tag:theconversation.com,2011:/au/topics/health-explainer-44067/articlesHealth Explainer – The Conversation2018-11-28T19:07:34Ztag:theconversation.com,2011:article/1025792018-11-28T19:07:34Z2018-11-28T19:07:34ZExplainer: what is irritable bowel syndrome and what can I do about it?<figure><img src="https://images.theconversation.com/files/247435/original/file-20181127-130890-1bspxq6.jpg?ixlib=rb-1.1.0&rect=51%2C0%2C5760%2C3388&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women are twice as likely to be diagnosed with irritable bowel syndrome as men.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Irritable bowel syndrome (IBS) is a common disorder that affects <a href="https://www.ncbi.nlm.nih.gov/pubmed/16409310">one in ten Australians</a>, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25734736">twice as many women</a> as men. Its symptoms include chronic abdominal pain, constipation or diarrhoea, and bloating. These have a significant <a href="https://www.ncbi.nlm.nih.gov/pubmed/19124023">impact on a person’s quality of life</a>.</p>
<p>Many people use the term irritable bowel syndrome to describe general symptoms of gut and bowel dysfunction. But diagnosis requires meeting strict, diagnostic criteria. Known as the <a href="https://www.ncbi.nlm.nih.gov/pubmed/27144617">ROME criteria</a>, these require a person to be experiencing abdominal pain, on average, at least one day per week. The pain must be associated with two or more of the following:</p>
<ul>
<li>defecation</li>
<li>a change in the frequency of stool</li>
<li>a change in the form (appearance) of stool</li>
<li>having occurred over the last three months with symptom onset at least six months before diagnosis.</li>
</ul>
<p>Tests aren’t always needed for a diagnosis if these symptoms are present. But an accurate diagnosis of IBS is important as some symptoms, such as pelvic pain, may overlap with other diseases such as endometriosis or inflammatory bowel disease. If other symptoms are present, a doctor <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/apt.13283">may need to perform</a> blood tests, pelvic ultrasound, endoscopy or stool tests to rule out similar disorders.</p>
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<p>
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Read more:
<a href="https://theconversation.com/i-have-painful-periods-could-it-be-endometriosis-101026">I have painful periods, could it be endometriosis?</a>
</strong>
</em>
</p>
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<p>Some symptoms are considered “red flag” symptoms and should prompt further testing and specialist referral. For example, if you have rectal bleeding, weight loss and are aged over 50 when symptoms start, it is not IBS.</p>
<h2>What causes it?</h2>
<p>A single cause for IBS has not been identified. IBS may <a href="https://www.ncbi.nlm.nih.gov/pubmed/26202154">run in families</a>, but we still don’t know if this is due to shared genetics or environmental factors. An <a href="https://www.ncbi.nlm.nih.gov/pubmed/17661757">episode of gastroenteritis</a>, an infection caused by viruses or bacteria, increases the risk of developing IBS. But this is usually temporary and symptoms gradually improve.</p>
<p>People with IBS often also have <a href="https://www.ncbi.nlm.nih.gov/pubmed/28087404">anxiety and depression</a>. Research suggests early childhood trauma can <a href="https://www.ncbi.nlm.nih.gov/pubmed/18177446">predispose some people</a> to IBS in later life. This is because the gut and brain talk to each other through nerve signals, the release of gut or stress hormones, and other pathways. </p>
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</figure>
<p>We have long known that emotions can directly alter gut function. But studies now show that gut function also affects emotions. One <a href="https://www.ncbi.nlm.nih.gov/pubmed/27444264">Australian study</a> indicated that for some people gut symptoms occur first and the psychological symptoms occur as a result. But this is not true for all people with IBS. </p>
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<em>
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Read more:
<a href="https://theconversation.com/stomach-and-mood-disorders-how-your-gut-may-be-playing-with-your-mind-50847">Stomach and mood disorders: how your gut may be playing with your mind</a>
</strong>
</em>
</p>
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<h2>What do I do?</h2>
<p>Non-drug treatments should be considered initially, and more than one treatment strategy may be needed to help improve symptoms.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/24076059">Good-quality evidence shows</a> a low-FODMAP diet reduces IBS symptoms. FODMAPs are carbohydrates that produce excess gas when digested. They can be found in roots such as onions and garlic, and fruits (or seeds) like legumes, apples, pears and mangoes. For the best result, a person should start a low-FODMAP diet under the guidance of an experienced dietitian.</p>
<p>It’s a common misconception that people should keep to a low-FODMAP diet for life. Foods like onions, which are high in FODMAPs, are also good prebiotics and promote the growth of friendly gut bacteria. Restricting these can result in low <a href="https://www.bmj.com/content/361/bmj.k2179">gut bacterial diversity</a>, which is linked to autoimmune diseases and obesity. That’s another reason a dietician should guide people through the diet over a few weeks and avoid unnecessary dietary restriction.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/247647/original/file-20181128-32185-zurod7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/247647/original/file-20181128-32185-zurod7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/247647/original/file-20181128-32185-zurod7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247647/original/file-20181128-32185-zurod7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247647/original/file-20181128-32185-zurod7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247647/original/file-20181128-32185-zurod7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247647/original/file-20181128-32185-zurod7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247647/original/file-20181128-32185-zurod7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">FODMAP foods include onions, but these also promote the growth of friendly gut bacteria.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Simple dietary measures include adding <a href="https://gi.org/wp-content/uploads/2014/08/IBS_CIC_Monograph_AJG_Aug_2014.pdf">more soluble fibre</a> to the diet. This can include psyllium, which can be bought as a powder from chemists and health food shops. Insoluble fibres like bran are generally unhelpful. </p>
<p>A trial of probiotics might help. These could be trialled for one month and then re-evaluated by the GP, but are unlikely to be useful if used indefinitely. Exercise <a href="https://www.ncbi.nlm.nih.gov/pubmed/21206488">has been shown</a> in randomised trials to improve gut symptoms in people with IBS.</p>
<p>Managing stress and anxiety are key to improving symptoms for many people. Psychological therapies have been <a href="https://gi.org/wp-content/uploads/2014/08/IBS_CIC_Monograph_AJG_Aug_2014.pdf">shown in trials</a> to help symptoms more than placebo or other interventions. This is particularly so when the psychologist is interested in IBS.</p>
<p>Clinical trials have also shown that, for some people, hypnotherapy that is directed at the gut is <a href="https://www.ncbi.nlm.nih.gov/pubmed/27397586">just as effective</a> as a low-FODMAP diet. The benefits are still seen at six months. Hypnotherapy is not for everyone, however, and multiple sessions are needed for symptoms to improve. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/247645/original/file-20181128-32230-1k9gk5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/247645/original/file-20181128-32230-1k9gk5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/247645/original/file-20181128-32230-1k9gk5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247645/original/file-20181128-32230-1k9gk5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247645/original/file-20181128-32230-1k9gk5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247645/original/file-20181128-32230-1k9gk5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247645/original/file-20181128-32230-1k9gk5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247645/original/file-20181128-32230-1k9gk5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Peppermint oil can help reduce stomach cramps related to IBS.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>What about medications?</h2>
<p>IBS affects quality of life but it doesn’t change a person’s risk of early death or cancer. So, treatments should have few side effects to be acceptable. Clinical trials have shown that medications such as <a href="https://www.bmj.com/content/337/bmj.a2313">peppermint oil (usually given in capsules) can reduce</a> troublesome abdominal cramps with minimal side effects. </p>
<p>Melatonin can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774717/">improve symptoms</a> through better sleep quality where sleep is disturbed.</p>
<p>The choice of drug should be tailored to each person’s symptoms. For instance, low-dose antidepressants can be helpful for some people, especially where significant depression or anxiety symptoms exist together with IBS. Medications that <a href="https://www.ncbi.nlm.nih.gov/pubmed/12848628">reduce inflammation</a> are <a href="https://www.ncbi.nlm.nih.gov/pubmed/25765462">generally unhelpful</a>, as consistent and clinically apparent inflammation is not part of the syndrome.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/so-you-think-you-have-ibs-coeliac-disease-or-crohns-heres-what-it-might-mean-for-you-39128">So you think you have IBS, coeliac disease or Crohn’s? Here’s what it might mean for you</a>
</strong>
</em>
</p>
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<p>A few new approaches are being trialled for IBS, including faecal transplants and new medications. But all of these need better long-term data before they appear on the market.</p><img src="https://counter.theconversation.com/content/102579/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Mahady does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Irritable bowel syndrome causes abdominal pain and constipation or diarrhoea. These symptoms overlap with other disorders, so it’s important to get the correct diagnosis and then the best treatments.Suzanne Mahady, Gastroenterologist & Clinical Epidemiologist, Senior Lecturer, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/948202018-06-20T01:40:09Z2018-06-20T01:40:09ZExplainer: why do people get haemorrhoids and how do you get rid of them?<figure><img src="https://images.theconversation.com/files/222129/original/file-20180607-137309-136nq26.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Almost half of all people will experience haemorrhoids at some point.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>You may think of piles as those dreaded things your mum said you’d get if you kept sitting on cold concrete. But actually, every healthy person has piles, or haemorrhoids. </p>
<p>They are columns of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755769/">cushioned tissue</a> and blood vessels found close to the opening of the anus. And they help you <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2710774/">maintain bowel continence</a> or, to put it simply, keep your poo in.</p>
<p>Haemorrhoids can be either external (when they grow very close to the anus opening) or internal (when they grow further away in the anus). </p>
<p>Internal haemorrhoids (which we all have) can become a problem when they are swollen or inflamed. </p>
<p>External haemorrhoids are covered by a rich <a href="https://www.aafp.org/afp/2002/0415/p1629.html">supply of pain fibres</a> and are more likely to be associated with pain. External haemorrhoids can <a href="https://www.ncbi.nlm.nih.gov/pubmed/2784180">develop clots</a> due to blood in them becoming stagnant and from trauma to blood vessels from straining. This can make them tender and swollen. </p>
<p>The exact cause of haemorrhoids isn’t entirely clear. But they are certainly common; around 50% of people have experienced <a href="https://www.ncbi.nlm.nih.gov/pubmed/21825884">symptomatic haemorrhoids</a> at some point in their lives. </p>
<h2>Who is most likely to get them?</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/222131/original/file-20180607-137315-1tdq3h7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/222131/original/file-20180607-137315-1tdq3h7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/222131/original/file-20180607-137315-1tdq3h7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=587&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222131/original/file-20180607-137315-1tdq3h7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=587&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222131/original/file-20180607-137315-1tdq3h7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=587&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222131/original/file-20180607-137315-1tdq3h7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=738&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222131/original/file-20180607-137315-1tdq3h7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=738&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222131/original/file-20180607-137315-1tdq3h7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=738&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Haemorrhoids can be internal or external.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Many people think constipation is the main reason for haemorrhoids. Constipation means <a href="https://www.ncbi.nlm.nih.gov/pubmed/18829389">hard stools and more straining</a> on the toilet, which can weaken the supportive tissue in the anal canal and push the haemorrhoids downwards. </p>
<p>Constipation does contribute to the risk of getting haemorrhoids, although one <a href="https://www.ncbi.nlm.nih.gov/pubmed/7942722">study looking at veterans</a> in the US found diarrhoea, rather than constipation, was associated with haemorrhoids. This could also be due to straining and prolonged sitting in the bathroom. </p>
<p>Other factors such as sex and ethnicity <a href="https://www.ncbi.nlm.nih.gov/pubmed/2295392">affect risk</a>. One US study found they were more common among those aged between 45-65 and reduced after the age of 65. Caucasians were found to be affected more frequently than African-Americans. </p>
<p>People on higher incomes are also more likely to suffer from haemorrhoids. A suggestion for why this might be the case <a href="https://www.ncbi.nlm.nih.gov/pubmed/937530">comes from a study</a> where a majority of patients with haemorrhoids were noted to be in occupations that involve prolonged sitting rather than manual labour. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-the-consistency-of-your-poo-says-about-your-health-65106">What the consistency of your poo says about your health</a>
</strong>
</em>
</p>
<hr>
<p>Haemorrhoids often occur during pregnancy and are <a href="https://www.ncbi.nlm.nih.gov/pubmed/20373920">most common</a> in the second and third trimesters. It’s thought hormonal changes, pressure from the growing uterus, alterations in blood flow and constipation contribute to their development.</p>
<p>For the majority of women, haemorrhoids and their symptoms will gradually resolve after giving birth.</p>
<h2>How do you know you have them?</h2>
<p>We classify problematic internal haemorrhoids as fitting into <a href="https://trove.nla.gov.au/work/10113496?selectedversion=NBD307874">four grades</a>. Grade one haemorrhoids have no prolapse (which refers to them protruding out of the anus) and are usually painless. Bleeding may be the only symptom. </p>
<p>Grade two are more uncomfortable and do prolapse. But this resolves on its own. Grade three are more severe, with a prolapse that will not resolve on its own but can be manually pushed back inside. </p>
<p>Grade four haemorrhoids have prolapsed and cannot be pushed back manually. They are usually the most painful type.</p>
<p>Haemorrhoids can often be confused with anal skin tags, which are benign growths of excess skin around the anal canal. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/222130/original/file-20180607-137322-yttite.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/222130/original/file-20180607-137322-yttite.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/222130/original/file-20180607-137322-yttite.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222130/original/file-20180607-137322-yttite.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222130/original/file-20180607-137322-yttite.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222130/original/file-20180607-137322-yttite.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222130/original/file-20180607-137322-yttite.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222130/original/file-20180607-137322-yttite.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">It’s advised to not spend more than three to four minutes on the toilet.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The only way to know for sure if you have haemorrhoids is to have a rectal examination by your doctor, which <a href="https://www.ncbi.nlm.nih.gov/pubmed/25022811">involves inspection</a> of the anus at rest and during straining. An instrument that visually inspects the rectum such as a proctoscope or a colonoscope can confirm internal haemorrhoids.</p>
<h2>How do you avoid them?</h2>
<p>Diet and lifestyle play an important role in preventing and managing haemorrhoids. Fibre can be beneficial, mainly due to reducing constipation and straining. Combined data of <a href="https://www.ncbi.nlm.nih.gov/pubmed/16405552">seven clinical trials</a> on haemorrhoids has shown supplementary fibre relieves symptoms and reduces risk of bleeding by around 50%. </p>
<p>General advice to increase oral fluid consumption, adopt regular exercise, minimise straining and the use of constipation-inducing medications (such as opioids) are sensible measures, even though there is little evidence in the medical literature to support them.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/busted-myths-what-spiders-chewing-gum-and-haemorrhoids-have-in-common-49899">Busted myths: what spiders, chewing gum and haemorrhoids have in common</a>
</strong>
</em>
</p>
<hr>
<p>A study of <a href="https://www.ncbi.nlm.nih.gov/pubmed/2563041">100 patients in England</a> with confirmed haemorrhoids found they spent more time defecating and reading on the toilet than age and sex matched controls (a group who didn’t have haemorrhoids). This <a href="https://www.ncbi.nlm.nih.gov/pubmed/28150480">led to a recommendation</a> that the amount of time spent on the toilet defecating be no more than three minutes once a day. </p>
<p>Hygiene may be important too, as a German study found people who had more frequent baths or showers were <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771040/">less likely to develop</a> external haemorrhoids with blood clots.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/222135/original/file-20180607-137315-1cx6z6e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/222135/original/file-20180607-137315-1cx6z6e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/222135/original/file-20180607-137315-1cx6z6e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=898&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222135/original/file-20180607-137315-1cx6z6e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=898&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222135/original/file-20180607-137315-1cx6z6e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=898&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222135/original/file-20180607-137315-1cx6z6e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1129&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222135/original/file-20180607-137315-1cx6z6e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1129&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222135/original/file-20180607-137315-1cx6z6e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1129&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People who take more showers may have fewer haemorrhoids.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>How do you treat them?</h2>
<p>The grade of the haemorrhoid, along with symptom severity, plays a role in medical decision making. Dietary and lifestyle changes should be introduced for all patients and can be helpful in managing symptoms for patients with grade one haemorrhoids. </p>
<p>A number of drugs, suppositories, creams and wipes are available too. Analgesic (pain relieving) topical creams would be a reasonable option to manage pain associated with haemorrhoids. But there is a lack of strong evidence to support a benefit for <a href="http://journals.sagepub.com/doi/pdf/10.1177/2040622317713957">topical treatment</a> in symptomatic haemorrhoids.</p>
<p>Flavonoids, a large class of plant pigments, have been <a href="https://www.ncbi.nlm.nih.gov/pubmed/22895941">shown to improve symptoms</a> of bleeding, discharge and itch. They are taken in tablet form.</p>
<p>In cases where symptoms persist and for those with grade two haemorrhoids, a gatroenterologist or surgeon can use rubber band ligation, which seems to be the most effective therapy. This is where a rubber band is applied to the base of a haemorrhoid via a proctoscope or colonoscope. The band <a href="http://journals.sagepub.com/doi/pdf/10.1177/2040622317713957">cuts off the blood supply</a> to the haemorrhoid causing it to slough off in around one to two weeks.</p>
<p>If this fails, or for grade three to four haemorrhoids, the most effective therapy appears to be <a href="http://journals.sagepub.com/doi/pdf/10.1177/2040622317713957">surgical excision</a> or haemorrhoidectomy. There are variations in surgical techniques and it would be worth consulting a colorectal surgeon for advice on the best approach for a particular patient.</p><img src="https://counter.theconversation.com/content/94820/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vincent Ho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Haemorrhoids can be painful, and may sometimes require surgery. We don’t know exactly why they can become problematic but there are some things you can do to reduce the risk of getting them.Vincent Ho, Senior Lecturer and clinical academic gastroenterologist, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/831062017-09-22T03:57:55Z2017-09-22T03:57:55ZExplainer: what are mitochondria and how did we come to have them?<figure><img src="https://images.theconversation.com/files/186721/original/file-20170920-905-19pmmiz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mitochondria live inside our cells but have a different genome. Here's why. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>We’ve probably all heard of mitochondria, and we may even remember learning in school that they are the “powerhouses of the cell” – but what does that actually mean, and how did they evolve? To answer this question, we have to go back about two billion years to a time when none of the complexity of life as we see it today existed. </p>
<h2>Where did mitochondria come from?</h2>
<p>Our primordial ancestor was a simple single-celled creature, living in a long-term rut of evolutionary stagnation. Then something dramatic happened – an event that would literally breathe life into the eventual evolution of complex organisms. One of the cells engulfed another and enslaved it as a perpetual source of energy for its host. </p>
<p>The increase in available energy to the cell powered the formation of more complex organisms with multiple cells, eyes, and brains. Slowly, the two species became intertwined – sharing some of their DNA and delegating specific cellular tasks – until eventually they became firmly hardwired to each other to form the most intimate of biological relationships. Two separate species became one. </p>
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Read more:
<a href="https://theconversation.com/viewpoints-the-promise-and-perils-of-three-parent-ivf-18402">Viewpoints: the promise and perils of three-parent IVF</a>
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<p>These energy slaves are the mitochondria, and there are hundreds or even thousands of them inside every one of your cells (with the exception of red blood cells) and in every other human alive. They still resemble their bacterial origin in appearance, but we can no longer exist without them, nor they without us. The evolutionary explosion powered by mitochondria is evident by the fact they are found in every complex multicellular organism that has ever existed, from giraffes to palm trees, mushrooms and dinosaurs. </p>
<p>As vestiges of their ancient origin, mitochondria still have their own genome (although some of their DNA has been transferred to our genome). It’s alien in appearance and composition when compared with our own nuclear genome (the DNA inside each of your cell’s nuclei that contains about 20,000 genes). In fact, our nuclear genome shares more in common with that of a sea sponge than with the mitochondrial genome inside our own cells. </p>
<p>Unlike the nuclear genome, the mitochondrial genome is small (containing just 37 genes), circular, and uses a different DNA code. The mitochondrial genome slinks its way across generations by stowing away within mitochondria harboured in each egg, and as such, is passed down from the mother only. This is different to the nuclear genome, half of which is inherited from your father and the other half from your mother. </p>
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Read more:
<a href="https://theconversation.com/do-you-share-more-genes-with-your-mother-or-your-father-50076">Do you share more genes with your mother or your father?</a>
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<h2>What do the mitochondria do?</h2>
<p>The mitochondrial genome is vital for the mitochondria’s main role: burning the calories we eat with the oxygen we breathe to generate the energy to power all of our biological processes. But this amazing source of energy is not without its cost.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/186947/original/file-20170921-10635-rk7evh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/186947/original/file-20170921-10635-rk7evh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186947/original/file-20170921-10635-rk7evh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186947/original/file-20170921-10635-rk7evh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186947/original/file-20170921-10635-rk7evh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186947/original/file-20170921-10635-rk7evh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186947/original/file-20170921-10635-rk7evh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186947/original/file-20170921-10635-rk7evh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The mitochondrial genome is passed down from the mother only.</span>
<span class="attribution"><span class="source">Natalya Zaritskaya/Unsplash</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Like any powerhouse, mitochondria produce toxic byproducts. Free radicals (highly reactive oxygen molecules with an odd number of electrons that can cause ageing and health problems) can be created by accidents that happen during energy production. </p>
<p>So in essence, mitochondria power <em>and</em> imperil our cells.</p>
<p>Because the mitochondrial genome is in close proximity to the source of free radicals, it’s more susceptible to their damaging effects. And the mitochondrial genome undergoes replication thousands of times more than the nuclear genome, simply because you have so many in each cell. Making copies of copies introduces mistakes. </p>
<p>A combination of these two effects results in the mitochondrial genome mutating up to 50 times faster than the nuclear genome, which is meanwhile kept safely in the nucleus. These mutations can be passed down to maternal offspring, causing devastating metabolic disorders in the next generation.</p>
<h2>What happens when something goes wrong?</h2>
<p>Only as recently as 1988 was the first disease caused by such a mutation in the mitochondrial genome identified. Now, we know about many such disorders, called mitochondrial diseases, which can be traced to mutations in the mitochondrial genome. These diseases can manifest at any age and result in a wide range of symptoms including hearing loss, blindness, muscle wasting, stroke-like episodes, seizures, and organ failure.</p>
<p>These diseases are currently incurable. But <a href="https://academic.oup.com/brain/article/139/6/1633/1754057/Emerging-therapies-for-mitochondrial-disorders">multiple lines of investigation</a> are currently underway to treat and <a href="https://theconversation.com/safety-in-numbers-how-three-parents-can-beat-genetic-diseases-2524">prevent transmission to subsequent generations</a>.</p>
<p>Despite this, during life, it’s inevitable that mutations will occur in the mitochondrial genome in an individual’s neurons, muscle, and all other cells. <a href="http://www.nature.com/ng/journal/v38/n5/full/ng1769.html?foxtrotcallback=true">Compelling work</a> now <a href="https://www.ncbi.nlm.nih.gov/pubmed/26014345">suggests</a> that the accumulation of these mistakes may contribute to the progressive nature of late-onset degenerative diseases such as Alzheimer’s and Parkinson’s. </p>
<p>The health of this seemingly alien genome is inextricably linked to that of our own bodies. As we come to grips with mitochondria’s importance in disease, we continue to uncover the intimate secrets of a two-billion-year relationship that has given complex life to the planet.</p><img src="https://counter.theconversation.com/content/83106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steven Zuryn receives funding from the National Health and Medical Research Council and the Stafford Fox Medical Research Foundation. </span></em></p>To explain why we have a mitochondria, we have to go back about two billion years to a time when none of the complexity of life as we see it today existed.Steven Zuryn, Group Leader, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/844322017-09-21T05:46:12Z2017-09-21T05:46:12ZExplainer: what is the flesh-eating bacterium that causes Buruli ulcer and how can I avoid it?<figure><img src="https://images.theconversation.com/files/186941/original/file-20170921-10588-6lz38o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Reports of Buruli ulcer cases are on the rise on Victoria's Mornington Peninsula.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/doctorjbeam/16214216615/in/photolist-qGN6GT-C1C66h-DJ6h2g-6a2b3E-eLG8ct-eLG7Ne-Y43Uxb-eLG7kt-eLG6VZ-7aeo7u-8KH2t3-dGK3hb-5s4FKD-j4pCbz-61W4q9-98fToe-7aaAbT-8KGVMY-8EGipX-5rQVT7-SJsC8Y-7D9y9X-7Ddmuq-Txy551-fL3cHb-e82qNT-j4qwHg-fL3vz7-fKKzMF-fKKmmV-fL38Jf-j4tE8J-j4rHgQ-efi751-j4uD5E-j4pDLD-j4tCAL-j4p6SZ-4SKrx6-j4sJj9-j4qzNB-j4tD7W-993AP6-j4p7Di-j4pxNr-j4uCCh-j4qBCt-j4tFrq-j4s1Mk-j4uEuU">michaelgreenhill/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>A Victorian teenager was <a href="http://www.theage.com.au/victoria/mysterious-flesheating-ulcer-at-epidemic-levels-in-mornington-peninsula-20170920-gyl2kf.html">recently reported</a> to be suffering from a Buruli ulcer, an infection caused by the “flesh-eating” bacteria <em>Mycobacterium ulcerans</em>. She was said to have caught it on Victoria’s Mornington Peninsula, where cases seem to be on the rise.</p>
<p>Buruli ulcer, also known as Bairnsdale ulcer, occurs in many areas of the world, including <a href="https://www2.health.vic.gov.au/about/news-and-events/healthalerts/buruli-ulcer-dec2016">Victoria</a>. Besides the Mornington Peninsula, Australian cases have <a href="http://members.ozemail.com.au/%7Egroverjohnson/Mulcerans.htm">also been reported</a> in tropical areas, including north of Mossman in Queensland, and the Capricorn Coast of Queensland near Yeppoon. </p>
<p>In Victoria, the <a href="https://www2.health.vic.gov.au/public-health/infectious-diseases/infectious-diseases-surveillance/search-infectious-diseases-data/victorian-summary">number of reported cases</a> has definitely increased over the past two years. As of September 2017, 159 cases have been reported, compared with 182 for the whole of 2016, 107 in 2015, and 89 in 2014.</p>
<p>Buruli ulcer is a major <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000911">public health problem</a> in West Africa, where cases have been described in 32 countries and untreated ulcers can result in significant disfigurement and disability, particularly in children.</p>
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Read more:
<a href="https://theconversation.com/buruli-ulcer-africas-neglected-but-third-most-common-mycobacterial-disease-56522">Buruli ulcer: Africa's neglected but third most common mycobacterial disease</a>
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<h2>How do you know it’s a Buruli ulcer?</h2>
<p>The hallmark of this infection is a non-healing sore, usually on the <a href="https://www.ncbi.nlm.nih.gov/pubmed/28821017">leg or arm</a>, which slowly enlarges over weeks to months. In the very early stages, the infection may start as a red lump. The edges of the ulcer are often medically described as “undermined”, which means the dead tissue may appear to extend far beyond the actual ulcer on the skin surface. </p>
<p>Ulcers are usually single, but they can be multiple or recurrent. Some patients can get a <a href="https://www.ncbi.nlm.nih.gov/pubmed/24392172">lot of swelling</a> of the infected area, and sometimes this may affect a whole limb. Extensive tissue damage requiring amputation is rare in Australia, but may be required for very advanced infections.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/186943/original/file-20170921-10615-1o9ruuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/186943/original/file-20170921-10615-1o9ruuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=779&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186943/original/file-20170921-10615-1o9ruuh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=779&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186943/original/file-20170921-10615-1o9ruuh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=779&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186943/original/file-20170921-10615-1o9ruuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=979&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186943/original/file-20170921-10615-1o9ruuh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=979&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186943/original/file-20170921-10615-1o9ruuh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=979&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Buruli ulcer is a major public health problem in Africa.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/interplast/419664931/in/photolist-D5T3v-9RDB1-D5TtC-D5TLg-D5Ppv-D5PFH-A2jqi-A2jqg-dqXcXn-dqXn9G-dqXcZe-RN5kwK-D5SQF">ReSurge International/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p><em>M. ulcerans</em> is a distant relative of organisms that cause tuberculosis (<em>Mycobacterium tuberculosis</em>) and leprosy (<em>Mycobacterium leprae</em>). It seems that this organism can evade the body’s immune system by producing a toxin called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC97217/">mycolactone</a>, which destroys immune cells. Without control by the immune system, the infection can proceed unchecked and cause progressive tissue death.</p>
<p>When we look down the microscope at tissues infected with other bacteria, we usually see lots of white cells which cause inflammation. But in the case of <em>M. ulcerans</em>, the telltale absence of white cells is often an important clue to diagnosis.</p>
<h2>What causes it?</h2>
<p><em>M. ulcerans</em> infection was first recorded in patients in eastern Victoria in the 1930s. But over the past 15 years, cases have been moving westwards along the coast to the Bellarine Peninsula south of Geelong. Since 2012, <a href="https://www2.health.vic.gov.au/about/news-and-events/healthalerts/buruli-ulcer-dec2016">cases have reversed</a> back to the Mornington Peninsula southeast of Melbourne.</p>
<p>Although cases can present at any time of year, more tend to present between June and November. A few patients only report very transient exposure, such as a weekend trip to the Bellarine Peninsula. From these patients, it is thought the <a href="https://www.ncbi.nlm.nih.gov/pubmed/24098820">incubation period</a> (the period between getting infected and the ulcer appearing) is around three to five months.</p>
<p>The reasons for where and in whom infection occurs isn’t clear. Circumstantial evidence <a href="https://www.ncbi.nlm.nih.gov/pubmed/18217548">seems to implicate mosquitoes</a>, as the <a href="https://www.ncbi.nlm.nih.gov/pubmed/18217547">bacteria can be found in mosquitoes</a>, occurs on exposed parts of the body where mosquitoes tend to bite, and seems to be associated with outdoor activities. So covering up and using mosquito repellents would seem to be the best preventative measures.</p>
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Read more:
<a href="https://theconversation.com/are-mosquitoes-to-blame-for-the-spread-of-flesh-eating-bacteria-64356">Are mosquitoes to blame for the spread of 'flesh-eating' bacteria?</a>
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<p>Oddly, cases seem to occur in very specific areas – on the Bellarine Peninsula some towns seem to be “hotspots” whereas others are relatively spared. An intriguing lead that may partly explain this is the <a href="https://www.ncbi.nlm.nih.gov/pubmed/20706592">discovery that possums</a>, and more specifically possum faeces, appeared to be infected, and sometimes without the possum apparently being unwell. Positive “possum poo” <a href="https://www.ncbi.nlm.nih.gov/pubmed/24498452">seems to occur</a> where human cases occur.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/186946/original/file-20170921-10652-112gm7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/186946/original/file-20170921-10652-112gm7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186946/original/file-20170921-10652-112gm7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=412&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186946/original/file-20170921-10652-112gm7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=412&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186946/original/file-20170921-10652-112gm7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=412&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186946/original/file-20170921-10652-112gm7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=518&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186946/original/file-20170921-10652-112gm7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=518&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186946/original/file-20170921-10652-112gm7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=518&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Possums could play a part in transmitting M. ulcerans infections.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/howfardad/12692986013/in/photolist-kkCSwr-boV7Dg-fi8qb6-qmAsx-bPheJX-7CpCD2-7en4Nq-jW1y9A-2WDS7b-js22Gu-jVZfHz-EWqux-ERYf3-amR2Sq-8g8KDP-finUXN-fi8Ci4-jVZfzF-finPMU-jW2HNd-jVZZXF-amR44Q-bFEx5-finX47-fi8tai-fi8wkn-dzHEnM-finEgj-amR6R1-nFjkr-finNym-finGb1-4tRaBu-dgxLJT-sngqdM-SvqoQk-s5Rnht-s5RnmB-rquKWv-rquKLF-saAFf8-sn9kVd-jVZQGD-8RqDmG-amNgix-amR6tG-jVZhcr-jVYHwB-fi8vgB-fi8mQk">Matt Francey/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This suggests that <em>M. ulcerans</em> may be a <a href="https://theconversation.com/au/topics/zoonotic-diseases-4865">zoonotic infection</a> – this is where human cases occur as a “spillover” from what is otherwise an animal infection. Clearly this isn’t the whole story, as <em>M. ulcerans</em> infection occurs in regions of the world with different mosquito and animal species.</p>
<h2>How is it treated?</h2>
<p>Unfortunately, these infections don’t respond to the usual antibiotics for skin infection, and it isn’t uncommon to see patients who have been on several courses of antibiotics before a diagnosis is made. </p>
<p>In the past, it was thought that <a href="https://www.ncbi.nlm.nih.gov/pubmed/17223763">all cases needed surgery</a>, similar to that for skin cancer. In Australia, surgery to remove the affected tissue is still sometimes required, but <a href="https://www.ncbi.nlm.nih.gov/pubmed/26883709">most cases</a> can be cured with long courses of antibiotics. The antibiotics used for <em>M. ulcerans</em> are usually reserved for other infections such as tuberculosis, which aren’t the first choice of treatment for skin infections. </p>
<p>The use of treatment solely with antibiotics is being tested in a <a href="http://www.who.int/mediacentre/factsheets/fs199/en/">trial in Africa</a>, and if successful would be good news for patients in regions where surgeons are scarce.</p>
<h2>What can I do to avoid it?</h2>
<p>Although the effectiveness of preventative measures is not confirmed, avoiding mosquitoes would seem to be the most prudent measure to prevent infection. This includes covering up exposed skin and using mosquito repellents in the warmer months. </p>
<p>Get unexplained lumps and sores checked out, particularly if they persist for weeks or months. There is a long list of other conditions that cause non-healing ulcers which may also require medical attention, such as skin cancers and diabetic foot infections. However, Buruli ulcers are more easily treated before the infection spreads, so early diagnosis is important.</p>
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Read more:
<a href="https://theconversation.com/explainer-how-diabetic-foot-disease-can-lead-to-amputations-and-even-death-66571">Explainer: how diabetic foot disease can lead to amputations and even death</a>
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<p>That said, <em>M. ulcerans</em> is very slow growing, so there’s no need to panic. Make sure you let your doctor know if you’ve been in any of the affected areas – while this infection is on the radar of doctors in these areas, it may not be top of the list for those elsewhere.</p><img src="https://counter.theconversation.com/content/84432/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allen Cheng receives funding from the National Health and Medical Research Council.</span></em></p>The hallmark of a Buruli ulcer is a sore, usually on the legs or arms, which slowly enlarges over weeks to months.Allen Cheng, Professor in Infectious Diseases Epidemiology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/428932017-08-29T04:56:53Z2017-08-29T04:56:53ZExplainer: what is Seroquel and should you take it for insomnia?<figure><img src="https://images.theconversation.com/files/90283/original/image-20150730-25757-6ur5s4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The evidence so far suggests off-label prescribing for insomnia places users at unnecessary risk of harm.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/pixotropic/199736547/">Flavio Ronco/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Quetiapine, sold under the brand name Seroquel, is a short-acting antipsychotic drug. It’s <a href="http://www.mims.com.au/index.php/news/mims-monthly-updates">used to treat</a> schizophrenia, <a href="http://www.blackdoginstitute.org.au/healthprofessionals/bipolardisorder/diagnosingbipolardisorder/bipolaribipolarii.cfm">bipolar I disorder</a> and as an add-on treatment for <a href="https://www.beyondblue.org.au/the-facts/depression/types-of-depression">major depression</a> and generalised anxiety disorder in people who haven’t responded to other therapies. The <a href="http://www.mims.com.au/index.php/news/mims-monthly-updates">recommended dose range</a> for these conditions is 200-800mg a day.</p>
<p>Off-label prescribing is when a drug is prescribed for uses outside those for which it has been licensed. It’s relatively common in psychiatry and may help patients who haven’t responded to standard treatments. But due to the lack of evidence for the safety and efficacy of off-label uses, there is a <a href="http://www.ncbi.nlm.nih.gov/pubmed/22448598">potential for harm</a>.</p>
<p>Doctors prescribe quetiapine off-label for <a href="http://www.australianprescriber.com/magazine/38/3/95/7">various conditions</a>, including anxiety, autism, post-traumatic stress disorder, substance abuse and obsessive compulsive disorder. It is also increasingly prescribed off-label for <a href="http://www.ncbi.nlm.nih.gov/pubmed/24534594">insomnia</a>, usually at <a href="http://www.ncbi.nlm.nih.gov/pubmed/23848159">lower doses</a> of 100mg or less a day. </p>
<p>But the evidence so far suggests the risks of prescribing quetiapine off-label outweigh any benefits. </p>
<h2>Rise in use</h2>
<p>Since quetiapine came onto the market in 1997, prescription rates have skyrocketed, especially in the United States, where it <a href="http://www.australianprescriber.com/magazine/38/3/95/7#R8">became</a> the fifth-biggest-selling pharmaceutical in 2010. </p>
<p>Prescriptions for quetiapine also increased significantly <a href="http://www.australianprescriber.com/magazine/38/3/95/7">in Australia</a> between 2000 and 2011. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/90286/original/image-20150730-25762-24w58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/90286/original/image-20150730-25762-24w58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/90286/original/image-20150730-25762-24w58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=351&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90286/original/image-20150730-25762-24w58.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=351&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90286/original/image-20150730-25762-24w58.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=351&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90286/original/image-20150730-25762-24w58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=441&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90286/original/image-20150730-25762-24w58.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=441&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90286/original/image-20150730-25762-24w58.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=441&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Quetiapine is sold under the brand name Seroquel.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/hopeless128/6293794859/in/photolist-5QAtA2-dXqq5t-2dG2v-dSiRbN-dLzTTw-nwBNWc-5QEKBJ-nyfnkn-aAakWt-aAd2n9-aAajpH-nTwy8T-8wMZCz-batkfa-aZ24z6">hopeless128/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Patients switching from another antipsychotic to quetiapine cannot account for these changes; the rise is <a href="http://www.australianprescriber.com/magazine/38/3/95/7">most likely due</a> to off-label prescribing. </p>
<p>In fact, drug company AstraZeneca <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653966/">paid US$520 million in 2010 to resolve allegations</a> the company illegally marketed Seroquel for uses not approved by the US Food and Drug Administration (FDA). </p>
<h2>Antipsychotic drugs</h2>
<p>All antipsychotic drugs – both first generation, which were developed in the 1950s, and second generation, developed since the 1950s – exert their effect mainly by blocking dopamine transmission in various parts of the brain. They block dopamine D2 receptors, which alleviates symptoms of psychosis such as hallucinations, delusions and thought disorder. </p>
<p>Other receptors may also be blocked. However, these blockages may cause serious side effects.</p>
<p>Quetiapine is a second-generation antipsychotic drug that also blocks histamine H1 and serotonin type 2A receptors. This is <a href="http://www.ncbi.nlm.nih.gov/pubmed/23848159">thought to account for</a> its sedative properties, which is why it’s used off-label for insomnia. </p>
<p>Antipsychotic drugs, especially first-generation antipsychotics such as haloperidol, fluphenazine and trifluoperazine, can be associated with some serious side effects, such as the neurological disorder <a href="http://www.nlm.nih.gov/medlineplus/ency/article/000685.htm">tardive dyskinesia</a>. This involves involuntary movements of the face, tongue and mouth and, less commonly, the limbs, head, neck and trunk. In some cases, tardive dyskinesia may be irreversible. </p>
<p>All antipsychotic drugs can also cause neuroleptic malignant syndrome, a neurological disorder which <a href="https://shop.amh.net.au/">can progress rapidly</a> over 24 to 72 hours. Neuroleptic malignant syndrome can cause instability, altered consciousness, muscle rigidity and even death. The incidence is greatest in young men.</p>
<p>Both first- and second-generation antipsychotics have been reported to contribute to <a href="http://www.mayoclinic.org/diseases-conditions/heart-arrhythmia/basics/definition/con-20027707">heart arrhythmia</a>, where the electrical impluses co-ordinating your heartbeats malfunction. In a recent large cohort <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa0806994">study</a>, researchers reported that antipsychotic drugs, including quetiapine, almost doubled the risk of sudden death from a heart attack. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90290/original/image-20150730-25773-1fr9h4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90290/original/image-20150730-25773-1fr9h4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90290/original/image-20150730-25773-1fr9h4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90290/original/image-20150730-25773-1fr9h4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90290/original/image-20150730-25773-1fr9h4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90290/original/image-20150730-25773-1fr9h4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90290/original/image-20150730-25773-1fr9h4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The use of antipsychotic drugs can be associated with some serious side effects.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/alyssafilmmaker/3628914665/">Alyssa L. Miller/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Quetiapine has fewer side effects than first-generation antipsychotics. But <a href="http://www.ncbi.nlm.nih.gov/pubmed/23848159">recent research</a> and clinical trials have reported considerable risk of metabolic side effects. These include weight gain, elevation of cholesterol and triglycerides, and diabetes, even when prescribed at recommended doses. </p>
<h2>Quetiapine as a sleeping drug</h2>
<p>Studies on the use of quetiapine for sedation have produced conflicting results. </p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/15029469">very small randomised placebo-controlled study</a>, funded by AstraZeneca (manufacturer of quetiapine) and involving 14 healthy subjects, reported that, compared to placebo, both 25mg and 100mg quetiapine administered at night increased the sleep quality and the amount of sleep. </p>
<p>Another independent <a href="http://www.ncbi.nlm.nih.gov/pubmed/20572379">study</a> conducted in Thailand did not support these findings. Researchers tested the drug in a randomised two-week controlled trial (where one group received the drug and another received a placebo). They found 25mg quetiapine at night for primary insomnia did not improve sleep. </p>
<p>Quetiapine can cause significant weight gain, even when used in small to moderate doses for sleep. It has also been associated with increased blood glucose (sugar) and <a href="http://www.msdmanuals.com/professional/endocrine-and-metabolic-disorders/lipid-disorders/dyslipidemia">dyslipidaemia</a> (an imbalance of fats circulating in the blood). These increase the risk of developing type 2 diabetes and heart disease. </p>
<p>In a retrospective <a href="http://www.ncbi.nlm.nih.gov/pubmed/19472052">study</a> in the United Kingdom, 43 psychiatric patients aged 19 to 65 years were prescribed low-dose quetiapine for insomnia, usually 100mg at bedtime. Over the 11-month study period, their weight increased by an average of 2.22kg.</p>
<p>Despite the safety concerns associated with using quetiapine as an antipsychotic, the risks may be acceptable when treating patients with serious mental illness, given there are few alternatives. </p>
<p>But the evidence so far suggests prescribing quetiapine off-label for people who have problems sleeping places them at unnecessary risk of harm.</p><img src="https://counter.theconversation.com/content/42893/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Petra Czarniak does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Quetiapine, sold under the brand name Seroquel, is a short-acting antipsychotic drug to treat major mental illnesses. It has also been increasingly prescribed off-label for insomnia.Petra Czarniak, Senior Lecturer, School of Pharmacy, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/764032017-06-01T02:28:26Z2017-06-01T02:28:26ZExplainer: what is chemotherapy and how does it work?<figure><img src="https://images.theconversation.com/files/167314/original/file-20170501-13007-cxpxep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Chemotherapy is the use of drugs to treat cancer. It is often paired with surgery, radiotherapy and immunotherapy in a cancer treatment plan.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=mOroT4zPV94GRCm1htB6MQ-1-0">From Shutterstock,</a></span></figcaption></figure><p>Chemotherapy is the use of drugs to treat cancer in humans and animals. It is rarely used in isolation and is often paired with surgery, radiotherapy and immunotherapy, or a combination of these.</p>
<p>Chemotherapy works by causing cancer cells to undergo a type of forced suicide, called <a href="http://science.howstuffworks.com/life/cellular-microscopic/apoptosis.htm">apoptosis</a>. </p>
<p>The severe side effects associated with chemotherapy are due to the drugs’ poor selectivity for cancerous tissue over healthy tissue.</p>
<p>The future for chemotherapy lies in the development of safer and more targeted drugs, and in personalised medicine where chemotherapy is individually selected for each patient based on genetic profiling.</p>
<hr>
<p><em><strong>Further reading – <a href="https://theconversation.com/how-cancer-doctors-use-personalised-medicine-to-target-variations-unique-to-each-tumour-47349">How cancer doctors use personalised medicine to target variations unique to each tumour</a></strong></em></p>
<hr>
<h2>How is chemotherapy used?</h2>
<p>In Australia the treatment of different cancers is based on specific guidelines in the <a href="https://www.eviq.org.au/">EviQ database</a> published by the New South Wales state government and the Cancer Institute of NSW. These provide guidance on what drugs should be used for each cancer type, their dose, and what other treatments should be given. </p>
<p>Sometimes chemotherapy is used to shrink tumours before surgery or radiotherapy; this is called <a href="http://chemoth.com/neoadjuvant-chemotherapy">neo-adjuvant chemotherapy</a>. Otherwise, chemotherapy is given after surgery or radiotherapy to mop up any remaining cancer cells. This is adjuvant chemotherapy.</p>
<p>The drug dose a patient receives is usually based on their <a href="http://www.calculator.net/body-surface-area-calculator.html">body surface area</a>, which is a number derived from a patient’s height and weight. </p>
<hr>
<p><em><strong>Further reading – <a href="https://theconversation.com/explainer-what-is-cancer-radiotherapy-and-why-do-we-need-proton-beam-therapy-60061">Explainer: what is cancer radiotherapy and why do we need proton beam therapy?</a></strong></em></p>
<hr>
<h2>How does it work?</h2>
<p>Chemotherapy drugs are grouped into families based on how they affect cancer cells. For example, some drugs attack the cell’s DNA, where its generic code is stored, and stop it being copied and reproduced by the cell. In contrast, other drugs attack a component of cells called <a href="https://www.ncbi.nlm.nih.gov/books/NBK9932/">microtubules</a>. These act as a type of skeleton which allows cells to hold their shape and move.</p>
<p>A common feature of all chemotherapy drugs is that they kill cancer cells through a process called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117903/">apoptosis</a>. This is where the drug does so much damage that the cell realises it can’t repair or function properly and shuts itself down.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/167311/original/file-20170501-12979-1nd6dj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/167311/original/file-20170501-12979-1nd6dj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167311/original/file-20170501-12979-1nd6dj6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167311/original/file-20170501-12979-1nd6dj6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167311/original/file-20170501-12979-1nd6dj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167311/original/file-20170501-12979-1nd6dj6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167311/original/file-20170501-12979-1nd6dj6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A feature of many chemotherapy drugs is that they kill cancer cells through a process called apoptosis. This involves cells undergoing ‘programmed suicide’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=Ji-chZ0qV6b_IIJKzNYYLA-1-16">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Where cancers continue to grow because they have become resistant to drug treatment, it is because they have found ways to repair, or get around, the damage caused by the drugs. </p>
<h2>Where did we find the drugs?</h2>
<p>Many people wrongly assume chemotherapy drugs are all synthetic and made in a laboratory, but many come from natural sources.</p>
<p>The <a href="http://chemoth.com/types/anthracyclines">anthracycline</a>-based drug doxorubicin comes from a bacterium that was first found living in the soil around a 13th-century Italian castle, <a href="https://en.wikipedia.org/wiki/Castel_del_Monte,_Apulia">Castel de Monte</a>. This drug acts by preventing DNA from being unzipped and is used <a href="http://chemocare.com/chemotherapy/drug-info/doxorubicin.aspx">to treat over 20 different types of cancer</a>. The fluid in an IV bag that contains one of these types of drugs will be highly coloured; either red or blue.</p>
<p>The taxel-based drugs <a href="https://theconversation.com/weekly-dose-taxol-the-anticancer-drug-discovered-in-the-bark-of-a-tree-56508">paclitaxel</a> and docetaxel come from the bark of trees found only in North America. The drugs bind to microtubules and stop them coming apart, which is an essential process in cell replication. These drugs are used primarily to treat breast, lung and ovarian cancers and leukaemia. </p>
<p>The vinca alkaloid-based drug <a href="https://www.drugs.com/cdi/vincristine.html">vinscristine</a> comes from the flower of the <a href="https://en.wikipedia.org/wiki/Catharanthus_roseus">perriwinkle plant</a>, which grows on the island of Madagascar. Examples of cancers that are treated with vincristine include the mainly childhood cancers called neuroblastomas, lymphomas and leukaemia.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/167312/original/file-20170501-12987-1h2iqee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/167312/original/file-20170501-12987-1h2iqee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167312/original/file-20170501-12987-1h2iqee.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167312/original/file-20170501-12987-1h2iqee.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167312/original/file-20170501-12987-1h2iqee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167312/original/file-20170501-12987-1h2iqee.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167312/original/file-20170501-12987-1h2iqee.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many people wrongly assume that chemotherapy drugs are all synthetic but many are obtained from natural sources.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=qo2KsbWGB7NIFxRzvR8-iw-1-9">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Even synthetic drugs have interesting origins. The <a href="https://www.cancer.org/cancer/cancer-basics/history-of-cancer/cancer-treatment-chemo.html">nitrogen mustard drugs were developed from chemical warfare agents</a>. The platinum-based <a href="https://theconversation.com/happy-50th-anniversary-to-cisplatin-the-drug-that-changed-cancer-treatment-38382">cisplatin</a> drug was discovered by accident when a physicist was studying the effects of electric fields on bacterial growth. </p>
<p>Platinum drugs are used to treat ovarian, testicular and lung cancers. These drugs work by preventing cells from replicating and reading DNA.</p>
<h2>Why the severe side effects?</h2>
<p>Most patients who have chemotherapy will experience severe side effects. These may include nausea and vomiting, fatigue, tingling in their arms and legs, hearing loss, hair loss, poor kidney and liver function, and an increased susceptibility to infection.</p>
<p>These side effects arise because the drugs are poorly selective for cancers. They attack any part of the body that grows quickly. That includes hair follicles, the lining of the mouth, stomach and intestines, and bone marrow. </p>
<p>Because fetuses are also fast-growing cells, <a href="http://www.cancer.net/navigating-cancer-care/dating-sex-and-reproduction/cancer-during-pregnancy">chemotherapy is very dangerous for pregnant women</a>.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/167310/original/file-20170501-13003-1hfxtc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/167310/original/file-20170501-13003-1hfxtc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=373&fit=crop&dpr=1 600w, https://images.theconversation.com/files/167310/original/file-20170501-13003-1hfxtc8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=373&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/167310/original/file-20170501-13003-1hfxtc8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=373&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/167310/original/file-20170501-13003-1hfxtc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=469&fit=crop&dpr=1 754w, https://images.theconversation.com/files/167310/original/file-20170501-13003-1hfxtc8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=469&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/167310/original/file-20170501-13003-1hfxtc8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=469&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chemotherapy drugs attack fast-growing cells in the body, such as hair follicles.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=mHPX_nukLfaBZe8yE6zxWA-1-99">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Sometimes it is necessary to give patients additional drugs to treat side effects. For example, blood contains both red and white blood cells. The job of red cells is to carry oxygen whereas white cells are used to fight infections. Chemotherapy is known to cause a drop in many patients’ white blood cell levels, and so they need to be given antibiotics to ensure they don’t get an infection.</p>
<p>Last year, the NSW government funded and approved <a href="https://www.medicinalcannabis.nsw.gov.au/clinical-trials/chemotherapy-trial">clinical trials to investigate the potential of medicinal cannabis</a> for alleviating the nausea and vomiting side effects of chemotherapy.</p>
<h2>The future of chemotherapy</h2>
<p>Scientists are continually working to find better and safer chemotherapy drugs. As we learn more about the underlying biology of cancer, we can find targets inside cancer cells that are not found in normal cells. By designing drugs that target these differences we can create drugs that will be free from side effects.</p>
<p>Scientists are also working on better ways to deliver the drugs we currently use. This includes putting the drugs in <a href="http://www.cancernetwork.com/oncology-journal/nanoparticle-delivered-chemotherapy-old-drugs-new-packages">nanoparticle formulations</a>, or attaching targeting molecules to the drugs so they can tell the difference between cancerous and normal cells.</p>
<hr>
<p><em><strong>Further reading – <a href="https://theconversation.com/explainer-what-is-nanomedicine-and-how-can-it-improve-childhood-cancer-treatment-69897">Explainer: what is nanomedicine and how can it improve childhood cancer treatment?</a></strong></em></p>
<hr>
<p>Finally, over the next decade we will see significant advances in the development of <a href="https://theconversation.com/how-cancer-doctors-use-personalised-medicine-to-target-variations-unique-to-each-tumour-47349">personalised medicine in cancer treatment</a>. </p>
<p>Currently, chemotherapy drugs are selected for patients based on the location of the cancer. But we are developing methods to select combinations of drugs that are more likely to work based on genetic profiling of the patient’s cancer cells. Such treatments are more likely to be effective and have fewer side effects.</p><img src="https://counter.theconversation.com/content/76403/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is affiliated with the Royal Australian Chemical Institute.</span></em></p>Chemotherapy is the use of drugs to treat cancer. It is often paired with surgery, radiotherapy and immunotherapy in a cancer treatment plan.Nial Wheate, BPharm Coordinator and Senior Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/679362017-03-15T19:14:52Z2017-03-15T19:14:52ZExplainer: what is delirium and is it dangerous?<figure><img src="https://images.theconversation.com/files/155427/original/image-20170203-1657-l344hg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People with delirium may hallucinate.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The woman suffered two strokes in succession. The <a href="https://theconversation.com/a-mini-stroke-is-a-warning-a-stroke-may-follow-64486">first was minor</a> and her condition improved quickly. The second came on suddenly and was <a href="https://theconversation.com/how-to-recognise-a-stroke-and-what-you-should-know-about-their-treatment-63651">more severe</a>. </p>
<p>Luckily she was able to receive clot-busting medication and the stroke went away in less than an hour, but then something odd happened: she became confused, disoriented and insisted on getting out of bed. She appeared not to understand or remember that doctors told her this was dangerous.</p>
<p>She accused the doctors, nurses and even her family of torturing her and hit out at them, screaming and crying. She required powerful sedative medications to keep her safely in bed while the anti-clotting drugs did their job.</p>
<p>This behaviour is characteristic of delirium. A <a href="https://www.ncbi.nlm.nih.gov/pubmed/24151504">recent Australian study</a> found one in ten people aged over 70 had been experiencing delirium before they arrived at hospital. Another one in ten developed delirium while in hospital – which means one in five elderly in hospital were suffering from delirium.</p>
<h2>What is delirium?</h2>
<p>Delirium is a neurological (nervous system) condition where a person becomes suddenly confused. They may see hallucinations, such as ants crawling on walls, or become delusional, believing others are out to get them for no reason.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/159928/original/image-20170308-24179-jkqcy8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/159928/original/image-20170308-24179-jkqcy8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/159928/original/image-20170308-24179-jkqcy8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=987&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159928/original/image-20170308-24179-jkqcy8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=987&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159928/original/image-20170308-24179-jkqcy8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=987&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159928/original/image-20170308-24179-jkqcy8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1240&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159928/original/image-20170308-24179-jkqcy8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1240&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159928/original/image-20170308-24179-jkqcy8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1240&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Hallucinations could include ants crawling on the wall where there aren’t any.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Delirium is dangerous. Compared to patients with the same illness, age and other characteristics who don’t develop delirium, those who do are <a href="https://www.ncbi.nlm.nih.gov/pubmed/19170790">almost three times</a> more likely to die during, or soon after, hospitalisation.</p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/24151504">earlier-mentioned Australian study</a> found patients with delirium were five times more likely to die if they came to hospital already with delirium, and 30 times more likely to die if it developed during their stay. </p>
<p>We now know delirium can <a href="https://www.ncbi.nlm.nih.gov/pubmed/24088092">cause permanent damage</a> to the brain. Some sufferers never return to normal. We also know that Alzheimer’s disease <a href="http://jamanetwork.com/journals/jamapsychiatry/article-abstract/2598162">progresses more rapidly</a> when sufferers get delirium.</p>
<h2>What causes it?</h2>
<p>Delirium can have different causes. Infections such as pneumonia or urinary tract infections are common causes. Dehydration, certain medications, an over-full bladder and even constipation – either alone or in combination – can also lead to delirium.</p>
<p>Younger people and children who are very unwell can develop delirium. It’s a very commonly seen condition in the intensive care unit.</p>
<p>Severe alcohol withdrawal that causes sudden mental and nervous-system changes can have similar symptoms to delirium; the condition is called Delirium Tremens. Intoxication with various licit and illicit drugs can also cause acute confusion and hallucinations.</p>
<p>Often there is more than one reason for delirium in hospital patients. The doctor will usually do a careful head-to-toe check along with basic urine and blood tests to determine the cause. Strokes and brain infections are very uncommon causes, so spinal taps and brain scans <a href="http://www.anzsgm.org/documents/PS13DeliriumstatementRevision2012.pdf">should take second place</a> to a traditional examination.</p>
<h2>How is it diagnosed?</h2>
<p>Unfortunately, doctors have difficulty diagnosing delirium. This is often because doctors spend little time with patients, and delirium fluctuates. From day to day, even hour to hour, a patient can go from being normal to very delirious. If they are seen at the normal stage, the delirium may not be noted. </p>
<p>Symptoms of delirium are often put down to the side effects of medications, age, dementia and even speaking a foreign language.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/159929/original/image-20170308-24211-k25ir0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/159929/original/image-20170308-24211-k25ir0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159929/original/image-20170308-24211-k25ir0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159929/original/image-20170308-24211-k25ir0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159929/original/image-20170308-24211-k25ir0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159929/original/image-20170308-24211-k25ir0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159929/original/image-20170308-24211-k25ir0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159929/original/image-20170308-24211-k25ir0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A doctor will do a full examination to see if the patient has delirium.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<p>There is no blood test or scan to <a href="http://www.anzsgm.org/documents/PS13DeliriumstatementRevision2012.pdf">diagnose for delirium</a> because of the uncertainty of its underlying biology. While some neurotransmitters (various small chemicals that carry electrical signals between brain cells) go up and some down during delirium, they are not useful diagnostic tests. </p>
<p>Diagnosis still relies on <a href="http://www.anzsgm.org/documents/PS13DeliriumstatementRevision2012.pdf">observing the characteristic signs</a>, and therefore watching carefully for them.</p>
<h2>Types of delirium</h2>
<p>There are different types of delirium. The hyperactive one is easiest to spot. This is where the sufferer is agitated, fidgety and potentially aggressive. They may be walking around and perhaps trying to leave the hospital. </p>
<p>The hypoactive form, with a drowsy, sleepy patient who is slow to respond, is more easily missed – or dismissed for the reasons mentioned before. This kind is more dangerous.</p>
<p>Delirium can also occur in the very last stages of life. <a href="https://theconversation.com/drugs-for-delirium-dont-work-and-may-in-fact-harm-69143">Terminal delirium</a> affects around one third of people in end-of-life care, which robs them of the chance to die with dignity. Treatment of terminal delirium symptoms is particularly important. </p>
<h2>How is it treated?</h2>
<p>Treating delirium requires treating the trigger, such as stopping the medication causing the side effects of delirium. Unfortunately, though, the delirium can persist well after the trigger has gone. </p>
<p>Despite being a common, dangerous condition, there is no effective treatment for delirium itself. In most cases, all that can be done is to keep the patient safe. </p>
<p>Antipsychotic medications (the kind used to treat schizophrenia) have been used in low doses to help with symptoms of hyperactive delirium. But a recent <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2588810">Australian trial in palliative care patients</a> found these medications were not only ineffective, but also detrimental to the patients. This reinforces the fact that medications should take second place to keeping the patient safe.</p>
<p>Relatives can help by reminding the patient of what is happening, and where, to re-orientate them. Hospital environments can be designed to be safe for older patients with confusion. For example, providing natural light helps to keep day-night rhythms more normal, allowing patients to wander without risking harm.</p>
<h2>Physical restraints</h2>
<p>Physical restraints, either obvious ones like shackles and ties, or less obvious like chairs and tables, should be minimised.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/A-lLLP8Me0E?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Survivors of delirium say the experience can be horrific and nightmarish.</span></figcaption>
</figure>
<p>Survivors tell us the <a href="https://www.youtube.com/watch?v=ZYhooW0YHJg">experience of delirium is horrifying and nightmarish</a>. They truly believe they are being persecuted and tortured. Being tied to a bed, not surprisingly, reinforces those beliefs and makes agitation worse. It should only be a last resort when safety is at risk.</p>
<p>Until an effective preventative is found, relatives, friends and carers of those susceptible to delirium – such as the very elderly and those with dementia – should be vigilant to the signs and ensure they are acted on when present.</p><img src="https://counter.theconversation.com/content/67936/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Lange is affiliated with the Royal Australasian College of Physicians, the Australian and New Zealand Society for Geriatric Medicine.</span></em></p>Delirium is a neurological (nervous system) condition where a person becomes suddenly confused. Around one in five elderly people in hospital suffer from delirium.Peter Lange, Consultant Geriatrician, PhD Candidate, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/647372016-11-15T19:06:31Z2016-11-15T19:06:31ZExplainer: how do our bodies balance themselves?<figure><img src="https://images.theconversation.com/files/143013/original/image-20161025-28405-11cqls5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We don't tend to realise it, but there are complex processes happening in our body at all times just to keep us upright. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Balance is the vital sense that gives much-needed stability to our teetering, upright bodies. Good balance is usually associated with having stable posture, but it also has a lot to do with visual stability.</p>
<p>The importance of the balance system is shown by the vast number of connections it makes with the brain. These connections reveal that the forces of motion we create and encounter in the environment can go on to affect many parts of the brain, including those that control <a href="http://link.springer.com/book/10.1007%2Fb97280">vision, hearing, sleep, digestion, and even learning and memory</a>.</p>
<h2>How does balance work?</h2>
<p>Every sensory system uses detectors or <em>receptors</em> outside the brain to gather information about the environment. For example, the visual system uses light-sensitive receptors in the retina to detect visible light. The balance system relies on specialised motion-sensitive receptor cells in the inner ear.</p>
<p>While obviously associated with hearing, the inner ear is also the shelter for balance. It has a labyrinthine structure, made up of a series of fluid-filled canals and ducts. Within this labyrinth are five balance receptors that are ideally placed to detect different types of movement. There are three receptors for head rotation, another for horizontal acceleration, and one for vertical acceleration (or gravity).</p>
<p>Each balance receptor is an organ made up of thousands of cells with long hair-like projections. As a result of head movement, these so-called <em>hair cells</em> are excited when their projections are pushed in a particular direction by fluid called endolymph. </p>
<p>Movement of endolymph within the inner ear is complex. When you spin a bowl of water, for instance, the water takes time to “catch up” with the turning bowl. This lag is due to inertia and applies to all fluids, including endolymph. </p>
<p>When the head begins to move, the endolymph initially stays still. This actually translates to a fast relative movement of the endolymph in the opposite direction to the head. This relative movement excites the hair cells that are aligned to detect that particular head movement. </p>
<p>So in an elegant and precise way, endolymph and hair cells work in concert to provide a constant stream of information about head movement to the brain.</p>
<p>The inner ear balance organs are remarkable in their ability to detect head movements both small and large, fast and slow, and in any direction. The brain uses signals from the organs to orchestrate a suite of balance reflexes that control our muscles, right down to our toes! </p>
<p>However these reflexes not only control our muscles of posture but our eye muscles as well. Together, these reflexes underlie our ability to remain upright with stable vision in an ever-changing and ever-moving physical environment.</p>
<h2>Why doesn’t our vision bounce up and down when we jog?</h2>
<p>Maintaining our upright posture is an obvious job for our exquisitely sensitive and responsive balance system. However, it also has a profound effect on the control of our eye movements. The up-down movement generated when walking or jogging would have a destabilising effect on our vision. </p>
<p>Like footage from a hand-held camera, even a simple jog along a flat path or a smooth road would result in unstable and shaky images. When watching hand-held camera footage, it can be unpleasant and difficult to focus on stationary objects like trees because they are moving too violently. </p>
<p>But what about our eyes? Thankfully, our visual field is remarkably stable when we jog. This is due to a reflex most of us take for granted, called the <em>vestibulo-ocular reflex</em>. </p>
<p>The vestibulo-ocular reflex is one of the fastest and most active reflexes in the human body. It uses head movements detected by the inner ear to generate compensatory eye movements that are equal – but opposite in direction – to head motion. This subconscious, ongoing adjustment of eye position results in a stable visual field, despite significant movement of the head. </p>
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<iframe src="https://player.vimeo.com/video/188254998" width="500" height="281" frameborder="0" webkitallowfullscreen="" mozallowfullscreen="" allowfullscreen=""></iframe>
<figcaption><span class="caption">Video: Infra-red camera tracking of eye movements while jogging in complete darkness. The vestibulo-ocular reflex works by activating extra-ocular muscles to move the eyes to compensate for head movements. The video begins with Alan standing still (rest), then jogging (jog), then standing still again (rest). Although the eye movements don’t appear to be big, they are exquisitely precise.</span></figcaption>
</figure>
<h2>What happens when balance goes wrong?</h2>
<p>For many, the idea of suddenly losing a sense like vision or hearing is terrifying (and rightly so), and a sudden loss of your sense of balance would be similarly catastrophic. </p>
<p>Initially, a debilitating and frightening dizziness would prevent you from completing even simple daily tasks without falling over. The worst symptoms would subside with time as you begin to rely more heavily on other senses such as vision. But even a partial loss of the vestibulo-ocular reflex would mean stopping and standing still every time you wanted to recognise a face or read the price of a grocery item. </p>
<p>The fact that we are almost totally unaware of this elegant reflex is evidence of the superb, undercover work the balance system does for us. It not only allows us to walk without falling over, but also gives us a constant and reliable view of a beautifully changing world.</p><img src="https://counter.theconversation.com/content/64737/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lauren Poppi receives funding from National Health and Medical Research Council of Australia and the Neuro-Otological Society of Australia.</span></em></p><p class="fine-print"><em><span>Alan Brichta receives funding from National Health And Medical Research Council of Australia and the Garnett Passe and Rodney Williams Memorial Foundation. </span></em></p>The fact we are almost totally unaware of this elegant reflex is evidence of the superb, undercover work the balance system does for us.Lauren Poppi, PhD candidate in Anatomy, University of NewcastleAlan Brichta, Professor School of Biomedical Sciences and Pharmacy (Anatomy), University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/648702016-10-31T23:46:42Z2016-10-31T23:46:42ZExplainer: what is an epidural for labour?<figure><img src="https://images.theconversation.com/files/142443/original/image-20161020-5004-8ez06v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An epidural takes up to 45 minutes to work, so if the baby's coming it could be too late. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/downloading_tips.mhtml?code=&id=162604985&size=medium&image_format=jpg&method=download&super_url=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTQ3Njk1ODc4OCwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfMTYyNjA0OTg1IiwiayI6InBob3RvLzE2MjYwNDk4NS9tZWRpdW0uanBnIiwibSI6IjEiLCJkIjoic2h1dHRlcnN0b2NrLW1lZGlhIn0sInZKUHJ6ZER4L1dyc2tjYngybmRja2JjeVA3USJd%2Fshutterstock_162604985.jpg&racksite_id=ny&chosen_subscription=134&license=multi_share&src=Bs5k9y1aTXv8sZMsGzOLTQ-1-19">from www.shutterstock.com.au</a></span></figcaption></figure><p><a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009234.pub2/abstract">Epidurals were developed</a> for pregnant women to address the severe pain of labour. In Australia about <a href="http://www.aihw.gov.au/publication-detail/?id=60129553770">one in three</a> pregnant women in labour has an epidural for this reason.</p>
<p>A specialised medical doctor who has training and experience in this technique performs it in a hospital with an epidural service. This doctor is <a href="http://www.anzca.edu.au/documents/ps03-2014-guidelines-for-the-management-of-major-r.pdf">usually an anaesthetic consultant</a> (anaesthetist) or a trainee under their supervision, or a GP anaesthetist.</p>
<p>An epidural is sometimes called a “major regional block” because a large region of the body has pain blocked in it, or a “neuraxial block” because it blocks the pain nerves around the middle axis of the body.</p>
<h2>Why is it sometimes ‘too late’?</h2>
<p>A woman must request an epidural and give her consent before the procedure. The doctor then inserts an intravenous line (an “IV”). The procedure is performed between contractions, with the woman sitting up or lying on her side. It is safe to have an epidural early in labour or even before labour is induced as long as the woman <a href="http://www.cochrane.org/CD007238/PREG_early-versus-late-initiation-of-epidural-analgesia-for-labour">has no medical reason</a> to avoid one. </p>
<p>Medical reasons include conditions that increase the risk of bleeding and infection around the spinal nerves, which can lead to spinal nerve damage.</p>
<p>Another reason is if a woman is fully dilated or just about to give birth as there may not be time for an epidural. This is because the procedure itself takes time to perform, may be challenging to perform at this stage of labour due to pushing and the need for the woman to keep very still, and it then takes time for the medications to work.</p>
<p>In general, the aim is for women to have adequate pain relief <a href="https://www.ncbi.nlm.nih.gov/pubmed/15477051">45 minutes after the epidural procedure</a> has started. If birth is expected within this time, the risks of an epidural, outlined below, are generally thought to outweigh the benefits of possible pain relief.</p>
<h2>How is it administered?</h2>
<p>An epidural involves placing a very small soft plastic tube into the epidural space in the lower part of the back. The epidural space is near the spine in the central part of the back, where the pain nerves of childbirth are located. </p>
<p>The doctor usually delivers two different types of medications down the epidural tube into the epidural space. These are local anaesthetics (drugs like lignocaine, commonly used to numb tooth pain for dental work) and morphine-like medications (opioids). </p>
<p>The two different drugs work together to improve pain relief. This means less of each drug can be used so there is less likelihood of side effects. These medications then surround the nerves and block signals from the nerves to relieve pain.</p>
<p>The medications block mainly the small pain nerves, and not the large muscle nerves. This means a woman can still move her legs and push effectively, while getting pain relief. This is often known as a “light epidural”.</p>
<p>One recent technique is known as patient controlled epidural analgesia. This is when a woman can press a button to control the delivery of medication into the epidural space, and so the amount of pain relief she receives.</p>
<p>A woman usually has to stay in bed during an epidural for labour or birth. This is because the epidural can also block some other small nerves (those that control balance), so increasing the risk of a fall.</p>
<h2>What are the advantages?</h2>
<p>While the major advantage of an epidural is to provide complete or near complete pain relief for labour, other advantages include reducing blood pressure spikes during the pain of contractions in women with high blood pressure (preeclampsia) and <a href="https://www.thewomens.org.au/patients-visitors/cbe/cbepark/twins-triplets-and-more/">allowing twins to be safely delivered vaginally</a>.</p>
<p>Another advantage is if the woman needs a caesarean section then the epidural can often be simply “topped up”. This means the doctor delivers a different medication or an increased amount of the same medication via the epidural tube.</p>
<p>This leads to a <a href="http://www.cochrane.org/CD004350/PREG_regional-versus-general-anaesthesia-for-caesarean-section">much stronger epidural block</a> causing the woman’s legs to become very heavy and pain relief to extend higher up her body to her breasts. This is needed so the woman does not feel pain during surgery yet she is awake to experience the birth. In the past this type of epidural was commonly used during labour and was known as a “heavy epidural”. </p>
<h2>What are the risks?</h2>
<p>It is important to monitor the woman and the unborn baby when a woman has an epidural because there can be changes in her blood pressure or the unborn baby’s heart rate. </p>
<p>There is no increased risk of caesarean section with an epidural, however women who have an epidural have on average a 14 minute longer second stage of labour - when the woman is fully dilated until she gives birth. There’s also an increased risk of needing instruments such as forceps during a vaginal birth (<a href="http://www.cochrane.org/CD000331/PREG_epidurals-for-pain-relief-in-labour">one woman in eight without</a> an epidural compared with one in six women with an epidural). </p>
<p>Sometimes an epidural can fail. <a href="https://www.ncbi.nlm.nih.gov/pubmed/15321183">There may have been a failure</a> to locate the epidural position (sometimes due to the anatomy of the woman), pain may continue 45 minutes after the initiation of the epidural, replacement of an epidural is needed if it is not working, there is patchy or one-side anaesthesia, or there is an accidental puncture in the layer of tissue around the spinal canal known as the dura.</p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/15477051">criteria and standards</a> for <a href="https://www.ncbi.nlm.nih.gov/pubmed/15321183">best practice</a> when a hospital department offers an epidural pain relief service for pregnant women include at least 88% of women having adequate pain relief 45 minutes from the start of the epidural procedure, fewer than 15% of women having their epidural replaced at any point during labour, fewer than 1% of women having an accidental dural puncture, at least 85% of women having an excellent epidural experience overall, and at least 98% of women being satisfied with their pain relief in labour.</p>
<p>In Australia we are fortunate to have skilled, specialised medical doctors who work as part of a team to provide pregnant women with choice, and safe and effective anaesthesia so their experience of childbirth can be pain free and enjoyable.</p><img src="https://counter.theconversation.com/content/64870/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alicia Dennis receives funding from NHMRC ECF Health Practitioner Fellowship, is a Fellow of the Australian and New Zealand College of Anaesthetists, is Chair of the Public Practice Advisory Committee of the Australian Society of Anaesthetists, and is a staff specialist anaesthetist and Director of Anaesthesia Research at the Royal Women's Hospital, Parkville, Australia </span></em></p>Epidurals were developed for pregnant women to address the severe pain of labour. In Australia approximately one in three pregnant women in labour has an epidural for pain relief.Alicia Dennis, Associate Professor of Obstetric Anaesthesia, MBBS, PhD, PGDipEcho, FANZCA, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/635032016-10-20T02:07:30Z2016-10-20T02:07:30ZExplainer: what is carpal tunnel syndrome and what happens if I get it?<figure><img src="https://images.theconversation.com/files/134217/original/image-20160816-12998-joqdi4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Though symptoms may be innocuous at first, the longer carpal tunnel is left untreated the worse it will be. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>It often begins as an easily dismissed tingle in the thumb or an ache in the wrist. Building slowly but persistently to a searing, tearing pain from the wrist to the fingers. Culminating in sleepless nights, workless days and a numb but simultaneously excruciating, useless hand. Carpal tunnel syndrome is a painful and disabling condition. It’s also very common.</p>
<p>The carpal tunnel itself is a tunnel in the wrist made up of bony structures that are the base and walls, with a roof constructed by a dense fibrous sheet called the flexor retinaculum.</p>
<p>Through this tunnel courses a bundle of nerves, blood vessels and tendons that are the cables of supply to the hand. The syndrome is a result of pressure on the all important median nerve that travels through this space-limited tunnel. </p>
<p>The median nerve supplies sensation and strength to most of the thumb, several fingers and part of the palm. It is thought increased swelling or fluid in the carpal tunnel places pressure on this nerve resulting in the distressing symptoms experienced. Swelling may occur for several reasons, for example with repetitive hand movements or in pregnancy. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/134215/original/image-20160816-13037-1x0aa3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/134215/original/image-20160816-13037-1x0aa3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134215/original/image-20160816-13037-1x0aa3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=547&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134215/original/image-20160816-13037-1x0aa3m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=547&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134215/original/image-20160816-13037-1x0aa3m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=547&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134215/original/image-20160816-13037-1x0aa3m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=687&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134215/original/image-20160816-13037-1x0aa3m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=687&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134215/original/image-20160816-13037-1x0aa3m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=687&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Diagram of the carpal tunnel.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Who’s at risk?</h2>
<p>Carpal tunnel syndrome has been reported to account for <a href="http://pn.bmj.com/content/5/4/210.abstract">more days off work</a> than any other occupation-related injury. Some <a href="http://www.neurology.org/content/86/16_Supplement/P4.081">7.8% of the US working population</a> are estimated to be affected and a <a href="http://jnnp.bmj.com/content/74/12/1674">UK study estimated</a> an annual incidence of 120 per 100,000 women and 60 per 100,000 men. </p>
<p>An <a href="http://www.racgp.org.au/afp/2009/september/carpal-tunnel-syndrome/">audit performed in general practice</a> in Australia found there are about 195,000 appointments annually with patients for carpal tunnel syndrome.</p>
<p>It <a href="http://www.ncbi.nlm.nih.gov/pubmed/25778497">seems to occur more commonly</a> in women, particularly during pregnancy. Although the mechanism is unclear, it is thought a combination of hormonal factors as well as increased fluid in the body of a pregnant woman increases the pressure in the carpal tunnel. </p>
<p>While we may not be able to modify these aspects, there are risk factors that may be more amenable. Increased body mass index and obesity increase your risk of developing this syndrome, as does diabetes. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21586523">Some data also associates</a> increased occupational risk, particularly tasks requiring hand force or repetitive wrist movement.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/134216/original/image-20160816-13017-1pqzs30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/134216/original/image-20160816-13017-1pqzs30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134216/original/image-20160816-13017-1pqzs30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=540&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134216/original/image-20160816-13017-1pqzs30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=540&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134216/original/image-20160816-13017-1pqzs30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=540&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134216/original/image-20160816-13017-1pqzs30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=679&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134216/original/image-20160816-13017-1pqzs30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=679&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134216/original/image-20160816-13017-1pqzs30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=679&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Diagram of carpal tunnel syndrome.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>How do I know if I have it?</h2>
<p>Sufferers of carpal tunnel syndrome might feel tingling or pain in their fingers or hand. It’s often intermittent at the start – just a nuisance – and then it gets worse. Sufferers may experience sharp pain and numbness that wakes them at night. Shaking the hand might help it settle, but not always. At its most severe, the hand may be weak, holding things is difficult, lifting things is out of the question. </p>
<p>Discussing these symptoms with your doctor is important and you may need to have a nerve conduction study. This study involves testing the function of the nerves in your hand. It can be uncomfortable, but it is safe. More importantly, it tells you if your nerve is trapped in the tunnel. </p>
<h2>What can I do?</h2>
<p>There are several options for treatment. A wrist splint can be helpful; it supports your wrist and reduces trauma to the nerve. Different medications and a local steroid injection to help with the pain can also be useful. </p>
<p>If things don’t improve, you may go on to have carpal tunnel release surgery. The procedure aims to loosen the lid on the tunnel and relieve the pressure on the nerve. It’s not as scary as it sounds and is the most commonly performed hand surgery. Surgery under local anaesthetic or via endoscopic means (“key hole”) are even available now. </p>
<h2>Will it get better?</h2>
<p>Severity has historically been the instigator for treatment. We often leave things until they have to be done, surgery especially.</p>
<p>However a worse outcome is associated with longer duration of symptoms, <a href="http://pn.bmj.com/content/5/4/210.abstract">particularly over six months</a>. If the nerve is too far compressed, it may not rebound, despite surgery. So if your symptoms are persistent and start to bother you, talk to your local doctor.</p><img src="https://counter.theconversation.com/content/63503/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vinojini Vivek is affiliated with and employed by Melbourne Health. </span></em></p>Carpal tunnel syndrome is common. It’s painful, disabling and needs attention before it is too far gone.Vinojini Vivek, Neurophysiology Fellow, Melbourne HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/636992016-09-19T19:58:27Z2016-09-19T19:58:27ZExplainer: what are cataracts?<figure><img src="https://images.theconversation.com/files/135769/original/image-20160829-17859-bvfh20.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cataracts are one of the leading causes of visual impairment globally.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Cataract_in_human_eye.png">Rakesh Ahuja, MD/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Nearly <a href="http://www.aihw.gov.au/media-release-detail/?id=6442464587">one-third of Australians</a> aged 55 or over (or around 1.5 million people) have an untreated cataract. In 2013-14, there were <a href="http://www.aihw.gov.au/eye-health/cataract-surgery/">229,693 hospital admissions</a> for cataract surgeries, making cataracts one of the most prevalent conditions among Australians. </p>
<p>Cataracts remain one of the <a href="http://www.who.int/mediacentre/factsheets/fs282/en/">leading causes</a> of visual impairment globally; they are responsible for blindness in <a href="http://www.who.int/blindness/causes/priority/en/index1.html">20 million people</a> worldwide.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/135769/original/image-20160829-17859-bvfh20.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/135769/original/image-20160829-17859-bvfh20.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=436&fit=crop&dpr=1 600w, https://images.theconversation.com/files/135769/original/image-20160829-17859-bvfh20.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=436&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/135769/original/image-20160829-17859-bvfh20.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=436&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/135769/original/image-20160829-17859-bvfh20.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=547&fit=crop&dpr=1 754w, https://images.theconversation.com/files/135769/original/image-20160829-17859-bvfh20.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=547&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/135769/original/image-20160829-17859-bvfh20.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=547&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cataracts are one of the leading causes of visual impairment globally.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Cataract_in_human_eye.png">Rakesh Ahuja, MD/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>What is a cataract?</h2>
<p>The word cataract comes from the Latin <em>cataracta</em>, which means waterfall. It is a clouding of the normally transparent crystalline lens in the eye. </p>
<p>The lens works together with the cornea to focus light onto the retina, which converts light to electrical signals that are transferred to the brain. This gives us the images we see.</p>
<p>Cataracts commonly cause blurring of vision, glare from bright lights – especially oncoming vehicle headlights – halos around lights, loss of colour saturation and poorer night vision. Affected people may notice they <a href="http://eyebulletin.com/what-is-second-sight-and-how-does-it-happen/">no longer need their reading glasses</a> as a cataract causes a paradoxical increase in the focusing power of the lens.</p>
<p>Because cataracts develop slowly and painlessly, they may progress for many years before being diagnosed. If left untreated, however, they may eventually cause severe visual impairment in the affected eye. Cataracts commonly occur in both eyes but may occur in one eye alone, or <a href="http://www.optometry.org.au/your-eyes/your-eye-health/eye-diseases/cataract.aspx#cat4">progress at different rates in each eye</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/135596/original/image-20160826-17865-1a0rmb3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/135596/original/image-20160826-17865-1a0rmb3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=589&fit=crop&dpr=1 600w, https://images.theconversation.com/files/135596/original/image-20160826-17865-1a0rmb3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=589&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/135596/original/image-20160826-17865-1a0rmb3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=589&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/135596/original/image-20160826-17865-1a0rmb3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=740&fit=crop&dpr=1 754w, https://images.theconversation.com/files/135596/original/image-20160826-17865-1a0rmb3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=740&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/135596/original/image-20160826-17865-1a0rmb3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=740&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">If left untreated, cataracts may eventually cause severe visual impairment in the affected eye.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>What causes cataracts?</h2>
<p>Cataract formation is part of the normal ageing process of the lens. More than <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/D1A5409787D800F2CA257C73007F12F3/$File/eyehlth.pdf">70% of men and women</a> aged 80 and above will have a cataract.</p>
<p>The most common type of cataract is age-related, which is thought to occur due to breakdown and degradation of lens proteins over time. <a href="https://www.ncbi.nlm.nih.gov/pubmed?term=7725232">This process can be accelerated</a> by smoking, chronic diseases, such as diabetes and high blood pressure, and exposure to ultraviolet light and radiation.</p>
<p>Less commonly, cataracts can occur following <a href="https://www.ncbi.nlm.nih.gov/pubmed?term=16107513">prolonged use of steroid medications</a>, such as those taken for rheumatoid arthritis and other chronic inflammatory conditions. They can also occur following <a href="http://emedicine.medscape.com/article/1211083-overview">trauma or radiation to the eye</a>.</p>
<p>A very small number – around 2.2 per 10,000 babies <a href="http://bjo.bmj.com/content/86/7/782.full">in one Australian study</a> – are born with congenital cataracts. These usually occur on their own or uncommonly in association with other diseases, such as rubella infection.</p>
<h2>How are cataracts treated?</h2>
<p>No medications exist to treat a cataract or slow its progression. Stronger spectacles may be all that is needed to manage early cataracts. However, surgery may eventually be required as a cataract progresses and causes troublesome vision impairment. </p>
<p>Cataract surgery has been practised for thousands of years and has involved the same principle: removal of the cloudy lens. The <a href="http://news.bbc.co.uk/2/hi/health/7194352.stm">Romans used to do this</a> by inserting a sharp needle into the eye and rotating it. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/135597/original/image-20160826-17859-1vs4yv4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/135597/original/image-20160826-17859-1vs4yv4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/135597/original/image-20160826-17859-1vs4yv4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/135597/original/image-20160826-17859-1vs4yv4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/135597/original/image-20160826-17859-1vs4yv4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/135597/original/image-20160826-17859-1vs4yv4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/135597/original/image-20160826-17859-1vs4yv4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/135597/original/image-20160826-17859-1vs4yv4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The most common type of cataract surgery performed in Australia is called phacoemulsification.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The most common type of cataract surgery performed in Australia is called phacoemulsification. Typically, an uncomplicated surgery <a href="http://www.cataractcare.com.au/faq">lasts just under ten minutes</a> and is done as a day procedure.</p>
<p>Local anaesthetic is used to numb the eye and a small incision is made through the front of the eye; a hand-held ultrasound probe then breaks apart the cloudy lens contents. This material is suctioned out of the eye and a plastic lens is inserted in its place. </p>
<p>Cataract surgery is one of the <a href="http://www.aihw.gov.au/eye-health/cataract-surgery/">most frequently performed procedures</a> in Australia and has a very high success rate. </p>
<p>Although very uncommon, <a href="http://www.nhs.uk/Conditions/Cataract-surgery/Pages/Risks.aspx">complications can occur</a>. These include retinal detachment, infection, incorrect refractive power of the lens, swelling of the cornea and dislocation of the newly implanted lens. These rare complications may require further surgeries or medications and could lead to permanent visual impairment in the affected eye.</p>
<h2>Can we prevent cataracts?</h2>
<p>The progression of age-related cataract may be slowed by <a href="http://www.ncbi.nlm.nih.gov/pubmed/21617534">wearing sunglasses</a> when outdoors from an early age, avoiding smoking, carefully controlling blood sugar levels if diabetic, and consuming plenty of fruits and vegetables. </p>
<p>Antioxidant supplements are sometimes recommended for prevention of cataracts. Unfortunately, studies have shown these to <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004567.pub2/abstract">be ineffective</a>.</p>
<p>If you experience symptoms of a cataract, the first point of call should be an optometrist who can perform a bulk-billed eye examination and refer you to an ophthalmologist if a cataract is found. </p>
<p>However, wait lists for public hospital clinics may be lengthy (months, to over a year) for minor cataracts not severely affecting vision.</p>
<hr>
<p><em>The author thanks Dr Cameron McLintock, ophthalmology registrar at Queensland Health, for his contributions to this article.</em></p><img src="https://counter.theconversation.com/content/63699/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Yosar does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More than a million Australians have an untreated cataract and hundreds of cataract surgeries are performed daily, but what are they?Jason Yosar, Associate Lecturer, School of Medicine, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/641702016-09-04T20:08:57Z2016-09-04T20:08:57ZExplainer: what’s meningococcal meningitis and what are the signs?<figure><img src="https://images.theconversation.com/files/135867/original/image-20160830-28233-12h30o1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Your child will receive a meningococcus vaccine, but it doesn't cover all the subtypes.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><a href="http://www.smh.com.au/nsw/nsw-health-warn-of-meningococcal-outbreak-20160817-gqv7a1.html">Stories of meningococcal outbreaks</a> tell us it’s that season again. But what is meningococcal meningitis, why does it occur in seasons, and why does it strike fear into the hearts of so many?</p>
<p>Meningococcus (Nisseria meningitidis) is type of bacterium that only occurs in humans. It is found living intermittently in the nasal passages of about 20% of people completely without symptoms – with peak carriage in young people. </p>
<p>For a reason that’s still unclear (perhaps because of genetic make up), in certain people, it finds its way into the bloodstream to cause a severe infection of the fluid that surrounds the brain – also known as meningitis. </p>
<p>In meningitis, the meninges – the membrane that surrounds the brain – becomes inflamed due (usually) to infection. About 5% to 10% of patients die and a further 10% to 20% survive but are left with significant disabilities.</p>
<h2>Causes</h2>
<p>The bacterium is transmitted mainly through droplet transmission (such as sneezing) and has an incubation period (the period before the person shows signs of illness) of up to seven days. This is the reason people with suspected meninigitis will be placed in isolation when hospitalised.</p>
<p>The bacteria come in several “serogroups” (A, B, C, W-135, X and Y make up the majority of cases) – subtypes that have slightly different structure – but all cause meningitis. Serogroup B is the most common in Australia.</p>
<p>Meningococcus has the ability to invade cells of the upper nasal passage and then, through several proteins, cause a severe inflammation of the meningeal tissue surrounding the brain. </p>
<p>The bacteria also have the ability to evade the body’s immune system, making it harder to fight infection. This is why certain patients with deficiencies in their immune system and who have had their spleen removed are at increased risk of fatal meningococcal meningitis.</p>
<p>The reason for higher likelihood of infection in late winter and early spring isn’t known, but it is <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0107486">thought to be</a> related to infection at the same time by other organisms such as influenza or mycoplasma (the bacterium that causes pneumonia). During the winter months, people spend more time in confined spaces together, which could also contribute.</p>
<h2>Signs and symptoms</h2>
<p>The disease can occur at any age, but is particularly common in young children and young adults. Just like other forms of meningitis, it presents with fever, severe headache and later on confusion. What makes meningococcal meningitis quite unique is that it’s often associated with septicaemia, where bacteria enter the bloodstream and can potentially be fatal very quickly.</p>
<p>Patients will present with low blood pressure, a typical purplish rash and muscle aches, vomiting and mottling of the arms or legs. These are all critical signs and people should seek urgent medical help.</p>
<p>Medical staff may suspect a diagnosis based on clinical examination and will proceed to make the diagnosis by sampling the cerebrospinal fluid that surrounds the brain and spine. This is done by placing a needle between the vertebrae in the lower back to access the area around the spine where the fluid is situated.</p>
<p>While awaiting the results of the sample, medical staff are likely to commence antibiotics to cover the infections they suspect including meningococcus.</p>
<p>If the patient has developed septicaemia and is critically ill, they may need admission to an intensive care unit to support the function of their organs while the infection is treated. Sometimes the severity of the septicaemia may cause damage to the tissue and the patient may be left with significant disability and require rehabilitation to regain as much function as possible.</p>
<h2>Treatment</h2>
<p>Prior to 1988, the medication of choice was penicillin, administered in high doses through the intravenous route. After isolating <a href="http://www.ncbi.nlm.nih.gov/pubmed/3134848">penicillin-resistant meningococci</a>, the medication of choice has been a different antibiotic (ceftriaxone) administered in high doses intravenously.</p>
<p>Since the infection is so dangerous, people who come into close contact with the patient before they are isolated are given antibiotics to prevent them from getting infected. There’s a <a href="https://www.ncbi.nlm.nih.gov/pubmed?term=24163051">0.4% chance of cross infection without antibiotics</a>. This should be done as soon as possible after the patient is diagnosed. The public health department is notified of the case and will ensure adequate advice and follow-up of people coming into contact with the patient.</p>
<h2>Prevention</h2>
<p>There is a <a href="https://theconversation.com/what-is-meningitis-b-and-why-dont-older-children-get-the-vaccine-55247">vaccine available against meningococcus</a> although the different vaccines do not cover all of the subtypes. This is because certain subtypes are very uncommon in Australia so the different vaccines are designed for specific purposes. For example the “4vMenCV” covers several subgroups and is recommended for people travelling to places such as Africa and Asia, and pilgrims to the Haj. </p>
<p>In Australia, meningococcal infections caused by strain C are the most common and are vaccine-preventable in all age groups, including babies and young children. The highest rate of meningococcal disease occurs in children under five years of age, although this has decreased since the introduction of the free meningococcal C vaccine under the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/nips">National Immunisation Program</a>. Vaccination for meningococcus subtype C (usually in the form of Hib-MenC) is given at 12 months of age.</p>
<p>Meningococcal meningitis is a life-threatening infection, so if your child has fevers, an intense headache, nausea or vomiting or a purplish rash or mottled skin, seek medical help immediately or call an ambulance.</p><img src="https://counter.theconversation.com/content/64170/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sergio Diez Alvarez is affiliated with NSW CEC Antimicrobial Stewardship Committee</span></em></p>Stories of meningococcal outbreaks tell us it’s that season again. But what is meningococcal, why does it occur in seasons, and why does it strike fear into the hearts of so many?Sergio Diez Alvarez, Director Of Medicine, The Maitland and Kurri Kurri Hospital, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/598892016-08-10T00:24:33Z2016-08-10T00:24:33ZExplainer: what is age-related macular degeneration?<figure><img src="https://images.theconversation.com/files/130178/original/image-20160712-9292-1gsz5ls.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In some people AMD progresses so slowly that people do not notice the change in their vision.</span> <span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1457706924510-773f3c796de3?ixlib=rb-0.3.5&q=80&fm=jpg&crop=entropy&s=a577e1cee35179131ae189f5ed25ae15">Ken Wu/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Age-related macular degeneration (AMD) is the main cause of blindness in Australia. One <a href="http://www.mdfoundation.com.au/LatestNews/MDFoundationDeloitteAccessEconomicsReport%202011ExecSummary.pdf">in seven people</a> aged over 50 have some signs of macular degeneration.</p>
<p>You are reading this article because of your macula, which is the part of the eye affected by macular degeneration. The macula is the central part of the retina or back of the eye that allows you to see fine detail.</p>
<p>In some people, macular degeneration progresses so slowly they don’t notice the change in their vision. In others, the disease progresses faster leading to vision loss in one or both eyes. </p>
<p>The substantial visual impairment linked with age-related macular degeneration means patients have reduced ability to engage in everyday activities, such as reading and driving. </p>
<p>This can result in major disability and be a burden to the person and <a href="https://www.mja.com.au/journal/2006/184/9/modifiable-risk-factors-age-related-macular-degeneration?0=ip_login_no_cache%3D54465b09d6befaee39439148b5e46059">the health care</a> system.</p>
<h2>Forms and causes</h2>
<p>Age-related macular degeneration has two forms: wet and dry. Dry is the most frequent and leads to gradual loss of vision. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/130182/original/image-20160712-9271-11exi8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130182/original/image-20160712-9271-11exi8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/130182/original/image-20160712-9271-11exi8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130182/original/image-20160712-9271-11exi8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130182/original/image-20160712-9271-11exi8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130182/original/image-20160712-9271-11exi8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130182/original/image-20160712-9271-11exi8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130182/original/image-20160712-9271-11exi8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Small whitish-yellow blobs of fat and protein called drusen on the macula is an early sign of macular degeneration.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/communityeyehealth/15765705300/in/photolist-czUqTm-7t9FpY-spNxPQ-dRHCyW-q2amVb-uYgohk">Community Eye Health/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The most common early sign of dry macular degeneration is the presence of small whitish-yellow blobs of fat and protein called drusen on the macula. </p>
<p>These naturally occur as part of the ageing process and are <a href="http://www.aao.org/eye-health/diseases/drusen-causes">believed to be the result</a> of the eye’s failure to eliminate waste products in the cells of the eye.</p>
<p>In the early stages, drusen are small and few and don’t affect vision. But as these blobs become larger, most people report reduction in their central vision.</p>
<p>The wet form of age-related macular degeneration is <a href="http://www.sciencedirect.com/science/article/pii/S0161642006009985">responsible for most of the condition’s severe visual loss</a> but is much less common. It is caused by the growth of abnormal blood vessels that leak and scar underneath the retina. Both the wet and dry forms are painless.</p>
<p>It is currently unclear exactly what causes the processes that lead to macular degeneration, which can make it difficult to prevent. </p>
<p>Age is the strongest known risk factor and the disease is more likely to occur after 50, although it can occur earlier. Cases of macular degeneration have been seen in people in their thirties but this is uncommon.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/130187/original/image-20160712-9302-127na3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130187/original/image-20160712-9302-127na3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/130187/original/image-20160712-9302-127na3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130187/original/image-20160712-9302-127na3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130187/original/image-20160712-9302-127na3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130187/original/image-20160712-9302-127na3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130187/original/image-20160712-9302-127na3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130187/original/image-20160712-9302-127na3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The macula is why you’re reading this article.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>There is also such a thing as <a href="http://www.aao.org/eye-health/diseases/juvenile-macular-degeneration">juvenile macular degeneration</a>, which is a series of inherited eye disorders affecting children and young adults – but this is considered different to the age-related form.</p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066589/">family history of macular degeneration</a> can increase the risk of getting the disorder by 50%. Studies have shown macular degeneration is <a href="http://archopht.jamanetwork.com/article.aspx?articleid=264670">more common in women</a> than men as well as in people of <a href="http://archopht.jamanetwork.com/article.aspx?articleid=420320">Caucasian and Chinese</a> ethnicity than other ethnic groups.</p>
<p>Smoking is another known risk factor. <a href="http://www.sciencedirect.com/science/article/pii/S0161642000005807">Studies have demonstrated smokers</a> have up to three or four times the risk of getting macular degeneration than non-smokers. </p>
<h2>Symptoms and diagnosis</h2>
<p>The main <a href="http://www.mdfoundation.com.au/symptoms.aspx">symptom of age-related macular degeneration</a> is visual distortion: straight lines appear wavy or bent. People with AMD may also experience difficulty in activities that require fine vision, such as reading or recognising faces. </p>
<p>People with macular degeneration can develop dark patches or blind spots in the centre of their vision. </p>
<p>Symptoms of dry macular degeneration can take five to ten years to become severe. Wet AMD, however, can develop more quickly leading to severe visual loss. </p>
<p>Macular degeneration can be diagnosed by an ophthalmologist who may recommend the Amsler grid test. This is when a special piece of paper with horizontal and vertical lines is used to check visual fields. If any section of the lines is missing or distorted, macular degeneration is a possible cause. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/130188/original/image-20160712-9267-gtoefc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130188/original/image-20160712-9267-gtoefc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/130188/original/image-20160712-9267-gtoefc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130188/original/image-20160712-9267-gtoefc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130188/original/image-20160712-9267-gtoefc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130188/original/image-20160712-9267-gtoefc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130188/original/image-20160712-9267-gtoefc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130188/original/image-20160712-9267-gtoefc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">If any section of the lines is missing or distorted, macular degeneration is a possible cause.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The ophthalmologist will then examine the back of the eye with a slit lamp (a high-intensity light source) microscope and take digital photographs of the retina. </p>
<p>A non-invasive test called ocular coherence tomography uses light waves to scan the retina. It can give a detailed 3D-picture of the macula and show if there are any abnormalities. </p>
<h2>Treatment and prognosis</h2>
<p>There is currently no cure for macular degeneration but treatments are now available for the wet form. These are aimed at maintaining vision for as long as possible and preventing progression of the disease. </p>
<p>The <a href="https://nei.nih.gov/health/maculardegen/armd_facts">main treatment</a> for wet age-related macular degeneration is anti-vascular endothelial growth factor (anti-VEGF) medication. This medication blocks the VEGF, a protein that stimulates blood vessel growth, and prevents the growth of new abnormal blood vessels in the retina. </p>
<p>In some patients, laser surgery can also be used to destroy abnormal blood vessels. Early detection and treatment of wet AMD is vital to reduce the risk of severe vision loss and possibly blindness. </p>
<p>Treatment for dry macular degeneration aims to maintain the best vision for as long as possible. Some ophthalmologists recommend antioxidant supplements to minimise progression – particularly zinc, vitamins C and E and beta carotene.</p>
<p>Quitting smoking can also prevent or slow the progression of dry macular degeneration. A balanced diet of adequate fish intake and dark leafy green vegetables and fruits is recommended. </p>
<p>You can also reduce the risk of age-related macular degeneration by protecting your eyes; wearing sunglasses that have lenses that block and absorb UV rays when outside for long periods of time.</p><img src="https://counter.theconversation.com/content/59889/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bamini Gopinath receives funding from Macular Disease Foundation Australia. </span></em></p>Macular degeneration affects the part of the eye that allows you to see fine detail. Age-related macular degeneration is the main cause of blindness in Australia.Bamini Gopinath, Principal Research Fellow, Sensory Loss Epidemiology, Westmead Institute, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/547392016-07-28T01:49:44Z2016-07-28T01:49:44ZExplainer: the A, B, C, D and E of hepatitis<figure><img src="https://images.theconversation.com/files/132130/original/image-20160727-5669-1163oug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The thing all five viruses have in common is they can cause mild to very severe liver damage.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-276250463/stock-photo-tubes-of-blood-sample-for-testing.html?src=oLBl58Liiq_SORkDiOnCCA-1-44">wk1003mike/Shutterstock</a></span></figcaption></figure><p>Hepatitis means inflammation of the liver. While we usually think of hepatitis A to E viruses, anything that causes inflammation or damage to the liver can be considered as a form of hepatitis. </p>
<p>Hepatitis A, B, C, D and E are very different viruses. Hepatitis A is genetically closer to the common cold than it is to hepatitis B, for example. Hepatitis C is closer to the virus that causes dengue fever.</p>
<p>The thing all five have in common is they can cause mild to very severe liver damage. </p>
<p>Viral hepatitis caused around <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30579-7/abstract">1.45 million deaths</a> in 2013, making it the seventh leading cause of death world-wide; 96% of these were due to hepatitis B and C. </p>
<h2>Hepatitis A</h2>
<p>Hepatitis A is spread by contaminated food and water, and from person to person via faecal transmission, particularly in household settings. </p>
<p><a href="http://www.ijidonline.com/article/S1201-9712(07)00212-3/fulltext">Hippocrates</a> first described epidemics of diarrhoea and jaundice as far back as the fifth century BCE.</p>
<p>Although hepatitis A can cause significant illness, the body usually recovers without treatment and becomes immune to future infections.</p>
<p>Vaccines can prevent hepatitis A; these are <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-4#4-4-7">recommended for travellers and other groups</a> at particular risk of infection. Vaccination given early after exposure can also prevent hepatitis A from developing. </p>
<h2>Hepatitis B</h2>
<p>This is the most prevalent form of viral hepatitis worldwide. It’s also the leading cause of liver cancer. </p>
<p>An estimated <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61412-X/abstract">250 million</a> people live with hepatitis B worldwide. Around <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12049/abstract">220,000 Australians</a> are thought to be living with chronic hepatitis B. </p>
<p>Hepatitis B can be transmitted from person to person through sex or blood-to-blood contact. But most people living with chronic (long-term) hepatitis B acquired it at birth from their mother, or early in life. Following infection, the chance of developing chronic hepatitis B in infancy is around 90%, but falls to 5% among adults.</p>
<p>A safe and highly effective vaccine has been available for hepatitis B since the 1980s. It has been provided for all infants born in Australia <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-5#4-5-3">since May 2000</a>. </p>
<p>In <a href="http://www.sciencedirect.com/science/article/pii/S0264410X0901233X">China</a>, the proportion of children aged under five who had chronic hepatitis B fell from 9.7% in 1992 to 1% in 2006 after a vaccination program was introduced. The program has prevented millions of deaths from liver cancer and liver cirrhosis in China alone.</p>
<p>Effective antiviral treatments are also available for chronic hepatitis B. These can prevent liver damage and liver cancer from occurring. But even in a well-resourced country such as Australia, <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12345/abstract">only a minority</a> of people needing treatment and care for hepatitis B are receiving it. </p>
<h2>Hepatitis C</h2>
<p>This is the most common cause of viral hepatitis in Australia; an estimated <a href="http://kirby.unsw.edu.au/surveillance/2015-annual-surveillance-report-hiv-viral-hepatitis-stis">230,000 people</a> live with chronic infection. </p>
<p>Hepatitis C is the leading cause of liver cancer and liver transplants nationally. </p>
<p>Most hepatitis C infections in Australia were acquired through unsafe injecting drug use. But in some low-resource countries, ongoing transmission of hepatitis C in health care settings is a major problem. </p>
<p>Around 80% of people infected with hepatitis C develop chronic infection; those who do clear the infection naturally remain susceptible to future infections. </p>
<p>No vaccine for hepatitis C is available.</p>
<p>On March 1, new treatments were listed on the Pharmaceutical Benefits Scheme (PBS). Although <a href="https://theconversation.com/what-price-a-life-hepatitis-c-drug-out-of-reach-for-millions-33625">expensive</a>, these treatments represent a huge advance and are a <a href="http://gut.bmj.com/content/early/2016/04/12/gutjnl-2016-311504.abstract">cost-effective way</a> to prevent both new infections and deaths due to existing hepatitis C infections. With cure rates of the order of 90% with 8-24 weeks of tablets, and minimal side effects, these agents have the potential to drastically reduce the impact of hepatitis C.</p>
<p>The real key to unlocking this potential is the very <a href="http://www.pbs.gov.au/info/healthpro/explanatory-notes/general-statement-hep-c">liberal access criteria</a> the Commonwealth government has applied to these treatments. As a result, uptake of treatment for hepatitis C in Australia <a href="http://www.ashm.org.au/HCV/rollout-of-DAAs">has risen</a> more than 20-fold. </p>
<h2>Hepatitis D</h2>
<p>Hepatitis D is a satellite virus that can only infect people who also have hepatitis B. </p>
<p>It is estimated that approximately 5% of people living with hepatitis B globally also have <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918112/">hepatitis D</a>, which can lead to more severe liver disease.</p>
<h2>Hepatitis E</h2>
<p>Hepatitis E, like hepatitis A, is spread through contaminated food and water. </p>
<p>The first outbreak of hepatitis E infection <a href="https://www.mja.com.au/journal/2016/204/7/first-reported-outbreak-locally-acquired-hepatitis-e-virus-infection-australia">acquired in Australia</a> was reported earlier this year. </p>
<p>While hepatitis E is usually relatively mild, it can cause serious illness late in pregnancy, with a death rate of <a href="http://www.who.int/mediacentre/factsheets/fs280/en/">up to 20%</a> among pregnant women in their third trimester.</p>
<p>A vaccine against hepatitis E has been developed but is currently <a href="http://www.who.int/mediacentre/factsheets/fs280/en/">licensed only in China</a>.</p>
<p>While viral hepatitis remains a substantial public health challenge in Australia and world-wide, with political will, adequate investment and global partnerships, the world can <a href="http://www.worldhepatitisalliance.org/en/news/may-2016/governments-track-eliminate-viral-hepatitis-2030">eliminate viral hepatitis</a> by 2030.</p><img src="https://counter.theconversation.com/content/54739/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Cowie receives funding from the Australian Government Department of Health, the Victorian Government Department of Health and Human Services, and the Royal Melbourne Hospital Office for Research. </span></em></p>Hepatitis A, B, C, D and E are very different viruses. Hepatitis A is genetically closer to the common cold than it is to hepatitis B. Hepatitis C is closer to the virus that causes dengue fever.Benjamin Cowie, Director, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/496932016-04-06T09:45:34Z2016-04-06T09:45:34ZWhy make-believe play is an important part of childhood development<figure><img src="https://images.theconversation.com/files/107823/original/image-20160111-6981-j1axdq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Trying on new roles. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/boston_public_library/11454785166/in/photolist-isdLxY-iiie9s-iihX6r-isdoKs-8az3Zm-pavLsT-isd5JP-isdNPm-moKZsn-dyPQMd-isdcun-ise6Xr-moMM8C-isdvYW-isdJUY-isdXze-isdJdh-iiiw2e-isdKGj-isdang-isdpgs-isdXyT-moLAjp-moMGsq-isd7px-isdbKg-ise4xM-isdHT9-isdQrE-isdqqS-isd9sF-isdEyJ-iiicqu-ise6We-isdLBf-isdb84-isd6vP-isdmyd-isd5Wn-isdCXY-dyPQQ1-isdkys-isd8tr-isd7HZ-jMA7Tc-nqh9Ej-8ag3X2-2htcw-y1kA3z-isdemZ">Boston Public Library/Flickr</a></span></figcaption></figure><p>Visit any preschool classroom during free play and you will likely see a child pretending to be someone else. Make-believe play is a ubiquitous part of early childhood. And beyond being fun for kids, pretending and other kinds of <a href="http://press.uchicago.edu/ucp/books/book/chicago/C/bo3617303.html">imaginative play</a> are also believed by some to be <a href="http://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780195393002.001.0001/oxfordhb-9780195393002-e-003">critical to healthy child development</a>. </p>
<p>Research has found a relationship between pretend play and a child’s <a href="http://www.tandfonline.com/doi/abs/10.1080/10400419.2005.9651477#.VucalYwrJhA">developing creativity</a>, <a href="http://imaginarycompanions.uoregon.edu/files/2014/07/TaylorCarlson1997-qwbe8t.pdf">understanding of others</a> and <a href="http://psycnet.apa.org/psycinfo/1985-00967-001">social competence with peers</a>.</p>
<p>As a psychologist who studies imaginary play and childhood development and is no stranger to the preschool classroom, I have met many children for whom an imaginary friend or impersonation of a character is more than just an amusing pastime. Such activities often reflect what children have on their minds.</p>
<p>So how might imaginary play lead to benefits for kids? And does imaginary play make for more socially astute kids? Or is that that kids who more socially adept tend to engage in this kind of play more?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/107815/original/image-20160111-6964-ql7e7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/107815/original/image-20160111-6964-ql7e7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=442&fit=crop&dpr=1 600w, https://images.theconversation.com/files/107815/original/image-20160111-6964-ql7e7c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=442&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/107815/original/image-20160111-6964-ql7e7c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=442&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/107815/original/image-20160111-6964-ql7e7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=555&fit=crop&dpr=1 754w, https://images.theconversation.com/files/107815/original/image-20160111-6964-ql7e7c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=555&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/107815/original/image-20160111-6964-ql7e7c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=555&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pretending and learning.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/joybot/19156808315/in/photolist-vbPDGx-fie1tZ-e1XaXq-7k6DhM-fitfmA-fitewY-4nU97i-frYqkt-az5Azs-7imNMJ-76ZGCz-6XbTsP-6jNrAD-8WpyZH-nJbwJT-nro8bB-yPNGEs-qxKoR-ueZjSX-uUooNV-8WsD2h-bVvQMo-vc8HXB-8rGN25-bCMmqb-9snbMe-9wF8Zp-8WTeMf-8WTf8b-fidZDc-9t7S2k-fitcGQ-8WTeL1-nt9UXF-fidYN6-fidZd2-STFYX-v7xwdK-b3uGxv-9ggzZC-v9v6i3-ueYbma-9fY4wf-a4NCra-uUdLYs-9Lnhaz-9sqbeq-cERHTj-rjh1Xf-5EsEEZ">Sarah Joy/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Learning to think from different perspectives</h2>
<p>Imaginary play could encourage social development because children are simultaneously behaving as themselves and as someone else. This gives them a change to explore the world from different perspectives, and is a feat that requires thinking about two ways of being at once, something that children may have difficulty doing in other circumstances.</p>
<p>You can imagine how this could be a part of a child’s developing social abilities.</p>
<p>For instance, if a child is pretending to be a mother, he or she must imagine what it would feel like if the baby cries or doesn’t behave. If a child is pretending to be the family dog, he or she needs to figure out how to communicate with the “owner” without speaking. </p>
<p>The child who creates an imaginary friend has the opportunity to explore all the nuances of friendship – without having to manage the unpredictability of another person’s behavior or risking the friendship ending.</p>
<p>The child who impersonates a superhero can play out and achieve goals such as helping others and performing daring rescues. This kind of power is not easily found in early childhood. Getting to be the hero and taking care of others must be a nice change from being taken care of and ordered around. </p>
<h2>Learning the delicate art of negotiation</h2>
<p>When children play these make-believe games with other kids, they must constantly consider their own behaviors and signals to send clear messages about what they are doing. And they also have to pay attention to signals coming from other participants in the game and learn how to decipher them. </p>
<p>This kind of communication also happens in real-world interactions. But within the world of fantasy play, successful coordination requires extra attention to all of these details. Children must engage in sophisticated levels of communication, negotiation, compromise, cooperation and coordination to keep the play moving forward. </p>
<p>In fact some research suggests that children engaging in social pretend play spend almost as much time negotiating the terms and context of the play <a href="http://dx.doi.org/10.1016/0885-2006(89)90015-X">as they do enacting it</a>. This might come in handy as they grow up and manage the rules of neighborhood games of Capture the Flag, the division of labor on group projects in high school and the benefits associated with a first job offer. </p>
<h2>Are the benefits of play correlational or causative?</h2>
<p>The studies that connect pretend play to all of those positive outcomes are correlational. In other words, a socially astute, competent child might be more interested in pretend play, rather than pretend play making a child more socially astute. Alternatively, some other variable, like parenting, might be responsible for connections between engagement in fantasy and getting along well with others. </p>
<p>In fact, Angeline Lillard, a prominent scholar in the field, looked at dozens of studies with her colleagues, and found <a href="https://www.apa.org/pubs/journals/features/bul-a0029321.pdf">little evidence to support</a> the idea that pretend play causes positive developmental outcomes. </p>
<p>Instead, these authors assert, pretending might be one route to these outcomes. Or both pretend play and positive outcomes might be supported by other factors, such as the presence of supportive, encouraging adults, play that focuses on positive, pro-social themes, and the characteristics of the children themselves, such as their intelligence and sociability. </p>
<p>At the same time, the researchers are also quick to point out that children love to play and are motivated to do so. Adults who want to foster perspective-taking, empathy, negotiation skills and cooperation would do well to think about how lessons related to these skills could be embedded in the materials, themes and general content of children’s imaginative play.</p><img src="https://counter.theconversation.com/content/49693/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tracy Gleason does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research has found a relationship between pretend play and a child’s developing creativity, understanding of others and social competence with peers.Tracy Gleason, Professor of Psychology, Wellesley CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/561402016-03-29T03:12:16Z2016-03-29T03:12:16ZExplainer: what is restless leg syndrome?<figure><img src="https://images.theconversation.com/files/115943/original/image-20160322-32294-1i6tn8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's difficult to sleep when your legs are tap dancing under the sheets.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Restless leg syndrome is a common affliction characterised by uncomfortable feelings in the legs accompanied by an irresistible urge to move the legs to relieve the sensations. People with restless leg syndrome often keep their legs moving by pacing or constantly moving their legs while sitting. The sensations commonly occur at night and have been described by patients as itching, throbbing, pulling, pins and needles or a creepy crawly feeling. </p>
<p>Onset of the sensations usually occur, or get worse, while the person is relaxed, sitting or lying down. Restless leg syndrome is known to affect both males and females of any age but is more common in <a href="http://www.ncbi.nlm.nih.gov/pubmed/25553600">women</a> and <a href="http://www.sciencedirect.com/science/article/pii/S0167494311001531">older</a> individuals. Misdiagnosis is not unusual since the symptoms tend to come and go and may be quite mild.</p>
<h2>Causes</h2>
<p>In many cases of restless leg syndrome the cause is not known. However, it is thought to have a genetic link as many who experience restless leg syndrome have <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514082/">relatives</a> who also experience the sensations. </p>
<p>Restless leg syndrome has been associated with some medical conditions including Parkinson’s disease, diabetes and peripheral neuropathy (any damage or disease of the nerves that impairs sensation, movement or gland function depending on which nerves are affected). </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/26740290">It can also be seen</a> in those with iron deficiency or poor kidney function. Some women experience restless leg syndrome during pregnancy. Pregnant women who experience restless leg syndrome usually find the symptoms occur in the third trimester, with symptoms ceasing within four weeks of delivery.</p>
<p><a href="http://www.hindawi.com/journals/bn/2013/585439/abs/">Research</a> has shown restless leg syndrome is likely related to dysfunction of neural circuits of the basal ganglia (a group of structures at the base of the brain with links to the area that controls movement), which uses the neurotransmitter dopamine. Dopamine is needed to control muscle activity for smooth, purposeful movement, so disruption of the dopamine pathways leads to involuntary movements. Parkinson’s disease is also a disorder of dopamine pathways of the basal ganglia and Parkinson’s patients often experience restless leg syndrome.</p>
<p>Individuals with chronic kidney failure, diabetes or peripheral neuropathy usually find relief from restless leg syndrome with treatment of the underlying condition.</p>
<p>Symptoms of restless leg syndrome <a href="http://www.aafp.org/afp/2008/0715/p235.html">may also be aggravated</a> by certain medications. These include anti-nausea drugs, antipsychotic drugs, antidepressants and some cold and allergy medications that contain sedating antihistamines. The intake of alcohol or lack of good-quality sleep often triggers the condition.</p>
<h2>Diagnosis</h2>
<p>There is no test for restless leg syndrome. The four criteria below are used to diagnose the condition:</p>
<ul>
<li><p>symptoms worsen at night and are minimal in the morning</p></li>
<li><p>there is a strong urge to move the affected limb or limbs</p></li>
<li><p>symptoms are triggered when trying to rest or relax</p></li>
<li><p>symptoms are relieved by moving the affected limb, and return when movement stops.</p></li>
</ul>
<p>The descriptions given by the patient provide important information about when and how often the symptoms occur, so triggers can be identified and avoided where possible. Family history also helps to provide clues about the cause of the symptoms and potential interventions for treatment.</p>
<p>Diagnosing restless leg syndrome in children is particularly challenging since children find it hard to describe their symptoms and where and how often they experience them. This sometimes results in misdiagnosis as growing pains or attention deficit disorder.</p>
<h2>Treatment and prognosis</h2>
<p>Doctors focus on relieving symptoms by identifying triggers and relieving factors, and the presence or absence of symptoms during the day. Often the symptoms will resolve with treatment of an underlying disorder such as diabetes or peripheral neuropathy.</p>
<p>Making changes to your lifestyle may affect mild or moderate symptoms. This might include stopping or reducing your intake of caffeine, alcohol or tobacco. </p>
<p>If the symptoms are related to a dietary deficiency in iron, folate or magnesium, the symptoms can be treated with adjustments of diet or supplementing the diet with the appropriate supplement. This may be identified through a blood analysis by a GP. </p>
<p>When symptoms are more severe or associated with an underlying disorder, it is very important to consult a GP, who may refer you to a specialist.</p>
<p>While there is no cure for restless leg syndrome, there are options for therapy and control of symptoms to increase periods of restful sleep. Symptoms generally increase with age and the rate of this increase varies greatly depending largely on the associated disorder. </p>
<p>Some people experience periods of remission, which may last a few days or months. However, symptoms will usually reappear. </p>
<p>It is important to note that a diagnosis of restless leg syndrome is not an indication of any other, more serious, disorder such as Parkinson’s disease.</p><img src="https://counter.theconversation.com/content/56140/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Lavender does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Restless leg syndrome is a common affliction characterised by uncomfortable feelings in the legs accompanied by an irresistible urge to move the legs to relieve the sensations.Andrew Lavender, Lecturer, School of Physiotherapy and Exercise Science, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/562742016-03-24T20:51:37Z2016-03-24T20:51:37ZLynch syndrome explainer: a common cancer risk few have heard of<figure><img src="https://images.theconversation.com/files/115960/original/image-20160322-32320-op35ay.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When the DNA repair tool is faulty or broken, cancer happens.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Lynch syndrome is a common, inherited condition that affects thousands of Australians and greatly increases the risk of developing cancer. Yet 95% of those who have it don’t know about it.</p>
<p>Lynch syndrome is the most prevalent inherited cancer syndrome affecting both men and women. It is <a href="http://www.genetics.edu.au/Publications-and-Resources/PublicationsBrochuresandPamphlets/Understanding%20Genetic%20Tests%20for%20Lynch%20Syndrome">caused</a> by an inherited gene mutation affecting one of four mismatch repair or “cancer protection” genes (MLH1, MSH2, MSH6, PMS2). </p>
<p>Mismatch repair genes should repair mistakes that can occur when DNA is copied for cell division. Faulty mismatch repair genes allow errors to accumulate in cells, which can lead to uncontrolled cell growth and cancer. </p>
<p>Up to <a href="http://cancerforum.org.au/wp-content/uploads/2015/06/12_Should_we_consider_introducing_systematic_screening_for_Lynch_Syndrome.pdf">one in 250</a> people may carry a mismatch repair gene fault. As many as <a href="http://www.lynchsyndrome.org.au/wp-content/uploads/2015/09/Rachel-Susman-Jan-Wakeling-LWL-syndrome-10-Sept-2015.pdf">one in 280</a> carry a fault in a Lynch syndrome gene.</p>
<p>A parent with Lynch syndrome has a 50% chance of passing on the faulty gene to their children, regardless of gender. However, because a carrier inherits one faulty gene and one properly functioning gene, some people with Lynch syndrome may never develop cancer.</p>
<p>Lynch syndrome does not cause cancer and has no readily identified symptoms, but the faulty gene predisposes carriers to a dramatically increased risk of developing one or more primary cancers over their lifetime. As this <a href="http://lscarisk.org/">tool</a> shows, the risk varies by type of tumour, age, gender and the particular mismatch repair gene that is <a href="http://gut.bmj.com/content/early/2015/12/09/gutjnl-2015-309675.long">affected</a>. In people with the syndrome, cancers are often fast growing, may occur <a href="http://gut.bmj.com/content/early/2015/12/09/gutjnl-2015-309675.abstract">simultaneously</a> and tend to occur from a much younger age (under 50 and sometimes in the 20s or earlier). </p>
<p>If an individual knows they have Lynch syndrome, they can adopt life-saving strategies for cancer prevention, early detection and treatment. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/_dARj1Y4R0w?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Lynch syndrome awareness video.</span></figcaption>
</figure>
<h2>What cancers are associated with Lynch syndrome?</h2>
<p>Patterns of Lynch syndrome cancers in families were first observed by Dr Aldred Warthin in the 1890s. However, the condition is named after Dr Henry Lynch, who persisted against the prevailing wisdom of the 1960s-70s – which disputed a hereditary basis for cancer – to document, describe and establish the genetic basis for Lynch syndrome. </p>
<p>For a time, Lynch syndrome was called hereditary non-polyposis colon cancer. That was an unfortunate misnomer because Lynch syndrome cancers <em>can</em> involve polyps and <em>don’t</em> just involve colon cancers. </p>
<p>Lynch syndrome is most commonly associated with colorectal and endometrial cancers. It also significantly <a href="http://jnci.oxfordjournals.org/content/104/18/1363.long">increases the risk of cancer</a> of the ovary, stomach, hepatobiliary tract (liver/gallbladder), urinary tract, pancreas, brain, skin, oesophagus and small bowel.</p>
<p>Some tumours may also present differently in individuals with Lynch syndrome. Examples include the unusually flat, difficult-to-detect polyps and tumours sometimes observed in <a href="http://www.lynchsyndrome.org.au/wp-content/uploads/2016/03/M-appleyard-Colonoscopy-in-Lynch-Syndrome-Sept-2015.pdf">bowel</a> and <a href="http://clincancerres.aacrjournals.org/content/16/7/2214.long">breast</a> cancers.</p>
<h2>How is Lynch syndrome diagnosed?</h2>
<p>GPs should suspect an individual may carry a Lynch syndrome gene when there is a compelling <a href="http://www.lynchsyndrome.org.au/the-facts/getting-tested/">family history of cancer</a>. This means three or more family members have been diagnosed with cancers identified above, two consecutive generations or more are affected by those cancers, and one of those affected family members was diagnosed with cancer before 50 years of age. It should also be suspected where a patient has little or no access to their family’s health history information and has already had one or more relevant cancers before age 50. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/115945/original/image-20160322-32315-ur6fc1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/115945/original/image-20160322-32315-ur6fc1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/115945/original/image-20160322-32315-ur6fc1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=319&fit=crop&dpr=1 600w, https://images.theconversation.com/files/115945/original/image-20160322-32315-ur6fc1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=319&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/115945/original/image-20160322-32315-ur6fc1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=319&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/115945/original/image-20160322-32315-ur6fc1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=401&fit=crop&dpr=1 754w, https://images.theconversation.com/files/115945/original/image-20160322-32315-ur6fc1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=401&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/115945/original/image-20160322-32315-ur6fc1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=401&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Family history of cancer as above could signify Lynch syndrome. Source: Lynch syndrome Australia.</span>
</figcaption>
</figure>
<p>If Lynch syndrome is not identified and the patient develops cancer, they will typically require surgery to remove the tumour. Current best practice for all colon and endometrial tumours for patients under age 50, or who have a strong family cancer history, is for the treating team to order a pathology test to check mismatch repair genes are functioning properly. </p>
<p>Unfortunately, research reveals <a href="https://aihi.mq.edu.au/project/achieving-behaviour-change-management-lynch-syndrome-and-prevention-cancer">less than half</a> of these tumours are tested and patient <a href="http://www.mdpi.com/2075-4426/4/2/218">follow-up</a> is confusing and inconsistent. </p>
<p>Any patient suspected of carrying Lynch syndrome should be referred to a family cancer clinic. There, a genetic counsellor will conduct a thorough assessment and explain the gene-testing process and its implications. With patient consent, the clinic will arrange testing of a tissue sample from a past tumour (either the patient’s or another family member’s) to search for a mismatch repair gene mutation. </p>
<p>If a gene mutation is detected, risk-reducing strategies are discussed. Diagnosis for other family members then involves a relatively simple blood test, which looks for the same mutation.</p>
<h2>How is Lynch syndrome managed?</h2>
<p><a href="http://www.lynchsyndrome.org.au/the-facts/managing-the-risk/">Managing</a> Lynch syndrome involves a surveillance plan of regular tests to detect problems early. Then polyps can be removed before they become cancerous or cancers can be removed at an early stage. The potential for risk-reducing surgery (to remove organs, such as ovaries, that are high risk yet difficult to screen) or supplements such as aspirin (which <a href="http://www.ncbi.nlm.nih.gov/pubmed/26109217">longitudinal studies</a> suggest may significantly reduce the incidence of Lynch syndrome cancer) may also be considered.</p>
<p><a href="https://www.eviq.org.au/">Guidelines</a> recommend annual colonoscopies (from age 25 or 30, depending on the gene mutation, or five years younger than youngest relative diagnosed with bowel cancer) and prophylactic removal of the uterus, fallopian tubes, ovaries and cervix be considered after childbearing is complete, or by age 40.</p>
<p>Frequent colonoscopies are important because the average <a href="http://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-12-50">time from polyp to bowel cancer reduces</a> from ten years in the general population to just 35 months in patients with Lynch syndrome. Similarly, the average age for developing uterine cancer reduces from 64 years to <a href="http://www.genetics.edu.au/Publications-and-Resources/PublicationsBrochuresandPamphlets/Understanding%20Genetic%20Tests%20for%20Lynch%20Syndrome">42-46</a> years.</p>
<p>An individual’s surveillance plan may be further tailored to address <a href="http://gut.bmj.com/content/early/2015/12/09/gutjnl-2015-309675.long">specific cancer risks</a> for them, based on family history or environmental factors. For example, a family history of gastric or skin cancers may justify including annual endoscopy or dermatological reviews.</p>
<p>Effective diagnosis and management of individuals with Lynch syndrome can be life-saving. Unfortunately, this is not the experience for thousands of Australian families. It’s important we raise awareness of this condition among medical professionals, health organisations and the general public.</p><img src="https://counter.theconversation.com/content/56274/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharron O'Neill is a Director for Lynch Syndrome Australia and is part of a Macquarie University research team led by Dr Natalie Taylor and funded by the Translational Cancer Research Network.</span></em></p><p class="fine-print"><em><span>Natalie Taylor receives funding from The Cancer Institute New South Wales Translational Cancer Research Network</span></em></p>Lynch syndrome is a common, inherited condition that affects thousands of Australians and greatly increases their risk of developing cancer. Yet 95% of those who have it don’t know about it.Sharron O'Neill, Senior lecturer, UNSW SydneyNatalie Taylor, Senior Research Fellow in Behaviour Change and Implementation Science, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/495972016-03-24T02:46:17Z2016-03-24T02:46:17ZExplainer: what’s the link between insomnia and mental illness?<figure><img src="https://images.theconversation.com/files/112878/original/image-20160225-15182-su389a.jpg?ixlib=rb-1.1.0&rect=0%2C90%2C1024%2C649&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sleep problems can also create a loop of mental illness.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/alyssafilmmaker/3687665853/">Alyssa L. Miller/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Poor sleep can make us feel down, worried and stressed. So it’s no surprise that how well we sleep has a direct impact on our physical and mental health. </p>
<p>Sleep problems such as <a href="https://theconversation.com/explainer-what-is-insomnia-and-what-can-you-do-about-it-36365">insomnia</a> are a common symptom of many mental illnesses, including <a href="http://www.ncbi.nlm.nih.gov/pubmed/24014057">anxiety, depression</a>, <a href="https://sleepfoundation.org/ask-the-expert/sleep-hygiene-insomnia-and-mental-health">schizophrenia</a>, <a href="http://www.health.harvard.edu/newsletter_article/Sleep-and-mental-health">bipolar disorder and attention deficit hyperactivity disorder</a> (ADHD). </p>
<p>The relationship between insomnia and mental illness is bidirectional: about <a href="http://www.ncbi.nlm.nih.gov/pubmed/2769898">50% of adults with insomnia</a> have a mental health problem, while up to <a href="http://www.health.harvard.edu/newsletter_article/Sleep-and-mental-health">90% of adults</a> with depression experience sleep problems. </p>
<p>Sleep problems can also create a loop, <a href="https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Sleep-Disorders">slowing recovery</a> from mental illness. People with depression who continue to experience insomnia, for instance, are <a href="http://www.health.harvard.edu/newsletter_article/Sleep-and-mental-health">less likely to respond</a> to treatment for depression. They are also at greater risk of relapse than those without sleeping problems. </p>
<h2>Emotional processing</h2>
<p>It is unclear how insomnia makes a person more likely to develop mental illness. Research suggests, however, that it may affect our <a href="http://www.sciencedaily.com/releases/2013/05/130522131208.htm">ability to process negative emotions</a>. </p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0301051108002263">In one study</a>, sleep-deprived people were found to show greater emotional reactivity to unpleasant images than to pleasant images or images with neutral emotional content. People who weren’t sleep-deprived showed no differences in emotional reactivity. </p>
<p><a href="http://www.sciencedaily.com/releases/2013/05/130522131208.htm">In another study</a>, brain scans revealed that people with insomnia showed greater activity in the brain’s emotional processing area when they used a strategy to reduce their negative reactions to images than when they did not use this strategy. </p>
<p>That suggests insomnia makes it difficult to react appropriately to negative emotions. This may exacerbate their sleep difficulties and make them vulnerable to experiencing depression. </p>
<p>Cognitive behaviour therapy treatment of insomnia includes training in how to interpret emotional information less negatively.</p>
<p>There is also some evidence that mental illnesses may arise from <a href="https://theconversation.com/why-sleep-could-be-the-key-to-tackling-mental-illness-50102">problems within brain circuits</a> that overlap with those that regulate our body clocks or sleepiness timing system.</p>
<h2>Treating mental illness and insomnia</h2>
<p>Treatment of mental illness is likely to lead to <em>some</em> improvement in <a href="http://journals.cambridge.org/abstract_S0790966714000597">sleep problems</a>, especially for <a href="http://www.sleepdex.org/mentalillness.htm">mild symptoms of mental illness</a>. </p>
<p>But insomnia <em>tends</em> to persist unless it is <a href="http://www.ncbi.nlm.nih.gov/pubmed/20853442">directly targeted</a> for treatment. In <a href="http://www.ncbi.nlm.nih.gov/pubmed/17335324">one research trial</a>, 51% of individuals who overcame depression after psychological treatment (cognitive behaviour therapy) or medication were still experiencing insomnia.</p>
<p>Research is now focusing on whether treatment of insomnia <a href="http://www.ncbi.nlm.nih.gov/pubmed/24014057">will also improve mental health outcomes</a> for people with mental illness, including depression and anxiety. </p>
<p>There is some evidence that both medication and psychological treatment of insomnia (via <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2279754/">cognitive behaviour therapy</a>) will <a href="http://www.sleep.theclinics.com/article/S1556-407X(06)00064-6/abstract">improve the symptoms</a> of mental health problems. </p>
<p>So can <a href="http://www.trialsjournal.com/content/15/1/56">mental illness be prevented</a> by treating insomnia? </p>
<p>A recent Australian <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00536-2/fulltext">research trial</a> with 1,149 participants does suggest that treatment of insomnia reduces depression symptoms. </p>
<p>Participants who completed a cognitive behaviour therapy-based insomnia intervention showed a lower incidence of depression symptoms than those who were given health information with no insomnia treatment content.</p>
<p>If you have insomnia, speak to your doctor. If warranted, he or she can refer you to a specialist sleep doctor or psychologist. They can assess how your insomnia and any associated mental health difficulties interact and tailor your treatment accordingly.</p><img src="https://counter.theconversation.com/content/49597/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jo Abbott does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The relationship between insomnia and mental illness is bidirectional: about 50% of adults with insomnia have a mental health problem; up to 90% of adults with depression have sleep problems.Jo Abbott, Research Fellow / Health Psychologist, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/548002016-03-22T04:37:33Z2016-03-22T04:37:33ZExplainer: what are birthmarks and why do we get them?<figure><img src="https://images.theconversation.com/files/112659/original/image-20160224-32745-nvyemr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Birthmarks are not scuff marks caused by the physical process of birth.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/croweb/2876971552/">Ben Crowe/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Birthmark is the term used to describe any of the large number of common skin marks that are present at birth or appear soon afterwards. It doesn’t mean they were caused by the physical process of birth.</p>
<p>Birthmarks generally result from an overgrowth of a structure that is normally present in the skin. For example, an overgrowth of blood vessels produces vascular birthmarks or haemangiomas; an overgrowth of pigment cells produces congenital naevi or moles. </p>
<p>There are a number myths and superstitions about birthmarks. Moles were considered evidence of guilt during the <a href="https://en.wikipedia.org/wiki/Witches%27_mark">Salem Witch Trials</a>. The “maternal impression” myth suggests that if a woman experiences an especially strong emotion during pregnancy and touches a particular location on her body, her baby may be born with a birthmark on that part of her baby’s body. </p>
<p>The reality is that the cause of birthmarks is unknown. For most babies they don’t create major problems and many birthmarks do not require any treatment. They do not predict future prosperity or special personality traits. They are not caused by the actions or omissions of the pregnant mother.</p>
<p>Fortunately lasers and other medical breakthroughs have provided options for those birthmarks that do not fade spontaneously and are problematic or unsightly.</p>
<h2>Café au lait macules</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/112489/original/image-20160223-16455-rfvzx7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/112489/original/image-20160223-16455-rfvzx7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/112489/original/image-20160223-16455-rfvzx7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112489/original/image-20160223-16455-rfvzx7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112489/original/image-20160223-16455-rfvzx7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112489/original/image-20160223-16455-rfvzx7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112489/original/image-20160223-16455-rfvzx7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112489/original/image-20160223-16455-rfvzx7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Cafe au lait spot.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Café au lait macules are pale brown or milk coffee-coloured birthmarks. They can occur at any site on the body, are usually less than 5mm in diameter and are not dangerous or harmful. Café au lait macules are usually present at birth but may occur later in childhood or increase in number with age.</p>
<p>Treatment is generally not required, however, if there are multiple larger lesions, the child should be seen by a dermatologist to look for evidence of neurofibromatosis (a genetic condition that carries a high risk of developing a tumour). Lasers can lighten Café au lait macules and improve their cosmetic appearance.</p>
<h2>Congenital melanocytic naevus</h2>
<p>A congenital melanocytic naevus or congenital mole, is a harmless growth of the pigment cells that may be present at birth or appear within the first few months. Congenital naevi can occur at any site on the body, vary in size from several millimetres to several centimetres and may be flat or raised.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/114418/original/image-20160309-22132-1dv8vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/114418/original/image-20160309-22132-1dv8vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/114418/original/image-20160309-22132-1dv8vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114418/original/image-20160309-22132-1dv8vxv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114418/original/image-20160309-22132-1dv8vxv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114418/original/image-20160309-22132-1dv8vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114418/original/image-20160309-22132-1dv8vxv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114418/original/image-20160309-22132-1dv8vxv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Congenital naevus.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Congenital naevi can turn into melanomas, but for congenital melanocytic naevi smaller than 5 cm in diameter the risk is very small and nothing needs to be done about most of them. If there is unexpected growth or change, they can be surgically removed. Once the child is old enough to cooperate excision can be performed to improve the cosmetic appearance.</p>
<p>Giant congenital melanocytic naevi are a risk factor for skin cancer. Long-term follow-up of these lesions is essential to detect and treat any development of skin cancer as early as possible. </p>
<h2>Mongolian spot</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/112495/original/image-20160223-16416-15gzx87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/112495/original/image-20160223-16416-15gzx87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112495/original/image-20160223-16416-15gzx87.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112495/original/image-20160223-16416-15gzx87.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112495/original/image-20160223-16416-15gzx87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=570&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112495/original/image-20160223-16416-15gzx87.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=570&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112495/original/image-20160223-16416-15gzx87.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=570&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mongolian spot on a six month old.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Mongolian spots are blue-brown stains that may look like a bruise and are usually present at birth over the lumbar spine, buttocks, side of the body or shoulders. They are more common in Asian children. </p>
<p>They often fade naturally over time. They generally do not require any treatment, however lasers can be used to lighten Mongolian spots and improve their appearance. </p>
<h2>Haemangioma or strawberry naevus</h2>
<p>An haemangioma, or strawberry naevus is a raised or oval dome shaped vascular mark that may occur at any site on the body. One or more strawberry naevi appear some weeks after birth. It grows rapidly over three to six months to form a bright red raised soft area which can vary in size from half a centimetre to several centimetres. Up to 10% of infants may develop these <a href="http://www.dermnetnz.org/vascular/haemangioma.html">haemangiomas</a> in the first year.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/112496/original/image-20160223-16459-1nixlm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/112496/original/image-20160223-16459-1nixlm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/112496/original/image-20160223-16459-1nixlm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112496/original/image-20160223-16459-1nixlm5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112496/original/image-20160223-16459-1nixlm5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112496/original/image-20160223-16459-1nixlm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112496/original/image-20160223-16459-1nixlm5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112496/original/image-20160223-16459-1nixlm5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Strawberry birthmark.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>The sooner they are treated the better. This can be done with laser, propranalol or a short course of cortisone, prescribed by a doctor, taken by mouth. Untreated, most haemangiomas eventually shrink and disappear. However before they disappear they may grow rapidly, ulcerate or interfere with the eyes, nose, or mouth. Some may ulcerate or bleed. While frightening at the time, this is rarely life threatening and can usually be managed with dressings and by applying pressure to the area. If small, bleeding haemangiomas can be excised. </p>
<h2>Port wine stain</h2>
<p>A port wine stain is a blood vessel malformation composed of expanded thin walled blood vessels. It produces a persistent, flat, clearly outlined red birthmark on the skin. <a href="http://www.dermnetnz.org/vascular/vascular-malformation.html">Port Wine stains</a> are present at birth in up to 2% of children. Initially the affected area is flat and pale pink.</p>
<p>Rather than fade over time like many birthmarks, port wine stains become darker, raised and rough as the child grows. Any site may be affected but port wine stains most commonly occur on the head and neck. Port Wine Stains may be single or multiple, vary in size from a few millimetres to many centimetres in diameter.</p>
<p>Port wine stains can have a significant psychological effect on children. Port wine stains on the face, especially if treated early will respond well to laser. Multiple treatments may be required. Adult port wine stains can also be treated, but tend to require more treatment sessions than children’s. </p>
<h2>Salmon patch or stork bite</h2>
<p>The salmon patch or stork bite is the most common vascular mark found at birth. It is a pale red or pink flat mark on the forehead, upper eyelid, upper lip or at the back of the neck. They occur in up to 50% of children.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/112657/original/image-20160223-16422-1nkp1ej.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/112657/original/image-20160223-16422-1nkp1ej.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/112657/original/image-20160223-16422-1nkp1ej.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112657/original/image-20160223-16422-1nkp1ej.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112657/original/image-20160223-16422-1nkp1ej.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112657/original/image-20160223-16422-1nkp1ej.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112657/original/image-20160223-16422-1nkp1ej.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112657/original/image-20160223-16422-1nkp1ej.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Salmon patches, or stork bites, occur in up to 50% of children.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/abbybatchelder/3999190241">Abigail Batchelder/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Most salmon patches on the face disappear within two to five years. Those on the back of the neck tend to persist, however they become hidden once the scalp hair grows. Treatment is not usually required. Salmon patches on the forehead may become more visible with crying or activity. If salmon patches persist, vascular lasers can be used to lighten their colour.</p><img src="https://counter.theconversation.com/content/54800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rodney Sinclair does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Birthmark is the term used to describe common skin marks that are present at birth or appear soon afterwards. It doesn’t mean they were caused by the physical process of birth.Rodney Sinclair, Professor of Dermatology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/538652016-03-09T05:01:45Z2016-03-09T05:01:45ZExplainer: what happens to your skin when you get sunburnt?<figure><img src="https://images.theconversation.com/files/112261/original/image-20160222-25855-2kiau8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's a reason your sunburn is still so sore a few days after burning.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>Most Australians are familiar with the painful red skin, blisters and peeling that follow too much time in the sun. Last summer, 2.4 million Australian adults were getting sunburnt <a href="http://www.cancer.org.au/news/media-releases/new-research-shows-almost-2.4-million-aussie-adults-sunburnt-on-summer-weekends.html">each weekend</a>. </p>
<p>But what’s actually happening in the skin during a sunburn?</p>
<h2>DNA damage</h2>
<p>Sunburn is a radiation burn, caused when the ultraviolet (UV) rays of sunlight <a href="http://www.ncbi.nlm.nih.gov/pubmed/24891049">damage DNA</a> in the upper layer of skin cells. The sun emits three kinds of UV radiation – UVA, B and C. </p>
<p>UVC is mostly absorbed by the earth’s atmosphere, but UVA and B rays reach the ground and can penetrate unprotected skin. UVB penetrates the epidermis, the top layer of the skin, while UVA goes deeper.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/114408/original/image-20160309-22114-1o0ddzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/114408/original/image-20160309-22114-1o0ddzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114408/original/image-20160309-22114-1o0ddzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=598&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114408/original/image-20160309-22114-1o0ddzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=598&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114408/original/image-20160309-22114-1o0ddzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=598&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114408/original/image-20160309-22114-1o0ddzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=752&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114408/original/image-20160309-22114-1o0ddzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=752&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114408/original/image-20160309-22114-1o0ddzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=752&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Layers of human skin.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>The particles that transmit light (photons) from UVA rays interact with the skin and this damages the skin’s <a href="http://www.sciencedirect.com/science/article/pii/S0027510704004890">proteins and membranes, as well as DNA</a>. Photons from UVB rays are absorbed by <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709783/">DNA itself</a>, and the extra energy can cause some of the DNA to link up incorrectly.</p>
<p>This stops accurate DNA replication, so cells start repairs to try to fix the mistakes. Too many DNA errors overwhelm the cell and cause it to begin to self-destruct, to remove cells that can’t be safely replicated.</p>
<h2>Immune invasion</h2>
<p>Once the cells of the top layer of skin (called keratinocytes) detect DNA damage in themselves, they begin producing molecules to attract immune cells into the skin. This causes the skin’s blood vessels to leak into the spaces between cells and other skin structures. </p>
<p>It’s this extra fluid and the swelling it causes that lead to the red skin, hot sensation and painful sensitivity of freshly sunburnt skin. </p>
<p>Immune cell invasion begins while you’re still sitting on the beach, but increases about an hour after you come in from the sun. The process peaks 24 to 48 hours later, which is why the redness and painfulness of a sunburn can keep developing for a couple of days. </p>
<p>Some of the immune cells start cleaning up skin cells in self-destruct mode, while others release chemicals that further damage weakened cells. Their actions may also trigger a kind of allergic reaction that makes the skin <a href="http://onlinelibrary.wiley.com/doi/10.1111/exd.12742/full">itchy</a>. </p>
<p>Within several hours, blisters form where whole layers of keratinocytes have been killed. The dead layer lifts away from the layers underneath, and the space between fills up with the fluid that has leaked into the skin.</p>
<h2>Get ready for next time</h2>
<p>Once inflammation subsides, the lower layer of skin cells begins to <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709783/">grow quickly</a> to replace the dead cells. Post-sunburn peeling is large sheets of dead cells being shed from the upper layer of the skin to make way for this new growth.</p>
<p>DNA damage also causes the cells in the upper layer of skin to signal the cells that produce melanin (the pigment that gives our hair and skin its colour) to get to work. This is what provides the tan that can come after the redness has faded. </p>
<p>The melanin settles over the skin cells to shield them from future UV exposure. But don’t rely on your tan to fully protect you next time – it’s only as protective as <a href="http://www.ncbi.nlm.nih.gov/pubmed/24891049">SPF 2 sunscreen</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/111910/original/image-20160218-1276-67u0n8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/111910/original/image-20160218-1276-67u0n8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/111910/original/image-20160218-1276-67u0n8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/111910/original/image-20160218-1276-67u0n8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/111910/original/image-20160218-1276-67u0n8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/111910/original/image-20160218-1276-67u0n8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/111910/original/image-20160218-1276-67u0n8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/111910/original/image-20160218-1276-67u0n8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Best get someone else to do your back.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/maxually/537551450/in/photolist-Pv6js-ayf2M-PEAj7-qYhwC8-65SLvW-dbTAN2-9RLbeL-7joWpE-8io8be-4KP1a6-3tA1p-a6ed3J-a6bmGi-a6ecWA-a6ecKC-8P8F4U-Pj7XC-jGz2Q-8zSyPc-8jVrJT-7Gd3-eg3KR-KnASg-4oFBHb-6rWxRH-2bWw2U-QB4DL-5nVZo-9ed3y-51BMvz-f57GnS-NiQU-qQxhEU-nBjPvZ-9YR5Tu-51BLZX-28vmYF-iYfjTh-o44JLR-67RfGj-m2SE6-8cKrM9-fcP72L-4HsqWh-2KY4Q-4oBzba-7vCY28-cBxRf-c4nLDu-4CeQi">Maxually/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>There’s nothing you can do for sunburn except giving the skin time to heal itself. In the meantime, you can relieve the discomfort by staying out of the sun, drinking plenty of water, applying a cool compress, and taking over-the-counter medications such as paracetamol. </p>
<p>If the pain can’t be managed by these measures, or there is extensive blistering, nausea, fever or dizziness, it’s time to <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/sunburn">see a doctor</a>.</p>
<p>Once your sunburn has subsided and you’re thinking of venturing out again, you can best avoid another painful bout by using sun protection whenever the UV index reaches <a href="http://www.cancer.org.au/preventing-cancer/sun-protection/uv-alert/">three or higher</a>. This usually happens daily from September to April in the southern states and all year round further north. Use the <a href="http://www.cancer.org.au/preventing-cancer/sun-protection/uv-alert/sunsmart-app.html">SunSmart app</a> to find out today’s UV index and sun protection times in your area.</p><img src="https://counter.theconversation.com/content/53865/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Last summer, 2.4 million Australian adults were getting sunburnt each weekend. But what’s actually happening in the skin during a sunburn?H. Peter Soyer, Professor of Dermatology, The University of QueenslandKatie Lee, Study coordinator and research assistant, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/505132016-03-03T04:44:12Z2016-03-03T04:44:12ZExplainer: what are panic attacks and what’s happening when we have them?<figure><img src="https://images.theconversation.com/files/105190/original/image-20151210-7428-1rgdbaj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's important to remember the symptoms of a panic attack are "just" caused by anxiety and are not life-threatening. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>What would you think was happening to you if out of nowhere your heart started to race, you were drenched in sweat, you found yourself trembling uncontrollably, short of breath, with chest pain and feeling nauseated, dizzy and lightheaded as though you might faint? </p>
<p>You might also be feeling very cold or very hot, with tingling sensations in your fingers and toes. You might feel removed from the world around you – as though it wasn’t real – and be worried that you might lose control or that you are going insane. You might try to work out what is happening and conclude you are having a heart attack or dying. </p>
<p>A panic attack is a sudden, intense feeling of fear or discomfort with at least four of the signs described above. For some people, a panic attack can come out of nowhere, like a sudden thunderstorm from a clear blue sky. For other people, panic attack may be more predictable, such as an abrupt escalation of a milder anxiety about giving a speech or speaking to someone in authority.</p>
<p>Just as a panic attack can follow an experience of relative calm or of mild anxiety, panic can resolve to a relatively calm state or to ongoing, less intense symptoms. But the symptoms of panic attack are severe and frightening. Many people experiencing a panic attack believe they are seriously ill and seek medical help. </p>
<h2>What is happening to the body?</h2>
<p>Often one of the first symptoms of a panic attack is hyperventilating (rapidly breathing in and out), which upsets the natural balance of oxygen and carbon dioxide in our system. One view says a low level of carbon dioxide in the blood directly triggers the symptoms of panic, such as feeling lightheaded and dizzy. When we breathe quickly we also build up oxygen in our blood. Paradoxically, too much oxygen is also associated with <a href="http://www.sciencedirect.com/science/article/pii/S0167876010001388">feeling short of breath</a>. </p>
<p>Hyperventilation causes many of the other symptoms of a panic attack such as dizziness, blurred vision, tingling, muscle tension, chest pain, heart rate increases, nausea and temperature changes.</p>
<p>People who experience panic misinterpret the bodily signs of hyperventilation as indicating immediate physical danger and believe they have little control over the symptoms. When we then say things to ourselves such as “I might be having a heart attack” and “I can’t cope with this”, the anxiety gets worse.</p>
<p>In a <a href="http://www.ncbi.nlm.nih.gov/pubmed/23816952">2013 study</a>, researchers showed when people with no history of panic inhaled air with increased carbon dioxide they reported fear, discomfort and panic symptoms. People with a history of panic attack experience these symptoms at lower concentrations of carbon dioxide, suggesting they are hypersensitive to this internal signal for danger.</p>
<p>Panic attacks can occur with a range of diagnosed mental illnesses, including anxiety disorders, depressive disorders and substance use disorders, as well as physical illnesses, especially illnesses that affect heart function, breathing, balance and digestion. It is very important to understand and deal with panic attacks so they don’t lead to a more serious condition known as panic disorder.</p>
<p>People with panic disorder have a history of panic attacks and worry they will have further panic attacks. They change the way they live to ensure they do not have another panic attack. They avoid activities like exercise that cause feelings similar to panic attack (shortness of breath, sweating) and avoid situations where they fear another panic attack may occur. This avoidance brings many additional problems, as social, family and occupational worlds shrink due to fear of panic.</p>
<h2>What should you do if you have a panic attack?</h2>
<p>Panic attacks are common, with almost 23% of a people from a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1958997/">large US study</a> of the general population reporting at least one panic attack during their lives. Panic attacks are <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1958997/">more common in females</a> than males. They are also more common in family members of people with panic disorder.</p>
<p>Panic attacks are <a href="http://www.ncbi.nlm.nih.gov/pubmed/22901344">more common</a> among people who believe symptoms of anxiety are dangerous and harmful, rather than annoying and uncomfortable. They are also more likely if you are under emotional pressure, have been ill, are tired, are hungover or smoke.</p>
<p>As many of the symptoms of panic attack are physical and can be caused by a number of physical conditions, the first thing to do if you have symptoms like the ones described here is to see your doctor to check whether there is a medical reason for the symptoms.</p>
<p>If the symptoms are due to panic, then there are effective psychological approaches for controlling panic attacks. These focus on:</p>
<ol>
<li><p>monitoring and slowing breathing, as overbreathing causes many panic sensations</p></li>
<li><p>correcting the interpretations about what the symptoms mean by looking at the things we say to ourselves before, during and after a panic attack. It is very important to remember the symptoms are “just anxiety” and are not life-threatening.</p></li>
</ol>
<hr>
<p><em>There is useful information about panic attack and how to cope with it available through <a href="https://www.lifeline.org.au/Get-Help/Facts---Information/Panic-Attacks/Panic-Attacks">Lifeline</a>.</em></p><img src="https://counter.theconversation.com/content/50513/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lynne Harris is a clinical psychologist and works for the Australian College of Applied Psychology</span></em></p>A panic attack is a sudden, intense feeling of fear or discomfort. For some people, a panic attack can come out of nowhere, like a sudden thunderstorm from a clear blue sky.Lynne Harris, Professor of Psychological Sciences, School of Psychological Sciences, Australian College of Applied Psychology and Honorary Assoc Prof with the Faculty of Health Sciences, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/548902016-02-24T19:03:51Z2016-02-24T19:03:51ZDoes cannabis cause mental illness?<figure><img src="https://images.theconversation.com/files/112091/original/image-20160219-12655-w40hdh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One in three adults have smoked pot at some point in their lives.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/hippie/2701078196/">Philippa Willitts/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Cannabis is the most <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848">commonly used illicit drug</a> in Australia, with one in three adults using it at some point in their life. It’s legal in some places around the world, and offered medicinally in others. But what does smoking pot do to your mental health? </p>
<p>The potential harms associated with using cannabis depend on two things above all others. </p>
<p>The first is the <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.12703/full">age at which you first begin</a> to use cannabis, particularly if it’s before 18. Using cannabis during <a href="http://www.sciencedirect.com/science/article/pii/S0163725814002095">key stages</a> of brain development <a href="http://www.sciencedirect.com/science/article/pii/S0163725814002095">can impact</a> on synaptic pruning (when old neural connections are deleted) and the development of white matter (which transmits signals in the brain). </p>
<p>The second is the patterns of use: the frequency, dose and duration, particularly if you’re using at least weekly. The bigger or more potent the dose, the more tetrahydrocannabinol (THC) you are ingesting. THC is the main psychoactive component of cannabis and appears to act on areas of our brain involved in the regulation of our emotional experiences. </p>
<h2>Depression and anxiety</h2>
<p>Many studies of the relationship between cannabis use and mental illnesses such as <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9156179&fileId=S0033291713001438">depression</a> and <a href="http://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-14-136">anxiety</a> have suffered from methodological issues by not controlling for related factors.</p>
<p>The few longitudinal studies that have been conducted have mixed findings. </p>
<p>A 2014 review of the existing research <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9156179&fileId=S0033291713001438">concluded</a> that using cannabis placed an individual at moderate risk of developing depression. </p>
<p>Unfortunately it was not within the scope of the research to determine if cannabis use was <em>causing</em> depression or if the relationship instead reflects the association between cannabis use and social problems. Cannabis use is associated with other factors that increase risk of depression such as school dropout and unemployment. </p>
<p>The relationship between cannabis use and anxiety is also complex. Many people use cannabis for its euphoric and relaxing effects. But some people also experience feelings of anxiety or paranoia when intoxicated. As such, cannabis could be used to relieve anxiety or stress for some while causing others to feel anxious. </p>
<p>A 2014 review of the available research <a href="http://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-14-136">concluded</a> that using cannabis placed an individual at a small risk of developing anxiety. But the authors noted that while the weight of evidence supported the coexistence of cannabis use and anxiety, there was relatively little evidence to suggest that cannabis <em>caused</em> anxiety. </p>
<p>Not included in these previous reviews of depression and anxiety disorders were two <a href="http://www.sciencedirect.com/science/article/pii/S0924977X15004204">recent investigations</a> of cannabis use in the <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=2491944">United States</a> using data from 2001-2002 and 2004-2005. These included a host of variables such as demographic status and family environment.</p>
<p>Each found a significant association between cannabis use and the onset of depression and anxiety disorders. But this association was no longer significant when considering the impact of the included variables. </p>
<p>Clearly, the relationship between cannabis use and depression and anxiety disorders is complex and involves the individual’s reasons for cannabis use and external situations. That is, cannabis may be used to help cope with social problems that were not necessarily caused by cannabis use.</p>
<h2>Schizophrenia</h2>
<p>In contrast, the <a href="http://www.ncbi.nlm.nih.gov/pubmed/17662880">relationship</a> between cannabis use and risk of developing symptoms of psychosis has been <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=211301">well established</a> in many different review articles. </p>
<p>This research has found that <a href="http://link.springer.com/article/10.1007%2Fs40429-014-0018-7">early and frequent cannabis use</a> is a component cause of psychosis, which interacts with other risk factors such as family history of psychosis, history of childhood abuse and expression of the COMT and AKT1 genes. These interactions make it <a href="http://www.ncbi.nlm.nih.gov/pubmed/19783132">difficult to determine</a> the exact role of cannabis use in causing psychosis that <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033190">may not have otherwise occurred</a>. </p>
<p>Regardless, the connection between cannabis use and psychosis is not surprising. There is a <a href="http://search.proquest.com/docview/217290288?pq-origsite=gscholar">strong resemblance</a> between the acute and transient effects of cannabis use and symptoms of psychosis, including impaired memory, cognition and processing of external stimuli. This combines to make it hard for a person to learn and remember new things but can also extend to the experience of deluded thinking and hallucinations.</p>
<p>We also know that cannabis use by people with established psychotic disorder <a href="http://www.ncbi.nlm.nih.gov/pubmed/18978312">can exacerbate symptoms</a>. </p>
<p>Overall, the evidence suggests cannabis use will <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=211301">bring forward diagnosis</a> of psychosis by an average of 2.7 years. </p>
<p>The risk of developing schizophrenia <a href="http://www.ncbi.nlm.nih.gov/pubmed/17662880">increases with the duration and dose</a> of cannabis use. Regular cannabis users have double the risk of non-users. Those who have used cannabis at some point in their life have a 40% increased risk compared with non-users. </p>
<p>That said, it is important to view this increased risk in context. The proportions of individuals with psychosis among the population and among cannabis users are low. <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.12703/full">Current estimates</a> suggest that if frequent long-term cannabis use was known to cause psychosis, the rates of incidence would increase from seven in 1,000 in non-users to 14 in 1,000 cannabis users.</p>
<p>If you or a family member or friend have problems or concerns about cannabis, visit <a href="http://www.ncpic.org.au">www.ncpic.org.au</a> or access the free national Cannabis Information and Helpline on 1800 30 40 50.</p><img src="https://counter.theconversation.com/content/54890/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The National Cannabis Prevention and Information Centre receives funding from the Department of Health. </span></em></p>The potential harms associated with using cannabis depend, above all others, on two things: the age at which you first begin to use cannabis and the frequency, dose and duration of use.Peter Gates, Senior Research Officer, National Drug & Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/542382016-02-23T11:13:04Z2016-02-23T11:13:04ZZika: ‘Aedes aegypti’ mosquitoes love biting humans, and that’s why they spread viruses so well<p>While researchers work to develop a Zika virus vaccine to combat the outbreak spreading through South America, <a href="http://www.who.int/emergencies/zika-virus/articles/mosquito-control/en/">efforts to control</a> the spread of the virus are focusing on the mosquito <em>Aedes aegypti</em>. </p>
<p>This particular mosquito is especially good at transmitting disease from one human to another. Besides Zika, this mosquito is also a vector for dengue, yellow fever and Chikungunya viruses. </p>
<p>I’ve been studying <em>Ae. aegypti</em> – where it lives and how it behaves – for 15 years. <em>Aedes aegypti</em> is adapted to live in close proximity with humans, and this close association likely contributes to the severity of this outbreak. </p>
<h2><em>Aedes aegypti</em> in a location near you?</h2>
<p><em>Aedes aegypti</em> is an invasive species to the Americas. It originated in Africa, and is thought to have been brought over with the early slave trade ships in the <a href="http://www.cambridge.org/us/academic/subjects/life-sciences/entomology/aedes-aegypti-l-yellow-fever-mosquito-its-life-history-bionomics-and-structure">15th through 17th century</a>.</p>
<p>This mosquito is found in tropical and subtropical areas, which include all of Central and much of South America. In the U.S. it can be found readily in the Southeast and some small pockets in the Southwest, but not in areas that experience cold or freezing temperatures and more pronounced changes in daylight. </p>
<p><em>Aedes aegypti</em> is a daytime biter, which means it’s active when its preferred food choice – human beings – are out and about.</p>
<h2><em>Aedes aegypti</em> just loves people</h2>
<p>There are many species of mosquitoes, but not all of them spread diseases in people. Some prefer to feed on other mammals or birds. <em>Ae. aegypti</em>, however, prefers to feed on human beings. In fact, <em>Aedes aegypti</em> prefers human blood over that of other animals, which increases its ability to transmit viruses from person to person. </p>
<p>All mosquitoes are attracted to the carbon dioxide in our breath because it clues them into <a href="http://dx.doi.org/0.1146/annurev-ento-120811-153618">a live, breathing blood source</a>. </p>
<p><em>Aedes aegypti</em> females also detect odor cues from <a href="http://dx.doi.org/10.1016/j.pt.2010.12.009">our sweat</a>. They are attracted to the <a href="http://dx.doi.org/10.1093/chemse/26.5.523">lactic acid</a> and <a href="http://dx.doi.org/10.1093/chemse/24.6.647">ammonia</a> on our breath and skin, as well as <a href="https://chemse.oxfordjournals.org/content/25/3/323.full">the fatty acids</a> secreted by the sebaceous glands at the base of our hair follicles (that would be the stuff that makes our hair look and smell oily).</p>
<p>Male <em>Ae. aegypti</em> feed on nectar and sugar, not blood, but they also can detect these odor cues so they can find potential mates that are hanging around humans.</p>
<p>While people generally smell good to female <em>Ae. aegypti</em> mosquitoes, some people smell especially good. </p>
<p>Your microbiota – the bacteria living on your skin – <a href="http://dx.doi.org/10.1111/j.1574-6941.2010.00908.x">are another factor</a> in this bouquet. Because we are all host to different groups of bacteria, we each have a different “smell” to the female mosquitoes, and that might be why some people smell more attractive than others. </p>
<p>And all of these factors vary with age. Because we get bigger with age, the skin surface area increases, so we can assume larger people (that is, adults) emit more of these attractants than smaller people (that is, children). </p>
<h2><em>Aedes aegypti</em> lay eggs in human-made containers</h2>
<p>Besides finding human blood tasty, female <em>Ae. aegypti</em> tend to lay their eggs in human-made containers such as buckets, leftover cups, tires or cemetery vases that fill with water. Rain or daily watering from sprinkler systems makes containers including potted plant bases, birdbaths and fountains nice homes for the developing larvae.</p>
<p>Other mosquito species prefer natural sources of water to lay eggs, such as small ponds or near flooded creek beds. The species that prefer these habitats won’t have the same proximity to humans as the species that likes to lay eggs in our backyards, like <em>Ae. aegypti</em>.</p>
<p>Because the proximity of water sources to humans affects the chances of being bitten by a potentially infected mosquito, several researchers have begun to classify which water containers are more attractive to female <em>Ae. aegypti</em>. In one extensive study in Iquitos, Peru, where dengue is prevalent, researchers found several factors that make a site <a href="http://dx.doi.org/10.1371/journal.pntd.0001015">more attractive to females</a>: </p>
<ul>
<li><p>If larvae are already present in a container, the female knows that it has all the necessary requirements for her future offspring. It’s sort of like choosing a restaurant in an unknown city: if it’s crowded, then you know it’s good. </p></li>
<li><p>A neglected container is more attractive than a managed container, because it can accumulate more nutrients from decaying leaves or other organic matter. The more nutrients, the bigger the larvae will grow. </p></li>
<li><p>A container that receives more sunlight is more attractive because it’s warmer and mosquitoes need warm temperatures to develop.</p></li>
<li><p>Finally, size matters. Of those human-made containers that are near human activity, larger containers tend to have more developing larvae than smaller containers. However, even though size matters, we can still find larvae in containers as small as coke cans. </p></li>
</ul>
<p>Educating the community about emptying unnecessary containers and covering larger water storage containers are an important part of the control effort and knowing what makes a container attractive can help people target specific containers. In areas where diseases transmitted by <em>Ae. aegypti</em> are present, this becomes extremely important.</p>
<h2>Arming ourselves with more knowledge</h2>
<p>Knowing that <em>Ae. aegypti</em> prefer humans, we can protect ourselves by wearing long-sleeved shirts and long pants, and using mosquito repellents that contain DEET or other <a href="http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/protection-against-mosquitoes-ticks-other-arthropods">CDC-approved repellents</a>.</p>
<p>By clearing the areas around our homes of containers that can hold water or making sure we periodically empty our containers, we can reduce the population and thus reduce how often we are bitten.</p>
<p>Just because you’ve been bitten by a mosquito doesn’t mean you have been bitten by one that is carrying a disease. Even if you are bitten by an <em>Ae. aegypti</em> mosquito, it doesn’t necessarily mean that you have been exposed to Zika, or any other virus. Not all <em>Ae. aegypti _are infected and not all mosquitoes are _Ae. aegypti</em>.</p><img src="https://counter.theconversation.com/content/54238/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Megan Wise de Valdez does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Aedes aegypti is adapted to live in close proximity with humans, and this close association likely contributes to the severity of the Zika outbreak.Megan Wise de Valdez, Assistant Professor of Biology, Texas A&M University-San AntonioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/453182016-02-23T01:17:22Z2016-02-23T01:17:22ZExplainer: what is eczema and what can you do about it?<figure><img src="https://images.theconversation.com/files/106405/original/image-20151217-32606-108jo3x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If you or someone in your family has suffered with severe eczema, you've probably tried all sorts of remedies to alleviate the itching.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-270420824/stock-photo-woman-has-itch-on-gray-background.html?src=pp-photo-281163671-OG3ZUW2WABrImPXX79et2A-8&ws=1">Africa Studio/Shutterstock</a></span></figcaption></figure><p>Eczema is a genetic disorder with an environmental trigger, which affects <a href="http://www.asthmaaustralia.org.au/Eczema.aspx">one in three</a> people at some time in their life. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/106408/original/image-20151217-32600-w4c943.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/106408/original/image-20151217-32600-w4c943.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/106408/original/image-20151217-32600-w4c943.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1014&fit=crop&dpr=1 600w, https://images.theconversation.com/files/106408/original/image-20151217-32600-w4c943.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1014&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/106408/original/image-20151217-32600-w4c943.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1014&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/106408/original/image-20151217-32600-w4c943.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1274&fit=crop&dpr=1 754w, https://images.theconversation.com/files/106408/original/image-20151217-32600-w4c943.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1274&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/106408/original/image-20151217-32600-w4c943.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1274&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-74586262/stock-photo-mechanism-of-eczema.html?src=OG3ZUW2WABrImPXX79et2A-1-57">Alila Medical Media/Shutterstock</a></span>
</figcaption>
</figure>
<p>People with eczema essentially have sensitive skin that is easily irritated. The irritation produces dryness by disrupting the function of the external waterproof skin barrier, allowing water to leave the skin.</p>
<p>The main gene associated with eczema – or atopic dermatitis, as it’s known clinically – is <a href="http://jcs.biologists.org/content/joces/122/9/1285.full.pdf">filaggrin</a>. Filaggrin mutations reduce the ability of the skin to withstand environmental insults and to repair itself after injury. </p>
<p>Disruption to the skin barrier allows allergens to enter the deeper layers of the skin and activate the immune system. </p>
<p>How the immune system reacts to these allergens determines the severity of the skin inflammation and the duration of the disruption to the skin barrier function. </p>
<h2>What can you do about it?</h2>
<p>If you or someone in your family has suffered with severe eczema, you’ve probably tried all sorts of remedies to alleviate the itching. Here are five tips to calm your skin:</p>
<p>1) <strong>Avoid things that irritate the skin</strong>. No matter how wonderful a hot shower feels on itchy skin, it actually aggravates eczema. Keep showers to five minutes or less and use luke-warm water. </p>
<p>Wash with water alone: no soap, no soap substitute, no soap-free wash and definitely no bubble bath. Just water. </p>
<p>2) <strong>Avoid overheating</strong>. Heat makes the itch worse, irrespective of the cause. Turn the heating down to 18 to 20 degrees Celsius (64 to 68 degrees Farenheit) and put on an extra layer of clothing. </p>
<p>Take the doona off your bed and sleep under good old-fashioned cotton blankets. Overheating at night leads to scratching in your sleep. If there is blood on your sheets in the morning, that is a sure sign your bed is too hot at night.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/106410/original/image-20151217-32609-sitrrv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/106410/original/image-20151217-32609-sitrrv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/106410/original/image-20151217-32609-sitrrv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/106410/original/image-20151217-32609-sitrrv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/106410/original/image-20151217-32609-sitrrv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/106410/original/image-20151217-32609-sitrrv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/106410/original/image-20151217-32609-sitrrv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Apply moisturiser frequently and liberally.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-203589715/stock-photo-girl-applying-cream-on-allergic-skin-eczema-treatment.html?src=OG3ZUW2WABrImPXX79et2A-1-4">Kaspars Grinvalds/Shutterstock.</a></span>
</figcaption>
</figure>
<p>3) <strong>Take a <a href="https://www.aad.org/public/diseases/eczema/atopic-dermatitis">bleach bath</a></strong>. This is a simple method to reduce the bacteria on the surface of your skin. For a full tub of water, use half a cup of bleach. Never apply bleach directly to the skin. (More safety tips and instructions are <a href="https://www.aad.org/public/diseases/eczema/atopic-dermatitis">available here</a>.) </p>
<p>If the eczema is weeping, oozing or has honey-coloured crusts, there is almost always golden staph on the skin surface aggravating the eczema. Bleach baths are a good alternative to antibiotics. </p>
<p>4) <strong>Use lots and lots of moisturiser</strong>. To fix eczema you will also need to restore the skin barrier. That requires frequent and liberal use of moisturiser, including after the eczema appears to have cleared up. </p>
<p>There are lots of moisturisers on the market. Trial and error is the best way to find the right moisturiser for your skin. Keep in mind that if you use a light one, you need to reapply it more often than a heavy one.</p>
<p>While tablets can help stop the inflammation, in general that’s not enough to stop the eczema. </p>
<p>5) <strong>Use your topical <a href="http://www.eczema.org/corticosteroids">corticosteroid</a> creams as directed</strong>. Additives reduce the skin thinning that can occur with prolonged use of potent topical steroids. Your dermatologist is the best person to advise you on this.</p>
<h2>Emerging therapies</h2>
<p>Researchers are investigating whether a new class of drugs, called <a href="https://theconversation.com/explainer-what-are-biologics-and-biosimilars-45308">biologics</a>, could help manage severe eczema. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/106409/original/image-20151217-32590-169wr7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/106409/original/image-20151217-32590-169wr7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/106409/original/image-20151217-32590-169wr7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/106409/original/image-20151217-32590-169wr7p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/106409/original/image-20151217-32590-169wr7p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/106409/original/image-20151217-32590-169wr7p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/106409/original/image-20151217-32590-169wr7p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/106409/original/image-20151217-32590-169wr7p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Biologics show promise but they’re still several years away.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-70176649/stock-photo-close-up-of-a-patients-elbow-showing-plaques-of-dry-skin-typically-seen-with-psoriasis.html?src=G3rf0xH0dBoWj_h2TD4Yig-2-69">Quayside/Shutterstock</a></span>
</figcaption>
</figure>
<p>Biologics try to block critical steps within certain pathways, which can terminate inflammation.</p>
<p>Biologics are most commonly produced from bacteria or yeast cultures. Specific genes are inserted into bacteria and yeast that have been inactivated so they are no longer dangerous to humans. </p>
<p>Production of biologics in this way is slow, low-volume, high-tech and expensive. Consequently, biologics can cost tens of thousands of dollars per patient per year. </p>
<p>A number of <a href="https://www.centerwatch.com/clinical-trials/listings/location/international/Australia/East%20Melbourne/">clinical research trials</a> are underway to test these agents. People with severe eczema, which is not adequately controlled with current treatments, may consider enrolling to participate in a research trial. </p>
<p>It will still take three to five years for the results of these trials to be fully assessed and to know whether biologic agents are safe and effective in the management of eczema. If they are, they could revolutionise the management of severe eczema.</p><img src="https://counter.theconversation.com/content/45318/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rodney Sinclair does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People with eczema essentially have sensitive skin that is easily irritated.Rodney Sinclair, Professor of Dermatology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/510132016-01-12T11:14:34Z2016-01-12T11:14:34ZExplainer: Why can’t anyone tell me how much this surgery will cost?<figure><img src="https://images.theconversation.com/files/107549/original/image-20160107-13988-6icz0p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Why is it so hard to figure out what medical care costs?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-126678482/stock-photo-bill-from-the-doctor-concepts-of-rising-medical-cost.html?src=mC4Ftc7f7Km7CO7mOTCD7Q-1-0">Bill image via www.shutterstock.com.</a></span></figcaption></figure><p>Thanks to rising annual deductibles and a push toward consumer-driven health care, people are increasingly encouraged to <a href="http://health.usnews.com/health-news/health-wellness/articles/2015/03/31/price-shopping-getting-the-best-deals-on-medical-care">shop around</a> for medical care. Many <a href="http://www.npr.org/sections/health-shots/2014/11/05/360351551/how-much-is-that-mri-really-massachusetts-shines-a-light">states</a> or state hospital associations have price transparency initiatives, and there are a number of private companies that also purport to help consumers find value for their health care dollar. </p>
<p>But the search for the best price is often stymied, not necessarily by a lack of information, but by a lack of <em>relevant</em> information.</p>
<p>Price in health care is a squishy concept. Different words relating to cost – charge, price and out-of-pocket cost – all have different meanings and there is no standard among consumer transparency websites about which of these prices to report. So, while the price variation between hospitals is well-recognized, less often discussed is that when consumers search for price, the variation in information reported means they may see wide variation within the same hospital for the same procedure. The lack of standards in this respect can leave consumers confused and means some price transparency efforts may be doing more harm than good.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/107567/original/image-20160107-14020-1h2etmk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/107567/original/image-20160107-14020-1h2etmk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/107567/original/image-20160107-14020-1h2etmk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/107567/original/image-20160107-14020-1h2etmk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/107567/original/image-20160107-14020-1h2etmk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/107567/original/image-20160107-14020-1h2etmk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/107567/original/image-20160107-14020-1h2etmk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sometimes, searching for hospital prices adds to confusion about what a procedure will cost.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-280947350/stock-photo-medical-team-performing-operation-group-of-surgeon-at-work-in-operating-theatre-toned-in-blue.html?src=-_-Tjlzppny641emrSnB7w-1-8">Surgery image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Searching for a price</h2>
<p>As an example of how confusing things can get, in mid-December 2015 I searched for the price of spinal fusion surgery, a common procedure, at a hospital near my Michigan home, the Henry Ford Health System.</p>
<p>My first stop was the website run by the Michigan Health & Hospital Association, the trade association representing hospitals in the state. There, I found out that the average charge at Henry Ford was about US$71,000. Then I looked for other sources of price information for consumers. The first result that came up in a Google search for “compare hospital prices” was a site called <a href="http://www.opscost.com/">OpsCost</a>. That site showed me a billed price of about $67,000 at Henry Ford and also told me Medicare reimbursed about $33,000 for the procedure. I looked for something on the site that would explain why there was a difference between these numbers, and how they relate to other insurers, but couldn’t find it. </p>
<p>Then, I tried <a href="https://healthcarebluebook.com/">Healthcare Bluebook</a>, which allowed me to narrow into a zip code but not a specific hospital. That website said that the “fair price” for my spinal fusion procedure in the zip code where Henry Ford is located would be about $39,000. I tried another, <a href="http://www.fairhealth.org/">Fair Health</a>, which also let me search just by zip code. That website said my procedure cost $9,350.</p>
<p>It’s easy to see how a well-intentioned consumer would get frustrated.</p>
<h2>Why is there so much variation?</h2>
<p>None of the prices in the above examples are wrong, per se. They just give the cost of different things. And, most importantly, none of them likely reflect the cost that someone with insurance would pay for the procedure.</p>
<p>The first two examples, from the hospital association and OpsCost, show the billed, or <a href="http://www.medicalbillinganswers.com/chargemaster.html">chargemaster</a>, amounts at Henry Ford. That is akin to a “sticker price” for the service. It is rare that anyone with health insurance would pay an amount that high if the hospital is included in their insurer’s network. Just as a car buyer might haggle down from the sticker price of a vehicle, an insurance company negotiates a lower price for its members. </p>
<p>People with insurance pay less than the chargemaster amount, but it’s hard to tell just how much less. This is known as the negotiated price, or sometimes the actual paid amount. In some instances, the insurer pays very close to the chargemaster price, while in others they pay much less. That can vary based on the insurer or by the hospital, making the chargemaster price virtually meaningless for comparing hospital prices for those with commercial insurance.</p>
<p>The prices quoted by Healthcare Bluebook and Fair Health are both meant to estimate actual amounts paid by insurers to hospitals. These prices are disclosed in an explanation of benefits statement (it’s the amount after the insurance discount is removed), but you usually don’t see that until after the procedure is done and you get the statement. </p>
<p>The negotiated price is usually a closely guarded secret. Because of this fact, the websites do not have or do not reveal Henry Ford’s or any other hospitals’ actual negotiated prices. So unless you know someone with the same insurance who just had done the same procedure at the same hospital, you’d have a hard time finding that number. In addition, neither website asked about the generosity of my insurance benefit, which determines my out-of-pocket cost, the actual amount I would owe.</p>
<p>Then, there’s the issue of what is encompassed in the quoted price, which is likely the source of the large discrepancy between what Fair Health reported as a fair cost ($9,350) and what Healthcare Bluebook reported ($39,000). Healthcare Bluebook estimated the hospital’s facility fee, physician fee and anesthesia fee based on typical recovery time and prices. The Fair Health price is a bit unclear, but it seems to include only the price of the actual surgery, not taking anesthesia or the cost of the hospital stay into account.</p>
<p>What if you don’t have insurance? In some cases, patients are billed chargemaster prices. However, many hospitals will work with these people to lower large bills. Additionally, thanks to the Affordable Care Act, anyone without insurance who is eligible for financial assistance must be billed a lower amount, usually based on average insurer payments. Uninsured people with higher incomes may still pay chargemaster prices within the law.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/107568/original/image-20160107-13988-xn2n40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/107568/original/image-20160107-13988-xn2n40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/107568/original/image-20160107-13988-xn2n40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/107568/original/image-20160107-13988-xn2n40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/107568/original/image-20160107-13988-xn2n40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/107568/original/image-20160107-13988-xn2n40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/107568/original/image-20160107-13988-xn2n40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Too many prices.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-231221170/stock-photo-frustrated-man-with-laptop-computer.html?src=owkeoSGaulqmYNV8a5Qrmw-3-56">Man at computer image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>What’s a consumer to do?</h2>
<p>The best thing you can do if you know you have a major medical expense coming up is call your insurer. Most large insurers now have tools that help consumers shop around for health care providers, and they can often give you an idea of the variation in costs you would face at different providers in your network and specific to your plan.</p>
<p>Next, as a policy recommendation, we need to be careful about releasing information on billed charges under the guise of price transparency, and particularly about calling these numbers prices. They bear little relevance to what the vast majority of consumers will pay and simply distract from finding relevant information on actual prices facing patients.</p>
<p>Price transparency is undoubtedly hard to implement. But it doesn’t have to be as hard as we are making it.</p><img src="https://counter.theconversation.com/content/51013/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Betsy Q Cliff has received funding from the Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services. </span></em></p>Price in health care is a squishy concept. Different words relating to cost – charge, price and out-of-pocket cost – all have different meanings.Betsy Q Cliff, Doctoral Student, School of Public Health, University of MichiganLicensed as Creative Commons – attribution, no derivatives.