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[Correspondence] Mobilising experience from Ebola to address plague in Madagascar and future epidemics

As of Nov 10, 2017, there were a total of 2119 confirmed, probable, and suspected cases of plague, and 171 deaths from plague in Madgascar. This outbreak is spreading throughout the country, affecting both rural and urban areas, and anthropologists have been mobilised by global health agencies to contribute to the emergency global health response. Many of these specialists previously worked on the 2014–16 Ebola virus disease epidemic in west Africa and possess experience and expertise gained from this context.

[Perspectives] The disaster artists

In Case of Emergency is a timely exhibition on natural disasters and their human antecedents and consequences. Antibiotic resistance, global warming, and post-extinction revival are all covered in this exhibition at the Science Gallery, Trinity College Dublin, Ireland. The gallery is a bright and dynamic space now firmly established as a leading element in the cultural and intellectual life of the city. Compact in size and smart in design, the gallery has woven a unique and original spell with the Irish public and international visitors since opening in 2008.

[Clinical Picture] Vanishing lung syndrome: giant bullous emphysema

A 44-year-old man with a 17-year history of tobacco and cannabis use presented to the emergency department with acute dyspnoea and left-sided pleuritic chest pain. He had no other medical conditions and took no regular medications. On examination he was thin and hypoxic, with a silent, hyper-resonant left hemithorax. Chest radiograph showed a large left upper lobe bulla (figure), and an incidental air rifle pellet. He was given pulmonary rehabilitation, started on regular inhaled therapy with regular tiotropium and budesonide-formoterol and salbutamol as required, and given smoking cessation support.

Helsinki for holidays if you are safety conscious

The newly released 2018 Travel Risk Map reveals threat levels across the globe in three categories – medical, security and road safety.

Produced by security specialists International SOS, the charted risks across the three categories shows that Finland is the safest place on the planet.

Also listed as ‘low’ threats for medical concern are Norway, Sweden as well as much of western Europe, the US, Canada and Australia.

International SOS say that their Medical Risk Ratings are determined by their assessment of a range of health risks and mitigating factors including: infectious diseases, environmental factors, medical evacuation data, the standard of available local emergency medical and dental care, access to quality pharmaceutical supplies, and cultural, language or administrative barriers.

Group Medical Director of Health Intelligence for International SOS Dr Doug Quarry said that there is an increased understanding of preventative agendas in medical and travel risk mitigation, however organisations need to do more to strategically support their travelling staff.

“A staggering 91 per cent of organisations have potentially not included their travel risk program in their overall business sustainability program and 90 per cent are seemingly ignoring the impact a wellbeing policy could have on their travelling workforce,” Dr Quarry said.

The Scandinavian countries also perform well for road safety, possessing a ‘very low’ risk of a road traffic accident. Countries that Australians visit in significant numbers that have a ‘high’ road risk include Thailand and South Africa.

Unfortunately the number of Australians who died while travelling overseas rose past 1600 last financial year according to the Australian Government’s Department of Foreign Affairs and Trade (DFAT).

DFAT updates their travel advice to countries continuously and urges any Australian travelling overseas to register on the DFAT’s Smart Traveller website. This will allow the government to immediately alert Australians of any changes to the situation and know where Australians were if an evacuation was necessary.

Travel insurance remains an area of concern for Australian consular officials. Travellers without travel insurance are personally liable for covering any medical and associated costs they incur. The Australian Government won’t pay for your medical treatment overseas or medical evacuation to Australia or a third country.

The latest survey results undertaken by DFAT that looks at how Australians use travel insurance reveals Australians are not adequately using travel insurance, especially when it came to cruises. Half (48 per cent) of recent cruise goers who took out insurance were exposed to the risk of being unknowingly uninsured. This was a combination of those (38 per cent) who took out a general travel insurance policy that may not have adequately covered them for a cruise, and / or those (30 per cent) who were not certain that their travel insurance covered them for all countries their cruise liner visited.

The Australian Government provides regularly updated travel advice to all Australians at http://smartraveller.gov.au/Pages/default.aspx.

MEREDITH HORNE

Thunderstorm asthma

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

With then end of the year fast approaching, there are many joys that this time of year brings, but also many hazards. One such hazard is increased risk of thunderstorm asthma. It is now just over a year since the disastrous thunderstorm in Victoria that triggered a mass asthma emergency, with 8,500 people requiring hospital care and ten sadly losing their lives.

While Victorian hospitals featured prominently in the Victorian response, we also know that many patients accessed GP care and advice, including through after hours GP services.

Research is being conducted to better understand why epidemic thunderstorm asthma events occur. It is believed that grass pollens swept up into the clouds as a storm forms, absorb moisture and then burst open filling the air with small allergen particles. Unlike the larger grass pollen grains that cause hay fever, these particles are small enough to be drawn deep into the lungs. The irritation caused resulting in swelling, narrowing and additional production of mucus in the small airways of the lung, making it very difficult to breath.

Symptoms are quick to come on and typically involve wheezing, chest tightness and coughing, much like asthma.

As GPs, it important to be aware that it is not just people with asthma or a history of asthma that are susceptible to a thunderstorm asthma event. Anyone who suffers seasonal hay fever is also at risk. It is important that our at-risk patients understand this and know how to minimise their risks and manage any symptoms if they experience epidemic thunderstorm asthma.

Thunderstorm asthma is now recognised as a serious health threat and over the last year a range of resources have been made available to GPs to assist them in preparing their patients for the grass pollen season and any epidemic thunderstorm asthma event.

 GPs should make sure they are up to date with the recommendations in the Australian Asthma Handbook and can undertake the free NPS Medicinewise Clinical E-Audit Asthma Management – supporting patients to achieve good control.This tool will help you improve the individual management of your patients by identifying risk factors, reviewing asthma control, adjusting management and reinforcing the benefits of maintaining an up-to-date written asthma action plan.

The National Asthma Council Australia has also made available a range of resources for GPs and other healthcare professionals in the event of another thunderstorm asthma event, which can be accessed here. These include information papers on epidemic thunderstorm asthma and managing allergic rhinitis in people with asthma and advice on preventative treatment.

In addition, the Asthma Australia website also contains general information about asthma which may be of use to GPs, including how to prepare for and respond to an asthma emergency. They also have specific resources for health professionals.

The key is ensuring at-risk patients understand the risks, know how to reduce them, and have an action plan for responding to symptoms. 

This will be my last column for 2017, with the year seeming to go very quickly due to the never-ending advocacy of the AMA on GP issues. On behalf of the Council of General Practice I will take this opportunity to wish you all a safe and happy time with family and friends over the holidays. 

The road ahead for 2018

BY DR ROD McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

Another calendar year has flown.  CPHD meets regularly to make sure AMA’s positions are informed by those with a Specialist qualification and choosing to self-identify as public hospital doctors.  This embraces the Specialist employed experience and the continuing quest for continuous public hospital medical quality and general systems improvement.  We have an influencing position that is enhanced by more members taking opportunity to solidify CPHD’s base and keep us rich with progressive ideas.  Industrial negotiations for employed medical practitioners are currently underway in several jurisdictions, many of which have been impacted by the federal government’s alteration of previously understood arrangements related to salary packaging.  It will be of acute interest to observe how these negotiations are managed, as most have mandated elections from the time of my writing to October 2018.

COAG – Public Hospital funding Agreement

In July 2017, the States and Commonwealth executed a health care funding Agreement out to 2020.  It laudably touts incentives aimed to reduce avoidable sentinel events, hospital acquired complications and avoidable readmissions.  However, if a State does not achieve an arbitrary benchmark, the otherwise locked in 45 per cent of their public hospital funding could be at risk (including a slice of an additional $2.9 billion of capped services growth funding). 

There becomes a risk that any public hospital not adequately meeting its risk improvement targets, irrespective of cause, will then bear funding cuts, yet still be required to meet the defined Agreement imperatives (thus a potentially downward spiral of ‘doing more with less’).  Such a hospital would be incentivised to rapidly make change in the hope of reducing its funding loss.  Public hospitals may insist members work unsociable hours (for alleged quality & efficiency reasons), roll-out an unmanaged expansion of private practice arrangements (to cover funding shortfalls) and redirect Doctor’s clinical support time to the design of new systems (all to avoid the penalties).  CPHD will work on these and a host other concerns that require our reasoned and measured response.  In 2018, CPHD will monitor against such potentially perverse outcomes that may arise from the underpinning by an ultimately penalty-based regime, let alone the potential for cherry-picking. 

Private Practice

For this health care funding agreement round, the Commonwealth seems to have flagged its willingness to consider change to the arrangements applying to private patients admitted to public hospitals.  As discussed in October, there are good reasons why CPHD is concerned about any attempt to substantially reform existing arrangements, including availability of specialist clinical skills & equipment, supplementation of public hospital income and breadth of case mix available for optimum teaching, training and research.

CPHD recognises and supports the long-standing rights of public hospital patients who elect to receive services as a private patient, but appreciates there does need to be balance.  It is a no-brainer that clinical need, not private/public status, must be the determinant for patient prioritisation and that the patient must be free to make informed choice without unfair inducements or undue pressure to convert to private insurance.  Equally, Doctors must be assured of their right to provide care without undue pressure to encourage conversion from public status.  CPHD will be at the vanguard of any mooted change agenda. 

Personal Safety

In my August Australian Medicine piece I expressed how I am regularly horrified at the experiences of violence in our community and our workplaces.  Therefore, CPHD motives are obvious in its lead advocacy for better investment in security, awareness, technology and facilities to make all employees safe when at work.  It seems to me our response should be health professional holistic rather than just doctor specific (i.e. protecting the team).  We still want accessible and personable care for the public so excessive responses are to be avoided (think armed security in Victorian emergency departments previously batted off by AMA because the idea presented more dangers than it solved).  CPHD will produce an AMA position to reduce workplace dangers in light of escalating population growth, mental health / substance abuse presentations and the anger born amongst some from frustrations at the lack of public hospital responsiveness and capacity. 

Overall, your Council of Public Hospital Doctors is in the business of emerging trend identification and response.  No doubt in 2018 some ‘curly’ policy pronouncement will emerge from government ranks but we are consultative, responsive and equipped to ensure our public patients and our public employed clinical ranks are protected from the excess of public service thought bubbles or political ideology.

I offer season’s greetings to all of our AMA membership family.  It is important for all to ensure they have a sensible break and attend to personal well-being, family and friends, and to start 2018 refreshed and invigorated.  See you in the New Year! 

 

GPs are tops – ABS latest stats

Australians still love their local doctors.

At least that is the finding of the latest Australian Bureau of Statistics (ABS) data, which shows that patients around the nation are satisfied with their GPs.

The ABS’s latest Patient Experiences in Australia Survey reinforces previous findings that Australia’s dedicated GPs are meeting increasing demand and providing quality services.

GPs attracted a very high satisfaction rating from patients in the survey.

The survey produced positive results for medical specialists and emergency department doctors as well, but GPs are the doctors who have the most frequent contact with patients.

According to the survey, 83 per cent of Australians saw a GP in the last 12 months and around 78 per cent of patients have a preferred usual GP.

AMA President Dr Michael Gannon described the results of the survey as outstanding.

“Importantly, the proportion of people waiting longer than they felt acceptable for a GP appointment decreased from 23 per cent in 2013-14 to 18 per cent in 2016-17,” Dr Gannon said.

“Of those who patients who saw a GP for urgent medical care, 75 per cent were seen within 24 hours of making an appointment.

“The survey shows that cost is not a barrier to accessing GP care, with only 4 per cent of respondents saying that they at least once delayed seeing a GP or did not see a GP when needed due to cost.

“Of those patients who saw a GP in the last 12 months, 92 per cent reported that the GP always or often listened carefully to them, 94 per cent reported that their GP always or often showed them respect, and 90.6 per cent reported that their GP always or often spent enough time with them.

“These results are outstanding when you consider the pressure under which our GPs are working today.”

Dr Gannon said GPs are a critical part of the health system, and they must be valued and supported.

General practice remains under significant funding pressure due to cuts by successive governments, he said, but GPs continue to provide high quality and accessible primary care services across the country.

“When people are sick, they want to see a GP,” Dr Gannon said.

“As the Government looks to shape the future of our health system, it needs to build its investment in general practice, which remains the most cost effective part of the system.”

CHRIS JOHNSON

 

[Comment] Where is the science in humanitarian health?

In 1948, in the aftermath of the partition of India and Pakistan, a journal article on the health situation of refugees and internally displaced persons stated that “this report is based entirely on impressions”.1 Another of the earliest articles about a humanitarian emergency, the East Bengal cyclone in 1970, stated that “relief supplies and volunteers poured in, but no one knew the magnitude or geographic distribution of losses and needs.”2 How did these volunteers know what skills were needed? What supplies and commodities to distribute? How did they know where to go or who to help? Impressions, best intentions, and customary practices were the rule at the time, and health interventions were rarely supported by epidemiological or clinical studies that provided evidence of effectiveness.

Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache [Research]

BACKGROUND:

We previously derived the Ottawa Subarachnoid Hemorrhage Rule to identify subarachnoid hemorrhage (SAH) in patients with acute headache. Our objective was to validate the rule in a new cohort of consecutive patients who visited an emergency department.

METHODS:

We conducted a multicentre prospective cohort study at 6 university-affiliated tertiary-care hospital emergency departments in Canada from January 2010 to January 2014. We included alert, neurologically intact adult patients with a headache peaking within 1 hour of onset. Treating physicians in the emergency department explicitly scored the rule before investigations were started. We defined subarachnoid hemorrhage as detection of any of the following: subarachnoid blood visible upon computed tomography of the head (from the final report by the local radiologist); xanthochromia in the cerebrospinal fluid (by visual inspection); or the presence of erythrocytes (> 1 x 106/L) in the final tube of cerebrospinal fluid, with an aneurysm or arteriovenous malformation visible upon cerebral angiography. We calculated sensitivity and specificity of the Ottawa SAH Rule for detecting or ruling out subarachnoid hemorrhage.

RESULTS:

Treating physicians enrolled 1153 of 1743 (66.2%) potentially eligible patients, including 67 with subarachnoid hemorrhage. The Ottawa SAH Rule had 100% sensitivity (95% confidence interval [CI] 94.6%–100%) with a specificity of 13.6% (95% CI 13.1%–15.8%), whereas neuroimaging rates remained similar (about 87%).

INTERPRETATION:

We found that the Ottawa SAH Rule was sensitive for identifying subarachnoid hemorrhage in otherwise alert and neurologically intact patients. We believe that the Ottawa SAH Rule can be used to rule out this serious diagnosis, thereby decreasing the number of cases missed while constraining rates of neuroimaging.

[Review] An update on Zika virus infection

The epidemic history of Zika virus began in 2007, with its emergence in Yap Island in the western Pacific, followed in 2013–14 by a larger epidemic in French Polynesia, south Pacific, where the first severe complications and non-vector-borne transmission of the virus were reported. Zika virus emerged in Brazil in 2015 and was declared a national public health emergency after local researchers and physicians reported an increase in microcephaly cases. In 2016, WHO declared the recent cluster of microcephaly cases and other neurological disorders reported in Brazil a global public health emergency.