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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

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

Mindfulness yoga best for Parkinson Disease

Patients with Parkinson Disease can now be prescribed a mind-body therapy that has a strong evidence-base of effectiveness. According to a randomised clinical trial published in JAMA Neurology, a program of mindfulness yoga will not only improve motor dysfunction and mobility at least as well as a program of standard stretching and resistance exercises but it will also significantly lessen anxiety symptoms and improve quality of life. While clinical practice guidelines have almost uniformly recommended exercise for patients with Parkinson’s, to date there has been no robust evidence that yoga is any better than any other physical exercise program. While the fact that this study shows that mindfulness yoga is equivalent to a conventional exercise program in terms of motor symptoms is of interest, the researchers say it is the improvement in depression and anxiety symptoms that is of most importance. These symptoms are common in Parkinson disease and are a major factor affecting these patients’ quality of life. “Considering that [Parkinson Disease] is not only a physically limiting condition but also a psychologically distressing life event, health care professionals should adopt a holistic approach in [Parkinson Disease] rehabilitation,” they wrote. Much of the clinically and statistically significant improvement in anxiety and depression symptoms seen in the study, the researchers attribute to the mindfulness component of the yoga therapy. The moderate to large psychological benefit of mindfulness yoga was said to be ‘remarkable’, as the patients assigned to receive this intervention attended a mean of only six sessions. The actual study was neither huge nor of long duration, however it was randomised and had ‘adequate statistical power to detect a clinically meaningful effect.’ The Hong Kong researchers randomised almost 190 patients with mild to moderate, idiopathic Parkinson Disease to either a weekly, 90-minute session of mindfulness yoga or a weekly 60-minute session of stretching and resistance training exercises. The intervention went for a period of eight weeks and both groups were encouraged to perform 20-minutes of home-based practice twice a week over the duration of the program. The participants were assessed at baseline, at eight weeks (immediately after the intervention) and then at 20 weeks. The assessments were conducted by independent assessors who were not aware of which intervention the patient had undertaken. Interestingly while the effects of both the interventions on motor symptoms and mobility were very similar straight after program, with benefits lessening at the 20 week mark (three months after the intervention had finished), the psychological benefit of mindfulness yoga seen at eight weeks was just as pronounced 12 weeks later at the 20 week mark. This suggests that a relatively short program of mindfulness yoga might have longer term benefits in helping patients with Parkinson Disease manage stress and symptoms, the study authors said. But, of course, further research is needed to compare different mindfulness practices, the long-term effectiveness and compliance. Nonetheless, the study authors say these study findings are sufficiently strong for doctors to at least consider recommending this type of therapy to patients with Parkinson Disease. “Future rehabilitation programs could consider integrating mindfulness skills into physical therapy to enhance the holistic well-being of people with neurodegenerative conditions,” they concluded.

Reference

Kwok JYY, Kwan JCY, Auyeung M, Mok VCT, Lau CKY, Choi KC, et al. Effects of Mindfulness Yoga vs Stretching and Resistance Training Exercises on Anxiety and Depression for People With Parkinson Disease: A Randomized Clinical Trial. JAMA Neurol. 2019 Apr 8. DOI: 10.1001/jamaneurol.2019.0534
By Dr Linda Calabresi
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Dr Brett Montgomery
  • Clinical Articles

Don’t kiss your kids? Questioning the recent advice about CMV in pregnancy

As many mothers will know, health professionals seem ever ready to stoke up guilt with their advice. Don’t smoke. Don’t drink. Have your vaccines. Take your folate tablets. Eat a nutritious diet, but avoid soft cheese, cured meat, food that’s been long in a fridge, or (the list goes on). Avoid cats. Don’t co-sleep. Breast is best. And if other women can manage all this, why can’t you? As reported this week, Australia’s college of obstetricians (RANZCOG) has just added another task to the burgeoning to-do lists of doctors and midwives. We’re now to tell women to try to avoid cytomegalovirus (CMV). They have reasons for doing so, but as a GP and academic, I find myself sceptical.

What is CMV, and why does it matter in pregnancy?

CMV is a widespread virus which often causes only a mild illness. Most adults have been infected with it in the past, and are immune. But it’s different in pregnancy. If a pregnant woman is not already immune to CMV, and if she catches the virus, it can sometimes infect her fetus. And when it does, sometimes this causes problems such as hearing loss, epilepsy or developmental delay. Though previously thought to be rare, researchers now think congenital CMV is under-recognised. They estimate that one or two in every 1,000 infants may develop symptoms from being born with CMV – not rare, but uncommon. The virus is spread through fluids such as saliva, snot and urine. Child-rearing is messy; if toddlers catch CMV, it’s easy for them to pass it on to non-immune parents.

The new guideline

So what are women now urged to do to avoid CMV? To quote from the new RANZCOG guideline:
  • Do not share food, drinks, or utensils used by children (under the age of three years)
  • Do not put a child’s dummy/soother in your mouth
  • Avoid contact with saliva when kissing a child (“kiss on the forehead not on the lips”)
  • Thoroughly wash your hands with soap and water for 15-20 seconds especially after changing nappies or feeding a young child or wiping a young child’s nose or saliva
  • Clean toys, countertops and other surfaces that come into contact with children’s urine or saliva.
Does that sound easy? If you think so, perhaps double-check with a friend who has young children. From my spot poll of parents, many feel that careful adherence to these rules would be unmanageable. Homes are not hospitals; interacting with our loved ones is not a sterile procedure. I can’t help but feel that we are setting mothers up to fail by introducing these standards, and thereby compounding the guilt they carry. Early parenthood is a risky time of life for mental health issues like depression. If we are to make new mothers feel guilty about such fundamental human interactions as sharing meals and kissing, won’t we intensify their stress at this vulnerable time? If mothers feel they must respond to a joyful kiss from their toddler not with reciprocation, but with admonishment – “not on the lips, darling, only the cheek” – mightn’t this affect their bonding with their child?

What about the evidence?

The stresses above might be worth enduring if there was good evidence that these behavioural changes made a difference. But I’m unconvinced. According to researchers who recently reviewed the world evidence, there are only three studies looking at whether hygiene and behaviour recommendations can prevent congenital CMV. The largest was a study comparing how often women in a maternity hospital picked up CMV before and after hygiene advice. Infected proportions changed from 0.42% before the advice to 0.19% afterwards. But “before-after” studies aren’t a reliable guide to cause-and-effect. The most susceptible women may just have caught CMV earlier, leaving only women at less risk left for the second phase of the study. The best study design to establish cause-and-effect is a “randomised controlled trial”, in which women are randomly allocated to receive hygiene advice or not. There are two such trials. One was tiny, and found no significant difference between the non-pregnant women it randomised to hygiene advice. Separately, they followed 14 pregnant women who were given hygiene advice, who all remained uninfected, but they weren’t randomised – there was no group of pregnant women without such advice to compare to. The bigger trial randomised 166 non-immune mothers of young children to either receive hygiene advice or not. Despite providing free soap and gloves to the hygiene group, and visiting these women every three months to monitor their behaviour, exactly 7.8% of women in each group caught CMV – no difference. Pregnant women who knew from special tests that their child was shedding CMV had a low infection rate – presumably this test result was a motivator for behaviour change. But this is evidence for the effect of testing, not of giving hygiene advice. So I can’t see convincing evidence that routine hygiene advice works – not without the addition of tests of mothers’ immunity and children’s viral status. And doing such tests is not part of the new RANZCOG guideline – indeed, it explicitly advises against routine testing.

So what should we do?

I’m really torn on this issue. My heart aches for the families of children severely affected by congenital CMV. They must carry a heavy burden of guilt, wondering if they could have prevented the infection. I understand their motivation to prevent further harms. I share their desire for more research on CMV prevention. But I am saddened, too, by the prospect of a generation of women taught to see their toddlers as dangerous, all in the name of preventive measures which remain unproven. What do you think? Perhaps we need a community conversation about balancing the trade-offs here: the uncertain prevention of serious but uncommon outcomes versus widespread anxiety about normal family behaviours. Meanwhile, it’s time for me to close my laptop, share a meal with my family, and, later, kiss my kids goodnight.The Conversation Brett Montgomery, Senior Lecturer in General Practice, University of Western Australia This article is republished from The Conversation under a Creative Commons license. Read the original article.
By Dr Brett Montgomery
pregnancy
Lesley McCowan
  • Clinical Articles

Reducing stillbirth risk

A New Zealand-led international study published today provides the strongest evidence yet that women can more than halve their risk of stillbirth by going to sleep on either side during the last three months of pregnancy. This mega study (known as individual participant data meta-analysis) has also confirmed the risk of stillbirth associated with sleeping on the back applies to all pregnant women in the last trimester of pregnancy.

Risk factors

In New Zealand, stillbirth is defined as the loss of a baby after 20 weeks of pregnancy. An estimated 2.64 million babies die before birth globally each year, and around 300 babies are stillborn in Aotearoa New Zealand each year. About one in every 500 women in New Zealand will experience the tragedy of a late stillbirth and lose their baby during or after 28 weeks of pregnancy. We have analysed all available data worldwide from five previous studies, including our earlier research, the 2011 Auckland Stillbirth Study, which first identified a link between mothers’ sleeping position and stillbirth risk. The main finding in the mega study, which included information from 851 bereaved mothers and 2,257 women with ongoing pregnancies, was that going to sleep lying on the back (supine) from 28 weeks of pregnancy increased the risk of stillbirth 2.6 times. This heightened risk occurred regardless of the other known risk factors for stillbirth. However, the risk is additive, meaning that going to sleep on the back adds to other stillbirth risk factors, for example, a baby who is growing poorly in the womb. Existing common risk factors for late stillbirth are not easily modifiable. They include advanced maternal age (over 40), obesity, continued cigarette smoking and an unborn baby that is growing poorly, especially if the poor growth is not recognised before birth. Women also have a higher risk during their first pregnancy, or if they have already had three or more babies. Women of Pacific and South Asian ethnicity also have an elevated risk of late stillbirth, compared with European women. If modifiable risk factors can be identified, some of these baby deaths could be prevented. Importantly, our mega study has shown that if every pregnant woman went to sleep lying on her side after 28 weeks of pregnancy, approximately 6% of late stillbirths could be prevented. This could save the lives of about 153,000 babies each year worldwide.

Reduced blood flow

The relationship between the mother going to sleep lying on her back and stillbirth is biologically plausible. A supine position in late pregnancy is associated with reduced blood flow to the womb. Hence, women in labour and women having a caesarean section are routinely tilted onto their side to improve blood supply to the baby. Recent research carried out at the University of Auckland has provided sophisticated evidence about how the mothers’ position influences blood flow. Results obtained using Magnetic Resonance Imaging (MRI) demonstrate the major vessel in the mother’s abdomen, the inferior vena cava, being compressed by the pregnant womb when she is lying on her back. This reduces flow through this vessel by 80%.
The MRI images show the inferior vena cava (IVC) in blue and the aorta in red. In the left image, the mother is lying on her left side, while in the right image, she is on her back. provided, CC BY-SA
Although the mother’s circulation responds by increasing the flow through other veins, this does not fully compensate. The mother’s aorta, the main artery which carries oxygen-rich blood from her heart, is also partly compressed when the mother lies on her back. This decreases blood flow to the pregnant uterus, placenta and baby. We speculate that while healthy unborn babies can compensate for the reduced blood supply, babies that are unwell or vulnerable for some other reason may not cope. For example, our mega study showed that the risk of stillbirth after 28 weeks of pregnancy is increased approximately 16 times if a mother goes to sleep lying on her back and also is pregnant with a very small baby.

What to do

New Zealand research has shown that pregnant women can change their sleeping position. In a recent survey conducted in pregnant women from south Auckland, a community that has a high rate of stillbirth, more than 80% of women surveyed stated that they could change the position they went to sleep in with little difficulty if it was best for their baby. Our advice to pregnant women from 28 weeks of pregnancy is to settle to sleep on their side to reduce the risk of stillbirth, and to start every sleep, including day-time naps, on the side. It does not matter which side. It is common to wake up on the back, but we recommend that if this happens, women should simply roll back on to either side.The Conversation Lesley McCowan, Professor, Obstetrics & Gynecology, University of Auckland and Robin Cronin, Midwife researcher, University of Auckland This article is republished from The Conversation under a Creative Commons license. Read the original article.
By Lesley McCowan, Robin Cronin
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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

Anal cancer and HPV infection

Anal cancer is a neglected disease. Whether through shame and embarrassment, or self-diagnosis of a haemorrhoid, late presentations are not uncommon and have an overall five-year survival of only 65%. It is an important disease which is potentially preventable but, whether the measure is research time and money, media coverage or the allocation of a coloured ribbon, anal cancer has not received the attention it deserves. Before discussing who gets anal cancer, why they get it, how we might prevent it and the efforts being taken to do so, the anatomy and terminology need to be established and understood.
  • Gentle traction placed on the buttocks will reveal perianal lesions (those falling within 5 cm of the anal opening) however anal canal lesions will be visualised incompletely or not at all by means of this manoeuvre. This is vitally important to appreciate because accurate description of location has direct clinical relevance. Anal canal cancers are more aggressive and require chemoradiation, while perianal cancers behave more like skin cancers and wide excision is usually appropriate.
  • The anal canal has three zones – colorectal, transformation and lower canal. The transformation zone, centred on the dentate line, is where the glandular epithelium of the rectum meets the squamous epithelium of the lower canal, and is analogous to that in the cervix. It may encompass several centimetres, have poorly demarcated margins and is characterised by ongoing squamous metaplasia and constant replacement of glandular epithelium.
The transformation zone is where most anal canal cancers arise.

Who gets anal cancer?

While it is a rare disease in the general community (1–1.5/100,000), several sub-populations have very high rates of anal cancer:
  • HIV-positive men who have sex with men
  • Other HIV-positive individuals (male and female)
  • HIV-negative men who have sex with men
  • Organ transplant recipients
  • Women with a history of HPV-related vulval/vaginal/ cervical cancer or pre-cancer
About 95% of anal cancers are caused by HPV and the great majority of these are caused by HPV 16. HPV is a sexually transmitted infection and anal intercourse an efficient means of HPV transmission; however, anal intercourse is not a prerequisite for anal HPV infection. Anal HPV infection is common in both sexes (whether or not anal intercourse is reported) but most anal infections are transient. Anal cancer is a rare outcome associated with persistence of the virus and with other co-factors, such as smoking and immunosuppression.

Is prevention of anal cancer possible?

Vaccination Australia was the first country in the world to commence an organised HPV vaccination program, starting with girls and young women in 2007 and extending to school-aged boys in 2013. While vaccine efficacy for the prevention of anal cancer is anticipated to be similar to that for cervical cancer, proof of it will take longer to demonstrate. Unlike cervical cancer, the incidence of anal cancer continues to increase into old age and therefore the benefits of vaccination may take decades to become apparent. Screening for pre-cancer Digital anorectal examination (DARE) is currently recommended to detect the earliest anal cancers. In addition, some centres screen for anal pre-cancer using a model based on the multiple similarities which exist between cervical and anal cancer, namely the same virus infecting the same type of transformation zone, leading to development of the same precancerous, high-grade squamous intraepithelial lesion (HSIL) which can be detected cytologically. These commonalities translate, in the setting of anal cancer screening, to a process involving anal cytology, possibly anal HPV testing and high-resolution anoscopy (akin to colposcopy), followed by biopsy. Despite these correlations between cervical and anal HPV infection and the plausibility of similar screening protocols being applicable in both settings, a screening program for anal cancer has not been as widely implemented as may have been expected. Why is this? -Near-universality of HPV infection in men who have sex with men limits the effectiveness of HPV testing in triage. -Not enough is known about the natural history of anal HSIL and it is likely to differ in significant ways from cervical cancer. In gay men, for example, high-grade lesions appear to be quite common and a proportion may regress without treatment. -There is no accepted treatment for patients with biopsy-diagnosed anal HSIL. While the entire transformation zone of the cervix can be excised with few sequelae, this is not possible in the anal canal and there is no reliable evidence for any other interventions currently used.

Summary

At this stage neither HPV testing or anal cytology can be recommended as routine screening procedures for anal cancer and pre-cancer. Until certain key questions are answered, at-risk patients should be identified, reviewed annually by DARE and managed accordingly. Vaccination is worth offering to those in at-risk groups and is safe and effective in the immunosuppressed.   - 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

Night work increases miscarriage risk

Working as little as even two night shifts a week significantly increases a woman’s risk of miscarriage, Danish researchers say. Based on their analysis of data from a cohort of over 22,000 pregnant women primarily employed at hospitals, researchers found those women who worked two or more night shifts the previous week were 32% more like to have a miscarriage after week eight of their pregnancy, compared to women who did not work night shifts. In addition, increasing the number of night shifts and the number of consecutive night shifts during weeks three to 21 increased the risk of miscarriage even further in a dose-dependent manner. Interestingly, the study found no association between miscarriage and quick returns after a night shift (eg doing an evening shift after having completed a night shift the night before). The study findings, published recently in BMJ publication, Occupational and Environmental Medicine, support previous research that suggested a link between working nights and miscarriage. But previous studies had been limited by a lack of detailed data about the women’s exposure to night work which had meant the link between cause and effect could not be confirmed. Miscarriages are known to be very common with the researchers quoting the estimate that about one third of all human embryos are lost, most of them soon after conception. They also quote the figure that more than half of all miscarriages are the result of chromosomal abnormalities in the fetus. The finding of the association between night work and miscarriage at week eight supports the hypothesis that it is the environmental exposure that is the risk factor, as miscarriages associated with chromosomal abnormalities have generally occurred earlier in the pregnancy. Night work is believed to be a threat to the viability of pregnancies because of its effect on maternal levels of endogenous melatonin, a hormone thought to play a role in optimal function of the placenta. Exposure to light at night along with the disruption of the normal circadian sleep-wake cycles associated with night work both decrease melatonin release. The study potentially has significant implications and ramifications. “This new knowledge has relevance for working pregnant women as well as their employers, physicians and midwifes,” the study authors said. “Moreover, the results could have implications for national occupational health regulations,” they concluded.

Reference

Begtrup LM, Specht IO, Hammer PEC, Flachs EM, Garde AH, Hansen J, et al. Night work and miscarriage: a Danish nationwide register-based cohort study. Occup Environ Med. 2019 Mar 29. DOI: 10.1136/oemed-2018-105592 [epub ahead of print]
By Dr Linda Calabresi
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Lyn Phillipson & Louisa Smith
  • Clinical Articles

Are home care packages for the aged delivering?

The Royal Commission into Aged Care has unleashed a spate of claims of system failure within the residential aged care sector. Now, as the commission shifts its focus to care in the community, we’re also seeing claims of failure within the home care packages program. This scheme aims to support older people with complex support needs to stay at home. But what we’ve got is a market-based system where the processes involved in accessing support and managing services are making it difficult for vulnerable older Australians to receive the care they want. If this system is to be workable, older people need better information and more personalised supports to enable choice and control – especially those with complex needs.

Consumer directed care

A growing number of older Australians are receiving home care subsidised by the government. During the 2017-18 financial year, 116,843 people accessed home care packages.
From July 1 2015, all home care packages have been delivered on what’s called a Consumer Directed Care basis. This means that, theoretically, home care providers must work with consumers to design and deliver services that meet their goals and care needs, as determined by an Aged Care Assessment Team. However, in reviewing the active steps outlined in the government pathway to access a package, we must consider the person who is navigating this path. They are frail older people with complex support needs, often seeking help at times of crisis. These include the growing number of older Australians living with multiple medical conditions and complex age-related syndromes such as dementia. After a person has been assessed, they will receive a letter informing them they are eligible. However, due to long waiting lists, this does not provide them with immediate access to care; most wait many months before they are actually assigned a package by My Aged Care. When they eventually receive a letter confirming their package, the consumer will be approached by various service providers. They will need to sign a complex contract with their chosen provider. If the consumer is feeling frustrated and confused during these early stages, this is only the beginning. The recent marketisation of home care means managing their own care requires going through impersonal, centralised provider systems.
The Conversation, CC BY-ND

People need clear information to choose a provider

The first thing people assigned a home care package need to do is choose a care provider. There are now close to 900 different providers offering home care packages. This includes not-for-profits, as well as a growing number of for-profit providers competing for new business.
In reality, however, few older people research different providers. Once they’re assigned a home care package, their name is placed on a centralised database accessible by all registered service providers. The person then receives unsolicited phone calls from the sales teams of different providers, offering their services and trying to make appointments to come and visit. For consumers, this represents a shift from a familiar government model of care provision to a market model. Research shows consumers often don’t understand consumer directed care, and this can leave them vulnerable to the forceful marketing tactics employed by some providers. It can also make negotiating a complex contract with legal, financial and personal implications very difficult. To make informed choices between providers, people need accessible information. There is currently insufficient information for older people and their families to compare services on indicators of quality (such as the number of complaints agencies receive, the training of staff, the types of specialist services they offer, and so on). To address this gap, the government must commit to collecting and publishing data on home care quality. This would drive service improvement and increase people’s ability to make informed choices between different providers.

Service and administrative fees

To make informed choices, people also need to be able to compare services on the basis of price. The average profit per client for home care package providers was A$2,832 in 2016-17, but there’s significant variability between providers’ fees. For example, the use of people’s individual care budgets to cover administration or case management fees ranges between 10-45% of their total package. High fees and administrative costs may reveal the profit-driven motives of a few unscrupulous providers. Because of administrative fees, many people are spending a high portion of their individual budgets on case management to support their care. While there’s evidence case management can provide clinical benefits for older people, in the context of the current home care funding model, it may also leave people with less money for direct care services than they need.

People need support to manage their packages

We’re currently looking at the experiences of people with dementia using home care packages. Unsurprisingly, we’re finding that while they are grateful for the services they’re receiving, they are having a difficult time managing their care. For some this may be due to their limited decision-making capacity, but for many, their choice and control is being limited as much by the service model. For example, to enable providers to compete in the open market, many have adopted central 1800 numbers to support people to manage their services. This means if consumers want to change something, they are funnelled through this system. Think about your own experience of service helplines, such as with telephone or energy companies. Now consider a woman with dementia who needs to call a 1800 number to change the time of her shower so she can see her doctor. Rather than communicating with a local and known case manager, she now needs to speak to someone she doesn’t know and who is not familiar with her care needs. Instead of facilitating choice and control, this demand on the consumer to constantly articulate their needs to unfamiliar people means many are frustrated, and some are even opting out of services.

How can we improve things?

The three words the government associates with consumer directed home care are choice, control and markets. But the system doesn’t foster control. Although consumers technically have choices, the marketised and bureaucratic approaches of service providers make it difficult for consumers to articulate and receive support for their personal choices. The processes, information and supports available to assist older people and their families are inadequate to facilitate the type of choices and control one might associate with “consumer directed” care. There’s an urgent need to improve the processes for accessing timely home care packages, particularly for those with complex support needs. This includes the quality and accessibility of information, resources and decision-making tools. There’s also a significant need for training, advocacy and impartial support for choice, particularly for people with limited decision-making capacity, such as those living with dementia. Research and practice in aged care and disability in other settings provide extensive resources for person-centred planning and decision making which could be adapted for use in our home care system.The Conversation Lyn Phillipson, NHMRC-ARC Dementia Development Fellow, University of Wollongong and Louisa Smith, Research Fellow at AHSRI, University of Wollongong This article is republished from The Conversation under a Creative Commons license. Read the original article.
By Lyn Phillipson & Louisa Smith
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Dr Linda Calabresi
  • Clinical Articles

Is catheter ablation for AF worthwhile?

To ablate, or not to ablate? That is the question. That’s what international researchers were investigating in two studies just published in The Journal of the American Medical Association. And the answer? As so often happens in medicine, the answer is: it depends. Looking at the two studies, patients with symptomatic atrial fibrillation had a greater improvement in their quality of life at the one year mark if they had undergone catheter ablation than if they had been treated with medical treatment alone. But not to diminish the importance of quality of life as a measure of success, other findings from the latest research are also worth noting. In the larger of the two studies, a randomised controlled controlled trial of over 2200  patients presenting with symptomatic AF, researchers found after four years of follow-up that there was no significant difference in mortality between the group who had received catheter ablation and those who were treated with drug therapy alone. Similarly, the rate of disabling stroke, serious bleeding and cardiac arrest were the same between the two groups. As one would expect there was a higher rate of AF recurrence among the drug therapy group as compared with the catheter ablation group (70% vs 50%), however that 50% recurrence rate among those who’d undergone the ablation procedure is still pretty high and overall among that intervention group 19.4% underwent a repeat procedure. But the study authors who came from 10 different countries did not seem too deflated by the result. While their study failed to show benefit for catheter ablation in any of the primary outcomes such as death or stroke they did find some advantage in terms of secondary outcomes, including quality of life. They also point to a trend toward benefit of the procedure even if that benefit wasn’t large enough to reach clinical significance. The other JAMA study involved just 155 patients who had symptomatic paroxysmal or persistent AF and who were randomised to receive either catheter ablation or drug therapy. The Scandinavian researchers were particularly assessing their symptoms and their quality of life. After four years, the catheter ablation group ‘produced 14% more patients who achieved complete or near complete relief from their AF symptoms.’ What’s more the quality of life improved for patients in both groups. However, the improvement was greater in the ablation group. So, what does it all mean? Firstly, it needs to be pointed out that, in keeping with the guidelines the majority of patients included in these trials were symptomatic – only 10% were asymptomatic. In other words, there have to be symptoms or another very good reason to consider ablation in a patient with AF. Secondly, overall, the ablation group was more successful than the drug therapy group in relieving those symptoms. As an accompanying editorial puts it: “For patients with symptoms, in whom quality of life is impaired by AF, catheter ablation can improve quality of life to a greater extent than drug therapy. However, patients who choose drug therapy will also likely experience significant improvements in quality of life and have no worse risk for the most concerning complications of AF, stroke and death. Thus, there is no mandate for these patients to undergo catheter ablation at this time.” And that’s where we’re at.

Reference:

Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE, et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019 Mar 15. DOI: 10.1001/jama.2019.0693 [Epub ahead of print] Mark DB, Anstrom KJ, Sheng S, Piccini JP, Baloch KN, Monahan KH, et al. Effect of Catheter Ablation vs Medical Therapy on Quality of Life Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019 Mar 15. DOI: 10.1001/jama.2019.0692 [Epub ahead of print] Albert CM, Bhatt DL. Catheter Ablation for Atrial Fibrillation: Lessons Learned From CABANA. JAMA. 2019 Mar 15. DOI: 10.1001/jama.2018.17478 [Epub ahead of print] Blomström-Lundqvist C, Gizurarson S, Schwieler J, Jensen SM, Bergfeldt L, Kennebäck G, et al. Effect of Catheter Ablation vs Antiarrhythmic Medication on Quality of Life in Patients With Atrial Fibrillation: The CAPTAF Randomized Clinical Trial. JAMA. 2019 Mar 19; 321(11): 1059-68. DOI: 10.1001/jama.2019.0335
By Dr Linda Calabresi
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Jane Heller
  • Clinical Articles

Update on Q fever in Australia

With several hundred cases diagnosed each year, Australia has one of the highest rates of Q fever worldwide. Q fever is a bacterial infection which spreads from animals; mainly cattle, sheep and goats. It can present in different ways, but often causes severe flu-like symptoms. Importantly, the bacteria that cause Q fever favour dry, dusty conditions, and inhalation of contaminated dust is a common route of infection. There are now fears the ongoing droughts in Queensland and New South Wales may be increasing risk of the disease spreading. But there are measures those at risk can take to protect themselves, including vaccination.

What is Q fever and who is at risk?

Q fever is an infectious illness caused by the bacterium Coxiella burnetii, one of the most infectious organisms around. Q fever is zoonotic, meaning it can transmit to people from infected animals. It’s usually acquired through either direct animal contact or contact with contaminated areas where animals have been. Goats, sheep and cattle are the most commonly reported Q fever hosts, although a range of other animals may be carriers. Because of this association with livestock, farmers, abattoir workers, shearers, and veterinarians are thought to be at the highest risk of Q fever. People who also may be at risk include family members of livestock workers, people living or working near livestock transport routes, tannery workers, animal hunters, and even processors in cosmetics factories that use animal products. Q fever can be difficult to diagnose (it has sometimes been called “the quiet curse”). Infected people usually develop flu-like fevers, severe headaches and muscle or joint pain. These symptoms typically appear around two to three weeks after infection, and can last up to six weeks. A small proportion of people will develop persistent infections that begin showing up later (up to six years post-infection). These can include local infections in the heart or blood vessels, which may require lifelong treatment.

Are Q fever rates on the rise?

In Australia, 500 to 800 cases of Q fever (2.5 – 5 cases per 100,000 people) were reported each year in the 1990s according to the National Notifiable Diseases Surveillance System. A national Q fever management program was designed in 2001 to combat this burden. This program provided subsidised vaccination to at-risk people including abattoir workers, beef cattle farmers and families of those working on farms. Results were positive. Q fever cases decreased during the program and following its conclusion in 2006, leading to a historic low of 314 cases (1.5 cases per 100,000 people) in 2009. But since 2010, Q fever cases have gradually increased (558 cases or 2.3 per 100,000 were reported in 2016), suggesting further action may be necessary. Every year, the highest numbers of people diagnosed are from Queensland and NSW. And the true number of affected people is likely to be under-reported. Many infected people do not experience severe symptoms, and those who do may not seek health care or may be misdiagnosed.

Q fever and drought

The reason people are more susceptible to Q fever in droughts lies in the bacteria’s capacity to survive in the environment. Coxiella burnetii spores are very resilient and able to survive in soil or dust for many years. This also helps the bacteria spread: it can attach to dust and travel 10km or more on winds. The Q fever bacteria is resistant to dehydration and UV radiation, making Australia’s mostly dry climate a hospitable breeding ground. Hot and dry conditions may also lead to higher bacterial shedding rates for infected livestock. The ongoing drought could allow Q fever to spread and reach people who were previously not exposed. One study suggested drought conditions were probably the main reason for the increase in Q fever notifications in 2002 (there were 792 cases that year). This was the fourth driest year on record in Australia since 1900. We still need more evidence to conclusively link the two, but we think it’s likely that drought in Queensland and NSW has contributed to the increased prevalence of Q fever in recent years.

How can people protect themselves?

National guidelines for managing Q fever primarily recommend vaccination. The Q-VAX® vaccine has been in use since 1989. It’s safe and has an estimated success rate of 83–100%. However, people who have already been exposed to the bacteria are discouraged from having the vaccination, as they can develop a hypersensitive reaction to the vaccine. People aged under 15 years are also advised against the vaccine. Because the vaccine cannot be administered to everyone, people can take other steps to reduce risk. NSW Health recommends a series of precautions.
Author provided/The Conversation, CC BY-ND

What else can be done?

Vaccination for people in high-risk industries is effective to prevent Q fever infection, but must be administered well before people are actually at risk. Pre-testing requires both a skin test and blood test to ensure people who have already been exposed to the bacteria are not given the vaccine. This process takes one to two weeks before the vaccine can be administered, and it takes a further two weeks after vaccination to develop protection. This delay, along with the cost of vaccination, is sometimes seen as a barrier to its widespread use. Awareness of the vaccine may also be an issue. A recent study of Australians in metropolitan and regional centres found only 40% of people in groups for whom vaccination is recommended knew about the vaccine, and only 10% were vaccinated. We also need to better understand how transmission occurs in people who do not work with livestock (“non-traditional” exposure pathways) if we want to reduce Q fever rates.The Conversation Nicholas J Clark, Postdoctoral Fellow in Disease Ecology, The University of Queensland; Charles Caraguel, Senior lecturer, School of Animal and Veterinary Science, University of Adelaide; Jane Heller, Associate Professor in Veterinary Epidemiology and Public Health, Charles Sturt University; Ricardo J. Soares Magalhaes, Senior Lecturer Population Health & Biosecurity, The University of Queensland, and Simon Firestone, Academic, Veterinary Biosciences, University of Melbourne This article is republished from The Conversation under a Creative Commons license. Read the original article.
By Jane Heller, Charles Caraguel, Simon Firestone, Ricardo J. Soares Magalhaes, Dr Nicholas J Clark
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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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Healthed
  • Clinical Articles

Cutaneous Biopsies in General Practice

Cutaneous disorders are among the most common conditions presented to primary care doctors. Many are easily identifiable and may be dealt with effectively without the need for cutaneous biopsy. Nevertheless, in many instances the diagnosis is not obvious on clinical grounds. The rash may display atypical features or may not respond to therapy as predicted. In these cases, and when dealing with cutaneous tumours or worrying pigmented lesions, cutaneous biopsy with histological assessment becomes necessary. The art of cutaneous biopsy is to derive the maximum amount of information from the minimum amount of tissue, causing least discomfort to the patient. This will be achieved if due regard is given to the advantages and shortcomings of the various techniques available for biopsying cutaneous tissue, and if the pathologist is supplied with a good clinical history.

Clinical History

For several reasons, clinical history assists greatly in the interpretation of skin biopsies. Clinicopathological correlation is particularly important in many inflammatory cutaneous disorders. As the histological features can be very similar, clinical notes may help us to arrange a list of provisional diagnoses in order of likelihood. The key features to discuss with regard to cutaneous rashes include:
  • duration
  • distribution
  • description (macular, papular, vasculitic or vesicular)
  • drugs or other possible aetiological agents
  • provisional clinical diagnosis.
As there is wide variation in the normal microscopic picture from different sites, the area biopsied should also be stated. For biopsies performed to distinguish between squamous cell carcinoma and keratoacanthoma, the rate of growth of the lesion is important. When sending specimens of pigmented lesions, the degree of clinical suspicion should be stated, together with any history of melanoma within the individual or within the individual’s family. Any condition associated with cutaneous disorders, such as systemic lupus erythematosus, pregnancy or bone marrow transplant, should be mentioned in the clinical notes. The clinical history should also include the type of biopsy procedure used (see below) as this determines the way we handle the specimen in the laboratory. For example, the whole of an incisional biopsy will be blocked in order to gain the maximum amount of information, whereas an excisional biopsy will be transversely sectioned in order to fully assess the lateral excision margins in the case of a tumour biopsy.

Excision Biopsy

This is the best technique to use for pigmented lesions and cutaneous tumours. It allows for histological assessment and diagnosis of the lesion, and assessment of surgical excision margins. If appropriate, an orientation suture can be placed at one end of the excision, e.g. the superior end of the specimen, so that if the excision is inadequate, the margin involved can be indicated on an accompanying diagram. Occasionally, excision biopsy is appropriate for inflammatory cutaneous disorders where the condition is characterised by the formation of vesicles. The best chance of removing an intact vesicle (which greatly aids diagnosis) may be through excision.

Incision Biopsy

With incision biopsy, a thin elliptical biopsy is taken radially through the edge of the tumour or through the edge of a macular or annular rash. Incision biopsy is superior to punch biopsy for diagnosing rashes, more tissue is displayed on histological section and scarring is often reduced. A typical incision biopsy is 5-6 mm in length and about 2 mm in width. It should be deep enough to extend into the subcutaneous adipose tissue. The biopsy should run radially from the centre or central areas of the lesion to include approximately 1 mm of normal cutaneous tissue surrounding the lesion.

Punch Biopsy

Punch biopsies are easier to perform and, in general, are more convenient. Nevertheless, they nearly always yield less information than an incision biopsy. For tumours, the biopsy should be taken centrally. For cutaneous eruptions, the biopsy should be taken from an area typical of the rash. In some cases, multiple biopsies may increase the amount of information. In this procedure, it is best not to include normal skin. Punch biopsies come in various sizes. As 2 mm punches often yield inadequate information for diagnosis, a 3 mm punch biopsy is the smallest that should be used.

Shave Biopsy/Curettage

This technique is suitable for superficially-located lesions with plaque-like clinical features, e.g. seborrhoeic keratoses. It is not an appropriate technique for nodular lesions, cutaneous rashes or melanocytic lesions.

General comments concerning cutaneous biopsies

Preparation of the skin surface: Be gentle when cleaning the skin surface prior to biopsy; try not to disturb any overlying scale as the keratin layers sometimes contain diagnostic information (e.g. this is where dermatophytic fungi may be seen). Let any alcohol preparation dry before collecting specimens for immunofluorescence. Local anaesthesia: Only a small amount of local anaesthetic is required for punch biopsy procedures (0.5 mL maximum). Too much local anaesthetic within the tissues can distort the histological appearances and simulate dermal oedema. Marking the lesion: It is often prudent to mark the target area for biopsy with an ink marker, as some lesions can blanch following introduction of local anaesthetic. The erythema in many lesions is due to vascular dilatation occurring as part of the inflammatory disorder. Local anaesthetic can cause vasoconstriction and diminish the erythema clinically. This may result in a poorly targeted biopsy yielding subdiagnostic histology. Depth of biopsy: It is best to continue into the subcutaneous adipose tissue so that the entire dermis is represented on histological section. This helps greatly with the categorisation of many inflammatory skin disorders and also demonstrates the deep border of any cutaneous tumour. When performing a punch biopsy, the biopsy instrument appears to ‘give’ when it penetrates the dermal connective tissue into subcutaneous adipose tissue. A similar sensation will be noticed when dissecting free an incision biopsy. Care with biopsy tissue: All too often, after biopsy tissue has been retrieved from the patient, crush artefact occurs during its transfer into formalin. Crush artefact greatly distorts the histological appearance and repeat biopsy may become necessary. Rather than grasping the biopsy tissue with non-tooth forceps, it should be transferred to the specimen container using needle tips, a skin hook or fine forceps, delicately grasping one edge of the biopsy. Fixative: Ordinary blue, 10% buffered formalin supplied with the specimen jars is suitable for nearly all cutaneous biopsies, except those submitted for microbiological culture or immunofluorescent examination. Labelling: Please label all specimen containers with the patient’s name and details, which should match those stated on the request slip. Unlabelled specimens can still be processed and interpreted if they arrive with labelled paperwork; however, the medico-legal status of any generated report is doubtful. The report will usually be generated with a ‘specimen received unlabelled’ comment attached.

Conclusion

Diagnosing cutaneous conditions can be challenging. The chances of success are improved when the clinician, is armed with a variety of biopsy techniques for use in the correct clinical setting, and when the pathologist is supplied with an adequate clinical history.   - 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.
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