Home-based end of life care may prolong survival

A new study has backed home-based end of life care, finding that cancer patients who chose to die at home tended to live longer than those in hospitals.

Dr Jun Hamano and his colleagues at the University of Tsukuba in Japan studied 2069 palliative care patients – 1582 in hospital and 487 at home.

The investigators found that in the final weeks and days of life, home-based patients survived for as much as a week longer than those in hospitals, even after adjusting for demographic and clinical characteristics.

“The survival of patients who died at home was significantly longer than the survival of patients who died in a hospital in the days’ prognosis group (estimated median survival time, 13 days [95% confidence interval (CI), 10.3-15.7 days] vs 9 days [95% CI, 8.0-10.0 days]; P = .006) and in the weeks’ prognosis group (36 days [95% CI, 29.9-42.1 days] vs 29 days [95% CI, 26.5-31.5 days]; P = .007) as defined by Prognosis in Palliative Care Study predictor model A,” the researchers wrote.

The findings suggest oncologists should not hesitate to recommend home-based care simply because less medical treatment may be provided.

“The cancer patient and family tend to be concerned that the quality of medical treatment provided at home will be inferior to that given in a hospital and that survival might be shortened,” Dr Hamano said.

“However, our finding – that home death does not actually have a negative influence on the survival of cancer patients at all, and rather may have a positive influence – could suggest that the patient and family can choose the place of death in terms of their preference and values.

“Patients, families and clinicians should be reassured that good home hospice care does not shorten patient life, and may even achieve longer survival.”

The study was published online in CANCER, a peer-reviewed journal of the American Cancer Society.

Maria Hawthorne

Outdoor light the key to preventing myopia

Children need to spend at least one hour a day outside to help prevent myopia, new Australian research has found.

Researchers at Queensland University of Technology’s School of Optometry and Vision Science tracked the progress of 101 children aged between 10 and 15 years, the age at which myopia typically develops, from 42 Brisbane schools.

The children, 41 of whom were myopic and 60 were non-myopic, wore wristwatch light sensors to record light exposure and physical activity for a fortnight during warmer then colder months to give an overall measurement of their typical light exposure.

Their eye growth was measured, along with OCT images of the choroid to highlight novel eye growth changes in the posterior eye.

Lead researcher, Associate Professor Scott Read, said children exposed to the least outdoor light had faster eye growth and hence faster myopia progression.

“Australian kids generally spend more time outside than kids in many other countries, including some Asian countries with a high incidence of myopia,” Professor Read said.

“Still, in our study one-third of kids spent, on average, less than 60 minutes outside a day. Half of these kids were myopic and a handful of the non-myopic kids in this group looked like they were heading towards myopia during the study.

“Our findings suggest the protective effect of being outdoors seems to be related to light rather than physical activity as the study found no significant relationship with exercise and eye growth.

“While it is hard to completely discount near work, we included factors relating to near work in our analyses and these didn’t appear to be significantly related.”

The researchers hypothesise that outdoor light stimulates the production of factors in the retina including retinal dopamine, which helps to slow eye growth.

The research was first published in Invest Ophthalmol Vis Sci and was also presented at the Australian Vision Convention on 3-4 April.

Maria Hawthorne

News briefs

Gender differences in pre-hospital care

A Swedish study published in BMC Emergency Medicine has found that female trauma patients were less likely to be given the highest pre-hospital priority, the highest pre-hospital competence level, and direct transport to the designated trauma centre compared with male trauma patients. A retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County, Sweden, was conducted. A total of 383 trauma patients (279 males and 104 females) over 15 years of age with an Injury Severity Score (ISS) of more than 15 transported to emergency care hospitals in the Stockholm area were included. Male patients had a 2.75 higher odds ratio (95 % CI, 1.2–6.2) for receiving the highest pre-hospital priority compared with females on controlling for injury mechanism and vital signs on scene. “We found differences in trauma mechanism between genders, namely, that the second most common trauma mechanism for females was a low-energy fall (26.9 %) … Perhaps this might be one of the reasons why females, despite severe injury, are not recognised at scene as potential severe trauma patients since the trauma mechanism is considered to be of low energy. Recognising gender differences with educational efforts and in pre-hospital trauma management protocols may expedite the trauma care of female patients.”

Bad hair day in space for some astronauts

Research published in PLOS One has found that spaceflight alters human hair follicle gene expression, leading to a possible “inhibition of hair growth in space”, particularly among male astronauts. “We found that FGF18 expression in the hair follicle changed during spaceflight. Hair follicle growth during anagen is strongly suppressed by the local delivery of FGF18 protein. Epithelial FGF18 signaling and reduction of expression in the milieu of hair stem cells are crucial for the maintenance of resting and growth phases,” the authors wrote. They also found that “FGF18 expression is known to decrease in growing hair follicles; the increase in FGF18 expression in several astronauts during flight potentially reflects a temporary arrest in the hair growth cycle; FGF18 expression appears to be very sensitive to whether an astronaut is in space or earth-bound; FGF18 easily recovered to baseline levels after returning to Earth”. Gender also has its effect, they found. “Although there are many differences such as hormone levels or functions between males and females, female astronauts appear to have a better response against the features of the space environment, as one example, FGF18 expression in females was more stable in space than in males.”

FDA clears experimental Zika blood test for use

The US Food and Drug Administration (FDA) has announced that it will allow the use of an experimental test to screen blood donations for contamination with the Zika virus, the New York Times reports. Puerto Rico, who had halted local blood donations and had imported almost 6000 units of blood from the US, will therefore be able to resume local collection. Zika poses a special challenge to blood banks, the report said, because roughly 80% of people who are infected do not have symptoms. “A handful of cases of Zika infection via blood transfusion have been reported in Brazil. During the 2013 French Polynesian outbreak, researchers found roughly 3% of asymptomatic blood donors actually tested positive for Zika infection, which they deemed unexpectedly high. It is not yet known how commonly recipients of Zika-contaminated blood end up infected, or how they fare.”

ASR hip replacement case settles for $250 million

Hundreds of Australians implanted with a defective hip device will be eligible for a share of $250 million in compensation following the conditional settlement of a long-running class action, the ABC reports. A worldwide recall of DePuy ASR devices in 2010 involved around 100 000 patients worldwide and 5500 in Australia, with approximately 1700 of those patients eligible for a share in the settlement. The settlement was negotiated after 17 weeks in court, but has yet to be approved by the Federal Court. A lawyer speaking on behalf of those bringing the class action said hundreds of Australian patients had yet to have revision surgery and they were welcome to join the class action which will remain open for a period. “There was no admission of liability by the makers of the ASR DePuy hip replacements as a part of the settlement.”

[Comment] Oral misoprostol is as safe as Foley catheter for labour induction…or is it?

In The Lancet, the researchers of the PROBAAT-II study1 pass another milestone on the long and circuitous evolution of methods to ripen the uterine cervix during induction of labour. Before there were prostaglandins, there were mechanical methods. One was a simple Foley catheter bulb passed through the cervix and inflated in the potential space between the amniotic sac and the uterus.2 In the decades following the introduction of dinoprostone vaginal gel, the Foley catheter method was all but forgotten.

It’s official: Zika causes birth defects

The United States’ Centers for Disease Control and Prevention has declared that the Zika virus is a cause of microcephaly and other severe foetal brain defects, confirming long-held suspicions about the infection’s link to serious neurological disorders.

As the US gears up for outbreaks of the potentially deadly virus, the CDC has reported that an accumulation of evidence proves Zika can cause birth defects and pregnant women living in or travelling to areas of where it is prevalent should strictly follow steps to avoid mosquito bites and prevent sexual transmission of the virus.

“This study marks a turning point,” CDC Director Dr Tom Frieden said. “It is now clear that the virus causes microcephaly. We’ve now confirmed what mounting evidence has suggested, affirming our early guidance to pregnant women and their partners to take steps to avoid Zika infection.”

The CDC report, published in the New England Journal of Medicine, said its conclusion was not based on any one discovery but rather an accumulation of evidence from a number of recently published studies and a careful evaluation using established scientific criteria.

The CDC announcement came as the Australasian Society for Infectious Diseases reminded GPs to be on heightened alert for tropical diseases in patients with febrile illnesses – particularly those who have recently travelled overseas.

Society President Professor Cheryl Jones said serious tropical diseases including Zika, multi-drug resistant malaria and dengue were endemic in many overseas destinations popular with Australians, including Thailand, Vietnam, Myanmar, Laos and Cambodia, and there was also a local outbreak of dengue in northern Queensland.

“There has never been a more critical time for Australian health professionals to get up to speed with developments in tropical medicine,” Professor Jones said. “With malaria resistance growing and no antiviral treatment available for dengue, Zika and other mosquito-borne viruses, it is imperative that Australian doctors are able to identify these diseases and refer patients swiftly.”

Her warning came as a senior US public health official, Dr Anne Schuchat, told a White House briefing that the virus “seems to be a bit scarier than we initially thought”.

Dr Schuchat, who is a deputy director of the US Centers for Disease Control and Prevention, said that initially it was thought the species of mosquito primarily associated with carrying the disease was only present in about 12 states, but that had now been revised up to 30 states.

Authorities are particularly concerned about the US territory of Puerto Rico, where they fear there may be hundreds of thousands of infections, but the speed of the disease’s spread has them concerned it may soon appear in continental US as temperatures rise.

“While we absolutely hope we don’t see widespread local transmission in the continental US, we need the states to be ready for that,” Dr Schuchat said.

While the Zika virus has been documented in 61 countries since 2007, the World Health Organization said its transmission has really taken off since it was first detected in Brazil in May last year, and it is now confirmed in 33 countries in Central and South America, as well as 17 countries and territories in the Western Pacific, including New Zealand (one case of sexual transmission), Fiji, Samoa, Tonga, American Samoa, Micronesia and the Marshall Islands.

Its appearance has been linked to a big jump in cases of microcephaly, Guillian-Barre syndrome (GBS) and other birth defects and neurological disorders, and the WHO said that there was now “a strong scientific consensus” that the virus was the cause.

In Brazil, there were 6776 cases of microcephaly or central nervous system malformation (including 208 deaths) reported between October last year and the end of March. Before this, an average of just 163 cases of microcephaly were reported in the country each year.

The WHO reported 13 countries or territories where there has been an increased incidence of GBS linked to the Zika virus. French Polynesia experienced its first-ever Zika outbreak in late 2013, during which 42 patients were admitted to hospital with GBS – a 20-fold increase compared with the previous four years. All 42 cases were confirmed for Zika virus infection.

Similar increases in the incidence of GBS cases have been recorded in other countries where there is Zika transmission, including Brazil, Colombia, El Salvador, Venezuela, Suriname and the Dominican Republic.

Scientists have also detected potential links between the infection and other neurological disorders. In Guadeloupe, a 15-year-old girl infected with Zika developed acute myelitis, while an elderly man with the virus developed meningoencephalitis. Meanwhile, Brazilian scientists believe Zika is associated with an autoimmune syndrome, acute disseminated encephalomyelitis.

Scientists worldwide are working to develop a vaccine for the virus, and an official with the US National Institute of Allergy and Infectious Diseases said initial clinical trials of a vaccine might begin as soon as September.

Meanwhile, research on other aspects of Zika, including its link with neurological disorders, sexual transmission and ways to control the mosquitos that spread the disease is being coordinated internationally.

So far, the only confirmed cases of Zika in Australia have involved people who were infected while travelling overseas, and authorities are advising any women who are pregnant or seeking to get pregnant to defer travelling to any country where there is ongoing transmission of the virus.

Adrian Rollins

[Perspectives] Majid Ezzati: a positive enthusiasm for global health

Among the books on the shelves of Majid Ezzati’s office in the Imperial College Faculty of Medicine at St Mary’s Hospital in London are three small black iron cooking stoves of the kind found by the million in huts and houses in low-income countries around the world. In most offices you might view the stoves as offbeat mementos of a conference somewhere, or a holiday. These are not. Their presence reflects a line of research that Ezzati has been pursing for two decades: the malign effects of the smoke they emit.

Maelstrom of money blows over wind farms

The nation’s peak medical research organisation has committed more than $3 million to investigate whether or not wind farms effect human health amid ongoing controversy on the issue.

There have been persistent claims that wind farms are responsible for a range of health problems despite a lack of evidence, and the National Health and Medical Research Council (NHMRC) has commissioned two studies to try to determine if there is a link.

The Sydney-based Woolcock Institute of Medical Research has been awarded $1.94 million to conduct two randomised controlled trials to examine whether inaudible sounds emanating from wind turbines are causing health problems including headaches, dizziness, nausea and sleep disturbances, while a Flinders University researcher has been provided with $1.36 million to compare the relative effects of wind farms and traffic noise on sleep.

The announcement has come less than a year after the NHMRC completed its own exhaustive study, which found that there was “currently no consistent evidence that wind farms cause adverse effects in humans”.

A year earlier, the AMA had come to a similar conclusion. In a Position Statement released in 2014, the AMA found that “available Australian and international evidence does not support the view that the…sound generated by wind farms…causes adverse health effects”.

The-then Chair of the AMA’s Public Health Committee, Professor Geoffrey Dobb, said that although some people living near wind farms may genuinely experience health problems, these were not directly attributable to wind turbines.

Instead, it has been suggested many may be suffering from a ‘nocebo’ effect, and are becoming ill because of anxiety and dislike of wind farms rather than as a result of any sounds emanating from them.

But this has been vociferously rejected by advocates, who insist the health effects are real, and have campaigned hard for more research.

They have influential political backers in Parliament, including senior Nationals MPs and key crossbench senators, and found a receptive audience in former Prime Minister Tony Abbott. Under Mr Abbott’s leadership, the Government appointed a National Wind Farm Commissioner to monitor and investigate complaints about the wind industry, and established an Independent Scientific Committee on Wind Turbines to advise on the potential health and environmental effects of the industry, at a combined cost of more than $2.5 million over four years.

An investigation by Fairfax Media has found that a third of all complaints to the Commissioner have related to wind farms not yet constructed, while the Scientific Committee has held just two brief meetings since it was formed and is yet to provide any advice to Government.

A leading critic of the Government’s policy agenda, including the NHMRC’s research program, Sydney University public health expert Professor Simon Chapman, said internationally there had been at least 25 reviews which found little evidence that wind farms harmed health.

Professor Chapman told the Sydney Morning Herald the health effects that did exist could be put down psycho-social factors like pre-existing antipathy to wind farms and anxiety, and the research was a waste of money.

“It’s really quite disgraceful – it’s money literally poured down the drain,” he told the SMH.

But lead researcher for the Woolcock project, Professor Guy Marks, defended the research, arguing that there existed a “genuine scientific question that needs to be solved”.

“This is a hotly debated area, with many residents convinced that their health is suffering, and other people sure that it’s all a figment of their imagination,” Professor Marks said.

“As far as I am concerned, the science isn’t settled yet [and] it’s important to find out, for the sake of the communities and interests involved,” his co-researcher, Professor Ron Grunstein, said.

But even if the Woolcock and Flinders University studies find that there is no link, few expect it to be the end of the matter.

“Regardless of what we find, there will be passionate advocates that will never be convinced of our conclusion,” Professor Grunstein admitted.

The AMA Position Statement on Wind Farms and Health 2014 can be viewed at: position-statement/wind-farms-and-health-2014

Adrian Rollins

[Comment] First Liberal budget good for Canadian science, but what about global health?

The Canadian federal election last October brought new leadership to government, and with it an expectation that Prime Minister Justin Trudeau’s Liberal Party would be kinder to Canadian researchers.1 After almost 10 years of Conservative Party rule, during which previous Prime Minister Stephen Harper made few friends among scientists, it was with eager anticipation that Canadians awaited the new budget on March 22, 2016.2

Get back to the BEACH, Govt told

AMA President Professor Brian Owler has urged the Federal Government to reverse its decision to axe funding for one of the most extensive and sustained studies of general practice in the world, arguing the move is “completely at odds” with its stated primary care focus.

In a decision that has shocked and dismayed medical practitioners and researchers, the long-running Bettering the Evaluation and Care of Health (BEACH) program, which began tracking the activities of Australian GPs in 1998, is being wound up after the Federal Department of Health announced it would not be renewing funding for the research after the current contract expires on 30 June.

Professor Owler has written to Health Minister Sussan Ley urging her to reconsider the move, which he said was particularly ill-considered given major changes planned for primary care.

“Research into general practice and primary care attracts very little funding support in comparison to other parts of the health system,” the AMA President said. “The reality is that we need more of this type of research, not less.”

The Government’s decision to axe its funding for BEACH has come less than two week after Ms Ley unveiled the Health Care Homes initiative to give GPs a central role in improving the care of patients with chronic and complex disease. Simultaneously, the Government is trialling its My Health Record e-health record system and is persisting with a four-year freeze on Medicare rebates.

Professor Owler said the Commonwealth had contributed just $4.6 million of the $26 million that had been used to fund the BEACH program over the years.

“This is a very small investment that has delivered significant policy outcomes and, with all the changes planned for general practice and primary care, I think there is a very strong case to extend funding for the program,” he said.

The wealth of data on general practice that the program had collected had proven invaluable in driving evidence-based policy development, Professor Owler said, and warned that there was “no credible source of information and analysis that is capable of filling the gap that will be left when the program ceases”.

The program’s director, Professor Helena Britt of Sydney University’s Family Medicine Research Centre, said the Government’s decision to cease its contribution had come at a time when the program was already facing a funding crunch caused by a downturn in contributions from other sources including non-government organisations and pharmaceutical companies.

“BEACH has always struggled to gain sufficient funds each year,” Professor Britt said. “However, this notification comes when we also have a large shortfall in funding coming from other organisations…due to the closure of many government instrumentalities and authorities, and the heavy squeeze on pharmaceutical companies’ profits resulting from changes to the PBS.

“We therefore have no choice but to close the BEACH program.”

Professor Britt said she had been inundated with inquiries and messages of support from individuals and groups around the country and internationally.

Professor Britt said the BEACH data, which is drawn from an annual sample of GPs providing detailed information on everything from the hours they work to the diseases and other conditions they treat, was a unique resource, and the program’s closure would “leave Australia with no valid reliable and independent source of data about activities in general practice”.

“BEACH has been the only continuous national study of general practice in the world which relies on random samples of GPs, links management actions to the exact problem being managed, and provides extensive measurement of prevalence of diseases, multi-morbidity and adverse medication events,” a statement issued by the Family Medicine Research Centre said.

The data from the latest BEACH survey, which began in April last year and closed at the end of March this year, is being collated and Professor Britt said she hoped to issue a report on the results, possibly in mid-June.

Asked about the possibility of funding coming from other sources, Professor Britt said it was “early days”.

One of the biggest concerns is what will happen to the rich store of data accumulated through the program’s 18 years of operation, during which time more than 11,000 GPs have been surveyed.

Professor Britt said the data was used by a huge range of researchers and organisations, and her group was looking at ways to ensure people would continue to have access to it.

“We would be happy to find a place with a senior analyst who could take request to analyse the data for specific purposes,” she said. “We would like to be able to keep that access up there for at least a little while.”

Adrian Rollins

US gears up for ‘scary’ Zika

The United States is gearing up for outbreaks of the potentially deadly Zika virus amid concerns the mosquito-borne infection can also be sexually transmitted and may cause neurological disorders in adults as well as children.

As Australian health authorities monitor the appearance of the disease, particularly in areas of the country where mosquito vectors are present, a senior US public health official, Dr Anne Schuchat, told a White House briefing that the virus “seems to be a bit scarier than we initially thought”, and health authorities are ramping up efforts to research the disease and raise public awareness of the threat.

“While we absolutely hope we don’t see widespread local transmission in the continental US, we need the states to be ready for that,” Dr Schuchat said.

Adrian Rollins

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