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

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Opioid,Withdrawal,Symptoms,And,Depression.,Bad,Pain,Medication
Helen Tobler
  • Clinical Articles

Long-acting injectables for opioid dependence

Two options are now widely available in primary care, reducing stigma and improving convenience...

By Helen Tobler
woman-1401617_1920
Dr Linda Calabresi
  • Clinical Articles

Poo Transplants Beat Antibiotics

Faecal transplantation has been gaining momentum as a mainstream treatment over recent years, but now a systematic review published in the MJA puts it ahead of antibiotics in effectiveness against Clostridium difficile-associated diarrhoea. The literature search examined all the randomised controlled trials on the topic up until February this year, including some recently published studies, and concluded there was moderate quality evidence that faecal microbiota transplantation is more effective in patients with Clostridium difficile-associated diarrhoea than either vancomycin or placebo. The review also found that samples that had been frozen and then thawed prior to transplantation were as effective as fresh samples. “Our systematic review also highlights the fact that frozen/thawed transplants – a more convenient approach that reduces the burden on a donor to supply a sample on the day it is needed – is as effective as fresh [faecal microbiota transplant],” the authors said. However, there was less clarity about the optimal method of administering the transplanted microbiota. “Our analysis indicates that naso-duodenal and colonoscopic application may be more effective than retention enemas, but this conclusion relies on indirect comparisons of subgroups,” they concluded suggesting that further research was needed to determine the best route of administration. There also needs to be more evidence into the most appropriate donor – whether they should be related, unrelated or anonymous, or whether ‘pooling stool from several donors’ would be the best way to go. “Over the past 20 years the worldwide incidence of [Clostridium difficile-associated diarrhoea] has more than doubled, and outbreaks have been associated with greater morbidity and mortality, although to a lesser extent in Australia,” the study authors said. Even though recent guidelines from Europe and North America now recommend these transplants to treat antibiotic-resistant Clostridium difficile-associated diarrhoea, the international authors of the review said these recommendations were based on relatively poor evidence. It is expected this systematic review that includes more scientifically robust clinical trials will inform future guidelines on the topic, particularly in Australia and New Zealand whose guidelines on treating Clostridium difficile-associated diarrhoea currently need updating. Ref: doi: 10.5694/mja17.00295

By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

Rectal Exams Still Important – Sorry

Most GPs of a certain vintage would have heard the old adage “if you don’t put your finger in, you put your foot in.” It refers of course to the digital rectal examination and its importance as part of a thorough physical examination especially when symptoms indicate some potential pathology in that area. However it would be fair to say that most doctors, let alone patients are not particularly enthusiastic about this particular test. Indeed you could almost hear the collective sigh of relief when the authoritative guidelines suggested regular DRE was not useful as a means of screening for prostate cancer. The downside of this change in recommendation and general avoidance behaviour is that one can become deskilled in this examination, potentially missing an opportunity to diagnose a variety of conditions from prostate abnormalities to cancer. In the latest MJA, Dr Christopher Pokorny from the South Western Sydney Medical School at UNSW gives a synopsis of indications for DRE and a run through of the appropriate technique. “About 25% of colorectal cancers occur in the rectum and up to half can be palpated, but accuracy depends on training, experience, examination technique and the length of the examining finger,” Dr Pokorny writes. His list of indications for the procedure include the more obvious symptoms such as PR bleeding or mucus, change in bowel habit and prostatic symptoms but also a history of faecal urgency, difficult defaecation, faecal incontinence and anorectal pain (with the caveat that DRE should be avoided if there is an obvious anal fissure). Placing the patient in the left lateral position for the procedure is recommended with the patient drawing their knees to their chest and assuming that the patient is safe from falling off the examination couch. Assessment is made of the skin around the anus – looking for fissures, fistulae, skin tags, skin diseases such as warts or psoriasis, abscesses and haemorrhoids. The well-lubricated, gloved finger is then gently inserted, rotated in a clockwise direction into the rectum. Dr Pokorny suggests a systematic examination of the rectal mucosa anteriorly, posteriorly and laterally for masses that should be described as soft, hard, irregular or smooth. Prostatic abnormalities in men and ovarian or uterine abnormalities in women may be noted being careful not to confuse a palpable cervix in a woman with a mass. Finally, the doctor needs to check for any blood, including malaena on the glove. Dr Pokorny does concede the value of this examination is limited by the body habitus of the patient, and the length of the examiner’s fingers. Nonetheless, it is unwise to miss this diagnostic opportunity in general practice. “DRE is an often neglected but important part of the physical examination and should be performed whenever symptoms suggest anorectal or prostatic pathology,” he concludes. MJA doi:10.5694/mja17.00373

By Dr Linda Calabresi
shutterstock_1350420863
Prof Shaun Roman
  • Clinical Articles

The Handmaid’s Tale and counting sperm: are fertility rates actually declining?

With the release of a new TV series based on Margaret Atwood’s The Handmaid’s Tale, and a recent study claiming male sperm count is decreasing globally, fertility is in the spotlight. Many want to know if the dystopian future Atwood created in which the world has largely become infertile, is in fact possible. And are we on our way there already?

What this latest study found

The recent paper that hit headlines all over the world highlighted the issue of declining sperm numbers in Western men. The study is a meta-analysis, which gathers together similar studies and combines the results. Each of the studies in the analysis has different men assessed at different times by different researchers. This means, as a whole, it is not as powerful as a study examining the same men over time. And many of the individual studies assessed have their own problems.
Read more - Health Check: when does fertility decline?

So is fertility actually declining?

The current estimate is that Western men produce 50 million sperm per millilitre in an ejaculate, which is lower than previously. However, only one sperm is needed to fertilise an egg, so 50 million sperm per ml suggests human males don’t have a problem just yet. There are data indicating that from below 40 million sperm per ml there is a linear relationship between sperm numbers and probability of pregnancy. The World Health Organisation (WHO) suggests 15 million per ml sperm is a minimum to be considered fertile. The minimum is based on men who have successfully fathered a child in the last 12 months. By definition, 5% of the men with numbers below 15 million per ml will still be able to reproduce. For females the issue that needs to be understood is that there is already a small window of time women are fertile, and this is decreasing as women are more educated and career-focused. Women have their highest number of eggs when they are still a fetus in their mother’s womb. About one sixth of the eggs are left at birth and by puberty the number is 500,000 eggs or less. From puberty until 37 years of age there is a steady decline from 500,000 to 25,000 eggs. After 37 years, the rate of decline increases and by menopause (average age of 51 in the US) only 1,000 eggs remain. It’s important to realise these are average numbers and there is no guarantee a woman will have 25,000 eggs at 37. The other issue is quality. Chromosomal issues (such as Down’s syndrome - where a person has three copies of chromosome 21 instead of two) increase with maternal age. IVF is seen as a way of rescuing fertility, but the success rate of 41.5% is for women younger than 35, and measures pregnancies, not live births. By 40 years old, that success rate is 22% and by 43 years it’s 5%.
Read more - Explainer: what causes women’s fertility to decline with age?
In short, the situation for women is not great, but the numbers are not changing with time (estimates of fertility from 1600 to 1950 don’t differ).

What is affecting fertility today?

The key determinant in women’s fertility is education - not individuals’ education but that of the community as a whole. If your community becomes educated, your fertility declines, as women become educated and less likely to have children in their youth. Choosing to delay having a child is not the only issue. Lifestyle choices matter. We know smoking, alcohol and obesity all affect the number and quality of eggs a woman has. As a female has all the eggs she will ever have when she is in her mother’s womb, the mother smoking will affect those eggs. Smoking in pregnancy is declining slowly (from 15% in 2009 to 11% in 2014) but is still very high in the Indigenous population (45%).
Read more: Why women’s eggs run out and what can be done about it
Smoking and alcohol are said to be major factors contributing to male sperm numbers but the evidence is limited by the nature of the studies. The effects of obesity and stress have the clearest evidence. For example, increased levels of anxiety and stress have been associated with lower sperm count. Life stress (defined as two or more stressful events in the last 12 months) has been found to have an effect, but not job stress. For men, the numbers themselves represent a blunt measure of fertility. It’s the quality of the sperm produced that’s of concern. The WHO minimum is that only 4% of male sperm need to be of good appearance to be considered fertile. It’s not really possible for us to be able to tell which of many factors may be influencing sperm appearance.

Problems with studying fertility

While we can talk about what research says on fertility, there are a few inherent problems with researching in this field. Most of the data we have on sperm count come from two sources: men attending an infertility clinic, and those undergoing a medical prior to military service. The first is restricted to those who likely already have a problem. The second is limited to one age group. Meta-analyses, which combine the results from lots of studies, are limited to those all using the same tools and approaches so they can be compared. As a result, a large meta-analysis that suggested smoking is detrimental was limited to men attending an infertility clinic, which would indicate many of them are likely to be infertile anyway. Another big study used conscripts in the US and Europe but failed to find an association between fertility and alcohol consumption. This is because it only assessed the alcohol consumed the week prior to the medical - and most recruits probably wouldn’t be out drinking in the days leading up to their medical.

So could we become extinct?

The reproduction rate is below that required for total population replacement in the US, Australia, and many other countries. But the human population in total is still growing as it ages.
Read more: Most men don’t realise age is a factor in their fertility too
The start of this millennium also represented the time when births for women aged 30-34 overtook those in the 25-29 age group, and the 35-39 age group overtook the 20-24 age group. Teenage pregnancy (15-19 years) is now level with older mums (40-44) in Australia. The quality of the sperm and egg is more important than the numbers. While we are still investigating what quality means to future generations, we do know that infertility represents a predictor of increased death rates. Men diagnosed with infertility had a higher risk of developing diabetes, ischaemic heart disease, alcohol abuse and drug abuse. The ConversationUltimately it’s not a numbers game but a quality game. This is true not just for the chances of having a child but having a healthy child. More immediately, fertility is a predictor of general health. While it does not appear that we are going to be extinct soon (at least not through reproductive failure), sperm quality could be a signal of wider health problems and should be investigated further. Shaun Roman, Senior Lecturer, University of Newcastle This article was originally published on The Conversation. Read the original article.
By Prof Shaun Roman
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A/Prof Michael McDowell
  • Clinical Articles

New Autism Guidelines Miss The Mark

The first national guidelines for diagnosing autism were released for public consultation last week. The report by research group Autism CRC was commissioned and funded by the National Disability Insurance Scheme (NDIS) in October 2016. The NDIS has taken over the running of federal government early intervention programs that provide specialist services for families and children with disabilities. In doing so, they have inherited the problem of diagnostic variability. Biological diagnoses are definable. The genetic condition fragile X xyndrome, for instance, which causes intellectual disability and development problems, can be diagnosed using a blood test. Autism diagnosis, by contrast, is imprecise. It’s based on a child’s behaviour and function at a point in time, benchmarked against age expectations and comprising multiple simultaneous components. Complexity and imprecision arise at each stage, implicit to the condition as well as the process. So, it makes sense the NDIS requested an objective approach to autism diagnosis.
Read more: The difficulties doctors face in diagnosing autism
The presumption of the Autism CRC report is that standardising the method of diagnosis will address this problem of diagnostic uncertainty. But rather than striving to secure diagnostic precision in the complexity and imprecision of the real world, a more salient question is how best to help children when diagnostic uncertainty is unavoidable.

What’s in the report?

The report recommends a two-tiered diagnostic strategy. The first tier is used when a child’s development and behaviour clearly meet the diagnostic criteria. The process proposed does not differ markedly from current recommended practice, with one important exception. Currently, the only professionals who can “sign off” on a diagnosis of autism are certain medical specialists such as paediatricians, child and adolescent psychiatrists, and neurologists. The range of accepted diagnosticians has now been expanded to include allied health professionals such as psychologists, speech pathologists and occupational therapists. This exposes the program to several risks. Rates of diagnosed children may further increase with greater numbers of diagnosticians. Conflict of interest may occur if diagnosticians potentially receive later benefit as providers of funded treatment interventions. And while psychologists and other therapists may have expertise in autism, they may not necessarily recognise the important conditions that can present similarly to it, as well as other problems the child may have alongside autism. The second recommended tier of diagnosis is for complex situations, when it is not clear a child meets one or more diagnostic criteria. In this case, the report recommends assessment and agreement by a set of professionals – known as a multidisciplinary assessment. This poses important challenges:
  • Early intervention starts early. Multidisciplinary often means late, with delays on waiting lists for limited services. This is likely to worsen if more children require this type of assessment.
  • Multidisciplinary assessments are expensive. If health systems pay, capacity to subsequently help children in the health sector will be correspondingly reduced.
  • Groups of private providers may set up diagnostic one-stop shops. This may inadvertently discriminate against those who can’t pay and potentially bias towards diagnosis for those who can.
  • Multidisciplinary assessments discriminate against those in regional and rural areas, where professionals are not readily available. Telehealth (consultation over the phone or computer) is a poor substitute for direct observation and interaction. Those in rural and regional areas are already disadvantaged by limited access to intervention services, so diagnostic delays present an additional obstacle.
A diagnostic approach reflects a deeper, more fundamental problem. Methodological rigour is necessary for academic research validity, with the assumption autism has distinct and definable boundaries. But consider two children almost identical in need. One just gets over the diagnostic threshold, the other not. This may be acceptable for academic studies, but it’s not acceptable in community practice. An arbitrary diagnostic boundary does not address complexities of need.

We’re asking the wrong question

The federal government’s first initiative to fund early intervention services for children diagnosed with autism was introduced in 2008. The Helping Children With Autism program provided A$12,000 for each diagnosed child, along with limited services through Medicare. The Better Start program was introduced later in 2011. Under Better Start, intervention programs also became available for children diagnosed with cerebral palsy, Down syndrome, fragile X syndrome and hearing and vision impairments. While this broadened the range of disabilities to be funded, it did not address the core problem of discrimination by diagnosis. This is where children who have equal needs but who for various reasons aren’t officially diagnosed are excluded from support services. Something is better than nothing, however, and these programs have helped about 60,000 children at a cost of over A$400 million. Yet the NDIS now also faces a philosophical challenge. The NDIS considers funding based on a person’s ability to function and participate in life and society, regardless of diagnosis. By contrast, entry to both these early intervention programs is determined by diagnosis, irrespective of functional limitation.
Read more: Understanding the NDIS: will parents of newly diagnosed children with disability be left in the dark?
While funding incentives cannot change prevalence of fragile X syndrome in our community (because of its biological certainty), rates of autism diagnoses have more than doubled since the Helping Children with Autism program began in 2008. Autism has become a default consideration for any child who struggles socially, behaviourally, or with sensory stimuli. Clinicians have developed alternative ways of thinking about this “grey zone” problem. One strategy is to provide support in proportion to functional need, in line with the NDIS philosophy. Another strategy is to undertake response-to-intervention. This is well developed in education, where support is provided early and uncertainty is accepted. By observing a child’s pattern and rate of response over time, more information emerges about the nature of the child’s ongoing needs. The proposed assessment strategy in the Autism CRC report addresses the question, “does this child meet criteria for autism?”. This is not the same as “what is going on for this child, and how do we best help them?”. And those are arguably the more important questions for our children.
The ConversationThis article was co-authored by Dr Jane Lesslie, a specialist developmental paediatrician. Until recently she was vice president of the Neurodevelopmental and Behavioural Paediatric Society of Australasia. Michael McDowell, Associate Professor, The University of Queensland This article was originally published on The Conversation. Read the original article.
By A/Prof Michael McDowell
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Dr Linda Calabresi
  • Clinical Articles

How long do anxiety patients need medication?

It is well-known that when a patient with depression is commenced on antidepressants and they are effective, they should continue them for at least a year to lower their risk of relapse. The guidelines are pretty consistent on that point. But what about anxiety disorders? Along with cognitive behavioural therapy, antidepressants are considered a first-line option for treating anxiety conditions such as generalised anxiety disorder, obsessive-compulsive disorder and post-traumatic disorder. Antidepressants have been shown to generally effective and well-tolerated in treating these illnesses. But how long should they be used in order to improve long-term prognosis? Internationally, guidelines vary in their recommendations. If the treatment is effective the advice has been to continue treatment for variable durations (six to 24 months) and then taper the antidepressant, but this has been based on scant evidence. To clarify this recommendation, Dutch researchers conducted a meta-analysis of 28 relapse prevention trials in patients with remitted anxiety disorders. Their findings, recently published in the BMJ, support the continuation of pharmacotherapy. “We have shown a clear benefit of continuing treatment compared with discontinuation for both relapse… and time to relapse”, the authors stated. In addition, the researchers found the relapse risk was not significantly influenced by the type of anxiety disorder, whether the antidepressant was tapered or stopped abruptly or whether the patient was receiving concurrent psychotherapy However, because of the duration of the studies included in the meta-analysis, only the advice to continue antidepressants for at least a year could be supported by evidence. After this, the researchers said there was no evidence-based advice that could be given. “[However] the lack of evidence after this period should not be interpreted as explicit advice to discontinue antidepressants after one year,” they said. The researchers suggested that those guidelines that advise antidepressant should be tapered after the patient has achieved a sustained remission should be revised. In fact, they said, there were both advantages and disadvantages to continuing treatment beyond a year, and more research was needed to help clinicians assess an individual’s risk of relapse. This is especially important as anxiety disorders are generally chronic and there have been indications that in some patients, the antidepressant therapy is less effective when reinstated after a relapse. “When deciding to continue or discontinue antidepressants in individual patients, the relapse risk should be considered in relation to side effects and the patient’s preferences,” they concluded. Ref: BMJ 2017;358:j392 doi:10.1136/bmj:j3927

By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

If In Doubt Cut It Out

New guidelines suggest excising a changing skin lesion after one month As with facing an exam where you haven’t studied, or finding yourself naked in a public place – missing a melanoma diagnosis is the stuff of nightmares for most GPs. In a condition where the prognosis can vary dramatically according to a fraction of a millimetre, the importance of early detection is well-known and keenly felt by clinicians. According to new guidelines published in the MJA, Australian doctors’ ability to detect classical melanomas early has been improving as evidenced by both the average thickness of the tumour when it is excised and the improved mortality rates associated with these types of tumours. Unfortunately, however the atypical melanomas are still proving a challenge. Whether they be nodular, occurring in an unusual site or lacking the classic pigmentation, atypical melanomas are still not being excised until they are significantly more advanced and consequently the prognosis associated with these lesions remains poor. As a result, a Cancer Council working group have revised the clinical guidelines on melanoma, in particular focusing on atypical presentations. The upshot of their advice? If a patient presents with any skin lesion that has been changing or growing over the course of a month, that lesion should be excised. The Australian guideline authors suggest that in addition to assessing lesions according to the ABCD criteria (asymmetry, border irregularity, colour variegation, and diameter >6mm) we should add EFG (elevated, firm and growing) as independent indicators of possible melanoma. “Any lesion that is elevated, firm and growing over a period of more than one month should be excised or referred for prompt expert opinion,” they wrote. In their article, the working group do acknowledge that it is not always a delayed diagnosis that is to blame for atypical melanomas being commonly more advanced when excised. Some of these tumours, such as the nodular and desmoplastic subtypes can grow very rapidly. “These subtypes are more common on chronically sun-damaged skin, typically on the head and neck and predominantly in older men,” the authors said. However, the most important common denominator with melanomas is that they are changing, they concluded. A history of change, preferably with some documentation of that change such as photographic evidence should be enough to raise the treating doctor’s index of suspicion. “Suspicious raised lesions should be excised rather than monitored,” they concluded. Ref: MJA Online 9.10.17 doi:10.5694/mja17.00123

By Dr Linda Calabresi
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Prof Louise Newman
  • Clinical Articles

Can People Really Repress Memories?

The Australian newspaper recently reported the royal commission investigating institutional child sex abuse was advocating psychologists use “potentially dangerous” therapy techniques to recover repressed memories in clients with history of trauma. The reports suggest researchers and doctors are speaking out against such practices, which risk implanting false memories in the minds of victims. The debate about the nature of early trauma memories and their recovery isn’t new. Since Sigmund Freud developed the idea of “repression” – where people store away memories of stressful childhood events so they don’t interfere with daily life – psychologists and law practitioners have been arguing about the nature of memory and whether it’s possible to create false memories of past situations. Recovery from trauma for some people involves recalling and understanding past events. But repressed memories, where the victim remembers nothing of the abuse, are relatively uncommon and there is little reliable evidence about their frequency in trauma survivors. According to reports from clinical practice and experimental studies of recall, most patients can partially recall events, even if elements of these have been suppressed.

What are repressed memories?

The concept of repressing traumatic memories was part of this model. Repression, as Freud saw it, is a fundamental defensive process where the mind forgets or places events, thoughts and memories we cannot acknowledge or bear elsewhere.Freud introduced the concept that child abuse is a major cause of mental disorders such as hysteria, also known as conversion disorder. People with these disorders could lose bodily functions, such as the ability to move one of their limbs, following a stressful event. Freud also suggested that if these memories weren’t recalled, it could result in physical or mental symptoms. He argued symptoms of a mental disorder can be a return of the repressed memories, or a symbolic way of communicating a traumatic event. An example would be suddenly losing speech ability when someone has a terrible memory of trauma they feel unable to disclose. This idea of hidden traumas and their ability to influence psychological functioning despite not being recalled or available to consciousness has shaped much of our current thinking about symptoms and the need to understand what lies behind them. Those who accept the repression interpretation argue children may repress memories of early abuse for many years and that these can be recalled when it’s safe to do so. This is variously referred to as traumatic amnesia or dissociative amnesia. Proponents accept repressed traumatic memories can be accurate and used in therapy to recover memories and build up an account of early experiences.
Read more: Dissociative identity disorder exists and is the result of childhood trauma

False memory and the memory wars

Freud later withdrew his initial ideas around abuse underlying mental health disorders. He instead drew on his belief of the child’s commonly held sexual fantasies about their parents, which he said could influence formation of memories that did not did not mean actual sexual behaviour had taken place. This may have been Freud caving in to the social pressures of his time. This interpretation lent itself to the false memory hypothesis. Here the argument is that memory can be distorted, sometimes even by therapists. This can influence the experience of recalling memories, resulting in false memories. Those who hold this view oppose therapy approaches based on uncovering memories and believe it’s better to focus on recovery from current symptoms related to trauma. This group point out that emotionally traumatic memory can be more vividly remembered than non-traumatic memories, so it wouldn’t hold these events would be repressed. They remain sceptical about reclaimed memories and even more so about therapies based on recall – such as recovered memory therapy and hypnosis. The 1990s saw the height of these memory wars, as they came to be known, between proponents of repressed memory and those of the false memory hypothesis. The debate was influenced by increasing awareness and research on memory systems in academic psychology and an attitude of scepticism about therapeutic approaches focused on encouraging recall of past trauma. In 1992, the parents of Jennifer Freyd, who had accused her father of sexual assault, founded the False Memory Syndrome Foundation. The parents maintained Jennifer’s accusations were false and encouraged by recovered memory therapy. While the foundation has claimed false memories of abuse are easily created by therapies of dubious validity, there is no good evidence of a “false memory syndrome” that can be reliably defined, or any evidence of how widespread the use of these types of therapies might be.
Read more: We’re capable of infinite memory, but where in the brain is it stored, and what parts help retrieve it?

An unhelpful debate

Both sides do agree that abuse and trauma during critical developmental periods are related to both biological and psychological vulnerability. Early trauma creates physical changes in the brain that predispose the individual to mental disorders in later life. Early trauma has a negative impact on self-esteem and the ability to form trusting relationships. The consequences can be lifelong. A therapist’s role is to help abuse survivors deal with these long-term consequences and gain better control of their emotional life and interpersonal functioning. Some survivors will want to have relief from ongoing symptoms of anxiety, memories of abuse and experiences such as nightmares. Others may express the need for a greater understanding of their experiences and to be free from feelings of self-blame and guilt they may have carried from childhood. Some individuals will benefit from longer psychotherapies dealing with the impact of child abuse on their lives. Most therapists use techniques such as trauma-focused cognitive behavioural therapy, which aren’t aimed exclusively at recovering memories of abuse. The royal commission has heard evidence of the serious impact of being dismissed or not believed when making disclosures of abuse and seeking protection. The therapist should be respectful and guided by the needs of the survivor.
Read more: Why does it take victims of child sex abuse so long to speak up?
Right now, we need to acknowledge child abuse on a large scale and develop approaches for intervention. It may be time to move beyond these memory wars and focus on the impacts of abuse on victims; impacts greater than the direct symptoms of trauma. The ConversationIt’s vital psychotherapy acknowledges the variation in responses to trauma and the profound impact of betrayal in abusive families. Repetition of invalidation and denial should be avoided in academic debate and clinical approaches. Louise Newman, Director of the Centre for Women’s Mental Health at the Royal Women’s Hospital and Professor of Psychiatry, University of Melbourne This article was originally published on The Conversation. Read the original article.
By Prof Louise Newman
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Dr Krissy Kendall
  • Clinical Articles

Science or Snake Oil: do men need sperm health supplements?

Infertility, defined as the inability of a couple to conceive after at least 12 months of regular, unprotected sex, affects about 15% of couples worldwide. Several factors can lead to infertility, but specific to men, infertility has been linked to lower levels of antioxidants in their semen. This exposes them to an increased risk of chemically reactive species containing oxygen, which can damage sperm. These reactive oxygen species are naturally involved in various pathways essential for normal reproduction. But uncontrolled and excessive levels of reactive oxygen species results in damage to your cells (or “oxidative stress”). This can affect semen health, and damage the DNA carried in the sperm, leading to the onset of male infertility.
Read more: Science or Snake Oil: is A2 milk better for you than regular cow’s milk?

Can supplements improve sperm health?

Antioxidants have long been used to manage male infertility as they can help alleviate the detrimental role of reactive oxygen species and oxidative stress on sperm health. Generally speaking, studies have shown favourable effects with supplementation, but results have been rather inconsistent due to large variations in study design, antioxidant formulations, and dosages. Several lab studies have reported beneficial effects of antioxidants such as vitamins E and C on the mobility of the sperm and DNA integrity (absence of breaks or nicks in the DNA). But these haven’t been able to be replicated in humans. There is some research suggesting six months of supplementation with vitamin E and selenium can increase sperm motility and the percentage of healthy, living sperm, as well as pregnancy rates. Other studies have found improvements in sperm volume, DNA damage, and pregnancy rate following treatment with supplements l-carnitine (an amino acid), Coenzyme Q10, and zinc. But there seems to be an equal number of studies showing no improvements in sperm motility, sperm concentration, the size or shape of sperm, or other measures. Perhaps it’s the inconsistency in results, and the overall desire to improve fertility rates that has led some companies to create their own sperm-saving cocktails.

The research behind Menevit

Menevit is a male fertility supplement aimed at promoting sperm health. It’s a combination of antioxidants, including vitamins C and E, zinc, folic acid, and selenium, formulated to maintain sperm health.
Read more: Most men don’t realise age is a factor in their fertility too
The makers of Menevit claim the antioxidants it contains can help maintain normal sperm numbers, improve sperm swimming, improve sperm-egg development, and protect against DNA damage. Following three months of supplementation, participants taking Menevit recorded a statistically significant improvement in pregnancy rate compared to the control group (38.5% versus 16%). But no significant changes in egg fertilisation or embryo quality were detected between the two groups.To date, there has only been one published study conducted on the actual product. The lead author of the study is also the inventor of the product. At first glance these findings may seem promising, but a few things warrant attention. As mentioned, the principle investigator of the study is also the inventor of the product, something many would argue is a conflict of interest. The study also reported no improvements in DNA integrity or sperm motility, the two most cited benefits of supplementing with antioxidants. Furthermore, the study looked at who was pregnant three months later, not who actually gave birth to a child. The dosages used in the Menevit product are also much lower than what’s been in previous studies. For example, significant improvements in total sperm count have been observed following 26 weeks of supplementation with folic acid and zinc. But this study used 66mg of zinc (compared to 25mg in Menevit) and 5mg of folic acid (compared to 500 micrograms in Menevit). It’s hard to say you would get the same results from the lower doses. And studies showing improvements in sperm motility and DNA integrity following vitamin E and selenium supplementation used much larger doses than what is found in Menevit. The dosage of vitamin E used in previous studies has ranged from 600-1,490 international units, Menevit has 400 international units. The dose of selenium studied was 225 micrograms, compared to only 26 micrograms in the Menevit product.

Your best bet for healthy sperm

Before you stock up on every antioxidant out there, take a quick look at your lifestyle. Sperm health can be affected by unhealthy lifestyle factors like poor diet, alcohol consumption, smoking, and stress.
Read more: The Handmaid’s Tale and counting sperm: are fertility rates actually declining?
Following a diet comprised of whole foods (not packaged, processed foods), avoiding excessive consumption of alcohol, engaging in regular physical activity, and not smoking can go a long way when it comes to improving the health of your sperm. The ConversationAs for sperm supplements such as Menevit, there’s a great deal of research that still needs to be done before we can say for sure it’s a worthwhile investment. Krissy Kendall, Lecturer of Exercise and Sports Science, Edith Cowan University This article was originally published on The Conversation. Read the original article.
By Dr Krissy Kendall
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Dr Linda Calabresi
  • Clinical Articles

A Proven, Practical Alternative For Pain

There has been a lot of noise around opioid use lately. In particular, in the States where it’s been declared a public health emergency. While concerted efforts are being made to ensure that patients who are experiencing chronic pain are not also in a position where they also have to deal with opioid addiction, in the cases of severe, acute pain most doctors would consider pain relief the priority and opioids the gold standard. Well it seems that too may need a rethink. According to a new randomised controlled trial just published in JAMA, an oral ibuprofen/paracetamol combination works just as well at reducing pain, such as that felt with a suspected fractured arm as a range of other oral opioid combinations including oxycodone and paracetamol. The US researchers randomly selected over 400 patients who presented to emergency with moderate to severe arm or leg pain, severe enough to warrant investigation by imaging to receive an oral paracetamol/ibuprofen combination pain relief or one of three other opioid combination analgesics including oxycodone/paracetamol, hydrocodone/paracetamol or codeine/paracetamol. Two hours after ingestion there were no statistically significant or clinically important difference in pain reduction between the four groups. A limitation of the study was that it didn’t compare adverse effects, however the study authors said their findings support the use of the paracetamol/ibuprofen combination as an alternative to oral opioid analgesics, at least in cases of severe arm or leg pain. Their findings also contradict the long-held idea that non-opioid pain killers are less effective than opioids, an idea that has been underpinned by the WHO pain ladder that has guided clinicians managing both cancer and non-cancer pain since 1986. Even though most scripts for opioids are written out in the community, previous research has showed that long-term opiate use is higher among those patients who were initially treated in hospital. “Typically, treatment regimens that provide adequate pain reduction in the ED setting are used for pain management at home,” an accompanying editorial stated. “[This trial] provides important evidence that nonopioid analgesia can provide similar pain reduction as opioid analgesia for selected patients in the ED setting.” What’s more, the effectiveness of this paracetamol and ibuprofen combination for moderate to severe pain may also translate to its more widespread use for acute pain in other clinical conditions traditionally treated with opioid medication, however this would need further investigation, the editorial author concluded. Ref: JAMA 2017; 318(17): 1661-1667. Doi:10.1001/jama.2017.16190 JAMA 2017; 318(17) 1655-1656

By Dr Linda Calabresi
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Dr Linda Calabresi
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Pressure increased on hypertension treatment

New US guidelines are the most aggressive yet in terms of targets for blood pressure control. Put out by the American College of Cardiology and the American Heart Association, and published in JAMA, the guidelines recommend we now consider anyone with a BP of 120/80 mmHg or above as having abnormal blood pressure. People who have a systolic between 120 and 130 mmHg but whose diastolic is still below 80 mmHg are to be considered to have elevated BP. But those who have both a systolic up to 10mmHg above target (120-130mmHg) and a diastolic between 80 and 90 mmHg should now be classified as having stage 1 hypertension. An accompanying editorial estimates that this reclassification will result in a 14% increase in the US population who should be recognised as having hypertension. But before clinicians start reaching for the script pad, the guidelines recommend this stage 1 hypertension be initially treated with non-pharmacological therapies – basically addressing the factors that most likely pushed their blood pressure up to start with – lose weight, exercise more, reduce salt intake, cut down on alcohol. The exception to this, is that group of patients whose absolute 10 year CVD risk predictor has them with a 10% or more chance of having a major CV event. In these cases, it’s gloves off. The less than 130/80 target for high risk patients is very similar to Australian guidelines. What’s different is that this is now a recommended target for everyone. The new US guidelines recommend everyone with a BP over 140/90 mmHg be treated with medication (preferably two agents) regardless of their absolute CV risk. Our Heart Foundation says try other lifestyle changes in people with a very low CV risk and no other comorbidities until we reach the 160/100 mmHg mark. The other new development in the US guidelines is the recommendation to use BP measurements from ambulatory or home BP monitoring to both confirm a diagnosis of hypertension and titrate therapy. This is in keeping with Australian recommended practice. The US guidelines were developed by an expert committee after examining all the current evidence and conducting a series of systematic reviews looking at some key clinical questions. “From a public health perspective, considering the high population-attributable risk of CVD associated with hypertension, the potential benefits of tighter control of hypertension are substantial,” the guideline authors wrote. However, they do acknowledge that such an aggressive approach does carry risks, especially in the elderly. “Although studies do suggest that lower BP is better for most patients, including those older than 75 years, the balance of the potential benefits of hypertension management and medication costs, adverse effects, and polypharmacy must be considered for each individual patient,” they said. Ref: JAMA. Published online November 20, 2017. doi:10.1001/jama.2017.18706

By Dr Linda Calabresi
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Dr Jenny Robson
  • Clinical Articles

Schistosomiasis

Schistosomiasis, also known as bilharzia, is the second most prevalent tropical disease after malaria and is a leading cause of morbidity in many parts of the world. It is not uncommon in Australia because of the many travellers who visit endemic areas and swim or bathe in freshwater lakes and streams. Places commonly implicated include Lake Kariba and Lake Malawi in Africa. Immigrants and refugees from bilharzia endemic countries are also likely to present with untreated infection. With increasing travel to and migration from Africa and the Americas knowledge of the dangers and means of avoiding schistosomiasis is essential. Schistosomiasis is caused by trematodes of the genus Schistosoma. The principal schistosomes of medical importance, S japonicum, S mansoni, S mekongi (intestinal schistosomiasis) and S haematobium (urinary schistosomiasis), infect people who enter water in which infected snails (intermediate hosts) are living. The larval cercariae shed by the snail actively penetrate unbroken skin and develop into schistosomulae that migrate through the lungs to the liver where they mature into adults. Female worms lay eggs that pass through the vessels and tissues to the lumen of the gut or bladder (depending on localisation of worms). A proportion of eggs escape from the host and may be found in faeces or urine. The host's immune response to eggs that become lodged in the tissues is largely responsible for disease, Figure 1.  

Geographic distribution

This is governed by the distribution of the intermediate host snail. S haematobium                         Africa, Middle East, India (only Maharashtra) S japonicum                               Philippines, Indonesia (only Sulawesi), parts of China S mansoni                                   Africa, Middle East, some Caribbean Islands, parts of South America (Brazil, Surinam, Venezuela) S mekongi                                   Laos and Cambodia S intercalatum                           10 countries within the rainforest belt of West Africa.

At-risk groups

Owing to the absence of suitable snail hosts, transmission cannot occur in Australia. A history of overseas travel or residence is essential for this diagnosis. Chronic schistosomiasis is more likely to be seen in migrants and refugees from endemic areas. In Australia, where the definitive host is freshwater and marine birds, non-human trematodes may cause schistosomal dermatitis (cercarial dermatitis, swimmer's itch). Onset is usually within 15 minutes of skin contact with cercariae.

Clinical presentation

Disease due to schistosomiasis depends on the infecting species and the intensity of infection. Acute schistosomiasis occurs two to 12 weeks post infection and symptoms last for periods varying from one day to a month or more; recurrence of symptoms 2-3 weeks later is common. Between 40-95% of individuals, not previously exposed to infection, develop symptoms which include fever, malaise, headache, abdominal pain, diarrhoea and urticaria. Many have eosinophilia. After the initial acute onset, most become asymptomatic, although those with S haematobium infections may develop microscopic or macroscopic haematuria. Rare complications result from ectopic deposition of eggs in the spinal cord and brain. Most travellers are only mildly infected and are therefore often asymptomatic and unlikely to develop the severe manifestations of chronic schistosomiasis. Severe disease occurs in patients with heavy and prolonged infection. Hepatosplenomegaly, portal hypertension, ascites and oesophageal varices may result from intestinal schistosomiasis. And frank haematuria with varying degrees of impairment of the urinary bladder and ureters may occur with S haematobium infections.

Diagnosis

The prepatent period of S japonicum, S mansoni and S mekongi is 6-8 weeks, and for S. haematobium 10-12 weeks. Examination of faeces or urine before this time often yields false negative results. Similarly, with serology, testing too early may result in false negative results. Antibody development occurs slightly before eggs are detected. Eosinophilia (greater than 0.60 x103/mL) is present in up to 80% of patients with infections; however, its absence does not exclude infection.

Parasitologic examination

Diagnosis is by demonstration of eggs of S japonicum, S mansoni and S mekongi  in faeces, or eggs of S haematobium in urine. At least two stool or urine specimens should be submitted for examination over a period of 10 days. Whilst eggs may be found in all specimens of urine, there is some evidence of a diurnal periodicity with a peak of excretion around midday. Collection of the terminal portion of urine collected between noon and 2 pm is therefore recommended. Schistosome eggs can also be demonstrated in rectal snips or bladder biopsies. Viability of eggs can be assessed if the biopsies are received fresh.

Serologic examination

At our laboratory, antibodies are detected by enzyme immunoassay (EIA) using purified egg S mansoni antigen. Antibodies to this antigen may be undetectable in the pre-patent period lasting 8-10 weeks. The test detects genus specific antibodies. In the absence of a diagnosis based on egg identification, travel history provides the best assessment of likely species.

Interpretation

Parasitologic Faeces is concentrated (modified formalin-ethyl acetate) and urine either centrifuged or filtered; all of the concentrate or sediment is examined. Because of the low sensitivity of these techniques, a negative faecal or urine examination does not exclude schistosomiasis. Microscopic examination of eggs enables the species of parasite to be determined. At least two examinations on different days are recommended. Serologic Schistosome serology cannot distinguish between past or current infection nor differentiate the species of infection. Clinical history and further investigations should be considered when establishing the diagnosis. Recent infections may be serologically negative.

Preventative measures

Cercariae can burrow through the mucosa of the mouth as well as through unbroken skin. All fresh water in endemic areas should be considered suspect, although snails tend to live in slow-flowing and stagnant waters, rather than in rapids and fast-flowing waters. If freshwater contact is unavoidable, bathing water should be heated to 50°C for five minutes or treated with iodine or chlorine as for the treatment of drinking water. Water can also be strained through paper filters, or allowed to stand for 2-3 days before use. This exceeds the usual life span of the cercariae. Of course, the container must be kept free of snails. High waterproof boots or hip waders are recommended if wading through streams or swamps. It is wise to carry a pair of rubber gloves to protect hands when contact with fresh water is anticipated. Vigorous towel drying, and rubbing alcohol on exposed skin immediately after contact with untreated water, may also help reduce cercarial penetration. Vegetables should be well cooked and salads avoided as these may have been washed in infected water, allowing cercariae to attach themselves to the leaves.

Treatment

Praziquantel (Biltricide) 20 mg/kg bodyweight every four hours for 2-3 doses depending upon the species is recommended. In travellers, this is likely to achieve cure rates in the order of 90%. Tablets are scored and available as a 600mg dose dispensed six per pack. In patients at risk of chronic disease, such as refugees and migrants, it is important to be aware of complications that may arise from chronic infection: liver fibrosis, portal hypertension and its sequelae, and colorectal malignancy in the intestinal forms; obstructive uropathy, superimposed bacterial infection, infertility and possibly bladder cancer.

Follow-up

Follow-up schistosomiasis serology is recommended in 12 to 36 months after treatment. Follow-up serology may differ between immigrants and returned travellers. Travellers may show a more rapid serological decline post-treatment due to a shorter duration of infection and lower parasite burden. Immigrants may even show a rise in titre within the first 6-12 months post-treatment. Persisting titres should not automatically justify retreatment, this should be based on symptoms, parasite identification or eosinophilia. Viable eggs may continue to be excreted for up to one month after successful treatment. Non-viable and degenerate eggs can be found in tissue biopsies for years after infection has occurred.
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

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