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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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Dr Linda Calabresi
  • Clinical Articles

Efudix wins over other AK treatments

Got a patient with multiple sun spots on their head that need treatment? Well it looks like the old, tried and true 5FU cream is still the way to go, according to a randomised trial just published in the New England Journal of Medicine. Among more than 600 randomly assigned patients, Dutch researchers compared the effectiveness of four topical treatments commonly used to treat multiple actinic keratoses as part of a ‘field treatment’. In addition to the 5% fluorouracil cream (Efudix), the study looked at the effectiveness of 5% imiquimod cream (Aldara), methyl aminolevulinate photodynamic therapy (MAL PDT or Metvix PDT) and 0.015% ingenol mebutate gel (Picato gel). After 12 months, the study showed that the Efudix was the most effective in terms of maintaining a reduction of at least 75% of actinic keratoses from the baseline. In other words, this cream was the best of the four therapies, at getting rid of these sun spots completely. “And the differences between fluorouracil cream and imiquimod, PDT and ingenol mebutate were significant,” the study authors said. They found the likelihood of success for those patients using fluorouracil was almost 75%, compared with only 54% for imiquimod, 38% for PDT and 29% for those using ingenol mebutate. And this independent study didn’t do anything tricky with the dosing regimen either. “In our trial, we used the most commonly prescribed dosing regimens of the therapies studied,” they said. In terms of sticking to the dosing regimen, patients were much better adhering to the schedule when they were taking ingenol mubutate (99% adherence) or PDT (97%) rather than the fluorouracil (89%) or the imiquimod (88%), but this appeared to directly correlate with how often they had to take the therapy and for how long. Overall, however this adherence rate did not reflect treatment satisfaction rate. “Satisfaction with treatment and improvement in health-related quality of life at 12 months after the end of treatment were highest in the fluorouracil,” the study authors reported. Nothing like a treatment actually working to make a patient feel happy about having had it. A bonus of this study, according to the researchers was the inclusion of patients with the more severe actinic keratosis lesions (Grade III lesions), patients who have been commonly excluded from previous similar trials of topical treatments. “[Including these patients] is more representative of patients seen in daily practice,” they said. In addition to effectiveness, cost is another appealing factor for fluorouracil over the other treatments. This study has the capacity to change practice. The study authors quote the prevalence actinic keratoses among whites aged 50 and over as being at 37.5%. While cryotherapy remains the treatment of choice for single lesions, where there are multiple lesions present field treatment should be considered. Currently the guidelines for this field treatment don’t advocate one treatment over any other, more or less suggesting all four of the treatments in this study as being efficacious. However, as these Dutch researchers say “our results could affect treatment choices in both dermatology and primary care.”

Reference

Jansen MHE, Kessels JPHM, Nelemans PJ, Kouloubis N, Arits AHMM, van Pelt HPA, et al. Randomized Trial of Four Treatment Approaches for Actinic Keratosis. N Engl J Med. 2019 Mar 7; 380(10): 935-46.  DOI: 10.1056/NEJMoa1811850
By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

Stop drinking and lose weight to prevent breast cancer

The spectre of breast cancer looms large for the majority of Australian women. But now researchers say if we tackle obesity and overweight as well as cutting out regular alcohol consumption we can prevent thousands of cases of this disease which is our most common cancer in women and second leading cause of cancer death. A new study has quantified how much these modifiable risk factors contribute to the incidence of breast cancer and predicts how many future cases they will cause. And it’s a bit frightening. According to this large Australian collaborative study, published in the international Journal of Cancer, if all Australian women maintained a healthy weight we could prevent 17,500 breast cancers in the next 10 years. And if women stopped drinking alcohol regularly (even one drink a day) it was estimated 11,600 future breast cancers could be avoided over the next decade. The researchers from University of NSW’s Centre for Big Data Research in Health were able to quantify the burden of these two risk factors after pooling six Australian cohort studies that included over 200,000 women. They were also able to differentiate the contribution of the various factors in premenopausal as opposed to postmenopausal breast cancers. “Regular alcohol consumption is the potentially modifiable risk factor responsible for the largest burden of breast cancer for premenopausal women in Australia, accounting for 12.6% of the burden and 2,600 cases of breast cancer over the next 10 years,” the study authors said. Body weight, or more accurately ‘body fatness’ was not a major factor for developing breast cancer before menopause. Apparently, this is the first time that regular alcohol consumption has been shown to be the leading modifiable contributing factor to breast cancer risk in this age group. And even though the finding would suggest that reducing the number of drinks per day would lessen the risk, the researchers found that the increased risk held true even with an average of one drink a day. Certainly bad news for more than half of Australian women who currently report drinking alcohol regularly, even if they are keeping to the current Australian recommendation not to drink more than two drinks a day on average. Among postmenopausal women, body fatness represents the biggest danger, accounting for 12.8% of the burden (17,500 breast cancer cases) over a decade. Given that three in five postmenopausal women in Australia are currently estimated to be overweight or obese this represents a key target for intervention. And alcohol consumption too, still made a substantial contribution to the risk in this cohort (6.6% or 9,000 breast cancer cases). Other modifiable risk factors included taking the oral contraceptive pill premenopause, and, among postmenopausal women taking menopausal hormone therapy (MHT). As the researchers point out, the issue of oral contraceptives as a breast cancer risk is a little complicated as it has to be weighed up against the protective effect these medications have against endometrial, ovarian and colorectal cancers as well as their reproductive health benefits. And as for MHT, the major breast cancer risk was for women taking MHT for five years or more. “Our findings thus support the current Australian and international recommendations of using MHT for the shortest duration possible, and only to alleviate menopausal symptoms, not for the prevention of chronic disease,” they said. Interestingly, for postmenopausal women at least, being physically active or having a history of breast feeding didn’t seem to alter the risk of developing breast cancer in the future. However, what the study has highlighted is the importance of targeting weight and alcohol as the most effective means to reduce the incidence of breast cancer. “The findings provide evidence to support targeted and population-level cancer control activities in Australia and beyond,” the study authors said.  

Reference

Arriaga ME, Vajdic CM, Canfell K, MacInnis RJ, Banks E, Byles JE, et al. The preventable burden of breast cancers for premenopausal and postmenopausal women in Australia: A pooled cohort study. Int. J. Cancer. 2019 Feb 25. DOI: 10.1002/ijc.32231
By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

Offer Q fever vaccine to all rural Australians

Anyone living in country Australia should consider being vaccinated against Q fever, according to researchers. The recommendation was made on the basis of their study, published in the Medical Journal of Australia which showed that living in a rural area for more than three months was associated with an increased risk of contracting Q fever even if there was little contact with farm animals, the traditional reservoir of the infection. In fact, the risk among country dwellers was 2.5 times higher than among people who had never lived rurally, according to the study which looked for evidence of past infection among 2740 blood donors in Queensland and NSW. “The prevalence of Q fever, caused by Coxiella burnetii, is substantial in Australia despite the availability of a safe and effective vaccine,” the study authors wrote. They point to stats that show that between 2013 and 2017 there were more 2500 notifications of Q fever in this country. They say this is very likely to be an underestimate, as most infections (up to 80%) are asymptomatic and sometimes they may have non-specific symptoms. But what we do know is that when Q fever does cause significant symptoms the morbidity can be substantial - pneumonia, hepatitis, endocarditis, and osteomyelitis. In addition, 10-15% of symptomatic patients will develop a protracted post-Q fever fatigue syndrome. To check just how many people have or have had the condition, researchers assessed blood donors from metropolitan Sydney and Brisbane, as well as blood donors in rural areas, namely the Hunter New England region of NSW and Toowoomba in Queensland. As well as collecting data on exposure, occupation and vaccination, the sera of the subjects was tested for both the C. burnetii antibody (as a measure of past exposure) and C. burnetii DNA (measuring current infection). No patient in the study was found to be currently infected with Q fever. Overall, 3.6% of the participants had evidence of past infection. And even though seroprevalence was higher in the rural areas compared to metropolitan areas, a significant proportion of those people from the city who tested positive for past Q fever had a history of living in the country at some time in the past. As you would expect, people working with sheep, cattle or goats, abattoir workers and people who had assisted at an animal birth were at highest risk. Vaccination of these people is already recommended. Non-farming people who just lived in rural areas were found to be at risk. “Having lived in a rural area, but with no or rare contact with sheep, cattle or goats, was itself an independent predictor of antibody seropositivity after accounting for the effects of other exposures”, the study authors said. Hence the recommendation we vaccinate everyone living in the country. But, as an accompanying editorial points out, expanding the current vaccination program is not without its challenges. Screening for humoral antibody and cell-mediated skin testing is required prior to vaccination so the need for at least two GP visits, access to intradermal skin testing and the cost are all potential barriers, the editorial authors said. There is also an issue with a lack of evidence about the safety and effectiveness of the Q fever vaccine in children. Nonetheless, all the experts agree: if we want to reduce the burden of Q fever in Australia, we will need to look beyond the select populations we are currently targeting for vaccination because there are obviously risk factors other than sheep, cattle and goats, at play.

References

Gidding HF, Faddy HM, Durrheim DN, Graves SR, Nguyen C, Hutchinson P, Massey P, Wood N. Seroprevalence of Q fever among metropolitan and non‐metropolitan blood donors in New South Wales and Queensland, 2014–2015. Med J Aust. 2019 Apr; 210(7): 309-15. DOI: 10.5694/mja2.13004 Francis JR, Robson JM. Q fever: more common than we think, and what this means for prevention. Med J Aust. 2019 Apr; 210(7): 305-6. DOI: 10.5694/mja2.50024
By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

Dysplastic naevi: the controversy continues

The entity ‘mildly dysplastic naevus’ has been removed from the World Health Organisation’s classification of dysplastic naevi. Dysplastic naevi are now to be graded as ‘low grade dysplastic naevus’ (previous moderately dysplastic naevus) or ‘high grade dysplastic naevus’ (previous severely dysplastic naevus).
  • Current data suggest no further treatment is necessary for lentiginous junctional/compound naevi and dysplastic naevus with low grade dysplasia (previous mildly dysplastic and moderately dysplastic naevi) with clear histologic margins and no pigment evident clinically, unless there was a high level of prebiopsy clinical concern.
  • Re-excision with a 2-5mm clinical clearance is recommended for high grade dysplastic naevi (previous severely dysplastic naevi) with involved histologic margins.
  • There is growing evidence that observation may be reasonable for low grade dysplastic naevi (previous moderately dysplastic naevus) if they were excised with clinically clear margins/ no residual clinical pigment is observed, despite histologically involved margins. More data may be required before this is accepted into clinical practice.
  • There does not appear to be a clear consensus regarding whether high grade dysplastic (previous severely dysplastic) naevi require re-excision, if initially excised with clear margins, albeit less than 2mm.
    •  

    Dysplastic naevus: the controversy since the 1970s

    The entity of dysplastic naevus has been shrouded in controversy since first described in the 1970s.1 This appears to be due to:
    1. Interobserver differences between histopathologists in applying the previous three tier grading system for dysplasia
    2. Perceived risk of progression to melanoma, and
    3. The possibility of benign entities simulating melanoma, all of which contribute to uncertainty and variability in management.2,3
    Dysplastic naevi are benign neoplasms of melanocytes.3 Dysplasia in melanocytes may occur de novo or in association with either congenital dermal naevi or common dermal naevi. It is probable that dysplasia arising in pre-existing naevi results from successive acquisition of genetic abnormalities.3 Both common naevi and dysplastic naevi demonstrate BRAF or NRAS mutations.3 It was at one time proposed that there is a step-wise model of tumour progression from dysplastic naevi through mild, to moderate, then severe dysplasia, and finally melanoma.4 However, there is no evidence that dysplastic naevi are, in fact, common precursors of melanoma.4 In actuality, the most common naevus remnant found in association with melanoma is the common acquired naevus.4 Given the large number of dysplastic naevi, compared with the comparatively small number of melanomas arising in association with dysplastic naevi, it seems that the rate of progression from dysplastic naevus to melanoma is extremely low.4 Dysplastic naevi seen associated with melanomas have an increased incidence of TERT promoter mutations, a common early genetic event in the evolution of melanoma in situ.3 This suggests that some dysplastic naevi are an intermediate entity between benign naevus and melanoma.3 There is a lack of data examining the frequency of similar genetic alterations in non-melanoma associated dysplastic naevi; thus, although the risk of progression is very low, it is suggested that naevi with high grade dysplasia or added genetic events (e.g. TERT promoter mutation) are considered for complete excision.3 It has been suggested that dysplastic naevi represent a marker of increased risk for an individual developing melanoma.5 It is difficult to establish the risk of melanoma at a separate site in patients with dysplastic naevi, as the reported incidence of dysplastic naevi in fair-skinned individuals varies widely (between 2% and 50%).4 One study has demonstrated that only the diameter of the dysplastic naevus had a significant association with a personal history of melanoma,6 whilst another study has shown that individuals with many naevi, whether common or dysplastic, have an increased risk of developing melanoma.7 Thus it would seem that two factors are associated with an individual’s risk of developing melanoma: a large number of common or dysplastic naevi (>100) and the larger size of the naevi (>4.4mm).6 It is generally agreed that there is low interobserver agreement between pathologists when grading dysplastic naevi, particularly in those lesions exhibiting moderate atypia to early in situ melanoma.8,9 This leads to uncertainty with regard to management of these lesions, especially if there is margin involvement. In 2017, Wall et al.2 conducted a survey investigating the management of dysplastic naevi by Australian dermatologists. This survey demonstrated that, similarly to comparable studies reported within the USA and Canada, most dermatologists would re-excise a moderately or severely dysplastic naevus with involved margins.2 There is, however, variability in Australian dermatologists’ approaches to severely dysplastic naevi (clinically concerning for melanoma) which are completely excised on biopsy, with 44% re-excising with a 5mm margin, and the remainder considering no further treatment necessary.2 In addition, whilst between 5-12% of US and Canadian dermatologists re-excise mildly dysplastic naevi involving margins, that rate in Australian dermatologists is 49%.2 A consensus statement released by Kim et al.10 in 2015 identified a critical gap in knowledge with regard to management of dysplastic naevi with involved margins. This consensus statement recommended that mildly to moderately dysplastic naevi with clear histologic margins need no re-excision. If a biopsy report reveals severe dysplasia with positive margins, re-excision to achieve a 2-5mm clinical margin is recommended. The statement suggested that mildly dysplastic naevi with positive histologic margins after biopsy (and no residual pigment) may be observed, and while observation may be a reasonable option for moderately dysplastic naevi with positive histologic margins (and no clinical pigment), more data are required to make a definitive recommendation.10 A further multi-centre retrospective cohort study in 2018 by Kim et al.11 suggests that close observation is a reasonable management approach for moderately dysplastic naevi with positive histologic margins. No specific recommendations are made regarding a severely dysplastic naevus with clear margins on biopsy.  

    WHO redefines melanocytic naevi

    The World Health Organisation (WHO) released their new Classification of Skin Tumours in 2018.3 They define dysplastic naevus as ‘a subset of melanocytic naevi that are clinically atypical and characterized histologically by architectural disorder and cytological atypia, always involving their junctional component.10 Diagnostic criteria for dysplastic naevi traditionally include a division of cytoarchitectural atypia into mild, moderate and severe categories.3 Pathologists often further subdivide these categories into ‘mild to moderate’ and ‘moderate to severe’ to reflect the histological field effect often perceived in these lesions. Lentiginous junctional or compound naevi (previously labelled mildly dysplastic naevi) are not associated with increased melanoma risk/progression to melanoma, and are also common within the population.3 The WHO consensus meeting working group recommends against the continued use of the term ‘mildly dysplastic naevus’ and instead recommends the use of low grade and high grade dysplasia. So, where are we now with these new recommendations regarding the grading of dysplastic naevi, and what are the management implications? It seems that the new WHO recommendations support the view that biopsies of the previously known mildly dysplastic naevi need no further treatment, having removed the entity from their classification. It would appear that there is agreement that dysplastic naevi with high grade dysplasia (previous severely dysplastic naevi) with involved margins requires re-excision to achieve a 2-5mm clinical margin of clearance. However, there appears to be no recommendations or clear consensus regarding whether these high grade dysplastic (previous severely dysplastic) naevi require re-excision, if initially excised with clear margins, albeit less than 2mm. With regard to dysplastic naevi with low grade dysplasia (previous moderately dysplastic naevi), there is a slowly growing body of evidence to suggest that it may be reasonable for these cases to be observed if they were excised with clinically clear margins/no residual clinical pigment is observed, despite histologically involved margins. Given the current variation in clinical management of these lesions, as well as the continued lack of interobserver agreement between histopathologists when diagnosing these lesions, more data may be required before this recommendation is accepted. In conclusion, as the consensus statement by Kim et al.10 recommends, the decision to re-excise dysplastic naevi should be based on both the clinical and histologic findings. If the prebiopsy level of clinical concern is high, re-excision should be considered if the biopsy reveals positive margins, even if the level of histopathological dysplasia is low. In addition, there may be clinical scenarios warranting re-excision of a mildly, mildly-moderately/moderately dysplastic lesion (now known as lentiginous junctional/compound naevi and dysplastic naevus with low grade dysplasia respectively), including patient preference.10  

    References:

    1. Duffy K, Grossman D. The dysplastic nevus: from historical perspective to management in the modern era. J Am Acad Dermatol. 2012;67 (1): 1. E1-18. DOI: 10.1016/j.jaad.2012.03.013
    2. Wall N, De’Ambrosis B, Muir J. The management of dysplastic naevi: a survey of Australian dermatologists. Australasian Journal of Dermatology. 2017;58:304-307. DOI: 10.1111/ajd.12720
    3. Elder DE, Massi D, Scolyer RA, Willemze R, editors (2018). WHO classification of skin tumours. 4th Ed. Lyon: IARC.
    4. Busam KJ, Gerami P, Scolyer RA (2019). Pathology of Melanocytic Tumors. 1st Ed. Philadelphia: Elsevier.
    5. Elder DE. Dysplastic naevi: an update. Pathology. 2010;56(1):112-120.
    6. Xiong M, Rabkin M, Piepkorn M, Barnhill R, Argenyi Z, et al. Diameter of dysplastic naevi is a more robust bio marker of increased melanoma risk than degree of histologic dysplasia: a case-controlled study. J Am Acad Dermatol. 2014;71(6):12578.e4. DOI: https://doi.org/10.1016/j.jaad.2014.07.030
    7. Holly EA, Kelly JW, et al. Number of melanocytic nevi as a major risk factor for malignant melanoma. J Am Acad Dermatol. 1987;17:459-468. DOI: https://doi.org/10.1016/S0190-9622(87)70230-8
    8. Hiscox B, Hardin MR, Orengo IF, Rosen T, Mir M, Diwan AH: Recurrence of moderately dysplastic nevi with positive histological margins. J Am Acad Dermatol . 2017;76:527530.  DOI: 10.1016/j.jaad.2016.09.009
    9. Stefanato C. The “Dysplastic Nevus” Conundrum: A look back, a peek forward. Dermatopathology. 2018;5:53-57. DOl: https://doi.org/10.1159/000487924 
    10. Kim C, Swetter S, Curiel-Lewandrowski C, Grichnik J, Grossman D, et al. Addressing the knowledge gap in clinical recommendations for management and complete excision of clinically atypical nevi/dysplastic nevi. JAMA Dermatol. 2015;151(2):212218. DOI: 10.1001/jamadermatol.2014.2694
    11. Kim C, Berry E, Marchetti M, Swetter S, Liam G, et al. Risk of subsequent cutaneous melanoma in moderately dysplastic nevi excisional biopsies but with positive histologic margins. JAMA Dermatology. 2018;154(12):1401-1408 DOI: 10.1001/jamadermatol.2018.3359
      - 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 Linda Calabresi
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    Dr Linda Calabresi
    • Clinical Articles

    Pancreatic cancer support

    It’s still probably one of medicine’s most devastating diagnoses – pancreatic cancer. Despite all the scientific advances that have been made in treating so many malignancies, the prognosis for pancreatic cancer is most often pretty bleak. Consequently, patients presented with this diagnosis are most likely to be in need of significant support. PanSupport (pansupport.org.au) is a newly-developed site, produced by the University of Melbourne that is likely to prove incredibly valuable to patients battling this condition, and their families. This resource not only provides valuable information about pancreatic cancer and its treatment, but it also gives practical advice with regard aspects of management such as diet and exercise. Importantly it also directs patients to any potential clinical trials for which they may be eligible. In keeping with the very practical and realistic approach of the entire site, Pansupport also includes information about palliative care and Advanced Care directives, allowing patients to access what they need to know in their own time frame. The PanSupport website has been developed in collaboration with the Pancare Foundation, RMIT University and the Peter MacCallum Cancer Centre. It has been funded with a Cancer Grant Initiative funded by the Australian Government. >> Find out more about PanSuport here 

    By Dr Linda Calabresi
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    Dr Patty Thille
    • Clinical Articles

    How anti-fat bias in health care endangers lives

    When Ellen Maud Bennett died a year ago, her obituary published in the local newspaper gained national media attention in Canada, though she wasn’t a celebrity. Bennett’s obituary revealed she died from cancer days after finally being diagnosed — after years of seeking help. Her diagnosis came so late, beyond the point where treatments were possible, because the 64-year-old woman was repeatedly told her health problems were caused by her weight — or more specifically, by the amount of fat on her body. She died because of bad assumptions that caused poor quality care. And she used her own obituary to share her dying wish:
    “Ellen’s dying wish was that women of size make her death matter by advocating strongly for their health and not accepting that fat is the only relevant health issue.”
    How to know if this might be happening to you? When do you need to advocate for yourself? I studied the phenomenon of anti-fat stigma in Canadian primary care clinics for my PhD. Knowing how it happens might help.

    Fatness as a sign of inferiority

    Bodily fatness is a stigmatized body characteristic in Canada and other wealthy countries. Within any given culture, some characteristics or histories are assumed to reflect a character flaw. The characteristic is treated as a sign of inferiority. The result is loss of social status and widespread societal discrimination. With bodily fatness, the assumed character flaws are laziness, ignorance or weak willpower. In a comprehensive review published 10 years ago, there was strong evidence of fatness-related discrimination in employment, while other sectors were less researched. Studies carried out since that time confirm the pattern — including within health care.

    ‘Just eat more salads’

    Poor quality clinical care due to anti-fat stigma occurs when doctors or nurses assume the stereotype holds true. One common way this happens: a clinician simply tells you to “lose weight,” as Bennett heard many times when seeking help. That’s like telling patients to “lose blood sugar.” Telling people to produce an outcome is not good quality clinical care. This is especially awful when weight is not related to the topic at hand — an ear infection, for example. Sometimes, clinicians do this as “opportunistic counselling.” It’s done assuming the benefits outweigh harms — except we know that doing this for weight reduces trust in health-care providers. And reduced trust can lead to avoidance, for obvious reasons — needs aren’t met. Unfortunately, some clinicians give very simplistic weight loss advice, such as “eat more salads,” without any assessment of what the patient already knows, does, has tried or can afford and fit into their lives. Simplistic advice is patronizing at best; it assumes patients are ignorant, as per the stereotype. This approach vastly underestimates the knowledge of a patient, gained in part through repeated past attempts to change body composition. One Canadian study found that half of those classified as overweight, and 71 per cent of those categorized as obese, had attempted to reduce their body weight in the last year. Simplistic messages — “lose weight” or “exercise more” — assume thinness is easy and simply involves some lifestyle tweaks. When such advice is given without assessment of health concerns — for instance, headaches — anti-fat biases can endanger lives.

    Bias trumps science, sometimes

    Clinicians should, at minimum, recommend actions that have a chance at producing an outcome. Lifestyle changes only produce modest effects for most, yet many clinicians assume much bigger impacts. Obesity Canada, an organization that uses evidence-based action to better prevent and manage obesity, reminds health-care providers that the typical body weight reduction from sustained lifestyle changes is five per cent of body weight. Dramatic life changes, such as those of participants on the TV show The Biggest Loser, can slow the body’s resting metabolic rate, triggering weight regain. Science also tells us that factors beyond lifestyle are influencing population shifts around body weight and fatness. But these scientific findings are still not routinely integrated into health-care professionals’ understandings of weight. As a result, many still emphasize poor willpower as the core problem. You shouldn’t have to advocate for yourself to get adequate health care. You should be able to trust your health-care professionals.

    How to advocate for yourself

    There are many people working to ensure access to good quality health care. But tackling discrimination is complex. You can help. When clinicians make one of these common mistakes or in some other way block you being diagnosed or treated, you are on good grounds to challenge them. Say something like: “What would you do if someone with a thin body had this problem?” Then encourage them to treat you in the same way. Send them this or other articles. Write your story and give it to them. Find a Health-At-Every-Size® practitioner, and check for local resources (such as the Good Fat Care website in Winnipeg). After receiving poor quality care, register a complaint with the provider’s professional licensing body. They may not investigate your individual complaint but do track trends. Patient advocates are also available in some hospitals to help you get the care you need. News stories come and go. But the issues Ellen Maud Bennett raised in her obituary should not disappear from our consciousness so quickly. You deserve good care, just as she did. This article is written in memory of Ellen Maud Bennett, with the permission of her sister.The Conversation Patty Thille, Assistant Professor in Physical Therapy, University of Manitoba This article is republished from The Conversation under a Creative Commons license. Read the original article.
    By Dr Patty Thille
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    Dr Linda Calabresi
    • Clinical Articles

    Anorexia and cancer risk

    You’d think having anorexia nervosa was bad enough. But among all the negative effects it can have on your body, could it also increase your risk of cancer? Or does the condition perversely mimic the caloric restriction and fasting that have been demonstrated to benefit the prevention of some malignancies - meaning could it protect against cancer? That's what European oncology researchers wanted to find out through their systematic review and meta-analysis of a series of studies involving more than 42,000 people with the eating disorder. The result was both encouraging and intriguing. It appears that overall there was no association of anorexia nervosa with risk of cancer. But that’s not the whole story. On further analysis it appears anorexia nervosa was associated with some cancers and not others. In some cases the condition increased the risk and in others it appeared protective, hence the balancing out effect of no association overall. “Findings from our meta-analysis suggest that anorexia nervosa was associated with decreased breast cancer incidence compared with the general female population, with high confidence,” said the study authors in JAMA Network Open. And on the down side, the researchers found anorexia nervosa appeared to be associated with an increased risk of developing lung and oesophageal cancer, although the evidence was less compelling than that for breast cancer. As the authors point out, the breast cancer protection makes sense in terms of physiology. Anorexia notoriously interferes with a woman’s hormones, reducing her levels of oestradiol as well as insulin-like growth factor 1. Women with anorexia often have delayed puberty, early menopause and an overall decreased lifetime exposure to oestrogen so it stands to reason that a hormone-sensitive cancer, such as breast cancer is less likely to develop. But the increased risk of lung and oesophageal cancer is harder to explain. One might think, given the types of cancer we’re talking about that perhaps there was a greater prevalence of smoking among people with anorexia nervosa. But no. “[T]he increased risk of developing lung or oesophageal cancer does not seem to be attributable to a higher prevalence of smoking among women with anorexia nervosa,” they said. Interestingly the authors refer to a 2016 meta-analysis that determined smoking prevalence was much higher among people with bulimia nervosa than the general population, but not anorexia nervosa. The researchers offer no explanation for the association between anorexia and lung and oesophageal cancer, conceding the evidence isn’t strong. However they do warn that the findings suggest perhaps a need for greater vigilance in investigating symptoms suggestive of cancers of either the respiratory tract or the GIT in anorexia nervosa patients. As with most studies, the study authors call for further research to confirm or refute these associations, suggesting that the findings have possibly important implications. “Understanding the mechanisms underlying these associations could have important preventive potential,” they concluded.  

    Reference:

    Catalá-López F1, Forés-Martos J, Driver JA, Page MJ, Hutton B, Ridao M, et al. Association of Anorexia Nervosa With Risk of Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019; 2(6): e195313. DOI: 10:1001/jamanetworkopen.2019.5313
    By Dr Linda Calabresi
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    Dr Linda Calabresi
    • Clinical Articles

    Quality improvement in aged care

    If you look after patients in an aged care facility you should really have a look at this resource. It’s from the Australian Government’s Department of Health and it basically gives you all you need to know about the most recent initiative to ensure high standard of care in these facilities. From July 1, all aged care facilities that receive government subsidies for the services they provide will need to collect and provide data on three specific adverse outcomes that residents might experience. Specifically the government is asking these facilities to record information on pressure injuries, use of physical restraint and unplanned weight loss because these are indicators of clinical quality, or more exactly indicators of poor clinical quality. Every three months residential facilities will need to submit this Quality Indicator (QI) data to the Department of Health which will generate a report. So where do GPs fit in? According to the resource information, GPs will need to get involved in making sure facilities proactively respond to this QI information. The actions GPs are being asked to take are mainly about getting engaged in the programme – ask questions, ask to see the 3-monthly QI reports and help with the interpretation of the information from these reports. It will also be important that GPs contribute ideas on how to improve care. Even though this new initiative is only looking at three indicators, and there are many more that could be considered such as pain and falls, these three were chosen because they each have a broad impact across a number of other care areas – these are the canaries in the mine so to speak. Improve these and a whole lot of other areas of care improve as well. It’s not our usual type of recommended resource but if you’re a GP looking after patients in aged care you will recognise how this initiative could be very important to the health of our elderly patients. Check it out.   >> Access the resource here

    By Dr Linda Calabresi
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    Dr Bruce Baer Arnold
    • Clinical Articles

    Assassination by pacemaker: Australia needs to do more to regulate internet-connected medical devices

    In the future, people are going to be just a little bit cyborg. We’ve accepted hearing aids, nicotine patches and spectacles, but implanted medical devices that are internet-connected present new safety challenges. Are Australian regulators keeping up? A global recall of pacemakers has sparked new fears and splashy headlines about hacked medical devices. But the next 20 years of medicine will normalise the use of intelligent implants to control pain, provide data for diagnostic purposes and supplement ailing organs, which means we need proper security as well as access in case of emergency.
    Read More: Three reasons why pacemakers are vulnerable to hacking
    Pharmaceuticals and medical devices in Australia are regulated by the Therapeutic Goods Administration (TGA), an arm of the national Health Department. Can we rely on Australia’s medical devices regime? Recurrent criticisms by parliamentary committees and government inquiries suggest the regulator may be struggling.

    The job of the TGA

    The TGA regulates medical devices such as stents, pacemakers, joint implants, breast implants, and the controversial vaginal mesh that has featured recently in the media (and a Senate inquiry) over claims it seriously injured patients. The role of the TGA is vital, because defective devices can result in injury or death. They have a major cost for the public health system and affect patient quality of life. They often result in litigation, sometimes with billion-dollar settlements. In undertaking its mission, the TGA looks to information from manufacturers and distributors, from overseas regulators and its own staff. Like counterparts such as the US Food and Drug Administration, TGA staff are under pressure to get products into the marketplace and reduce “red tape”.

    The TGA and cybersecurity

    Wireless medical devices need greater security than, say, an internet-connected fridge. It is axiomatic that they must work. We need to ensure that information provided by the devices is safeguarded and that control of the devices – implantable or otherwise – is not compromised. To do that, we can use existing tools such as robust passwords, encryption and systems design. It also requires product vendors and practitioners to avoid negligence. Regulators must proactively foster and enforce standards. Put simply, bodies like the TGA need to deal with software rather than simply bits of metal and plastic. It is unclear whether the TGA has the expertise or means to do so.

    Solutions, not panic

    The past decade has seen a succession of inquiries into the TGA, including the 2015 Sansom Review and 2012 Senate PIP Inquiry. Each has demonstrated that the TGA is not always keeping up with its task. Problems are ongoing: think defective joint implants, breast implants and vaginal mesh. But there are some potential paths towards improvement. Accountability One solution is to ensure the TGA is more accountable. Currently, if someone wishes to bring a claim alleging a device was improperly permitted, the TGA has immunity from civil litigation about regulatory failure. Removal of immunity will force it to focus on outcomes. That can be reinforced by giving it independence from the Department of Health, making it report direct to Parliament and ensuring the openness emphasised by the Pearce Inquiry. Regulatory capture Medical products regulation in Australia has been a matter of penny wise, pound poor. The TGA is funded by fees from the manufacturers and distributors that it regulates, in addition to some government funding. It needs a discrete budget that recoups costs but is not dependent on companies that complain regulation is expensive. It needs enough resources to do its job well in the emerging age of the internet of things, including access to independent expertise regarding cybersecurity and devices. A device register How many devices have been implanted and how many removed? The lack of data about medical devices is a problem. The government has so far not embraced recommendations for a comprehensive device register, one allowing timely identification of what was implanted and by whom.
    Read More: Vaginal mesh controversy shows collective failure of the TGA and Australia’s specialists
    Such a register would provide a means for determining problems with devices or medical practice. We need timely, consistent reporting of problems on a mandatory basis, as well as recall and transparent investigation of what went wrong. Disclosure of interests The inquiry into vaginal mesh revealed the WA Branch of Australian Medical Association had a financial interest in a device that may have seriously affected numerous women. There must be full disclosure of such interests, with meaningful sanctions where disclosure has not been made. This requires action by the TGA, professional bodies and the government.

    So, what about assassination by wireless pacemaker?

    The cybersecurity of medical devices is a matter for everyone. We need the TGA to work with manufacturers, distributors and health professionals to mandate best practice. Should, for example, manufacturers and practitioners ensure that implants do not rely on default passwords that are easily crackable? What about access by emergency services? The ConversationThere is a fundamental need to develop and enforce a national safety standard regarding all wireless implants. For that we need thoughtful policy, not just headlines. Bruce Baer Arnold, Assistant Professor, School of Law, University of Canberra This article was originally published on The Conversation. Read the original article.
    By Dr Bruce Baer Arnold
    Woman,Coughing
    Dr Linda Calabresi
    • Clinical Articles

    Risk of post-op pneumonia halved

    A single 30minute educational session with a physio about post-op breathing exercises prior to elective upper abdo surgery, halves that patient’s risk of respiratory complications compared with usual care, Australian research shows. The randomised study conducted among 441 patients across three hospitals in Australia and New Zealand showed the pre-op intervention reduced the risk of post-operative pulmonary complications from 27% in the control group to 12% in the physio-taught group. In fact, the number need to treat to prevent one such complication was only seven. The effect was greatest in men, those undergoing colorectal surgery, those aged under 65 and those educated by an experienced physiotherapist. So what did this all-important physio session involve? Well, as they say in the classics – it wasn’t rocket science. The physiotherapists had a standard script which included educating the patient about the high likelihood of a pulmonary complication following this type of surgery (10 to 50% according to the literature) and the importance of early ambulation as well as breathing exercises in preventing these. Many patients are unlikely to up and about in the first couple of days following major upper abdominal surgery but at least the breathing exercises can be done from the moment the patient regains consciousness – two sets of 10 slow, deep breaths followed by three coughs, using an abdominal support pillow to reduce pain. And this is to be repeated hourly. This was emphasised in the education session which was conducted at some stage in the six weeks prior to surgery. The physio session also included a practice run through of these exercises. However, interestingly the control group also received pre-op written information about these same facts and exercises, and were reminded of them post-op as part of standard care. What then made the difference? “One explanation for the effectiveness of pre-operative physiotherapy to reduce [post-operative pulmonary complications] is that the preparation, motivation and training of the patient before surgery brings the timing of breathing exercise initiation to immediately after regaining consciousness after surgery,” the study authors suggested. A degree of atelectasis is common with this type of surgery and general anaesthetic. The immediate commencement of these exercises could facilitate the re-inflation of the lungs, and prevent the progression of this atelectasis. The primary end point of this study was the development of one or more of seven respiratory symptoms or signs in the 14 days post op including chest xray evidence of consolidation or collapse, cough with coloured sputum or a respiratory-related high white cell count. One of the secondary endpoints was pneumonia, the relative risk of which was reduced by 52% courtesy of the intervention. In essence, the study showed how the right education and motivation given at the right time can dramatically improve health outcomes with results that are directly applicable to tens of millions of patients awaiting surgery such as this worldwide. “[P]atients reported that pre-operative physiotherapy empowered them to treat themselves and placed high value on its role in improving their post-operative recovery,” the researchers said. Ref: BMJ 2018;360:j5916 doi:10.1136/bmj.j5916

    By Dr Linda Calabresi
    shutterstock_309987251
    Dr Smathi Chong
    • Clinical Articles

    Not so simple Herpes Simplex

    Herpes simplex virus (HSV) 1 and 2 are closely related to each other and more distantly related to Varicella Zoster virus (VZV), which causes Varicella (chicken pox) and Herpes Zoster (shingles). Traditionally HSV1 causes most oral herpes and HSV2 causes most genital herpes. But this is no longer so and has changed, probably due to more frequent oral sex. Figures from Clinipath 2017:
    HSV Swab Origin HSV1 HSV2 VZV
    Oral sites 93% 2% 5%
    Genital/perineal sites 45% 50% 5%
    HSV1 is frequently acquired in childhood and 75% of Australian adults would have had HSV1 by early adulthood. This would have been from oral contact with close friends and relatives who were shedding the virus, often asymptomatically. The classic “cold sores” are a blistering painful rash around the mouth Like other viruses in the Herpes family, this ‘lifelong’ infection can lay dormant and reactivate. The risk of reactivation and severe reactivation is higher in immunosuppressed individuals but in most people there is no readily identifiable reason for their reactivation. Stress is often blamed. Less common infections include:
    • HSV encephalitis (HSV1 in adults) and HSV meningitis (usually HSV2 in adults)
    • Conjunctivitis/keratitis – usually HSV1 or VZV (shingles affecting trigeminal nerve)
    • Herpetic whitlow – painful vesicles affecting the finger or thumb caused by HSV1 or 2

    Genital Herpes

    This causes most angst in patients as there is a social stigma. Approximately one in 7 of the general Australian adult population is seropositive to HSV2 but most are asymptomatic or subclinical. HSV Serology has a more limited role. Many clinicians (and patients) expect Herpes serology to be able to do more than it can! Test results may not answer many clinical or patients’ questions. A positive serology simply indicates a patient has been infected with HSV at some time in the past. It is not able to time the initial infection unless seroconversion (HSV IgG changing from negative to positive) can be demonstrated. In Herpes reactivation, the IgG would already be positive. Serology does not indicate the site of infection (e.g. oral or genital) although a strong positive HSV2 serology in the setting of painful genital lesions is likely to indicate genital herpes. Serology does not confirm whether symptoms are due to herpes. A positive PCR on a genital lesion would be more helpful. Positive serology is not able to tell if the person is infectious at the time of the test. HSV Serology or PCR would NOT be able to determine whether a person’s partner has been unfaithful! False positive (perhaps up to 5%) and false negative serology results can occur. Serology is often negative in acute primary herpes infection as HSV IgG can take a few weeks to a few months to become positive. Serology positivity may also decline over time. HSV IgM is no longer performed in most labs as they often throw up more confusion due to the non-specific nature of the test.

    HSV in Pregnancy

    HSV can cause severe neonatal infections including meningo-encephalitis, disseminated disease and even death. The highest risk is in symptomatic primary herpes infection of the birth canal/genital track. Herpes simplex serology may be more useful in the setting of pregnancy in patients with genital lesions suggestive of herpes to help risk stratify whether the episode is likely to be primary HSV. The highest risk would be PCR proven active genital lesions and negative serology. Treatment including anti-viral therapy and consideration of caesarean section may be discussed with the obstetrician. Management of the neonate with high risk of HSV should be handled by a neonatologist or paediatrician.

    Treatment

    These viruses may be treated with aciclovir, valaciclovir or famciclovir.
    General Practice Pathology is a new 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 Smathi Chong
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    Prof Graeme Suthers
    • Clinical Articles

    Pharmacogenomics in general practice

    Despite potential savings of more than $1 billion annually, awareness of pharmacogenomic tests among Australian prescribers is low and national guidelines for their use have not been developed. This void contributes directly to the continued prescribing of ineffective medications, unacceptably high rates of adverse drug reactions and associated personal and economic costs. Pharmacogenomics (PGx) is the study of how the genome of an individual patient influences their response to a medication.

    By Prof Graeme Suthers, Dr Kym Mina, Dr Tom Polasek

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