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[Comment] Offline: Sweden seeks a renaissance in global health

We gather in the atrium of the Royal Swedish Academy of Sciences, founded in 1739, surrounded by statues of Carl Linnaeus and portraits of the great (male) heroes of science (Newton, Galileo, Brahe). Reflecting on the pride and responsibility that Swedish scientists feel for their stewardship of the Nobels, some recalled with fond nostalgia the great lost years of Swedish influence in global health. The amplification of Sweden’s presence in health stemmed from the nation’s distinctive values, innovative research, policy translation, and strong activism.

[Comment] New pathways of treatment for psoriatic arthritis

Psoriatic arthritis occurs in up to 30% of patients with psoriasis.1 The prevalence of psoriasis varies geographically, ranging between 1% and 3% of the population, depending on genetic variation.2 Since the discovery of the cytokine interleukin 17A in 1993, and the subsequent discovery of one of the key cells that produce interleukin 17A and related cytokines, the T-helper-17 cell, in 2005,3 this pathway has been a focus of research in the pathogenesis of psoriasis and closely related conditions, psoriatic arthritis and spondyloarthritis.

[Editorial] A platinum age for rheumatology

On June 14–17, over 14 000 rheumatologists, health-care professionals, and patients will gather in Madrid, Spain, for the European League Against Rheumatism (EULAR) Annual Congress. 2017 is a particularly special year for the organisation as EULAR celebrates its 70th anniversary. Since our inception, The Lancet has been pleased to have shared in the rich history of rheumatology research, including The “Rheumatic Disease”, coauthored by the founding President of EULAR, Mathius Pierre Weil, in 1928 and today’s issue, which highlights recent and innovative developments in therapeutics and management strategies for rheumatic diseases.

[Obituary] Mark Arnold Wainberg

HIV researcher and activist. He was born in Montreal, QC, Canada, on April 21, 1945, and drowned while on vacation in Bal Harbour, FL, USA, on April 11, 2017, aged 71 years.

[Perspectives] Elizabeth Mayer-Davis: leader in adolescent diabetes

“Doing a lot of seemingly different things that are actually connected”, is the way that Elizabeth Mayer-Davis describes working life as Chair of Nutrition at the University of North Carolina at Chapel Hill, NC, USA. She is currently prioritising research into glycaemic control and weight management in type 1 diabetes; and soon hopes to be working on a trial to investigate how an automated insulin delivery system (the so-called bionic pancreas) will impact on diet and bodyweight. “When it comes to research, I try and see where the gaps in research lie, and work out where I can make a difference”, she says.

News briefs

Antiretroviral therapy gives patients with HIV infection 10 more years

Life expectancy of 20-year-old patients starting treatment for HIV has increased by about a decade in the European Union and North America since the introduction of antiretroviral therapy in the mid-1990s, according to research published in The Lancet HIV. The authors, from the University of Bristol, proposed that their findings could reduce stigmatisation and help people with HIV infection gain employment and obtain medical insurance, as well as encouraging diagnosed patients to start treatment as soon as possible. Their projections indicate that the life expectancy of a typical 20-year-old patient who began treatment since 2008 and had a low viral load after a year of treatment may approach that of the general population (about 78 years). The study analysed data from 18 EU and North American studies for 88 504 people with HIV infection who started antiretroviral treatment between 1996 and 2010. It tracked how many people died during the first 3 years of their treatment, their cause of death, HIV viral load, immune cell (CD4) count and whether they were infected through injecting drugs. Fewer people who started treatment between 2008 and 2010 died during the first 3 years of treatment than those who started treatment between 1996 and 2007. The number of deaths during treatment directly attributable to AIDS declined between 1996 and 2010, probably the result of newer drugs being more effective in restoring immune function. Measures of HIV also improved, with the average CD4 cell count after a year of treatment increasing from 370 cells per microlitre of blood in 1996–1999 to 430 cells per microlitre in 2008–2010, while the proportion of people with a low HIV viral load increased from 71% to 93%. Between 1996 and 2013, the life expectancy of 20-year-old patients treated for HIV infection increased by 9 years for women and 10 years for men in the EU and North America. Projections based on death rates in the second and third year of treatment for Europeans and North Americans estimated that 20-year-old men and women starting therapy between 2008 and 2010 who survived the first year of treatment would live to 73 and 76 years respectively.

http://dx.doi.org/10.1016/S2352-3018(17)30086-3

Untethered proteins found in MKD

Researchers from the Garvan Institute of Medical Research in Sydney have shown that a family of untethered proteins builds up in the cells of children with a rare genetic condition, mevalonate kinase deficiency (MKD). Individuals with MKD experience repeated and frequent inflammatory febrile episodes that last for days and are accompanied by hepatosplenomegaly, lymphadenopathy, arthralgia, and skin rash. These febrile crises are similar to those associated with hyperimmunoglobulinemia D and periodic fever syndrome. The attacks usually begin in infancy and continue throughout life, although they are most frequent in children. In blood cells from people with MKD, the investigators found that several intracellular proteins from the same family (Rab proteins) had no isoprenoid tail. Much like a child holding the string of a balloon, an isoprenoid tail is thought to act as a molecular tether for the protein to which it is attached. The isoprenoid tails on Rab proteins keep them close to the cell membrane; without their tethers, the Rab proteins, and other related proteins, are free to move into other parts of the cell. It is thought that this could initiate the disease process in MKD, triggering inflammation. The researchers found that untethered Rab proteins are found only in people in MKD, and not other rare diseases that have similar clinical symptoms (the periodic fever syndromes) or in the parents of children with MKD. These findings, published in the Journal of Allergy and Clinical Immunology, pinpoint a key feature of MKD that could be used to fast-track diagnosis of the disease, a process that is often difficult and protracted.

http://dx.doi.org/10.1016/j.jaci.2017.02.033

AMA nomination sought for NHMRC committee

Expressions of interest are being sought for an AMA nomination for consideration as a member of the National Health and Medical Research Council’s working committee reviewing its ethical guidelines on organ and tissue donation and transplantation.

The NHMRC has asked the AMA to nominate a member for the committee as it plans to start a review of the following ethical guidelines: 

  • Organ and tissue donation after death, for transplantation – Guidelines for ethical practice for health professionals, 2007;
  • Making a decision about organ and tissue donation after death, 2007;
  • Organ and tissue donation by living donors – Guidelines for ethical practice for health professionals, 2007;
  • Making a decision about living organ and tissue donation, 2007; and
  • Ethical guidelines for organ transplantation from deceased donors, 2016.

An integral part of this process will be the establishment of the Organ and Tissue Working Committee (OTWC) comprised of members who have experience or expertise in one or more of the following:

  • Health ethics;
  • Religion;
  • The donation and transplantation of organs and tissues from living donors;
  • The donation and transplantation of organs and tissues from deceased donors;
  • The coordination of organ and tissue donation and transplantation;
  • Community and consumer issues related to transplantation, donation and/or health ethics;
  • Government policy regarding donation and transplantation of organs and tissues from living and deceased donors; and
  • Aboriginal and Torres Strait Islander health issues.

The NHMRC is currently seeking nominations of persons for appointment to the OTWC for the period to 30 December 2019. The AMA has been asked to provide a nominee with experience or expertise in ‘the donation and transplantation of organs and tissues from living and deceased donors’. 

The NHMRC will consider nominations from a number of organisations and there is no guarantee the AMA’s nominee will be appointed.

The NHMRC will seek formal declarations of interest, following initial consideration of all nominations. The NHMRC’s Policy on the Disclosure of Interests Requirements for Prospective and Appointed NHMRC Committee members. This policy can be found on their website at: https://www.nhmrc.gov.au/_files_nhmrc/file/about/committees/nhmrc_policy_disclosure_of_interests_committee_members_150513.pdf

The OTWC will be effective for the period 1 July 2017 to 30 December 2019.

 Deadline for consideration as AMA nomination

AMA members should send their nomination, along with their Curriculum Vitae, to the Federal AMA Secretariat at ethics@ama.com.au by COB Monday, 12 June. Your personal information will be protected in accordance with the AMA’s privacy policy which can be found on the AMA’s website at privacy-policy

 

Art and Medicine

By Dr Jim Chambliss

It is often said that a picture speaks a thousand words.

Contemporary medical technology provides incredibly intricate pictures of external and internal human anatomy.

However, technology does not communicate holistic representations of the social, behavioural and psychosocial impacts associated with illness and the healing process.

Studies have shown that increased reliance on reports from expensive laboratory tests, radiology and specialised diagnostic technology has resulted in inadequacy of physical examination skills; decline in patient empathy, and less effective doctor/patient communication.

Having commenced in May this year and continuing until July 8, continuing professional development workshops which explore and promote the value of art expression in the development of observation skills, human sensitivity and relevant healthcare insights will be presented at the National Gallery of Victoria exhibition of the original works of Vincent van Gogh.

The program will incorporate empirical research to illustrate the way neuropsychological conditions can influence art and creativity. The objectives of the workshops are to:

 • advance understanding of the impact of medical, psychological and social issues on the health and wellbeing of all people;

 • promote deeper empathy and compassion among a wide variety of professionals;

 • enhance visual observation and communication skills; and

 • heighten creative thinking.

Over the last 15 years, the observation and discussion of visual art has emerged in medical education, as a significantly effective approach to improving visual observation skills, patient communication and empathy.

Pilot studies of implementing visual art to teach visual diagnostic skills and communication were so greatly effective that now more than 48 of the top medical schools in the USA integrate visual arts into their curriculum and professional development courses are conducted in many of the most prestigious art galleries and hospitals.

The work of Vincent van Gogh profoundly illustrates the revelations of what it means to be uniquely human in light of neurological characteristics, behavioural changes and creative expression through an educated, respectful and empathic perspective.

The exact cause of a possible brain injury, psychological illness and/or epilepsy of van Gogh is unknown.

It is speculated by numerous prominent neurologists that Vincent suffered a brain lesion at birth or in childhood while others opine that it is absinthe consumption that caused seizures.

Two doctors – Felix Rey and Théopile Peyron – diagnosed van Gogh with epilepsy during his lifetime.

Paul-Ferdinand Gachet also treated van Gogh for epilepsy, depression and mania until his death in 1890 at the age of 37.

After the epilepsy diagnosis by Dr Rey, van Gogh stated in a letter to his brother Theo, dated 28 January 1989: “I well knew that one could break one’s arms and legs before, and that then afterwards that could get better but I didn’t know that one could break one’s brain and that afterwards that got better too.”

Vincent did not, by any account, demonstrate artistic genius in his youth. He started painting at the age of 28 in 1881.

In fact, his erratic line quality, compositional skills and sloppiness with paint were judged in his February 1886 examinations at the Royale Academy of Fine Arts, Antwerp to be worthy of demotion to the beginners’ painting class. His original drawings and paintings were copies from others’ art, while his sketches in drawing class showed remarkably different characteristics.

Increased symptoms of epilepsy and exposure to seizure triggers (absinthe and sleep deprivation) ran parallel with van Gogh’s most innovative artistic techniques and inspirations following his move to Paris in 1886 to 1888.

These symptoms increased, accompanied by breathtaking innovation following his move to Arles, France in 1888 and his further decline in mental and physical health.

In Paris he was exposed to the works of many of the most famous impressionistic and post impressionistic painters, but so much of his new techniques and imagery were distinctly innovative in detail without traceable influences from others.

While in Paris his work transitioned from drab, sombre and realistic images to the vibrant colours and bold lines.

His ebb-and-flow of creative activity and episodes of seizures, depression and mania were at their most intense in the last two years of his life when he produced the greatest number of paintings.

His works are among the most emotionally and monetarily valued of all time. Vincent’s painting of Dr Gachet (1890) in a melancholy pose with digitalis flowers – used in the treatment of epilepsy at that time – sold for $US82.5 million in May, 1990, which at the time set a new record price for a painting bought at auction.

Healthcare professionals and art historians have written from many perspectives of other medical and/or psychological conditions that impacted van Gogh’s art and life with theories involving bipolar disorder, migraines, Meniere’s decease, syphilis, schizophrenia, alcoholism, emotional trauma and the layman concept of ‘madness’.

What was missing as a basis to best resolve disputes over which mental or medical condition(s) had significant impact on his life was a comprehensive foundation of how epilepsy or mental illness can influence art and possibly enhance creativity based on insights from a large group of contemporary artists.

Following a brain injury and acquired epilepsy I gained personal insight into what may have affected the brain, mind and creativity of van Gogh and others who experience neurological and/or psychological conditions.

The experience opened my eyes to the medical, cognitive, behavioural and social aspects of two of the most complex and widely misunderstood human conditions.

Despite having no prior experience or recognisable talent, I discovered that my brain injury/epilepsy had sparked a creative mindset that resulted in a passion for producing award-winning visual art.

I enrolled in art classes and began to recognise common topics, styles and characteristics in the art of contemporary and famous artists who are speculated or known to have had epilepsy, such as Vincent van Gogh, Lewis Carroll, Edward Lear and Giorgio de Chirico.

Curiosity for solving the complex puzzle of how epilepsy could influence art led me to pursue a Masters in Visual Art which included a full course exclusively about Vincent van Gogh.

I subsequently obtained the world’s first dual PhD combining Visual Arts, Medicine and Art Curation at the University of Melbourne.

The PhD Creative Sparks: Epilepsy and enhanced creativity in visual arts (2014) was based on the visual, written and verbal insights from more than 100 contemporary artists with epilepsy and provided:

 • objective and subjective proof that epilepsy can sometimes enhance creativity – supported by brain imaging illustrating how that can occur;

 • a comprehensive inventory of the signature traits of neurological and psychological conditions that have significant interpretive value in healthcare practice and consideration in art history;

 • the largest collection of images of the visual narratives from people with epilepsy;

 • comparative data to distinguish epilepsy from other medical and mental conditions; and

 • the Creative Sparks Art Collection and Website – artandepilepsy.com.

Interest in these research discoveries and art exhibitions provided opportunities for me to deliver presentations at national and international universities, hospitals and conferences. Melbourne University Medical School sponsored an innovative series of workshops through which to teach neurology and empathy by an intriguing new approach.

 Jim Chambliss has a dual PhD in Creative Arts and Medicine and has explored the ways epilepsy and other health conditions can influence art and enhance creativity.

Information about his Art and Medicine Workshops involving Vincent van Gogh can be obtained by visiting artforinsight.com or artandepliepsy.com

 

Increasing funding to improve outcomes for eating disorders

The Federal Budget allocated $80 million for Australians with a mental illness such as severe depression, eating disorders, schizophrenia and post-natal depression resulting in a psychosocial disability, including those who had been at risk of losing their services during the transition to the NDIS.

The Government also announced it will provide $9.1 million over four years to improve access to psychological services through telehealth in regional, rural and remote Australia.

Health Minister Greg Hunt has also freshly announced that eating disorders will be included in the 5th Mental Health Plan and that the current Medicare Benefits Schedule Review Taskforce investigate Medicare coverage for the treatment of those with an eating disorder.

The National Mental Health Commission described the funding announcement as timely.

“Timely that eating disorders will be recognised officially as serious and complex mental illnesses with serious physical consequences,” said the Commission’s chief executive Peggy Brown.

The Butterfly Foundation, which is the country’s peak support organisation for people with conditions such as anorexia and bulimia, says that the current health system is failing people with an eating disorder.

Its chief executive, David Murray, said: “Too many times in the past 12 months Butterfly staff have sat vigil with families as the health system has failed.”

“When suicide is up to 31 times more likely to occur for someone with an eating disorder, clearly the Government should address this problem with a dedicated focus.”

According to the National Eating Disorders Collaboration (NEDC), an initiative of the Australian Government Department of Health, more than 1 million Australians suffer from eating disorders and represent the third most common chronic illness for young females.

The NEDC also cites research that shows anorexia has the highest death rate of any mental illness and carry a very high rates of mortality with one in 10 people who suffer from an eating disorder dead within 10 years.

Deaths associated with eating disorders are typically caused by medical complications (such as cardiovascular issues and multiple organ failure), suicide or complications relating to substance use.

A 2012 Deloitte Access Economics report examined the economic and social impact of eating disorders in Australia and found the total socio economic cost of eating disorders to be $69.7 billion per year.  These costs can be reduced with early detection.

The Australian Medical Association believes that a greater focus is needed on ensuring appropriate access to early intervention and treatment services for young people especially in rural and remote locations.  The AMA also believes that a nationally coordinated approach is necessary in order to develop effective and consistent practices in preventing and addressing the incidence of unhealthy body image and eating disorders. 

If this article has raised concerns about eating disorders, please contact the Butterfly Foundation national hotline on 1800 33 4673; or visit www.thebutterflyfoundation.org.au for support and resources for eating disorder sufferers and their families and carers.

Meredith Horne