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Cardiology

Clinical Articles

Managing the cardiovascular time bomb in patients on antipsychotics

The physical health of mentally ill patients is a "massive problem and we are doing very badly at it,” psychiatrist Dr Matthew Warden told doctors at a recent Healthed evening seminar in Sydney. In particular, the prevalence of high cardiovascular risk among patients with a history of psychosis, means this population was a "ticking time bomb", said Dr Warden, who is the Director of Acute Inpatient Services for Mental Health at St Vincent’s Hospital in Melbourne. Even without antipsychotic medication, a disproportionate number of people with a history of psychosis are overweight or obese, do very little if any physical exercise and smoke. And it is well-known that the metabolic side-effects associated with antipsychotic medications increases this cardiovascular risk enormously. Consequently, there has been growing pressure on psychiatrists to assess, monitor and manage the physical health of their patients with psychosis, but Dr Warden said, realistically this needs to be also done by GPs as they will usually be managing these patients long-term and "they are better at it.” Baseline metabolic measurements need to be taken at first episode of psychosis, including weight, BMI, BP, lipid levels, fasting blood sugar and smoking status. Weight, in particular needs to be monitored carefully following the commencement of antipsychotic medication, as weight gain is extremely common, especially with olanzapine which, Australia-wide is the most commonly prescribed antipsychotic. In answer to a GP’s question following his talk, Dr Ward said it is extremely difficult to avoid or reverse this medication-induced weight gain with diet and exercise alone. In addition, weight loss pharmacotherapy such as phentermine is contraindicated in people with a history of psychosis. Key to managing the weight gain issue was to choose an antipsychotic with the least long-term side effects from the outset. Olanzapine and clozapine are associated with the greatest weight gain while lurasidone and the partial agonists, aripiprazole and ziprasidone have the least effect on weight. Alternatively, for patients who may have been started on olanzapine or similar, swap to a more weight-neutral medication at the first sign they were gaining weight or developing other metabolic side-effects. It is more likely that a person who as gained weight on olanzapine, will lose that weight if switched to another weight-neutral medication early. The longer that patient stays on olanzapine and the weight gain is sustained, the harder it will be to shift even if the medication is changed, Dr Warden said. In addition to managing weight gain in mentally ill patients, Dr Warden also encouraged GPs to offer smoking cessation advice and help. Even though this population were often considered among the most dependent and heaviest smokers, his own research had found a significant number of patients could successfully quit or at the least cut down given the right advice and assistance. While most smoking cessation pharmacotherapy could be used, Dr Warden suggested that varenicline (Champix) was probably best avoided in these patients. At St Vincent’s Hospital in Melbourne, patients receiving antipsychotic therapy have their metabolic markers assessed at admission and at regular intervals after that, including measuring their serum prolactin. “Hyperprolactinaemia is a significant problem and should be monitored every six months if it is elevated or increasing particularly if there are symptoms then either reduce the dose or change antipsychotic or add in low dose aripiprazole which will lower prolactin levels,” Dr Warden explained. Dr Matthew Warden spoke on the “Management of Metabolic Dysregulation in Patients on Antipsychotics” at the Healthed, Mental Health in General Practice Evening Seminar held in Sydney in June, 2018.

By Dr Linda Calabresi

Obstetrics and gynaecology

Clinical Articles

Fewer Caesars with earlier induction

Among low-risk, nulliparous women, inducing a pregnancy at 39 weeks will not only be at least as safe as letting nature run its course but it will reduce the risk of having a Caesarean, according to US research. According to the randomised trial involving over 6000 women, those who were assigned to ‘expectant management’ ended up having a median gestational age of 40 weeks exactly, not a huge difference from the median gestational age of the induction group which was 39.3 weeks. However, the main aim of the study was to determine if induction at 39 weeks resulted in more adverse perinatal outcomes including conditions such as perinatal death, need for respiratory support, Apgars of less than three at five minutes, intracranial haemorrhage and the like. This potential association has been the concern which has dictated what is currently common obstetric practice. “When gestation is between 39 weeks 0 days and 40 weeks 6 days, common practice has been to avoid elective labour induction because of a lack of evidence of perinatal benefit and concern about a higher frequency of Caesarean delivery and other possible adverse maternal outcomes, particularly among nulliparous women”, the study authors said in the new England Journal of Medicine. What they found in their study however, was that these adverse perinatal outcomes occurred in only 4.3% of the babies born in the induction group and in 5.4% of those born to mothers who went into labour naturally. It appears the relative risk was reduced by 20%. And even though the induction group tended to have longer labours they had quicker recovery times and shorter hospital stays. In terms of maternal outcomes, induction at 39 weeks was associated with a significant reduction in the risk of both Caesarean section and hypertensive disorders of pregnancies. The researchers estimated one Caesarean would be avoided for every 28 low-risk, first-time mothers induced at 39 weeks. The study authors suggest that these findings have the capacity to change practice, or at the very least, provide evidence to relook at current obstetric practice policies. “These results suggest that policies aimed at the avoidance of elective labour induction among low-risk nulliparous women at 39 weeks of gestation are unlikely to reduce the rate of Caesarean delivery on a population level”, they concluded. Ref: NEJM 2018; 379:513-23 DOI: 10.1056/NEJMoa1800566

By Dr Linda Calabresi

Cardiology

Clinical Articles

Salt may have been unfairly targeted as a killer in the healthy heart stakes, according to newly published research. The observational study of over 90000 people in 300 communities across 18 countries, found that sodium consumption was not associated with an increase in health risks unless the average daily consumption was excessive – more than 5g/day or 2.5 teaspoons of salt. And, this average high daily sodium intake was mostly seen in China, with only about 15% of communities outside of China exceeding this 5g a day limit. As part of this ongoing Prospective Urban Rural Epidemiology (PURE) study, participants aged 35-70 were assessed initially at baseline and then followed for an average of 8.1 years, over which time the occurrence of any major cardiovascular events or death was recorded. What the researchers found was that the risk of hypertension and strokes was only increased in communities where the average daily sodium intake was greater than 5g. Perhaps unexpectedly, this higher sodium intake was actually found to be also associated with lower rates of myocardial infarction and total mortality. Furthermore, the research found that very low levels of sodium intake were harmful, being associated with an increased risk of cardiovascular disease and mortality. The findings fly in the face of the current WHO guidelines that recommend, as a global approach we should be aiming for populations to reduce their sodium intake to below 2g/day. However, no communities in the study came close to achieving this target. In fact, no communities in the study had an average sodium intake of less than 3g/day, based on morning fasting urine samples from the participants. “Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate,” the Canadian study authors said. But before we all go and stock up on our Saxa, an accompanying editorial sounds a word of caution. While acknowledging the findings that ‘normal’ salt intake appeared to be at least health-neutral if not beneficial, the editorial authors remind us that the study is observational and has not taken into consideration a number of potential confounders such as diet. Without taking these confounders into account, one can’t assume that just decreasing salt intake in people at high risk of stroke or increasing it in people at risk of a heart attack will work, they said. “Nevertheless the findings are exceedingly interesting and should be tested in a randomised controlled trial,” they concluded, adding that such a trial, to be conducted in a US federal prison population had been proposed. Ref: Lancet Vol 392 No 10146 pp:496-506 Vol 392 No 10146 pp: 456-458

By Dr Linda Calabresi

Infectious diseases

Clinical Articles

The microbiology laboratory has made great strides in introducing clinically useful diagnostics over the past couple of decades, particularly in recent years with the development of molecular assays that ‘narrow the gap’ and provide early diagnoses. While introducing new tests, it has also been important to evaluate and discard old tests that may not contribute greatly to patient outcomes. One such test that has come under the spotlight is the classic Widal agglutination test in the diagnosis of typhoid. The Widal test, developed by George Fernand Widal in 1896, uses a suspension of killed Salmonella typhi as antigen to detect agglutinating antibodies to somatic O antigens and flagellar H antigens present in serum of typhoid patients. There are many reasons for its lack of clinical utility. Antibodies are not present in the acute illness and take time to develop. Significant cross reactivity can occur with other infectious agents that mimic typhoid including malaria, dengue, endocarditis, tuberculosis and chronic liver disease. Other limitations are of a technical nature and include non-standardisation of the antigen preparation used in the assay, interference with serological responses following typhoid vaccination commonly provided to travellers, and prior exposure and antibodies in patients most susceptible to typhoid, especially those from endemic areas visiting friends and relatives (VFRs). Unless multiple antigens are included, it generally does not detect the other causes of enteric fever, S. Paratyphi A, B and C. It is now time to discontinue this simple agglutination test for typhoid in modern medicine and consider more appropriate diagnostic tests. Typhoid fever Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. Whereas Salmonellae which cause gastroenteritis are zoonoses, humans are the only reservoir for S.Typhi and S. Paratyphi which cause enteric fever. Typhoid fever is still common in the developing world where it affects about 21.5 million people each year but is much less common in the Lucky Country such as ours where good sanitation prevails. About 100 cases are notified each year in Australia. In 2014, 92% of cases were acquired overseas. India continues to be the most common country of acquisition and in 2014 accounted for more than half of cases. Most transmission occurs through contaminated drinking water or food. Large epidemics are most often related to faecal contamination of water supplies or street-vended foods. A chronic carrier state – excretion of the organism for more than one year – occurs in about 5% of infected persons. Where no travel history is present, the likely source of infection is contaminated food or water from a human carrier akin to ‘Typhoid Mary’. Such an outbreak was reported in Auckland, New Zealand, this year where 20 local cases and one death occurred when a carrier from Samoa helped prepare food at a church community gathering. The incubation period is typically eight to 14 days but may be much longer. Without therapy, the illness may last for three to four weeks and death rates range between 12% and 30%. Increasing resistance to available antimicrobial agents, including fluoroquinolones, has occurred in recent years. Resistance to antimicrobials including amoxycillin, and trimethoprim+sulfamethoxazole has limited the options for treatment; reduced susceptibility to quinolones is common in infections acquired on the Indian subcontinent and in Southeast Asia. While awaiting the results of susceptibility testing, azithromycin or ceftriaxone should be used for initial therapy for infections acquired in these regions. Diagnosis of enteric fevers Two sets of blood cultures are the single most useful diagnostic procedure for diagnosis of enteric fever. Other bodily fluids and tissues may yield positive cultures including faeces, urine, and if seeded, bones and joints, liver and gall bladder. Food handlers, healthcare workers, carers of children, and carers of the elderly, and others who are not able to maintain their own personal hygiene, should further be excluded from working with food or caring for people until two consecutive stool specimens – collected at least 48 hours apart and the first specimen collected not sooner than 48 hours post-cessation of antibiotics – are culture negative. Prevention Both an oral live attenuated multi-dose vaccine and a killed vaccine are available. Booster doses after 3-5 years are generally required if continued exposure occurs. Vaccine efficacy is of the order of only 80%. What to order Blood culture x 2 (Salmonella Typhi and Salmonella Paratyphi) Faeces for Bacterial PCR and MCS; Urine MCS Collection Centres: Faeces and urine samples are accepted at all collection centres. Blood cultures are collected only at designated collection centres. Sample Blood (use blood culture bottles), faeces, urine Transportation Ambient Costs Medicare rebate applies Typhoid Mary Mary Mallon, better known as Typhoid Mary, was an Irish immigrant to New York and the first person in the United States identified as an asymptomatic carrier of the pathogen associated with typhoid fever. Over the course of her career as a cook, she was presumed to have infected 51 people, three of whom died. She was twice forcibly isolated by public health authorities and died after a total of nearly three decades in isolation. 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 Jenny Robson

Cardiology

Clinical Articles

Low density lipoprotein cholesterol is the well-known culprit in terms of cardiovascular risk. Courtesy of a large meta-analysis of statin trials done in 2010 (the Cholesterol Treatment Trialists Collaboration), we know that for people starting with higher LDL-C levels (approximately 3.4 mmol/L), they can lower their risk of having a major adverse vascular event by 22%, every time they lower their LDL-C level by 1mmol/L. But what happens once your LDL level is lower? Can you continue to increase your protection by lowering your LDL levels further? Or does the beneficial effect plateau at a certain level? Or, worse still can very low LDL levels actually cause harm? A new meta-analysis just published in JAMA Cardiology has gone some way in answering these questions. The researchers analysed data from the 26 statin studies in the CTTC as well as three large trials of non-statin, cholesterol-lowering therapy looking at those patients who had an LDL-C level of 1.8 mmol/L or less at baseline. They found the cardioprotective benefits continued as LDL-C levels declined to even lower levels. “We found consistent clinical benefit from further LDL-C lowering in patient populations starting as low as a median of 1.6 mmol/L and achieving levels as low as a median of 0.5 mmol/L”. What’s more, the incremental benefit was of an almost identical magnitude to that seen when the LDL-C levels were higher - 21% relative risk reduction per 1-mmol/L reduction in LDL-C through this range. “This relative risk reduction is virtually the same as the 22% reduction seen in the overall CTTC analysis in which the starting LDL-C was nearly twice as high,” they said. And even though very low cholesterol levels have been rumoured to be associated with everything from cancer to dementia, across all these studies there were no offsetting safety concerns with LDL-C lowering, even when extremely low levels were recorded, levels that were lower than those seen in newborns. Given the weight of benefit over risk, the study authors suggest the current targets for LDL-C could be lowered further, to even as low as 0.5 mmol/L to reduce cardiovascular risk. This suggestion is supported by an accompanying editorial, in which the author, Dr Antonio Gotto, a New York cardiologist, predicts the findings will be included as part of the revision of the American Heart Association National Cholesterol guidelines which is currently underway. He said the study findings would provide much needed evidence to help clinicians manage patients with these extremely low achieved cholesterol levels, that until recently have been very rare. “Whether one calls it a target or a threshold, practicing physicians need some guidance as they venture into achieved levels of LDL-C levels that are as foreign as travel to outer space. I have confidence that the new guidelines will be closer to a global positioning system map rather than just a compass and the stars”, he concluded. Ref: JAMA Cardiol. Published online August 1, 2018. doi:10.1001/jamacardio.2018.2258

By Dr Linda Calabresi

Diagnostics

Clinical Articles

Google predicts when people will die ‘with 95% accuracy’

Google has claimed it can predict with 95% accuracy when people will die using new artificial intelligence technology.

In a paper published in the journal Nature, the company’s Medical Brain team detailed how it is using a new type of artificial intelligence algorithm to make predictions about the likelihood of death among patients in two separate hospitals.

For predicting patient mortality, Google’s Medical Brain was 95% accurate in the first hospital and 93% accurate in the second. It works by analysing patient’s data, such as their age, ethnicity and gender. This information is then joined up with hospital information, like prior diagnoses, current vital signs, and any lab results, reports The Sun. But according to Bloomberg, what impressed medical experts most “was Google’s ability to sift through data previously out of reach: notes buried in PDFs or scribbled on old charts. The neural net gobbled up all this unruly information then spat out predictions. And it did it far faster and more accurately than existing techniques.” It is not the first time Google has made inroads into the medical industry. Its DeepMind subsidiary, considered by some experts to lead the way in AI research, “courted controversy” in 2013 after it was revealed it had access to 1.6 million medical records of NHS patients at three hospitals, reports The Independent. >> Read More Source: The Week UK

By Healthed

Psychiatry

Clinical Articles

Farmers experiencing drought-related stress need targeted support

For farmers, drought is a major source of stress. Their livelihoods and communities depend on the weather. To better support farmers and their families we need to better understand the impact of drought on them and their communities. Our research, published today in the Medical Journal of Australia, found young farmers who live and work on farms in isolated areas and are in financial hardship are the most likely to experience personal drought-related psychological stress. Read more: The lessons we need to learn to deal with the 'creeping disaster' of drought

What our study found

To examine farmers’ mental health during droughts, we examined data from the Australian Rural Mental Health Study and rainfall conditions in the months before farmers completed the survey. Importantly, the study covered the period of the Millennium Drought, which had devastating environmental, social and economic impacts on much of southeast Australia from 1997 to 2010. The study captured both drought and wet conditions, which enables comparisons between farmers’ mental health under different climate conditions. The study included 664 farmers from inner and outer regional, remote and very remote New South Wales. Farmers were defined as: (i) people who lived on a farm; (ii) people who worked on a farm; and (iii) people who lived and worked on a farm. The gender distribution of the participants was equal and the majority were 55-64 years old. Of the three groups investigated, farmers who both lived and worked on a farm reported more drought-related impacts and concerns. Moderately dry conditions were related to the highest scores for drought-related concerns and general psychological distress. Interestingly, higher levels of drought-related concerns were also reported following mild to moderate wet conditions. This is possibly related to much of the study area receiving very high spring rainfall during 2010 and suggests drought-related mental health impacts persist beyond the end of the drought. Read more: Farmer suicide isn't just a mental health issue

A range of social, demographic and community factors influenced the personal impact of drought for farmers:

Isolation plays a large role in the rural context. Farmers in outer regional, remote and very remote NSW experienced higher levels of concern about drought. Remoteness can mean people aren’t able to engage as much in social networks, which are essential for building resilience.
Financial hardship is increasing in rural areas but many people don’t seek financial assistance due to stigma and ingrained stoicism. Younger farmers may also be particularly impacted by less financial security than older farmers.
Age matters too. Farmers under the age of 35 experienced higher personal drought-related stress.

What can we do about it?

Protracted drought is a rare but recurring element of the Australian climate. Whatever the cause, future drought is inevitable. Read more: Hairdressers in rural Australia end up being counsellors too

Drought impacts are different from “rapid” climate extremes such as bushfires, floods or cyclones. So drought planning and preparedness needs to consider the impacts of drought on mental health and well-being differently to the way in which we prepare for and respond to “rapid” climate extremes. We know “rapid” climate extremes can have devastating impacts through loss of life, injury and other threats to communities. The effects can be acute or long-term. While many people cope and adapt to rapid climate extremes, we know a substantial proportion will go on to develop mental health problems as a result. Much less is known about chronic, slow-onset climate extremes such as protracted drought. The unfamiliarity, unpredictability and longevity of drought have substantial personal and social consequences over time. The mechanisms for such impacts are not as well known as for “rapid” climate extremes. Our findings suggest the disruption to community viability, the financial strain, loss of property and stock, and impact on future personal hopes are likely to play a role. Supporting rural communities, and especially farmers, to cope with droughts can have benefits for their well-being and mental health. Strengthening personal, financial and social support for farmers may help in adapting to droughts when drought-related stress is affecting their mental health. General practitioners are uniquely placed to support farmers experiencing persistent worry that is affecting their day-to-day functioning. But it’s often trusted people who engage with farmers regularly, such as rural financial counsellors and vets, who occupy first responder roles. Insights from our study are useful for informing the practical steps required to improve farmers’ mental health. These include:

reducing stigma about mental health problems to overcome barriers to seeking professional help and advice early
professional help to be more readily available and easier to access in rural and remote areas (such as e-health programs)
professional education for all health services, including general practitioners, so they can look out for and address the effects of drought-related stress – they need a good understanding of the pressures facing farmers and farming communities and the ways they can be more alert to their needs
community education and public health campaigns so farmers and rural residents can identify the effects of drought-related stress and take appropriate action
education and training for non-medical agricultural support services, such as rural financial counsellors, who need to be able to confidently identify early signs of drought-related stress and provide appropriate support
continued funding of Rural Adversity Mental Health Program coordinators who link rural and remote residents to services and provide community education and support
better opportunities and encouragement to maintain and develop community connections and social networks
reasonably priced and reliable internet access to enable increased use of e-health and relieve isolation
transparent and consistent information about the processes farmers need to follow to access grants and loans. Farmers should be able to apply for financial support when it’s needed rather than having to fit in with government budget cycles and deadlines. Efficient processing of grant and loan applications is needed to minimise the period of uncertainty and stress while waiting for the outcome.

Emma Austin, PhD Researcher, University of Newcastle; Anthony Kiem, Associate Professor – Hydroclimatology, University of Newcastle; Brian Kelly, , University of Newcastle; David Perkins, Director, Centre for Rural and Remote Mental Health and Professor of Rural Health Research, University of Newcastle; Jane Rich, Research Associate, University of Newcastle, and Tonelle Handley, Research fellow, University of Newcastle This article was originally published on The Conversation. Read the original article.

By Healthed