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 gluten-free is unhealthy if you don’t have coeliac disease

Coeliac disease, an allergy to gluten that causes damage to the intestine, affects 1% of Australians. But more than ten times this number, or around 11% of the population, follows a gluten-free diet by choice, and up to 30% of people in the United States try to reduce their gluten intake.

Gluten-free foods are frequently perceived as a healthier alternative, beca use of a alignment with a “wellness lifestyle”. But is there scientific evidence to support this?

Are gluten-free diets healthier?

Recent large studies have not found health benefits for a gluten-free diet, and in fact the opposite may be true.

Researchers followed a group of more than 100,000 people in the US for nearly 30 years and found a gluten-free diet was not associated with a healthier heart. It’s not clear whether this was due to something in the gluten-free foods, or the avoidance of wholegrains, which are considered protective against heart disease.

One study suggests gluten may be beneficial because it lowers levels of triglycerides in the blood. These are “bad” fats that increase the risk of heart disease.

Another large study has found an inverse association between gluten intake and type 2 diabetes. People with a lower gluten intake had higher rates of type 2 diabetes. The researchers found this group also had lower fibre intake, and wondered whether low fibre was the culprit. But even after accounting for the lower fibre intake, an association remained, suggesting avoiding gluten is not protective against developing type 2 diabetes.

Not eating enough gluten could increase the risk of diabetes.
from www.shutterstock.com

Gluten free and diabetes

Wholegrain products are made using the three parts of the grain – the bran (outside, which is rich in fibre), the germ (the seed) and the endosperm (the starchy, carbohydrate-rich centre). Together they form a bundle of fibre, carbohydrate, vitamins and minerals. Packaged gluten-free products such as bread frequently use only the carbohydrate component using refined flours from rice, corn or potato.

These high carbohydrate foods may cause a sharp rise in blood sugar levels and may predispose to diabetes in the long term. Packaged gluten-free products often have added sugars to enhance flavour, and add emulsifiers and thickeners to improve the texture and make it similar to bread.

Gluten-free markets have risen exponentially in the last decade due to consumer demand, even extending to the production of gluten-free food for dogs. Whether the market will expand or diminish with time is unknown, but food fashions are not new.

Consider the popularity of low-fat diets in the 1980s, when butter was a villain. Now butter is now back in vogue, with sales increasing. Similarly, red wine used to be considered protective for cardiac health, but guidelines for safe alcohol consumption now recommend reduced intake.

Of course, naturally gluten-free products such as plant-based foods, ancient grains and dairy are all part of a healthy and balanced diet, but there does not seem to be a health benefit for the processed and packaged gluten-free replacements over wheat-based versions.

Why are gluten-free diets so popular?

Non-coeliac gluten sensitivity is different from coeliac disease. In coeliac disease, gluten intake causes damage to the intestine’s lining, which reverses with a gluten-free diet. In non-coeliac gluten sensitivity (also called “gluten intolerance”), symptoms like bloating and wind are common, but no intestinal damage or long-term health effects occur.

To better understand this condition, researchers set out to determine whether it was gluten intake or the perception of gluten intake that may be contributing. They designed a study in which self-identified gluten-sensitive people were fed gluten-free, low gluten and high gluten foods, but didn’t know which they were eating.

All diets were also low in wind-causing sugars, called FODMAPs, which can cause similar symptoms. They found most of the group improved regardless of whether they were on a high gluten, low gluten or gluten-free diet. They concluded there was no evidence for gluten alone being responsible, but the reduction in FODMAPs could explain the symptom improvement.

Another reason people may report improvement when commencing a gluten-free diet is the exclusion of many other foods that are known not to be healthy, such as cakes, biscuits, crackers and beer. These dietary changes may also contribute to overall wellbeing.

So where to from here?

For people without coeliac disease, there’s no evidence to support claims a strict gluten-free diet is beneficial for health. It’s even possible the opposite is true, and the avoidance of dietary whole grains resulting in a low fibre intake may be detrimental.

Given gluten-free foods cost around 17% more, perhaps it’s time to reconsider a strict gluten-free diet chosen for health benefits alone, and instead include a diversity of gluten and gluten-free foods, with dietary variety as the key.

Suzanne Mahady, Gastroenterologist & Clinical Epidemiologist, Senior Lecturer, Monash University

This article was originally published on The Conversation. Read the original article.

This common gastric condition is often misdiagnosed

Functional dyspepsia often gets mistaken for gastro-oesophageal reflux disease (GORD), say the authors of a new paper published in Australian Prescriber.

The researchers, from the John Hunter Hospital and the University of Newcastle, say the defining symptoms of functional dyspepsia – early satiety and epigastric pain – are easily overlooked as they overlap with those of GORD and irritable bowel syndrome.

“Recent evidence suggests GORD is often the diagnostic label applied to patients even if they have typical symptoms of functional dyspepsia with little or no heartburn,” the researchers write.

“Correctly diagnosing functional dyspepsia is important to guide appropriate therapy and reduce unnecessary procedures or treatments,” they add.

The condition, which affects 10% of the population and is more prevalent among women, has two subtypes, the largest of which is characterised by early satiety, or postprandial fullness. Around 30% have the second subtype, and experience ulcer-like pain or burning, known as epigastric pain syndrome.

A history of early satiety or postprandial fullness is enough for a clinical diagnosis and to start treatment, although a range of red flag symptoms, including new onset in older age, weight loss, vomiting, bleeding, anaemia, family history of upper GI cancer or progressive dysphagia should prompt referral and an endoscopy.

The many treatment options available include:

Reassurance and explanation to relieve stress;
A change of diet, usually to smaller, regular low-fat meals;
Acid suppression with PPIs or an H2 receptor antagonist;
Prokinetics such as cisapride or ondansetron;
Fundic relaxors, if unresponsive to prokinetics;
Tricyclic antidepressants for epigastric pain;
Rifaximin;
Psyhcological therapy.

Functional dyspepsia has long been regarded as an idiopathic disorder, but recent research is changing this view. Cases in which the condition occurs after infectious gastroenteritis suggests that acute inflammation may play a role.

It has been proposed that either an infection, microbiome alteration or a food allergen induces increased duodenal permeability and eosinophilia, which activates a mucosal immune response. Local reflex responses to inflammation then alters gastroduodenal function.

“If correct, this model represents a paradigm shift with profound treatment implications,” the researchers write.

You can access the full paper here.

PPIs linked to gastric cancer

Long-term use of proton pump inhibitors (PPIs) more than doubles the risk of gastric cancers, according to research published this week in Gut.

The Hong Kong-based study included over 63,000 people who had undergone successful eradication of Helicobacter pylori infections. H. pylori infections are linked to stomach cancer and their eradication reduces risk. But a significant number of those who have had the infection eradicated will still go on to develop stomach cancer.

In this cohort, 153 study participants went on to develop gastric cancer, with a median follow-up of 7.5 years. Those who did develop cancer were 2.4 times more likely to have been long-term users of PPIs. The cancer risk rose with higher dosages and longer-term use of PPIs: those who used PPIs daily more than quadrupled their risk of gastric cancer, while more than a year of regular use resulted in a fivefold increase in risk.

However, users of histamine H2 receptor antagonists (H2RAs), another common acid reflux therapy, did not see their risk of gastric cancer rise.

The study authors say that the association is likely to be related to the profound acid suppression of PPIs that worsens atrophic gastritis, a known risk factor in gastric cancer. They say the lack of an association with H2RAs and gastric cancer further supports a specific role for PPIs in gastric cancer development.

“Physicians should therefore exercise caution when prescribing long-term PPIs to these patients even after successful eradication of H. pylori,” the authors conclude.

Commenting on the study, Associate Professor Richard Ferrero, who heads up a GI infection and inflammation research group at the Hudson Institute of Medical Research in Melbourne, said a study published in 1996 first raised alarm over possible deleterious effects of PPIs, showing that people with a H. pylori infection increased their risk of cancer if they were on PPI therapy. Since then, H. pylori eradication has been recommended before long-term PPI treatment.

“This new study now shows that even a prior H. pylori infection increases the risk of gastric cancer in subjects receiving long-term PPI therapy,” Dr Ferrero said. “The work has important implications as PPIs, which are among the top 10 selling generic drugs, are commonly prescribed to treat heartburn.”

He said the study’s design eliminated a number of important confounding factors, although the authors were unable to obtain detailed histological findings on gastric biopsies from participants.

“This may have helped explain why stomachs that have previously been infected with H. pylori are more likely to develop cancer in response to long-term PPI treatment,” Dr Ferrero commented.

Recent studies have linked PPIs to a string of unwanted effects, including pneumonia, dementia, cardiovascular problems and bone fracture.

You can access the study here.

[Correspondence] Hydration and contrast-induced kidney injury

Iodinated contrast is commonly used in gastroenterology practice and clinicians endeavour to avoid complications. The hypothesis tested by Estelle Nijssen and colleagues1 was whether hydration with saline might mitigate the complication of renal failure. However, the investigators did not measure or report the hydration status—as in preimaging urine osmolarity—of the patients before the intervention.

Why Australia is a world leader in hepatitis C treatment

The Australian government has listed yet another drug to cure hepatitis C on the Pharmaceutical Benefits Scheme (PBS). The drug Epclusa® – a combination of sofosbuvir 400mg and velpatasvir 100mg – is the first of the direct-acting antiviral treatments effective for all types of the disease. It will cost most patients A$38.80, and A$6.30 for concession card holders. Before the PBS listing, the cost exceeded A$20,000.
A number of hepatitis C treatments have been listed on the PBS since March 2016. The government has committed to investing A$1 billion over five years to treat the 230,000 Australians living with the disease.

Australia is a leading country in the global response to hep C. Since March 2016, around 40,000 people with hep C have had treatment. An estimated 95% of them have been cured.

The World Health Organisation recently set ambitious goals for the “elimination of hepatitis C as a major public health threat”. These included having 80% of people treated and an 80% reduction in the spread of the virus by 2030. Given there are around 70 million people infected with hep C worldwide, only 20% diagnosed, and no effective vaccine, the task ahead is enormous.

But Australia is impressively heading towards these targets and may present a model for other countries to adopt. A recent report by the Kirby Institute estimated Australia was on track to eliminate hepatitis C by 2026 – four years earlier than the WHO goal.

Why are we doing this?

The government has taken such a proactive approach to treating hepatitis C for several reasons.

The first is the large burden of serious liver disease, such as liver cancer and liver failure. A recent report from the Australian Institute for Health and Welfare showed rates of liver cancer increased five-fold from 1982 to 2013, with hep C the major cause. Nearly 1,500 Australians died from liver cancer in 2011-2012 and that number could more than double over the coming decade.

Secondly, most people affected with hepatitis C are injecting drug users. Although Australia has led harm-reduction strategies, such as needle syringe programs and access to methadone for people who inject drugs, several thousand new infections continue to occur each year.

A third reason is the appeal of the new direct-acting antiviral treatments themselves, which can cure 95% of people treated and have the capacity to prevent serious liver disease and spread of hep C. By contrast, treatments such as Harvoni (sofosbuvir plus ledipasvir) and Zepatier (grazoprevir plus elbasvir), which were added to the PBS in March 2016 and January 2017 respectively, are highly effective, but only active against one or two of the hep C strains.

The latest treatment, Epclusa, is one tablet, to be taken daily, which combines two existing drugs – sofosbuvir and velpatasvir. It is highly effective against all six hep C strains, has a treatment duration of around three months and minimal side effects.

Another treatment effective for all the strains – which combines glecaprevir and pibrentasvir – is expected to be available in Australia in 2018. Treatment duration will be only two months for patients without advanced liver disease.

What’s behind Australia’s success?

Australia has managed to develop a program of unrestricted access to treat people with hepatitis C – all adults with hep C are eligible. Most countries have restricted access to those with more advanced disease. Many have denied access to people with ongoing drug and alcohol use.

The key to this universal access was the Australian government’s capacity to negotiate much lower drug prices than in other high-income countries, following strong advocacy from the hepatitis C sector. For instance, Australia paid an estimated ten-fold lower price per patient treated in 2016 than did Germany.

Many countries restrict access to hep C treatment for injecting drug users.
from shutterstock.com

In December 2015, the government committed to providing sizeable funding for tackling hepatitis C for five years with a cap in expenditure and no cap in the treatment number. Australia also managed to involve non-specialists in hep C treatment, who from March 2016 were able to prescribe the new treatments.

General practitioners and other non-specialists now write at least half of prescriptions for the new antivirals, with around 80% of treatments dispensed in community pharmacies.

In almost all other countries, treatment of hep C is largely through specialist hospital-based clinics. In many countries only specialists can prescribe. Australia’s history of GP involvement in HIV antiviral treatment and drug dependency treatment was an important foundation to build a concerted hep C education and training program on.

Australia has also reached highly marginalised populations in large numbers. An estimated 20% of people who inject drugs have access to the new treatments, and numbers treated through the prison system are expanding rapidly. As mentioned, Australia has been a world leader in harm reduction for people who inject drugs (resulting in only 1% being HIV-infected), and has also led the world in evaluating the new treatments in this key population group.

Most Australian jurisdictions are developing programs for new treatment access in drug and alcohol services and prisons. All these measures have provided the optimal framework for taking advantage of the incredible curative potential of the hep C treatments and their capacity to improve quality of life, prevent advanced liver disease, and limit the spread of hep C.

How to sustain momentum

A key to ensuring momentum of the initial surge of hep C treatment will be ongoing screening of high-risk populations. These include people with current or past injecting drug use and immigrants from high-prevalence countries, such as Egypt and Pakistan, where unsafe medical procedures have been responsible for most infections. In Australia, around 20% of people with hepatitis C remain undiagnosed.

Finally, raising awareness through days like World Hepatitis Day and overcoming the stigma many people with hep C carry will be fundamental to success. The potential of revolutionary hep C treatments to empower the whole sector, together with continued advocacy and government support, should see Australia head towards elimination of the disease over the next decade.

Greg Dore, Professor of Medicine, Clinical Researcher and Epidemiologist, UNSW

This article was originally published on The Conversation. Read the original article.

How and why the brain and the gut talk to each other

It’s widely recognised that emotions can directly affect stomach function. As early as 1915, influential physiologist Walter Cannon noted that stomach functions are changed in animals when frightened. The same is true for humans. Those who stress a lot often report diarrhoea or stomach pain.
We now know this is because the brain communicates with the gastrointestinal system. A whole ecosystem comprising 100 trillion bacteria living in our bowels is an active participant in this brain-gut chat.

Recent discoveries around this relationship have made us consider using talk therapy and antidepressants as possible treatments for symptoms of chronic gut problems. The aim is to interfere with the conversation between the two organs by telling the brain to repair the faulty bowel.

Our research found talk therapy can improve depression and the quality of life of patients with gastrointestinal conditions. Antidepressants may also have a beneficial effect on both the course of a bowel disease and accompanying anxiety and depression.

What are gastrointestinal conditions?

Gastrointestinal conditions are incredibly common. About 20% of adults and adolescents suffer from irritable bowel syndrome (IBS), a disorder where abdominal discomfort or pain go hand-in-hand with changes in bowel habits. These could involve chronic diarrhoea and constipation, or a mixture of the two.

IBS is a so-called functional disorder, because while its symptoms are debilitating, there are no visible pathological changes in the bowel. So it is diagnosed based on symptoms rather than specific diagnostic tests or procedures.

People with chronic gut conditions can experience severe pain that affects their quality of life.
from shutterstock.com

This is contrary to inflammatory bowel disease (IBD), a condition where the immune system reacts in an exaggerated manner to normal gut bacteria. Inflammatory bowel disease is associated with bleeding, diarrhoea, weight loss and anaemia (iron deficiency) and can be a cause of death. It’s called an organic bowel disease because we can see clear pathological changes caused by inflammation to the bowel lining.

Subtypes of inflammatory bowel disease are Crohn’s disease and ulcerative colitis. Around five million people worldwide, and more than 75,000 in Australia, live with the condition.

People with bowel conditions may need to use the toilet 20 to 30 times a day. They also suffer pain that can affect their family and social lives, education, careers and ability to travel. Many experience anxiety and depression in response to the way the illness changes their life. But studies also suggest those with anxiety and depression are more likely to develop bowel disorders. This is important evidence of brain-gut interactions.

How the brain speaks with the gut

The brain and gut speak to each other constantly through a network of neural, hormonal and immunological messages. But this healthy communication can be disturbed when we stress or develop chronic inflammation in our guts.

Stress can influence the type of bacteria inhabiting the gut, making our bowel flora less diverse and possibly more attractive to harmful bacteria. It can also increase inflammation in the bowel, and vulnerability to infection.

Chronic intestinal inflammation may lower our sensitivity to positive emotions. When we become sick with conditions like inflammatory bowel disease, our brains become rewired through a process called neuroplasticity, which changes the connections between the nerve signals.

Anxiety and depression are common in people suffering chronic bowel problems. Approximately 20% of those living with inflammatory bowel disease report feeling anxious or blue for extended periods of time. When their disease flares, this rate may exceed 60%.

Interestingly, in a recent large study where we observed 2,007 people living with inflammatory bowel disease over nine years, we found a strong association between symptoms of depression or anxiety and disease activity over time. So, anxiety and depression are likely to make the symptoms of inflammatory bowel disease worse long-term.

It makes sense then to offer psychological treatment to those with chronic gut problems. But would such a treatment also benefit their gut health?

Gut feeling: how your microbiota affects your mood, sleep and stress levels

Inflammatory bowel disease

Our recent study combined data from 14 trials and 1,196 participants to examine the effects of talk therapy for inflammatory bowel disease. We showed that talk therapy – particularly cognitive behavioural therapy (CBT), which is focused on teaching people to identify and modify unhelpful thinking styles and problematic behaviours – might have short-term beneficial effects on depression and quality of life in people with inflammatory bowel disease.

But we did not observe any improvements in the bowel disease activity. This could be for several reasons. Inflammatory bowel disease is hard to treat even with strong anti-inflammatory drugs such as steroids, so talk therapy may not be strong enough.

Talk therapy may only help when it’s offered to people experiencing a flare up in their disease. The majority of the included studies in our review were of people in remission, so we don’t know if talk therapy could help those who flare.

On the other hand, in our latest review of 15 studies, we showed antidepressants had a positive impact on inflammatory bowel disease as well as anxiety and depression. It’s important to note the studies in this review were few and largely observational, which means they showed associations between symptoms and antidepressant use rather than proving antidepressants caused a decrease in symptoms.

Irritable bowel syndrome

When it comes to irritable bowel syndrome, the studies are more conclusive. According to a meta-analysis combining 32 trials,
both talk therapy and antidepressants improve bowel symptoms in the disorder. A recent update to this meta-analysis, including 48 trials, further confirmed this result.

The studies showed symptoms such as diarrhoea and constipation improved in 56% of those who took antidepressants, compared to 35% in the group who received a placebo. Abdominal pain significantly improved in around 52% of those who took antidepressants, compared to 27% of those in the placebo group.

Symptoms also improved in around 48% of patients receiving psychological therapies, compared with nearly 24% in the control group, who received another intervention such as usual management. IBS symptoms improved in 59% of people who had cognitive behavioural therapy, compared to 36% in the control group.

Stress management and relaxation were found to be ineffective. Interestingly, hypnotherapy was also found effective for bowel symptoms in 45%, compared to 23% of control therapy participants.

What now?

Better studies exploring the role of talk therapy and antidepressants for symptoms of inflammatory bowel disease need to be conducted. We should know in a few years which patients are likely to benefit.

In the meantime, there is enough evidence for doctors to consider referring patients with irritable bowel syndrome for talk therapy and antidepressants.

Antonina Mikocka-Walus, Senior Lecturer in Health Psychology, Deakin University

This article was originally published on The Conversation. Read the original article.

The scratch test for determining the inferior hepatic margin

Still a valuable component of the physical exam

Evaluation of liver size by palpation is a basic component of the physical examination. Suspicion of an enlarged liver should prompt the clinician to examine for possible causes (Box 1) and investigate further with appropriate imaging such as ultrasonography. Palpation to detect the inferior liver margin may not be accurate or possible in certain clinical conditions (eg, obesity, abdominal distension, tenderness, or guarding). In such cases the scratch test may be useful. We describe the technique of the test and review the evidence base for its use.

The scratch test is a type of auscultatory percussion which was described as far back as 1840, and used to ascertain the size and form of various organs, including the heart and liver.2 The principle behind the scratch test is that the sound from a scratch on the skin overlying the relatively solid liver will be transmitted to a stethoscope located at another point over the liver better than a scratch not over the liver (ie, separated from the stethoscope by bowel or air).

Method for performing the scratch test3

The diaphragm of the stethoscope is placed on the xiphisternum (point C in Box 2).
The examiner repeatedly and lightly strokes the skin with a single finger, parallel to the suspected liver edge, starting from the right lower quadrant and moving towards the costal margin along the midclavicular line (point A in Box 2).
The examiner will hear very little transmission of sound to the stethoscope until the scratches reach the liver edge (point B in Box 2), at which point there will be a sudden increase in volume and quality of the sound transmission.
A control manoeuvre is recommended to exclude a false positive finding, which can occur in up to 10% of cases.3
To ensure that the sound transmission is not purely through the skin, we suggest using the same stroking technique to scratch up the midline to the xiphisternum until the point of sound transmission is reached (point D in Box 2).
If the distance from the detected liver edge to the xiphisternum (BC) is more than the control distance (CD), then it can be assumed that the transmission of sound heard at point B was through liver.
If the distance from the detected liver edge to the xiphisternum (BC) is less than or equal to CD, then it can be assumed that the sound conduction was likely due to skin conduction and that the liver edge did not extend beyond the right costal margin.

A video demonstrating the use of the scratch test is available online at mja.com.au.

Is the scratch test still useful in practice?

Very few studies have formally evaluated the scratch test and yet, based on limited evidence, calls have been made to abandon this test.4,5 We believe this call is premature for a number of reasons, as follows.

Small numbers of participants in previous studies, leading to low precision.
Conflating the reference standard of the inferior hepatic margin with the overall hepatic span — the lower hepatic margin does not correlate with the overall liver span given the variation in the superior border of the liver.
Interobserver variation in choosing landmarks (eg, midclavicular line).4
Elementary statistical analyses restricted to correlation coefficients — the question with a physical examination manoeuvre is not absolute accuracy, but whether it is useful enough to yield some information. In our evaluation of the scratch test,3 we noted only a moderate correlation (Spearman correlation coefficient, 0.37) but that 37% of ratings fell within 2 cm and 53% within 3 cm of the ultrasound-located edge. This level of accuracy is still potentially clinically useful.
Lack of definition as to whether the start of the sound transmission was taken as the liver edge or the point of maximal sound transmission. In our study,3 we noted, anecdotally, a difference of about 2.5 cm between these two points, which could be an added source of error. We also noted that by using the point of initial sound transmission, the accuracy rate could increase to 43% of ratings falling within 2 cm and 76% falling within 3 cm of the ultrasound-located value.
Lack of any control site for auscultation to guard against skin transmission of sound.
The scratch test was sometimes performed by the same examiner who performed other manoeuvres, such as palpation, and so was not interpreted independently.
Lack of any training or standardisation of examiners.

Further, a Bland–Altman plot indicates that raters tend to overestimate small spans and underestimate large spans,3 so physicians should be aware of this bias. With some practice and an awareness of this bias, we believe the scratch test can still be a valuable part of the physical exam.

Box 1 –
Causes of an enlarged liver1

Hepatocellular carcinoma
Liver metastases
Fatty infiltration (alcoholic and non-alcoholic)
Haematological disease
- Myeloproliferative neoplasms
- Lymphoma
- Leukaemia
Infiltration
- Amyloidosis
- Haemochromatosis
Acute hepatitis
Biliary obstruction
Right heart failure or pulmonary hypertension (usually pulsatile)

Box 2 –
Landmarks on the abdomen in relation to the measurements used for the scratch test*

* The costal margin is marked with a solid line.

Is it time to stop prescribing PPIs?

Proton pump inhibitors remain a standard treatment for acid-related gastrointestinal problems, but a slew of recent studies have linked the drugs to a worrying range of potential problems.

The latest of these, published this month in the American Journal of Gastroenterology, links PPIs to an increased risk of ischaemic stroke.

The Taiwanese study looked at the stroke risks of 200,000 people on a PPI treatment course compared with a similar number of matched controls. There was a 36% higher risk of stroke during a 120 day follow-up after PPI medication.

Gender, history of myocardial infarction, diabetes, hypertension, NSAID use or type of PPI taken had no effect on the risk.

The researchers cautioned that their study was retrospective and therefore couldn’t prove cause and effect. But they speculated PPIs could increase plasma levels of asymmetric dimethylarginine, which is a risk factor for cardiovascular events.

Here are some other recent studies which have placed a serious question mark over the prescribing of PPIs:

A meta-analysis published in JAMA earlier this year found that PPI use increased the risk of recurrent Clostridium difficile infection by more than half.
Regular users of PPIs have a 44% greater risk of dementia, according to a German study of 74,000 people aged 75 or older.
The Sax Institute’s 45 and Up study showed a 70% increased risk of hospitalisation for infectious gastroenteritis in people using PPIs.
PPI use has been linked to chronic kidney damage even in the absence of acute disease. A study compared 125,000 people on PPIs with 18,000 users of H2 blockers, which are generally prescribed for the same conditions. Those on PPIs were much more likely to develop kidney disease.
A large Australian study confirmed a link between PPIs and fracture risk. It found 35% of elderly women on PPIs were subsequently diagnosed with osteoporosis, compared with 24% not on PPI therapy.
And finally, an Italian study found that people discharged from hospital with a PPI prescription had a 50% higher risk of dying within the year compared with those discharged without PPIs.

PPIs are one of the most commonly prescribed gastric acid suppressants, with over 19 million scripts written annually in Australia.

But the dangers of long-term PPI use is becoming increasingly recognised, with some Australian hospitals insisting on a deprescribing plan for all patients discharged with a PPI script.

Last year, the Gastroenterological Society of Australia published its top five low-value practices and interventions as part of the EVOLVE initiative.

One of these recommendations was to stop prescribing long-term PPIs “without attempting to reduce the medication down to the lowest effective dose or cease the therapy altogether”.

Clinical experience of patients with hepatitis C virus infection among Australian GP trainees

Since March 2016, new direct-acting antiviral agents (DAAs) for treating infection with hepatitis C virus (HCV) have been available in Australia under the Pharmaceutical Benefits Scheme (PBS). This represents a revolution in the treatment of hepatitis C, as DAA regimens have cure rates of more than 90%, minimal adverse effects, and low treatment complexity. In contrast to previous HCV treatments, general practitioners are authorised to prescribe HCV DAAs. The Fourth National HCV Strategy emphasises that, to maximise the impact of HCV DAAs, most HCV treatment will need to move from hospital-based clinics to the primary care setting.1

An estimated 230 000 Australians live with chronic HCV infection,2 with annual notification rates about twice as high among males as among females, and highest for people aged 30–50 years.3 Eliminating hepatitis C as a public health problem by using highly efficacious, well tolerated DAAs is possible, but would require a major increase in the number of people treated.4

Registrar Clinical Encounters in Training (ReCEnT) is a prospective cohort study that collected detailed data on more than 150 000 consultations by GP trainees in five Australian GP training programs during 2010–2015. ReCEnT documents the content of trainees’ consultations, and both informs and evaluates training program changes. Our methodology, described in detail elsewhere,5 and statistical analysis are summarised in the online Appendix. As most learning by GP trainees is acquired in an apprenticeship model in the workplace (supplemented by away-from-practice educational sessions),6 we aimed to determine prevalence of management of and testing for HCV in the consultations of trainee GPs.

Although at least 1.2% of the Australian population are infected with HCV,7 hepatitis C was managed as a problem (eg, discussed, investigated, referral of the patient) in only 0.08% of consultations (online Appendix, Table). This indicates that the current exposure of registrars to the diagnosis and management of HCV infections during training is very limited. Patients for whom HCV was managed were older than other patients, and more likely to be male or Indigenous Australian. HCV testing was performed in 0.7% of consultations, and the patients tested were significantly younger (mean age, 32 v 40 years; P < 0.001), and more likely to be female, Indigenous Australian, or from a non-English speaking background than those who were not (online Appendix, Table). Doctors who tested for HCV were younger, and were more likely to be female, graduates of Australian universities, and practising in a city (online Appendix, Table).

Our data indicate that the clinical exposure of GP trainees to patients infected with HCV is limited, and that their experiential training in this condition may be inadequate. Further, HCV testing was only infrequently ordered, and the wrong groups were targeted; we found that males and older patients were less likely to be tested, despite higher HCV seroprevalence in these groups. If hepatitis C is to be eradicated as a public health problem in Australia, it is important that diagnosing and treating HCV infections are prominent in the GP training curriculum.