Time to end HIV-positive proceduralists ban
A LETTER to the MJA has highlighted that Australia is lagging behind the rest of the world when it comes to lifting the ban on HIV-positive proceduralists. This follows the UK’s decision to end the ban for HIV-positive surgeons and dentists who are clinically well, receiving treatment and have an undetectable viral load. The letter author, Dr Sean Atkinson, sexual health registrar at Cairns Hospital, wrote that even during the height of the HIV epidemic in the early 1990s, there were no HIV transmissions among the 22 171 patients who were exposed to HIV-positive proceduralists in the pre-antiretroviral therapy (ART) era. There have been only 10 published cases indicating transmission from proceduralists to patients since HIV was first reported, with the current risk estimated at 1 in 1 672 000. Dr Atkinson also highlighted two major problems with Australia’s blanket ban on HIV-positive surgeons and dentists — that the prospect of a career-ending diagnosis could result in proceduralists avoiding testing, and that the ban sent the wrong message to the public that people with HIV are infectious and dangerous, even with treatment. He argued that lifting the ban would encourage proceduralists to get tested regularly, resulting in better outcomes for both them and their patients. He wrote that, considering the effectiveness of ART in supressing HIV, it was time for Australia to align with the more than 20 other countries which had lifted the ban, “because the risk of transmission from [HIV-positive proceduralists], when treated for HIV and using standard precautions, is likely to be negligible”.

Internet-delivered CBT reduces absenteeism
AUSTRALIAN research has found internet-delivered cognitive behaviour therapy (iCBT) was associated with reduced self-reported absenteeism in employees with depression, anxiety and social phobia. The study, published in the MJA, reanalysed data from five randomised controlled trials (RCTs) of iCBT between 2008 and 2010. The study included 284 participants from the trials, with a mean age of 43 years (range, 18–68 years). About 70% were women. In each of the five RCTs used in the study, the intervention group received relevant iCBT and the control group was drawn from people on waitlists for the same therapy. The iCBT course for each condition was completed over 11 weeks in six online lessons, guided by clinical psychologists, with assignments, automated emails and resource guides. The study found that participants who completed iCBT self-reported fewer working days lost due to illness, halving their rate of absenteeism when compared with the control group. The researchers wrote that before their study, relatively little was known about which interventions for depression, anxiety and social phobia affected occupational attendance. They said their large sample represented a significant contribution to knowledge in the area of workplace psychiatry. “The importance of considering occupational outcomes of treatment interventions goes beyond economic arguments”, they wrote, saying patients want to be fully functional at work and often feel that the benefits of work help their recovery. The authors suggested that future research should focus on replicating their findings in other disorders, other iCBT courses, and in socioeconomic groups outside of Australia

Index highlights need for social protection for older people
THE United Nations will this week release its 2014 Global AgeWatch Index, which ranks 96 countries according to the social and economic wellbeing of older people, to coincide with the International Day of Older Persons on 1 October. The countries in the index, including Australia, represent 790 million people aged 60 years and over, which is 91% of the global older population. The executive summary to the report said the index showed one in four people in low- and middle-income countries were living without a pension. “Providing basic social protection to older people is about recognising the right to a dignified old age as well as the need for financial independence”, the summary said. “The Index shows that policies supporting people in later life such as pensions, educational and employment opportunities, free healthcare and subsidised transport exist but need to be implemented faster and more systematically.” The index placed Norway at the top as the best country in which to be old, replacing Sweden, which topped the list in 2013. The country ranked as the worst was Afghanistan, which was also at the bottom of the list in 2013. Australia was ranked 13 overall, up one ranking from 2013. However, Australia’s ranking was at 61 in “income security” while it was placed at 2 for “capability” and 5 for “health status”. “The Index tells us that economic growth alone will not improve older people’s wellbeing and specific policies need to be put in place to address the implications of ageing”, the summary said. “Policies on income security in Mexico (30) have lifted it 26 places in the overall rankings since last year despite being less wealthy than Turkey [ranked 77].” The index also predicted that the percentage of people aged over 60 years in Australia will increase from 20.1% this year to 27.6% by 2050.

Link between broad-spectrum antibiotics and childhood obesity
REPEATED exposure to broad-spectrum antibiotics between the ages of 0 and 23 months has been linked to early childhood obesity, a study published in JAMA Pediatrics has found. The researchers studied a cohort of 64 580 children during 2001–2013 using electronic health records from primary care practices affiliated with a children’s hospital. Obesity outcomes were measured using the National Health and Nutrition Examination Survey 2000 body mass index norms. The study found 69% of children were exposed to antibiotics before age 24 months, with a mean of 2.3 episodes per child. Cumulative exposure to antibiotics was associated with later obesity, with the effect strongest for broad-spectrum antibiotics. This association persisted even after accounting for a number of known risk factors including sex, urban primary care practice, insurance type, diagnosis of asthma and steroid use. However, the study found no significant link between early obesity and narrow-spectrum antibiotics. If validated by other studies, the authors said the result “suggests a potentially modifiable risk factor for childhood obesity” and supports the need to limit antibiotic use to cases where efficacy is well demonstrated, and to use narrow-spectrum drugs when possible. The researchers suggested that repeated use of antibiotics “may have an impact on intestinal flora that alters long-term energy homeostasis”, and hypothesised that this might combine with physiological, environmental, socioeconomic and medical factors affecting a child’s risk for obesity.

Social support crucial for young acute MI patients
A STUDY has found that lower social support is linked to worse health outcomes for young men and women following acute myocardial infarction (AMI). The research, published in the Journal of the American Heart Association, used data from an observational study of young AMI patients (aged 18–55 years) in the US and Spain, who were categorised as having either low or moderate/high perceived social support. Outcomes including health status, depressive symptoms and quality of life were measured at baseline and 12 months post-AMI. Among the 3432 patients in the study cohort, 21.2% were classified as having low social support, with comparable results for men and women. Patients with low social support were more likely to be single, living alone and unemployed than those with higher social support. After multivariable adjustment, patients with low social support reported lower mental functioning, lower quality of life and more depressive symptoms. This effect was independent of other clinical and demographic factors. The authors also found that social support had no connection to clinical presentation/treatment, suggesting that the association between low social support and poor health outcomes happened outside of hospital, either before admission or during follow-up. The researchers said their findings were “most relevant for risk stratification and identifying patients who could benefit from additional support posthospitalization”. The authors wrote that given the low mortality rate in young patients with AMI, “it is important to focus on outcomes such as health status, depression and quality of life when designing interventions for patients with low social support”.

Chronic opioid therapy recommendations
CHRONIC opioid therapy for the management of non-cancer pain must be managed according to best practice and only used as part of a multifaceted approach, a position statement published in Neurology has recommended. The statement, from the American Academy of Neurology, was based on a review of the science and policy issues surrounding the “emerging public health epidemic” of prescription opioid-related morbidity and mortality in the US. More than 100 000 people had died, directly or indirectly, from the effects of prescribed opioids in the US since policy changes in the late 1990s dramatically liberalised opioid use, the authors wrote. While the statement acknowledged that opioids provide short-term pain relief, it said there was still no substantial evidence that opioids provide significant long-term maintenance of chronic pain relief without increasing the risk of overdose, dependence and addiction. Additional effects of long-term opioid use ranged from infertility, cardiac issues, sleep-disordered breathing, opioid-induced hyperalgesia, to death as a result of unintentional poisoning. The statement said that patients on chronic opioid therapy needed to be managed according to best practice, and outlined several universal guidelines. These included tracking pain and function to recognise tolerance, documenting the daily morphine equivalent dose (MED) in mg/day for all sources of opioids, random urine drug tests, using an opioid patient treatment agreement, and screening for depression and any history of substance misuse in patients. The authors wrote that avoiding escalation of daily opioid doses to more than 80–120 mg/day MED was vital to best practice. If a dose exceeded this level, the statement recommended consultation with a pain management specialist, particularly if pain and function had not substantially improved. The authors said that “the risks for chronic opioid therapy for some chronic conditions such as headache, fibromyalgia and chronic low back pain likely outweigh the benefits”. The statement concluded that ongoing research and data collection regarding opioid efficacy and management was needed, as well as revision of state and federal laws and policy to assure patient safety.

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