clinical review ondeeperpalpation 25 insideistockphoto/mO montage UPDaTe stroke management 27 real caSeS A Gp reassesses their chance addiction diagnostic tools after a close call 31Gambling is as a psychologist and co-direc- with the conflict of suffering the DSM-IV, both pathological andprevalent a health tor of the University of Sydney consequences that arise – criti- problem gambling can be diffi- Gambling Research Unit, says cism from family and financial cult to diagnose says Professorproblem as type 2 it is important to distinguish implications – and the excite- Blaszczynski.diabetes. So how between pathological and prob- ment they experience.” “Unlike alcohol or substance TravellerS’ cHecKSdo you identify lem gambling. Professor Shane Thomas, abuse, the physical signs are not Health measures forthose at risk early “Pathological gambling is a director of the Primary Care evident, and often gamblers are visitors to madagascar 33 recognised psychiatric condition Research Unit at Monash quite adept at concealing theand efficiently? and is included as a disorder of University, says the best way to debts from their partner.Nicole Vanderkroef impulse control,” he says. understand the issue is to con- “So is it often a major shock SeXUal HealinGinvestigates. “To meet the criteria for this sider the DSM-IV criteria par- to the family and that has major should older women receive the HpV vaccine?I diagnosis, a patient must meet ticularly in regard to patients ramifications in terms of trust in N our everyday lives gam- as least five out of the 10 crite- displaying some of the com- their relationships.” 34 bling is around us, even if ria for pathological gambling as mon co-morbidities of problem we don’t particularly go outlined in the DSM-IV. gambling. PSycHOlOGical PrOBlemS looking for it. One of the “There is also a broader cat- “There are certain conditions Professor Blaszczynski says that JOUrnal GraBbiggest events in any office cal- egory of people who are con- that are highly co-morbid with gambling often has psychologi- the health legacy ofendar is Melbourne Cup day. We sidered ‘problem gamblers’, problem gambling but were not cal co-morbidities, and can be hormone replacementsee the lottery drawn each week. and these are people who expe- previously recognised,” he says. used by some patients as a poor therapy 37And poker machines greet us in rience some degree of harm as “If a patient displays condi- coping mechanism to deal withpubs and clubs. a result of their behaviour but tions such as depression and/or their depression. So in some ways, it’s no may not necessarily evidence any hazardous alcohol use, there is “The person may be depressedwonder that 2.5%-5% of the impaired control. a reasonable chance they could and experience stresses or peri-Australian population display “These people may enjoy also be affected by problem ods of boredom, and then for aat-risk gambling behaviour. gambling, and gamble more than gambling.” variety of reasons end up gam-And some studies suggest that they can afford, but are faced But despite criteria such as the bling,” he says. “Over time theythe prevalence of problem gam- gamble more, and as a resultbling exceeds that of stroke and Key signs of problem gambling become more depressed and startcoronary heart disease.1 to chase their losses, which sends In 1999, the AMA released a THE Victorian government’s problem gambling fact sheet for them into a downward spiral.position statement recommend- GPs suggests a few key signs of problem gambling. These “In other cases, people seeing that medical practitioners include: gambling as a source of incomeregularly screen patients at risk • unexplained stress, anxiety or sleeplessness and believe they’ll win. They’llof problem gambling or display- • poor health or nutrition start to lose their money, so theying associated symptoms.2 • ongoing financial problems that can’t be logically explained escalate their gambling in a vain So what exactly is the nature • relationship issues that seem to involve a lack of trust in his/ attempt to win their money backof problem gambling as a dis- her partner and as a consequence becomeorder? And how can diagnosis • feelings of guilt related to mood swings, anger or frustration depressed and may get involvedand treatment be made more vented at family or friends in substance abuse.”simple and clear in a time-poor • parental neglect issues in the family Dr Dan Riddle (PhD), aenvironment? • very little food, utilities or furniture in the house. psychologist and professional Professor Alex Blaszczynski, > page 26 12 september 2008
26 ondeeperpalpation clinical review > from page 25 began stealing money from her about lifestyle behaviour in a [gambling] problem.” development officer for the workplace to pay the debts. standard consult. Dr Riddle emphasises that DSm-iv criteria for Melbourne General Practice “So it’s important to look at They’ve developed a one-item gambling is not just a financial pathological gambling Network, agrees that problem the root cause of the problem,” screen for general practice, and or psychological problem but 1. Preoccupation with gambling can stem from an exist- Dr Riddle says. “And the doctor say that simply asking a patient also a health problem, and often gambling ing source of stress. will need to use his or her experi- “Have you ever had a problem the GP will be the first and only 2. Increasing need to He gives the example of a ence and expertise to determine with your gambling?” could port of call. gamble to generate 40-year-old female patient who which is the primary issue and make all the difference. “A GP might be the only excitement had developed a gambling prob- what is secondary.” “When people are asked this health professional that a patient 3. Repeated unsuccessful lem with poker machines. question, they are inclined to is in touch with,” he says. “And efforts to control, cut back At the time, she lived across One-iTem Screen answer truthfully,” Professor often they are well trusted by the or stop gambling the road from her mother-in-law, Professor Thomas, along with Thomas says. patient. So the impetus is to train 4. Restlessness or irritability who was very intrusive in her his colleges Professors Leon “They go along to their GP and empower GPs with informa- when attempting to cut life. She began gambling as an Piterman and Alun Jackson, feeling unwell, and in the back tion, because they are the ones down or stop gambling escape from the tension at home, suggest GPs include a question of their mind they kind of hope on the frontline.” 5. Escaping from problems but this soon escalated and she about gambling when they ask that the doctor will pick up their However, he also acknow- or of relieving a dysphoric mood through gambling 6. “Chasing” one’s losses 7. ying to family members, L therapist or others to conceal gambling 8. Committing illegal acts to finance gambling 9. Disruption of significant relationship 10. Relies on others to provide money to relieve a desperate financial situation. ledges that effective education can be a “minefield” because GPs are already overloaded with so much information. The trick, he says, is to pro- vide training that gives doctors a broad sense of the problem and then follow this up with con- cise, practical and easily access- ible reference material. Dr Riddle says a great exam- ple of this is the Solution for Problem Gambling program, which was launched by the Melbourne General Practice Network in conjunction with the Victorian government in June this year. The program provides a resource kit and training sup- port to divisions to help GPs in the identification and manage- ment of patients with problem gambling.3 Professor Blaszczynski agrees that GPs are in an ideal position to identify patients that may oth- erwise go undiagnosed. “Often patients will present at a GP with symptoms of insom- nia, anxiety or stress-related problems, and because of the social stigma associated with gambling, they’ll often fail to disclose that [gambling] is the cause of it,” he says. He says that the important issue is not whether a patient would or wouldn’t disclose that they have a problem with gam- bling, but rather being able to give the patient an opportunity to talk about it. “Most patients want to talk about their gambling,” he says. “Sometimes all they really need is to be asked.” References available at www.medicalobserver.com.au
Three part clinical review ondeeperpalpation 27 series inside UPDaTe Anxiety disorders in children and adolescents 29 real caSeS The tragic conclusion to the story of refugees maria and Francine 35Dreamstime.comcomplementary practice SKin DeeP A patient is concernedComplementary medicines are gaining in popularity with patients. But can doctors embrace themand still provide optimum care? In part one of a three-part series, Nicole Vanderkroef investigates. about holes on the soles of the feet 40MENTION complementary and news stories about CMs, them. The majority of GPs therapy we are talking about.”medicine (CM) in conversation they are looking to their doctors reported that they needed to Dr Kotsirilos says it is espe- TravellerS’ cHecKSand the idea is likely to stimulate for help in wading through all look for CM information every cially crucial to assess not only What can be done toa range of responses. the information. few months or less. When they the evidence, but also whether At one end of the scale, it A recent study of 612 Aus- did look, it was mostly about the the treatment carries a high prepare the last-minutecan conjure up visions of witch- tralian users of CMs found con- safety and effectiveness of CMs, or low risk for adverse reac- traveller? 39doctors mixing exotic herbs, or sumers most frequently sought and respondents rated CM text- tions and interactions withfortune-tellers making incanta- information from friends and books, specific websites, Internet pharmaceuticals. GP TiPtions over crystals; at the other family on CMs but would pre- searches, CM journals and drug “Clinical experience and The bbQ system ofend, discussion might hinge on fer to get this information from information phone services as patient feedback play an impor- grading meat has athe latest randomised trial of an their doctor or pharmacist.2 the most useful sources. tant part,” she says. “But in myarthritis treatment. This shift has also created a practice, I am obviously going to novel medical use 41 As the older stereotypes dis- change in attitude among some DiSTinGUiSHinG THeraPieS [use] those treatments that haveappear, the attitudes of patients doctors, and a strong demand by The sheer volume of comple- stronger supporting evidence andand GPs are changing fast. CM GPs for reliable and easily acces- mentary therapies creates prob- pose low risk to patients.”is becoming better understood sible information on the efficacy lems for GPs trying to determine The downside is that thisand more widely accepted, and and risks associated with com- which are backed by evidence. takes time, and Dr Kotsirilospatients have begun to believe plementary therapies. For this reason, Dr Vicki points out that this can be a sig-there might be benefits in using In March this year, the Kotsirilos, founding president nificant drain on doctors.therapies such as acupuncture National Prescribing Service sur- of the Australasian Integrative “Time is a significant factoror natural supplements to treat veyed a random sample of 4032 Medicine Association (AIMA), for doctors – time to educatesome conditions. GPs to find out exactly what says it’s important to be able to themselves about evidence- Data on the use of comple- their attitudes were towards distinguish each category of CM based complementary therapies,mentary therapies support this CMs, their current CM prac- and assess each individually. and the longer time required togrowing trend. Approximately tices, the type of information “There are many types of address them in a consult.”67% of Australians used CMs they were interested in and how therapies – some are evidence- In Australia, the Nationalin the past year,1 and that figure they accessed it. based and some not,” she says. Institute of Complementaryis expected to continue to rise. Preliminary results showed “Bunching them all together Medicine attempts to make this So it probably comes as no sur- that 91.8% of GPs sought in one category obscures which is easier by splitting CMs into fourprise that, while patients are fac- information about CMs when which. That’s why it’s important categories, along the lines of itsing a barrage of advertisements patients said they were using to be clear about which type of > page 28 7 November 2008
28 ondeeperpalpation clinical review > from page 27 practices involve tactile ther- level of acceptance is evident for This growing support has US counterpart, the National apies and structured exercise CMs such as reiki, homeopathy, also been reflected among med- CASe STuDy Center for Complementary and regimes, such as chiropractic reflexology and applied kinesiol- ical professional organisations. Alternative Medicine:3 medicine, yoga and tai chi. ogy, with doctors less confident In 2002, the Australian Medical DR Vicki Kotsirilos recalls a • Mind-body medicine describes • Energy medicine involves the of their efficacy and safety.4 Association released a formal patient with dysmenorrhoea techniques designed to enhance use of energy fields, as in reiki The literature indicates that position statement on CMs and PMS. The 22-year- the mind’s capacity to affect and qigong. Australian doctors do recom- which recognised “that evidence- old woman had displayed bodily function and symptoms. mend CM therapies, either by based aspects of complementary symptoms of these These include meditation and an imPorTanT cHoice referral or, to a lesser degree, medicine are part of the reper- conditions from menarche, therapies using creative outlets Keeping the above definitions in by practising in the area them- toire of patient care and may and required NSAIDs and such as art, music or dance. mind, GPs have shown a prefer- selves. And, while a recent sur- have a role in mainstream medi- bed rest to manage the • Biologically based prac- ence for certain types of CM. vey revealed it’s unlikely the use cal practice”.5 symptoms. tices use substances found in Acceptance of acupunc- of CMs could be considered a The RACGP/AIMA joint Several complementary nature, such as herbs, foods ture, hypnosis and meditation ‘normal’ part of medical practice working party recognises that therapies were and vitamins. by Australian doctors is rela- in Australia, a minority of GPs evidence-based aspects of CM are recommended. These • Manipulative and body-based tively high. In contrast, a lower actively practice in the area.4 part of the repertoire of patient included regular exercise; stress management and muscle relaxation techniques; a diet high in plants, legumes, fish, vegetables and fruits; low doses of calcium and magnesium; and the herb, Vitex agnus-castus. After two months, the patient reported a significant reduction in the severity of her symptoms and no longer required NSAIDs to manage the pain. care in mainstream medical prac- tice. It also points out that it’s essential for consumers and GPs to have access to quality infor- mation about CMs so that they are empowered to make well- informed treatment choices. line in THe SanD Dr Kotsirilos says it’s important that GPs integrate evidence- based CMs into their practices to give patients more choice. “[CMs] should work in con- junction with conventional medicine rather than opposing it,” she says. “Treatments like evidence-based nutritional and herbal medicine can comple- ment [conventional medicine] but should not replace it.” Professor Marc Cohen from the School of Health Sciences at RMIT University echoed these views in an article for the Medical Journal of Australia.7 “Ultimately, medicine has a single aim: to relieve human suf- fering. When measured against this benchmark, different thera- pies can be seen as either effec- tive or ineffective, rather than orthodox or unorthodox. “No single professional group has ownership of health, and the best health care requires a multi- disciplinary approach. Thus, there is an imperative for all healthcare professionals to work together [to] benefit their patients and the wider community.” References available at www.medicalobserver.com.au NEXT WEEK: Part 2 – Herbs, supplements and acupuncture.
One size fits all?Medical Observer Friday, 21 March 2008http://www.medicalobserver.com.au/Clinical/0,1734,2278,21200803.aspxThe mantra is eat less and exercise more to combat obesity. But are lifestylechanges the best solution for everyone? Nicole Vanderkroef investigates.AUSTRALIANS are on a metaphoric treadmill – and not in a good way.For the past 20 years we have been told to eat less and exercise more, and yet the national obesity ratecontinues to rise.1For some reason, despite all the information available to the public, people are unable to successfullylose weight.Governments have suggested a variety of solutions with varying success. The former HowardGovernment announced a funding plan of more than $37 million for 320 local programs promotinghealthy and active lifestyles last October.2And the newly elected Rudd Government committed $1.7 million over four years in its The First 100Days report to evaluate best practice in community-based obesityprevention programs around the country.3But are these programs focusing on lifestyle changes the best solution for all Australians, especiallythose at the higher end of the obese range?WHY WEIGHT?Throughout the medical fraternity, doctors agree that there are a number of reasons why people becomeobese in the first place.Dr Tim Gill (PhD), executive officer of the Australian and New Zealand Obesity Society, says it issimply a matter of energy balance.“When it comes down to it, all people who put on weight are in a positive energy balance – theyconsume more than they burn off,” Dr Gill says. “But the reasons why people do this are morecomplex.”Professor Joseph Proietto, head of the Weight Control Clinic at Austin Health, Melbourne, cites a fallin the hormones leptin and cholecystokinin and a rise in ghrelin, which occur following weight loss, asplaying a major role in preventing people from losing weight.“Bariatric surgery may do more than just reduce the physical size of the stomach,” Professor Proiettosays.“It appears that a band around the upper part of the stomach sends a signal to the brain to suppresshunger.”He also says that there is more and more evidence that genes could be permanently turned off byenvironmental factors. He quoted examples of studies that have shown malnourished expectantmothers are more likely to produce obese children, and studies in rats that support the epigeneticfeatures of obesity.Dr Vicki Kotsirilos, GP and founding president of the Australasian Integrative Medicine Association(AIMA), says the relationship between hormones and weight is complicated.“Your weight affects your hormones, and your hormones can also affect your weight – it works bothways,” she says.She says that stress can also be a factor for weight gain, and it has been shown that excess cortisollevels produce weight gain. Stress can also cause emotional eating and bingeing.Dr Kotsirilos pointed to two studies that cite the role of soft drinks and green tea in controlling weight.Framingham Study researchers found individuals consuming ≥1 soft drink per day had a higherprevalence of metabolic syndrome than those consuming <1 soft drink per day.And on a four-year follow-up of patients, new-onset metabolic syndrome developed in 765 (18.7%) of4095 participants consuming <1 drink per day and in 474 (22.6%) of 2059 persons consuming ≥1 softdrink per day.4A study in healthy Japanese men found 12 weeks of daily consumption of oolong tea, containing 690mg catechins from added green tea extract, reduced body fat.5However Dr Gill, Dr Kotsirilos and Professor Proietto all agree that each patient will have differentreasons behind their obesity and will therefore require different treatments, especially those with a BMIhigher than 35.PLAN OF ATTACKDr Vicki Kotsirilos says that a patient’s lifestyle has to be assessed and changed first and foremost.“It may take several consults to assess how much a patient has to change their lifestyle, and whetherthey have any existing medical problems,” she says.
She adds that if she makes a plan with a patient to introduce lifestyle changes, and the patient doesn’tlose any weight, she would then ask them to complete a food diary over 3-5 days.“There is a lot of misinformation out there in terms of what actually are low-calorie foods and portioncontrol,” she says. “This is where there is a place for bariatric surgery – when lifestyle changes alonehave failed to make a difference.”Professor Joseph Proietto agrees. “For people that are only mildly overweight, lifestyle changes shouldbe the only option,” he says.“But for people that are severely overweight, with a BMI higher than 35, relying on lifestyle changesalone is unreasonable.”Associate Professor Xianqin Qu, from the Department of Medical and Molecular Biosciences at theUniversity of Technology, Sydney, says that there are two types of obesity: primary obesity, whichoccurs due to lifestyle factors, and secondary obesity, which is caused by other factors, such as amedical condition, hormone imbalance or genetics.She says that each type of obesity needs to be treated differently, and in her experience, many of herpatients have benefited from natural and alternative therapies as a supplement to conventionalmedicine.Dr Gill says it’s strange that if a patient comes in with high blood pressure and fails to make lifestylechanges, you don’t think twice about prescribing medication. But with obesity, we are reluctant to doso.Another problem Dr Gill identifies is our culture. He says that being overweight has been normalised,and often people think that because they are not morbidly obese, that their excess weight will notgravely affect their health.“TV shows like The Biggest Loser reinforce the notion that only very large people have negativeoutcomes from their weight,” Dr Gill says.“It’s a case of ‘them, not me’.”Dr Kotsirilos agrees. “The Biggest Loser gives people unrealistic expectations. In that show, people arein a highly supported environment. But in reality, most people don’t have access to that.”KEEPING IT OFFProfessor Proietto says there is another reason why TV shows like The Biggest Loser are a problem.“The Biggest Loser sends the wrong message to people who are trying to lost weight,” ProfessorProietto says.“It doesn’t show the biggest battle of all – keeping the weight off.”Accordingly, Dr Kotsirilos argues that when treating a patient for obesity, you need to look at thewhole picture.“We need holistic approaches to weight loss,” Dr Kotsirilos says.“That’s what makes the real and long-lasting difference to patient’s lives.“As GPs, we are in an ideal position to treat each person on an individual level,” she says.“And the best way is to function as part of a team to promote the right message to patients.”Dr Gill says offering financial benefits for GPs would make a great difference.“At the moment, there are actually disincentives for GPs to treat obesity, because it is time consumingand leads to over-servicing,” he says.He adds that GPs are in a prime position to help prevent obesity because they are often the first port ofcall for patients.“The sooner we recognise the complexity of the problem on a national level,” he says, “the sooner wewill start to make some real gains in this area.”References1. World Health Organization (WHO) 2006, Chronic Disease Information Sheets: Physical Activity,accessed 7 March 20082. Former Minister for Health and Ageing Tony Abbott, Media release 12 October 2007, accessed 7March 20083. Australian Government, February 2008, First 100 Days: Achievements of the Rudd Government,accessed online 7 March 20074. Dhingra R, et al. Soft Drink Consumption and Risk of Developing Cardiometabolic Risk Factors andthe Metabolic Syndrome in Middle-Aged Adults in the Community. Circulation, 2007;116:480-885. Nagao T, et al 2005. Ingestion of a tea rich in catechins leads to a reduction in body fat andmalondialdehyde-modified LDL in men. The American Journal of Clinical Nutrition, 2005;81:122-29
Photosynthetic organisms found 18 m down in Antarctic lake ... http://www.cosmosmagazine.com/news/395/photosynthetic-o... COSMOS magazine News · Ancient worlds · Life & Environment News Photosynthetic organisms found 18 m down in Antarctic lake by Nicole Yannoulatos Monday, 3 July 2006 Cosmos Online SYDNEY, 3 July 2006 – Even in the frigid gloom of an Antarctic lake, 18 metres below the surface, algae is converting light into energy. Scientists from New Zealands National Institute of Water and Atmospheric Research (NIWA) have been studying the microscopic algae that live under these extreme conditions and were excited to find that these microbes are still able to photosynthesise in the near-dark. "We had seen them photosynthesise in the lab," said Kay Vopel, one of the aquatic ecologists who made the discovery. "But we couldnt say for certain how they would behave until we actually went down and studied them in situ." Vopel and fellow scientist Ian Hawes made the Related articles measurements in November 2004 at Lake Hoare, an Subterranean bacteria hint at life on Mars 18-metre deep ice-covered melt-water lake in the Dry Valleys of Antarctica. Scientists have long been Space submersible gets Antarctic test interested in the bacteria and microscopic algae that Sydney harbours missing malaria link inhabit such lakes, because they offer insights into the extreme conditions under which life can exist. Strange deep-sea bacteria grown in lab NASA predicts colour of alien plants The major issue that could affect the photosynthesis is the light. The ice that covers the lake is so thick that the scientists werent sure whether the microbes would still be able to photosynthesise with such a small amount of light reaching those depths. They found that these algae can use what little light is available and photosynthesise quite successfully. These are among the lowest natural light levels at which photosynthesis has ever been recorded. "There are some tantalising observations of marine plants growing on rocks in very deep water, and of algae and cyanobacteria growing in caves where there may be even less light, but these are certainly amongst the lowest where field observations have been made," says Hawes. This discovery, published in the July issue of Limnology and Oceanography, can not only help to shed light on the past Antarctic climate, but could even glean an insight into finding life on other planets. If microbes can survive in these harsh conditions, it may provide insight into where and how life originated on earth, and where evidence of life might occur on other planets in our solar system. But this is not the end of the Lakes role in understanding hostile environments. Since the photosynthesising microbes were only measured in a certain part of the lake, Vopel and Hawes plan to return in November to measure bacteria that use other chemicals such as hydrogen sulphide.1 of 2 22/1/09 10:45 PM
Mouse study shows ultrasound affecting brain development |... http://www.cosmosmagazine.com/node/533 COSMOS magazine News · Health & Mind News Mouse study shows ultrasound affecting brain development by Nicole Yannoulatos Wednesday, 9 August 2006 Cosmos Online SYDNEY, 9 August 2006 - The impact of ultrasounds on embryonic brains may be more damaging that was previously thought, according to U.S. researchers. A study conducted by Pasko Rakic and colleagues at Yale University in New Haven, Conneticutt, has found that a significant number of nerve cells in the brain of embryonic mice do not migrate to the appropriate location following exposure to ultrasound. "Proper migration of neurons during development is essential for normal development of the brains cerebral cortex, and its function can be impaired if neuronal migration is disrupted," said Rakic, chairman of the Ultrasound probing of embryonic mouse brains Department of Neurobiology at the university. shows some disruption of normal developmental His team analysed how effectively neurons in the brains activity, say researchers of one 146 mouse embryos migrated to the brains Credit: Jim Gathany/CDC cerebral cortex once exposed to ultrasound waves. They found that after several prolonged exposures, a small number of neurons did not migrate to their necessary position in the upper layers of the cerebral cortex, and instead moved to the lower layers or became embedded in supporting white matter in the brain. In an accompanying commentary, Verne Caviness of Bostons Massachusetts General Hospital and Ellen Grant of Harvard Medical School, explain how the implications of this research for the developing brain is unknown. They argued that since the number of misplaced cells is so small, their effect may be little more than minimal background noise. The cells also appear to retain their intended cell characteristics, despite migrating to the wrong position. Caviness and Grant describe how after the neurons have Related articles migrated, a large proportion of them are naturally Neuroscientists discover why old dogs cant learn eliminated as cells die from the development of new new tricks tissues in the brain as the embryo grows. Essentially, all of the misplaced cells in the mouses brain may be Old age memory loss explained eliminated and will be of no consequence for the New stem cell technique eliminates ethical issues organisation of the cortex.1 of 2 22/1/09 10:49 PM