Young men at risk with alopecia diagnosis
A LEADING dermatologist has warned doctors to be aware of the risk of self-harm and psychological distress in young men and boys with rapid onset alopecia areata. In a letter to the MJA Professor Rodney Sinclair, director of the Department of Dermatology at the Epworth Hospital, Melbourne, wrote that in 2011 the deaths of four boys aged between 14 and 17 years who were affected by alopecia areata were recorded by the coroner as suicide. Professor Sinclair wrote that all the teenagers, who had no psychological disorders before developing alopecia, were under the care of a psychologist or psychiatrist at the time of death. “Social withdrawal and school avoidance began after the alopecia”, he wrote, saying alopecia leads to a rapid and profound alteration in physical appearance. “Common issues identified among young men and boys with alopecia areata include poor self-image, grief and loss, and sleeping disorders. The chronic relapsing nature of the condition, the unknown triggers and sudden, unpredictable relapse are major frustrations”, he said.

Missed opportunities plague COPD diagnosis
THE early diagnosis and management of chronic obstructive pulmonary disease (COPD) needs better primary care rather than greater respiratory expertise, according to Professor Chris van Weel, of the Australian Primary Health Care Research Institute at the Australian National University, Canberra. Professor van Weel was commenting on a large retrospective UK-based analysis published in The Lancet, which found that opportunities to diagnose COPD had been missed in 85% of patients in the 5 years immediately preceding diagnosis. The researchers assessed the medical records of 38 859 patients with COPD aged 40 years or older, and identified missed opportunities to diagnose COPD from routinely collected patient data by reviewing patterns of health care use and comorbidities present before diagnosis. They wrote that their findings on the many opportunities missed could be “incorporated to serve as part of a case-finding strategy for patients with COPD and associated comorbidities”. “We suggest that a case-finding approach should be modified to include: all patients older than 40 years with a diagnosis of asthma and who currently smoke; all smokers older than 40 years who have a lower respiratory prescribing event; and follow-up of existing recommendations for smokers aged older than 40 years with any respiratory symptoms, especially if they are male”, they wrote. Understanding historical patterns of illness relied on “a doctor having access to all current and past records and information”, they wrote. Professor Weel said patient-centred continuity of care was needed, “with an eye to the prevailing epidemiology, to assess signs and symptoms over time”.

“Hot desking” risks spread of TB
MODERN open-plan office design and the practice of “hot desking” could increase the risk of transmitting tuberculosis (TB) in the workplace, according to the authors of a case report published in the MJA. The authors described the case of a 34-year-old previously well man, employed in a large commercial business, who presented to his GP with a 4-week history of influenza-like symptoms. The man was initially diagnosed with bronchitis. However, after an episode of haemoptysis he saw another GP who had trained in a country with a high burden of TB, who diagnosed the disease. A total of 108 of the man’s family friends and work colleagues were screened; with 10 of his 89 work colleagues who had no other risk factors than the workplace exposure screening positive for TB. The authors said the case study revealed a delay in diagnosis of the index case, with the infected patient having at least 6 weeks of contact with the other staff. “Delays in diagnosis have been shown to be associated with greater transmission of infection as they increase the exposure period and can result in progression to advanced disease that is more likely to transmit infection”, they wrote. “Our case study does highlight the issue of low awareness of TB among community and health care workers that has been previously described in other lower incidence settings, with lack of awareness especially the case among GPs who are usually the first point of contact with the health system for infected patients.”

High stress linked to injury claims
AUSTRALIAN researchers have found high stress levels lead to higher levels of disability in people injured in transport or work accidents who make a workers’ compensation claim. The research, published in JAMA Psychiatry, found that the largest negative health effects were associated with problems understanding what the claims process required and the stress linked to the time taken to deal with claims, as well as the number of medical assessments and the amount of compensation received. The prospective cohort study included a random sample of patients from three states who were hospitalised with injuries and were followed up at 3 months, and 1, 2 and 6 years. At the 6-year interview, the researchers found that those with the highest level of stress had the highest levels of disability, anxiety and depression, and a lower quality of life compared with other claimants. The researchers suggested the workers’ compensation schemes should be redesigned to make them less stressful for claimants. They also suggested screening and early intervention for claimants who exhibited characteristics, such as mental health problems, as these indicated vulnerability to stressors in the claims process. “A mix of interventions … may be the best means of ensuring that injury compensation schemes deliver on their founding objective of enhancing recovery rather than impeding it”, they wrote.

Blunt warning on acupuncture needles
ACUPUNCTURE needles with blunt and irregular tips, metallic lumps and “loosely attached pieces of material” have been found in an Australian review of two leading brands of disposable needles published in BMJ Open. The authors used scanning electron microscope images of 10 randomly chosen needles from each brand before and after the needles had been used on a needling practice kit, finding some metallic lumps and loose fragments were missing after needling. They wrote that if these needles had been used on patients, the lumps and fragments could have been deposited in human tissue, possibly causing contact dermatitis, or other adverse events such as bruising, bleeding or strong pain. They wrote that their findings highlighted the need for “improved quality control” in the manufacture of acupuncture needles, particularly the needle tips which “should be properly formed, sharpened and cleansed”. Although disposable one-use needles had eased the concern about infection caused by poorly cleaned reusable needles, further improvement in production could “further enhance the safety and comfort of acupuncture users”, they wrote.

Two HPV vax doses reduces genital warts risk
USING a 2-dose quadrivalent human papillomavirus (HPV) vaccination schedule, rather than the gold standard 3-dose, may be more cost-effective and almost as effective in reducing the risk of genital warts, according to research published in JAMA. Researchers observed the first occurrence of condyloma — the earliest measurable preventable disease outcome for the HPV vaccine — using data gathered over 4 years from more than a million Swedish women aged 10–24 years. They found the maximum risk reductions occurred after three doses of the vaccine, but two doses were also associated with considerable risk reduction. “The number of condyloma cases prevented by 3 doses vs 2 doses was 59 cases per 100 000 person-years, which is a small difference”, they wrote. Overall, a total of 20 383 cases of condyloma were found during follow-up including 322 cases after receipt of at least one dose of the vaccine. The authors wrote that their study did not account for HPV outcomes other than condyloma and that studies with longer follow-up were needed. However, they said “determining vaccine dose-level protection is essential to minimise program costs and increase mass vaccination program feasibility”.

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