Unit also provides a gynaecology service led by Dr Aseel Alkiaat and specialists from King Edward Hospital.  For further information go to www.bhs.health.wa.gov.auFor-health-professionals
By Dr Julia Marcello
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Dr Linda Calabresi
  • Clinical Articles

Probiotics Don’t Help in Kids’ Gastro

Giving children with acute gastroenteritis probiotics will not help them recover more quickly, according to two large randomised controlled trials. At least if the probiotic includes Lactobacillus rhamnosus. The research, published in the New England Journal of Medicine, provides solid evidence against the adjunctive treatment, which, as the study authors point out, has been recommended by many health professionals and authoritative bodies. “Many experts consider acute infectious diarrhoea to be the main indication for probiotic use,” they said. However, the two studies, both conducted on children aged three months to four years with a less than 72-hour history of acute vomiting and diarrhoea, failed to show any benefit of taking a five-day course of the probiotics. One of the studies conducted across six tertiary paediatric centres in Canada, involved almost 900 children with acute gastroenteritis randomly assigned to receive either a combination probiotic (L. rhamnosus and L. helveticus) or placebo. The other very similar study, this one involving US centres, included 970 children with gastroenteritis and tested the effectiveness of giving the single probiotic Lactobacillus rhamnosus against placebo. The results of the two trials, using almost identical outcome measures were the same – the probiotics did not make a difference. “Neither trial showed a significant difference in the duration of diarrhoea and vomiting, the number of unscheduled visits to a health provider or the duration of day-care absenteeism,” an accompanying editorial concluded. The role of probiotics in the management of gastroenteritis in children has been an area of controversy and contradiction not only among individual specialists but also among different expert bodies, with guideline recommendations varying from “not recommended” by the Centers of Disease Control and Prevention to “strongly recommended” by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. But now, it appears this grey area has now become very black and white. “Taken together, neither of these large, well-done trials provides support for the use of probiotics containing L. rhamnosus to treat moderate-severe gastroenteritis in children,” the editorial stated. The caveat, of course, is that this evidence while robust only applies to this particular probiotic. There might still be probiotics out there that do make a difference. The editorial author referred to a recent large randomised-controlled trial conducted in rural India that found giving healthy newborns the probiotic, L. planatarum in the first few days of life was associated with a significantly lower risk of sepsis and lower respiratory tract infection in the subsequent two months. So while these studies might appear to be the nail in the coffin for L. rhamnosus -containing probiotics, it is still a case of ‘watch this space’ with regard the role of probiotics more generally.

Reference

Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O'Connell KJ, et al. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. N Engl J Med. 2018 Nov 22; 379(21): 2002-2014. DOI: 10.1056/NEJMoa1802598 Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, et al. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med. 2018 Nov 22; 379(21): 2015-26. DOI: 10.1056/NEJMoa1802597 LaMont JT. Probiotics for Children with Gastroenteritis. N Engl J Med 2018 Noc 22; 379(21): 2076-77. DOI: 10.1056/NEJMe1814089
By Dr Linda Calabresi
measuring height
Dr David Kanowski
  • Clinical Articles

Child Too Short? Too Tall? What to Do

Short or tall stature is considered to be height below or above the 3rd or 97th percentile respectively. Abnormal growth velocity, showing on serial height measurements, is also an important finding. Growth charts based on the US NHANES study are available from www.cdc.gov/growthcharts/charts.htm. Copies of growth charts, together with height velocity and puberty charts are available at the Australasian Paediatric Endocrine Group (APEG) website, https://apeg.org.au/clinical-resources-links/growth-growth-charts/. Local Australian growth charts are currently not available. The height of the parents should be considered in evaluating the child. Expected final height can be calculated from the parents’ heights as follows: For boys: Expected final height = mean parental height + 6.5cm For girls: Expected final height = mean parental height – 6.5cm Assessment of bone age (hand/wrist) is also useful. With familial short or tall stature, bone age matches chronological age. Conversely, in a child with pathological short stature, bone age is often well behind chronological age, and may continue to fall if the disease is untreated. The stage of puberty is relevant, as it will affect the likely final height. A short child who is still pre-pubertal (with unfused epiphyses) is more likely to achieve an adequate final height than one in late puberty.

Short stature

Causes to consider include:
  • Malnutrition, the commonest cause worldwide
  • Chronic disease, for example, liver/renal failure, chronic inflammatory diseases
  • Growth hormone deficiency, with/without other features of hypopituitarism
  • Other endocrinopathies, for example, hypothyroidism, (rarely) Cushing’s syndrome
  • Genetic/syndromic causes, for example, Down, Turner, Noonan, Prader-Willi syndromes
  • Depression or social deprivation should also be considered
  • Idiopathic short stature is a diagnosis of exclusion
Appropriate initial screening investigations can include liver and renal function tests, blood count, iron studies, thyroid function tests, coeliac disease screen, thyroid function tests, urinalysis (including pH) and karyotype. Other specialised tests may be needed, based on suspicion. In the lower range, IGF-1 shows considerable overlap between normal and abnormal levels, especially in the setting of poor nutrition. Small children tend to have low levels, regardless of whether growth hormone deficiency is the underlying cause. Random growth hormone levels vary widely because of pulsatile secretion and are also not a reliable test. Therefore, unless there is a clear underlying genetic or radiological diagnosis associated with clearly low IGF-1, stimulation testing is typically required to formally diagnose growth hormone deficiency and may be essential for funding of growth hormone treatment.

Tall stature

Causes include:
  • Chromosomal abnormalities, for example, Klinefelter syndrome (qv), XYY syndrome
  • Marfan syndrome
  • Homocystinuria
  • Hyperthyroidism
  • Growth hormone excess (see Acromegaly; Growth hormone; Insulin-like growth factor-1 (IGF-1))
  • Precocious puberty
  • Other syndromic causes, for example, Sotos, Beckwith-Wiedemann syndromes
  • Familial tall stature (predicted final height should match mid-parental height)
Investigation of stature is a specialised area and early discussion with a paediatric endocrinologist is indicated if there is clinical concern, for example, height below the 3rd percentile at age five, slow growth (crossing two percentile lines away from the median), significant height/ weight discrepancy (more than two centile lines), suspected/confirmed metabolic or genetic abnormality, or clinical evidence of malnutrition or marked obesity.

References

  1. Cohen P, Rogol AD, Deal CL, Saenger P, Reiter EO, Ross JL, et al. Consensus statement on the diagnosis and treatment of children with idiopathic short stature: a summary of the Growth Hormone Research Society, the Lawson Wilkins Pediatric Endocrine Society, and the European Society for Paediatric Endocrinology workshop. J Clin Endocrinol Metab. 2008 Nov; 93(11): 4210-7. DOI: [10.1210/jc.2008-0509]
  2. Nwosu BU, Lee MM. Evaluation of short and tall stature in children. Am Fam Physician. 2008 Sep 1; 78(5): 597-604. Available from: www.aafp.org/afp/2008/0901/p597.pdf.
  General Practice Pathology is a regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.
By Dr David Kanowski
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Dr Amanda Henry
  • Clinical Articles

Health Check: How Long Should I Wait Between Pregnancies?

Women often wonder what the “right” length of time is after giving birth before getting pregnant again. A recent Canadian study suggests 12-18 months between pregnancies is ideal for most women. But the period between pregnancies, and whether a shorter or longer period poses risks, is still contested, especially when it comes to other factors such as a mother’s age. It’s important to remember that in high-income countries most pregnancies go well regardless of the gap in between.

What is short and long

The time between the end of the first pregnancy and the conception of the next is known as the interpregnancy interval. A short interpregnancy interval is usually defined as less than 18 months to two years. The definition of a long interpregnancy interval varies – with more than two, three or five years all used in different studies. Most studies look at the difference every six months in the interpregnancy interval makes. This means we can see whether there are different risks between a very short period in between (less than six months) versus just a short period (less than 18 months). Most subsequent pregnancies, particularly in high-income countries like Australia, go well regardless of the gap. In the recent Canadian study, the risk of mothers having a severe complication varied between about one in 400 to about one in 100 depending on the interpregnancy interval and the mother’s age. The risk of stillbirth or a severe baby complication varied from just under 2% to about 3%. So overall, at least 97% of babies and 99% of mothers did not have a major issue. Some differences in risk of pregnancy complications do seem to be related to the interpregnancy interval. Studies of the next pregnancy after a birth show that:

What about other factors?

How much of the differences in complications are due to the period between pregnancies versus other factors such as a mother’s age is still contested. On the one hand, there are biological reasons why a short or a long period in between pregnancies could lead to complications. If the gap is too short, mothers may not have had time to recover from the physical stressors of pregnancy and breastfeeding, such as pregnancy weight gain and reduced vitamin and mineral reserves. They may also not have completely recovered emotionally from the previous birth experience and demands of parenthood. If the period between pregnancies is quite long, the body’s helpful adaptations to the previous pregnancy, such as changes in the uterus that are thought to improve the efficiency of labour, might be lost. However, many women who tend to have a short interpregnancy interval also have characteristics that make them more at risk of pregnancy complications to start with – such as being younger or less educated. Studies do attempt to control for these factors. The recent Canadian study took into account the number of previous children, smoking and the previous pregnancy outcomes, among other things. Even so, they concluded that risks of complications were modestly increased with a lower-than-six-month interpregnancy period for older women (over 35 years) compared to a 12-24-month period. Other studies, however, including a 2014 West Australian paper comparing different pregnancies in the same women, have found little evidence of an effect of a short interpregnancy interval.

So, what’s the verdict?

Based on 1990s and early 2000s data, the World Health Organisation recommends an interpregnancy interval of at least 24 months. The more recent studies would suggest that this is overly restrictive in high-resource countries like Australia. Although there may be modestly increased risks to mother and baby of a very short gap (under six months), the absolute risks appear small. For most women, particularly those in good health with a previously uncomplicated pregnancy and birth, their wishes about family spacing should be the major focus of decision-making. In the case of pregnancy after miscarriage, there appears even less need for restrictive recommendations. A 2017 review of more than 1 million pregnancies found that, compared to an interpregnancy interval of six to 12 months or over 12 months, an interpregnancy interval of less than six months had a lower risk of miscarriage and preterm birth, and did not increase the rate of pre-eclampsia or small babies. So, once women feel ready to try again for pregnancy after miscarriage, they can safely be encouraged to do so.
By Dr Amanda Henry
pregnancy
Dr Linda Calabresi
  • Clinical Articles

Safety Data on Ondansetron in Pregnancy

Finally, we’ve got some robust evidence to answer the question - is ondansetron safe to take for morning sickness. Published in JAMA, a very large retrospective study involving over 1.8 million pregnancies, almost 90,000 of which included exposure to ondansetron in the first trimester has found that taking the drug did not increase the risk of cardiac malformations or congenital malformations overall. However, first trimester ondansetron was associated with a very small increased risk of oral clefts (three additional cases per 10,000 women treated). Interestingly the increased risk for oral clefts was confined to cleft palate, there was no evidence for an increased risk of cleft lip. The information will be eagerly received by the thousands of pregnant women who experience severe nausea and vomiting, and the clinicians who care for them many of whom have been prescribing ondansetron because of its effectiveness, despite the lack of detailed safety data. “Although not formally approved for the treatment of nausea and vomiting during pregnancy, ondansetron, a 5-HT receptor antagonist, has rapidly become the most frequently prescribed drug for nausea and vomiting during pregnancy in the United States because of its perceived superior antiemetic effects and improved adverse effect profile compared with treatment alternatives,” the study authors said. “In 2014, an estimated 22% of pregnant women used ondansetron in the United States,” they said. The major strengths of this study lie in the size of the cohort and the fact that the information on ondansetron exposure was based on filled prescriptions, thereby negating any possible recall bias. Both these factors are particularly important given how rare these abnormalities are and how many possible confounders there could be. As for limitations of the study, of course just because a prescription has been filled doesn’t always mean the medication has been taken, but even if the exposure wasn’t as great as calculated, the risk would be only lessened rather than raised. There is also the possibility that there might have been some other unrecognised factor involved especially since all the women in the study were uninsured and treated under Medicaid insurance and therefore included a higher percentage of women from disadvantaged communities. However, given the detailed information collected on these women and their pregnancies, and the multiple analyses conducted on this data, the likelihood of unmeasured confounders affecting the findings was thought to be low. Overall the results of this study should provide reassurance for clinicians and pregnant women, according to an accompanying editorial, written by a US obstetrician and gynaecologist. “As clinicians and pregnant women engage in informed, shared decision-making surrounding treatment for nausea and vomiting, the current information is important for contextualising risks in light of the potential benefits,” he concluded.

References

Huybrechts KF, Hernández-Díaz S, Straub L, Gray KJ, Zhu Y, Patorno E, et al. Association of Maternal First-Trimester Ondansetron Use With Cardiac Malformations and Oral Clefts in Offspring. JAMA. 2018 Dec 18; 320(23): 2429-37. DOI: [10/1001/jama.2018.18307] Haas DM. Helping Pregnant Women and Clinicians Understand the Risk of Ondansetron for Nausea and Vomiting During Pregnancy. JAMA. 2018 Dec 18; 320(23): 2425-6. DOI: [10.1001/jama.2018.19328]
By Dr Linda Calabresi
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Myriam Gharbi, Joseph H Drysdale, Hannah Lishman, Rosalind Goudie, Mariam Molokhia, Alan P Johnson, Alison H Holmes, Paul Aylin & Alastair D Hay
  • Clinical Articles

Don’t Delay Antibiotics for UTI

So here’s the exception that proves the rule. Urinary tract infections need immediate treatment with antibiotics to avoid an increased risk of sepsis and death. That’s the quite definitive conclusion from a large retrospective study involving GP data from the UK recently published in the BMJ. After analysing the records of over 150,000 patients, aged 65 and over presenting to their GP with a suspected or confirmed UTI, the researchers found those whose antibiotic treatment was delayed or deferred were up to eight times more likely to develop sepsis in the following 60 days compared to the group who were given antibiotics from the beginning. And those patients who were not given antibiotics at all, they were twice as likely to die as their medicated counterparts. Most of the infections were caused by Escherichia Coli, and trimethoprim or nitrofurantoin were the most common antibiotics prescribed. As the study showed, sepsis is not a common sequela of UTI, occurring in just .5% of cases. But the fact remains if antibiotics were delayed or withheld altogether the incidence jumped to 2.2% and 2.9% respectively which is significant and totally unnecessary. Understandably outcomes were worse the older the patient, and men had more adverse outcomes than women, but even accounting for multiple variable factors the basic conclusion remained the same. “Our study suggests the early initiation of antibiotics for UTI in older high-risk adult populations (especially men aged >85 years) should be recommended to prevent serious complications”, the study authors said. Of concern to the researchers was the relatively large number of older patients (about 7%) who were diagnosed with a UTI but not treated. They suggest antimicrobial stewardship programmes encouraging more judicious use of antibiotics may be at least, in part, to blame. That, and the risk of elderly patients developing Clostridium difficile infection following antibiotic use. But while ‘delayed or deferred’ antibiotic treatment was not generally associated with serious adverse outcomes for some self-limiting illnesses such as upper respiratory tract infections, this study suggests it is not a good idea for UTIs. “In our study, deferred antibiotics were associated with less severe adverse outcomes than no antibiotics for older adults but still showed a significantly higher risk of mortality compared with immediate antibiotics,” the researchers said. An accompanying editorial by a UK GP academic says the study highlights one of the many dilemmas that occur in general practice. “[GPs face] the daily challenge of ensuring that patients who are unlikely to benefit are not treated, whereas those who require antibiotics receive the right class, at the right time, at the right dose, and for the right duration,” he wrote. And while agreeing with the study authors concluding advice, that all older patients with suspected UTI should be treated from day one he does suggest further research is needed. Research could help determine the most appropriate antibiotic in this situation, and if there are any particular groups in this 65 and over cohort who it would be safe to leave off antibiotic treatment until the result of the culture and sensitivities are known. - Myriam Gharbi, NIHR Health Protection Research Unit, Imperial College London; Joseph H Drysdale, Department of Primary Care and Public Health, Imperial College London; Hannah Lishman, Medical School, St George's University of London UK; Rosalind Goudie, Nuffield Department of Population Health, University of Oxford, UK; Mariam Molokhia, Department of Primary Care and Public Health Sciences, King's College, London, UK; Alan P Johnson, Healthcare-Associated Infections and Antimicrobial Resistance Division, London, UK; Alison H Holmes, NIHR Health Protection Research Unit, Imperial College London; Paul Aylin, NIHR Health Protection Research Unit, Imperial College London This article is referenced from THEBMJ. Read the original article. - Alastair D Hay, Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, Bristol, UK This article is referenced from THEBMJ. Read the original article.

By Myriam Gharbi, Joseph H Drysdale, Hannah Lishman, Rosalind Goudie, Mariam Molokhia, Alan P Johnson, Alison H Holmes, Paul Aylin & Alastair D Hay

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