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Anorexia and cancer risk

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

Reference:

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

Female patients who present with vulval pain or itch have usually put up with symptoms for some time before coming to the doctor. When it comes to this area of the female anatomy there is still a lot of ignorance and embarrassment in the world outside our surgeries. And while it is true you can find the answer to almost any question on the net, for these particular problems there’s a lot of dodgy information out there. So here’s an information source you can trust and recommend. Care down there (www.caredownthere.com.au) is a consumer-directed website written by respected health professionals that provides accurate, up-to-date and practical information and advice about all things vulval. From herpes to vulval sclerosis, the site covers the broad range of conditions that can affect women as well as providing some fundamental education about how to distinguish between normal anatomy and physiology and something going awry. The site was founded by Dr Gayle Fischer and Dr Jennifer Bradford who are well-known, well-respected members of the Australasian College of Dermatologists and the Royal Australian and the New Zealand College of Obstetricians and Gynaecologists. The content has been developed by a group of Australian health professionals with an interest and experience in vulval problems including dermatologists, gynaecologists, a pain management specialist, a sexual health physician, a psychologist and a pelvic floor physiotherapist. It is sponsored by Epiderm but exists as an independent resource. If you’re wanting to direct your female patients to a resource that is both comprehensive and authoritative, this really does fit the bill.   >> Access the resource here

By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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Are you burnt out at work? Ask yourself these 4 questions

It’s normal to feel stressed at work from time to time. But for some people, the stress becomes all-consuming, leading to exhaustion, cynicism and hatred towards your job. This is known as burnout. Burnout used to be classified as a problem related to life management, but last week the World Health Organisation re-labelled the syndrome as an “occupational phenomenon” to better reflect that burnout is a work-based syndrome caused by chronic stress. The newly listed dimensions of burnout are:
  • feelings of energy depletion or exhaustion
  • increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job
  • reduced professional efficacy (work performance).
In the era of smartphones and 24-7 emails, it’s becoming increasingly difficult to switch off from the workplace and from those who have power over us. The new definition of burnout should be a wake-up call for employers to treat chronic stress that has not been successfully managed as a work health and safety issue.

How do you know if you’re burnt out?

If you think you might be suffering burnout, ask yourself the following questions:
  1. has anyone close to you asked you to cut down on your work?
  2. in recent months have you become angry or resentful about your work or about colleagues, clients or patients?
  3. do you feel guilty that you are not spending enough time with your friends, family or even yourself?
  4. do you find yourself becoming increasingly emotional, for example crying, getting angry, shouting, or feeling tense for no obvious reason?
If you answered yes to any of these questions, it might be time for change. These questions were devised for the United Kingdom Practitioner Health Programme and are a good starting point for all workers to identify if you are at risk of burning out. (You can also complete the British Medical Association’s online burnout questionnaire, although it’s tailored for doctors so the drop-down menu will ask you to select a medical specialty). If you think you’re suffering burnout, the first step is to talk to your line manager or workplace counsellor. Many workplaces now also have confidential external psychologists as part of their employee assistance programme.
Wes Mountain/The Conversation, CC BY-ND

What causes burnout?

We all have different levels of capacity to cope with emotional and physical strains. When we exceed our ability to cope, something has to give; the body becomes stressed if you push yourself either mentally or physically beyond your capacity. People who burn out often feel a sense of emotional exhaustion or indifference, and may treat colleagues, clients or patients in a detached or dehumanised way. They become distant from their job and lose the zeal for their chosen career. They might become cynical, less effective at work, and lack the desire for personal achievement. In the long term, this is not helpful for the person or the organisation. While burnout isn’t a mental health disorder, it can lead to more serious issues such as family breakdowns, chronic fatigue syndrome, anxiety, depression, insomnia, and alcohol and drug abuse.

Who is most at risk?

Any worker who deals with people has the potential to suffer from burnout. This might include teachers, care workers, prison officers or retail staff. Emergency service workers – such as police, paramedics, nurses and doctors – are at even higher risk because they continually work in high-stress conditions. A recent survey of 15,000 US doctors found 44% were experiencing symptoms of burnout. As one neurologist explained:
I dread coming to work. I find myself being short when dealing with staff and patients.
French research on hospital emergency department staff found one in three (34%) were burnt out because of excessive workloads and high demands for care. Lawyers are another profession vulnerable to burnout. In a survey of 1,000 employees of a renowned London law firm, 73% of lawyers expressed feelings of burnout and 58% put this down to the need for a better work-life balance. No matter what job you do, if you are pushed beyond your ability to cope for long periods of time, you’re likely to suffer burnout.

It’s OK to say no to more work

Employers have an organisational obligation to promote staff well-being and ensure staff aren’t overworked, overstressed, and headed towards burnout. There are things we can all do to reduce our own risk of burnout. One is to boost our levels of resilience. This means we’re able to respond to stress in a healthy way and can bounce back after challenges and grow stronger in the process. You can build your resilience by learning to switch off, setting boundaries for your work, and thinking more about play. As much as you can, inoculate yourself against job interference and prevent it from ebbing into your personal life. No matter what your profession, don’t let your job become the only way you define yourself as a person. And if your job is making you miserable, consider moving jobs or at least have a look at what else is out there. You may surprise yourself. If you or anyone you know needs help or support, you can call Lifeline on 13 11 14.The Conversation Michael Musker, Senior Research Fellow, South Australian Health & Medical Research Institute This article is republished from The Conversation under a Creative Commons license. Read the original article.
By Dr Linda Calabresi
Clinical Articles iconClinical Articles
vcacinations in pregnancy

Improving vaccination rates in pregnancy

Increasingly, pregnant women are heeding the warnings about the dangers of pertussis and getting vaccinated but the same does not appear to be happening with influenza protection. According to an Australian retrospective analysis, pertussis vaccination of pregnant women in Victoria increased from 38% in 2015 to 82% two years later. However, when they looked at rates of influenza vaccination the prevalence fluctuated according to the season but even so, the overall rate was only 39%. Looking first at the factors that appeared to influence whether a woman got vaccinated at all, the researchers found women who were older, who were having their first child, attended antenatal care earlier in the pregnancy and who were receiving GP-led care were more likely to receive immunisation (thumbs up for the GPs). On the negative side, the likelihood of vaccination was significantly lower in women born overseas, those who smoked during pregnancy and among Aboriginal and Torres Strait Islander women. Overall it appeared the more contact a pregnant woman had with the health system, especially if that contact was with health professionals who are well-versed in all things immunisation, ie GPs, the more likely it was that vaccination would be offered, accepted and delivered. The variation in coverage rates across different hospital-led organisations reflects the fact that immunisation for flu and pertussis has not yet become part of standard, best practice guidelines for routine antenatal care. “Fewer than half the respondents indicated that vaccines were always or usually administered during routine antenatal care,” they wrote. Following on from these general observations, researchers tried to determine why it was that vaccination coverage for pertussis rose so dramatically between 2015 and 2017, and why coverage for influenza prevention didn’t. “This may reflect continued promotion by state and national bodies of the importance of maternal pertussis vaccination, and increased awareness among pregnant women of the seriousness of pertussis in infants,” they said. By contrast, the researchers suggest that influenza is often believed to pose a greater health risk to the mother as opposed to the infant, and this along with concerns about the safety of the flu vaccine itself may, at least in part, explain the poor uptake of this vaccine. To improve this situation and increase rates of protection for Australian pregnant women and their children, the study authors had a number of recommendations. Most importantly they suggest we need to build vaccination against pertussis and influenza into the standard of care for all antenatal practices – be they hospital based, midwife-led or part of the GP antenatal shared care program. Basically we need to bring vaccination up and centre into our consciousness, so women get offered the vaccine and then ensure our systems have the capacity to be able to provide this vaccination as the opportunity arises. “Maternal vaccination should be embedded in all antenatal care pathways, and systems should be improved to increase the uptake of vaccination by pregnant women,” they conclude. Other recommendations included highlighting the benefits of vaccination to those groups of women most at risk such as women who smoke and Aboriginal and Torres Strait Islander women. But key to all the recommendations is making vaccination just part of routine care. As an accompanying editorial points out, “Embedding vaccination into standard pregnancy care, whether delivered by GPs, midwives or obstetricians, normalises the process, improves access to vaccination and reduces the risk of missing opportunities for vaccination.”  

References:

Rowe SL, Perrett KP, Morey R, Stephens N, Cowie BC, Nolan TM, et al. Influenza and pertussis vaccination of women during pregnancy in Victoria, 2015-2017. Med J Aust 2019 Jun 3; 210(10): 454-62. DOI: 10.5694/mja2.50125 Marshall HS, Amirthalingam G. Protecting pregnant women and their newborn from life-threatening infections. Med J Aust 2019 Jun 3; 210(10): 445-6. DOI: 10.5694/mja2.50174
By Dr Linda Calabresi
Clinical Articles iconClinical Articles
Simple blood test a mortality predictor

Smartvax

It’s only been around a few years, but this little bit of technology has already received world wide acclaim for its ability to improve the safety of vaccines in the real-world setting. In simple terms, Smartvax is a program practices install into their software system that sends an SMS directly to patients three days after they receive a vaccination. Patients are asked if they experienced an adverse reaction to the vaccine. A straightforward Yes (Y) or No (N) is all that is required. A No reply ends the conversation, but a Yes will trigger a brief questionnaire that examines the nature of the adverse reaction. If the reaction resulted in the need to seek medical attention this is then flagged in the GP’s software inbox as well as with the local health authority. In practical terms this means adverse reactions are tracked in real time and act as an early warning signal that something could be amiss with a vaccine. Smartvax was developed by Perth GP, Dr Alan Leeb and Ian Peters, following a spate of serious and unexpected adverse reactions among young children who received one brand of flu vaccine back in 2010. It was apparent that a better, more time-sensitive system of monitoring side effects to vaccines was needed to ensure the safety of patients. With the widespread use of mobile phones, the day three post vax text has proven a very effective means of tracking reactions, with a high level of acceptance by patients. In a study from one NSW general practice, the response rate to the SMS  text was 85% post-childhood vaccination, and even in the over 65 year age range the response rate was 74%. Smartvax has now been adopted by more than 280 practices around Australia. The technology can also be used as a reminder system to prompt patients when their next vaccine is due. This is such a clever idea and as general practice becomes more and more tech savvy one can envisage a day when Smartvax is a basic requirement for all clinics that provide vaccinations.   >> Access the resource here

By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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Gene-directed prescribing coming to general practice

It’s been around for some time now. The idea of checking a person’s genes to guide appropriate prescribing is not new. It is pretty much standard practice when treating many if not most cancers. But pharmacogenomics in general practice? Looking at an individual’s genetic variants to work out the best treatment for their depression, high cholesterol or gout? Yes – it’s coming. As authors of a recently published review in the Australian Journal of General Practice say, all practising clinicians will have had the experience of patients responding differently to medications despite every indication the medication should be effective, based on all the evidence from randomised controlled trials. It is known that certain genes that regulate the absorption, distribution, metabolism and excretion (ADME) of medications are commonly responsible for this difference in response, as these genes can vary between individuals. Researchers have also identified another group of genes that can influence medication responses directly, which, while less common can have important implications for prescribing. “For example, carbamazepine should not be prescribed to patients with certain human leucocyte antigen (HLA) genotypes because of an increased risk of Stevens-Johnson syndrome and toxic epidermal necrolysis,” the Australian review authors said. Overall, there have been at least 15 genes identified for which testing can be useful and clinically beneficial in guiding prescribing of 30 different medications. How important will this be in general practice? According to this review at least, very. Firstly the likelihood of having a genetic variation that will influence how a person responds to a common medication is incredibly high. “A recent study of 5400 Australians who underwent testing of just four ADME genes showed that 96% had at least one clinically actionable pharmacogenomic variant,” the review authors said. And then the likelihood that a person will be prescribed one of the drugs that we can now predict the response based on genetic testing is also incredibly high. On analysis of PBS data from 2017, the researchers determined that in that year approximately 1.7 million Australians had filled a prescription for at least one the drugs that has the highest level of evidence of clinically relevant gene-medication association. In their review the authors present a number of case studies which demonstrate the usefulness of genetic testing in clinical practice. These include a patient with anxiety and depression who fails to respond to standard treatment leading to a significant deterioration of her condition. Genetic testing of CYP enzymes found the patient had a genetic variation that meant they rapidly metabolised certain antidepressants, but could be prescribed an alternative medication that wasn’t as dependent on the affected enzyme. Another example involved an older Han Chinese man who needed to be prescribed allopurinol for gout. Because this particular ethnicity has a 20% chance of carrying a gene that puts them at risk of developing severe cutaneous adverse reaction to allopurinol, gene testing was done to help ensure this risk was minimised. Similarly, a genetic variation that gives a higher than normal risk of muscle toxicity when taking simvastatin or atorvastatin can be tested for prior to patients being prescribed these medications, and a safer alternative statin offered. Fundamentally this type of testing will lead to more effective, safer prescribing. The problem is of course, pharmacogenomic testing does not attract a Medicare rebate in Australia and the cost is prohibitive for most patients, even though, according to the review authors the costs are decreasing all the time. A panel of common CYP enzymes now costs between $150 and $200. But the authors suggest this situation will have to change. Even on the basis of economics alone, the government needs to consider allowing rebates for at least some pharmacogenomic tests. “A report in 2008 estimated that the widespread implementation of such testing in Australia could yield savings in excess of $1 billion annually by the avoidance of adverse medication reactions alone,” they said. And imagine how much time, money and angst could be saved if doctors could ensure the first antidepressant a patient is prescribed had a high likelihood of having an effect, rather than the current trial and error approach. However while we wait for better reimbursement for this testing, the authors suggest the doctors consider using the tests where appropriate in patients who are prepared to pay. “Responsible doctors can use the tests and evidence that are already available to improve prescribing decisions for their patients,” they conclude.

Reference

Polasek TM, Mina K, Suthers G. Pharmacogenomics in general practice: The time has come. AJGP. 2019 March; 48(3): 100-5. Available from: https://www1.racgp.org.au/ajgp/2019/march/pharmacogenomics-in-general-practice
By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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Lactose intolerance and genetic testing

A genetic test is now available to assist in the diagnosis of lactose intolerance in both children and adults.

Key points

  • Lactose intolerance affects approximately 75% of the population.
  • Genetic testing can confirm lactose tolerance (also referred to as lactase persistence).
  • The test differentiates between primary lactose intolerance, due to lactase deficiency, and secondary causes of lactose intolerance, due to other more serious conditions that affect the small bowel.
  • The test is not affected by intercurrent illness and can be performed non-invasively on patients of all ages.
The test only needs to be performed once during a person’s lifetime.

How does the test work?

Testing is now available to detect the genetic variant (LCT-13910C>T) that accounts for close to 100% of lactase persistence in Europeans. Three other genetic variants that have a similar effect and are more common in non-European populations are also detected. These variants are thought to act as enhancers of the lactase gene that in turn stimulates lactase production. When one of these variants is found, a diagnosis of primary lactose intolerance can be excluded. Lactose intolerance can be secondary to other conditions that affect the small bowel, such as gastroenteritis, inflammatory bowel disease and coeliac disease. Genotyping can help to distinguish these causes of intolerance.

What causes lactose intolerance?

Lactose is the major carbohydrate in mammalian milk. Lactose intolerance is caused by deficiency of lactase, the enzyme required for digestion of lactose. Symptoms include abdominal pain, diarrhoea, nausea, flatulence and/or bloating, following the consumption of lactose-containing foods.

Who is affected by lactose intolerance?

After infancy, approximately 75% of the population lose the ability to digest lactose, due to a deficiency in lactase, referred to as primary lactose intolerance. The remainder of people maintain their tolerance for lactose-containing foods because of genetic variants that enable continued production of lactase, referred to as lactase persistence. The prevalence of primary lactose intolerance varies significantly with ethnic background. Lactose intolerance is uncommon in populations that consume large amounts of dairy, for example, northern Europeans (as low as 10%), but is frequent in other populations (as high as 100% in Asiatic countries). It is hypothesised that this is the result of selective genetic advantage; populations that have historically been dependent on dairy food sources for nutrition have survived by having genetic variants that allow tolerance for lactose.

Other testing alternatives

Currently, testing for lactose intolerance can also be performed by a hydrogen breath test with lactose load, or by measurement of intestinal lactase enzyme activity in a biopsy obtained during endoscopy. These tests may give a false-positive result when lactase levels have been affected by a recent viral illness or coeliac disease. These procedures are also not suitable for testing children younger than seven years old. Genotyping is not affected by intercurrent illness and can be performed non-invasively on patients of all ages.

Genetic testing limitations

Please note that genotyping will not identify very rare genetic variants associated with persisting lactase activity, and therefore the absence of a variant can only be used to support a diagnosis of lactose intolerance along with other clinical and laboratory findings.

Arranging a test

  1. Complete a standard pathology request form to refer the patient for ‘lactase persistence’ or ‘lactose intolerance genetic testing’.
  2. Collect or send the patient to a pathology collection centre for a blood test or buccal swab. No special preparation or booking is necessary.
  3. The result is reported back to the doctor, usually within five business days of the laboratory receiving the patient’s sample.

Cost

Medicare does not cover the cost of this test and the patient will receive an invoice for $75.*

References

  • Bayless T, Brown E, Paige DM. Lactase non-persistence and lactose intolerance. Curr Gastroenterol Rep. 2017 May; 19(5): 23. DOI: 10.1007/s11894-017-0558-9
  • Mattar R, de Campos Mazo DF, Carrilho FJ. Lactose intolerance: diagnosis, genetic, and clinical factors. Clin Exp Gastroenterol. 2012; 5: 113-21. DOI: 10.2147/CEG.S32368
  • Tishkoff SA, Reed FA, Ranciaro A, Voight BF, Babbitt CC, Silverman JS, et al. Convergent adaptation of human lactase persistence in Africa and Europe. Nat Genet. 2007 Jan; 39(1): 31-40. DOI: 10.1038/ng1946
  • Heyman MB, Committee on Nutrition. Lactose intolerance in infants, children, and adolescents. Pediatrics. 2006 Sep; 118(3): 1279-86. DOI: 10.1542/peds.2006-1721
*Correct at time of printing. Please to refer to the Sonic Genetics website, www.sonicgenetics.com.au, for current pricing. 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 Kym Mina
Clinical Articles iconClinical Articles
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One in 10 patients have ongoing concussion symptoms

Concussion is a temporary disturbance in brain function following an impact to the head. It can also occur after a blow to the body, if the force is transmitted to the head. Most people associate concussion with sports but they can occur anywhere, even at work or school. There are many signs and symptoms of concussion, which may present differently between individuals. These include headaches, nausea, vomiting, slurred speech, dizziness, temporary loss of memory, and inability to focus. Loss of consciousness only occurs in around 10% of concussions. Most people with concussions recover relatively quickly. Around 90% will recover within several days to a couple of weeks. But sometimes symptoms continue beyond a couple of weeks. When symptoms persist beyond three months, the person may be diagnosed as having persistent post-concussion symptoms.

Rest is not always best

We don’t know exactly how common concussions are, because they’re under-reported. Some people don’t think they are a serious injury, so don’t seek treatment, while others mask their injury because they don’t want to be seen as weak. The World Health Organisation classifies concussion, which is a type of traumatic brain injury, as a critical public health issue. Complete physical and mental rest used to be recommended after a concussion. Since 2017, however, the concussion treatment guidelines have evolved to reflect the science. While rest in the immediate 24-48 hours after a concussion is still advised, patients are now encouraged to undertake low-intensity exercise (such as walking, light jogging, or stationary cycling) and light mental stimulation (such as work or study) over the following days. Recovery is individual, but the intensity of physical and mental activity should gradually increase over time and should not exacerbate or worsen the symptoms.

Persistent symptoms

Formerly known as post-concussion syndrome, persistent post-concussion symptoms occur in around 1-10% those who have suffered a concussion. The exact prevalence is unknown due to methodological differences between studies and how persistent post-concussion symptoms are defined within these studies. As with concussion, persistent post-concussion symptoms vary among individuals but may include headaches, balance problems, light or noise sensitivity, anxiety and depression. We still don’t know why some people’s symptoms persist for many months, sometimes even years. But we suspect psychology may play a role. While the evidence is limited, early psychological intervention for those with ongoing symptoms, which involves educating the person on why they are feeling this way, has been shown to be effective at reducing the anxiety and depression that accompany persistent post-concussion symptoms. Despite psychological support, some express continued physical symptoms, such as headaches, balance problems, and light/noise sensitivity; reflecting possible changes or abnormalities in the brain. Fatigue, both mental and physical, is common in people with persistent post-concussion symptoms, but is often overlooked, despite it significantly impacting on quality of life.

What can measures of fatigue tell us?

Our new research suggests people with persistent post-concussion symptoms may have ongoing problems with fatigue and cognitive function because of changes to the way information is transmitted to and from their brain. We used transcranial magnetic stimulation, a non-invasive brain stimulation technique, to measure participants’ brain function and neural processing. When compared to both age-matched controls, as well as a group of people who have recovered from a previous concussion, we found people with persistent post-concussion symptoms were slower to complete the set activities – and their outcomes were more varied. We have previously compared brain responses via this method in retired Australian Rules and Rugby league players and found abnormal responses compared to other people of the same age with no history of head trauma. The next stage of our research is to better understand who is vulnerable to persistent post-concussion symptoms and how the condition can be treated. We understand how to diagnose and treat concussion in the short term, but we’re yet to uncover how to best assist people with persistent post-concussion symptoms to return to leading productive lives.   Alan Pearce, Associate Professor, School of Allied Health, La Trobe University This article is republished from The Conversation under a Creative Commons license. Read the original article.
By Prof Alan Pearce
Clinical Articles iconClinical Articles
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All benzos risky in pregnancy

Benzos increase the risk of having a miscarriage in early pregnancy, regardless of whether you’re taking a short-acting one for insomnia or a longer-acting one for anxiety, Canadian researchers say. According to their large case-controlled study involving almost 450,000 pregnancies, benzodiazepine exposure in early pregnancy was associated with an 85% higher risk of spontaneous abortion compared to pregnancies where that class of drugs were not taken. And this increased risk remained the same, after a whole range of possible confounders had been adjusted for, including maternal mood and anxiety disorders. But this isn’t the new bit. Previous research, including both a UK population-based study and an Israeli prospective study had confirmed the link between benzos and spontaneous abortion. In Australia, benzodiazepines have been given a Category C rating in terms of safety in pregnancy. (Drugs owing to their pharmacological effects have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations.) “Benzodiazepines cross the placental barrier and accumulate in the fetal circulation at levels that are one to three times higher than the maternal serum levels”, the researchers explained. What hasn’t been known, to date, is whether this is a class effect or are some benzos worse than others. Well – according to this study published in JAMA Psychiatry – ‘the risk was similar among pregnancies exposed to short-acting …and long-acting benzodiazepines during early pregnancy.’ So it didn’t matter if you were prescribed long-acting clonazepam or short-acting lorazepam (interestingly the two most frequently prescribed benzos), the risk was more or less the same. “All benzodiazepine agents were independently associated with an increased risk of [spontaneous abortion],” the study authors said. In addition the study found the risk increased as the daily dose of benzodiazepines increased, suggesting a dose-response effect. So basically the more doses of benzos a pregnant woman takes, either in terms of strength or duration, the greater the risk she will miscarry. Overall, the researchers concluded that pregnant women should avoid taking benzodiazepines, and if they have to take them only take the lowest dose possible for shortest duration possible. “Alternative nonpharmacologic treatments exist and are recommended, but if benzodiazepines are needed, they should be prescribed for short durations,” they concluded.  

Reference

Sheehy O, Zhao JP, Bérard A. Association Between Incident Exposure to Benzodiazepines in Early Pregnancy and Risk of Spontaneous Abortion. JAMA Psychiatry. 2019 May 15. DOI: 10.1001/jamapsychiatry.2019.0963 [Epub ahead of print]  
By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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How anti-fat bias in health care endangers lives

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

Fatness as a sign of inferiority

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

‘Just eat more salads’

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

Bias trumps science, sometimes

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

How to advocate for yourself

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

Glucosamine’s effectiveness in treating arthritis remains controversial, however a study suggesting that the supplement, when taken regularly, will help prevent heart attacks certainly adds to its appeal. According to findings from a large prospective study just published in The BMJ, habitual glucosamine use is associated with a 15% lower risk of cardiovascular events. Breaking that down a bit further, it appears regular glucosamine lowered the risk of dying from a cardiovascular event by 22%, lowered the risk of coronary heart disease by 18% and lowered the risk of stroke by 9%. All statistically significant results. The research involved over 440,000 people from the UK biobank who didn’t have cardiovascular disease at the outset. Courtesy of an initial questionnaire, researchers knew who was taking glucosamine and how often. Interestingly about 20% of the cohort, reported they took the non-vitamin, non-mineral supplement daily – a figure the researchers said was representative in other adult populations around the world – including Australia. The cohort was then followed for a median of seven years. Over this time there were over 10,000 CVD events including heart attacks and strokes, with over 3,000 of these resulting in death. Even though the study was basically observational, the size of the sample strengthens its value. As does the fact that the researchers obtained a wealth of information about the patient’s diet, medical history and lifestyle at the initial questionnaire, which was all utilised in the final analysis. Consequently the 15% lower risk of a cardiovascular event associated with taking glucosamine can’t be easily written off as caused by another confounder. The researchers were able to conclude the association was “independent of traditional risk factors, including sex, age, income, body mass index, physical activity, healthy diet, alcohol intake, smoking status, diabetes, hypertension, high cholesterol, arthritis, drug use, and other supplement use.” So how does it work? How does glucosamine positively affect the cardiovascular system? According to the study authors, there are a number of plausible mechanisms that could explain the link. One relates to the anti-inflammatory properties of glucosamine. There already exists evidence that regular glucosamine reduces CRP levels, a marker of systemic inflammation. Another theory relates to how glucosamine affects metabolism. “[A] previous study found that glucosamine could mimic a low carbohydrate diet by decreasing glycolysis and increasing amino acid catabolism in mice; therefore, glucosamine has been treated as an energy restriction mimetic agent,” they said. But while the study findings appear very exciting, the study authors themselves suggest caution, claiming their study had some limitations. Among these limitations was the fact that details about the dose, duration of use, type of glucosamine supplement was not recorded. Obviously further research is needed to test this association. Nonetheless, the trial is destined to fuel on-going interest in the supplement, albeit for a totally different condition from the one we’re used to.  

References:

Ma H, Li X, Sun D, Zhou T, Ley SH, Gustat J, et al. Association of habitual glucosamine use with risk of cardiovascular disease: prospective study in UK Biobank. BMJ. 2019 May 14; 365: l1628. DOI: 10.1136/bmj.l1628
By Dr Linda Calabresi
Clinical Articles iconClinical Articles
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Pancreatic cancer support

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

By Dr Linda Calabresi
Clinical Articles iconClinical Articles

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