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No Cable Spaghetti in the Brain

Source: Max Planck Society via Medical Xpress

Our brain is a mysterious machine. Billions of nerve cells are connected such that they store information as efficiently as books are stored in a well-organized library. To this date, many details remain unclear, for instance the set of rules that governs the connections between nerve cells and the organization of information therein.

An international team led by scientists of the Max Planck Institute for Dynamics and Self-Organization in Göttingen has now shed new light on these long-standing questions and found that networks are not governed by randomness. Some scientists considered this possibility for the organization of the brain, because randomly connected networks work well in computing applications. To test the random wiring hypothesis, the team examined whether the brain is using random connections to process visual stimuli. To this end, they calculated predictions that rely on the random wiring hypothesis and compared the results with precision measurements of the cortical architecture in various mammals. The result: random connections do not suffice to explain the observed layout of the brain. The scientists conclude that initially random connections in the visual cortex are reorganized to a precisely determined layout using self-organization. Random wiring, in the end, plays a small role… Read More>>

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Researchers Discover How Immune Cells Resist Radiation Treatment

Source: Medical Xpress

Researchers at The Tisch Cancer Institute at the Icahn School of Medicine at Mount Sinai have discovered a key mechanism by which radiation treatment (radiotherapy) fails to completely destroy tumors. And, in the journal Nature Immunology, they offer a novel solution to promote successful radiotherapy for the millions of cancer patients who are treated with it.

The team found that when radiotherapy damages skin harboring tumors, special skin immune cells called Langerhans cells are activated. These Langerhans cells can uniquely repair the damage in their own DNA caused by radiotherapy, allowing them to become resistant to radiotherapy and to even trigger an immune response causing skin tumors such as melanoma, to resist further treatment

Investigators mimicked the effect of immunotherapy drugs called “immune checkpoint inhibitors” to boost the immune system to attack tumors. This in turn blocked the ability of Langerhans cells to repair their own DNA after radiotherapy causing them to die, preventing an immune response that protects skin tumors.

“Our study suggests that this combination approach—combining radiotherapy with drugs that rev up a healthy immune response—will help make radiation therapy much more effective,” says the study’s lead author, immunologist Jeremy Price, PhD… Read More>>

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Researchers Urge Caution in Prescribing Commonly Used Drug to Treat ADHD

Source: Medical Xpress

Authors of new Cochrane Review remain uncertain about effect of widely used medicine on ADHD symptoms, despite large amount of research. Some evidence of increased sleeplessness and loss of appetite leads researchers to encourage more caution in use of methylphenidate.

The Cochrane Library publishes one of the most comprehensive assessments to date on the benefits and harms of a widely prescribed drug used to treat Attention Deficit Hyperactivity Disorder (ADHD).

ADHD is one of the most commonly diagnosed childhood disorders and can continue through adolescence into adulthood. Symptoms include difficulty focusing attention and remaining “on task”, excessively impulsive behaviour, and extreme hyperactivity. It is estimated to affect about 5% of children, and diagnosis is based on clinical judgement rather than objective diagnostic markers.

Methylphenidate, more commonly known by its brand names – Ritalin®, Concerta®, Medikinet®, and Equasym®, amongst others – has been used to treat ADHD for more than 50 years. A team of Cochrane researchers has carefully evaluated and summarized the findings from all of the available randomized trials of this widely used drug… Read More>>

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Investigating Hair Loss in Women

By Dr Vivienne Miller, GP and Fellow, The Royal Australian College of General Practitioners

Hair loss in men is not typically investigated, but rather is more accepted and is attributed to age and genetics. Although many women have these as the same causes for hair loss, they not uncommonly request investigation to see if there is a treatable cause.

Hair loss in women may be appear less severe than, but otherwise similar to men as a patterned hair loss (as a receding hairline and general thinning of the hair, especially over the crown)1 or may be some other distribution of hair loss (such as telogen effluvium, alopecia, traction alopecia or scalp disease). As with men, the patterned hair loss is genetic and in women becomes more noticeable after menopause, especially with very advancing age.

The normal cycle of follicular development that causes the hair to fall out needs to be understood in order to correctly assess the presentation. It is normal to lose up to one hundred hairs a day. During anagen, hair grows rapidly over two to six years, up to a centimetre every month.sup>2 If the anagen phase is short, the individual’s hair will naturally not grow easily to be as long. “Catagen” is when the hair ceases growing for several weeks and the root sheath adheres to the root. The resting, or “telogen”, phase, usually lasting three to four months, affects six to eight percent of hairs at any time.sup>2 The hairs during this phase naturally fall out more easily and with minimal effort.

If the physical examination and history does not suggest an obvious cause, iron deficiency and thyroid disease should be ruled out as common conditions that can cause increased hair loss. Polycystic ovarian syndrome with raised testosterone levels may also be associated with premature pattern hair loss. Occasionally, a scalp biopsy may be required. Rare causes include hormonally active adrenal tumours secreting DHEAS or cortisol.

1. Patterned Hair Loss, Better Health Channel,Victorian State Government

2. WebMD. Hair loss: The science of hair. March 1st 2010

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By Dr Vivienne Miller, GP and Fellow, The Royal Australian College of General Practitioners

Jeanne, aged 23 years, had been seeing a chiropractor for almost four months and having realignment of her thoracic spine, involving manipulation, massage and acupuncture, as she had a painful left shoulder and upper left back. The chiropractor had told her she had hypermobile joints and that to be sure there was no spinal pathology, she should have a thoracic vertebral MRI and imaging of her left shoulder. An x-ray done and interpreted by the chiropractor was normal, according to Jeanne. The GP who saw Jeanne paid special attention to the general orthopaedic examination. Jeanne was right handed and had had no significant injuries to her left shoulder in the past. She did, however, hang the shoulder down due to pain, compared to the other side. The pain was worsening over time and she had had it now for at least two weeks prior to seeking advice from the chiropractor. Jeanne had no evidence of significant hypermobility in her joints and no previous trauma. Her work was office-based and she answered the phone with her left hand and  rested it on her shoulder to speak. This was likely associated with the onset of the pain. 

Because of the significant wasting of the left supraspinatus and trapezius muscles, Jeanne was sent to an orthopaedic surgeon who specialised in the upper limb. He felt she was not hypermobile, but that the shoulder pain was due to the way she took phone calls and that it was worsened by (specifically) the manipulation of her left scapula by the chiropractor. He did not think she required imaging at this stage because clinically, she had scapulothoracic bursitis and spasm of her trapezius and supraspinatus muscles as her main problems. The frequent manipulation had worsened the condition and now she presented with “snapping scapular syndrome” (pain, discomfort, popping, grating or crackling in the region due to altered mechanics of the scapular moving over the thorax).1 If she did not improve over the next few weeks imaging would be advisable.

The specialist thought that Jeanne should alter her desk to answer the phone on her right hand side. She should have physiotherapy (without manipulation) to reduce the muscle spasm and to develop the strength in the muscles of her shoulder girdle and he prescribed anti-inflammatory medication (she had no history of asthma). Jeanne declined a steroid injection into the scapulothoracic bursa. She was to be reviewed by the GP over the next few months to ensure her recovery.

1.  Kuhne, M. et al, The Snapping Scapula, Diagnosis and Treatment


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ADHD: Fact or Fiction?

By Dr Vivienne Miller, GP and Fellow, The Royal Australian College of General Practitioners

Attention hyperactivity disorder (ADHD) tends to evoke strong feelings in people. Is it a real condition, a variation of normal, an excuse for poor parenting, the result of unhappy families or a genetic disease? Attention deficit disorder (ADD) is not associated with so much controversy, probably because the children are so much less boisterous, do not require as much supervision and hence, in this respect, they are “easier” children who do not embarrass their parents and supervisors by their behaviour.

The diagnostic features of ADHD are hyperactivity, inattention and impulsivity that are demonstrated in multiple settings. In addition to these three criteria, children must have six or more criteria from the inattentive signs and those over 17 years must have five.1

ADHD is a real condition, probably a variation of normal, and is a pervasive neurodevelopmental disorder (as recognised in DSM IV and V).1 Affected individuals do not “grow out of” ADHD,but many adults have learned to manage the condition, with or without medication. There is definite genetic evidence for ADHD.2,3

“ADHD is highly heritable and multifactorial; multiple genes and non-inherited factors contribute to the disorder. Prenatal and perinatal factors have been implicated as risks, but definite causes remain unknown.”

Affected individuals have a high risk of other mental health disorders, both in childhood and adulthood, namely learning disabilities, depression, bipolar disorder, anxiety, self-harm (both accidental and deliberate), oppositional/defiant disorder, conduct disorder and drug and alcohol abuse.3 In addition to this, ADHD is more common in patients with Asperger’s syndrome,4 Tourette’s syndrome3 and after head injuries.3 This should not be surprising, as it is a genetic neurocognitive disorder.

There is also has a strong environmental influence, especially regarding the family environment, education and the way these children are disciplined. Frustration and misunderstanding by teachers, parents and family may lead to more frequent and severe discipline. This then affects trust of authority and contributes to low self-esteem in youths with ADHD. Friendships are harder for these children to maintain as other parents may not consider these children well-behaved or obedient, and the friends themselves may become quickly irritated by their noisier and rougher hyperactive playmates. Social isolation from the more disciplined and academically successful classmates is common, leaving the more emotionally disturbed children and others with ADHD in the school as playmates. This may breed a vicious circle of poorer role models.

In addition to these co-morbidities and socialisation problems, the family itself may be blamed for the child’s rowdy behaviour and this puts a great stress on the parents.5 Divorce rates are higher in families with youths who have ADHD and happen more rapidly than in other couples.5 Importantly, there is evidence that these findings are not the only cause of the ADHD child’s behaviour, however, clearly, children are more settled in a stable family environment.5 It should also be noted that parents with children who have ADHD have a statistically higher chance of being diagnosed with ADHD and its co-morbidities.5

When all the research is taken into account, it is clear that ADHD is a genetic neurocognitive disorder that is highly heretible and lifelong. The affected individuals function with greater difficulty socially and their family stress is increased by this condition. There is a lifelong higher risk of co-morbidities in individuals who have ADHD, based on genetics and the environmental influences. ADHD should therefore not be blamed on the family or environment alone, and ADHD is definitely not fiction.


1. DSM V

2. Thapar, A., Cooper, M. Attention Deficit Disorder, The Lancet, 16th Sept 2016

3. Attention Deficit Hyperactivity Disorder, National Institute of Mental Health
NIMH » Attention Deficit Hyperactivity Disorder (ADHD)

4. Roy, M. et al. Asperger Syndrome: a frequent comorbidity in first diagnosed adult ADHD patients Psychiatr Danub. 2013 Jun;25(2):133-41

5. Wymbs, B. et al. Rate and predictors of divorce among parents of youth with ADHD

J Consult Clin Psychol. 2008 Oct; 76(5): 735–744.

Asperger Syndrome: a frequent comorbidity in first diagnosed adult ADHD patients? – PubMed – NCBI Rate and predictors of divorce among parents of youth with ADHD

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Taming Hot Flashes Without Hormones: What Works, What Doesn’t

Source: The North American Menopause Society via Medical Xpress

Some three-quarters of North American women have menopausal hot flashes, but many cannot use hormones for medical reasons or choose not to. Numerous products and techniques are promoted for hot flashes, but do they work, and are they safe? To answer these questions, a North American Menopause Society (NAMS) panel of experts weighed the evidence and made recommendations in a position statement, “Nonhormonal management of menopause-associated vasomotor symptoms,” published online in the Society’s journal, Menopause.

From 50 to 80 percent of women approaching menopause try nonhormonal therapies for hot flashes. Many don’t really work, and sticking with those therapies can just prolong the misery. With little guidance on what does work, many women just experiment with products or suffer. “Many women try one thing after another, and it is months before they stumble upon something that truly works for them,” said Janet S. Carpenter, PhD, RN, FAAN.

US surveys show just how uncertain women are about these therapies, with one survey demonstrating that nearly half feel confused about their options for managing menopause symptoms and another showing that 75% don’t feel fully informed about herbal products. But with this careful, critical look at all the available studies, healthcare providers can confidently advise women on how to handle hot flashes without hormones… Read More>>


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Healthed will be focusing on Menopause Management in the Women’s and Children’s Health Updates in 2016. Register now for the Sydney, Melbourne, Adelaide, Brisbane or Perthseminars.
Full program coming soon!
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No Libido, No Problem

By Dr Vivienne Miller, GP and Fellow, The Royal Australian College of General Practitioners

John, aged 38 years and in excellent health, came in by himself for advice as his wife had had enough. She wanted him to get a referral to have sexual counselling, but John couldn’t see how it would help. This was because John had never had any sex drive at all, even from puberty. Although he had erections with a full bladder in the morning or with stimulation, he didn’t masturbate, he couldn’t relate to his mates getting excited by a pretty girl or a sexy photo, he was certainly not interested in intercourse, and hadn’t been with previous relationships either.  His wife had accepted, until now, that sex a few times a year with John was her future. She had managed to conceive her two children with John through careful timing and pleading. They were truly conceived through two acts of love, because he didn’t want to disappoint her and he did want to be a father.

After a long discussion, it was clear that this was his wife’s problem more than John’s, and that there was nothing physically or mentally wrong with John. His problem was not even an issue to him, but he understood intellectually that he was different to other men and felt sorry about his wife being so frustrated.  The relationship was otherwise very good and she didn’t want to take up his suggestion of another lover on the side. She wanted him to be “normal”.

‘Hyposexual desire disorder” is an underreported condition. The diagnosis is based on the history, physical examination and the exclusion of medical conditions as indicated (especially thyroid disease and hypoandrogenism).1  Medications and mental problems (especially stress, depression, relationship problems and fatigue) are common causes of this condition. Absent desire is associated in some cases with the patient not being completely frank about their sexual orientation, or past sexual trauma. The condition is more common in women.1

There is no effective treatment for lifelong hyposexual desire disorder,1 such as in John’s case (which is the rarest form).  Testosterone is not indicated for this condition in eugonadal men in Australia, and the results are inconsistent for this indication.1 Psychotherapy and sexual therapy are commonly suggested but research data is lacking.1 Dual couple sexual therapy has evidence of success, as does cognitive behavioural therapy for relationship and mental health issues.1

After a long consultation, John decided not to pursue any form of counselling. He decided he would try to accommodate his wife’s requests more frequently, come to some compromise with her and show her he loved her in other ways.


1. Keith A. Montgomery, MD Sexual Desire Disorders. Psychiatry, 2008 Jun; 5(6): 50–55.

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The Significance of Detecting Vertebral Crush Fractures on Chest X-Rays

By Dr Vivienne Miller, GP and Fellow, The Royal Australian College of General Practitioners

Chest x-rays are commonly ordered for other reasons, and so incidental thoracic vertebral crush fractures are often overlooked in the report by radiologists. The importance of their documentation is that they suggest osteoporosis and the Medicare guidelines state that a vertebral crush fracture of 20% or greater qualifies as a fracture from minimal trauma. This then means that the patient may access bone mineral densitometry with a Medicare refund.1

This is important, as only patients over 70 years of age or those who have certain medical conditions can currently access bone mineral densitometry with a Medicare refund.

If patients have osteoporosis formally diagnosed (a T score of -2.5 or less) and are aged 70 years and over, or have had a fracture with minimal trauma, or have specific endocrinological reasons for the osteoporosis, they may have subsidised medication to prevent further bone loss.2 It should be noted that the Osteoporosis guidelines in Australia are less strict than the PBS Authority Guidelines and suggest that treatment be offered to a wider range of individuals.3

Radiologists are almost always happy to amend a report to confirm a significant vertebral crush fracture; GPs need to look at the chest x-rays to ensure this condition does not go unrecognised. Finally, bureaucratic as it sounds, it may be necessary to help patients (in particular those with financial stress) access subsidised osteoporosis testing and possibly treatment. This is simply done by ordering a chest X-ray to identify vertebral crush fractures in those who have a significant kyphosis clinically.

Regarding bone densitometry, currently, Medicare benefits are payable for:

  • the diagnosis and monitoring of bone loss if a patient has certain specific medical conditions or is undergoing particular treatments likely to cause rapid bone loss;
  • the confirmation of clinically suspected low bone mineral density, usually following a fracture;
  • the subsequent monitoring of established low bone mineral density; and/or
  • those patients over the age of 70 years.1

Regarding antiresorptive treatment requiring an Authority:

Primary prevention

Treatment as the sole PBS-subsidised anti-resorptive agent for osteoporosis in a woman aged ≥ 70 years with a bone mineral density (BMD) T-score of ≤ –2.5.1,2 The date, site (femoral neck or lumbar spine) and score of the qualifying BMD measurement must be documented in the woman’s medical record when treatment is initiated.

Secondary prevention

Treatment as the sole PBS-subsidised anti-resorptive agent for established postmenopausal osteoporosis in a woman with fracture due to minimal trauma. The fracture must have been demonstrated radiologically and the year of plain X-ray, computed tomography or magnetic resonance imaging must be documented in the woman’s medical record when treatment is initiated.2


1. Department of Health: Bone Densitometry and Medicare

2. Pharmaceutical Benefits Scheme

3. Osteoporosis Australia. Medicine: Medical Guide (2nd Edition 05/14)

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Hearing Voices Network

By Dr Vivienne Miller, GP and Fellow, The Royal Australian College of General Practitioners

General practitioners who are interested in mental health are likely to have heard about the “Hearing Voices Network”.  This is an international, not-for-profit organisation that has been set up in most states and territories across Australia.  It promotes the use of talking therapies and exploring the meaning of the voices, especially pertaining to their content.1  This management strategy may be appealing to people who are concerned about hearing voices, and in this author’s opinion, could, with the correct approach, be of great benefit as adjuvant therapy for many mental health patients. However, there are significant concerns.

The Hearing Voices Network emerged following research by Professor Marius Romme and Sondra Escher from Maastricht University, in conjunction with a Dutch self-help group in 1987. The Network (rightly) believes there are many explanations for hearing voices and:

Although the Network is open to many diverse opinions we accept the explanation of each individual voice hearer.”1

Herein lies the first problem. This organisation states they can help people who hear voices. However, as the Network does not involve itself in any medical assessment or diagnosis, it can and does absolve itself from any responsibility to the patient regarding advice about medical review. The UK Network’s homepage states the following:

“If you hear voices HVN can help – we are committed to helping people who hear voices. Our reputation is growing as the limitations of a solely medical approach to voices become better known. Psychiatry refers to hearing voices as ‘auditory hallucinations’ but our research shows that there are many explanations for hearing voices. Many people begin to hear voices as a result of extreme stress or trauma. We offer information, support and understanding to people who hear voices and those who support them.1

Hearing voices is a well-known symptom of many serious psychiatric conditions, such as bipolar disorder (type 1), schizophrenia, psychotic depression, post-traumatic stress disorder, adverse reactions to illicit drugs, dementia and borderline personality disorder.2  It is also a common, transient symptom of bereavement, in response to prayer3 and situationally (e.g. mishearing something in a crowded environment).

The second problem concerns how the Hearing Voices Network helps people who approach them. What is not immediately apparent is this organisation does not integrate with qualified doctors or psychiatrists who would classify a patient as having a psychosis, and the Network does not appear to favour the inclusion of health professionals. The website writes about their “allies”, suggesting an “us versus them” mentality, and says that they work “collaboratively and inclusively with other services” (these services are not actually defined or identified)4.

The third problem is the Network’s position statement on DSM V and psychiatry. The following underlined headings are directly from the UK website, followed by a summary of the points made under them.

Position Statement on DSM V and Psychiatric Diagnosis5

Main issues                                                                                                                                        Psychiatric diagnoses are scientifically unsound:     This section specifies drug company involvement, unreliable and flawed diagnoses in psychiatry and limited explanations for problems such as ‘schizophrenia’ (as it is noted in single quotation marks on the site).

Psychiatric diagnoses have damaging consequences: This section states that psychiatric diagnosis disempowers the patient, is medication-focused and that medication is harmful and ineffective and that human rights are violated, psychiatric diagnosis takes away hope and is discriminating.

This position statement is extremely concerning. People approaching the Hearing Voices Network are likely to be concerned about the voices, what is being said, how frequently and what they have been told by mental health specialists. They are much more likely to seek advice from such an organisation, as opposed to the small percentage of the population who have only experienced a transient or rare auditory hallucination.6 These more affected individuals may feel the Network understands them better than doctors and that they are accepted as not ‘mad’. The reasons for these people approaching the Network selects automatically those who are likely to have a high risk of developing, or already having, a serious mental illness.

Modern psychiatric management is accepted as the best option (not necessarily perfect or curative), for patients with psychosis. Yet, here is an organisation that does not advise its members of this option and in part discourages them from seeking medical advice. There is no responsibility taken for the consequences. It would be easy to think that this Network is using international criticism of DSM V to misinform and disadvantage people who have serious mental health problems and to foster mistrust of psychiatric health care.

GPs should be very wary of the Hearing Voices Network as one cannot safely trust such a group to guide patients appropriately.


1. Hearing Voices Network (UK)

2. Government of Western Australia Department of Health

3. McCarthy-Jones, S. et al. Spirituality and hearing voices: considering the relation Psychosis.   2013 Oct; 5(3): 247–258

4. Hearing Voices Network Australia

5. Hearing Voices Network (UK) Position Statement on DSM V and Psychiatric Diagnosis

6. McGrath, J. et al. Psychotic Experiences in the General Population A Cross-National Analysis Based on 31 261 Respondents From 18 Countries JAMA Psychiatry. 2015; 72(7):697-705. doi:10.1001/jamapsychiatry.2015.0575.

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