How common are superbugs in Australia, and what do we do when the antibiotics don’t work?

Image of a superbug We’re increasingly seeing bugs  
in Australia resistant to many antibiotics. We’re yet to see one resistant 
to ALL antibiotics.

Hospitals in Australia are increasingly seeing patients with infections that are resistant to all but a handful of antibiotics. Last year an infection caused by bacteria that were resistant to all antibiotics (a so-called “pan-resistant” strain) was detected in the US for the first time. We can expect pan-resistant strains here too.

Resistance is an inevitable consequence of antibiotic use. Almost all species of bacteria have evolved some degree of resistance since the introduction of antibiotics in the 1930s, but most remain sensitive to several classes of agents. A smaller subset of bacteria (known as multi-resistant strains) are only susceptible to a very limited range of antibiotics.

Antibiotics commonly cause allergies and other side effects (such as kidney and liver toxicity) and it is not unusual to have to change antibiotics several times during treatment of a serious infection. If you start with a multi-resistant strain it may not be too long before you run out of treatment options.

The impact of a particular germ is not simply dependent on whether an effective antibiotic is available. It is determined by the power (or “virulence”) of the organism, the dose you are exposed to, and the strength of your immune system.

Bacteria that are susceptible to most antibiotics are still responsible for most life and limb-threatening infections. For example, 80% of strains of the powerful organism Staphylococcus aureus, or golden staph, remain sensitive to commonly used drugs.

If a sensitive staph infection enters your bloodstream, your chance of being dead in 30 days is 13% (which is bad enough). But add in antibiotic resistance and you get what is now known as a “superbug”. Now, the risk of death at 30 days is 20%.

The term “superbug” doesn’t necessarily mean it cannot be treated by antibiotics and death or amputation is imminent. But it does mean most of our commonly used antibiotics will be ineffective. We’re forced to resort to antibiotics that are rarely used due to high cost, toxicity, and harmful side effects. The worry is these multi-resistant bugs are increasing all over the world, and therefore bugs that don’t respond to any antibiotics will too.

How common are ‘superbugs’?

One of the most concerning multi-resistant bugs to emerge affects a family of bacteria that live in the human gut called “enterobacteriaceae”, which includes E.coli. These bacteria have become increasingly resistant to the broad spectrum antibiotics called “carbapenems” that are reserved for the treatment of only the most serious infections.

Ten years ago we would have been confident all Australian enterobacteriaceae would be sensitive to carbapenems, but today about three in 1,000 are resistant – a nearly 10-fold increase.

Life-threatening disease caused by carbapenem-resistant bacteria is still rare in Australia, but elsewhere this type of resistance has been at crisis levels for a decade. In some parts of India, 28% of enterobacteriaceae infections are caused by bacteria resistant to these last-line antibiotics.

Resistance in enterobacteriaceae is of public health concern because they are such a common cause of infection. E.coli can easily move from the gut to the urinary tract in young sexually active women, who can expect to suffer at least one attack of cystitis(infection of the bladder) every two years. Sometimes a bladder infection can travel up to the kidney causing a much more serious infection that requires hospitalisation.

Early treatment of cystitis with effective antibiotics can prevent these complications. But recently, I have treated several women with cystitis caused by bacteria resistant to all oral antibiotics. These patients were not very sick, but the only way to resolve their symptoms (and reduce the chance of them developing more serious infections) was to administer intravenous antibiotics or to get permission to use an oral antibiotic (fosfomycin) that is not yet licensed in Australia. Both are expensive and inconvenient options.

Image of a person in a hospital bed
If a bladder infection travels up to the kidneys it usually requires hospitalisation. from www.shutterstock.com

These women had a history of overseas travel, but now we also see highly-resistant strains of enterobacteriaceae in people who have never left Australia.

People can harbour resistant bacteria in their gut and experience no ill effects. This is known as “colonisation”. Over the past decade, multi-resistance in a family of gut-living bacteria called enterococci has skyrocketed. In 2015, half of the samples of Enterococcus faecium found in blood in Australia were resistant to almost all antibiotics.

Because enterococci are intrinsically less powerful than germs like E.coli, they usually only cause disease in very sick, hospitalised patients, especially in those with foreign material in their bodies such as a prosthetic joint or heart valve.

Nevertheless, most hospitals will isolate patients who are colonised with multi-resistant enterococci to prevent transmission to more vulnerable patients. This can be very costly to the health system and distressing to the patient.

How do we treat the bugs once antibiotics can’t?

Once we run out of effective antibiotics, we will return to the way medicine was practised in the early 20th century. Amputation of an infected limb, currently a dreaded last option, will become one of the first things to consider.

Hospital wards will again be full of patients with abscesses in their abdomen or bones that can only be treated by repeated drainage and surgical procedures. Many routine operations, such as joint replacement, may become too risky to perform because of the risk of an untreatable post-operative infection.

The main hope is that the pharmaceutical industry will return to antibiotic discovery after decades of focusing on anti-viral drug development.

Highly-resistant bacteria are responsible for a relatively small proportion of the serious infections that occur each year in Australia. But this is rapidly changing. Improving infection control and restricting antibiotic use in humans and animals can slow the rate of emergence of antibiotic resistance, but it may be too little too late.

Repeated warnings about resistance seem to have done little to stop doctors prescribing antibiotics for mild bacterial infections (where they are usually unnecessary) and for viral infections (where they are simply ineffective).

Unfortunately it is the next generation of patients who will be most likely to suffer from this collective medical error.

This article was written by:
Image of Frank BowdenFrank Bowden – [Professor at ANU Medical School; Senior Staff Specialist Infectious Diseases; General Physician, Australian National University]

 

 

 

 

 

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Why you should eat a plant-based diet, but that doesn’t mean being a vegetarian

Image of a plate of vegetables Plant-based diets have been found to be 
far more beneficial for our health.

Plant-based diets are often shown to be good for health. Yet Australians eat a lot of meat and are sometimes reluctant to completely cut meat from their diet. So it’s important to know that eating a plant-based diet doesn’t have to mean becoming a vegetarian.

Plant-based diets are high in vegetables, wholegrain bread and cereals, legumes and whole fruits, yet can still contain small amounts of lean meats and reduced-fat dairy products.

A survey of Australians found most (70%) thought a plant-based diet would prevent disease. But what does the literature say? And is meat really bad for you?

Health benefits of plants

Plants are rich sources of many nutrients that are important for good health, including unsaturated fats, vitamins (such as folate), minerals (such as potassium), fibre and protein.

Eating a plant-based diet has been linked to lower risk of obesity and many chronic diseases, such as heart diseasetype 2 diabetesinflammation and cancer.

A recent study that followed more than 200,000 US adults for more than 20 years found that eating a diet high in plant foods and low in animal foods was associated with a 20% lower risk of diabetes compared with individuals eating a diet low in plant foods.

Well known variations to plant-based diets include the Mediterranean diet and the Dietary Approaches to Stop Hypertension. These dietary approaches are known as dietary patterns as they focus on the overall diet rather than single foods. Rich in vegetables, fruits, legumes and reduced-fat dairy products, these dietary patterns have been linked to lower risk of obesity and chronic disease.

Is the processing of plant foods important?

Processing can remove many of the nutritious benefits of plant foods and can often result in the addition of salt and sugar. For example, whole foods, such as an orange and wholemeal bread, retain more beneficial fibre than processed alternatives, such as fruit juice and white bread.

But not all processing is necessarily bad. For example, frozen and canned vegetables can be useful additions to the diet, just check the labels to see what has been added during processing.

Is meat bad for you?

Meat is a rich source of beneficial nutrients, such as protein, B vitamins, iron and zinc. But red meat can also contain high amounts of saturated fat and processed meats can be high in sodium.

Eating red and processed meats, such as burgers and hotdogs, has been linked to higher risk of cancerheart disease and death. In contrast, white meat intake, such as chicken and fish, has been linked to lower risk.

Cancer: Evidence is convincing for a link between red and processed meat and colorectal cancer. A review of available evidence, known as a meta-analysis, showed that colorectal cancer risk was 14% higher for every 100g of red and processed meat (about a large beef steak) eaten per day.

Heart disease and type 2 diabetes: Evidence mostly points towards higher risk of heart disease and type 2 diabetes with higher processed meat intake.

meta-analysis showed that each 50g daily serving of processed meat (about one to two slices of deli meats or one hot dog) was linked with a 42% higher risk of heart disease and a 19% higher risk of type 2 diabetes. But, eating unprocessed red meat was not associated with risk of developing heart disease or diabetes.

Early death: Evidence generally points towards higher risk of death with higher red and processed meat intake. A recent study that followed more than 500,000 US adults over 16 years showed that risk of all-cause death was 26% higher with greater processed and unprocessed red meat intake. When red meat was substituted for unprocessed white meat, risk of all-cause death was 25% lower.

Image of a hamburger
There’s evidence that red and processed meats increase risk of cancer and heart disease. from www.shutterstock.com

What should we be eating?

Eating a variety of unprocessed fruits, vegetables, wholegrains and legumes is key when it comes to maintaining a healthy, balanced diet.

Although high intakes of red and processed meats may increase risk of major diseases, a healthy, balanced, plant-based diet can still include small amounts of lean meat trimmed of visible fat (particularly unprocessed white meat) and reduced-fat dairy products.

Eating a plant-based diet is in line with the Australian Dietary Guidelines to promote health and well-being.

Australians are recommended to eat a wide variety of foods from the five core food groups (fruit, vegetables, cereals, lean meat and/or their alternatives and reduced-fat dairy products and/or their alternatives), to choose lean, reduced-fat meats and dairy products and to limit processed meats.

Top five tips for achieving a plant-based diet:

  • try some meat-free meals each week – include alternatives such as eggs, beans and tofu.
  • replace some of the meat with legumes – for example only add half the amount of beef and top up with chickpeas.
  • choose wholegrain cereals more often than white varieties – such as wholemeal bread and pasta.
  • eat a variety of colours of fresh vegetables and fruits and buy fresh produce in season.
  • canned and frozen vegetables are nutritious too – choose options low in salt and sugar.
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Four myths about water fluoridation and why they’re wrong

Image of a child drinking Adding fluoride to tap water to prevent  
tooth decay is one of our greatest public health achievements.
Yet, myths persist about whether it’s safe and works.

Evidence gathered over 60 years about adding fluoride to drinking water has failed to convince some people this major public health initiative is not only safe but helps to prevent tooth decay.

Myths about fluoridated water persist. These include fluoride isn’t natural, adding it to our water supplies doesn’t prevent tooth decay and it causes conditions ranging from cancer to Down syndrome.

Now the National Health and Medical Research Council (NHMRC) is in the process of updating its evidence on the impact of fluoridated water on human health since it last issued a statement on the topic in 2007.

Its draft findings and recommendations are clear cut:

NHMRC strongly recommends community water fluoridation as a safe, effective and ethical way to help reduce tooth decay across the population.

It came to its conclusion after analysing the evidence and issuing a technical report for those wanting more detail.

Here are four common myths the evidence says are wrong.

1. Fluoride isn’t natural

Fluoride is a naturally occurring substance found in rocks that leaches into groundwater; it’s also found in surface water. The natural level of fluoride in the water varies depending on the type of water (groundwater or surface) and the type of rocks and minerals it’s in contact with.

Fluoride is found in all natural water supplies at some concentration. Ocean water contains fluoride at around 1 part per million, about the same as levels of fluoridated drinking waterin Australia.

There are many places in Australia where fluoride occurs naturally in the water supply at optimum levels to maintain good dental health. For example, both Portland and Port Fairyin Victoria have naturally occurring fluoride in their water at 0.7-1.0 parts per million. 

What is the Difference Between Natural Fluoride and the Kind That is Artificially Added to Our Water Supply? |… http://fb.me/308yYJL8N 

The type of fluoride commonly found in many rocks and the source of the naturally occurring fluoride ion in water supplies is calcium fluoride.

The three main fluoride compounds generally used to fluoridate water are: sodium fluoridehydrofluorosilicic acid (hexafluorosilicic acid) and sodium silicofluoride. All these fully mix (dissociate) in water, resulting in the availability of fluoride ions to prevent tooth decay.

So regardless of the original compound source, the end result is the same – fluoride ions in the water.

2. Fluoridated water doesn’t work

What doesn’t work to improve oral health? Fluoridated water. What’s the solution? More fluoridated water.

Evidence for water fluoridation dates back to US studies in the 1940s, where dental researchers noticed lower levels of tooth decay in areas with naturally occurring fluoride in the water supply.

This prompted a study involving the artificial fluoridation of water supplies to a large community, and comparing the tooth decay rates to a neighbouring community with no fluoride.

The trial had to be discontinued after six years because the benefits to the children in the fluoridated community were so obvious it was deemed unethical to not provide the benefits to all the children, and so the control community water supply was also fluoridated.


Further reading: How fluoride in water helps prevent tooth decay


Since then, consistently we see lower levels of tooth decay associated with water fluoridation, and the most recent evidence, from Australia and overseas, supports this.

The NHMRC review found children and teenagers who had lived in areas with water fluoridation had 26-44% fewer teeth or surfaces affected by decay, and adults had 27% less tooth decay.

A number of factors are likely to influence the variation across populations and countries, including diet, access to dental care, and the amount of tap water people drink.

3. Fluoridated water causes cancer and other health problems

Despite widespread belief in fluoride’s safety, activists north of Boston push to eliminate it from water supplies http://ow.ly/IhzRq 

The NHMRC found, there was reliable evidence to suggest water fluoridation at current levels in Australia of 0.6-1.1 parts per million is not associated with: cancer, Down syndrome, cognitive problems, lowered intelligence, hip fracture, chronic kidney disease, kidney stones, hardening of the arteries, high blood pressure, low birth weight, premature death from any cause, musculoskeletal pain, osteoporosis, skeletal fluorosis (extra bone fluoride), thyroid problems or other self-reported complaints.


Further reading: Why do some controversies persist despite the evidence?


This confirms previous statements from the NHMRC on the safety of water fluoridation, and statements from international bodies such as the World Health Organisation, the World Dental Federation, the Australian Dental Association and the US Centers for Disease Control and Prevention.

Most studies that claim to show adverse health effects report on areas where there are high levels of fluoride occurring naturally in the water supply. This is often more than 2-10 parts per million or more, up to 10 times levels found in Australian water.

These studies are also often not of the highest quality, for example with small sample sizesand not taking into account other factors that may affect adverse health outcomes.

There is, however, evidence that fluoridated water is linked to both the amount and severity of dental fluorosis. This is caused by being exposed to excess fluoride (from any source) while the teeth are forming, affecting how the tooth enamel mineralises.

Most dental fluorosis in Australia is very mild or mild, and does not affect the either the function or appearance of the teeth. When you can see it, there are fine white flecks or lines on the teeth. Moderate dental fluorosis is very uncommon, and tends to include brown patches on the tooth surface. Severe dental fluorosis is rare in Australia.

4. Fluoridated water is not safe for infant formula

Some people are concerned about using fluoridated water to make up infant formula.

Mothers—please do not use tap water for your baby formula. It is not safe because of the fluoride in the water.
However, all infant formula sold in Australia has very low levels of fluoride, below the threshold amount of 17 micrograms of fluoride/100 kilojules (before reconstitution), which would require a warning label.

Therefore, making up infant formula with fluoridated tap water at levels found in Australian (0.6-1.1 parts per million) is safe, and does not pose a risk for dental fluorosis. Indeed, Australian research shows there is no association between infant formula use and dental fluorosis.

A consistent message

Adding fluoride to tap water to prevent tooth decay is one of our greatest public health achievements, with evidence gathered over more than 60 years showing it works and is safe. This latest review, tailored to Australia, adds to that evidence.

This article was written by:

 

 

 

 

 

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A short history of vaccine objection, vaccine cults and conspiracy theories

Image of an old anti-vaccination poster

 Edward Jenner, who pioneered vaccination, and two colleagues (right) 
seeing off three anti-vaccination opponents, with the dead lying at 
their feet (1808). I Cruikshank/Wellcome Images/Wikimedia Commons

When we hear phrases like vaccine objectionvaccine refusal and anti-vaxxers, it’s easy to assume these are new labels used in today’s childhood vaccination debates.

But there’s a long history of opposition to childhood vaccination, from when it was introduced in England in 1796 to protect against smallpox. And many of the themes played out more than 200 years ago still resonate today.

For instance, whether childhood vaccination should be compulsory, or whether there should be penalties for not vaccinating, was debated then as it is now.

Throughout the 19th century, anti-vaxxers widely opposed Britain’s compulsory vaccination laws, leading to their effective end in 1907, when it became much easier to be a conscientious objector. Today, the focus in Australia has turned to ‘no jab, no pay’ or ‘no jab, no play’, policies linking childhood vaccination to welfare payments or childcare attendance.

Of course, the methods vaccine objectors use to discuss their position has changed. Today, people share their views on social media, blogs and websites; then, they wrote letters to newspapers for publication, the focus of my research.

Many studies have looked at the role of organised anti-vaccination societies in shaping the vaccination debate. However, “letters to the editor” let us look beyond the inner workings of these societies to show what ordinary people thought about vaccination.

Many of the UK’s larger metropolitan newspapers were wary of publishing letters opposing vaccination, especially those criticising the laws. However, regional newspapers would often publish them.

As part of my research, I looked at more than 1,100 letters to the editor, published in 30 newspapers from south-west England. Here are some of the recurring themes.

Smallpox vaccination a gruesome affair

In 19th century Britain, the only vaccine widely available to the public was against smallpox. Vaccination involved making a series of deep cuts to the arm of the child into which the doctor would insert matter from the wound of a previously vaccinated child.

These open wounds left many children vulnerable to infections, blood poisoning and gangrene. Parents and anti-vaccination campaigners alike described the gruesome scenes that often accompanied the procedure, like this example from the Royal Cornwall Gazette from December 1886:

Some of these poor infants have been borne of pillows for weeks, decaying alive before death ended their sufferings.

Conspiracy theories and vaccine cults

Side-effects were so widespread many parents refused to vaccinate their children. And letters to the editor show they became convinced the medical establishment and the government were aware of the dangers of vaccination.

If this was the case, why was vaccination compulsory? The answer, for many, could be found in a conspiracy theory.

Their letters argued doctors had conned the government into enforcing compulsory vaccination so they could reap the financial benefits. After all, public vaccinators were paid a fee for each child they vaccinated. So people believed compulsory vaccination must have been introduced to maximise doctors’ profits, as this example from the Wiltshire Times in February 1894 shows:

What are the benefits of vaccination? Salaries and bonuses to public vaccinators; these are the benefits; while the individuals who have to endure the operation also have to endure the evils which result from it. Health shattered, lives crippled or destroyed – are these benefits?

Conspiracy theories went further. If doctors knew vaccination could result in infections, then they knew children died from the procedure. As a result, some conspiracy theorists began to argue there was something inherently evil about vaccination. Some saw vaccination as “the mark of the beast”, a ritual perpetuated by a “vaccine cult”. Writing in the Salisbury Times, in December 1903, one critic said:

This is but the prototype of that modern species of doctorcraft, which would have us believe that their highly remunerative invocations of the vaccine god alone avert the utter extermination of the human race by small-pox.

Of course, this is an extreme view. But issues of morality and religion still permeate the anti-vaccination movement today.

Individual rights

For many, the issue of compulsory vaccination was directly related to the rights of the individual. Just like modern anti-vaccination arguments, many people in the 19th century believed compulsory vaccination laws were an incursion into the rights enjoyed by free citizens.

By submitting to the compulsory vaccination laws, a parent was allowing the government to insert itself into the individual home, and take control of a child’s body, something traditionally protected by the parent. Here’s an example from the Royal Cornwall Gazette in April 1899:

[…] civil and religious liberty must of necessity include the right to protect healthy children from calf-lymph defilement […] trust […] cannot be handed over at the demand of a medical tradesunion, or tamely relinquished at the cool request of some reverend rural justice of the peace.

What can we learn by looking at the past?

If anti-vaccination arguments from the past significantly overlap with those presented by their counterparts today, then we can learn about how to deal with anti-vaccination movements in the future.

Not only can we see compulsory vaccination laws in Australia could, as some researchers say, be problematic, we can use the history of vaccine opposition to better understand why vaccination remains so controversial for some people.

This article was co-written by:

 

 

 

 

 

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Viewpoints: should euthanasia be available for people with existential suffering?

Image of a woman standing alone looking out to seaExistential suffering refers to an  
individual experiencing a lack of meaning or sense of purposelessness 
in life.

Euthanasia debates often focus on people experiencing unbearable physiological or psychological suffering. But research suggests “loss of autonomy” is the primary reason for requesting euthanasia, even among patients with terminal cancer. There have also been suggestions existential suffering could be one of the main motivations behind such requests.

Existential suffering refers to an individual experiencing a lack of meaning or sense of purposelessness in life. Such sentiments bring feelings of weariness, numbness, futility, anxiety, hopelessness and loss of control, which may lead a dying patient to express a desire for death.

Some bioethicists argue it is inconsistent to allow euthanasia for terminal illness but not for existential suffering, as both are a source of profound pain and distress. While existential suffering usually tracks closely with catastrophic illness, it’s worth considering a situation in which there are no motivating medical reasons for a request for euthanasia or assisted suicide. Should a person be eligible purely on the basis they no longer wish to live?

A case in point: a largely healthy retired palliative care nurse in the UK who ended her life at an assisted suicide clinic in Switzerland. Should she have received medical aid in dying based on her carefully considered decision that she did not want to subject herself to the perceived awfulness of the ageing process?


The case against

Xavier Symons, Research Associate, University of Notre Dame Australia

Some may think people who request euthanasia do so because of excruciating and unremitting pain. The reality is almost always more complex. Literature on assisted dyingsuggests individuals who request euthanasia are typically suffering from a profound sense of purposelessness, loss of dignity, loss of control, and a shattered sense of self.

A 2011 study of Dutch patients who requested euthanasia indicated that “hopelessness” – the psychological and existential realisation one’s health situation will never improve – was the predominant motivation of patients who requested euthanasia.

And a recently published Canadian study of requests for medical assistance in dying stated “loss of autonomy was the primary reason” motivating patients to end their lives. Symptoms also included “the wish to avoid burdening others or losing dignity and the intolerability of not being able to enjoy one’s life”.

One option to address such requests is to establish a state apparatus to assist patients in ending their lives. An alternative, and one I would advocate, is to address deficiencies in health care infrastructure, and attempt to alleviate the unique suffering that drives patients to request euthanasia in the first place.

Image of a helping hand
Spiritual or existential care can help someone who feels their life has lost meaning. from shutterstock.com

New approaches to end of life care, such as spiritual or existential care, engage at a deep level with the complexity of the suffering of patients with terminal illness. And, as has been stressed by several commentators, there is a need to improve access to palliative care in poorer regions, and provide optimal symptom management for patients wishing to die at home.

We could hypothesise about various situations where a person might request euthanasia without having a medical condition. Someone might wish to hasten their death because they are tired of life or afraid of ageing or death.

These cases are interesting insofar as they are not motivated by an underlying pathology. Yet there is much reason for concern.

Sanctioning euthanasia for the tired of life veers too close to a government endorsement of suicide. Where the state has a significant stake in suicide prevention, sanctioned euthanasia for existential suffering is not only counterproductive, it’s dangerous. Fundamentally, we would erode any meaningful difference between cases of suicide we regard as acceptable, and those we see as regrettable and befitting state intervention.

We might regard it as regrettable that an educated, wealthy 30-year-old takes their own life due to an existential crisis. Yet it is difficult to say how this is different in morally relevant respects from a 75-year-old who feels their life is complete and is undergoing an existential crisis.


The case for

Udo Schuklenk, Professor and Ontario Research Chair in Bioethics, Queen’s University, Canada

This discussion is mostly hypothetical. There seem to be few, if any, real-world cases where a competent person’s request for an assisted death is not motivated by an irreversible clinical condition that has rendered their lives not worth living in their considered judgement.

For instance, in the Netherlands, most people who ask for euthanasia and who are not suffering from a catastrophic illness, typically experience a terrible quality of life that is caused by an accumulation of usually age-related ailments. These involve anything from incontinence to deafness, blindness, lack of mobility and the like.

We do not give up on life for trivial reasons. Just think of the many refugees who – on a daily basis – are willing to risk their lives to escape an existence they do not consider worth living. Ending their lives is not typically on top of their to-do list.

Image of a man appearing to die in the desert
Think of the many refugees who risk their lives to escape an existence they do not consider worth living. Ending their lives is not on top of their to-do list.ZEIN AL-RIFAI/EPA

The case of the anti-choice activists – who deny there is ever a justifiable reason for euthanasia – has been intellectually and politically defeated. None of the jurisdictions that have decriminalised assisted dying have reversed course, and more jurisdictions are bound to make this end-of-life choice available.

Public support remains strong in each permissive jurisdiction, particularly so in Belgium and the Netherlands where the majority of citizens support the existing laws.

Inevitably the question of scope must be addressed: who ought to be eligible to ask for and receive assistance in dying? If a competent person wishes to see their life ended for non-medical reasons, and asks for assistance to do so, I think a just society ought to oblige him or her if the following conditions are met:

  1. the person has decisional capacity (is of “sound mind”)
  2. the decision is reached voluntarily (without coercion)
  3. no reasonable means are available, that are acceptable to the person, that would render their lives worth living again in their own best judgement
  4. based on everything we know, the condition that motivated their request is irreversible.

The view that medicine is a profession aimed only at maintaining life, regardless of a patient’s quality of life, is dying its own death. If a clinical, psychological or other professional intervention does not benefit a patient to such an extent that they consider their continuing existence worthwhile, by definition that is not a beneficial intervention.

Equally, if an intervention, at a burden acceptable to the person, renders in their considered judgement their lives worth living again, they will not ask for an assisted death.

In most corners of the world people have fought hard to increase their individual freedoms to live their lives by their own values. A significant state interest is harmed if the state wishes to infringe on such autonomy rights.


Xavier Symons

It is true the health system, and indeed the state, should respect patient autonomy. Yet in practice we often put other considerations ahead of concerns like autonomy. Patients may not receive the treatments they request for a variety of reasons, like they may be prohibitively expensive, have a negligible chance of success, or no medical justification.

I believe if it is harmful to the interests of the state to legalise euthanasia for patients without a terminal illness, then the state has a right to refuse.

Significantly more research needs to be conducted on the social impacts of euthanasia, and physician assisted suicide, for patients without a medical condition. In this case, we have no “Oregon model” – an assisted suicide regime seen by many as an example of a safe and well-regulated system – to confirm or assuage our concerns. Jurisdictions such as Oregon only allow assisted suicide for patients with a terminal illness.


Udo Schuklenk

I echo Xavier’s plea to improve health care in order to improve our quality of life, and, as a likely corollary of this, to reduce the number of requests for medical aid in dying. However, even in the best of all possible health care worlds, unless unbearable suffering itself has been eliminated, some patients will ask for an assisted death. No amount of “dignity therapy” rhetoric and references to small-scale studies changes that fact of the matter.

Xavier correctly mentions some reasons for doctors justifiably not providing certain patient-requested medical care. They are all based in different ways on harm-to-others justifications such as resource allocation rationales, or are futility-related (arguably also a case of harm-to-others given the reality of limited health care resources). This reasoning is not applicable to the case under consideration given the self-regarding nature of the request.

Xavier is correct that the state would be under no obligation to legalise euthanasia for not catastrophically ill patients if that was significantly harmful to the interests of the state. However, there is no evidence that the availability of euthanasia is harmful to state interests.

This article was co-aithored by:

Image of Xavier Symons

Xavier Symons – [Research Associate, University of Notre Dame Australia]

and 

Image of  Udo Schüklenk

 Udo Schüklenk – [Ontario Research Chair  in Bioethics and Public Policy, Queens College, Ontario] 


If this article has raised issues for you or anyone you know, call or visit Lifeline 13 11 14 www.lifeline.org.au, or the Suicide Call Back Service 1300 659 467 www.suicidecallbackservice.org.au

 

 

 

 

 

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Surgery to make intersex children ‘normal’ should be banned

Surgery to make intersex children ‘normal’ should be banned Intersex people are born with sexual anatomy 
that doesn’t fit binary notions of male or female bodies. 

Questions in the proposed new citizenship test that address family violence, child marriage and female genital mutilation imply opposition to these is an Australian value.

Indeed most Australians would agree female genital mutilation is an appalling breach of a girl’s right to bodily integrity, and that safeguarding children from violence is a vital goal in modern society. But protection from genital cutting should not only be granted to girls, but to all children.

While condemning female genital mutilation, Australian society appears to broadly accept routine circumcision of young boys, and genital modification surgeries on intersex children where the child’s genitals are reconstructed to resemble those typical of either a male or female. These procedures are legal and supported by Medicare.

In most cases, circumcisions and intersex surgeries occur without medical necessity or urgency: the children are healthy and no adverse medical consequences will arise if the surgery is not carried out immediately. Importantly, children undergoing such surgeries are often too young to understand what is happening to them and are legally too young to provide their consent.

Human rights concerns about underage male circumcision have been discussed in the past, yet infringements suffered by intersex children are an emerging area of controversy. Medically unnecessary, non-consensual intersex genital modification should be made illegal in Australia in the same way as female genital mutilation.

Children with intersex variations

Intersex children are born with sex characteristics, including genitals, gonads (testes and ovaries) and chromosome patterns, that do not fit typical binary notions of male or female bodies.

Nearly 2% of Australia’s population have intersex variations, which may not always be apparent at birth and may reveal themselves at puberty or later in life. While some intersex people may have atypical external genitalia, others may not.

Intersex variations describe physical or bodily traits – they do not describe gender or sexuality. Like non-intersex folks, intersex people may identify with any number of gender or sexual identities.


Read more: Boy, girl or …? Dilemmas when sex development goes awry


Genital “normalising” surgery

Many intersex children undergo what proponents call genital “normalising” procedures, which implies these children’s bodies are abnormal. The procedures, intended to make the children conform to social norms of male or female bodies, often include irreversible surgical modification of sexual organs. These may result in sterilisation by removal of their gonads (testes or ovaries), and life-long hormone treatments.

Those who advocate for these procedures to be carried out when children are still young often argue the chances of medical success are higher and the children will be able to grow up with a consistent gender identity. However, this ignores the human rights of these children to independently develop a gender identity and decide for themselves whether they want their bodies to be altered irreversibly.

Childs drawing showing a male and a female with genitals
Safeguarding children from violence is a vital goal in modern society. Man-wise/flickr

There are many examples of intersex people who, as children, were subjected to “normalising” procedures without their consent. In the 1970s, intersex advocate Georgie Yovanovic went through forced medical examinations, hormone treatments, surgery to descend her testicles, and ultimately a unilateral mastectomy without her consent or any explanation from doctors when she was a child and teenager.

Alice Springs-based musician Shon Klose was born without internal female organs. As a teenager in the 1980s, she was pressured into having medical treatment to create a vagina to have a more typical female body capable of heterosexual penetration. She did not receive any medical counselling, support or information.

Genital “normalising” procedures on young children still occur in Australia today. The recent Family Court of Australia case of five-year-old Carla is an example. Carla was born genetically male but with the external appearance of a female child and had undergone early childhood surgery to enhance the appearance of her genitalia.

In 1992, the High Court of Australia had established a precedent in Marion’s Case, that parents cannot consent on behalf of their children to have certain types of medical procedures, which therefore require court authorisation. Consequently, in 2015 Carla’s parents, who were raising her as a girl, sought permission to have her gonads surgically removed, which the Family Court granted.

Human rights violation

Greater visibility of intersex people is driving increasing resistance to these procedures. There is now growing global criticism of genital modification procedures on intersex children as a violation of human rights.

In 2013, Europe’s leading human rights organisation, the Council of Europe, identified intersex genital modification as a non-medically justified violation of children’s right to physical integrity. The Council encouraged states to “guarantee bodily integrity, autonomy and self-determination” to intersex people.

In 2015, Malta became the first country to explicitly outlaw the practice. No other country has done so at the time of writing. In the same year, the United Nations Office of the High Commissioner for Human Rights (OHCHR) held a conference to address what it called the human rights violations faced by intersex people. As the first of its kind, the meeting broadened global awareness of intersex issues and genital modification specifically.

Shortly after this, twelve UN entities including the OHCHR, UNICEF and the World Health Organisation, released a joint statement condemning anti-LGBTI discrimination and violence. They specifically pointed out that LGBTI persons may face

abuse in medical settings, including unethical and harmful so-called “therapies” to change sexual orientation, forced or coercive sterilization, forced genital and anal examinations, and unnecessary surgery and treatment on intersex children without their consent.

So, what about Australia?

There is growing awareness in Australia of the potential human rights abuses on intersex children.

A 2013 federal senate inquiry into the involuntary or coerced sterilisation of intersex people found there is no medical consensus regarding how and when genital “normalising” surgery should be conducted.

Among the committee’s recommendations was that all intersex medical procedures be managed by multidisciplinary teams in a human rights framework, and require authorisation by a court or tribunal. These recommendations did not lead to policy changes or legislative reform.

In 2016, Australian Human Rights Commissioner Ed Santow endorsed international calls to end medically unnecessary procedures to safeguard the human rights of intersex children.

In February 2017, the Rationalist Society of Australia – a secular free thought organisation – published its white paper on genital autonomy. This condemns all forms of medically unnecessary, non-consensual genital modification as violations of human rights. The white paper calls for the criminalisation of these procedures on equal footing with the prohibition of female genital mutilation.

Despite increasing international and national awareness of the human rights violations caused by genital modification procedures, Australia has not reformed its laws. Yet rights to bodily integrity and autonomy should be protected for all children. Until we safeguard every child from all forms of violence, opposition to genital cutting will not be an Australian value.

This article was authored by:

 

 

 

 

 

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Essays on health: microbes aren’t the enemy, they’re a big part of who we are

Mictobes aren't the enemy Modern diets are changing the 
compositions of our gut microbiota,and with that, our personalities.
We have long believed that “good” immune cells recognise and defend against “bad” invaders. That’s why a large proportion of medicine has been directed at killing microbial enemies and conquering microbial infections.

This militaristic understanding of immunity reflected the culture of the 20th century, which was dominated by nation building and world wars between “us” and “them.” It was a time when “survival of the fittest” came to be seen as the driver of evolution and competition and war were considered a natural part of what it is to be human.

But a radical shift in understanding the relationship between humans and microorganisms occurred with the discovery that only 50% of the cells in our bodies are human. The rest are microbes, such as bacteria, yeasts (members of the fungus family), viruses, and even insects. Together, these make up the microbiome.

Drawing of the digestive process
There are millions of microorganisms in our gut.from shutterstock.com
The 23,000 genes that comprise the human genome pale in comparison with the 3.3 million genes in the microbes that live in our guts. These produce proteins that help us digest food and support our immune systems.
 

Through the gut-brain axis, these genes even influence mood and memory. The gut-brain axis is a set of communication pathways between the gut and brain occurring largely through the actions of the gut microbiome.

Because we have evolved with microorganisms inside us, we now have specialised communities in our guts, on our skin, and in our mouths. Our microbes are understood to be so critical to our existence, many scientists consider us to be symbiotic organisms, made up of the host, the microbiome and the environment. This holy trinity is what they call the “holobiont”.

Considering human life as a function of the microbiome and our environment allows us to acknowledge that we may be affected by entities that harbour different evolutionary needs. For example, our food choices don’t just affect human health through nutrients and caloric balance, but also through their impacts on the gut microbiome.

Microbes and diet

The food we eat feeds our gut microbes and directly impacts their survival. Within two days of changing diet, our gut species change. Different gut bacteria thrive on different diets. For instance, Prevotella strains consume carbohydrates while Bacteroidetes prefer some fats, and Candida prefer glucose over protein. So, some species starve and others thrive based on what we eat.

The species in ours guts are also proving to be relevant to health and disease. Prevotella, for instance, has been linked to improved glucose tolerance and is much more prevalent in the guts of hunter-gatherer societies (such as the Hadza people in Tanzania) than those in Western societies. The reduction of Prevotella in gut-bacteria in Western populations is thought to partially explain modern epidemics such as diabetes and obesity.

Image of The Hadza people of Tanzania
The Hadza people of Tanzania have a much higher prevalence of glucose-tolerating Prevotella bacteria in their guts than those in Western societies.Woodlouse/Flickr, CC BY

It shouldn’t surprise us then, that microbes can shape our food choices to ensure their own survival. Some metabolites, the small byproducts of microbial digestion, can make us feel hungry, full or crave certain foods. However, the evidence in humans is so far somewhat circumstantial. A study of chocolate-craving and chocolate-indifferent people found different microbial metabolites in their urine, suggesting different bacteria were present in the gut.

Metabolites are important in terms of function, because we know these can send signals to the brain. Signals to regulate eating behaviour are also transmitted via the vagus nerve that runs between the brain and the gut. At least two human studies have shown blocking the vagus nerve induces weight loss in obesity, while stimulating it in rats has led to overeating.

Microbes and behaviour

Behaviour is also a function of the holobiont, not just the human host. Some metabolites are neuroactive, which means they can travel along the gut–brain axis and affect human mood, mental health and behaviour.

Much of the work exploring direct microbe-related behaviour has been done in mice and rats. These studies have had some pretty interesting results though. They’ve shown that behaviour can be transferred through poo transplants, that animals bred without any bacteria show unusual social and emotional behaviours, and that serotonin – the brain chemical associated with mood and depression – is produced largely in the gut. Together, these findings indicate a strong evidence base for the fact that the microbiome can affect host behaviour.

The best human evidence comes from the observed impacts of food on mood and behaviour – and microbes are the likely explanation. A good example is a study of healthy women some of whom consumed yogurt with a certain probiotic for one month. The researchers had the participants lie in a functional MRI scanner while they were shown pictures of faces with different emotions.

Those who had received the yogurt had reduced activity in the emotional processing brain regions, suggesting a dampening of the stress response, than those who didn’t have yogurt.

Image of a child with autism
Research suggests the gut microbiome may have a role in the development of autism spectrum disorders (ASD). from shutterstock.com

The protective value of a whole-food diet for depression also points to the importance of gut microbes for brain health. Mood disorders that can accompany conditions such as irritable bowel syndrome and inflammatory bowel diseases are thought to be related to microbial disruption in the bowel.

Recent research has also suggested the gut microbiome may have a role in the development of autism spectrum disorders (ASD). Research has found people with ASD have significantly higher numbers of Candida species in their intestines, for instance. Although determining causation is complicated, these microbes reduce the absorption of carbohydrates and release ammonia and other toxins which are thought to contribute to autistic behaviours.

There is also emerging evidence showing that differences in gut bacteria in children are related to behavioural problems, and potentially to future mental health risk.

There are numerous reports of changed gut bacteria in people experiencing mental illness such as schizophrenia and depression, as well as neurological disorders such as Parkinson’s disease. However, it is difficult to establish causation.

A compelling argument is made by studies that show microbiota transplants from people to mice actually change the behaviour of the recipient mice. One study used microbiota from people experiencing irritable bowel syndrome (IBS) and showed the mice who received the transplants experienced the same anxious behaviour that often accompanies IBS.

Changing the game

Cartoon image of a scientist with a microbe in a container
Many of our microbes aren’t good or bad, but they become bad because we change the game. from shutterstock.com
 We are ecosystems, whose members are intricately balanced by cooperation and competition. Many of our microbes are neither good nor bad. But they become bad because we change the game, giving them the opportunity to be bad.
 

For example, we are increasingly interfering in the ecosystem by using antibiotics and sanitisers, hormone and immune system treatments, cosmetic and plastic surgery, or biomedical implants and devices such as contact lenses or heart valves.

Although sanitation and nutrition have greatly improved in much of the world, antibiotic overuse has led to the rise of antibiotic resistant bacteria. Antibiotics also change what is in our microbiome. Many women would be familiar with Candida infections (thrush) that flourish after they use antibiotics, for instance.

Biomedical implants, contact lenses and dentures provide warm, moist and nutritious conditions for colonisation by microbes. Increased oestrogen use in birth control pills and other hormone treatments has been shown to promote yeast infection and reduce immune efficiency.

In fact, the hygiene hypothesis argues that infections help build our immune system and the proliferation of sanitising disinfectants in our homes could be contributing to skin allergies and respiratory conditions.

Image of a woman with deoderant
Body odours aren’t inherently unhealthy. from shutterstock.com

Our definitions of good and bad are cultural as much as biological. For example, body odours and stale breath which are caused by microbes are not inherently unhealthy, but the market for antiperspirants, deodorisers and mouthwash is flourishing. Increasing skin conditions, allergies and illness could be the result of our attempts to control and groom our microbes, good and bad.

Our diets have also changed rapidly and the flow–on changes to both human and microbial health are apparent. Non–communicable disease epidemics such as obesity and heart disease are clear consequences of highly processed foods and increasingly inactive lifestyles.

The changing modern diet may also have effects over generations, as we pass on our microbial communities to our children. Research in mice has found some bacterial strains could not recover in the grandchildren of mice fed low–fibre western diets, even when a high–fibre diet was reintroduced. It may not be long then, before the modern western diet will have irrevocably changed the gut bugs and health of future humans.

Rethinking the metaphor

For most of the twentieth century, we were at war with microbes. Vigilant immune systems defended against vicious and sneaky microbial attacks. The cold and flu medication Codral, as just one example, famously helped us “soldier on.”

We have to rethink this militaristic metaphor. If we are a complex ecosystem which relies on the microbes in it, we cannot wage war against them. If microbes are part of our immune systems, who is fighting whom?

How we talk about our microbes reflects how we think about ourselves and others. As holobionts, we need to figure out how to live with all the members of our bodies. How might our worlds (and bodies) be different if we behave as resilient communities where the “others” are different selves, rather than invaders, terrorists, colonisers, or competitors?

This essay was co-written by:
Image of Amy LoughmanAmy Loughman – [Associate Lecturer, Industry Fellow, RMIT University]
and
Image of Tarsh BatesTarsh Bates – [PhD candidate, University of Western Australia]

 


The authors will be presenting on this topic at the upcoming Emerging Issues in Science and Society event at Deakin University on Thursday, 6 July 2017. For more information and to book tickets, see the event’s website.

 

 

 

 

 

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Get headaches? Here’s five things to eat or avoid

How to avoid HeadachesDrinking more water can help with headaches. 

Last week I had a headache. Two hours in a traffic jam, hot day, no water, plans thrown into chaos. That day I was one of the five million Australians affected by headache or migraine. Over a year one person in two will experience a headache.

Mine was a “tension-type” headache, the most common category. Migraines are less common but about one person in eight will experience one in any given year.

Headaches are really common, so here are five things the research evidence indicates are worth trying to help manage or avoid them.

1. Water

A study was conducted in people who got at least two moderately intense or more than five mild headaches a month. The participants received a stress management and sleep quality intervention with or without increasing their water intake by an extra 1.5 litres a day.

The water intervention group got a significant improvement in migraine-specific quality of life scores over the three months, with 47% reporting their headaches were much improved, compared to 25% of the control group.

However, it did not reduce the number or duration of headaches. Drinking more water is worth a try. Take a water bottle everywhere you go and refill it regularly to remind you to drink more water.

2. Caffeine

Caffeine can have opposing effects. It can help relieve some headaches due to analgesic effects but also contribute to them, due to caffeine withdrawal. A review of caffeine withdrawal studies confirmed that getting a headache was the number one symptom of withdrawal, followed by fatigue, reduced energy and alertness, drowsiness, depressed mood, difficulty concentrating, fuzzy head and others.

When people were experimentally put though controlled caffeine withdrawal, 50% got a headache, with withdrawal symptoms occurring within 12-24 hours, peaking between 20-51 hours and lasting from two to nine days. Caffeine withdrawal can happen from a usual daily dose as low as 100 mg/day. One cup of brewed coffee contains 100-150mg caffeine, instant coffee has 50-100 mg depending on how strong you make it and a cup of tea can vary from 10-90mg. It appears that maintaining usual caffeine consumption may subconsciously relate to avoidance of withdrawal symptoms.

Image of a cup of coffee & cofee beans
Caffeine can lessen or worsen headaches.Jonathan Thursfiled

Caffeine can dampen down pain. in a systematic review that included five headache studies with 1,503 participants with migraine or tension-type headache, 33% of participants achieved pain relief of at least 50% of the maximum possible after receiving 100 mg or more caffeine plus analgesic pain medication (ibuprofen or paracetamol) compared to 25% for the analgesic group alone.

study in over 50,000 Norwegians, who have high caffeine intakes (more than 400 milligrams a day), examined the relationship with headaches. Those with the highest caffeine intakes (more than 540mg/day) were 10% more likely to get headaches, including migraine.

But when headache frequency was examined, high caffeine consumers were more likely to experience non-migraine headaches infrequently (less than seven per month) compared to those considered low caffeine consumers (less than 240mg a day). This was attributed to potential “reverse causation” where high caffeine consumers use caffeine to damp down headache pain. They found those with the lowest caffeine intakes (125mg a day) were more likely to report more than 14 headaches per month, which may have been due to greater sensitivity and avoidance of caffeine.

Hypnic headaches are a rare type that occurs in association with sleep. They typically last 15-180 minutes and are more common in the elderly. Hypnic headaches are treated by giving caffeine in roughly the amount found in a cup of strong coffee.

3. Fasting

Some people get a headache after fasting for about 16 hours, which equates to not eating between 6pm and 10am the next day. A study in Denmark found one person in 25 has been affected by a fasting headache. These headaches are most likely to occur when fasting for a blood test or medical procedure or if you are following a “fasting” weight loss diet or a very low energy meal replacement diet.

Fasting headaches are likely to be confounded by caffeine withdrawal. Check the test procedure instructions to see what fluids, such as tea, coffee and water are allowed and drink within those recommendations.

In a study 34 people with new-onset migraine who kept a headache diary for about a month, those who ate a night-time snack were 40% less likely to experience a headache compared to those who didn’t snack. For susceptible individuals this may prevent fasting headaches. Try a slice or wholegrain toast with a topping like cheese and tomato or avocado and tuna, with a cuppa.

4. Alcohol

Headache is the classic feature of alcohol induced hangovers. The amount of alcohol needed to trigger a hangover varies widely between individuals, from one drink to many. A number of factors mash up to produce a throbbing post alcohol headache. Increased urination and vomiting both increase risk of dehydration which leads to changes in blood and oxygen flowing to the brain.

Congeners, a group of chemicals produced in small amounts during fermentation, give alcoholic drinks their taste, smell and colour. Metabolites of alcohol breakdown in the liver can cross the blood-brain barrier contributing to hangover.

Alcohol can trigger tension-type headaches, cluster headaches and migraine. People with migraines have been shown to have lower alcohol intakes  compared to others. The wise advice is to drink responsibly, boost your water intake and don’t drink on an empty stomach. If you are sensitive to alcohol, avoidance is your best option.

5. Boost your intake of folate-rich foods

Image of a bowl of fresh vegetables
More folate in your diet helps migraines. ahmadpi/flickr

Some migraineurs are diet-sensitive. Triggers include cheese, chocolate, alcohol or other specific foods. A recent study found women with low dietary folate intakes had more frequent migraines. However a daily folic acid (1mg) supplement made no difference.

Boost your intake of foods rich in folate such as green leafy vegetables, legumes, seeds, chicken, eggs and citrus fruits. Use our Healthy Eating Quiz to check your nutrition, diet quality and variety. Keep a headache diary to identify triggers and then discuss it with your GP.

This article was written by:
Image of Clare Collins
Clare Collins – [Professor in Nutrition and Dietetics, University of Newcastle]

 

 

 

 

 

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Stigma and lack of awareness stop young people testing for sexually transmitted infections

 

Stigma-and-lack-of-awareness-stop-young-people-testing-for-sexually-transmitted-infectionsYoung people are disproportionately affected by 
sexually transmitted infections, but they face several barriers to getting tested.

Sexually transmitted infections (STIs) have afflicted humans for as long as records exist, but despite significant medical advances, we are not managing to keep them at bay. Instead, we see rising infection rates and even the re-emergence of some old foes, including syphilis.

Young people are disproportionately affected by STIs. In New Zealand, 67% of chlamydia cases and 57% of gonorrhoea cases are among people between the ages of 15 and 24. This is not solely due to sexual behaviour. Young women, for example, are more vulnerable to STIs as the vagina’s natural defences to infection have not fully matured.

Early detection and treatment are crucial if we want to reduce infection rates. In our research, published today in the Australian and New Zealand Journal of Public Health, we identify several barriers that stop young people from being tested for STIs.

An ongoing battle against STIs

Even in the presence of a human papillomavirus (HPV) vaccine and sophisticated antiretroviral therapy to manage human immunodeficiency virus (HIV), the pathogens that cause these STIs are not yet beaten. They continue to infect people, and we are perpetually in response mode.

Since the discovery of penicillin, antibiotics have been used to fight the bacterial STIs, such as chlamydia, gonorrhoea and syphilis. However, in many countries infection rates remain a serious issue. In New Zealand, rates of some STIs are higher than in other countries. For example, diagnosed rates of chlamydia are around 1.4 to 1.7 higher than those reported in Australia, the USA and the UK.

What’s more, it has become apparent over the past few years that syphilis is staging a comeback. Rates of syphilis in the UK have doubled over the last five years, and similar trends have been reported for Australia, the USA and New Zealand.

Antibiotic resistance and STIs

Image of the bacterium that causes gonorrhoea
The bacterium that causes gonorrhoea has developed resistance to every single class of antibiotics introduced for its treatment since the mid-1930s. from www.shutterstock.com, CC BY-ND

Antibiotic resistance arises when an infectious microorganism is no longer susceptible to an antibiotic to which it was previously sensitive. If an infection has been identified to be resistant to a conventional treatment, it can usually be treated with an alternative antibiotic. However, the number of antibiotics available is limited, and multi-drug resistance is becoming a reality for several organisms.

The bacterium that causes gonorrhoea is one such organism. It has developed ways to resist every single class of antibiotics introduced for its treatment since the mid-1930s. The only options for first-line treatment for gonorrhoea are the extended spectrum cephalosporins. However, isolates with decreased susceptibility to cephalosporins have now been reported in several countries, including New Zealand.

After this antibiotic fails, there are no more treatment options. Without new therapies we face a return to the pre-antibiotic era, which would mean waiting for the body to naturally clear a gonorrhoea infection with only painkillers for comfort and months of abstinence to avoid onwards transmission.

Barriers to testing and treatment

Our research identifies several barriers to STI testing. One of the most common reasons young people don’t get tested is that they underestimate the risk of contracting an STI.

Some people, especially young men, were afraid of the test procedure itself, imagining it to be invasive and painful. However, a regular check during symptom-free times usually requires only a urine test.

Other barriers include the misconception most STIs are not serious, embarrassment about a physical examination, being too busy, and the cost of tests. Many study participants expressed a preference for a same-sex health professional, but most said they would not be deterred from having a test if that was not possible.

Finally, the stigma associated with STIs remains a pervasive barrier to testing. A diagnosis suggests a violation of social norms and values, such as engaging in unprotected sex, sex with multiple partners, or sex with disreputable partners. Some participants in our study reported they were worried about their reputation if they were seen going for a test.

Consequences of STIs

If left untreated, STIs can cause serious and painful health problems, such as pelvic inflammatory disease in women, which can result in infertility. Among men, there is also some evidence that untreated STIs can lead to infertility.

Complicating matters is the fact that some STIs, chlamydia for example, usually don’t cause any obvious signs or symptoms. Nevertheless, timely detection and treatment is important to prevent future health impacts for the individual as well as the spread to others.

Our results imply that making people aware of their own risk and the severity of STIs may be one way to encourage early testing. Making STI tests free for everyone would remove the cost barrier. In New Zealand, STI tests are generally free to those under 22, but may attract a fee for older people who seek testing through their general practitioner.

The biggest challenge, however, is to lessen the social stigma associated with STIs. Normalising these infections by talking about them more openly with friends and family, as well as highlighting the importance of testing as part of general health care is a step towards overcoming these barriers and helping to bring down STI rates over time.

This article was written by:

Image of Hayley DenisonHayley Denison – [ Researcher in Public Health, Massey University]

 

 

 

 

 

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What is ‘cognitive reserve’? How we can protect our brains from memory loss and dementia

Cognitive ReserveCognitive Reserve - Engaging in 
cognitively stimulating activities can help build your resilience to 
cognitive decline.

As we get older we have a greater risk of developing impairments in areas of cognitive function – such as memory, reasoning and verbal ability. We also have a greater risk of dementia, which is what we call cognitive decline that interferes with daily life. The trajectory of this cognitive decline can vary considerably from one person to the next.

Despite these varying trajectories, one thing is for sure: even cognitively normal people experience pathological changes in their brain, including degeneration and atrophy, as they age. By the time a person reaches the age of 70 to 80, these changes closely resemble those seen in the brains of people with Alzheimer’s Disease.

Even so, many people are able to function normally in the presence of significant brain damage and pathology. So why do some experience symptoms of Alzheimer’s and dementia, while others remain sharp of mind?

It comes down to something called cognitive reserve. This is a concept used to explain a person’s capacity to maintain normal cognitive function in the presence of brain pathology. To put it simply, some people have better cognitive reserve than others.

Evidence shows the extent of someone’s cognitive decline doesn’t occur in line with the amount of biological damage in their brain as it ages. Rather, certain life experiences determine someone’s cognitive reserve and, therefore, their ability to avoid dementia or memory loss.

How do we know?

Being educated, having higher levels of social interaction or working in cognitively demanding occupations (managerial or professional roles, for instance) increases resilience to cognitive decline and dementia. Many studies have shown this. These studies followed people over a number of years and looked for signs of them developing cognitive decline or dementia in that period.

Image of an older person thinking
As we get older we have a greater risk of developing impairments in cognitive function, such as memory. from shutterstock.com

Cognitive reserve is traditionally measured and quantified based on self reports of life experience such as education level, occupational complexity and social engagement. While these measures provide an indication of reserve, they’re only of limited use if we want to identify those at risk of cognitive decline. Genetic influences obviously play a part in our brain development and will influence resilience.

Brain plasticity

The fundamental brain mechanisms that underpin cognitive reserve are still unclear. The brain consists of complex, richly interconnected networks that are responsible for our cognitive ability. These networks have the capacity to change and adapt to task demands or brain damage. And this capacity is essential not only for normal brain function, but also for maintaining cognitive performance in later life.

This adaptation is governed by brain plasticity. This is the brain’s ability to continuously modulate its structure and function throughout life in response to different experiences. So, plasticity and flexibility in brain networks likely contribute in a major way to cognitive reserve and these processes are influenced by both genetic profiles and life experiences.

A major focus of our research is examining how brain connectivity and plasticity relate to reserve and cognitive function. We hope this will help identify a measure of reserve that reliably identifies individuals at risk of cognitive decline.

Strengthening your brain

While there is little we can do about our genetic profile, adapting our lifestyles to include certain types of behaviours offers a significant opportunity to improve our cognitive reserve.

Activities that engage your brain, such as learning a new language and completing crosswords, as well as having high levels of social interaction, increase reserve and can reduce your risk of developing dementia.

Image of a man jogging
Regular physical activity increases cognitive reserve. Jenny Hill/Unsplash

Regular physical activity also improves cognitive function and reduces the risk of dementia. Unfortunately, little evidence is available to suggest what type of physical activity, as well as intensity and amount, is required to best increase reserve and protect against cognitive impairment.

There is also mounting evidence that being sedentary for long periods of the day is bad for health. This might even undo any benefits gained from periods of physical activity. So, it is important to understand how the composition of physical activity across the day impacts brain health and reserve, and this is an aim of our work.

Our ongoing studies should contribute to the development of evidence-based guidelines that provide clear advice on physical activity patterns for optimising brain health and resilience.

This article was written by”
Image of Professor Michael RiddingProfessor Michael Ridding – [University of Adelaide]

 

 

 

 

 

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