more_vertIn 1891, Friedrich Maass performed the first chest compressions on a human being. 80 years later, the first mass citizen training in cardiopulmonary resuscitation (CPR) was held in Seattle; over 100 000 members of the public were taught CPR. Out-of-hospital cardiac arrest (OHCA) describes the loss of mechanical cardiac function and the absence of systemic circulation. Time is crucial, with a lack of perfusion leading to continual cell death; with each second that passes the possibility of a good outcome decreases.
Preference: Cardiology and Cardiac Surgery
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AMA shines in Australia Day Honours
Former Australian Medical Association President Dr Mukesh Haikerwal has been awarded the highest honour in this year’s Australia Day awards by being named a Companion of the Order of Australia (AC).
He is accompanied by the current Editor-in-Chief of the Medical Journal of Australia, Laureate Professor Nick Talley, as well as longstanding member Professor Jeffrey Rosenfeld – who both also received the AC.
The trio top a long and impressive list of AMA members to receive Australia Day Honours this year.
AMA Federal Councillor, Associate Professor Julian Rait, received the Medal of the Order (OAM).
A host of other members honoured in the awards are listed below.
AMA President Dr Michael Gannon said the accolades were all well-deserved and made he made special mention of those receiving the highest Australia Day Honours.
“They have dedicated their lives and careers to helping others through their various roles as clinicians, researchers, teachers, authors, administrators, or government advisers – and importantly as leaders in their local communities,” Dr Gannon said.
“On behalf of the AMA, I pay tribute to all the doctors and other health professionals who were honoured today for their passion for their profession and their dedication to their patients and their communities.
“The great thing about the Honours is that they acknowledge achievement at the international, national, and local level, and they recognise excellence across all avenues of human endeavour.
“Doctors from many diverse backgrounds have been recognised and honoured again this year.
“There are pioneering surgeons and researchers, legends across many specialties, public health advocates, researchers, administrators, teachers, and GPs and family doctors who have devoted their lives to serving their local communities.
“The AMA congratulates all the doctors and other health advocates whose work has been acknowledged.
“We are, of course, especially proud of AMA members who are among the 75 people honoured in the medicine category.”
Dr Haikerwal, who was awarded the Officer in the Order of Australia (AO) in 2011, said this further honour was “truly mind-blowing” and another life-changing moment.
“To be honoured on Australia Day at the highest level in the Order of Australia is beyond imagination, beyond my wildest dreams and extremely humbling,” Dr Haikerwal said.
“For me to be in a position in my life and career to receive such an honour has only been made possible due to the unflinching support and unremitting encouragement of my closest circle, the people who have been with me through every step of endeavour, adversity, achievement, and success.”
CHRIS JOHNSON
AMA MEMBERS IN RECEIPT OF HONOURS
COMPANION (AC) IN THE GENERAL DIVISION
Dr Mukesh Chandra HAIKERWAL AO
Altona North Vic 3025
For eminent service to medical governance, administration, and technology, and to medicine, through leadership roles with a range of organisations, to education and the not-for-profit sector, and to the community of western Melbourne.
Professor Jeffrey Victor ROSENFELD AM
Caulfield North, Vic
For eminent service to medicine, particularly to the discipline of neurosurgery, as an academic and clinician, to medical research and professional organisations, and to the health and welfare of current and former defence force members.
Professor Nicholas Joseph TALLEY
Black Hill, NSW
For eminent service to medical research, and to education in the field of gastroenterology and epidemiology, as an academic, author and administrator at the national and international level, and to health and scientific associations.
OFFICER (AO) IN THE GENERAL DIVISION
Emeritus Professor David John AMES
East Kew, Vic
For distinguished service to psychiatry, particularly in the area of dementia and the mental health of older persons, as an academic, author and practitioner, and as an adviser to professional bodies.
Dr Peggy BROWN
Sanctuary Cove, Qld
For distinguished service to medical administration in the area of mental health through leadership roles at the state and national level, to the discipline of psychiatry, to education, and to health care standards.
Professor Creswell John EASTMAN AM
St Leonards, NSW
For distinguished service to medicine, particularly to the discipline of pathology, through leadership roles, to medical education, and as a contributor to international public health projects.
Professor Suzanne Marie GARLAND
Docklands, Vic
For distinguished service to medicine in the field of clinical microbiology, particularly to infectious diseases in reproductive and neonatal health as a physician, administrator, researcher and author, and to professional medical organisations.
Dr Paul John HEMMING
Queenscliff, Vic
For distinguished service to higher education administration, to medicine through contributions to a range of professional medical associations, and to the community of central Victoria, particularly as a general practitioner.
Professor Anthony David HOLMES
Melbourne, Vic
For distinguished service to medicine, particularly to reconstructive and craniofacial surgery, as a leader, clinician and educator, and to professional medical associations.
Dr Diana Elaine O’HALLORAN
Glenorie, NSW
For distinguished service to medicine in the field of general practice through policy development, health system reform and the establishment of new models of service and care.
MEMBER (AM) IN THE GENERAL DIVISION
Dr Michael Charles BELLEMORE
Croydon, NSW
For significant service to medicine in the field of paediatric orthopaedics as a surgeon, to medical education, and to professional medical societies.
Dr Colin Ross CHILVERS
Launceston, Tas
For significant service to medicine in the field of anaesthesia as a clinician, to medical education in Tasmania, and to professional societies.
Associate Professor Peter HAERTSCH OAM
Breakfast Point, NSW
For significant service to medicine in the field of plastic and reconstructive surgery as a clinician and administrator, and to medical education.
Professor Ian Godfrey HAMMOND
Subiaco, WA
For significant service to medicine in the field of gynaecological oncology as a clinician, to cancer support and palliative care, and to professional groups.
Dr Philip Haywood HOUSE
WA
For significant service to medicine as an ophthalmologist, to eye surgery foundations, and to the international community of Timor Leste.
Adjunct Professor John William KELLY
Vic
For significant service to medicine through the management and treatment of melanoma, as a clinician and administrator, and to education.
Dr Marcus Welby SKINNER
West Hobart, Tas
For significant service to medicine in the field of anaesthesiology and perioperative medicine as a clinician, and to professional societies.
Professor Mark Peter UMSTAD
South Yarra, Vic
For significant service to medicine in the field of obstetrics, particularly complex pregnancies, as a clinician, consultant and academic.
Professor Barbara S WORKMAN
East Hawthorn, Vic
For significant service to geriatric and rehabilitation medicine, as a clinician and academic, and to the provision of aged care services.
MEDAL (OAM) IN THE GENERAL DIVISION
Professor William Robert ADAM PSM
Vic
For service to medical education, particularly to rural health.
Dr Marjorie Winifred CROSS
Bungendore, NSW
For service to medicine, particularly to doctors in rural areas.
Associate Professor Mark Andrew DAVIES
Maroubra, NSW
For service to medicine, particularly to neurosurgery.
Dr David William GREEN
Coombabah, Qld
For service to emergency medicine, and to professional organisations.
Dr Barry Peter HICKEY
Ascot, Qld
For service to thoracic medicine.
Dr Fred Nickolas NASSER
Strathfield, NSW
For service to medicine in the field of cardiology, and to the community.
Dr Ralph Leslie PETERS
New Norfolk, Tas
For service to medicine, and to the community of the Derwent Valley.
Associate Professor Julian Lockhart RAIT
Camberwell, Vic
For service to ophthalmology, and to the development of overseas aid.
Mr James Mohan SAVUNDRA
South Perth, WA
For service to medicine in the fields of plastic and reconstructive surgery.
Dr Chin Huat TAN
Glendalough, WA
For service to the Chinese community of Western Australia.
Dr Karen Susan WAYNE
Toorak, Vic
For service to the community of Victoria through a range of organisations.
Dr Anthony Paul WELDON
Melbourne, Vic
For service to the community, and to paediatric medicine.
PUBLIC SERVICE MEDAL (PSM)
Dr Sharon KELLY
Yeronga, Qld
For outstanding public service to the health sector in Queensland.
Professor Maria CROTTY
Kent Town, SA
For outstanding public service in the rehabilitation sector in South Australia.
Why heart disease is so often missed in women
Heart disease is the No. 1 cause of death for women throughout the world. Approximately seven times more women will die from heart disease than breast cancer. Even in women with breast cancer, dying from heart disease is a leading cause of death.
Yet when I ask undergraduate students in my chronic disease class (most of whom are female) which disease causes the most deaths in women, only about half give the answer heart disease; a third say it is breast cancer.
This mirrors a 2012 survey from the United States, which found that only 56 per cent of female respondents identified heart disease as the leading cause of death.
Such a lack of awareness has very real consequences. Women who experience a heart attack in the U.S. are more likely to misunderstand the symptoms and delay seeking treatment. In Canada, early heart attack signs were missed in 78 per cent of women, according to the 2018 Heart Report from the Canadian Heart and Stroke Foundation.
Upon arrival in hospital, women’s symptoms can be dismissed by medical professionals as something else. They are also referred less for in-hospital treatments such as angioplasty (the clearing of a blockage in a heart artery) than men in the U.S., experiencing greater risk for death. Research has found a similar gender bias among general physicians in the United Kingdom and Germany as well as the U.S., resulting in less accurate diagnosis and treatment for women.
So, why this dismal knowledge of heart disease in women?
Not just a “widowmaker”
One reason is that research has historically been conducted in middle-aged and older men. This is, in part, because men had heart attacks during their working years, potentially limiting their economic productivity.
Women — who tended to suffer heart disease at a later age — received less attention.
There was also a fear of involving pregnant women in research, which led to all women of child-bearing age being restricted from participating in most research in the U.S. until the 1990s.
As a result, people both within and outside the medical profession had the impression that heart disease is for men.
This bias is easily recognized by the term “widowmaker” to describe the left main artery: One of the key arteries of the heart in which a blockage may lead to early death.
Smaller hearts and arteries
The second reason for our general lack of understanding of heart disease in women is due to differences in biology. We now know that the findings from research in men don’t fully apply to women — given differences in risk for heart disease and in anatomy.
As women get heart disease later in life than men, they also have more age-related risk factors than men — such as diabetes, which makes treatment more complex.
Women with diabetes have a 44 per cent greater risk for heart disease than men. In addition, gestational diabetes (which occurs during pregnancy and impacts approximately 5.5 per cent of births in Canada), is associated with a higher risk for heart disease compared to women who haven’t had gestational diabetes.
Early age of puberty and menopause have also been associated with greater heart disease risk.
And differences extend to anatomy. Given their smaller body size, women tend to have smaller hearts and arteries than men. This has been associated with higher mortality during bypass surgery.
Smaller arteries also make diagnostic techniques like the electrocardiogram (ECG) and coronary angiography (X-ray imaging of heart arteries) more challenging.
Women have different symptoms
One of the more perplexing facts about heart disease in women is that a heart attack can occur even without any heart arteries being blocked. This can happen with a “coronary artery spasm,” in which an artery of the heart suddenly closes upon itself. And it can happen with “spontaneous coronary artery dissection,” in which the inside of the heart artery tears, leading to a blood clot.
When there is no blockage, diagnosis by traditional methods is difficult.
(Shutterstock)
While women having a heart attack can feel severe pain in their chest, many also experience more subtle symptoms such as shortness of breath, discomfort in their arms, neck and jaw, sweating or nausea.
Despite these symptoms being fairly common in women, they are still referred to as “atypical,” indirectly suggesting that a woman’s experience is not normal. Yet they are normal for women.
A review of studies from nine countries found that women are also less likely to be referred to, and attend, cardiac rehabilitation programs.
And recent research from Sweden shows that failure to adhere to treatment guidelines results in greater premature death for women within five years after a heart attack compared to men. This confirms earlier findings in many other countries as well.
Female-only cardiac rehabilitation
While there is much work to be done, each year this gap in knowledge and treatment closes in North America thanks in part to Health Canada and the US Food and Drug Administration implementing guidelines to ensure the inclusion of women in research.
Continued advocacy by the Heart and Stroke Foundation and the American Heart Association is also important for increasing awareness both within and outside of the health care systems.
Additionally, more research in tailoring treatments to women, like female-only cardiac rehabilitation, will help in the design and application of treatments.
As individuals, the capacity to recognize and understand the signs and symptoms of heart disease could be life-saving — for our loved ones, friends, bystanders and even ourselves.
Scott Lear writes the weekly blog Feel Healthy with Dr. Scott Lear.
Scott Lear, Professor of Health Sciences, Simon Fraser University
This article was originally published on The Conversation. Read the original article.
[Correspondence] Targeted radiotherapy for early breast cancer – Authors’ reply
We reject the inference of a survival benefit for patients receiving partial-breast irradiation within the IMPORT LOW trial and caution against any such interpretation when the number of events reported is so small.1 There is no suggestion of a difference in disease-free and overall survival across IMPORT LOW treatment groups.1 The TARGIT trialists’ claim of survival benefit in their own trial relates to non-breast cancer deaths, and the data they cite are from a selected subset of patients. In IMPORT LOW, there were nine cardiac deaths occurring 6–36 months following randomisation, four after left-sided and five after right-sided breast cancer.
[Comment] Last nail in the coffin for PCI in stable angina?
Interventional cardiology began in Switzerland in 1977, when Andreas Gruentzig performed the first successful percutaneous transluminal coronary angioplasty (PTCA) on a 38-year-old man with angina and a focal proximal stenosis of the left anterior descending coronary artery. Despite numerous subsequent randomised trials and meta-analyses of these trials, which have shown no reduction in death or myocardial infarction,1 the use of percutaneous coronary intervention (PCI) has grown exponentially. Some of this growth was driven by data from clinical trials suggesting that PCI was more effective in relieving angina than medical therapy alone.
[Correspondence] Concerns about cardiotoxicity in the HERA trial
In the HERceptin Adjuvant (HERA) trial (Feb 16, p 1195),1 the investigators reported that cardiac toxicity remained low in all groups and occurred mostly during the treatment phase. Cardiac assessments included repeated use of the New York Heart Association classification and left ventricular ejection fraction assessed by a cardiologist. However, the absence of information regarding radiation-related cardiac hazard might have caused misinterpretation of the data.
[Correspondence] Concerns about cardiotoxicity in the HERA trial – Authors’ reply
We would like to thank Antonin Levy and colleagues for their interest in our Article reporting the 11-year outcome data from the HERceptin Adjuvant (HERA) trial,1 and their expressed concern that we might not have recorded all long-term cardiac consequences of treatment for early breast cancer, specifically, some that could be secondary to the use of radiotherapy.
[Comment] Hypertension in China: the gap between policy and practice
The high prevalence of hypertension in China is well known, with stroke being the most common cause of death and disability.1 Two large nationwide studies reported in The Lancet2,3 highlight that although the prevalence of hypertension in China is similar to that suggested in previous studies, it is simple deficiencies in the country’s health system that make a large contribution to the disease burden. Both studies used data from the PEACE (Patient-Centred Evaluative Assessment of Cardiac Events) Million Persons Project (MPP), which enrolled 1·7 million adults aged 35–75 years from across China.
OPINION – Can safer surgery be legislated?
BY DR PETER SUBRAMANIAM
In June, a Royal Australasian College of Surgeons Queensland Audit of Surgical Mortality report sparked Queensland government action that may trigger new federal and state laws for public reporting of patient safety data across public and private hospitals. By August, Queensland had released a discussion paper and its push for such standards nationally was supported by federal and state health ministers at COAG Health Council. The Council tasked the Australian Commission on Safety and Quality in Health Care to work with ‘interested jurisdictions’ on such standards and to incorporate the work into national performance and reporting frameworks.
Compliance with audits of surgical mortality like the Queensland report is a mandated professional practice requirement for all surgeons while all public hospitals and almost all private hospitals already participate in the audits. So, the question doesn’t appear to be hospitals’ compliance with public reporting of performance data on patients admitted to hospital under a surgeon. The relevant questions seem to be what constitutes metrics of patient safety-oriented surgical performance and whether legislation can protect patients’ safety.
What are the metrics of patient safety-oriented surgical performance?
Patients admitted under a surgeon in a hospital are treated by a surgical team regulated by the hospital’s organisational framework that is part of a public or private hospital network. So, correctly, the metrics of patient safety-oriented surgical performance are metrics of the effectiveness of both surgical team performance and organisational performance of the hospital and its parent organisation. Only if both sets of metrics are reported will the public be fully informed about whether the hospital, public or private, is effective at protecting their safety.
This concept of patient safety-oriented surgical performance is backed by evidence. Patient safety depends on effective surgical team communication and adverse events by individual surgical team members are typically rooted in faulty systems and inadequate organisational structures. This evidence is reflected in local experience of more than 33,000 cases over eight years reported in the Australian and New Zealand Audit of Surgical Mortality National Report 2016. Its key points include that surgical team communication is a key element of good patient care and delayed inter-hospital transfers of patients with limited reserves can significantly affect surgical outcomes.
So, metrics of patient safety-oriented surgical performance must show effective surgical team communication as being timely decisions and actions to prevent, diagnose and treat surgical complications and deteriorating patients e.g. prompt resuscitation and surgery for postoperative bleeding. Likewise, such metrics must also show effective hospital and parent organisational systems enabling surgical teams’ decisions in a way that protects patient safety e.g. prompt inter-hospital transfers, timely ICU bed and OR access, safe working hours and staff levels.
Can legislation protect surgical patient safety?
The results of the Australian and New Zealand Audit of Surgical Mortality suggest surgical patient mortality represents a segment of Australia’s aging population who are at the extreme of life with co-morbidities that are a stronger predictor of death than the type of surgery. When an acute surgical condition supervenes, they have a rapidly shrinking window of opportunity with almost a quarter being irretrievable. They are prone to surgical complications which often leads to cardiac or respiratory failure with rapid deterioration and death. Nonetheless, surgical mortality in Queensland and nationally has been improving over the last eight years so it is difficult to envisage how new legislation will add much to improving surgical patient safety.
Is legislation necessary?
In 2016, a number of NSW private hospitals did not participate in the audit of surgical mortality despite compliance by all public and private hospitals in all other jurisdictions through the system funded by all State and Territory Governments. If legislation is to bring private hospitals in line with this public reporting system, it should be directed specifically for this reason. If it is to improve surgical patient safety or to inform patient choice, it is not clear how it will improve on the current public reporting system supported by governments. If a national performance and reporting framework is being developed, it should be directed at metrics of surgical team and organisational performance.
It remains to be seen if Government will be surgical in its approach to patient safety.
___________________________________________________________________________
Dr Peter Subramaniam MBBS MSurgEd FRACS is a cardiothoracic surgeon in Canberra who is currently pursuing a Juris Doctor law degree at the Australian National University. He established the Australian and New Zealand Cardiac and Thoracic Surgeons national cardiac surgery database in the ACT as well as the multidisciplinary ACT Cardiac Surgery Planning Group. He also has extensive experience in undergraduate and postgraduate surgical education.
Views expressed in the opinion article reflect those of the author and do not represent official policy of the AMA.
Going bald? Here’s some more bad news…
Male-pattern baldness and premature greying are associated with a greater risk of heart disease before the age of 40 than obesity, according to a new study from India. Does this mean that doctors should be screening our hairline alongside traditional risk factors such as our weight and blood pressure?
Over the years, scientists have developed many cardiovascular disease “risk tools”, with varying levels of usefulness. The tools normally involve measuring “classical” risk factors for cardiovascular disease, including high blood pressure, elevated blood cholesterol levels, obesity and diabetes. Included in most of these risk tools is age, because risk of cardiovascular disease in later life is higher if you have risk factors in your forties.
Beyond these classical risk factors, several slightly odd risk factors have been identified. These include weak grip strength, skipping breakfast and being divorced. Previous research has also suggested that premature hair greying is linked to vascular (blood vessel) disease. Male-pattern baldness may also be an early sign of cardiovascular risk.
Fivefold greater risk
The new study, presented at the 69th Annual Conference of the Cardiological Society of India, looked at coronary artery disease, a major form of cardiovascular disease. They specifically studied men under the age of 40. This is important as the classical risk factors are not as good at predicting cardiovascular disease in younger people. This study investigated the links between premature hair greying, hair loss and coronary artery disease in young Indian men.
The researchers, from the UN Mehta Institute of Cardiology and Research Centre in Ahmedabad, compared men under 40 with coronary artery disease with age-matched healthy men. All participants had their degree of coronary artery disease measured using a variety of clinical tests. Participants also had their baldness and hair whiteness rated.
When the researchers compared results between the two groups, they found that men with coronary artery disease had significantly higher rates of premature greying (50% versus 30%) and male-pattern baldness (49% versus 27%). After adjusting for other factors, they found that male-pattern baldness carried a 5.6 times greater risk of coronary artery disease. Premature greying was associated with a 5.3 times greater risk.
These hair-related factors were apparently better predictors of coronary artery disease risk than obesity, which was only associated with a 4.1 times greater risk. All of the classical risk factors were worse at predicting coronary artery disease than male-pattern baldness and premature greying.
Gabrielle Ray/Shutterstock
Focus on what you can change
While the study is very interesting, it must be noted that the numbers recruited were relatively small (780 men with coronary artery disease and 1,270 healthy males). Also, the study only recruited Indian men. Before we reconsider how we screen for cardiovascular disease in people under 40, this type of study needs to be repeated in a larger, more diverse group of people.
If these findings are true, the next step is to understand why it is so. Obesity is a modifiable risk factor, so weight loss can be an important tool in reducing the risk of future cardiovascular disease. As of yet there is little we can do to reverse or prevent male-pattern baldness or premature greying, beyond cosmetic changes.
It is possible that these factors may be markers of biological age, which may influence cardiovascular risk. This might mean that there is little we can currently do to reduce this risk. There may also be genetic factors that link premature baldness or greyness with cardiovascular disease risk, but these have yet to be discovered.
It remains to be seen if male-pattern baldness or premature greying really are risk factors for cardiovascular disease across the general population. Until there is more evidence, it is best to be reminded that eating a healthy diet rich in fibre and getting regular exercise are excellent ways to reduce the risk of having heart problems in the future.
James Brown, Senior Lecturer in Biology and Biomedical Science, Aston University
This article was originally published on The Conversation. Read the original article.