[Comment] Building evidence for care beyond the medical centre

Digital health has been defined as the “convergence of the digital and genomic revolutions with health, health care, living, and society”.1 The term is often used interchangeably with mHealth or mobile health because of the central role played by mobile devices. Remote patient monitoring and telemedicine constitute a subset of digital health technologies that enable monitoring of patients outside conventional clinical settings, such as in the comfort of their own homes. Evidence regarding the efficacy, effectiveness, economics, and clinical preferences of remote patient monitoring and telemedicine is growing in many chronic diseases, including heart failure, diabetes, chronic obstructive pulmonary disease, and stroke diagnosis, and in post-surgical care, rehabilitation, and behavioural medicine.

[Correspondence] The oldest-old in China – Authors’ reply

We agree with Fuzhong Li and Peter Harmer that our data1 have limitations, including the unmeasured burden of non-communicable disease. In fact, we acknowledge this in our paper, and conclude that “further studies need to include chronic diseases”. Li and Harmer also point out that we did not assess the magnitude of rural–urban differences, and Tomohiro Morita and colleagues describe our rural–urban dichotomy as “too simplistic”. We agree that an investigation of rural–urban differences is important, which is why we adjusted for rural–urban residence as a covariate in our study.

Australian Indigenous kids have the highest prevalence of impetigo

West Australian researchers at Telethon Kids Institute have confirmed dangerous skin infections in many Aboriginal children across northern Western Australia are too often unrecognised and under-treated.

This is despite untreated skin infections such as scabies and impetigo (school sores) can lead to life-threatening conditions such as kidney disease, rheumatic heart disease and blood poisoning.

About 45 per cent of Aboriginal children living in remote communities across northern Australia are affected by impetigo at any one time – the highest prevalence in the world – and scabies is endemic in some communities.

Telethon Kids paediatric infectious diseases specialist Dr Asha Bowen said the recently published study in Public Library of Science (PLOS)journal Neglected Tropic Diseases, found underlying skin problems aren’t always noticed or treated – paving the way for serious complications later on.

Dr Bowen said Aboriginal people in the north of Australia have some of the highest rates of skin infection in the world.

Yet it can be so common in these communities it is regarded as normal, both by health workers and the community.

“When Aboriginal children are assessed at hospitals, it’s often for a more acute condition like pneumonia or gastroenteritis, and that tends to be what the clinicians focus on,” she said.

It was something researchers had suspected but couldn’t previously demonstrate with solid data.

“Now, after conducting a clinical study where we assessed new hospital admissions and compared the results to past records, we have the data to back it up,” Dr Bowen said.

“And that means we’re in a better position to do something about it.”

There remains a need to address the problem by improving training and awareness, and providing tools to help doctors and other healthcare workers better recognise and treat skin infections early on.

The study, led by Dr Daniel Yeoh of the Wesfarmers Centre of Vaccines and Infectious Diseases at Telethon Kids Institute and the Department of Infectious Diseases at Princess Margaret Hospital, was facilitated and supported by WACHS Pilbara, and WACHS Kimberley.

The AMA recognises the terrible effect Rheumatic Heart Disease (RHD) is having on Indigenous people in Australia. The AMA also recognises that impetigo plays a deadly role in RHD. Every year, RHD kills people and devastates lives – particularly the lives of young Indigenous Australians. It causes strokes in teenagers, and requires children to undergo open heart surgery.

MEREDITH HORNE

The AMA’s 2016 Report Card on Indigenous Health can be found here: article/2016-ama-report-card-indigenous-health-call-action-prevent-new-cases-rheumatic-heart-disease

Disease and nutrition being targeted in the Pacific

Combating disease and improving nutrition among Pacific islands populations is the focus of new initiatives funded by the Australian Government.

Foreign Minister Julie Bishop has announced a $7.7 million commitment towards innovative pilot programs targeting mosquito-borne diseases in Fiji, Vanuatu and Kiribati.

Another $2.5 million is being contributed towards nutrition programs in the Pacific.

Australia’s innovationXchange has partnered with Monash University’s Eliminate Dengue Program and national health ministries to target dengue, Zika virus, and Chikungunya.

The program uses naturally occurring Wolbachia bacteria to stop mosquitoes from transmitting these diseases to human populations.

“Dengue is an insidious virus that emerges quickly when the conditions are right and in its severe form, it can be fatal,” Ms Bishop said.

“In Fiji, Vanuatu and Kiribati, over 30,000 people have been infected in the last decade.

“These pilots build on Australia’s existing efforts to promote health security in the Pacific by building countries’ capacities to detect, assess and respond to diseases with epidemic potential.

“Given Australia’s close proximity to our Pacific neighbours, supporting regional health security also works to ensure our own national health security.”

Malnutrition is also a challenge in the Pacific, with about half of all children in Papua New Guinea stunted because of chronic under-nutrition.

Across the Pacific the prevalence of non-communicable diseases, including diabetes, is rising, and linked to poor diet choices.

The Government will invest $4 million in winners of the LAUNCH Food Challenge to improve nutrition in our region, including $2.5 million in the Pacific.

Winning initiatives will work to increase local production of healthy food using innovative technology and drive healthier food choices through improved public health communication.

LAUNCH Food is a global innovation challenge supported by Australia’s innovationXchange, USAID’s Global Development Lab and regional stakeholders.

The innovationXchange was established in March 2015 within the Department of Foreign Affairs and Trade to form new partnerships and identify innovative approaches to improve the effectiveness and impact of the Australian aid program, and public policy more generally.

CHRIS JOHNSON

[Comment] Gene therapy for RPE65-mediated inherited retinal dystrophy completes phase 3

The eye is an attractive organ for gene therapy because of the small amount of tissue that needs to be transfected, surgical accessibility for gene delivery, and the inbuilt control of the second eye. However, despite these benefits, no licensed ocular gene therapy exists for patients with otherwise incurable eye diseases. Stephen Russell and colleagues1 are therefore to be congratulated for doing the first, to our knowledge, phase 3 randomised controlled trial of a gene therapy for a genetic disease.

[Comment] Hunting hidden parasites: Trypanosoma cruzi

Pathogens are not aware of international borders, including pathogens that cause emerging and neglected tropical diseases. Although Chagas disease is endemic to Latin America, where it affects around 5·7 million people,1,2 it is now a disease of global concern mainly because of the movement of human populations. After the USA, Spain hosts the highest number (more than 50 000) of migrants infected with Trypanosoma cruzi, the parasite that causes this life-threatening disease.3,4 European countries should therefore adapt their legislation to control the main non-vector modes of T cruzi transmission (blood transfusions and haemoderivatives, and organ transplantation).

[Seminar] Haemolytic uraemic syndrome

Haemolytic uraemic syndrome is a form of thrombotic microangiopathy affecting predominantly the kidney and characterised by a triad of thrombocytopenia, mechanical haemolytic anaemia, and acute kidney injury. The term encompasses several disorders: shiga toxin-induced and pneumococcus-induced haemolytic uraemic syndrome, haemolytic uraemic syndrome associated with complement dysregulation or mutation of diacylglycerol kinase ɛ, haemolytic uraemic syndrome related to cobalamin C defect, and haemolytic uraemic syndrome secondary to a heterogeneous group of causes (infections, drugs, cancer, and systemic diseases).

Substance abuse needs mature policy approach

The AMA has called on the Federal Government to treat substance abuse and other behavioural addiction problems within the community as a high-level priority to address.

Substance dependence and behavioural addictions are chronic brain diseases and people affected by them should be treated like any other patient with a serious illness.

AMA President Dr Michael Gannon said while the Government responded quickly to concerns about crystal methamphetamine use, with the National Ice Action Strategy, broader drug policy appears to be a lower priority.

“I don’t think we need to underestimate the cancer in our society that methamphetamine causes. It’s destroying lives, it’s destroying communities, it’s destroying families,” Dr Gannon said.

“But we can acknowledge that and at the same time reflect on the carnage that legal drugs still cause.

“Twelve per cent of Australians are still smoking. It’s the only habit that kills over half of its regular users and certainly impairs the health of the remainder.

“And alcohol; it’s a difficult conversation. So many of us enjoy a drink. Not many of us would think that we are problem drinkers. But if you look at how deeply inculcated in our society drinking alcohol is, you start to get an idea about the potential harm it causes.”

Given the consequences of substance dependence and behavioural addictions, the AMA believes it is time for a mature and open discussion about policies and responses that reduce consumption, and that also prevent and reduce the harms associated with drug use and control.

“Services for people with substance dependence and behavioural addiction are severely under-resourced. Being able to access treatment at the right time is vital, yet the demand for services outweighs availability in most instances,” Dr Gannon said.

“Waiting for extended periods of time to access treatment can reduce an individual’s motivation to engage in treatment.”

Substance abuse is widespread in Australia. Almost one in seven Australians over the age of 14 have used an illicit substance in the past 12 months, and about the same number report drinking 11 or more standard alcoholic drinks in a single session.

Substance use does not inevitably lead to dependence or addiction. A patient’s progression can be influenced by many things, such as genetic and biological factors, the age at which the use first started, psychological history, family and peer dynamics, stress, and access to support.

The AMA recently released its Harmful Substance Use, Dependence, and Behavioural Addiction (Addiction) 2017 Position Statement, pointing outthat dependence and addiction often led to death or disability in patients, yet support and treatment services were severely under-resourced.

The costs of untreated dependence and addictions are staggering. Alcohol-related harm alone is estimated to cost $36 billion a year.

Those affected by dependence and addictions are more likely to have physical and mental health concerns, and their finances, careers, education, and personal relationships can be severely disrupted.

Left unaddressed, the broader community impacts include reduced employment and productivity, increased health care costs, reliance on social welfare, increased criminal activity, and higher rates of incarceration.

About one in 10 people in Australian jails is there because of a drug-related crime.

Dr Gannon said the Government’s updated National Drug Strategy was disappointing because no additional funding had been allocated to it, meaning that measures requiring funding support were unlikely to occur in the short to medium term.

“The recently-released National Drug Strategy 2017-2026 again lists methamphetamine as the highest priority substance for Australia, despite the Strategy noting that only 1.4 per cent of Australians over the age of 14 had ever tried the drug,” he said.

“The Strategy also notes that alcohol is associated with 5,000 deaths and more than 150,000 hospitalisations each year, yet the Strategy puts it as a lower priority than ice.”

Dr Gannon called on the Government to focus on the dependencies and addictions that cause the greatest harm, including alcohol, regardless of whether some substances are more socially acceptable than others.

“General practitioners are a highly trusted source of advice, and they play an important role in the prevention, detection, and management of substance dependence and behavioural addictions,” he said.

“Unfortunately, limited access to suitable treatment can undermine GPs’ efforts in these areas.”

Behavioural addictions also include pathological gambling, compulsive buying, and being addicted to exercise or the internet.

Like substance dependence, they are recognised as chronic diseases of the brain’s reward, motivation, memory, and related circuitry.

Go to: position-statement/harmful-substance-use-dependence-and-behavioural-addiction-addiction-2017 to read the full Position Statement.

CHRIS JOHNSON

Breast or otherwise, new mothers need support

Non-breastfeeding mothers need greater support to help them feed their babies without being made to feel guilty, the AMA insists.

Releasing the AMA’s Infant Feeding and Parental Health 2017 Position Statement recently, AMA President Dr Michael Gannon said new parents who did not breastfeed their infants should be supported in their efforts to ensure their children receive optimal nutrition.

Breastfeeding may not be the best choice for all families, and there must be a balance between promoting breastfeeding and supporting mothers who cannot or choose not to breastfeed.

“Mothers may feel a sense of guilt or failure, and it is important that their GPs and other medical practitioners reassure them about the efficacy and safety of formula feeding, and work to remove any stigma,” Dr Gannon said.

“Although it is different in composition, infant formula is an adequate source of nutrients. Parents seeking to bottle feed their infants need support and guidance about how much and how often to feed their infant, how to recognise when to feed their infant, and how to sterilise and prepare formula.”

Hospital-based milk banks provide a valuable source of nutrients for infants with a clinical need for donor human milk, such as those who are premature or underweight.

Informal breastmilk sharing arrangements that occur without medical oversight pose significant risks to infant health, including the transmission of harmful bacteria or communicable diseases.

Parents should be educated about the potential harms of sourcing unpasteurised and untested milk for their infants, to ensure they are able to make informed decisions.

Dr Gannon noted that breastfeeding was the optimal infant feeding method, with current Australian guidelines recommending exclusive breastfeeding until six months.

But mothers and other caregivers who cannot or choose not to breastfeed must have access to appropriate care and assistance to formula-feed their children.

“There’s no doubt that breast is best, and in Australia, 96 per cent of new mothers start out breastfeeding their baby,” Dr Gannon said.

“Babies who are breastfed are at less risk of infection, sudden infant death syndrome, and atopic diseases like asthma, eczema, and hay fever.

“The maternal antibodies in breastmilk help to protect infants before they are old enough for their first childhood vaccinations.

“Babies who are breastfed are less likely to become obese or develop type 2 diabetes as children and teenagers, and are less at risk of high blood pressure.

“Breastfeeding helps mothers bond with their babies, recover from childbirth, and regain their pre-pregnancy body weight, and it is also associated with reduced risk of some cancers.

“Yet we know that many mothers do not persist with breastfeeding. Only 39 per cent of infants are exclusively breastfed to four months, and just 15 per cent to six months.”

This highlights the need for more support to allow mothers to extend the duration of their breastfeeding if they wish to, Dr Gannon said.

Women can be discharged from hospital as early as six hours after giving birth, long before their milk has come in.

The AMA President said they should only be discharged when they are physically and emotionally ready to return home.

The Position Statement calls for doctors, medical students, and other health professionals to be appropriately trained and educated about the benefits of breastfeeding, including how to support mothers who experience difficulties with breastfeeding.

It also notes that parents should be aware that anatomical difficulties, such as colic, tongue tie, or feeding and swallowing disorders, occur in both breast- and formula-fed infants. Parents should consult their general practitioner for support and referral to appropriate medical care.

The Position Statement says that postnatal depression is estimated to affect one in seven new mothers in Australia, and women who are unable to breastfeed in line with their intentions may be at increased risk.

However, there is limited access to specialised mother and baby units, and women who are waiting to access these services need to be monitored and supported in the interim.

The full Position Statement position-statement/infant-feeding-and-parental-health-2017 can be viewed on the AMA’s website.

CHRIS JOHNSON

[Series] Human reproduction and health: an evolutionary perspective

According to life history theory, increased investment in reproductive function (physiology and behaviour) at different times throughout the life course affects the risk of many diseases and, ultimately, longevity. Although genetic factors contribute to interindividual and interpopulation variation in reproductive traits, the dominant source of variability is phenotypic plasticity during development and adult life. Reproductive traits in both sexes evolved sensitivity to ecological conditions, as reflected in contemporary associations of hormone concentrations with geographical setting, nutritional status, and physical activity level.