tag:theconversation.com,2011:/ca/topics/medical-journal-of-australia-5938/articles
Medical Journal of Australia – The Conversation
2019-09-01T19:48:55Z
tag:theconversation.com,2011:article/122532
2019-09-01T19:48:55Z
2019-09-01T19:48:55Z
Australia has a paracetamol poisoning problem. This is what we should be doing to reduce harm
<figure><img src="https://images.theconversation.com/files/290237/original/file-20190830-115387-2lcq5f.jpg?ixlib=rb-1.1.0&rect=5%2C10%2C3438%2C2282&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paracetamol overdoses can cause serious liver damage.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Most of us take paracetamol every now and again to reduce pain or fever. As far as medications go, it’s one we’re unlikely to associate with harm.</p>
<p>But in a study published today in the <a href="https://www.mja.com.au/journal/2019/211/5/paracetamol-poisoning-related-hospital-admissions-and-deaths-australia-2004-2017">Medical Journal of Australia</a>, my colleagues and I reveal a concerning increase in paracetamol poisonings, and resulting liver damage, in Australia over the last decade.</p>
<p>In fact, paracetamol is actually the <a href="https://www.mja.com.au/journal/2018/209/2/patterns-poisoning-exposure-different-ages-2015-annual-report-australian-poisons">number one pharmaceutical</a> Australian poisons centres receive calls about.</p>
<p>Paracetamol is safe if used appropriately, at a maximum of four grams per day in adults (equivalent to eight 500mg tablets, or six 665mg modified release tablets). However when this dose is exceeded, there is a potential for harm. And the bigger the dose, the greater the risk.</p>
<p>It’s time to consider restrictions, including reducing pack sizes and changing the way paracetamol is sold. </p>
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Read more:
<a href="https://theconversation.com/weekly-dose-paracetamol-may-be-our-favourite-mild-painkiller-but-it-doesnt-work-for-everything-57967">Weekly Dose: paracetamol may be our favourite mild painkiller, but it doesn't work for everything</a>
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<h2>Our study</h2>
<p>We analysed data from national hospital admissions, poisons centre calls, and coroners’ records to examine poisonings, liver injuries, and deaths. </p>
<p>The annual number of cases of paracetamol poisoning increased by 44% from 2007-2008 to 2016-2017. </p>
<p>In that time, we recorded more than 95,000 paracetamol-related hospitalisations.</p>
<p>Liver injury from paracetamol has doubled over the same period. This is likely because people are taking more tablets when they overdose than in previous years, increasing the risk of liver failure. </p>
<p>More than 200 people died from paracetamol poisoning in Australia in the ten year period.</p>
<h2>What a paracetamol overdose does to your body</h2>
<p>Paracetamol itself is not toxic, but in large amounts it overwhelms the body’s ability to process it safely. This can lead to build up of a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2637612/">toxic metabolite</a> (or break-down product), which binds to liver cells, causing these cells to die. </p>
<p>The quantity that constitutes a toxic dose depends on circumstances including the time period in which the paracetamol is taken, and the person’s weight. But any adult ingesting more than four grams in a day could be at risk.</p>
<p>In severe cases, liver failure means the person will need a liver transplant, or they won’t survive.</p>
<p>Paracetamol is the leading cause of <a href="https://www.ncbi.nlm.nih.gov/pubmed/16317692">acute liver failure</a> in the Western world. </p>
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Read more:
<a href="https://theconversation.com/we-need-to-talk-about-this-paracetamol-problem-dont-we-19051">We need to talk about this paracetamol problem....don't we?</a>
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<p>There is an antidote to paracetamol toxicity, called N-acetylcysteine (NAC), which is given as an intravenous infusion in hospital. Importantly, NAC works best when given early: it should be started before any symptoms appear. Symptoms of paracetamol poisoning – nausea, vomiting and abdominal pain – indicate damage has already started to occur. </p>
<p>Patients who take <a href="https://www.ncbi.nlm.nih.gov/pubmed/28644687">very large overdoses</a>, and overdoses with <a href="https://www.ncbi.nlm.nih.gov/pubmed/29451045">modified release paracetamol</a>, are more likely to sustain liver failure despite treatment with the antidote.</p>
<p>Modified release paracetamol comes in a higher strength, designed to be released over a longer period, which can be confusing and result in overdose. </p>
<h2>Accidental vs intentional overdosing</h2>
<p>Overdoses can be either accidental or intentional, and our figures include both. </p>
<p>Paracetamol is not a drug people become addicted to, or dependent on, in the same way people do with opioids or other drugs.</p>
<p>Intentional poisonings occur when people knowingly take too much paracetamol as a form of <a href="https://bmjopen.bmj.com/content/9/2/e026001">self-harm</a>. In our research, about three-quarters of cases were intentional. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290238/original/file-20190830-115391-1l9cry3.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">
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<span class="caption">Dosing mistakes can occur when parents are giving paracetamol to their children.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>People might accidentally overdose because they are in pain, and believe because paracetamol is so widely available, it must be safe. They take more than the recommended dose, or take multiple different paracetamol-containing products together, resulting in harm. </p>
<p>Poisons centres also receive calls about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3447018/">children having too much paracetamol</a>, usually due to dosing errors or a child finding and ingesting the medicine. </p>
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Read more:
<a href="https://theconversation.com/research-check-does-paracetamol-in-pregnancy-cause-child-behavioural-problems-63994">Research Check: does paracetamol in pregnancy cause child behavioural problems?</a>
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<h2>Some tips to avoid accidentally overdosing</h2>
<p>It’s important to be aware of the many brands of paracetamol-containing products, including cold and flu products, to avoid doubling up. People should also read the pack and ensure they follow the dosing instructions.</p>
<p>Parents should consider the following to avoid overdosing in children: </p>
<ul>
<li>paracetamol should be stored out of reach (for example, don’t leave it on the bench or change table after use)</li>
<li>paracetamol can be dosed every four to six hours, but must not exceed four doses in a 24 hour period</li>
<li>keep track of doses given and when by writing them down</li>
<li>read the label carefully and ensure you understand how to use the syringe/dosing device correctly.</li>
</ul>
<h2>Changing the way paracetamol is sold</h2>
<p>Paracetamol poisoning and resultant liver injury is preventable, and some simple public health measures could have a significant impact. </p>
<p>In Australia, paracetamol can be purchased outside of pharmacies (for example, in supermarkets) in packs of 20 tablets. In pharmacies, packs of 100 can be purchased without needing to speak to a pharmacist. </p>
<p>In both cases, there are no legal restrictions on the number of packs one person can purchase. This is out of step with many other countries, especially the UK and Europe.</p>
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Read more:
<a href="https://theconversation.com/is-it-ok-to-give-children-pain-killers-we-asked-five-experts-95148">Is it ok to give children pain killers? We asked five experts</a>
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<p>The UK restricted packs to 32 tablets in pharmacies and 16 tablets outside of pharmacies in 1998, as a response to increasing deaths from paracetamol. This resulted in a <a href="https://www.bmj.com/content/346/bmj.f403">long-term reduction</a> in paracetamol poisonings, liver injury, and deaths.</p>
<p>Many <a href="https://www.ncbi.nlm.nih.gov/pubmed/29319222">European counties</a> don’t allow non-pharmacy sales of paracetamol, and have small packs in pharmacies. Denmark has gone one step further, restricting paracetamol sales to those aged <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/bcpt.13003">18 and over</a>.</p>
<h2>Modified release paracetamol</h2>
<p>In our study, modified release paracetamol overdoses increased by 38% each year, and were disproportionately involved in deaths. </p>
<p>Modified release paracetamol has been <a href="https://www.ema.europa.eu/en/medicines/human/referrals/paracetamol-modified-release">completely banned</a> in Europe. This is due to documented harms, including increased risk of liver failure and death. </p>
<p>The Therapeutic Goods Administration <a href="https://www.tga.gov.au/changes-way-modified-release-paracetamol-products-are-supplied-questions-and-answers">recently announced</a> modified release paracetamol would become Schedule 3 in 2020, meaning it will be behind the pharmacist’s counter.</p>
<p>This restriction is a step in the right direction, but ignores the fact regular paracetamol can be purchased in large quantities without consultation with a health-care professional. </p>
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Read more:
<a href="https://theconversation.com/curious-kids-how-does-pain-medicine-work-in-the-body-82495">Curious Kids: How does pain medicine work in the body?</a>
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<p>Due to its widespread use, paracetamol is likely to remain a common source of poisoning. Our study shows it’s increasingly important we take measures to reduce harm from these events. </p>
<p>Restricting pack sizes and restricting availability of modified release paracetamol are crucial first steps. We also need increased public awareness of how to use paracetamol safely.</p>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14. For advice on suspected paracetamol overdose, call the <a href="https://www.poisonsinfo.nsw.gov.au/">Poisons Information Centre</a> on 13 11 26.</em></p><img src="https://counter.theconversation.com/content/122532/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose Cairns receives funding from the NHMRC to study suicide prevention.</span></em></p>
The annual number of paracetamol poisoning cases in Australia has increased by 44% over the last decade. To tackle this problem, we need tighter regulation around the way paracetamol is sold.
Rose Cairns, Lecturer in Pharmacy, University of Sydney
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/92343
2018-02-25T19:18:55Z
2018-02-25T19:18:55Z
Fewer alcohol-related visits to inner Sydney emergency room since ‘lockout laws’ introduced
<p>The emergency room at Sydney’s St Vincent’s Hospital has seen a 10% reduction in the incidence of fractures that are often caused by a punch to the face over the two years since the so-called “lockout laws” were introduced. </p>
<p>Published in the <a href="https://www.mja.com.au/journal/2018/208/4/fewer-orbital-fractures-treated-st-vincents-hospital-after-lockout-laws?utm_source=carousel&utm_medium=web&utm_campaign=homepage">Medical Journal of Australia</a> (MJA), the results indicate alcohol restrictions in inner Sydney have effectively reduced numbers of violent alcohol-related injuries.</p>
<p>The controversial 2014 NSW Liquor Amendment Act aimed to reduce alcohol-related violence by restricting access to alcohol in Sydney’s Kings Cross and the CBD entertainment precinct. The changes involved stopping alcohol service in pubs and clubs by 3am and a 1.30am “lockout” (to stop people entering the venue), as well as restrictions on takeaway sales after 10pm.</p>
<p>It’s actually the closing time of the venue that has the <a href="http://onlinelibrary.wiley.com/doi/10.1111/dar.12342/abstract">bigger impact</a> (rather than the lockout itself), so early last drinks is a better name than “lockout laws”.</p>
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Read more:
<a href="https://theconversation.com/are-residents-better-off-under-the-sydney-lockout-laws-83443">Are residents better off under the Sydney 'lockout laws'?</a>
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<p>The MJA study looked at the rates of alcohol-related orbital (eye socket) fractures before and after the changes to alcohol access. There were 27 fewer fractures that required surgical management during the period of the laws. That’s an estimated total saving of nearly half a million dollars in hospital, ambulance and other medical costs.</p>
<p>Some orbital fractures can be considered minor injuries. But in 2016, some of the same authors <a href="https://www.mja.com.au/journal/2015/203/9/presentations-alcohol-related-serious-injury-major-sydney-trauma-hospital-after">found a 25% reduction</a> in major alcohol-related injuries (such as the so-called “one punch” injuries) in the 12 months after the laws were introduced. Such injuries often result in doctors such as myself having to tell parents their child may have a serious head injury or possibly be brain dead.</p>
<p>This latest research adds to <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13621/abstract">compelling evidence from Australia</a> and internationally that demonstrates restricting access to alcohol by closing drinking venues early reduces serious assaults and injuries. </p>
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Read more:
<a href="https://theconversation.com/curfews-and-lockouts-battles-over-drinking-time-have-a-long-history-in-nsw-58220">Curfews and lockouts: battles over drinking time have a long history in NSW</a>
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<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/21906198">Norwegian study</a> showed the effect in both directions when towns changed opening hours of pubs and clubs after 1am. Alcohol-related assaults increased by almost 20% per hour with increased opening hours, and vice versa with early last drinks. </p>
<p>The biggest and most comprehensive study internationally on alcohol-related presentations to EDs, which include intoxication and other emergencies besides injuries, found almost one in ten of all attendances were alcohol-related. That equates to a <a href="https://www.ncbi.nlm.nih.gov/pubmed/29155471">staggering half a million patients</a> every year presenting to Australian EDs with alcohol-related harm. The economic cost is huge, but the human cost even bigger.</p>
<p>Emergency department staff are <a href="https://www.mja.com.au/journal/2016/204/4/perceptions-australasian-emergency-department-staff-impact-alcohol-related">frequently assaulted</a> by drunk patients. They frighten and disrupt the care of other patients, including children and the elderly. We surveyed more that 2,000 ED staff in 2014 and found nine out of ten had experienced violence from a drunk person in the emergency department.</p>
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<iframe src="https://player.vimeo.com/video/110223493" width="500" height="281" frameborder="0" webkitallowfullscreen="" mozallowfullscreen="" allowfullscreen=""></iframe>
<figcaption><span class="caption">Alcohol-related violence against emergency department staff is a serious issue.</span></figcaption>
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<p>The Sydney laws were <a href="https://www.liquorandgaming.nsw.gov.au/Documents/public-consultation/independent%20liquor%20law%20review/Liquor-Law-Review-Report.pdf">reviewed in 2016 by Justice Callinan</a> and relaxed by 30 minutes for the last drinks and lockouts, and 60 minutes for takeaway alcohol sales. Research points to the fact this will result in increased assaults and injuries, both for the general public and health workers.</p>
<p>The Queensland government recently introduced early (2am) last drinks across the state. This will result in a <a href="https://www.legislation.qld.gov.au/view/pdf/asmade/act-2016-004">significant reduction</a> in alcohol-related assaults and injuries, as well as massive cost savings and productivity gains.</p>
<p>Policymakers in other states and territories have the ability to turn off this tap of human misery and injury. They can’t stop it completely, but they can reduce it dramatically by introducing early last drinks.</p><img src="https://counter.theconversation.com/content/92343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Diana Egerton-Warburton has received Commonwealth funding for some of the studies cited in the article. She is an executive member of the National Alliance for Action on Alcohol (NAAA). She is also on the Australian National Advisory Council for Alcohol and Drugs (ANACAD).</span></em></p>
A new study exploring the number of alcohol-related injuries treated at Sydney emergency department has found the lockout seem to be having an impact.
Diana Egerton-Warburton, Associate Professor, Monash University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/81614
2017-07-30T20:10:53Z
2017-07-30T20:10:53Z
Snakebites are rarer than you think, but if you collapse, CPR can save your life
<figure><img src="https://images.theconversation.com/files/180118/original/file-20170727-28974-7lutuk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bites from brown snakes like this one were the most common, followed by
tiger snakes, then red-bellied black snakes.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Eastern_Brown_Snake_(Pseudonaja_textilis)_(8582601994).jpg">Matt Clancy/SunOfErat/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Despite the common belief that Australia has some of the most venomous snakes in the world, our <a href="http://www.mja.com.au">new research shows</a> being bitten by a snake is uncommon in Australia and dying from a snakebite is very rare. </p>
<p>And of the few unlucky people to collapse after venom enters their bloodstream, a bystander performing cardiopulmonary resuscitation (CPR) is the most likely thing to save them.</p>
<p>These are just some of the findings from 10 years of data from the Australian Snakebite Project published <a href="http://www.mja.com.au">today</a> in the Medical Journal of Australia.</p>
<p>Although many people go to hospital with a suspected snakebite, many do not turn out to have envenomation (when venom enters the bloodstream) after all.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/12675626">In more than 90% of cases</a> people are bitten by a non-venomous snake, venom is not injected when the snake bites (known as a “dry bite”) or are not even bitten by a snake (known as a “stick” bite).</p>
<p>Our analysis of about 1,548 cases of suspected snakebites from all around Australia, showed there were on average just under 100 snake envenomations a year, and about two deaths a year. </p>
<p>The most common snakebites were from brown snakes, then tiger snakes and red-bellied black snakes. Brown snakes were responsible for 40% of envenomations. Collapsing, then having a heart attack out of hospital was the most common cause of death (ten out of 23), and most deaths were from brown snakes.</p>
<h2>What happens after a snakebite and how can CPR help?</h2>
<p>Venom from a snakebite travels via the <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/lymphatic-system">lymphatic system</a> to the bloodstream. There, it circulates to nerves and muscles where it can cause paralysis and muscle damage. In the blood itself, the venom destroys clotting factors, which makes the blood unable to clot, increasing the risk of bleeding. </p>
<p>In the most severe cases, most commonly in brown snake bites, someone can collapse because they have low blood pressure (we don’t know for certain what causes the low blood pressure). In this situation, insufficient blood is pumped around the body for the brain and other vital organs. </p>
<p>Clearly the accurate diagnosis of snake envenomation and the timely administration of antivenom are essential to treating snakebites in hospital.</p>
<p>But when people collapse, CPR will keep the blood circulating to the vital organs – and is life-saving – however inexpertly a bystander performs it.</p>
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<a href="https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&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">If a snakebite victim collapses, CPR is vital to keep the blood circulating to the vital organs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/657810997?src=gSIYdvpfkdaGnxGsgex89A-1-50&size=medium_jpg">from www.shutterstock.com</a></span>
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<p>In other words, we found basic first aid <em>before</em> people reached hospital, of which bystander CPR is one, may be more important than any changes in how people are treated <em>in</em> hospital to improve people’s chance of survival. People who survived after collapsing received CPR on average within one minute of being bitten compared with 15 minutes for those who died.</p>
<p>Our study also showed that in most cases, people used <a href="https://theconversation.com/explainer-what-should-you-do-if-youre-bitten-by-a-snake-34238">other first-aid measures</a> (pressure bandages and immobilising both the limb and the patient). These aim to prevent the venom travelling from the bite site, via the lymphatic system, to the bloodstream.</p>
<h2>Antivenom saves lives for those who need it</h2>
<p>Our study confirmed the role of antivenom in treating snakebites and the need for it to be administered before irreversible damage is done to the nervous system and paralysis occurs. </p>
<p>However, we found one in four patients given antivenom had an allergic reaction to it and about one in 20 have severe anaphylaxis requiring urgent treatment. </p>
<p>So it is essential only patients with snake envenomation, and not just a suspected snakebite, are treated with antivenom. We found 49 patients (around 6%) were given antivenom unnecessarily, out of the total 755 patients who received it.</p>
<h2>What needs to change?</h2>
<p>We know <a href="https://www.ncbi.nlm.nih.gov/pubmed/27903075">the earlier</a> someone receives antivenom <a href="https://www.ncbi.nlm.nih.gov/pubmed/21143062">the better</a>. Yet our study found that the time from being bitten until receiving antivenom had not improved over the study period.</p>
<p>So we need to find ways to make sure patients get antivenom as early as possible. This requires laboratory tests that can identify patients with snake envenomation in the first couple of hours after the bite. </p>
<p>It is also essential anyone bitten by a snake or suspected to be bitten by a snake seeks immediate medical attention and goes to hospital by ambulance.</p>
<p>But the best thing is to avoid being bitten in the first place:</p>
<ul>
<li><strong>avoid snakes</strong>, difficult if you’re a snake handler (up to 11% of cases in our study), and take care if trying to catch or kill a snake (which led to a bite in 14% of cases)</li>
<li><strong>wear long pants and sturdy shoes</strong> when walking in the bush or rural areas (47% of snakebites were when people didn’t know one was nearby) or when gardening (8% of cases)</li>
<li><strong>be alert inside too</strong>, with 31% of snakebites near houses and 14% in buildings.</li>
</ul>
<p>Our study confirms Australian snakes <a href="https://theconversation.com/a-venomous-paradox-how-deadly-are-australias-snakes-79433">don’t really deserve</a> their deadly reputation, <a href="https://theconversation.com/yes-australian-snakes-will-definitely-kill-you-if-youre-a-mouse-51809">unless you’re a mouse</a>. But if you are bitten, or think you have been, hospital is still the best place for you.</p><img src="https://counter.theconversation.com/content/81614/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Geoff Isbister receives funding from the National Health and Medical Research Council. </span></em></p>
Don’t hold back. Performing CPR on a snakebite victim who has collapsed can save their life, however imperfect your technique.
Geoff Isbister, Director, Clinical Toxicology Research Group, University of Newcastle
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/81256
2017-07-23T20:10:08Z
2017-07-23T20:10:08Z
Women now have clearer statistics on whether IVF is likely to work
<figure><img src="https://images.theconversation.com/files/179120/original/file-20170721-1588-1pz6yr5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many couples undergo multiple rounds of IVF. Our new stats on the chances of a successful pregnancy reflect that.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/594690629?src=EJgxFDYkFWbBvXcHxn-NRQ-1-59&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Australian women considering IVF will now, for the first time, have a more meaningful idea of their chances of having a baby, whether it’s their first or subsequent round of IVF. </p>
<p>Overall, for women starting IVF, 33% have a baby as a result of their first cycle, increasing to 54-77% by the eighth cycle.</p>
<p>Our research, published <a href="http://www.mja.com.au">today</a>, reports the probability of IVF success from a patient’s perspective after repeated cycles, rather than how it is usually reported, for <a href="https://npesu.unsw.edu.au/sites/default/files/npesu/data_collection/Assisted%20reproductive%20technology%20in%20Australia%20and%20New%20Zealand%202014_0.pdf">each cycle</a>.</p>
<p>This will help women of all ages to make informed decisions, with their fertility doctor, about whether to start IVF, or if they have already started, whether to proceed to their next cycle.</p>
<p>Unlike previously reported statistics, our data better reflects that IVF can include both fresh and frozen embryos, and that many women undergo multiple IVF cycles over a course of treatment.</p>
<h2>Infertility affects about one in six couples</h2>
<p>While estimates vary, <a href="http://www.icmartivf.org/Glossary_2009_FertilSteril.pdf">infertility</a> affects about <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2009.00408.x/epdf">one in six couples</a>, causing significant personal suffering to as many as 186 million people <a href="https://academic.oup.com/humupd/article/21/4/411/683746/Infertility-around-the-globe-new-thinking-on">around the globe</a>.</p>
<p>Assisted reproductive technologies – more generally referred to as in-vitro fertilisation or IVF – have revolutionised how we treat infertility. Now, more than <a href="https://npesu.unsw.edu.au/sites/default/files/npesu/data_collection/Assisted%20reproductive%20technology%20in%20Australia%20and%20New%20Zealand%202014_0.pdf">70,000 treatment cycles</a> are performed in Australia and New Zealand each year.</p>
<p>A typical IVF cycle, involves stimulating a woman’s ovaries to produce multiple eggs, retrieving those eggs, which are then fertilised in the laboratory to create embyros. These embryos grow for two to six days before one, or occasionally two, fresh embryos are transferred to a woman’s womb.</p>
<p>Extra embryos are frozen and if necessary thawed and transferred in a subsequent cycle or cycles (known as “frozen/thaw” cycles).</p>
<h2>A complete IVF treatment cycle</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/179119/original/file-20170721-3327-110ctbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/179119/original/file-20170721-3327-110ctbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179119/original/file-20170721-3327-110ctbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179119/original/file-20170721-3327-110ctbs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179119/original/file-20170721-3327-110ctbs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179119/original/file-20170721-3327-110ctbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179119/original/file-20170721-3327-110ctbs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179119/original/file-20170721-3327-110ctbs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&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 new statistics reflect how IVF is conducted today.</span>
<span class="attribution"><span class="source">Chambers GM, et al. Med J Aust 2017; 207(3):114-118 © Copyright 2017 The Medical Journal of Australia – reproduced with permission.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>What we did</h2>
<p>We used data from the <a href="https://npesu.unsw.edu.au/data-collection/australian-new-zealand-assisted-reproduction-database-anzard">Australian and New Zealand Assisted Reproductive Technology Database</a>, which contains information on all IVF cycles performed in Australia and New Zealand.</p>
<p>We looked at data from 56,652 women starting IVF treatment for the first time who underwent 120,930 IVF cycles between 2009 and 2014. We excluded women who used donated eggs or embryos.</p>
<p>We linked all fresh and frozen/thaw IVF treatments to the initial episode of ovarian stimulation for each individual woman, which allowed us to report by “complete” treatment cycles.</p>
<p>We reported two measures: the live-birth rate for each consecutive IVF cycle (cycle-specific rate), and the <em>cumulative</em> live-birth rate for each consecutive IVF cycle. The latter took into account all previous cycles performed (for up to eight complete cycles), taking into account the age of the woman when she started treatment.</p>
<h2>What we took into account</h2>
<p>Around 30% of women drop out of treatment after an unsuccessful IVF cycle, mainly because of the <a href="https://academic.oup.com/humupd/article/18/6/652/628767/Why-do-patients-discontinue-fertility-treatment-A">physical and emotional demands of treatment, a poor chance of success with continued treatment</a> and the cost, which is around <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-12-142">A$2000-4000 per cycle</a> in Australia. </p>
<p>So we calculated two measures of the cumulative live-birth rate based on assumptions around the chance of future success for women who dropped out of treatment – a conservative and an optimal rate.</p>
<p>The conservative cumulative live-birth rate assumed these women would not have achieved a live birth if they continued with treatment. The optimal cumulative live-birth rate assumed these women would have had the same chance of a live birth as those who did continue with treatment. </p>
<p>The range between the conservative and optimal cumulative live-birth rates gives a reasonable appraisal of the probability of a women achieving her first live birth.</p>
<h2>What we found</h2>
<p>Overall, for women starting IVF, 33% had a baby as a result of their first cycle, increasing to 54-77% by the eighth cycle.</p>
<p>The cycle-specific rate varied by the age at which women started treatment and the number of previous cycles performed, but the cumulative live-birth rate continued to rise with repeated cycles.</p>
<p>Women who started IVF before they turned 35 had the highest success rates. For example, women under 30 had a 44% chance of a live birth in their first cycle, and a cumulative live-birth rate of between 69% (conservative) and 91% (optimal) after six cycles; women aged 30-34 had only marginally lower rates than these.</p>
<p>Women aged 40-44 had an 11% chance of a live birth in their first cycle, and a cumulative live-birth rate of between 21-34% after six cycles.</p>
<h2>The implications</h2>
<p>We hope providing success rates in this more meaningful way is reassuring for women and couples. Looking at the success rate over a course of treatment, most women will take home at least one baby. In fact, two out of three women who start IVF before they are 35 will, as a conservative estimate, take home a baby after three cycles.</p>
<p>However, these are population estimates and every couple is different. Our analysis does not take account of individual factors that affect the chance of IVF success. These <a href="https://academic.oup.com/humupd/article/16/6/577/740269/Predictive-factors-in-in-vitro-fertilization-IVF-a">include</a>, how long the couple has had trouble conceiving, the level of body fat (measured as body-mass index or BMI), and ovarian reserve (a measure of the reproductive potential of the ovaries).</p>
<p>Whether women should start IVF treatment or continue it should ultimately be a decision for the fertility doctor and patient, taking into account all medical and non-medical factors.</p>
<p>This type of analysis can also be used to inform policy on IVF treatments as it allows policymakers to look at the success of IVF over a full course of treatment, better reflecting clinical practice than success rates with individual cycles.</p><img src="https://counter.theconversation.com/content/81256/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Georgina Chambers is employed by the University of New South Wales (UNSW Sydney) and is Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW Sydney. The Fertility Society of Australia funds the NPESU to manage the Australian and New Zealand Assisted Reproductive Technology Database (ANZARD). She has received an institutional grant unrelated to this study from the Australian Research Council (ARC), for which Virtus Health, a publically listed IVF company, was the partner organisation (2010-2013). She also holds two current NHMRC Project Grants related to fertility treatment and outcomes. She is an ordinary member of the Fertility Society of Australia.
</span></em></p>
Women will now be better informed when it comes to deciding whether it’s worth undergoing another round of IVF.
Georgina Chambers, Associate Professor, Director of the National Perinatal Epidemiology and Statistics Unit, UNSW Sydney
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/78921
2017-06-09T05:01:06Z
2017-06-09T05:01:06Z
We know too much sugar is bad for us, but do different sugars have different health effects?
<figure><img src="https://images.theconversation.com/files/172880/original/file-20170608-29563-1dmhqa8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The type of sugar in popular soft drinks varies from country to country even if the brand name is the same.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Our recent article published in the <a href="https://www.mja.com.au/journal/2017/206/10/sugar-content-soft-drinks-australia-europe-and-united-states">Medical Journal of Australia</a> found that Australian and European soft drinks contained higher concentrations of glucose, and less fructose, than soft drinks in the United States. The total glucose concentration of Australian soft drinks was on average 22% higher than in US formulations.</p>
<p>We compared the composition of sugars in four popular, globally marketed brands – Coca-Cola, Fanta, Sprite and Pepsi – using samples from Australia, Europe and the US. While the total sugar concentration did not differ significantly between brands or geographical location, there were differences between countries in the concentrations of particular sugars, even when drinks were marketed under the same trade name.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=913&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=913&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=913&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1148&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1148&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172874/original/file-20170608-29563-pnrhx8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1148&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sucrose is made up of one glucose molecule and one fructose molecule.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Whether these differences have distinct effects on long-term health is currently unclear. Certainly, over-consumption of either glucose or fructose will contribute to <a href="http://ajcn.nutrition.org/content/98/4/1084.full.pdf">weight gain</a>, which is associated with a host of health conditions such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/15328324">type 2 diabetes</a> and <a href="http://circ.ahajournals.org/content/121/11/1356">heart disease</a>. And because the body metabolises glucose and fructose in different ways, their effects may differ.</p>
<h2>Sucrose, glucose and fructose</h2>
<p>Soft drinks, as they are referred to in Australia, or “sodas” in the US and “fizzy drinks” in the UK, are non-alcoholic, carbonated, sugar-sweetened beverages. <a href="http://www.coca-colacompany.com/cs/tccc-yir2012/operating_groups.html">Australia ranks seventh out of the top ten countries</a> for soft drink sales per capita.</p>
<p>Sugars are the chief ingredient in soft drinks and include glucose, fructose and sucrose. The source of sugars in popular soft drinks varies between global regions. This is because sugars are sourced from different crops in different areas of the world. </p>
<p>Soft drinks in Australia are primarily sweetened with sucrose from sugar cane. Sucrose, often referred to as “table sugar”, is composed of one glucose molecule and one fructose molecule joined by chemical bonds. This means equal amounts of glucose and fructose are released into the bloodstream when sucrose is digested.</p>
<p>Overseas, soft drinks are sweetened with sucrose-rich sugar beet (Europe) or high-fructose corn syrup (US). High-fructose corn syrup is also made up of glucose and fructose, but contains a higher fructose-to-glucose ratio than sucrose.</p>
<h2>Do they have different health impacts?</h2>
<p>Fructose over-consumption is <a href="https://www.ncbi.nlm.nih.gov/pubmed/26055949">known to contribute</a> to <a href="http://christinecronau.com/wp-content/uploads/2011/10/nrgastro.2010.41.pdf">fatty liver disease</a>. Fatty liver disease affects <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/liver-fatty-liver-disease">about one in ten people</a> in the West. Non-alcoholic fatty liver disease is the leading cause of liver disease.</p>
<p>Some researchers have suggested too much fructose in the diet can harm the liver in a similar fashion to alcohol. However, this concern is related to <em>added</em> fructose in the diet, not natural sources. Natural sources of fructose, such as fruit, honey and some vegetables, are not generally over-consumed and provide other important nutrients, such as dietary fibre and vitamins. So, fruit does not generally pose a risk for fatty liver disease.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/173054/original/file-20170609-1721-1lht3p3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Natural sources of fructose, such as fruit, are generally not over-consumed.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>High glucose consumption rapidly elevates blood glucose and insulin. This may affect <a href="https://www.ncbi.nlm.nih.gov/pubmed/15451897">brain function</a>, including <a href="https://lipidworld.biomedcentral.com/articles/10.1186/1476-511X-13-195">mood and fatigue</a>. Because high blood glucose is <a href="https://www.ncbi.nlm.nih.gov/pubmed/16919548">linked to diabetes</a>, consumption of high-glucose drinks may also raise the risk of diabetes and cardiovascular (heart) disease. </p>
<p>All soft drinks are considered energy-dense, nutrient-poor and bad for health. However, one of the inherent challenges in the field has been an inability to determine the actual dose of glucose or fructose in these drinks. </p>
<p>Studies that follow people over time, and link soft drink consumption to adverse health effects, are complicated by not knowing whether individuals in these studies are simply eating too many energy-rich foods, and whether soft drink consumption coincides with other poor health behaviours. So, further research is required to determine whether soft drinks containing different concentrations of fructose and glucose are associated with differing health risks. </p>
<h2>Soft drink policies</h2>
<p>There is still much to learn about the differences in composition of sugars and patterns of soft drink intake between countries. A small number of countries, including <a href="https://www.theguardian.com/society/2017/feb/22/mexico-sugar-tax-lower-consumption-second-year-running">Mexico</a> and <a href="http://www.bbc.com/news/world-europe-38767941">France</a>, have already implemented taxation on soft drinks. It remains to be determined whether these actions reduce the incidence of obesity, diabetes and heart diseases.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/173056/original/file-20170609-32402-pssvkt.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">Over-consumption of any kind of sugar leads to weight gain.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Australian policymakers are yet to take action to reduce soft drink consumption. A range of intervention strategies have been considered, including banning sugary soft drinks in schools and hospitals, taxation, and regulating beverage marketing. </p>
<p>The <a href="http://www.abc.net.au/news/2017-06-08/sugary-drinks-to-be-phased-out-of-nsw-health-facilities/8599820">New South Wales Health Department</a> has just announced sugary drinks will be phased out of vending machines, cafes and catering services in the state’s health facilities by December. This is a great move. Importantly, we must continue to increase public awareness of the adverse health effects of sugary soft drinks.</p><img src="https://counter.theconversation.com/content/78921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bronwyn Kingwell receives funding from the National Health and Medical Research Council of Australia.</span></em></p><p class="fine-print"><em><span>Pia Varsamis and Robyn Larsen 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>
A recent study found Australian soft drinks had higher concentrations of glucose than US soft drinks, which had more fructose. Does this mean Australian drinks are worse for health than US drinks?
Bronwyn Kingwell, Head, Metabolic and Vascular Physiology NHMRC, Senior Principal Research Fellow, Baker Heart and Diabetes Institute
Pia Varsamis, PhD Student, Metabolic and Vascular Physiology, Baker Heart and Diabetes Institute
Robyn Larsen, Postdoctural Research Fellow in Nutritional Biochemistry, Baker Heart and Diabetes Institute
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/78535
2017-06-04T20:25:05Z
2017-06-04T20:25:05Z
How can Australia have too many doctors, but still not meet patient needs?
<figure><img src="https://images.theconversation.com/files/171944/original/file-20170602-25664-qdxhuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If you live in a rural area, you would never think Australia had too many doctors.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The statement “we have plenty of doctors in Australia” would probably not pass the pub test. Especially if the pub was in a regional city, a remote town or a less-than-leafy suburb. But it is true all the same - statistically at least. </p>
<p>With <a href="http://www.oecd.org/health/health-data.htm">3.5 practising doctors</a> for every 1,000 people in 2014 (<a href="http://www.aihw.gov.au/workforce/medical/how-many-medical-practitioners/">4.4 per 1,000 in major cities</a>) we’ve never had so many. In 2003, there were 2.6 doctors for every <a href="http://www.oecd.org/health/health-data.htm">1,000 people in Australia</a>, which is closer to the proportion in similar countries now, such as New Zealand (2.8), the UK (2.8), Canada (2.6) and the USA (2.6).</p>
<p>Yet at 2.6 per 1,000 was when <a href="https://www.mja.com.au/journal/2003/179/4/medical-workforce-issues-australia-tomorrow-s-doctors-too-few-too-far">we decided we were “short”</a> and went on to <a href="https://www.mja.com.au/">double the number</a> of medical schools and almost triple the number of medical graduates in a little over a decade. </p>
<p>And then there’s this question: if we are now so flush with medicos, why do we still need to import so many from overseas? To fill job vacancies, the Australian government <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/work-pubs-mtrp">granted 2,820 temporary work visas</a> to overseas-trained doctors in 2014-15. In the same year, Australian <a href="http://www.medicaldeans.org.au/statistics/annualtables/">medical schools graduated</a> another 3,547.</p>
<p>This heroic level of doctor production and importation is right up there internationally. Among wealthy nations, Australia is vying for the top spot, with only <a href="http://www.oecd.org/health/health-data.htm">Denmark and Ireland</a> in the same league of doctor-production for population.</p>
<p>So why do we have too many doctors, but think we have too few?</p>
<h2>Our approach to medical training</h2>
<p>In a <a href="https://www.mja.com.au/">Medical Journal of Australia</a> editorial published today, we examine the question of “work readiness” in our new medical graduates from arguably the most important perspective: what the community needs from future doctors.</p>
<p>To what extent is our medical training system producing doctors who will be providing the high quality, person centred, affordable health services we need, given we are an ageing population living with higher levels of chronic and complex health conditions?</p>
<p>There have been arguably three problems with the Australian approach to the medical workforce to date. First, we didn’t finish the job of production; second, we’ve allowed too much medical specialisation in major cities; and third, our models of health care and the ways we pay for it are out of step with where community needs are heading.</p>
<h2>1. Production</h2>
<p>Back in the early 2000s, the biggest issue relating to the <a href="http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BN/%7E/link.aspx?_id=4FB58821DB2B49F58743E7802D1C4ED3&_z=z">training of Australia’s medical workforce</a> was a shortage of doctors in regional and remote areas. So, in addition to boosting medical student numbers overall, we set up rural clinical schools and regional medical schools, and increased admission of students who were already residents of rural areas. </p>
<p>While <a href="http://www.rrh.org.au/publishedarticles/article_print_2991.pdf">results of these policies</a> have been positive in terms of graduate rural career intentions and rural destinations, the job was really only half done. What we didn’t do is reform the training that goes on after medical school. </p>
<p>That involves internships and training for one of 64 specialty fellowships, including general practice. Because of that, too many of our medical graduates are now piling up in capital city teaching hospitals, locked in a <a href="https://ama.com.au/ausmed/trainee-doctors-face-uncertain-future">fierce competition</a> for ever-more sub-specialised training jobs. </p>
<p>Meanwhile regional Australia remains hooked on a temporary fix of importing doctors from overseas. Hence the <a href="http://www.abc.net.au/news/2017-04-13/government-bid-to-keep-medical-specialists-in-rural-areas/8440474">recently announced</a> funding for 26 new regional training hubs. The aim is to “flip” the medical training model, so the main training is offered regionally with a city rotation as required.</p>
<h2>2. Excessive specialisation</h2>
<p>There’s no question we need a reasonable number of doctors who are experts in a narrow field. However, <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/F3F2910B39DF55FDCA257D94007862F9/%24File/AFHW%20-%20Doctors%20report.pdf">there’s now an imbalance</a> between an inadequate number of medical generalists and excessive numbers of specialists in every major medical field. </p>
<p>Regional Australia in particular needs more generalists; that is rural generalist GPs, general surgeons, general physicians and the like.</p>
<h2>3. Financing and models of care</h2>
<p>Health expenditure is driven by three main factors: growth in population, providing more care for each patient and the increase in the proportion of older people with increased complex care needs. </p>
<p>Improvements in health-care technology means we can diagnose illness more accurately, less invasively and earlier, and we have more effective treatments. </p>
<p>However, in a system that pays on the basis of every service provided (regardless of need) there is also a risk of provider-induced demand. This can lead to <a href="https://www.safetyandquality.gov.au/atlas/">inappropriate medical care</a>, with examples in unwarranted eye, knee and back surgery, imaging, colonoscopy, and medication for depression and other conditions. </p>
<p>An undersupply of doctors is associated with lower rates of health-care use, whereas oversupply or mis-distribution can <a href="http://www.pc.gov.au/research/supporting/supplier-induced-medical-demand">lead to higher rates</a> of inappropriate care. Balancing the distribution of doctors according to need has important consequences for health-care costs.</p>
<h2>Time for action</h2>
<p>Make no mistake, Australia’s current health system is good by world standards. But the headwinds are building. The population is ageing, we’ve got more people with chronic and complex health-care needs, and the costs of new medicines and technologies continue to escalate. </p>
<p>Having injected a massive boost of doctors into a fee-paying healthcare system without regard to population need, workforce mix, geographic location, health-care models or financing reform, we have put the future at risk.</p>
<p>Let’s not let this bold experiment fail for want of follow-through. We need more urgency in providing the incentives and training opportunities to get our growing junior medical workforce into the specialties and areas that are underserved. </p>
<p>We have to stop allowing medical specialty training to be driven by the work rostering requirements of metropolitan hospitals. We must increase the number of specialist training positions based in regional centres. </p>
<p>And we especially need to expand the number of broadly-skilled <a href="http://www.abc.net.au/news/rural/2016-06-24/rural-health-election-promises/7540768">rural generalists</a> and get serious about efficient, team based, health-care models. This requires cooperation by all governments, medical schools, specialist colleges and the profession - and the time to act is now.</p><img src="https://counter.theconversation.com/content/78535/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Murray is Dean of a medical school and President of the peak body representing Australian and New Zealand medical schools. He is a past President of the Australian College of Rural and Remote Medicine.</span></em></p><p class="fine-print"><em><span>Andrew Wilson is a professor the University of Sydney Medical School. In 2015 he conducted a national review of medical internships for the Australian Health Ministers Advisory Committee. He is chair of the Pharmacuetical Benefits Advisory Committee. </span></em></p>
Australia has more doctors per population than most comparable countries, yet many living in rural and remote areas don’t receive the care they need. Changing the way we train doctors will fix this.
Richard Murray, Dean of Medicine & Dentistry, James Cook University
Andrew Wilson, Co-Director, Menzies Centre for Health Policy, University of Sydney
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/68225
2016-11-07T23:40:54Z
2016-11-07T23:40:54Z
Australian law needs a refresher on the science of HIV transmission
<figure><img src="https://images.theconversation.com/files/144765/original/image-20161107-4694-ry4k7e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Recent improvements in medical management of HIV infection are not well understood in the legal sector. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-309710009/stock-photo-image-concept-with-the-result-of-the-hiv-test.html?src=jsZ4xp3vaVRNZ8nFK-ccCw-1-3">www.shutterstock.com </a></span></figcaption></figure><p>Being diagnosed with HIV is a confronting experience. </p>
<p>However the stigma associated with HIV infection – a hangover from its social and medical history – is responsible for an exaggerated perception of transmission risk through sex, and the harms of living with HIV infection. </p>
<p>In our <a href="https://www.mja.com.au/journal/2016/205/9/sexual-transmission-hiv-and-law-australian-medical-consensus-statement">consensus statement published this week in the Medical Journal of Australia</a>, we detail the latest evidence on HIV transmission risk and recent advances in HIV prevention and treatment.</p>
<p>We propose that legal cases relating to HIV transmission should be considered in light of such evidence, and that alternatives to prosecution such as the public health management approach are often appropriate. </p>
<h2>HIV infection no longer a death sentence</h2>
<p>There have been many advances in HIV diagnosis, prevention and treatment since the identification of the first AIDS cases in the early 1980s. </p>
<p>In the initial days of the AIDS epidemic, patients would, after a number of years, develop serious infections and other illnesses due to their immune deficiency, usually resulting in death. When the first treatments became available, they bought time but often at the cost of serious medication side-effects, and complicated treatment regimens involving many tablets each day.</p>
<p>While it remains a serious infection, HIV is now a disease that can be effectively managed through medical treatment, regular health monitoring and healthy lifestyle. For many people with HIV, treatment involves taking only a single pill each day. Those taking antiviral therapy can expect to live a normal life, in good health, with a life expectancy similar to their HIV-negative counterparts. </p>
<p>These great improvements, familiar to those working in health, are not as well understood in the legal sector. </p>
<h2>Prosecutions for HIV infection</h2>
<p>Unlike other diseases, HIV has a long and uneasy relationship with criminal law. In the early years of the epidemic, the stigma around HIV, the fact that it was almost always fatal, and unfounded fears about its potential use as a weapon led to the criminalisation of HIV transmission and exposure. </p>
<p>Since 1991, there have been more than 38 criminal prosecutions for HIV transmission or exposure during sex in Australia. Despite the significant improvements in health and longevity of people living with HIV, the rate of criminal prosecutions has not decreased. </p>
<p>The courts have shown an understanding of the effectiveness of condoms: no one who has used condoms has been convicted. However, people continue to be prosecuted, including for “exposing” others to the risk of HIV infection, even in the absence of actual transmission. This occurs despite the relatively low per-act risk of HIV transmission and the fact that for most people the harms of HIV infection are far less serious than they once were.</p>
<h2>New approaches to limit HIV transmission</h2>
<p>HIV is actually difficult to transmit. <a href="https://www.mja.com.au/journal/2016/205/9/sexual-transmission-hiv-and-law-australian-medical-consensus-statement">Sexual transmission occurs</a> during only about 1% (or less) of penetrative sexual encounters, even when a condom is not used and the HIV-positive person is not on treatment.</p>
<p>HIV prevention messaging in the early days of the epidemic focused on sexual abstinence and condom use. However, prevention messaging is now more nuanced and has expanded to include new ways of reducing HIV transmission risk. A not insignificant number of people at risk of HIV infection choose to have sex without using a condom, which is why developing alternative methods of HIV prevention have been prioritised in recent years. Such research has delivered game-changing results: “treatment as prevention” and “pre-exposure prophylaxis”. </p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1105243">Treatment as prevention</a> refers to the greatly reduced risk of HIV transmission as a result of HIV-positive people taking antiviral treatment, which suppresses replication of the virus in the infected person’s body. When a person with HIV has a very low viral load (unmeasurable levels of HIV in the blood), the risk of sexual transmission becomes <a href="https://www.ncbi.nlm.nih.gov/pubmed/27404185">very low</a>. In fact, there has never been a documented case of HIV transmission from a person with an undetectable viral load.</p>
<p><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1011205">Pre-exposure prophylaxis</a> describes the use of antiviral medication by an HIV-negative person as a way of preventing HIV infection. Pre-exposure prophylaxis is a <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1506273">very effective means</a> of preventing HIV transmission, with only isolated cases of transmission identified among people applying this approach. This groundbreaking new strategy is available in Australia via limited pilot programs, and is being evaluated for Pharmaceutical Benefits Scheme listing.</p>
<h2>How the law treats people with HIV</h2>
<p>Criminal laws relating to HIV transmission and exposure vary from state to state, but a common factor is that people with HIV are expected to take “reasonable precautions” to prevent transmission. Condom use has long been accepted as meeting this threshold. </p>
<p>The evidence now supports acceptance of treatment as prevention (for the positive partner) and/or pre-exposure prophylaxis (for the negative partner) as meeting the same standard. And the limited harms of HIV infection as a consequence of acts involving low to negligible risk of transmission mean HIV cases generally do not belong in criminal courts.</p>
<p>There is an alternative. All states and territories have health protocols for managing allegations of risky behaviour. This public health approach – involving education, case management and, where required, behavioural orders and isolation – is a much more effective way of protecting public health.</p>
<p>As researchers and clinicians, we are intimately aware of the impact an HIV diagnosis can have. We have all supported patients coming to terms with an HIV diagnosis; many of us having had the painful task of delivering that devastating news. </p>
<p>The criminal law has a role to play, particularly should there ever be a case where a person deliberately transmits HIV. </p>
<p>However, with the advances of recent years in both prevention and treatment, authorities need to be more familiar with latest scientific and medical evidence, and consider alternatives to prosecution such as the public health management approach.</p>
<hr>
<p><em>Elizabeth Crock, <a href="http://www.ashm.org.au/">Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine</a>, co-authored the <a href="https://www.mja.com.au/journal/2016/205/9/sexual-transmission-hiv-and-law-australian-medical-consensus-statement">consensus statement</a>.</em></p><img src="https://counter.theconversation.com/content/68225/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Grulich has given expert evidence in legal cases involving HIV transmission. </span></em></p><p class="fine-print"><em><span>Nothing to disclose.</span></em></p><p class="fine-print"><em><span>David Cooper, David Nolan, Levinia Crooks, Mark Boyd, Michelle Giles, and Sharon Lewin 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>
HIV diagnosis is devastating for patients and their families. But the infection is no longer a death sentence, and should not be prosecuted as such say experts.
Mark Boyd, Professor, Chair of Medicine, University of Adelaide
Andrew Grulich, Professor and Program Head, UNSW Sydney
David Cooper, Scientia Professor of Medicine and Director, Kirby Institute, UNSW Sydney
David Nolan, Adjunct Professor, Institute for Immunology and Infectious Disease , Murdoch University
Levinia Crooks, Adjunct Associate Professor, La Trobe University
Michelle Giles, Associate Professor, Department of infectious diseases and Dept of Obstetrics and gynaecology, Monash University
Sharon Lewin, Director, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital and Consultant Physician, Department of Infectious Diseases, Alfred Hospital and Monash University, The Peter Doherty Institute for Infection and Immunity
Trent Yarwood, Infectious Diseases Physician, Senior Lecturer, James Cook University and, The University of Queensland
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/60322
2016-06-08T06:56:05Z
2016-06-08T06:56:05Z
Weekly Dose: methotrexate, the anti-inflammatory drug that can kill if taken daily
<figure><img src="https://images.theconversation.com/files/125468/original/image-20160607-31957-15rin20.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Methotrexate is used for arthritis, psoriasis, inflammatory bowel disease and cancer.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/neofedex/3447536476/in/photolist-6fDwu5-8P3fWH-aVhDDp-aVhDLc-aVhDGK-7pWQhW-aVhDPr-5rwZS-buU4UA-z5R6Uj-yqrh5Q">FedEx/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Methotrexate, sold under the brand name <a href="http://rheumatology.org.au/downloads/MTX280509.pdf">Methoblastin</a>, is an antifolate drug, which means it inhibits the activation of folic acid in the body. </p>
<p>It is taken once per week to treat a range of conditions. These include rheumatoid arthritis, the skin disorder psoriasis and inflammatory bowel disease. This weekly therapy is known as “low-dose methotrexate”.</p>
<p>Methotrexate was first developed in the 1950s as a cancer treatment and is still used for this in higher doses.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/125655/original/image-20160608-3506-15u8yne.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/125655/original/image-20160608-3506-15u8yne.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/125655/original/image-20160608-3506-15u8yne.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=766&fit=crop&dpr=1 600w, https://images.theconversation.com/files/125655/original/image-20160608-3506-15u8yne.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=766&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/125655/original/image-20160608-3506-15u8yne.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=766&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/125655/original/image-20160608-3506-15u8yne.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=963&fit=crop&dpr=1 754w, https://images.theconversation.com/files/125655/original/image-20160608-3506-15u8yne.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=963&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/125655/original/image-20160608-3506-15u8yne.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=963&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
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<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>How it works</h2>
<p>The methotrexate drug molecule is structurally similar to folic acid, which is important for making new cells. It inhibits the enzyme (dihydrofolate reductase) that turns folic acid into its active form. This reduces cell growth and is why methotrexate is used to treat some cancers.</p>
<p>The way methotrexate works for inflammatory conditions is less clear. But we know it has a <a href="https://www.ncbi.nlm.nih.gov/pubmed/17922664">range of effects</a> on DNA synthesis and immune signalling, which are thought to reduce the inflammation. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/125461/original/image-20160607-31962-1i1c9of.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/125461/original/image-20160607-31962-1i1c9of.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=896&fit=crop&dpr=1 600w, https://images.theconversation.com/files/125461/original/image-20160607-31962-1i1c9of.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=896&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/125461/original/image-20160607-31962-1i1c9of.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=896&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/125461/original/image-20160607-31962-1i1c9of.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1126&fit=crop&dpr=1 754w, https://images.theconversation.com/files/125461/original/image-20160607-31962-1i1c9of.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1126&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/125461/original/image-20160607-31962-1i1c9of.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1126&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Methotrexate can be used to treat autoimmune diseases such as psoriasis.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/mysiann/1638705074/in/photolist-3uNMVL-fCxFPs-fCg7wp-fCxGVY-fCg6mt-Kg165-nqGVx1-9aMqX4-3G3t78-3RtjQ9-6cNDrk-k8tv1T-57dTfe-fFMMaf-bzzU8S-bzzTZS-ohkePF-6cNDS2-gxHWXF-5pk8oV-5TP6yM-57FvDg-EHL7Bb-5ngmns-omBVEq-bTwp2k-dkaSyz-EUeBoZ-DWRzTB-58GiRZ-5TTDQY-bxcFC-5TTznf-dkaSKn-dkaSrr-e3dJ6L-dkaU4m-5TP9pV-5TTHQ5-dkaSNV-5TP1si-5TPiUV-5bkpSE-5h88GN-5TP8Xc-6if3u4-dkaTKm-dkaTT1-PmDER-oSG5j2">Mysi Ann/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>In rheumatoid arthritis, methotrexate reduces inflammation and damage to joints. Rather than just masking pain, methotrexate reduces it by reducing severity of the disease. For this reason, it’s known as a disease-modifying anti-rheumatic drug (DMARD).</p>
<h2>History</h2>
<p>Methotrexate was <a href="https://books.google.com.au/books/about/Methotrexate.html?id=VCAFHzHAotsC&redir_esc=y">developed in the 1950s</a> when researchers discovered that increased folic acid worsened leukaemia and that dietary deficiency of folic acid reduced the cancer cell count. </p>
<p>This inspired scientists to develop drugs structurally similar to folic acid that bound to its receptors in the body and inhibited its effects. </p>
<p>Methotrexate was synthesised in the 1950s and was shown to be effective for leukaemia and several types of solid tumours. Prior to this discovery, cancer treatments had been limited to surgery and radiotherapy. </p>
<h2>What it’s used for</h2>
<p>Methotrexate is still used intravenously in high doses to treat cancer. But its most common use now is in rheumatoid arthritis and other inflammatory conditions. Low-dose methotrexate (taken once a week) was shown to be effective in rheumatoid arthritis in <a href="http://www.nejm.org/doi/full/10.1056/NEJM198503283121303">1985</a>. It is now a drug of first choice for rheumatoid arthritis.</p>
<p>Methotrexate is also used as an intra-muscular injection to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285146/">terminate ectopic pregnancy</a>, as an <a href="http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionc/9/c9.4.2.pdf">alternative to surgery</a>. </p>
<h2>Use and cost</h2>
<p>There were <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">260,000 scripts</a> for methotrexate tablets dispensed on the Pharmaceutical Benefits Scheme (PBS) in 2015. </p>
<p>Methotrexate costs between A$0.73 and $1.87 per tablet on the <a href="http://www.pbs.gov.au/medicine/item/1622J-1623K-1818Q-2272N-2395C-2396D-4502Y-4512L-7250N-7251P">PBS</a>. Since it is taken only once per week, it is a very low-cost treatment. </p>
<h2>How it makes you feel</h2>
<p>The correct dose of methotrexate (commonly between 7.5mg to 25mg per week) will reduce inflammation and alleviate the condition it’s prescribed for, whether that’s rheumatoid arthritis, psoriasis, inflammatory bowel disease, and so on. But it can take one to two months to work.</p>
<p>The most common side effects include nausea and mouth ulcers, due to the drug’s inhibition of folate. This is because inhibiting folate targets rapidly dividing cells of the gastrointestinal tract.</p>
<p>Folic acid supplementation is used to <a href="http://www.cochranelibrary.com/editorial/10.1002/14651858.ED000063">prevent side effects</a> associated with low-dose methotrexate therapy. Preferably, folic acid is not taken on the same day methotrexate is taken. <a href="http://www.cochrane.org/CD000951/MUSKEL_folic-acid-or-folinic-acid-for-reducing-side-effects-of-methotrexate-for-people-with-rheumatoid-arthritis">Many studies</a> have shown that folic acid supplements do not hinder the effectiveness of methotrexate.</p>
<p>If methotrexate is taken too frequently – daily instead of weekly, for instance – it can suppress bone marrow, reducing blood cell production and impairing the immune system. This can make the body susceptible to infections and, in the worst-case scenario, <a href="https://www.mja.com.au/journal/2016/204/10/decade-australian-methotrexate-dosing-errors">result in death</a>.</p>
<p>In rare cases, this suppression of blood cell production can also occur at normal doses. This risk is higher in the elderly and in patients with reduced kidney function or dehydration. </p>
<p>Other severe (but rare) side effects include lung and liver damage with long-term usage. People prescribed methotrexate will be closely monitored by their doctor for these effects. </p>
<p>In addition to being an effective treatment for rheumatoid arthritis, methotrexate <a href="http://www.ncbi.nlm.nih.gov/pubmed/11955534">reduces the risk of death</a> from heart disease. This may be because it reduces inflammation, a risk factor for heart disease, and because it affects the cellular mechanisms that lead to the deposition of fat in arterial walls.</p>
<h2>Interactions</h2>
<p>Low-dose methotrexate interacts with drugs that inhibit the way the body uses folic acid, such as the antibiotics <a href="http://onlinelibrary.wiley.com/doi/10.1111/jcpt.12060/pdf">trimethoprim with sulfamethoxazole</a> (Bactrim, Resprim) and trimethoprim alone (Triprim, Alprim). Medicines that <a href="https://www.ncbi.nlm.nih.gov/pubmed/3913771">impair kidney function</a> can increase levels of methotrexate in the body. Taking these medicines in combination with methotrexate increases the risk of bone marrow suppression. </p>
<h2>The dangers of daily dosing</h2>
<p>A study published in the <a href="https://www.mja.com.au/journal/2016/204/10/decade-australian-methotrexate-dosing-errors">Medical Journal of Australia</a> detailed more than a decade’s worth of Australian data on methotrexate, looking at cases where people had accidentally taken methotrexate daily instead of weekly. </p>
<p>Taking methotrexate for as little as three days in a row is enough to cause serious consequences, including sepsis (infection of the blood) and death. Note that this is different to high-dose methotrexate in chemotherapy, where <a href="http://www.sciencedirect.com/science/article/pii/0002934380901059">“rescue therapy”</a> is used to prevent toxicity. </p>
<p>Since 2000, at least eight Australians have died and many more have been hospitalised after taking too much methotrexate. Methotrexate use is increasing, which has corresponded with an increase in accidental daily dosing reported to Australian Poisons Information Centres. </p>
<p>Given that most medicines are taken daily, these potentially fatal mistakes can be easy to make. Methotrexate is effective and safe if used correctly. Changes in packaging and labelling, and alerts in prescribing and dispensing software used by doctors and pharmacists, could help prevent overdosing. </p>
<p>If you have questions about your methotrexate treatment, speak with your doctor or pharmacist. For advice about dosing errors with methotrexate or any other medicine, contact the Poisons Information Centre, 13 11 26 (24 hours a day, 7 days a week), Australia-wide.</p><img src="https://counter.theconversation.com/content/60322/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose Cairns 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>
Methotrexate is a drug used for rheumatoid arthritis, psoriasis and inflammatory bowel disease. It is taken on just one day a week. Accidental daily dosing can cause life-threatening toxicity.
Rose Cairns, Research Associate, University of Sydney
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/41160
2015-05-05T20:16:31Z
2015-05-05T20:16:31Z
Former editor: outsourcing puts Medical Journal of Australia at risk
<p>Publishing is a volatile and competitive business. The Australian Medical Association (AMA), the owner of the <a href="https://www.mja.com.au/">Medical Journal of Australia</a> (MJA), rightly wants to ensure the highly trusted journal is produced with maximum efficiency while satisfying its editorial objectives.</p>
<p>The MJA’s twin objectives, expressed in the first issue 101 years ago, are to inform the medical community about recent advances and provide an evidence base to inform health policy for the nation. </p>
<p>I took the job as editor-in-chief because those goals are congruent with my 50-plus years of health research, management and leadership. But the recent decision to outsource production of the journal to international publishing company Elsevier – and the route it took to get there – made my position untenable. </p>
<h2>Ethical concerns</h2>
<p>Elsevier is highly successful but has an approach to business that <a href="http://www.abc.net.au/news/2015-05-01/academic-outrage-as-leading-health-journal-editor-sacked/6435850">worries</a> many academics and researchers. From 2000 to 2005, the company’s Australian office <a href="http://www.the-scientist.com/?articles.view/articleNo/27452/title/Elsevier-tweaks-custom-pub-rules/">created</a> “custom publications” paid for by pharmaceutical companies to present favourable data on its drugs. </p>
<p>Elsevier <a href="http://www.the-scientist.com/?articles.view/articleNo/27452/title/Elsevier-tweaks-custom-pub-rules/">created</a> the Australasian Journal of Bone and Joint Medicine, for instance, for pharma company Merck to promote Fosamax, a drug for osteoporosis, and Vioxx, an arthritis drug that was recalled for increasing users’ risk of heart attacks and strokes. </p>
<p>Professor Paul Zimmet, one the 19 (out of 20) editorial advisory committee members to sign a letter of resignation over the MJA’s decision to outsource production to Elsevier, <a href="http://www.abc.net.au/news/2015-05-01/academic-outrage-as-leading-health-journal-editor-sacked/6435850">explained to the ABC</a>:</p>
<blockquote>
<p>My concern is that the next step could be to follow up with appointing editorial staff that follow Elsevier’s agenda.</p>
</blockquote>
<p>Readers can make their own assessments of Elsevier’s reputation. I made mine and concluded that I did not take the MJA job to work with Elsevier. This put me at odds with the board of the Australian Medical Publishing Company (AMPCo), the AMA’s publishing company, and my three-year contract was terminated a week ago, one year early.</p>
<h2>Costs and quality</h2>
<p>AMA president Brian Owler <a href="https://ama.com.au/media/ensuring-future-medical-journal-australia">said in a press release</a> the decision to outsource production was financial, describing AMPCo’s financial position as “perilous” and “on the brink”:</p>
<blockquote>
<p>… to keep AMPCo on a sound long-term footing, and to ensure the ongoing publication of the MJA, further changes had to be made, including outsourcing some production functions and making AMPCo less dependent on the AMA to remain viable.</p>
</blockquote>
<p>The audited circulation of the MJA is about 30,000. It costs the AMA A$2.35 million to deliver the MJA to all its members (almost 30,000, though this number is kept under wraps). The A$78 each member pays for a year’s subscription is cheaper than any other medical journal, and certainly a bargain compared with The New Yorker or The Economist. </p>
<p>Nevertheless, the publisher ought to investigate and scrutinise the many ways to save money. Giving AMA members a choice of receiving the MJA only online is just one example of many. </p>
<p>The MJA is printed and posted out-of-house. The new outsourcing plan includes production, some administrative functions and sub-editing. Brian Owler <a href="http://www.abc.net.au/pm/content/2015/s4229256.htm">describes</a> this as:</p>
<blockquote>
<p>essentially … rearranging words on a page or making sure things sit together. </p>
</blockquote>
<p>This does not accord with the extensive intellectual contribution of the MJA’s sub-editorial and production staff to the journal. Like all medical association-owned journals – The British Medical Association Journal, its Canadian and American counterparts (BMJ and JAMA) and The New England Journal of Medicine (NEJM) – the MJA’s sub-editing, design and production have been integral to the editorial process and have been kept in-house to retain autonomy and flexibility. </p>
<p>The MJA publishes multiple categories of articles such as perspectives, editorials, critical comments and correspondence. This requires more editorial judgement than journals that publish nothing more than research papers, for which outsourcing of production may be straightforward. </p>
<p>In-house production ensures we make use of the creative talents of the full editorial team to ensure the journal is contemporary and responsive to readers’ expressed requests. Other association journals have ventured into new fields of publication with encouragement from their boards that have secured them financially, including speciality journals (JAMA) and continuing education (NEJM).</p>
<h2>The outsourcing process</h2>
<p>Towards the end of 2014, I found out that the board of the AMPCo had sought bids from publishers to outsource the production of the MJA. </p>
<p>Elsevier was the front runner and presented to the board about what it could offer. The chairman informed me after the presentation, but I had not been aware of the process and the bid had been prepared with no discussion with the editorial team. </p>
<p>Until that time, I was also not aware of the extent of the financial problems AMPCo faced or the urgency with which the board intended to address them. In the following months, I developed various proposals for additional revenue lines that closely matched the financial gains from outsourcing, but the board pressed on with the proposal to outsource.</p>
<p>All journals face challenges because of rapidly evolving information technology and the many alternatives to paper that now exist. </p>
<p>Once journals were paid for mainly by subscriptions and advertising. Now many journals are supported by <a href="https://theconversation.com/hard-evidence-is-open-access-working-19410">fees paid by authors</a> – several thousand dollars per paper in the more prestigious journals. The very notion of a paper is changing and hallowed phenomena such as peer-review are under threat. </p>
<p>Outsourcing production, in the face of these challenges, reminds me of the ill-fated A$7 co-payment for bulk-billed Medicare services that sank as a budget failure in 2014. It may relieve a problem briefly but it carries a heavy freight of side-effects, such as losing creative and experienced staff, at a time when they are needed to plan for the future. And it is not alone a satisfactory whole-of-system strategy to achieve financial sustainability.</p>
<p>The MJA needs a sophisticated and imaginative, future-informed business plan. While this shouldn’t be the exclusive domain of the editorial group but they should be intimately involved. </p>
<p>It’s unclear how the MJA will plot its course from this point. The waters are turbulent and it will require wisdom and much greater business and management acumen to survive and flourish. I certainly wish it well.</p><img src="https://counter.theconversation.com/content/41160/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Leeder 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 recent decision to outsource production of the journal to international publishing company Elsevier – and the route it took to get there – made my position untenable.
Stephen Leeder, Emeritus Professor, Menzies Centre for Health Policy, University of Sydney
Licensed as Creative Commons – attribution, no derivatives.