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[Comment] Lorcaserin: balancing efficacy with potential risks

Obesity remains among the most difficult diseases to treat, with lifestyle changes not always leading to sufficient weight loss or sustained long-term results.1 The history of weight-loss medications has been challenging because of adverse effects restricting their application.2 Given the worldwide obesity and diabetes twin epidemics,3 demands for effective treatments both from patients and physicians are high.

[Editorial] Looking beyond the Decade of Vaccines

When in 2010 the global health community declared the so-called Decade of Vaccines, it marked a path towards an ambitious vision for 2020: a world in which all individuals and communities enjoy lives free from vaccine-preventable diseases. The Global Vaccine Action Plan (GVAP) 2011–2020, a multisectoral effort led by WHO, set highly challenging targets, progress towards which would be assessed by the Strategic Advisory Group of Experts on Immunisation (SAGE). With the publication of the penultimate assessment report of the GVAP, and as the turn of the decade looms, it is time to take stock and look beyond 2020.

Divestment – medical students say no to fossil fuels

BY ALEX FARRELL, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

In August, the Australian Medical Students’ Association (AMSA) put our money where our mouth is, and announced our intention to divest from fossil fuels. It was a significant moment, as Australian medical students joined the growing movement in the medical sector, including the American Medical Association, the British Medical Association and the Canadian Medical Associations. 

Climate change is the biggest global health threat of this century. That was the conclusion of the Lancet Climate Change Commission, and a message that must be taken up with urgency by the medical profession. The impacts on health are clear; the increase in severe weather including drought and heat-waves, worsening air pollution and worsening of infectious and respiratory diseases. 

Australian medical students have always been passionate about taking tangible steps to reduce their impact on the environment, and the AMSA project Code Green has previously run campaigns such as #MoveMindfully and worked to improve the sustainability of AMSA events.

However, this was our biggest step yet, driven by Code Green, and one I am exceptionally proud of our organisation for taking. For those who are unfamiliar, divesting from fossil fuels is moving investments to a bank or portfolio that doesn’t directly or indirectly fund the fossil fuel industry. It is an advocacy tool that redirects money away from problematic industries and towards ethical alternatives. It is also a statement – a public statement of where we stand as medical students on the fossil fuel industry and its impact on human health.

The announcement was made in an address to medical students from across the country at the 2018 AMSA Global Health Conference in Melbourne, and was supported unanimously by student representatives from all the Australian medical schools. It is a signal that young doctors are conscious consumers who will make decisions about their choices to shop and invest with social and environmental impacts in mind. 

As future doctors of Australia, we want to invest in a healthy future. We know that there is more to medicine than just curing illness once our patients are already sick. We need to take into account the upstream factors that are making them sick, and the way our society and our environment affects our health.

Australia’s healthcare system is responsible for more than seven per cent of the nation’s total carbon footprint. Earlier this year, AMSA held a forum with a sustainability expert Dr David Pencheon, who founded the Sustainable Development Unit in the UK’s National Health Service. This unit successfully led the NHS to cut its carbon emissions by 11 per cent between 2007 and 2015. Whilst addressing the RACP Congress, Dr Pencheon said: “Doctors have nothing to lose, but the future.” As the ones who will see the impact of climate change play out in the lives and health of our patients, the current situation is no longer a status-quo we can accept. Many changes are necessary and possible, but for now, let’s keep it simple.

Divesting doesn’t require an overhaul of our health system. It doesn’t need a change in Government policy. It is simply a change of bank. Something that everyone, from the smallest student group, to the largest medical representative organisations and colleges, to clinics and hospitals, has the capacity to do. 

Internationally, medical associations are leading the way on divesting from fossil fuels. We have already seen doctors use divestment as a tool for public health in Australia, like the work of Dr Bronwyn King from ‘Tobacco Free Portfolios’. 

It is time that we join together to focus that energy and drive on climate change, following the example of Doctors for the Environment. Together, the investments that the medical industry make have a large impact. Let’s use that impact to join other global leaders to stand together for health, and against fossil fuels.  

Medicine made free for extremely rare disease

The Government has made a new medicine available for free for an extremely rare and life-threatening disease, potentially saving patients hundreds of thousands of dollars a year.

The new medicine Galafold® (migalastat) for the treatment of Fabry disease is now listed on the Life Saving Drugs Program, which provides free access to highly specialised medicines to treat patients with rare and life-threatening diseases.

Patients with Fabry disease have a rare enzyme deficiency, which means their bodies have trouble breaking down a fatty substance called globotriaosylceramide.

The condition usually presents in childhood with episodes of severe pain. Other symptoms include skins rashes, headaches, fatigue, vertigo, fever and vomiting and diarrhea.

It can result in potentially life-threatening complications including kidney failure, heart attack and stroke. It can have a major impact on patients and their families.

Currently, there are about 100 Fabry patients receiving enzyme replacement therapy through the LSDP.

Galafold® is a new oral medicine alternative for the treatment of Fabry disease patients aged 16 years and older.

It provides greater treatment choice for Fabry patients, reduces disease symptoms and dramatically improves quality of life, whilst also allowing patients to manage their own treatment at home without the need to have painful injections or infusions.

Without subsidy, Australian Fabry patients would pay hundreds of thousands of dollars for this treatment, putting them beyond the reach of most families who have to fight this extremely rare condition.

Health Minister Greg Hunt said it is the first medicine included on the Life Saving Drugs Program following the implementation of reforms to make the process more timely, transparent and improve patient access through the program.

“Our Government currently funds 14 different life-saving medicines for nine very rare diseases through the program, providing physical, emotional and financial relief for 400 Australian patients,” he said.

“These medicines are very expensive and would be too high of a financial burden on patients.”

Medicines funded through this program include high cost medicines that do not meet the criteria to be funded on the Pharmaceutical Benefits Scheme (PBS).

The new the Life Saving Drugs Program medical expert panel was announced in August. The panel, chaired by Australia’s former Deputy Chief Medical Officer Dr Tony Hobbs, supports the evaluation of medicines for funding on the program and provides advice to the Chief Medical Officer.

[Global Health Metrics] Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity.

When the doctor becomes the patient

Former Federal AMA President, Dr Steve Hambleton, fell ill suddenly and unexpectedly last week in Canberra.

He flew in to Canberra early on Wednesday, November 7 for a meeting of an MBS Review Committee. He made it to the meeting, but not for long. By midday, he was in the ED at Canberra Hospital.

After tests and care and an overnight stay in Canberra Hospital, he was on a 6.00am Thursday flight home to Brisbane and straight back in to hospital in his home town.

He underwent surgery later that day, and remains in hospital recovering.

In a brief window of opportunity during his transition from robust doctor to vulnerable patient, Steve found time to write a ‘Thank You’ note to all his carers, which is also an emotive account of his patient journey.

 

Thank you all …

Dr Steve Hambleton

Thank you to all the people who made my stay in the Canberra Hospital a little more bearable.

Thank you to Dr Eleanor who, when I asked for help, was decisive and supported my need to seek help. Thank you to Dr Andrew for making that call to the hospital to smooth the way for me.

Thank you to the staff at the triage desk, to whom I was just another person. I was treated with care and compassion. I was not that well, and not at my best, but very grateful. I wasn’t the only one there. Around me were people from all walks of life, with a bandage here or there, and their own personal stories to tell.  Some were impatient. But if it bothered them, they did not show it.

Thank you to the cleaners. Your work behind the scenes makes a huge difference. My body told me it was time to vomit, which is always a bit awkward when wearing a suit and tie. On one knee on the floor in a clean toilet rather than a soiled one made all the difference to me.  I am sorry if I made your next run a little bit harder.

Thank you to the triage nurse who kept me informed while I was in the waiting area, and for showing me to my bed.

Thank you to the emergency nursing staff. You don’t know how much comfort the sight of you in your uniform brings to those of us feeling helpless.

Getting changed out of my suit (which makes me feel important) into that gown confirmed that I was truly the patient on this occasion, totally dependent on the kindness and skills of others.

Thanks to the Emergency Physician who took a history from me. You asked me to describe my pain and I could not. It was pain, bad pain. It was waxing and waning every few minutes, and I was struggling to find an adjective that would help you. You smiled and were patient as you gently probed and questioned.

I was not a very good historian. In that moment there was a lot of my history I could not remember. Certainly not dates and times, and what happened in what order, and I don’t really have any chronic diseases. It made me think about how much harder it must be for those that do.

Thank you for putting in that intravenous line, which sort of validated for me that I was not a fraud and did need to be there.

Thank you to the student nurse, who recorded my observations and administered the first of the medications. I was not well, and probably did not express my thanks all that well.

Thank you to your Senior, who was quietly guiding you as you administered the analgesia. The pain did not go away immediately, but the warm feeling on my skin was reassuring that something was being done.

I wondered how the meeting that I left was going, and what my colleagues were thinking about my sudden departure.

Thank you to the wardsmen who transported me to the radiology department on two occasions. For your light-hearted banter as we weaved our way along the corridors in my bed, which seemed to have lost its steering. We need to get that trolley fixed – it just wouldn’t go straight. Sorry about the rubbish bin. It was a welcome distraction to take my mind off the way I was feeling.

Thank you to the ultrasound operator who was gently efficient – his job was to be in that darkened room, applying his knowledge of anatomy to help answer the clinical questions.

Thank you to the CT scan nurse and the radiographer for your part of the diagnostic journey.

I spent a long time in your emergency department. I love the reference to the flight deck, which is your central point. I was there long enough to hear shift changes and the handovers.

I heard you gently managing the patient with the mental illness, whose understanding and connection with our reality was tenuous at best.

I heard you keeping the patients’ relatives informed about the next steps on their journey.

I heard you manage the man with dementia who was someone’s brother/husband/father. He was loud, and he was angry as he fought his demons. Despite that, he was treated with the same kindness as all your other patients. Do you remember telling me that by the time he left the Department that he was “the nicest old man”. I hoped that you would be around if ever I was that man in the future.

I wanted to go home but needed to stay. I needed help and you gave it to me willingly and I am so grateful. When I leaned on the call button accidentally or when I needed extra help, you were there quickly.

Did you know that if you hold your breath you can watch your oxygen “sats” go down and make the alarm go off? The machines beep to tell you when things are going well, and when they are not.

Thank you for letting me use the phone to keep my family informed. It seemed every time you came into my room, I was talking to someone else.

Thank you for letting me go home when you knew that I was still not quite right. I know you worried about whether it was the right decision. Thank you for tolerating that uncertainty. 

Nothing in medicine is absolute – it’s all about trade-offs.

As I walked through the Department on the way out, I could not believe the patient load you were facing.

Thank you to the night registrar who, even at the end of his shift, had a smile for me.

Dr Steve Hambleton is a former President of the Federal AMA and AMA Queensland.

[Global Health Metrics] Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017

Improvements in global health have been unevenly distributed among populations. Deaths due to injuries, substance use disorders, armed conflict and terrorism, neoplasms, and cardiovascular disease are expanding threats to global health. For causes of death such as lower respiratory and enteric infections, more rapid progress occurred for children than for the oldest adults, and there is continuing disparity in mortality rates by sex across age groups. Reductions in the death rate of some common diseases are themselves slowing or have ceased, primarily for NCDs, and the death rate for selected causes has increased in the past decade.

[Correspondence] It’s time to consider pollution in NCD prevention

In the first paper of the Lancet Taskforce on non-communicable diseases (NCDs) and Economics Series, Rachel Nugent and colleagues (April 4, p 2029)1 describe the increases in numbers of deaths from NCDs that are projected to occur over the next 15 years, most of which occur in rapidly developing low-income and middle-income countries (LMICs). The Taskforce argues that targeted investments in NCD prevention and management could blunt the anticipated increases in the numbers of deaths, reduce poverty, enhance worker productivity, advance many of the Sustainable Development Goals, and thus produce great economic benefits.

[Comment] Long-acting technologies for infectious diseases in LMICs

Imagine a child in the Sahel protected from malaria for an entire season after just one injection of chemoprophylaxis. Or a woman at risk of HIV in Zambia taking a single capsule every 2 weeks that slowly releases an antiretroviral drug to protect her from infection. Could the risk of resistance to medications for infectious diseases be reduced through the use of long-acting (LA) patches, implants, or injectable drugs?

Global Burden of Disease Study trends for Canada from 1990 to 2016 [Research]

BACKGROUND:

The Global Burden of Disease Study represents a large and systematic effort to describe the burden of diseases and injuries over the past 3 decades. We aimed to summarize the Canadian data on burden of diseases and injuries.

METHODS:

We summarized data from the 2016 iteration of the Global Burden of Disease Study to provide current (2016) and historical estimates for all-cause and cause-specific diseases and injuries using mortality, years of life lost, years lived with disability and disability-adjusted life years in Canada. We also compared changes in life expectancy and health-adjusted life expectancy between Canada and 21 countries with a high sociodemographic index.

RESULTS:

In 2016, leading causes of all-age disability-adjusted life years were neoplasms, cardiovascular diseases, musculoskeletal diseases, and mental and substance use disorders, which together accounted for about 56% of disability-adjusted life years. Between 2006 and 2016, the rate of all-cause age-standardized years of life lost declined by 12%, while the rate of all-cause age-standardized years lived with disability remained relatively stable (+1%), and the rate of all-cause age-standardized disability-adjusted life year declined by 5%. In 2016, Canada aligned with countries that have a similar high sociodemographic index in terms of life expectancy (82 yr) and health-adjusted life expectancy (71 yr).

INTERPRETATION:

The patterns of mortality and morbidity in Canada reflect an aging population and improving patterns of population health. If current trends continue, Canada will continue to face challenges of increasing population morbidity and disability alongside decreasing premature mortality.