Issues
Volume 207 Issue 10
News
News briefs
Computational simulations suggest multiple sclerosis is a single disease Research at the University of Barcelona, published in PLOS Computational Biology, supports the view that multiple sclerosis, the symptoms and progression of which vary widely between patients, is nonetheless a single disease with consistent underlying mechanisms. Multiple sclerosis is an autoimmune disease that can cause a variety of problems, including blurred vision, impaired memory, and paralysis. Symptoms and patterns of disease progression over time vary among patients, leading to suggestions that it may consist of two or more different diseases. The researchers hypothesised that multiple sclerosis is a single disease with differing outcomes for different patients, but all driven by the same underlying biological mechanism: an immune system attack upon the protective sheaths around nerve cells, resulting in chronic inflammation and axonal degeneration. The researchers developed a mathematical model of multiple sclerosis based on experimental data from 66 patients who had been followed for up to 20 years. They used the model for computational simulations of the various biological processes known to be involved in the disease. To test the validity of their model, the investigators also ran simulations with data from a second group of 120 patients with multiple sclerosis. They found that changing the intensity of the underlying biological processes involved in multiple sclerosis at particular time points reproduced the variability of the disease courses seen in these patients. Their results support the hypothesis that the various symptoms and disease courses associated with multiple sclerosis are produced by the same underlying mechanisms. “This concept has significant therapeutic implications and will drive the development of new therapies because it implies that multiple sclerosis will produce significant disability if had for enough time in all patients,” says co-author Dr Pablo Villoslada. “Indeed, preventing relapses, although very important, will not be enough to achieve good control of the disease.” http://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1005757 Afternoon heart surgery linked to better outcomes for patients Outcomes for open heart surgery may be improved by moving surgery from the morning to the afternoon, according to a study published in The Lancet. The researchers identified a link between an individual’s circadian clock and their risk of heart damage and major cardiac events after heart surgery. The study also provides early insights into the mechanism behind this link, finding that the expression of nearly 300 genes in myocardial tissue varied according to the time of day. After open heart surgery, some patients develop damage to the heart that affects its ability to pump blood, resulting in poor outcomes, including heart failure and a heightened risk of death. Previous research has suggested that cardiovascular events (such as myocardial infarction) in the morning may be associated with a higher risk of damage than afternoon events, but the reasons have been unclear. The Lancet study, from the University of Lille in France, included an observational investigation of the association between time of day of surgery and outcomes, a randomised controlled trial investigating whether there was a causal link between the two, and a human tissue analysis to identify genes involved in the circadian effect on heart surgery. In the 6-year observational study, researchers tracked the medical records of 596 people who had had heart valve replacement surgery (half with surgery in the morning, half in the afternoon) for 500 days, to monitor any major cardiac events, such as a heart attack, heart failure or death from heart disease. Patients who had afternoon surgery had a 50% lower risk of a major cardiac event than those who had surgery in the morning (9.4% compared with 18.1%), which is equivalent to one major event avoided for every 11 patients who had afternoon surgery. In the randomised controlled trial, conducted from January 2016 to February 2017, 88 patients were randomly scheduled for heart valve replacement surgery in the morning or afternoon, and their health was monitored until they left hospital. There were no deaths in either group, and the average stay in hospital was 12 days. Patients who had afternoon surgery had lower levels of heart tissue damage after surgery than patients who had morning surgery. The researchers then tested 30 heart tissue samples from a subgroup of patients included in the trial (14 from the morning surgery group, 16 from the afternoon surgery group). They found that the afternoon surgery samples more quickly regained their ability to contract when placed in conditions that replicated the heart refilling with blood. Genetic analysis found that 287 genes in myocardium were differentially active in the afternoon and morning surgery samples. This suggests that cardiac physiology is subject to the activity of the body’s circadian clock, and that surgical outcomes reflect the heart’s poorer ability to repair itself in the morning than in the afternoon. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32132-3/fulltext
Cate Swannell
Perspectives
The future of health care in Australia
Our future health system must focus on overcoming health inequality
The Hon Catherine King
Challenging how tobacco is sold in Australia
Despite being addictive and deadly, tobacco is widely accessible in all communities
Becky Freeman
Legal does not mean unaccountable: suing tobacco companies to recover health care costs
The potential benefits of holding tobacco companies to account through litigation may affect future Australian tobacco control strategies.
Ross MacKenzie · Eric LeGresley · Mike Daube
Medical education
Spontaneous pneumomediastinum
A 20-year-old man with asthma presented with a 5-day history of coughing bouts and pleuritic chest pain
Ching Soong Khoo · Siti Soraya Ab Rahman
Spirometry: key to the diagnosis of respiratory disorders
Poor quality spirometry or incorrect interpretation compromises clinical diagnosis and management
John R Wheatley
Book/media/app reviews
Comprehensive guide to the diagnosis and management of occupational lung diseases
Parkes’ occupational lung disorders, 4th edition
Arthur (Bill) W Musk
Commentaries and clinical tips for assessing respiratory diseases
Challenging concepts in respiratory medicine: cases with expert commentary
David J Barnes
Editorials
Lung health in a changing world
Respiratory health is threatened by changes to our climate and environment — but there is also good news
Matthew J Peters · Jane E Bourke
Youth mental health: building beyond the brand
Youth mental health is a hot topic. How much progress have we made, and what’s next?
Patrick D McGorry
Research
High flow or titrated oxygen for obese medical inpatients: a randomised crossover trial
Current recommendations to titrate oxygen administration are confirmed
Janine Pilcher · Michael Richards · Leonie Eastlake · Steven J McKinstry · George Bardsley · Sarah Jefferies · Irene Braithwaite · Mark Weatherall · Richard Beasley
Composite reliability of workplace-based assessment of international medical graduates
WBA is a reliable method if multiple tools and assessors are used over a period of time
Balakrishnan (Kichu) R Nair · Joyce MW Moonen-van Loon · Mulavana Parvathy · Brian C Jolly · Cees PM van der Vleuten
Research letter
Patients with thunderstorm asthma or severe asthma in Melbourne: a comparison
Sensitivity to rye grass may predict susceptibility to thunderstorm-related asthma
Michael F Sutherland · Emma Le Portelli · Allison L Collins · Muhammad Aziz Rahman · Christine F McDonald
Guideline summary
COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update
Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and chronic airflow limitation, and is associated with exacerbations and comorbidities
Ian A Yang · Juliet L Brown · Johnson George · Sue Jenkins · Christine F McDonald · Vanessa M McDonald · Kirsten Phillips · Brian J Smith · Nicholas A Zwar · Eli Dabscheck
Narrative review
Occupational lung diseases in Australia
Occupational exposures are an important determinant of respiratory health
Ryan F Hoy · Fraser Brims
Mesothelioma in Australia: a review
The incidence of this fatal disease is presumed to have peaked with the prohibition of asbestos, but remains high
Arthur (Bill) W Musk · Nicholas de Klerk · Fraser J Brims
Letters
Cortisone injections for tennis elbow should be an “avoid”, rather than a recommended procedure
To the Editor: We are strong supporters of Choosing Wisely, which promotes appropriate use of medical procedures and evidence-based medicine. We bring to your attention an example of a recommendation published in the 2017 edition of the Australian Therapeutic Guidelines for rheumatology,1 which is contrary to level 1 evidence (ie, multiple randomised control trials) and the Choosing Wisely ethos. The guidelines suggest that local corticosteroid injections may be considered for lateral epicondylitis (tennis elbow) and repeated if needed. The recommendation uses the less than prudent justification: “local corticosteroid injection can provide pain relief for 6–12 weeks”.1 There are now at least five high quality randomised control trials of corticosteroid injection for tennis elbow with 6 or more months follow-up, and collectively they show harm of corticosteroid compared with placebo injection or conservative treatment for time periods greater than 3 months. We reference three of these trials,2-4 and others show consistent results. There are no high quality published trials showing benefit of corticosteroid over placebo injection at time periods greater than 3 months, and one review, in fact, showed an association of poorer long term outcome with repeated injections.5 It is not reasonable, nor should it be good clinical practice, to justify a possible medium term harm by reference to a much shorter term benefit. Based on current evidence, corticosteroid injection for tennis elbow should become a Choosing Wisely “avoid” procedure. Practice guidelines such as the Australian Therapeutic Guidelines for rheumatology ought to more carefully consider level 1 evidence to avoid supporting a prevailing traditional treatment option that is not evidence-based. In treatments with potential benefits and harms that have been tested by randomised control trials, recommendations should only support those treatments with a high quality trial evidence of benefits outweighing harms.
John W Orchard · Bill Vicenzino
Euthanasia and physician-assisted suicide: focus on the data
To the Editor:Emanuel1 enjoins readers to focus on the data concerning euthanasia and physician-assisted suicide (PAS), and to aim at improving the care of dying patients, but advances straw arguments on the basis of three claims in the end-of-life debates that are disputed by neither advocates nor opponents of assisted dying. From the fact that euthanasia and PAS are rarely requested and rarely cause death, Emanuel argues that legalising them will not help solve the problem of inadequate symptom management or improve palliative care. But he adduces no evidence that supporters of legalisation make this claim. Describing legalisation as “really a sideshow in end-of-life care — championed by the few for the few” minimises the plight of those who would avail themselves of euthanasia and PAS, and is belied by the consistent majority support in Western communities for legalisation.2 Pain is recognised, by both advocates and opponents of legalisation, to not be the primary reason why people seek euthanasia and PAS. To claim that the real motivators of requests for assistance (eg, depression, loss of control and loss of dignity) “are not relieved by increasing the dose of morphine, but by antidepressants and therapy”, perpetuates the myth that medicine can, and should, always provide therapeutic answers to such personal dilemmas.3 Emanuel describes requests for euthanasia and PAS as amounting to “traditional suicide condoned and assisted by the medical community”, on the grounds that they are motivated by psychological factors. This statement begs the question about the ethical and legal propriety of euthanasia and PAS by equating PAS with other categories of suicide, without adequate analysis. No one would be surprised at the data supporting Emanuel’s claim that all medical procedures have problems and complications, and that euthanasia and PAS are no exceptions. But to conclude from this that “the common view of euthanasia and PAS as quick, flawless, and painless ways to die is unrealistic” introduces an alleged “common view” that is also unsupported. These are all examples that seem to advance evidence-based arguments in support of a particular ethical and policy position, but one that has been decided ahead of the evidence.
Malcolm H Parker
Careers
Port Augusta GP on “cloud nine”
Dr Amanda Bethell claims the Royal Australian College of GPs’ top honour at the GP17 annual conference
Cate Swannell
Conferences in Australia and New Zealand
This calendar will be updated each month. If you have an event you would like to add, please include relevant details in an email to cswannell@mja.com.au
Cate Swannell
Supplement
Beyond brand: inside youth mental health
Med J Aust 2017; 207 (10 Suppl).
News briefs
Cate Swannell
The MJA 2017: the year in review, and looking forward to 2018
Nicholas J Talley
Safeguarding the health of future generations
Elizabeth O'Brien
Neville Wran’s voice: how the Premier’s Teflon-coated vocal cords came unstuck
Evangelos Tseros · Faruque Riffat · Carsten E Palme · Hedley G Coleman · Narinder P Singh
News briefs
Cate Swannell
The future of health care in Australia
The Hon Greg Hunt
Tackling antimicrobial resistance globally
Ruth Kelly · Sally C Davies
The kids are OK: it is discrimination not same-sex parents that harms children
Ken W Knight* · Sarah EM Stephenson* · Sue West* · Martin B Delatycki · Cheryl A Jones · Melissa H Little · George C Patton · Susan M Sawyer · S Rachel Skinner · Michelle M Telfer · Melissa Wake · Kathryn N North · Frank Oberklaid