Greater recognition and response for treating eating disorders

Federal Health Minister Greg Hunt has launched the Butterfly Foundation’s National Agenda for Eating Disorders.

The Butterfly Foundation will receive an additional $1.2 million over the next two years to roll this out nationally through the National Eating Disorders Collaboration.

The goal of the National Agenda is to ensure Australia has a national approach to help people with eating disorders and to establish a bank of information around what works, so people suffering from this disease can access the best treatment for their needs.

The Agenda was developed in consultation with Australia’s eating disorders experts and those with a lived experience of an eating disorder.

Launching the National Agenda in September, Mr Hunt said that the Federal Government was committed to bringing together State and Territory governments and industry to deliver a consistent response in treating and supporting people with eating disorders.

The Government in the Budget this year announced it will provide almost $3 million for more support and better treatment for people suffering from eating disorders.

Eating disorders not only affect an individual’s relationship with food, but also body image, confidence, mental health, and overall health.

In May, Minister Hunt requested the Medical Benefits Schedule Review Taskforce investigate options for Medicare coverage for the treatment needs of those people with an eating disorder, including physical, psychological, behavioural, nutritional, occupational and social needs. The aim is to increase the skills of health professionals to identify and respond to eating disorders through a nationally consistent approach.

The Butterfly Foundation’s Chief Executive Christine Morgan believes this is critical because currently the foundation believes that only 25 per cent of Australians with an eating disorder currently seek treatment.

“The Agenda addresses critical areas of health system reform and identifies the priorities needed to provide access to evidence-based multi-disciplinary treatment and dosages to any Australian with or at risk of an eating order,” Ms Morgan said.

Mr Hunt also announced funding of $1.7 million to support expansion of the 1800 ED HOPE national helpline, allowing 1800 ED HOPE’s hours to be increased so it remains open from 8am to midnight seven days a week. This expansion will happen by February, 2018.

The telephone helpline is the only of its kind in Australia.

The Butterfly Foundation welcomed the support for the hotline saying they are committed to: “Ensuring there is no divide between those who can afford treatment and those who can’t.”

Ms Morgan said the announcement marked a milestone in Australia’s recognition and response to people living with an eating disorder.

“The launch of the first National Agenda for Eating Disorders, coupled with the Minister’s restated commitment to a review of Medicare to more comprehensively cover the needs of those with eating disorders, constitutes the policy realignment that has been sadly lacking to date,” she said.

The Butterfly Foundation has also recently launched an Australian-first Youth Intensive Outpatient Program in Sydney, a low cost program, costing families $120 per patient per week over the 10-week program.

The AMA expressed support for a nationally coordinated approach in order to develop effective and consistent practices in preventing and addressing the incidence of unhealthy body image and eating disorders. The AMA’s position paper Body Image and Health can be found here: position-statement/body-image-and-health-2002-revised…

Anyone needing support with eating disorders or body image issues is encouraged to contact Butterfly’s National Helpline on 1800 33 4673 or support@thebutterflyfoundation.org.au

MEREDITH HORNE

[Correspondence] Conscious sedation or general anaesthesia for lumbar puncture in children in Poland

Children with acute lymphoblastic leukaemia who are treated according to the intercontinental ALL-IC-BFM-2009 protocol have between 15 and 22 lumbar punctures with intrathecal drug administration during the first 12 months of therapy, depending on risk group and central nervous system involvement. Families in Poland are putting considerable pressure on paediatric oncology centres to do lumbar punctures under general anaesthesia, instead of using conscious sedation alone. Conscious sedation is usually done with midazolam, analgesics, and topical anaesthetic ointment.

My gender and my degree

BY DR DANIKA THIEMT

The ﬁrst documented English-speaking female doctor was Dr James Miranda Barry, a medical ofﬁcer of the British Army between 1813 and 1865. Dr Barry devoted her life to the British Army, earning the highest medical rank available: Inspector General of military hospitals. In an era when academic professions were the sole privilege of male members of society, it was necessary for Dr Barry to conceal her gender, living and practising medicine as a man. Her sad reality was exposed only posthumously where examination revealed her secret. Even in death, she was denied her right to her true identity; her gender kept secret for a further 100 years.

In Australia, medical training was opened to women in the late 1800s, and our ﬁrst female graduate was registered to practice in 1891. Female medical trainees are now thriving, with female medical graduates in Australia outnumbering men since the mid-1990s. Women currently make up more than two-ﬁfths of vocational trainees, focused largely in obstetrics and gynaecology (74.5 per cent), paediatrics (72.8 per cent) and general practice (63.1 per cent). Contrast this to the ﬁgures from oral and maxillofacial surgery, intensive care and surgery and female trainees make up less than a third of trainees. How, when we see women making up half or more of medical graduates and provisional trainees, are we still seeing unequally representation in the ongoing workforce? What is happening along the way? How and why does a speciality that starts out gender-neutral result in a specialist workforce that is predominantly male?

Fixing gender inequity in medicine requires supporting women in leadership. Diversity in the boardroom enhances corporate performance and, to advance as a profession, we need to attract and retain female leaders. Female specialists, on average, earn 16.6 per cent less than their male counterparts. Although differences in average hours worked account for some discrepancies, other contributory factors include a lack of women in senior positions and a lack of part-time or ﬂexible senior roles. There are already inspiring and engaged female leaders within our profession, leading the world in clinical practice, medical research and education. We should be harnessing their talent to inspire the next generation.

The changing demographic of our workforce could, in part, be to blame. Trainees are graduating from medical school later and spending more time in vocational training. This leads to greater family and social pressures on trainees and possibly an increase in the need for breaks or ﬂexible training options. Evidence shows that access to ﬂexible training helps to retain female trainees and is desired by both female and male trainees regardless of parental status. We need to dispel the belief that trainees must choose between career and family and instead focus on how we enable trainees to have both.

Gender inequity extends beyond medical workforce.Many of my female colleagues report being mistaken for nursing or allied health staff, a rare occurrence among my male colleagues. Similarly, senior female doctors are often overlooked by patients who prefer to talk to the male junior by her side. How do women thrive in medicine and become leaders when public perception seems to favour male doctors? I watch senior medical staff respond to “Miss” in conversation rather than the respectful “Dr”. Although this seems petty in the scheme of everyday practice, it is easy for female doctors to believe that our degrees come second to our gender. Although the actions of some do not make a rule, it is time that we stand together as a profession to advance women in medicine. It is time to advocate for female leadership not only in the eyes of the profession but also in the eyes of the public.

Equity isn’t about creating a false forced equality. We aren’t all equal and that should be celebrated. It certainly shouldn’t hold us back. Opportunities to become leaders won’t be taken by all of our trainees, but they should be provided to all, regardless of gender.

(A version of this article first appeared in Emergency Medicine Australasia in 2016.)

[Editorial] Pushing the boundaries in paediatric surgery

Aside from the difficult psychosocial aspects of illness in babies and children, paediatric surgery and paediatric surgical research face inimitable challenges. These include the consequences of anaesthesia and radiation exposure in children, the implications of long-term complications, and, in many cases, the necessity of long-term care despite the inevitability of a transition to adult services. Diseases requiring paediatric surgery are sometimes rare and heterogenous in nature, with complex cases requiring multidisciplinary management.

Questions asked and answered during Press Club appearance

In addition to delivering a wide-ranging 30-minute speech at the National Press Club, AMA President Dr Michael Gannon spent another half hour at the podium fielding questions from the Canberra Press Gallery.

The issues raised by the inquiring reporters ranged from doctors’ fees, to refugee health, to codeine prescriptions, to marriage equality – and a whole lot in between.

On the subject of cost-shifting by the States to patients covered by private insurance who are attending public hospitals, Dr Gannon said he had made the point directly to Health Minister Greg Hunt, that flexibility must be maintained.

“We don’t want a situation where insured patients are prohibited from care in public hospitals,” Dr Gannon said.

“They might live in a rural area where there’s no alternative; no fancy, shiny, private hospital there in the region. It might be the case that a doctor with sub-specialist expertise only works in a public hospital. It may be that they need the intensive care unit that only exists in a public hospital. It may simply be the patient’s choice. So, wherever we land, we must end up with flexibility.

“One of the things that’s led to this problem is the fact that the States and the Territories and the Commonwealth have underinvested in public hospitals. So, the public hospitals are looking for new revenue streams, and sometimes they’re a bit too tricky and clever trying to get hold of insured patients when they’re not actually providing any greater level of care.

“But I also think this is an area where the private health insurers need to step up to their part of the responsibility.”

In his speech, Dr Gannon described the push by insurers for doctors to publish their fees and customer referrals as “dangerous territory”.

In response to questioning about that, he said informed financial consent was very important.

“But I don’t trust a website owned by the insurers to produce un-vetted information about the quality of the magazines in the waiting room, whether or not the receptionist was rude, and I have great concerns about people not being able to obviously interpret quality data,” he said.

“It’s a lot more complicated than a cheesy website might appear.”

Drug testing welfare recipients

The AMA President was highly critical, when he was asked about it, of the Government’s plan to drug test welfare recipients.

“If I had to put a nasty star on the Government’s last Budget, it was this mean and non-evidence-based measure. It simply won’t work,” Dr Gannon said.

“This is not an evidence-based measure (and) will not help. We don’t expect people in most industries to have drug testing before they turn up to work.

“It’s simply unfair and it already picks on an impaired and marginalised group. It’s not evidence-based. It’s not fair. And we stand against it.”

NDIS

On the question of the NDIS eligibility of people with mental health conditions, Dr Gannon said the scheme needed certainty of funding to ensure proper access and eligibility.

“This is going to be a very difficult and vexed issue for Governments now going forward,” he said.

“Talk to the experts. Talk to the GPs, the psychiatrists, the psychologists, the carers who are there providing that care every day. Look at the evidence. Look at what works, and fund it according to what might be expected to work from international evidence, or from talking to home-grown experts here in Australia.”

Same-sex Marriage

On marriage equality, the President said he wouldn’t lecture parliamentarians on legislative approaches, but a risk existed that the wider discussion on the issue will have mental health impacts on people directly affected.

“Equally, we live in a democracy where people are entitled to have their say. I faced criticism of our Position Statement from within the membership, and I have made it very clear that we, as an organisation, are a broad enough church that we can accommodate different views on this topic,” he said.

“And I am not uncomfortable with the Australian people being given their say. We believe that this is an area of discrimination and therefore does have health impacts. We would like to see it resolved. We would like to see the Government, the Parliament, getting on in other crucial areas of public policy, but we are silent on the exact details about how we get there.”

Codeine prescriptions

On codeine, and the AMA’s agreement with the decision to make it available only by prescription, Dr Gannon said the AMA’s position was not a unilateral statement.

“This is very much the AMA supporting the Therapeutic Goods Administration, the TGA, in their independent science-based analysis of the issues,” he said.

“Now, many people might not know that there’s already 25 countries where codeine requires a prescription. Many people might not know that the science tells us that we all metabolise codeine very differently. So for a significant minority of us, we metabolise it in a way that is extremely potent, every bit as powerful as morphine, and is a common cause of death from opioid overdose.

“Not only have we told the Minister we support the TGA’s decision, we are also telling the State and Territory Health Ministers that we do not want to see exemptions from this. That’s wading into very, very dangerous territory, when the independent regulator looking at scientific evidence is overrun by an industry that has a different view.”

Euthanasia

On palliative care and support of doctors who may wish to assist patients to die, he was very clear.

“We have inadequate legislation in most parts of Australia to protect doctors acting ethically and lawfully with inadequate doctrine of double effect legislation,” Dr Gannon said.

“Ninety-nine per cent of end-of-life decisions do not involve requests to die. That is a very, very, very small part of the system.

“And surely the aspiration of all people, whether they favour voluntary euthanasia or not, is to improve palliative care services.

“The AMA Position Statement makes it extremely clear that we understand this is a decision for society: it’s Parliament’s, it’s legislators’. The AMA’s position is that doctors should not participate in these arrangements.”

Refugee health care

Regarding the level of health care provided to asylum seekers in offshore detention, Dr Gannon said the ethical principles were very clear.

People seeking the protection of the Australian Government are entitled to healthcare standards the same as Australian citizens.

“So, that’s a matter of ethics and that’s a matter of law. What we’ve developed over the past 12 months or so is a relationship with the Chief Medical Officer of the Department of Immigration and Border Protection, so that when we receive discussions on individual healthcare episodes we are able to talk about them,” he said.

“… a difficult and vexed issue where a form of medical care, namely termination of pregnancy – which could relatively easily be provided on Nauru – can’t legally be provided because it’s illegal on the island.

“That means that if that cannot be provided, that those patients must be transferred to the mainland. This is a hotly contested political issue. I am not an immigration expert. But I like to think I’m an expert in medical ethics, and I’ve stated our position very clearly as to the health standards that we would expect.”

Private health insurance

On private health insurance, Dr Gannon said agreement must be reached on basic level of cover, or at least better transparency, so people know what they’re covered for.

“The policies that are nothing more than to dodge the tax penalty, they’re junk,” he said.

“The policies that limit you to care in a public hospital, I need to be convinced why they’re any better than being a public patient in our excellent public hospitals.

“Now I don’t want to spend my entire life arguing with the insurers. They have a right to make a profit. In fact they’ve got a corporate responsibility to deliver a profit. But they cannot deliver that profit on the back of diminished services to private patients. And if they don’t get it and they don’t get it soon, they will drive their industry off the cliff.”

CHRIS JOHNSON

The full transcript of Dr Gannon’s Q&A session at the National Press Club can be found here:

media/dr-michael-gannon-national-press-club-q-and

[Comment] Procalcitonin-guided antibiotic stewardship from newborns to centennials

In 1993, Assicot and colleagues1 reported in The Lancet that procalcitonin was a marker of systemic infections in neonates and paediatric patients. In 2004, Christ-Crain and colleagues2 reported that procalcitonin guidance substantially reduced antibiotic use in adult patients presenting to the emergency room with lower respiratory tract infections, and in 2010, Bouadma and colleagues3 reported that a procalcitonin-guided strategy to treat suspected bacterial infections in non-surgical adult patients in intensive care units reduced antibiotic exposure and selective pressure with no apparent adverse outcome.

Rehydration study shows water still best choice

A Griffith Universitystudy has found that once food is consumed, water should be the drink of choice for most of us following a workout.

Ten endurance trained athletes aged between 18 and 30 cycled intensively for one hour on four separate occasions as a part of the small study that has been published in the peer-reviewed scientific journal Physiology and Behaviour.

Participants were provided with one beverage to drink as they desired following the exercise. The beverages included water (used on two of the trials), a carbohydrate-electrolyte (sports drink) Powerade or the milk-based drink Sustagen Sport.

In addition, on two occasions during recovery, the participants were given access to a variety of food which could also be voluntarily consumed.

“The fluid provided from all beverages was equally well retained, despite different consumption volumes, and resulted in participants’ body weights returning to near pre-exercise levels,” said Associate Professor Ben Desbrow from Griffith’s Menzies Health Institute Queensland.

“The findings from this study demonstrate that the consumption of food following exercise plays an important role in causing fluid retention when different beverages are consumed. The take home message was that when participants consumed a fluid containing calories (i.e. the Powerade or Sustagen Sport trials), their combined energy intake from the drink and food was greater than on the water trials.”

Associate Professor Desbrow said it was imperative, when making post-exercise nutrition recommendations, to consider beverage selection within the context of an individual’s broader health targets.

“For those with a weight loss goal, a calorie-free drink such as water is the perfect choice,” he said.

“It rehydrates equally effectively as other beverages, without supplying additional energy.”

MEREDITH HORNE

[Comment] After Charlie Gard: ethically ensuring access to innovative treatment

July 24, 2017, marked the end of the long-running legal battle over treatment for UK infant Charlie Gard.1 International medical experts, invited by the High Court to examine Charlie, concluded that proposed innovative treatment could no longer offer even theoretical benefit. His parents accepted that it was time to allow Charlie to die, while bitterly lamenting that he had missed a potential window of opportunity for treatment.2 Charlie Gard died 4 days later, after withdrawal of intensive medical treatment.

[Correspondence] Formulated data do not reflect facts – Authors’ reply

We thank Pauline Hull for her interest in our Article.1 Hull criticises our emphasis on increased maternal mortality and severe morbidity although there have been no deaths or hysterectomies. We decided on the composite outcome before the analysis was done, and we have reported all individual endpoints for transparency. We maintain our position that admission to an intensive care unit and receiving blood transfusion are important events. We are also concerned about the rare events of only nine (0·6%) in the 1515 mothers with antepartum caesarean section without indication and the sparsity of events might affect the robustness of conclusions.

[Correspondence] Intensive speech and language therapy after stroke

Caterina Breitenstein and colleagues (April 15, p 1528)1 reported that 3 weeks of intensive speech and language therapy significantly enhanced verbal communication in people aged 70 years or younger with chronic aphasia after stroke. The primary outcome measure was assessed using the Amsterdam-Nijmegen Everyday Language Test (ANELT) A-scale, and the mean difference of the ANELT A-scale score improved 2·61 (SD 4·94) points from baseline to after intensive speech and language therapy, but not from baseline to after treatment deferral.