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Psychiatry

Clinical Articles

Get Depressed Patients to Lift Weights

Resistance exercise training significantly reduces depressive symptoms, a new meta-analysis has found. According to international researchers who looked at over 30 randomised clinical trials on the subject, resistance exercise training including activities such as weight lifting reduced depressive symptoms by an average of a third. In fact, the meta-analysis findings suggested that resistance exercise training may be particularly helpful for reducing symptoms in patients with more severe depression. The study results, published in JAMA Psychiatry, concluded that only four people needed to be treated in order to have one to show significant benefit from the intervention. And the improvement inn depressive symptoms occurred regardless of the patient’s overall health status, the volume of resistance training exercise the patient undertook or any improvements in strength the patient experienced. And while the study authors made sure to point out their analysis was not comparing this exercise program with other treatments for depression, reducing symptoms by an average of a third certainly compares with other treatments currently available for this condition. “The available empirical evidence supports [resistance exercise training) as an alternative or adjuvant therapy for depressive symptoms,” the researchers said. What we still don’t know, apparently is exactly what sort of exercise, at what intensity, how frequently and for how long is required until a significant improvement in the depression is achieved. Many of the randomised controlled trials included in the meta-analysis did not measure all these parameters. What the researchers did find was that supervised training programs appeared more effective than non-supervised, which may reflect adherence to the exercise regimen. They also said the most common frequency of resistance exercise training was three times a week. The study authors suggested the limitations of the studies included in this analysis should help direct further research. “Future trials, matching different exercise modes on relevant features of the exercise stimulus, will allow more rigorous and controlled comparisons between exercise modalities, and the examination of interactions between factors such as frequency, intensity, duration and exercise modality,” they said. But regardless of the lack of fine print, the results of this moderate-sized effect of resistance exercise training reported in this study and the complete lack of adverse effects, would seem sufficient to justify recommending it to patients with depression, at least as an adjunctive treatment for one of Australia’s most common mental illnesses. Ref: JAMA Psychiatry doi:10.1001/jamapsychiatry.2018.0572

By Dr Linda Calabresi

Art of medicine

Clinical Articles

Health Experts Respond to the 2018 Budget

The winners of this year’s health budget are aged care, rural health and medical research. The government has announced A$1.6 billion over four years to allow 14,000 more older Australians to remain in their home for longer through more high-level home care places. For those in aged care, an additional A$82.5 million will be directed to improve mental health services in the facilities. The budget includes A$83.3 million over five years for a rural health strategy, which aims to place more doctors and nurses in the bush and train 100 additional GPs. There’s A$1.3 billion over ten years for a National Health and Medical Industry Growth Plan, which includes A$500 million for new research in the field of genomics. Other key announcements include: - A$1.4 billion for new and amended listings on PBS - A$302.6 million in savings over forward estimates by encouraging greater use of generic and bio similar medicines - A$253.8 million for a new Aged Care Quality and Safety Commission.
Read more:Infographic: Budget 2018 at a glance

Aged care

Helen Dickinson, Associate Professor, Public Service Research Group at UNSW It was well foreshadowed that this budget would bring with it significant provisions for aged care. It has been widely reported that reforms to pension and superannuation tax have resulted in disaffection in the Coalition within older age groups. Making older Australians the cornerstone of budget measures is a calculated political tactic in a budget that in the short term makes only limited tax cuts for low- and middle-income earners. The A$1.6 billion for 14,000 new places for home-care recipients will be welcome, but are a drop in the ocean, given there are currently more than 100,000 people on the national priority list for support. Additional commitments around trials for physical activities for older people, initiatives to improve connections to communities and protections for older people against abuse will bolster those remaining in homes and communities. Commitments made for specific initiatives for Aboriginal and Torres Strait Islander people and aged care facilities in rural and remote Australia will be welcomed, although their size and scope will likely result in little to address older age groups with complex needs. While investment in aged care services will be welcome, it remains to be seen whether this multi-million-dollar commitment will succeed in clawing back support from older voters. Recent years have seen around A$2 billion of cuts made to the sector through adjustments to the residential care funding formula. The current financial commitments go some way to restoring spending, but do not significantly advance spending beyond previous levels in an area of the population we know is expanding substantially in volume and level of need and expectation. A number of new budget commitments have been announced in relation to mental health services for older people in residential aged care facilities, for a national mental health commission, and for Lifeline Australia. However, given the current turbulence in mental health services, it’s unclear whether these will impact on the types of issues that are being felt currently or whether this will further disaggregate an already complex and often unconnected system.

Equity, prevention and Indigenous health

Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy at the University of Sydney The government states its desire for a stronger economy and to limit economic imposts on future generations, but this budget highlights a continued failure to invest in the areas that will deliver more sustainable health care spending, reduce health disparities, and improve health outcomes and productivity for all Australians. We know what the best buys in primary prevention are. But despite the fact that obesity is a heavy and costly burden on the health care system, and the broad agreement from experts on a suite of solutions, this can is once again kicked down the road. There is nothing new to address the harms caused by excessive alcohol use or opioid abuse. The crackdown on illegal tobacco is about lost taxes rather than smoking prevention. There is A$20.9 million over five years to improve the health of women and children – an assorted collection of small programs which could conceivably be claimed as preventive health. There is nothing in this budget to address growing out-of-pocket costs that limit the ability of many to access needed care. Additional funding (given in budget papers as A$83.3 million over five years but more accurately described as A$122.4 million over 2018-19 and 2019-20, with savings of A$55.6 million taken in 2020-21 and 2021-22) is provided for rural health that should help improve health equity for country Australians. Continued funding is provided for the Indigenous Australians’ Health Program (A$3.9 billion over four years); there is new money for ear, eye and scabies programs and also for a new Medicare item for remote dialysis services. There are promises for a new funding model for primary care provided through Aboriginal Community Controlled Health Services (but no details) and better access for Indigenous people to aged care. The renewal of the Remote Indigenous Housing Agreement with the Northern Territory will assist with improved health outcomes for those communities.

PBS, medicines and research

Rosalie Viney, Professor of Health Economics at the University of Technology Sydney The budget includes a notable increase in net expenditure on the Pharmaceutical Benefits Scheme (PBS) of A$1.4 billion for new and amended listings of drugs, although most of these have already been anticipated by positive recommendations by the Pharmaceutical Benefits Advisory Committee (PBAC). Access to a number of new medicines has been announced. The new and amended medicine listings are clearly funded through savings in PBS expenditure from greater use of generic and bio-similar medicines, given the net increase in expenditure over the five year outlook is around A$0.7 billion. In terms of medical research, there is an encouraging announcement of significant further investments through the Medical Research Futures Fund. This will be welcomed by health and medical researchers across Australia. What is notable is the focus on the capacity of health and medical research to generate new jobs through new technology. While this is certainly important, it is as much about boosting the local medical technology and innovation industry than on improving health system performance. And the announcements in the budget are as much about the potential job growth from medical innovation as on providing more or improved health services. There is new funding for medical research, development of diagnostic tools and medical technologies, and clinical trials of new drugs. The focus on a 21st century medical industry plan recognises that health is big business as well as being important for all Australians. All of this is welcome, but it will be absolutely critical that there are rigorous processes for evaluating this research and ensuring the funding is allocated based on scientific merit. This can represent a major challenge when industry development objectives are given similar standing in determining priorities as health outcomes and scientific quality.

Rural health

Andrew Wilson, Co-Director, Menzies Centre for Health Policy at the University of Sydney Rural Australians experience a range of health disadvantages including higher rates of smoking and obesity, poorer survival rates from cancer and lower life expectancy, and this is not solely due to the poor health of the Aboriginal community. The government has committed to improving rural health services through the Stronger Rural Health Strategy and the budget has some funding to underpin this. The pressure to fund another medical school in rural NSW and Victoria has been sensibly addressed by enhancing and networking existing rural clinical schools through the Murray Darling Medical Schools network. This will provide more opportunities for all medical students to spend a large proportion of their studentship in a rural setting while not increasing the number of Commonwealth supported places. There is a major need to match this increased student capacity with a greater investment in specialist training positions in regional hospitals to ensure the retention of that workforce in country areas. Hopefully the new workforce incentive program will start to address this.

Hospitals and private health insurance

Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University There was no new money in today’s budget for Australia’s beleaguered public hospitals. The government is still locked in a deadlock with Queensland and Victoria, which have refused to agree to the proposed 6.5% cap on yearly funding increases from the Commonwealth. With health inflation of about 4% and population growth close to 2% the cap doesn’t allow much room for increased use due to ageing or new technology. There is no change in the government’s private health insurance policy announced last year and nothing to slow the continuing above-inflation premium rises. On the savings side, there was also no move yet on the private health insurance rebate which some experts think could be scrapped. Kees Van Gool, Health economist, University of Technology Sydney; Andrew Wilson, Co-Director, Menzies Centre for Health Policy, University of Sydney; Helen Dickinson, Associate Professor, Public Service Research Group, UNSW; Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney; Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University, and Rosalie Viney, Professor of Health Economics, University of Technology Sydney This article was originally published on The Conversation. Read the original article.

By Dr Kees Van Gool, Prof Andrew Wilson, A/Prof Helen Dickinson, A/Prof Lesley Russell, A/Prof Peter Sivey, Prof Rosalie Viney

Infectious diseases

Clinical Articles

New Virus Putting Babies in Hospital

In the last few months of 2017, over 200 Australian infants were hospitalised due to infection with the little known human parechovirus, say Australian public health experts in the latest issue of the MJA. The infected infants were admitted with conditions such as severe sepsis and meningoencephalitis. Less common presentations included acute abdomen from intussusception, pseudo-appendicitis and even bowel perforation. According to the MJA review, parechovirus was originally included under the echovirus umbrella back in the 1960’s, but became an entity in its own right, in the 90’s. There are close to 20 genotypes of the virus, but to date only three (genotypes 1,3 and 6) are thought to cause human disease. For the most part parechovirus causes mild gastro or respiratory tract infections. However, one of the genotypes – genotype 3 - has been found to be considerably more dangerous, especially in babies. “It is now recognised as a leading cause of sepsis-like illness and central nervous system infection, particularly in young infants,” the review authors wrote. The first ‘epidemic’ in Australia of this parechovirus genotype occurred in spring-summer of 2013-2014. Another outbreak occurred two years later – the spring-summer of 2015-2016. This most recent ‘epidemic’ appeared to start in Victoria last August and has now spread nationwide with over 200 infants hospitalised to December. For GPs, the key presenting features to be on the lookout for are fever, irritability and sepsis-like illness – which aren’t very specific. More helpfully - while not all infected children will have a rash, if the presenting infant is ‘red, hot and angry’ -think parechovirus, the authors recommend. Infants younger than three months are most likely to be hospitalised and, of course, really young infants (less than a month old) are at greatest risk of complications so should be sent to hospital earlier rather than later. To diagnose this infection, specific PCR testing needs to be requested of either stool or CSF. Just testing for enteroviruses will not be sufficient. Unfortunately, as yet there is no specific treatment for parechovirus. Given the presentation is the same as that of bacterial sepsis, the review authors suggest antibiotics be commenced until cultures come back negative and bacterial infection is excluded. But other than that, the treatment is mainly supportive and close monitoring and perhaps hospitalisation is required. Of particular concern are a number of studies that suggest infection that is severe enough to require the child be hospitalised is associated with high risk of neurological sequelae. As a consequence, the authors recommend that all children hospitalised with parechovirus be followed up with a paediatrician – at least until they start school- ‘to monitor development and learning, and manage complications including seizures.’ In terms of a vaccine, there is not one yet developed against parechovirus. They suggest research efforts should focus on developing vaccines that target the most pathogenic genotypes of a virus rather than trying to eradicate the entire genus such as has occurred in China with the vaccine against EV71 – a specific enterovirus that causes a complicated hand, foot and mouth disease. Regardless the need to find a vaccine is a priority. “The high morbidity in young children provides a strong case for prevention,” they concluded. Ref: MJA doi: 10.5694/mja18.00149

By Dr Linda Calabresi

Sexual health

Clinical Articles

Not so simple Herpes Simplex

Herpes simplex virus (HSV) 1 and 2 are closely related to each other and more distantly related to Varicella Zoster virus (VZV), which causes Varicella (chicken pox) and Herpes Zoster (shingles). Traditionally HSV1 causes most oral herpes and HSV2 causes most genital herpes. But this is no longer so and has changed, probably due to more frequent oral sex. Figures from Clinipath 2017:

HSV Swab Origin HSV1 HSV2 VZV

Oral sites 93% 2% 5%

Genital/perineal sites 45% 50% 5%

HSV1 is frequently acquired in childhood and 75% of Australian adults would have had HSV1 by early adulthood. This would have been from oral contact with close friends and relatives who were shedding the virus, often asymptomatically. The classic “cold sores” are a blistering painful rash around the mouth Like other viruses in the Herpes family, this ‘lifelong’ infection can lay dormant and reactivate. The risk of reactivation and severe reactivation is higher in immunosuppressed individuals but in most people there is no readily identifiable reason for their reactivation. Stress is often blamed. Less common infections include:

HSV encephalitis (HSV1 in adults) and HSV meningitis (usually HSV2 in adults)

Conjunctivitis/keratitis – usually HSV1 or VZV (shingles affecting trigeminal nerve)

Herpetic whitlow – painful vesicles affecting the finger or thumb caused by HSV1 or 2

Genital Herpes

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

HSV in Pregnancy

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

Treatment

These viruses may be treated with aciclovir, valaciclovir or famciclovir.

General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.

By Dr Smathi Chong