[Seminar] Glaucoma

Glaucoma is a heterogeneous group of diseases characterised by cupping of the optic nerve head and visual-field damage. It is the most frequent cause of irreversible blindness worldwide. Progression usually stops if the intraocular pressure is lowered by 30–50% from baseline. Its worldwide age-standardised prevalence in the population aged 40 years or older is about 3·5%. Chronic forms of glaucoma are painless and symptomatic visual-field defects occur late. Early detection by ophthalmological examination is mandatory.

[Editorial] Food industry must act to safeguard the future of antibiotics

WHO has urged farmers and the food industry to stop routine use of antibiotics in healthy animals to promote growth and prevent infectious diseases. WHO guidelines, which were released ahead of World Antibiotic Awareness Week (Nov 13–19), aim to tackle the growing threat of antimicrobial resistance to human health. Use of antibiotics promotes development of drug-resistant bacteria in food-producing animals, which can subsequently be transmitted to humans, and curbing use of antibiotics in animals can reduce the prevalence of resistant bacteria in animals and humans.

[Comment] Effectiveness trials in asthma: time to SaLSA?

In your next clinical consultation, you may well find yourself asking the question “What is the likelihood that this treatment will benefit this patient at this time?” Evidence-based practice answers this question with data collected under ideal conditions from a double-blind, randomised, placebo-controlled trial (RCT). However, what evidence-based practice doesn’t tell us is that, when it comes to asthma and many other chronic diseases, only a minority of patients in your clinic would ever meet the eligibility criteria for these RCTs.

[Comment] A global coalition for the fight against heart disease and stroke

As political leaders prepare for the third UN High-level Meeting on Non-communicable Diseases (NCDs) in 2018, the World Heart Federation (WHF) is bringing together a global coalition of international, regional, and national stakeholders in cardiovascular diseases (CVDs) to drive the urgent action needed to combat heart disease and stroke.

The wind against, Out Back

BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

Professor Paul Worley, as you all are now aware, is our inaugural Rural Health Commissioner.

Just pick up any medical newsletter and you will get his background, credentials, experience and why he was appropriately chosen for this difficult role.

So rather than attempt another biography, I’d like to share a story he shared with some of us in a workshop we attended at the Rural Medicine Australia Conference in Melbourne. The subject was “When paying your bills is not enough” and was addressed to the RDAA Female Doctors group, mainly to an all-woman audience.

This story allows you to get to know a bit of his personal perspective*, and it may give you a glimpse of the man.

Paul rides his bike with his two sons in the countryside around Adelaide. You know, where the Tour Down Under is held. Gorgeous countryside, the rolling hills were for them to attack and conquer. And one morning they did. The three of them were in their glory, on top of the world, three athletic cyclists. This was so easy! What a super sport, didn’t they have such great stamina, quadriceps, speed?

Time to go home, they turned around and quickly realised they had been cycling with the wind on their backs. The road back home was another journey altogether, against the wind. Their lungs burned, lactic acid in those super quadriceps, stamina waning. This was really tough! They required frequent rest breaks, more hydration, and some internal resilience to get the job done. Same road, same equipment, they now had a new force to deal with, fighting this hidden powerful adversary. The way home was humbling.

Paul then summarised: pedalling with the wind on your back is like being a man in this medical workforce.

The journey, the achievement necessary to succeed appears to be the same for both men, women, IMGs, visible minorities, those with English as a second language.

But there are those of us who are pedalling against the wind. My extrapolation, I think those of us in Rural Australia are also pedalling against the wind.

Our “winds” are:

The Tyranny of distance;
Lack of both medical and personal resources;
Insufficiency in the workforce;
Impossible rosters;
The need to be a GP and a specialist at the same time;
Third World chronic diseases;
Decrementing infrastructure with hospital closures;
Environmental hardships such as 50 degrees and dogs;
Lack of broadband internet;
Disrespect from our Urban critical colleagues;
Loneliness, depression, distance from family; and
Lateral violence.

If you haven’t thought of your journey from this light, just take a look from Paul’s perspective.

Dr Worley will affect you profoundly as the orchestrator of new Rural Pathways. I want you to know, I think he gets it, this new Rural Health Commissioner. I hope you meet him soon, he is familiar with Rural Medicine. But you will also find he knows humility, fighting against the wind. He knows us.

* With acknowledgement to his wife Liz for the idea.

Diabetes data linked to double death rates

The Australian Institute of Health and Welfare (AIHW) has examined data from National Diabetes Services Scheme and the National Death Index to provide a more complete understanding of deaths among people with diagnosed diabetes.

With 280 Australians developing diabetes every day, the bearing of the disease and its complications have a major personal cost to the individual and their family as well the health system.

The AIHW believes their comprehensive picture of diabetes-related deaths is important for population-based prevention strategies and could help to improve care for all people with diabetes.

The report found that overall death rates among people with diabetes were almost twice as high as the general population. And, with around 1.7 million Australians having diabetes, the numbers are significant.

“Overall in Australia, there is a trend toward lower death rates, but for people with type 2 diabetes, these improvements have not been seen,” AIHW spokeswoman Dr Lynelle Moon said.

“In fact, death rates among people with type 2 diabetes increased by 10 per cent between 2009 and 2014, mainly driven by the increase among the very old (85 and over).”

The disparity in death rates between people with diabetes and the general population was highest at younger ages – death rates were 4.5 times as high for people aged under 45 with type 1 diabetes and almost 6 times as high for those with type 2 diabetes, compared with the Australian population of the same age.

“Overall, diabetes, coronary heart disease and stroke were the most common underlying causes of death among people with type 1 or type 2 diabetes,” Dr Moon said.

“Kidney failure was also a leading cause of death for people with type 1 diabetes, while dementia was a common cause of death in those with type 2 diabetes.”

The report also shows that death rates among people with diabetes increased with socioeconomic disadvantage and remoteness.

People with diabetes living in the lowest socioeconomic areas experienced higher death rates than those in the highest socioeconomic areas. Among people with type 2 diabetes, the highest death rates were in remote and very remote areas.

Diabetes is the fastest growing chronic condition in Australia; increasing at a faster rate than other chronic diseases such as heart disease and cancer, according to figures from Diabetes Australia.

The total annual cost impact of diabetes in Australia is estimated to be at $14.6 billion. This includes a cost to the Australian health system of around $875 million per year in amputations. Diabetes Australia estimates that 4,400 amputations are performed in Australian hospitals every year, with up to 85 per cent of these preventable.

Diabetes Australia believes that awareness and early detection is incredibly important to address this growing concern and has called on the Australian Government to implement a Diabetes Amputation Prevention Initiative to ensure systematic early detection of foot problems, and early treatment to prevent amputations.

“Most people in the community have no idea that diabetes causes so many amputations. We need to raise awareness within the community and with key political leaders about the scale of the problem, its impact and what we need to do to fix it,” Diabetes Australia CEO Professor Greg Johnson said.

“Every year thousands of Australians are not so lucky and have to undergo traumatic and debilitating amputations. The sad truth is that health outcomes for people undergoing major amputations are poor. Many people will die in the first five years after a major amputation.”

MEREDITH HORNE

WHO discusses health strategies for our region

Low breastfeeding rates and “aggressive” baby formula marketing have been raised as an urgent issue by delegates at the World Health Organisation’s Western Pacific Regional Committee in Brisbane last month.

The annual meeting brings together ministers of health and senior officials from 37 countries and areas to decide on issues that affect the health and well-being of the Region’s nearly 1.9 billion people.

A new WHO regional action plan has been developed to strengthen protections for children from the harmful impact of food marketing.

WHO remains concerned that the baby food industry manipulates policies and practices by creating a positive public image as well as denying wrong-doing. WHO also believes evidence suggests that infant formula industry advertisements, gifts and sponsorships promote misconceptions and myths and ultimately have a negative impact on feeding practices.

Marketing of breast-milk substitutes, including infant formula, follow-up formula and growing-up milk, to caregivers continues to undermine breastfeeding in the first six months and continued breastfeeding beyond that age.

“The baby formula business is booming,” WHO’s regional director Dr Shin Young-soo said.

“And that is undermining breastfeeding.”

WHO believes that globally, 13 per cent of child deaths can be prevented with exclusive and continued breastfeeding.

Protecting children from the harmful impact of food marketing is critical in a region where more than 6.3 million children are overweight or obese. Countries were at the forum to develop a regional action plan to provide greater protection for children and support better health and nutrition, from birth onwards.

“When children are exposed to food marketing, their diets change,” Dr Shin said.

WHO and the Australian Government have also launched their first ever country cooperation strategy, on the sidelines of the 68th session of the WHO Regional Committee for the Western Pacific.

Issues discussed at the forum included: eliminating major communicable diseases, including measles and rubella, as well as mother-to-child transmission of HIV, hepatitis B and syphilis; financing of priority public health services; strengthening regulation of medicines and the health workforce; improving food safety; and health promotion for sustainable development.

Dr Shin Young-soo said the forum was important to the region because: “Our strength in solidarity is our best defence against whatever the future holds.”

It also provided a vision for WHO’s joint work with Australia over the next five years to improve the health of Australians and contribute to better health outcomes in the broader region.

Dr Shin said the strategy with Australia is the first of its kind, but it builds on a history of strong cooperation while also looking towards the future. Traditionally, country cooperation strategies are established between WHO and developing countries, where the Organisation has offices and provides direct support.

“I sincerely thank Minister Hunt and the Department of Health for their commitment to this strategy – and for paving the way for other high-income countries in this Region, with a new form of engagement that goes beyond the traditional donor country relationship,” he said.

Health Minister Greg Hunt, who attended the meeting, said the strategy: “Strengthens our systems to guard against emerging diseases at home and abroad, boosts our public health capacities and improves our already robust regulations to ensure we have safe and effective medicines and treatments.”

Australia’s breastfeeding guidelines are in line with WHO recommendations that infants up to six months should be exclusively breastfed. However, the Department of Health Australian National Breastfeeding Strategy expired in 2015.

The AMA believes that breastfeeding should be promoted as the optimal infant feeding method. AMA has also called for doctors and other health professionals to be appropriately trained on the benefits of breastfeeding, including how to support mothers who experience difficulties with breastfeeding.

AMA’s position statement can be read here: position-statement/infant-feeding-and-parental-health-2017 .

MEREDITH HORNE

[Editorial] Eliminating viral hepatitis: time to match visions with action

Viral hepatitis caused an estimated 1·4 million deaths in 2015—similar to tuberculosis and more than either HIV or malaria, yet historically these diseases have received insufficient attention from donors and policy makers. In May, 2016, the World Health Assembly adopted the Global Health Sector Strategy on Viral Hepatitis, 2016–20, which aims to eliminate viral hepatitis as a major public health threat by 2030. The strategy set global targets to reduce new viral hepatitis infections by 90% and to reduce deaths due to viral hepatitis by 65%, focusing mainly on hepatitis B virus (HBV) and hepatitis C virus (HCV), which are responsible for most of the global burden.

[Seminar] Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis is characterised by the progressive loss of motor neurons in the brain and spinal cord. This neurodegenerative syndrome shares pathobiological features with frontotemporal dementia and, indeed, many patients show features of both diseases. Many different genes and pathophysiological processes contribute to the disease, and it will be necessary to understand this heterogeneity to find effective treatments. In this Seminar, we discuss clinical and diagnostic approaches as well as scientific advances in the research fields of genetics, disease modelling, biomarkers, and therapeutic strategies.

[Correspondence] Diet, atherosclerosis, and helmintic infection in Tsimane

In The Lancet, Hillard Kaplan and colleagues (March 17, p 1730)1 noted that more than two-thirds of Tsimane adults suffer from intestinal helminths. Despite such a high inflammatory burden, the authors found a very low prevalence of coronary atherosclerosis, as measured by coronary artery calcium. Preclinical and clinical studies show that inflammation is involved in the pathogenesis of atherosclerosis and reductions in inflammatory processes could result in cardiovascular benefits. Furthermore, autoimmune diseases are associated with an increased cardiovascular risk and a worse outcome following cardiovascular events.