New hope for COPD patients with anxiety: study

The link between anxiety and chronic obstructive pulmonary disease (COPD) has long been a treatment challenge.

Now a well-designed trial has found cognitive behavioural therapy (CBT) reduces anxiety and keeps COPD patients out of hospital.

UK researchers randomised 279 patients with COPD of varying levels of severity and concomitant anxiety to either CBT plus self-help leaflets or self-help leaflets alone.

The intervention was delivered one-to-one by respiratory nurses who had completed at least three days of training in CBT, and included components such as breathing control, relaxation, distraction to avoid triggers for panic and positive self-talk. Patients received up to six 30-minute CBT sessions, depending on their need.

In both the treatment and control groups, patients experienced improvements in anxiety at three months (as assessed by the Hospital Anxiety and Depression Anxiety Subscale). However, the change in the CBT group was superior by a clinically important difference (mean difference 1.52, 95% CI 0.49-2.54, p=0.003).

CBT was associated with fewer emergency department attendances and hospital admissions and more Quality Adjusted Life Years. It was also found to be more cost-effective than self-help leaflets alone, with the advantages sustained at 12 months.

Writing in the European Respiratory Society’s journal ERJ Open Research, the authors concluded CBT should be incorporated into routine clinical care pathways for patients with COPD.

“Training respiratory staff can lead to better recognition and treatment of breathlessness and anxiety symptoms, in patients who otherwise may not have engaged with mental health services,” they wrote.

“Begging for an intervention”

Professor Christine Jenkins, head of the Respiratory Group at the George Institute for Global Health, welcomed the study, saying it was “a well-designed trial showing good outcomes in an area begging for an intervention”.

“We are generally not good at managing anxiety in COPD, even though we know there is a strong feedback loop between anxiety and respiratory symptoms,” she said. “When a patient becomes anxious their breathing rate goes up and they can experience dynamic hyperinflation. Beta-agonists also ramp up anxiety.”

Professor Jenkins said she had seen many COPD patients for whom anxiety had played a major role in their presentation.

“I can recall patients who have been extremely breathless, but who within an hour of getting into the ED and being in the reassuring presence of health professionals, have completely calmed down such that they are very stable,” she said.

Previous studies of pharmacotherapy or cognitive behavioural therapy to treat anxiety in COPD patients had been small or inconclusive, Professor Jenkins said.

“It’s really nice to see this adequately powered randomised controlled trial showing you can train nurses to deliver CBT and it leads to patients gaining better control over their breathing so they have fewer hospital visits,” she said.

“Using CBT in this way is entirely feasible in Australia, whether it were to be delivered by respiratory nurses or clinical psychologists involved in pulmonary rehab programs.”

Removing barriers to CBT

The researchers screened 1518 COPD outpatients and found 59% had a HADS-Anxiety Subscale of eight or more, making them eligible for the study.

However, around one quarter of eligible patients (26%) declined to take part. The authors said while this was not unusual in a clinical trial setting, it was unknown whether a similar refusal rate would occur outside of trial conditions.

“Screening for comorbid anxiety symptoms in the clinic and having a nurse skilled in both respiratory and CBT management may remove stigma or other barriers to CBT, improve engagement and allow more holistic care,” they wrote.

The study found no correlation between baseline anxiety score and severity of lung function. Patients with major psychiatric problems or receiving current psychological treatment were excluded from the trial.

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.

[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.

[Comment] Treatment of bronchiectasis exacerbations in children: which antibiotic?

Bronchiectasis in children that is unrelated to cystic fibrosis is a relatively neglected disease. However, it is an important cause of respiratory morbidity in low-income and middle-income countries (occurring as a sequela of lower respiratory tract infection) as well as in specific populations in high-income countries such as Aboriginal or Maori and Pacific Islander populations.1 Most adult bronchiectasis has its roots in childhood disease, with up to 80% of adult patients reporting chronic symptoms from childhood.

[Series] Bronchiectasis in children: diagnosis and treatment

Bronchiectasis is conventionally defined as irreversible dilatation of the bronchial tree. Bronchiectasis unrelated to cystic fibrosis is an increasingly appreciated cause of chronic respiratory-related morbidity worldwide. Few randomised controlled trials provide high-level evidence for management strategies to treat the children affected by bronchiectasis. However, both decades-old and more recent studies using technological advances support the notion that prompt diagnosis and optimal management of paediatric bronchiectasis is particularly important in early childhood.

[Perspectives] Anne Chang: a champion of childhood lung health

At a health centre in Melbourne for Aboriginal and Torres Strait Islanders in the late 1980s, medical student Anne Chang had her eyes opened to Indigenous disadvantage in Australia. “The patients there had diseases not seen in mainstream medicine”, she says. “Pus from the children’s ears and chronic cough with purulent nasal discharge were common.” It was one of many experiences of health inequities that helped drive her passion for improving the health of disadvantaged groups. “People who are worse off should be given the best care”, says Chang, now Professor and Head of the Child Health Division at Menzies School of Health Research in Darwin and Consultant Paediatric Respiratory Physician at Children’s Health Queensland Hospital in Brisbane.

[Comment] Helping children with hearing loss from otitis media with effusion

Otitis media with effusion occurs during viral upper respiratory tract infections in around two-thirds of infants and young children because their Eustachian tube anatomy and function do not provide adequate ventilation and drainage of natural mucus production during a cold until the age of around 5 years. Children are also much more prone to develop a middle ear infection during an upper respiratory tract viral infection. Even with the introduction and widespread use of pneumococcal conjugate vaccines, acute otitis media following an upper respiratory tract viral infection remains common in childhood.

Climate change and health

According to experts interviewed by ABC News, Australia is missing out on billions in short-term health savings that could come with tougher greenhouse emission targets.

Tony Capon, Professor of Planetary Health at the University of Sydney, says that air pollution can lead to premature deaths and problems such as heart attacks and asthma.

He and others point to ballpark figures suggesting the energy and transport sectors alone cost Australia at least $6 billion a year in health problems.

“They’re conservative figures and we’re not taking account of this information in our public policy,” Professor Capon said.

“We consider these costs external and we don’t look at the full ledger.”

Experts like Professor Capon argue that a move towards less- polluting forms of energy and transport would deliver much- needed savings to Australia’s budget bottom line.

Research suggests cutting emissions can pay for itself through savings on health costs, not only in China but in developed countries too.

Burning fossil fuels produces CO2, which is bad for the climate, but it also tends to produce air pollutants such as sulphur dioxide, nitrogen dioxide and very fine particles that can play havoc with our respiratory and cardiovascular systems, even in countries with good pollution laws.

While air pollution levels in Australia may be low when compared to countries such as China, there is evidence that even low levels can be damaging to health.

[Articles] Causes and incidence of community-acquired serious infections among young children in south Asia (ANISA): an observational cohort study

Non-attribution of a cause in a high proportion of patients suggests that a substantial proportion of pSBI episodes might not have been due to infection. The predominance of bacterial causes among babies who died, however, indicates that appropriate prevention measures and management could substantially affect neonatal mortality. Susceptibility of bacterial isolates to first-line antibiotics emphasises the need for prudent and limited use of newer-generation antibiotics. Furthermore, the predominance of atypical bacteria we found and high incidence of respiratory syncytial virus indicated that changes in management strategies for treatment and prevention are needed.

[Clinical Picture] Bochdalek hernia

A male newborn baby was delivered by caesarean section at 38 weeks’ gestational age because of a prenatal ultrasound diagnosis of a congenital diaphragmatic hernia. Shortly after delivery he was in respiratory distress and cyanotic, and unable to move freely. He was rapidly intubated and treated with high-frequency oscillatory ventilation. When he was stable, an x-ray was carried out at the bedside. This showed herniated bowel loops in the left hemithorax, displacement of the mediastinum to the contralateral side, and severely reduced lung space and unclear lung fields bilaterally.