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Cardiology

Clinical Articles

Salt may have been unfairly targeted as a killer in the healthy heart stakes, according to newly published research.The observational study of over 90000 people in 300 communities across 18 countries, found that sodium consumption was not associated with an increase in health risks unless the average daily consumption was excessive – more than 5g/day or 2.5 teaspoons of salt. And, this average high daily sodium intake was mostly seen in China, with only about 15% of communities outside of China exceeding this 5g a day limit.As part of this ongoing Prospective Urban Rural Epidemiology (PURE) study, participants aged 35-70 were assessed initially at baseline and then followed for an average of 8.1 years, over which time the occurrence of any major cardiovascular events or death was recorded.What the researchers found was that the risk of hypertension and strokes was only increased in communities where the average daily sodium intake was greater than 5g. Perhaps unexpectedly, this higher sodium intake was actually found to be also associated with lower rates of myocardial infarction and total mortality. Furthermore, the research found that very low levels of sodium intake were harmful, being associated with an increased risk of cardiovascular disease and mortality.The findings fly in the face of the current WHO guidelines that recommend, as a global approach we should be aiming for populations to reduce their sodium intake to below 2g/day.However, no communities in the study came close to achieving this target. In fact, no communities in the study had an average sodium intake of less than 3g/day, based on morning fasting urine samples from the participants.“Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate,” the Canadian study authors said.But before we all go and stock up on our Saxa, an accompanying editorial sounds a word of caution. While acknowledging the findings that ‘normal’ salt intake appeared to be at least health-neutral if not beneficial, the editorial authors remind us that the study is observational and has not taken into consideration a number of potential confounders such as diet. Without taking these confounders into account, one can’t assume that just decreasing salt intake in people at high risk of stroke or increasing it in people at risk of a heart attack will work, they said.“Nevertheless the findings are exceedingly interesting and should be tested in a randomised controlled trial,” they concluded, adding that such a trial, to be conducted in a US federal prison population had been proposed. Ref:LancetVol 392 No 10146 pp:496-506Vol 392 No 10146 pp: 456-458

By Dr Linda Calabresi

Infectious diseases

Clinical Articles

The microbiology laboratory has made great strides in introducing clinically useful diagnostics over the past couple of decades, particularly in recent years with the development of molecular assays that ‘narrow the gap’ and provide early diagnoses.While introducing new tests, it has also been important to evaluate and discard old tests that may not contribute greatly to patient outcomes. One such test that has come under the spotlight is the classic Widal agglutination test in the diagnosis of typhoid.The Widal test, developed by George Fernand Widal in 1896, uses a suspension of killed Salmonella typhi as antigen to detect agglutinating antibodies to somatic O antigens and flagellar H antigens present in serum of typhoid patients. There are many reasons for its lack of clinical utility.Antibodies are not present in the acute illness and take time to develop.Significant cross reactivity can occur with other infectious agents that mimic typhoid including malaria, dengue, endocarditis, tuberculosis and chronic liver disease.Other limitations are of a technical nature and include non-standardisation of the antigen preparation used in the assay, interference with serological responses following typhoid vaccination commonly provided to travellers, and prior exposure and antibodies in patients most susceptible to typhoid, especially those from endemic areas visiting friends and relatives (VFRs).Unless multiple antigens are included, it generally does not detect the other causes of enteric fever, S. Paratyphi A, B and C.It is now time to discontinue this simple agglutination test for typhoid in modern medicine and consider more appropriate diagnostic tests.Typhoid fever Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. Whereas Salmonellae which cause gastroenteritis are zoonoses, humans are the only reservoir for S.Typhi and S. Paratyphi which cause enteric fever.Typhoid fever is still common in the developing world where it affects about 21.5 million people each year but is much less common in the Lucky Country such as ours where good sanitation prevails. About 100 cases are notified each year in Australia. In 2014, 92% of cases were acquired overseas. India continues to be the most common country of acquisition and in 2014 accounted for more than half of cases.Most transmission occurs through contaminated drinking water or food. Large epidemics are most often related to faecal contamination of water supplies or street-vended foods.A chronic carrier state – excretion of the organism for more than one year – occurs in about 5% of infected persons. Where no travel history is present, the likely source of infection is contaminated food or water from a human carrier akin to ‘Typhoid Mary’. Such an outbreak was reported in Auckland, New Zealand, this year where 20 local cases and one death occurred when a carrier from Samoa helped prepare food at a church community gathering.The incubation period is typically eight to 14 days but may be much longer.Without therapy, the illness may last for three to four weeks and death rates range between 12% and 30%. Increasing resistance to available antimicrobial agents, including fluoroquinolones, has occurred in recent years. Resistance to antimicrobials including amoxycillin, and trimethoprim+sulfamethoxazole has limited the options for treatment; reduced susceptibility to quinolones is common in infections acquired on the Indian subcontinent and in Southeast Asia.While awaiting the results of susceptibility testing, azithromycin or ceftriaxone should be used for initial therapy for infections acquired in these regions.Diagnosis of enteric fevers Two sets of blood cultures are the single most useful diagnostic procedure for diagnosis of enteric fever. Other bodily fluids and tissues may yield positive cultures including faeces, urine, and if seeded, bones and joints, liver and gall bladder.Food handlers, healthcare workers, carers of children, and carers of the elderly, and others who are not able to maintain their own personal hygiene, should further be excluded from working with food or caring for people until two consecutive stool specimens – collected at least 48 hours apart and the first specimen collected not sooner than 48 hours post-cessation of antibiotics – are culture negative.Prevention Both an oral live attenuated multi-dose vaccine and a killed vaccine are available. Booster doses after 3-5 years are generally required if continued exposure occurs.Vaccine efficacy is of the order of only 80%.What to order Blood culture x 2 (Salmonella Typhi and Salmonella Paratyphi)Faeces for Bacterial PCR and MCS;Urine MCSCollection Centres: Faeces and urine samples are accepted at all collection centres. Blood cultures are collected only at designated collection centres.Sample Blood (use blood culture bottles), faeces, urineTransportation AmbientCosts Medicare rebate appliesTyphoid MaryMary Mallon, better known as Typhoid Mary, was an Irish immigrant to New York and the first person in the United States identified as an asymptomatic carrier of the pathogen associated with typhoid fever. Over the course of her career as a cook, she was presumed to have infected 51 people, three of whom died. She was twice forcibly isolated by public health authorities and died after a total of nearly three decades in isolation. General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs.The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.

By Dr Jenny Robson

Cardiology

Clinical Articles

Low density lipoprotein cholesterol is the well-known culprit in terms of cardiovascular risk.Courtesy of a large meta-analysis of statin trials done in 2010 (the Cholesterol Treatment Trialists Collaboration), we know that for people starting with higher LDL-C levels (approximately 3.4 mmol/L), they can lower their risk of having a major adverse vascular event by 22%, every time they lower their LDL-C level by 1mmol/L.But what happens once your LDL level is lower? Can you continue to increase your protection by lowering your LDL levels further? Or does the beneficial effect plateau at a certain level? Or, worse still can very low LDL levels actually cause harm?A new meta-analysis just published in JAMA Cardiology has gone some way in answering these questions.The researchers analysed data from the 26 statin studies in the CTTC as well as three large trials of non-statin, cholesterol-lowering therapy looking at those patients who had an LDL-C level of 1.8 mmol/L or less at baseline.They found the cardioprotective benefits continued as LDL-C levels declined to even lower levels.“We found consistent clinical benefit from further LDL-C lowering in patient populations starting as low as a median of 1.6 mmol/L and achieving levels as low as a median of 0.5 mmol/L”.What’s more, the incremental benefit was of an almost identical magnitude to that seen when the LDL-C levels were higher - 21% relative risk reduction per 1-mmol/L reduction in LDL-C through this range.“This relative risk reduction is virtually the same as the 22% reduction seen in the overall CTTC analysis in which the starting LDL-C was nearly twice as high,” they said.And even though very low cholesterol levels have been rumoured to be associated with everything from cancer to dementia, across all these studies there were no offsetting safety concerns with LDL-C lowering, even when extremely low levels were recorded, levels that were lower than those seen in newborns.Given the weight of benefit over risk, the study authors suggest the current targets for LDL-C could be lowered further, to even as low as 0.5 mmol/L to reduce cardiovascular risk. This suggestion is supported by an accompanying editorial, in which the author, Dr Antonio Gotto, a New York cardiologist, predicts the findings will be included as part of the revision of the American Heart Association National Cholesterol guidelines which is currently underway.He said the study findings would provide much needed evidence to help clinicians manage patients with these extremely low achieved cholesterol levels, that until recently have been very rare.“Whether one calls it a target or a threshold, practicing physicians need some guidance as they venture into achieved levels of LDL-C levels that are as foreign as travel to outer space. I have confidence that the new guidelines will be closer to a global positioning system map rather than just a compass and the stars”, he concluded.Ref:JAMA Cardiol. Published online August 1, 2018. doi:10.1001/jamacardio.2018.2258

By Dr Linda Calabresi

Diagnostics

Clinical Articles

Google predicts when people will die ‘with 95% accuracy’

Google has claimed it can predict with 95% accuracy when people will die using new artificial intelligence technology.
In a paper published in the journal Nature, the company’s Medical Brain team detailed how it is using a new type of artificial intelligence algorithm to make predictions about the likelihood of death among patients in two separate hospitals.
For predicting patient mortality, Google’s Medical Brain was 95% accurate in the first hospital and 93% accurate in the second.It works by analysing patient’s data, such as their age, ethnicity and gender. This information is then joined up with hospital information, like prior diagnoses, current vital signs, and any lab results, reports The Sun.But according to Bloomberg, what impressed medical experts most “was Google’s ability to sift through data previously out of reach: notes buried in PDFs or scribbled on old charts. The neural net gobbled up all this unruly information then spat out predictions. And it did it far faster and more accurately than existing techniques.”It is not the first time Google has made inroads into the medical industry. Its DeepMind subsidiary, considered by some experts to lead the way in AI research, “courted controversy” in 2013 after it was revealed it had access to 1.6 million medical records of NHS patients at three hospitals, reports The Independent. >> Read MoreSource: The Week UK

By Healthed

Psychiatry

Clinical Articles

Farmers experiencing drought-related stress need targeted support

For farmers, drought is a major source of stress. Their livelihoods and communities depend on the weather. To better support farmers and their families we need to better understand the impact of drought on them and their communities.Our research, published today in the Medical Journal of Australia, found young farmers who live and work on farms in isolated areas and are in financial hardship are the most likely to experience personal drought-related psychological stress. Read more: The lessons we need to learn to deal with the 'creeping disaster' of drought

What our study found

To examine farmers’ mental health during droughts, we examined data from the Australian Rural Mental Health Study and rainfall conditions in the months before farmers completed the survey.Importantly, the study covered the period of the Millennium Drought, which had devastating environmental, social and economic impacts on much of southeast Australia from 1997 to 2010. The study captured both drought and wet conditions, which enables comparisons between farmers’ mental health under different climate conditions.The study included 664 farmers from inner and outer regional, remote and very remote New South Wales. Farmers were defined as: (i) people who lived on a farm; (ii) people who worked on a farm; and (iii) people who lived and worked on a farm.The gender distribution of the participants was equal and the majority were 55-64 years old.Of the three groups investigated, farmers who both lived and worked on a farm reported more drought-related impacts and concerns. Moderately dry conditions were related to the highest scores for drought-related concerns and general psychological distress.Interestingly, higher levels of drought-related concerns were also reported following mild to moderate wet conditions. This is possibly related to much of the study area receiving very high spring rainfall during 2010 and suggests drought-related mental health impacts persist beyond the end of the drought. Read more: Farmer suicide isn't just a mental health issue

A range of social, demographic and community factors influenced the personal impact of drought for farmers:

Isolation plays a large role in the rural context. Farmers in outer regional, remote and very remote NSW experienced higher levels of concern about drought. Remoteness can mean people aren’t able to engage as much in social networks, which are essential for building resilience.
Financial hardship is increasing in rural areas but many people don’t seek financial assistance due to stigma and ingrained stoicism. Younger farmers may also be particularly impacted by less financial security than older farmers.
Age matters too. Farmers under the age of 35 experienced higher personal drought-related stress.

What can we do about it?

Protracted drought is a rare but recurring element of the Australian climate. Whatever the cause, future drought is inevitable. Read more: Hairdressers in rural Australia end up being counsellors too

Drought impacts are different from “rapid” climate extremes such as bushfires, floods or cyclones. So drought planning and preparedness needs to consider the impacts of drought on mental health and well-being differently to the way in which we prepare for and respond to “rapid” climate extremes.We know “rapid” climate extremes can have devastating impacts through loss of life, injury and other threats to communities. The effects can be acute or long-term. While many people cope and adapt to rapid climate extremes, we know a substantial proportion will go on to develop mental health problems as a result.Much less is known about chronic, slow-onset climate extremes such as protracted drought. The unfamiliarity, unpredictability and longevity of drought have substantial personal and social consequences over time. The mechanisms for such impacts are not as well known as for “rapid” climate extremes.Our findings suggest the disruption to community viability, the financial strain, loss of property and stock, and impact on future personal hopes are likely to play a role.Supporting rural communities, and especially farmers, to cope with droughts can have benefits for their well-being and mental health. Strengthening personal, financial and social support for farmers may help in adapting to droughts when drought-related stress is affecting their mental health.General practitioners are uniquely placed to support farmers experiencing persistent worry that is affecting their day-to-day functioning. But it’s often trusted people who engage with farmers regularly, such as rural financial counsellors and vets, who occupy first responder roles.Insights from our study are useful for informing the practical steps required to improve farmers’ mental health. These include:

reducing stigma about mental health problems to overcome barriers to seeking professional help and advice early
professional help to be more readily available and easier to access in rural and remote areas (such as e-health programs)
professional education for all health services, including general practitioners, so they can look out for and address the effects of drought-related stress – they need a good understanding of the pressures facing farmers and farming communities and the ways they can be more alert to their needs
community education and public health campaigns so farmers and rural residents can identify the effects of drought-related stress and take appropriate action
education and training for non-medical agricultural support services, such as rural financial counsellors, who need to be able to confidently identify early signs of drought-related stress and provide appropriate support
continued funding of Rural Adversity Mental Health Program coordinators who link rural and remote residents to services and provide community education and support
better opportunities and encouragement to maintain and develop community connections and social networks
reasonably priced and reliable internet access to enable increased use of e-health and relieve isolation
transparent and consistent information about the processes farmers need to follow to access grants and loans. Farmers should be able to apply for financial support when it’s needed rather than having to fit in with government budget cycles and deadlines. Efficient processing of grant and loan applications is needed to minimise the period of uncertainty and stress while waiting for the outcome.

Emma Austin, PhD Researcher, University of Newcastle; Anthony Kiem, Associate Professor – Hydroclimatology, University of Newcastle; Brian Kelly, , University of Newcastle; David Perkins, Director, Centre for Rural and Remote Mental Health and Professor of Rural Health Research, University of Newcastle; Jane Rich, Research Associate, University of Newcastle, and Tonelle Handley, Research fellow, University of NewcastleThis article was originally published on The Conversation. Read the original article.

By Healthed

Psychiatry

Clinical Articles

Managing the anxious child

Children who persistently or frequently experience high anxiety need help, says psychologist Jennie Hudson, Professor and Director of the Centre for Emotional Health, at Sydney’s Macquarie University.“There has been a tendency to believe kids are going to grow out of [their anxiety]”, she said. In the past, anxiety in children was believed to be normal part of growing up. In fact, in the first Australian Child and Adolescent Mental Health survey in 1998, the question of anxiety disorders in children was not included at all.But the reality is, anxious children grow into anxious teenagers and then into anxious adults, and by then it is not only harder to treat it is also too late to reverse much of the negative impact this condition has had on these people’s lives, she explained in an interview following her presentation on the subject at HealthEd’s Mental Health in General Practice evening seminar held recently in Sydney.“Children need strategies to manage their anxiety now,” she said. “We, as health professionals need to be encouraging parents to seek help if they feel their child’s anxiety is interfering with their life.”For GPs who are wondering about the most appropriate advice to give parents of anxious children, a key principle is to encourage children not to avoid tasks or situations they fear. Parents need to support their child in facing the situations that make them afraid, even if it is ‘bit by bit’, and celebrate each time they manage to accomplish even part of a feared task be it at school, sport or socially.“There is a natural tendency for a parent to protect their child from feeling anxious – they will answer for the child who gets worried about replying or say they don’t need to give the speech in class that is making them nervous for example” but this tends to fuel the anxiety. By enabling the child to practise avoidance, the parent is inadvertently endorsing the child’s belief that this is something to be feared.Another important principle in managing anxiety in children is to try and get the child to identify their worried thoughts, what it is that they fear is going to happen.Commonly a child will catastrophise the consequences of a situation for example “failing this maths test means my life will be ruined”. Once the fear is described the parent and child can discuss, logically why this feared consequence is unlikely to happen.“We call it ‘detective thinking’ – encouraging the child to develop strategies to undertake a realistic appraisal of the situation,” Professor Hudson explained.In terms of resources available for parents, there are a number Professor Hudson recommends. “Helping Your Anxious Child: A Step-by-Step Guide for Parents,” written by Australian psychologists Ronald Rapee, Ann Wignall, Susan Spence, Vanessa Cobham, and Heidi Lyneham is practical, relevant and up-to-date.Another good option is “Helping Your Child with Fears and Worries 2^nd Edition: A self-help guide for parents” written by UK experts in anxiety, Cathy Creswell and Lucy Willetts.As well as written material, there are some online programs and resources available, Professor Hudson said.Macquarie University, Sydney has developed a couple of online programs, one called Cool Kids for 7-16-year-olds (https://www.mq.edu.au/about/campus-services-and-facilities/hospital-and-clinics/centre-for-emotional-health-clinic/programs-for-children-and-teenagers#Online) and another called Cool Little Kids (https://coollittlekids.org.au/ ) for children aged seven and under.Another good, evidence-based, online program is Brave (http://www.brave-online.com/) designed for 7-16-year-olds, and developed by researchers at the University of Queensland.Useful fact sheets for parents are available from the Macquarie University’s, Centre for Emotional Health website (https://www.mq.edu.au/research/research-centres-groups-and-facilities/healthy-people/centres/centre-for-emotional-health-ceh/resources) as well as the Raising Children: The Australian parenting website (www.raisingchildren.net.au)For children with anxiety, CBT is recommended as the first line of treatment. As the risk of adverse effects with CBT is negligible it is recommended that treatment in children be commenced early on the basis of concern of the parent, carer or health professional.There are a number of reliable screening measures for anxiety in children, including the Spence Children’s Anxiety Scale (www.scaswebsite.com). The SCAS has a parent, child and teacher report along with Australian norms for 6-18-year-olds. The DASS21 is a reliable screening and monitoring tool for older adolescents.Currently in Australia only two of the SSRIs, fluvoxamine and sertraline, are approved for use in children and adolescents with obsessive compulsive disorder, Professor Hudson said.“There have been trials in Australia and the US combining CBT and sertraline. In our study, combining CBT and sertraline did not improve outcomes over and above CBT and placebo for children and adolescents with anxiety,” she added.

By Dr Linda Calabresi

Sexual health

Clinical Articles

The HIV pandemic: time to recalibrate and target the weak spots

HIV remains a global challenge. Between 36.7 million and 38.8 million people live with the disease worldwide. And more than 35 million have died of AIDS related causes since the start of the epidemic in the mid-1980s. Two years ago the International Aids Society and The Lancet put together a commission made up of a panel of experts to take stock and identify what the future response to HIV should be. The report is being released to coincide with the 22nd International Aids Conference in Amsterdam. The Conversation Africa’s Health and Medicine Editor Candice Bailey spoke to Head of the International AIDS Society Professor Linda-Gail Bekker, who also led the commission, about its report.What have we learnt about the global HIV response in the last 30 years?The world had an emergency on its hands 30 years ago with the arrival of HIV. A huge amount of effort was put into trying to find solutions. And there were some incredible breakthroughs. First was the miracle of lifesaving antiretroviral treatment, the biggest game changer over the last three decades. Great strides have been made in rolling out the treatment. UNAIDS tells us that 22 million people are currently on treatment. That’s truly remarkable.But we’ve also learnt that relying on the current pace is insufficient. That’s clear from the figures. In some countries the incidence is rising, and in many parts of the world the incidence rate has stalled or plateaued. We are not seeing the downturn that we need to be able to reach the global goal of ending the HIV pandemic by 2030.The biggest lesson we’ve learnt is that we need to reinvigorate the prevention message especially since we have new tools to combat HIV transmission in many different settings. This includes Pre-exposure prophylaxis (PrEP) – a daily antiretroviral that’s given to people who have a high risk of contracting HIV to lower their chances of getting infected – as well as treatment as prevention, which involves giving people living with HIV antiretrovirals to suppress their viral loads.For a sustainable response and looking forward to the next era, it will be important to position our responses to HIV within the broader health agenda. Patients don’t only have HIV, they have other issues. There are mental health needs and there are sexual and reproductive health needs, so HIV treatment and care must fit into that broader agenda. This will enable a more sustainable response.This is a challenge in many parts of the world where HIV is in a siloed response and people are only treated by HIV specific services. There needs to be a service delivery model that considers the broader health agenda. This goes beyond integration. We need to think about where can we take the lessons from HIV into other diseases. In the case of HIV, person centred and community-based care has become critical to ensure people get access to treatment.The message is simple: the epidemic is far from over and it’s not time to disengage. We’re here for the long haul. To ensure we have a sustainable approach we need to recalibrate.The commission is calling for a new way of doing business that will seek common cause with other global health issues. We understand that the HIV response will need resources. This will be a great way to get a double bang for the buck.What’s still going wrong?In many regions we have left whole sectors of the population behind. These include men who have sex with men, women who trade sex and people who inject drugs. They aren’t getting proper services because of policy, prejudice and stigma.And different regional pockets need particular attention. One is in Eastern Europe and Central Asia where there has been a 30% increase in new infections since 2010. This is particularly concerning. Its clear that whole regions are being left behind because of politics, denial and stigma.Here the administrations are not doing the evidence based thing – they are failing their people and the response.Another pocket is West and Central Africa. These are countries that are not reducing rates of infection as quickly as we had hoped, often due to limited resources. Nigeria, for example, needs help with the reduction of mother to child transmission.These are areas that are going to need attention, help and encouragement.But we don’t want to put out the notion that we are in trouble across the world.In East and South Africa, for example, we have made significant gains. There is still a lot to be done but the trends are going in the right direction. In many ways South Africa really is a good news story because its administration and politics favour an enthusiastic response to do the right thing. Domestic funding around HIV has increased. South Africa still has the biggest number of people in the world living with HIV – 7.9 million according to the latest HSRC report. But the country is beginning to turn the ship around. That’s something we can be incredibly proud of.There are, nevertheless, still pockets that need attention. For example, adolescent girls and young women under the age of 25 in KwaZulu-Natal are roughly three times more likely than men younger than 25 to be living with HIV. We have had them in our sights but we now need a concentrated effort to tackle HIV in this cohort otherwise we will miss the target.We need to look at the evidence and where can we make an impact with integrated care. This would be through HIV programmes that are part of sexual and reproductive health along with economic empowerment initiatives such as getting girls to stay in school and making sure they have opportunities to make autonomous decisions about sexual and reproductive health.Doing everything for everyone is a waste of money and time. We need to sharpen the tip of our response. We must put our responses where we get the biggest bang for buck and call on those resources that offer prevention and treatment.What are the biggest challenges between now and 2030?Resources are the constant challenge globally. We live in a world where politics is unpredictable. We need to constantly advocate for funding while diversifying funding opportunities.The second challenge is stigma and discrimination. Policy and ideology that is counter productive also feeds into stigma and discrimination. We need to do to something about laws that criminalise behaviour, like sex work, and stigmas towards intravenous drug users, gay people and men who have sex with men. Decriminalising sex work in South Africa, for example, would go a long way to reduce stigma, enable services and help the public health approach.Continuing to understand how to reach young women and girls and protect them socially and medically; those are also big challenges.Finally, in South Africa there is a challenge to find men who are not in the health services and get them into care and onto treatment. We know that a suppressed viral load means no HIV transmission and so this should be on its agenda.Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape TownThis article was originally published on The Conversation. Read the original article.

By Prof Linda-Gail Bekker

Cardiology

Clinical Articles

Treating depression in MI patients saves lives

Effectively treating depression in patients who have just experienced a heart attack will not only improve their quality of life, it could well improve their mortality, new research from Korea suggests.Among 300 patients who had recently experienced acute coronary syndrome and had depression as a comorbidity, those randomised to a 24-week course of escitalopram were 30% less likely to have a major adverse cardiac event over a median of eight years compared with those given placebo.In actual numbers, 40.9% (61)of the 149 patients given escitalopram had a major adverse event (including cardiac death, MI or PCI) over the period of follow-up compared with 53.6% (81) of the placebo group (151 patients), according to the study findings published in JAMA.It has long been known that depression is a common morbidity associated with acute coronary syndrome. It is also known that patients who have this comorbidity tend to have worse long-term cardiac outcomes than those who are depression-free.But what has yet to be proven is the benefit of treating this depression, at least in terms of mitigating this increased risk of a poor cardiac outcome. To date studies on the topic have yet to prove a significant benefit, with research providing conflicting results.According to the study authors, in this trial there was a significant correlation between improvement in the depression and better protection against major cardiac events. Even when they excluded those people who were still taking the antidepressant one year after the acute coronary syndrome, the protective effect was still present. Consequently, they hypothesised that the protection was more a reflection of the successfully treatment of the depression rather than the particular medication.This was consistent with a trend seen in previous research using different medications and treatments. However, the better result could be because escitalopram is more effective in treating acute coronary syndrome depression than other agents that were studied previously, the authors suggested.“Escitalopram may have modifying effects on disease prognosis in ACS-associated depressive disorder through reduction of depressive symptoms,” the study authors suggested.There were a number of caveats with regard this study that the authors said needed to be considered. These included the fact the cohort was entirely Korean which may have caused an ethnic bias, the depressive symptoms were less severe than in previous studies (though this was more likely to lead to the effect being an under-estimate) and also the severity of the underlying heart disease (namely heart failure) was relatively low.Nonetheless the researchers were able to conclude that among patients with depression who had had a recent acute coronary event, 24 weeks of treatment of escitalopram significantly reduced the risk of dying or having a further adverse cardiac event after a median of 8.1 years.How generalisable these findings are, will need to be the subject of further research.Ref:JAMA 2018;320 (4): 350-357. Doi: 10.1001/jama.2018.9422

By Dr Linda Calabresi

Psychiatry

Clinical Articles

Teenagers, smart phones and ADHD

Teenagers who are constantly checking their phones are more likely to develop ADHD symptoms than their less social-media-engaged peers, US researchers say.In what the study authors say is the first longitudinal study investigating the issue, researchers found that the frequency of digital media use among over 2500 non-ADHD 15-and 16-year-olds was significantly associated with the subsequent development of ADHD symptoms over a two-year period of follow up.A high frequency of media activity – most commonly checking their smart phone was associated with an 10% increased likelihood of developing inattentive and hyperactive-impulsive symptoms in this teenage cohort. Associations were significantly stronger in boys and participants with more mental health symptoms, such as depressive symptoms and delinquent behaviours.But while the association was statistically significant, further research was needed to determine if the digital media use was the cause of problem, the US authors said in JAMA.“The possibility that reverse causality or undetected baseline ADHD symptoms influenced the association cannot be ruled out”, they said.To date, the potential risks of intense engagement in social media is largely an evidence-free zone, they said. Prior longitudinal studies on this topic have most commonly involved computers, televisions and video-game consoles. But the engagement associated with these devices is markedly different to that seen with modern media platforms especially in terms of accessibility, operating speed, level of stimulation and potential for high-frequency exposure.And as an accompanying editorial points out, television and gaming are sporadic activities whereas the current widespread use of smartphones means social media is now close at hand.“In 2018, 95% of adolescents reported having access to a smartphone (a 22-percentage-point increase from 2014-2015), and 45% said they were online ‘almost constantly’”, the US editorial author explained.This instant access to highly engaging content is designed to be habit-forming.Also the effect of current social media engagement not only involves exposure to violence in games and displacement of other activities that were the major issues in the past. Social media today has been designed to engage the user for longer periods and reward repeated users. New behaviours to consider include frequent attention shifts and the constant media multitasking, which might interfere with a person’s ability to focus on a single task, especially a non-preferred task.It is also hypothesised that the ready availability of desired information may affect impulse control (no waiting is required). And the ‘always-on’ mentality may be depriving young brains of ‘down time’, allowing the mind to rest, tolerate boredom and even practise mindfulness.The study researchers were keen to emphasise their research findings are a long way from proving digital media increases the risk of ADHD symptoms, and even if they did, the public health and clinical implications of this are uncertain.However, the editorial was more enthusiastic about the study’s implications.“With more timely digital media research, parents may feel more confident in the evidence underlying recommendations for how to manage the onslaught of media in their households,” it said.The editorial author suggested the findings support American Academy of Pediatrics guidelines that recommend adolescents focus on activities that have been proven to promote ‘executive functioning’ such as sleep, physical activity, distraction-free homework and positive interactions with family and friends – with the implication being – ‘switch the phone off’.Ref:JAMA 2018; 320(3): 255-263 doi:10.1001/jama.2018.8931JAMA 2018; 320(3): 237-239

By Dr Linda Calabresi

Cardiology

Clinical Articles

Diagnosed with hypertension? Think aldosteronism

All newly-diagnosed hypertensive patients should be screened for primary aldosteronism before they are started on treatment, Australian experts suggest in the latest issue of the MJA.“Primary aldosteronism is common, specifically treatable, and associated with significant cardiovascular morbidity and mortality,” say researchers Dr Jun Yang, Professor Peter Fuller and Professor Michael Stowasser.They refer to a recent systematic review of over 30 studies, that found among a cohort of people with severe or resistant hypertension (systolic BP >180mmHg and diastolic BP >110), 16.4% were found to have primary aldosteronism.Admittedly these studies were carried out in tertiary centres. There been far fewer studies on the issue conducted in primary care with somewhat mixed results, with one small Australian study suggesting 11.5% of people with significant hypertension in the general practice setting had primary aldosteronism.But its not only the patients with severe hypertension that need to be considered for primary aldosteronism screening, the authors suggest.They point to an Italian study including over 1600 GP patients selected randomly who were screened for primary aldosteronism and found a prevalence of 5.9%. Importantly 45% of these had mild hypertension (BP 140-159/90-99mmHg).According to the article authors, these patients, because would have most likely remained undiagnosed if not for the study. And the effect of the untreated aldosterone excess would have most likely led to poor blood pressure control and increased cardiovascular, renal and metabolic morbidity long-term.In other words, identifying these patients early in the course of the disease could allow more appropriate treatment and ultimately avoid the end-organ damage that is more likely to occur if diagnosis is delayed until after the development of severe hypertension.“Targeted treatment of [primary aldosteronism] using surgery or mineralocorticoid receptor antagonists, such as spironolactone and eplerenone, rather than non-specific antihypertensive medications, can reverse the underlying cardiovascular pathology,” they said.The recommended biochemical screening tool for primary aldosteronism is the aldosterone to renin ratio which is elevated in this condition because plasma aldosterone is normal or elevated while renin is suppressed.The experts suggest screening prior to commencing antihypertensive therapy as many of these drugs, including beta blockers, calcium channel blockers, ACE inhibitors, ARBs and diuretics usually interfere with this aldosterone to renin ratio.The test isn’t perfect, they admit, as it can be influenced by a number of confounders including salt intake and age, but as a screening tool it has been proven, in trials both in Australia and internationally to be very useful, resulting in significantly increased numbers of patients diagnosed.Current Australian hypertension guidelines recommend clinicians consider primary aldosteronism in patients with hypertension particularly those with moderate to severe or treatment-resistant hypertension. But, as the article authors point out, given the prevalence of primary aldosteronism and the health burden associated with this cardiovascular risk factor both to the Australian population and the economy, maybe it is time to consider screening all newly-diagnosed hypertensive patients for this condition, before the commencement of non-specific antihypertensive therapy.“This diagnostic strategy should lead to significant individual and population health and economic impacts as a result of many patients with hypertension being offered the chance of curative or simpler treatment at an early stage of their disease.”Ref:MJA doi:10.5694/mja17.00783

By Dr Linda Calabresi

Neurology

Clinical Articles

Study: Vitamin D unlikely to protect individuals from brain-related disorders.

New research from South Australian scientists has shown that vitamin D (also commonly known as the sunshine vitamin) is unlikely to protect individuals from multiple sclerosis, Parkinson's disease, Alzheimer's disease or other brain-related disorders.The findings, released today in the science journal 'Nutritional Neuroscience' reported that researchers had failed to find solid clinical evidence for vitamin D as a protective neurological agent."Our work counters an emerging belief held in some quarters suggesting that higher levels of vitamin D can impact positively on brain health," says lead author Krystal Iacopetta, PhD candidate at the University of Adelaide.Based on a systematic review of over 70 pre-clinical and clinical studies, Ms Iacopetta investigated the role of vitamin D across a wide range of neurodegenerative diseases."Past studies had found that patients with a neurodegenerative disease tended to have lower levels of vitamin D compared to healthy members of the population," she says."This led to the hypothesis that increasing vitamin D levels, either through more UV and sun exposure or by taking vitamin D supplements, could potentially have a positive impact. A widely held community belief is that these supplements could reduce the risk of developing brain-related disorders or limit their progression.""The results of our in-depth review and an analysis of all the scientific literature however, indicates that this is not the case and that there is no convincing evidence supporting vitamin D as a protective agent for the brain," she says.>> Read more Source: News Medical Net

By Healthed

Oncology

Clinical Articles

The link between sebaceous gland tumours and colon cancer.

A case report A 56-year-old patient presents with a smooth, round, slightly scaly lump on the forehead, 2mm in maximum dimension. The clinical diagnosis was query basal cell carcinoma and it was excised. Microscopic findings were of sebaceoma and following immunohistochemistry staining shows loss of nuclear positivity of the DNA mismatch repair enzymes MSH2 and MSH6, which is usually associated with high-degree microsatellite instability (MSI), and raises the possibility of Muir Torre syndrome associated tumour.The patient underwent investigations, including colonoscopy, and was found to have a fungating lesion in the sigmoid colon.The patient had a left-sided hemicolectomy and the microscopic findings were of a moderately differentiated adenocarcinoma. It also has the same loss of nuclear positivity of the DNA mismatch repair enzymes MSH2 and MSH6, which further raises the possibility of Muir Torre syndrome associated tumour.DiscussionNot all skin cancers are straight-forward and some can be associated with internal malignancies or visceral cancers.Skin cancers can be syndromic; they can occur together and characterise a particular abnormality or condition and Muir Torre syndrome (MTS) is a good example. Syndromes are mostly inherited as autosomal dominant traits. MTS is characterised by the development of sebaceous tumours, often multiple, in association with visceral neoplasms, usually gastrointestinal carcinomas. MTS is found as a variant of the autosomal dominant disorder, hereditary non-polyposis colorectal cancer (HNPCC), with tumours demonstrating microsatellite instability (MSI) and germline mutations in the DNA mismatch repair genes MutS homolog MSH2 and MLH1.Muir Torre syndromeThis syndrome was first noted by Muir et al in 1967 and Torre in 1968 and is defined by the occurrence of a sebaceous neoplasm and internal malignancy in the absence of other predisposing factors. Cancers of the gastrointestinal and genitourinary tracts are the most common, with colorectal cancers often occurring at or proximal to the splenic flexure, contrary to most sporadic colorectal cancers.The skin lesions which develop in MTS include sebaceous adenoma, sebaceoma and sebaceous carcinoma.Multiple keratoacanthomas (with or without areas of sebaceous differentiation) are seen in some cases and reticulated acanthoma with sebaceous differentiation.Multiple sebaceous tumours and sebaceous tumours occurring before the age of 50 years are strong indicators of the syndrome.The cutaneous tumours may precede or follow the direct manifestation of the visceral cancer and may occur sporadically in family members. The visceral tumours behave less aggressively than would be expected from the histologic findings and this is particularly true for tumours with MSI.Detection of MSI in cutaneous neoplasms may form the basis of a non-invasive screening technique for hereditary non-polyposis colon syndrome (also known as Lynch syndrome), of which the Muir Torre syndrome is regarded as an allelic variant and represents 1-2% of cases with Lynch syndrome.MTS is inherited as an autosomal dominant trait. Mutations in one of the DNA mismatch repair genes MLH1, MSH2, MSH6 and PMS2 have been found in these patients.Recommendations in Muir Torre syndrome- Consider MTS in patients presenting with a sebaceous neoplasm. Immunohistochemistry examination of tumours for MLH1 and MSH2 protein can be used as a screening test to identify patients. -Individuals with or at risk of MTS or HNPCC should have:1) Colonoscopy every 1-2 years, beginning at age 20–25, or 10 years younger than the youngest age at diagnosis in the family is strongly recommended. 2) Annual history and physical examination, including a complete skin examination and urinalysis, as well as periodic endometrial sampling and/or transvaginal ultrasound for women.
General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs.The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.

By Dr Esther Myint

Pass the salt

Salt may have been unfairly targeted as a killer in the healthy heart stakes, according to newly published research.The observational study of over 90000 people in 300 communities across 18 countries, found that sodium consumption was not associated with an increase in health risks unless the average daily consumption was excessive – more than 5g/day or 2.5 teaspoons of salt. And, this average high daily sodium intake was mostly seen in China, with only about 15% of communities outside of China exceeding this 5g a day limit.As part of this ongoing Prospective Urban Rural Epidemiology (PURE) study, participants aged 35-70 were assessed initially at baseline and then followed for an average of 8.1 years, over which time the occurrence of any major cardiovascular events or death was recorded.What the researchers found was that the risk of hypertension and strokes was only increased in communities where the average daily sodium intake was greater than 5g. Perhaps unexpectedly, this higher sodium intake was actually found to be also associated with lower rates of myocardial infarction and total mortality. Furthermore, the research found that very low levels of sodium intake were harmful, being associated with an increased risk of cardiovascular disease and mortality.The findings fly in the face of the current WHO guidelines that recommend, as a global approach we should be aiming for populations to reduce their sodium intake to below 2g/day.However, no communities in the study came close to achieving this target. In fact, no communities in the study had an average sodium intake of less than 3g/day, based on morning fasting urine samples from the participants.“Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate,” the Canadian study authors said.But before we all go and stock up on our Saxa, an accompanying editorial sounds a word of caution. While acknowledging the findings that ‘normal’ salt intake appeared to be at least health-neutral if not beneficial, the editorial authors remind us that the study is observational and has not taken into consideration a number of potential confounders such as diet. Without taking these confounders into account, one can’t assume that just decreasing salt intake in people at high risk of stroke or increasing it in people at risk of a heart attack will work, they said.“Nevertheless the findings are exceedingly interesting and should be tested in a randomised controlled trial,” they concluded, adding that such a trial, to be conducted in a US federal prison population had been proposed. Ref:LancetVol 392 No 10146 pp:496-506Vol 392 No 10146 pp: 456-458

By Dr Linda Calabresi

Clinical Articles

Cardiology

Typhoid in the modern era

The microbiology laboratory has made great strides in introducing clinically useful diagnostics over the past couple of decades, particularly in recent years with the development of molecular assays that ‘narrow the gap’ and provide early diagnoses.While introducing new tests, it has also been important to evaluate and discard old tests that may not contribute greatly to patient outcomes. One such test that has come under the spotlight is the classic Widal agglutination test in the diagnosis of typhoid.The Widal test, developed by George Fernand Widal in 1896, uses a suspension of killed Salmonella typhi as antigen to detect agglutinating antibodies to somatic O antigens and flagellar H antigens present in serum of typhoid patients. There are many reasons for its lack of clinical utility.Antibodies are not present in the acute illness and take time to develop.Significant cross reactivity can occur with other infectious agents that mimic typhoid including malaria, dengue, endocarditis, tuberculosis and chronic liver disease.Other limitations are of a technical nature and include non-standardisation of the antigen preparation used in the assay, interference with serological responses following typhoid vaccination commonly provided to travellers, and prior exposure and antibodies in patients most susceptible to typhoid, especially those from endemic areas visiting friends and relatives (VFRs).Unless multiple antigens are included, it generally does not detect the other causes of enteric fever, S. Paratyphi A, B and C.It is now time to discontinue this simple agglutination test for typhoid in modern medicine and consider more appropriate diagnostic tests.Typhoid fever Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. Whereas Salmonellae which cause gastroenteritis are zoonoses, humans are the only reservoir for S.Typhi and S. Paratyphi which cause enteric fever.Typhoid fever is still common in the developing world where it affects about 21.5 million people each year but is much less common in the Lucky Country such as ours where good sanitation prevails. About 100 cases are notified each year in Australia. In 2014, 92% of cases were acquired overseas. India continues to be the most common country of acquisition and in 2014 accounted for more than half of cases.Most transmission occurs through contaminated drinking water or food. Large epidemics are most often related to faecal contamination of water supplies or street-vended foods.A chronic carrier state – excretion of the organism for more than one year – occurs in about 5% of infected persons. Where no travel history is present, the likely source of infection is contaminated food or water from a human carrier akin to ‘Typhoid Mary’. Such an outbreak was reported in Auckland, New Zealand, this year where 20 local cases and one death occurred when a carrier from Samoa helped prepare food at a church community gathering.The incubation period is typically eight to 14 days but may be much longer.Without therapy, the illness may last for three to four weeks and death rates range between 12% and 30%. Increasing resistance to available antimicrobial agents, including fluoroquinolones, has occurred in recent years. Resistance to antimicrobials including amoxycillin, and trimethoprim+sulfamethoxazole has limited the options for treatment; reduced susceptibility to quinolones is common in infections acquired on the Indian subcontinent and in Southeast Asia.While awaiting the results of susceptibility testing, azithromycin or ceftriaxone should be used for initial therapy for infections acquired in these regions.Diagnosis of enteric fevers Two sets of blood cultures are the single most useful diagnostic procedure for diagnosis of enteric fever. Other bodily fluids and tissues may yield positive cultures including faeces, urine, and if seeded, bones and joints, liver and gall bladder.Food handlers, healthcare workers, carers of children, and carers of the elderly, and others who are not able to maintain their own personal hygiene, should further be excluded from working with food or caring for people until two consecutive stool specimens – collected at least 48 hours apart and the first specimen collected not sooner than 48 hours post-cessation of antibiotics – are culture negative.Prevention Both an oral live attenuated multi-dose vaccine and a killed vaccine are available. Booster doses after 3-5 years are generally required if continued exposure occurs.Vaccine efficacy is of the order of only 80%.What to order Blood culture x 2 (Salmonella Typhi and Salmonella Paratyphi)Faeces for Bacterial PCR and MCS;Urine MCSCollection Centres: Faeces and urine samples are accepted at all collection centres. Blood cultures are collected only at designated collection centres.Sample Blood (use blood culture bottles), faeces, urineTransportation AmbientCosts Medicare rebate appliesTyphoid MaryMary Mallon, better known as Typhoid Mary, was an Irish immigrant to New York and the first person in the United States identified as an asymptomatic carrier of the pathogen associated with typhoid fever. Over the course of her career as a cook, she was presumed to have infected 51 people, three of whom died. She was twice forcibly isolated by public health authorities and died after a total of nearly three decades in isolation. General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs.The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.

By Dr Jenny Robson

Clinical Articles

Infectious diseases

LDL – The Lower the Better

Low density lipoprotein cholesterol is the well-known culprit in terms of cardiovascular risk.Courtesy of a large meta-analysis of statin trials done in 2010 (the Cholesterol Treatment Trialists Collaboration), we know that for people starting with higher LDL-C levels (approximately 3.4 mmol/L), they can lower their risk of having a major adverse vascular event by 22%, every time they lower their LDL-C level by 1mmol/L.But what happens once your LDL level is lower? Can you continue to increase your protection by lowering your LDL levels further? Or does the beneficial effect plateau at a certain level? Or, worse still can very low LDL levels actually cause harm?A new meta-analysis just published in JAMA Cardiology has gone some way in answering these questions.The researchers analysed data from the 26 statin studies in the CTTC as well as three large trials of non-statin, cholesterol-lowering therapy looking at those patients who had an LDL-C level of 1.8 mmol/L or less at baseline.They found the cardioprotective benefits continued as LDL-C levels declined to even lower levels.“We found consistent clinical benefit from further LDL-C lowering in patient populations starting as low as a median of 1.6 mmol/L and achieving levels as low as a median of 0.5 mmol/L”.What’s more, the incremental benefit was of an almost identical magnitude to that seen when the LDL-C levels were higher - 21% relative risk reduction per 1-mmol/L reduction in LDL-C through this range.“This relative risk reduction is virtually the same as the 22% reduction seen in the overall CTTC analysis in which the starting LDL-C was nearly twice as high,” they said.And even though very low cholesterol levels have been rumoured to be associated with everything from cancer to dementia, across all these studies there were no offsetting safety concerns with LDL-C lowering, even when extremely low levels were recorded, levels that were lower than those seen in newborns.Given the weight of benefit over risk, the study authors suggest the current targets for LDL-C could be lowered further, to even as low as 0.5 mmol/L to reduce cardiovascular risk. This suggestion is supported by an accompanying editorial, in which the author, Dr Antonio Gotto, a New York cardiologist, predicts the findings will be included as part of the revision of the American Heart Association National Cholesterol guidelines which is currently underway.He said the study findings would provide much needed evidence to help clinicians manage patients with these extremely low achieved cholesterol levels, that until recently have been very rare.“Whether one calls it a target or a threshold, practicing physicians need some guidance as they venture into achieved levels of LDL-C levels that are as foreign as travel to outer space. I have confidence that the new guidelines will be closer to a global positioning system map rather than just a compass and the stars”, he concluded.Ref:JAMA Cardiol. Published online August 1, 2018. doi:10.1001/jamacardio.2018.2258

By Dr Linda Calabresi

Clinical Articles

Cardiology

Google predicts when people will die ‘with 95% accuracy’

Google has claimed it can predict with 95% accuracy when people will die using new artificial intelligence technology.
In a paper published in the journal Nature, the company’s Medical Brain team detailed how it is using a new type of artificial intelligence algorithm to make predictions about the likelihood of death among patients in two separate hospitals.
For predicting patient mortality, Google’s Medical Brain was 95% accurate in the first hospital and 93% accurate in the second.It works by analysing patient’s data, such as their age, ethnicity and gender. This information is then joined up with hospital information, like prior diagnoses, current vital signs, and any lab results, reports The Sun.But according to Bloomberg, what impressed medical experts most “was Google’s ability to sift through data previously out of reach: notes buried in PDFs or scribbled on old charts. The neural net gobbled up all this unruly information then spat out predictions. And it did it far faster and more accurately than existing techniques.”It is not the first time Google has made inroads into the medical industry. Its DeepMind subsidiary, considered by some experts to lead the way in AI research, “courted controversy” in 2013 after it was revealed it had access to 1.6 million medical records of NHS patients at three hospitals, reports The Independent. >> Read MoreSource: The Week UK

By Healthed

Clinical Articles

Diagnostics

Farmers experiencing drought-related stress need targeted support

For farmers, drought is a major source of stress. Their livelihoods and communities depend on the weather. To better support farmers and their families we need to better understand the impact of drought on them and their communities.Our research, published today in the Medical Journal of Australia, found young farmers who live and work on farms in isolated areas and are in financial hardship are the most likely to experience personal drought-related psychological stress. Read more: The lessons we need to learn to deal with the 'creeping disaster' of drought

What our study found

A range of social, demographic and community factors influenced the personal impact of drought for farmers:

Isolation plays a large role in the rural context. Farmers in outer regional, remote and very remote NSW experienced higher levels of concern about drought. Remoteness can mean people aren’t able to engage as much in social networks, which are essential for building resilience.
Financial hardship is increasing in rural areas but many people don’t seek financial assistance due to stigma and ingrained stoicism. Younger farmers may also be particularly impacted by less financial security than older farmers.
Age matters too. Farmers under the age of 35 experienced higher personal drought-related stress.

What can we do about it?

Protracted drought is a rare but recurring element of the Australian climate. Whatever the cause, future drought is inevitable. Read more: Hairdressers in rural Australia end up being counsellors too

reducing stigma about mental health problems to overcome barriers to seeking professional help and advice early
professional help to be more readily available and easier to access in rural and remote areas (such as e-health programs)
professional education for all health services, including general practitioners, so they can look out for and address the effects of drought-related stress – they need a good understanding of the pressures facing farmers and farming communities and the ways they can be more alert to their needs
community education and public health campaigns so farmers and rural residents can identify the effects of drought-related stress and take appropriate action
education and training for non-medical agricultural support services, such as rural financial counsellors, who need to be able to confidently identify early signs of drought-related stress and provide appropriate support
continued funding of Rural Adversity Mental Health Program coordinators who link rural and remote residents to services and provide community education and support
better opportunities and encouragement to maintain and develop community connections and social networks
reasonably priced and reliable internet access to enable increased use of e-health and relieve isolation
transparent and consistent information about the processes farmers need to follow to access grants and loans. Farmers should be able to apply for financial support when it’s needed rather than having to fit in with government budget cycles and deadlines. Efficient processing of grant and loan applications is needed to minimise the period of uncertainty and stress while waiting for the outcome.