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    Children as haematopoietic stem cell donors: ethically challenging and legally complex

    Shih-Ning Then, Ian H Kerridge and Michael Marks
    Med J Aust 2018; 208 (8): . || doi: 10.5694/mja17.00758
    Published online: 7 May 2018

    Clinicians should be aware of the particular physical and psychological risks of haematopoietic stem cell donation in the paediatric setting, and the varying laws between states and territories

    Allogeneic donor blood and bone marrow transplantation can treat a range of malignant and non-malignant diseases. For children with aplastic anaemia, severe combined immunodeficiency, leukaemia, sickle-cell disease, thalassaemia and inborn errors of metabolism, it may provide the only possibility of cure and long term survival. Although associated with considerable recipient mortality (5–12% transplant-related mortality at one year)1 and morbidity, advances in tissue typing, supportive care, patient selection, conditioning regimens and the prevention and treatment of graft-versus-host disease have dramatically improved outcomes, with up to 80% of recipients becoming long term survivors of bone marrow transplant.2

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      Parechovirus: an important emerging infection in young infants

      Philip N Britton, Cheryl A Jones, Kristine Macartney and Allen C Cheng
      Med J Aust 2018; 208 (8): . || doi: 10.5694/mja18.00149
      Published online: 30 April 2018

      Summary

       

      • Epidemics of human parechovirus (HPeV) causing disease in young children have occurred every 2 years in Australia since 2013. HPeV genotype 3 caused the epidemic from late 2017 to early 2018.
      • Most HPeV infections cause no or mild symptoms including gastroenteritis or influenza-like illness. Characteristically, young infants present with fever, irritability and on occasions a diffuse rash (“red, hot and angry” babies).
      • Severe disease can manifest as meningoencephalitis, seizures or sepsis-like presentations (including septic shock), or less common presentations including signs of surgical abdomen.
      • Testing for HPeV by specific molecular tests is indicated in children younger than 6 months of age with characteristic presentations without another confirmed diagnosis including febrile illnesses with other suggestive features (eg, rash, seizures), sepsis syndromes (including shock), and suspected meningoencephalitis (which may be detected by magnetic resonance imaging only).
      • There are no effective antiviral therapies. Treatment is primarily supportive, including management of complications.
      • Some infants with severe HPeV infection may have adverse neurodevelopment. Follow-up by a paediatrician is recommended.

       


      • 1 University of Sydney, Sydney, NSW
      • 2 The Children's Hospital at Westmead, Sydney, NSW
      • 3 University of Melbourne, Melbourne, VIC
      • 4 Melbourne Academic Centre for Health, Melbourne, VIC
      • 5 National Centre for Immunisation Research and Surveillance, Sydney, NSW
      • 6 Monash University, Melbourne, VIC


      Correspondence: allen.cheng@monash.edu
      Acknowledgements: 

      Allen Cheng and Philip Britton are supported by NHMRC Fellowship funding. We thank the PAEDS surveillance nurses and investigators and investigators on the Australian childhood encephalitis and related studies including Julia Clark, Nigel Crawford, Jim Buttery, Christopher Blyth, Joshua Francis, Brendan McMullan, Alison Kesson, Nicole Dinsmore, Alissa McMinn, Sonia Dougherty, Carolyn Finucane and Christine Heath.

      Competing interests:

      No relevant disclosures.

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        Presentations to NSW emergency departments with self-harm, suicidal ideation, or intentional poisoning, 2010–2014

        Jayashanki Perera, Timothy Wand, Kendall J Bein, Dane Chalkley, Rebecca Ivers, Katharine S Steinbeck, Robyn Shields and Michael M Dinh
        Med J Aust 2018; 208 (8): . || doi: 10.5694/mja17.00589
        Published online: 23 April 2018

        Abstract

        Objective: To evaluate population trends in presentations for mental health problems presenting to emergency departments (EDs) in New South Wales during 2010–2014, particularly patients presenting with suicidal ideation, self-harm, or intentional poisoning.

        Design, setting and participants: This was a retrospective, descriptive analysis of linked Emergency Department Data Collection registry data for presentations to NSW public hospital EDs over five calendar years, 2010–2014. Patients were included if they had presented to an ED and a mental health-related diagnosis was recorded as the principal diagnosis.

        Main outcome measures: Rates of mental health-related presentations to EDs by age group and calendar year, both overall and for the subgroups of self-harm, suicidal ideation and behaviour, and intentional poisoning presentations.

        Results: 331 493 mental health-related presentations to 115 NSW EDs during 2010–2014 were analysed. The presentation rate was highest for 15–19-year-old patients (2014: 2167 per 100 000 population), but had grown most rapidly for 10–14-year-old children (13.8% per year). The combined number of presentations for suicidal ideation, self-harm, or intentional poisoning increased in all age groups, other than those aged 0–9 years; the greatest increase was for the 10–19-year-old age group (27% per year).

        Conclusions: The rate of mental health presentations to EDs increased significantly in NSW between 2010 and 2014, particularly presentations by adolescents. Urgent action is needed to provide better access to adolescent mental health services in the community and to enhance ED models of mental health care. The underlying drivers of this trend should be investigated to improve mental health care.

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        • 1 Royal Prince Alfred Hospital, Sydney, NSW
        • 2 Sydney Nursing School, University of Sydney, Sydney, NSW
        • 3 The George Institute for Global Health, Sydney, NSW
        • 4 Flinders University, Adelaide, SA
        • 5 University of Sydney, Sydney, NSW
        • 6 Sydney Medical School, University of Sydney, Sydney, NSW


        Acknowledgements: 

        We acknowledge the NSW Ministry of Health and the Centre for Health Record Linkage (CHeReL) for granting access to and linkage of the data. This project was funded by the NSW Agency for Clinical Innovation and Emergency Care Institute.

        Competing interests:

        No relevant disclosures.

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          Tick-induced allergies: mammalian meat allergy and tick anaphylaxis

          Sheryl A van Nunen
          Med J Aust 2018; 208 (7): . || doi: 10.5694/mja17.00591
          Published online: 16 April 2018

          Summary

           

          • Mammalian meat allergy after tick bites and tick anaphylaxis are the most serious tick-induced allergies. They are often severe, should be largely avoidable and offer fascinating insights into the development and prevention of allergies.
          • Australian clinicians reported the first cases of tick anaphylaxis and discovered the association between tick bites and the development of mammalian meat allergy. The subsequent finding of the allergen epitope within the meat responsible for the allergic reaction, α-gal (galactose-α-1,3-galactose), stimulated further interest in this emergent allergy.
          • Reports of mammalian meat allergy associated with bites from several tick species have now come from every continent where humans are bitten by ticks. The number of diagnosed patients has continued to rise.
          • Clinically, mammalian meat allergy and tick anaphylaxis present quite differently. The prominent role of cofactors in triggering episodes of mammalian meat allergy can make its diagnosis difficult.
          • Management of mammalian meat allergy is complicated by the manifold potential therapeutic implications due to the widespread distribution of the mammalian meat allergen, α-gal. Exposures to α-gal-containing medications have proved lethal in a minority of people, and fatal tick anaphylaxis has been reported in Australia. Prevention of tick bites is prudent and practicable; killing the tick in situ is crucial to both primary and secondary prevention of allergic reactions.
          • Mechanisms in the development of mammalian meat allergy constitute a paradigm for how allergies might arise.

           


          • 1 Royal North Shore Hospital, Sydney, NSW
          • 2 Tick-Induced Allergies Research and Awareness Centre, Sydney, NSW


          Correspondence: vannunen@med.usyd.edu.au
          Competing interests:

          No relevant disclosures.

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            Damp housing, gas stoves, and the burden of childhood asthma in Australia

            Luke D Knibbs, Solomon Woldeyohannes, Guy B Marks and Christine T Cowie
            Med J Aust 2018; 208 (7): . || doi: 10.5694/mja17.00469
            Published online: 16 April 2018

            Abstract

            Objective: To determine the proportion of the national childhood asthma burden associated with exposure to dampness and gas stoves in Australian homes.

            Design: Comparative risk assessment modelling study.

            Setting, participants: Australian children aged 14 years or less, 2011.

            Main outcome measures: The population attributable fractions (PAFs) and number of disability-adjusted life years (DALYs) for childhood asthma associated with exposure to damp housing and gas stoves.

            Results: 26.1% of Australian homes have dampness problems and 38.2% have natural gas as the main energy source for cooktop stoves. The PAF for childhood asthma attributable to damp housing was 7.9% (95% CI, 3.2–12.6%), causing 1760 disability-adjusted life years (DALYs; 95% CI, 416–3104 DALYs), or 42 DALYs/100 000 children. The PAF associated with gas stoves was 12.3% (95% CI, 8.9–15.8%), corresponding to 2756 DALYs (95% CI, 1271–4242), or 67 DALYs/100 000 children. If all homes with gas stoves were fitted with high efficiency range hoods to vent gas combustion products outdoors, the PAF and burden estimates were reduced to 3.4% (95% CI, 2.2–4.6%) and 761 DALYs (95% CI, 322–1199).

            Conclusions: Exposure to damp housing and gas stoves is common in Australia, and is associated with a considerable proportion of the childhood asthma burden. Strategies for reducing exposure to indoor dampness and gas combustion products should be communicated to parents of children with or at risk of asthma.

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            • 1 University of Queensland, Brisbane, QLD
            • 2 Woolcock Institute of Medical Research, Sydney, NSW
            • 3 Liverpool Hospital, Sydney, NSW
            • 4 South Western Sydney Clinical School, University of New South Wales, Sydney, NSW


            Correspondence: l.knibbs@uq.edu.au
            Acknowledgements: 

            This work was supported by the National Health and Medical Research Council (Luke Knibbs: Early Career Fellowship [APP1036620]; Guy Marks: Centres of Research Excellence grant [APP1030259]), the Centre for Air Quality and Health Research and Evaluation (Luke Knibbs, Christine Cowie: postdoctoral fellowships), and the New South Wales Ministry of Health (funding to Christine Cowie and Guy Marks).

            Competing interests:

            No relevant disclosures.

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              Planetary health: what is it and what should doctors do?

              Anthony G Capon, Nicholas J Talley AC and Richard C Horton
              Med J Aust 2018; 208 (7): . || doi: 10.5694/mja18.00219
              Published online: 16 April 2018

              Planetary health is the business of the medical profession because the health of our patients is at risk

              During the lifetime of many MJA readers, there have been remarkable improvements in human health. Since 1950, global average life expectancy has risen 25 years to its current level of 72 years, and global infant mortality rates have decreased substantially from around 210 per 1000 live births to just over 30 per 1000 now.1-3

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              • 1 Professor of Planetary Health, University of Sydney, Sydney, NSW
              • 2 Editor-in-Chief, Medical Journal of Australia, Sydney, NSW
              • 3 Editor-in-Chief, Lancet, London, UK


              Correspondence: tony.capon@sydney.edu.au
              Competing interests:

              Anthony Capon is a member of the Editorial Advisory Committee. Anthony Capon and Richard Horton are members of the Commission on Planetary Health.

              • 1. Whitmee S, Haines A, Beyrer C, et al. Safeguarding human health in the Anthropocene epoch: report of the Rockefeller Foundation-Lancet Commission on planetary health. Lancet 2015; 386: 1973-2028.
              • 2. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World population prospects: the 2017 revision. New York: United Nations, 2017. https://www.un.org/development/desa/publications/world-population-prospects-the-2017-revision.html (viewed Feb 2018).
              • 3. Hug L, Shannon D, You D. Levels and trends in child mortality report 2017. New York: United Nations Inter-agency Group for Child Mortality Estimation; 2017. http://www.who.int/maternal_child_adolescent/documents/levels_trends_child_mortality_2017/en (viewed Feb 2018).
              • 4. Steffen W, Broadgate W, Deutsch L, et al. The trajectory of the Anthropocene: the great acceleration. The Anthropocene Review 2015; 2: 81-98.
              • 5. Hanna EG, McIver LJ. Climate change: a brief overview of the science and health impacts for Australia. Med J Aust 2018; 208: 311-315.
              • 6. Knibbs LD, Woldeyohannes S, Marks GB, Cowie CT. Damp housing, gas stoves, and the burden of childhood asthma in Australia. Med J Aust 2018; 208: 299-302.
              • 7. Horsley JA, Broome RA, Johnston FH, et al. Health burden associated with fire smoke in Sydney, 2001–2013. Med J Aust 2018; 208: 309-310.
              • 8. van Nunen SA. Tick-induced allergies: mammalian meat allergy and tick anaphylaxis. Med J Aust 2018; 208: 316-321.
              • 9. Pencheon D. Developing a sustainable health care system: the United Kingdom experience. Med J Aust 2018; 208: 284-285.
              • 10. McMichael AJ, Dear KB. Climate change: heat, health, and longer horizons. Proc Natl Acad Sci U S A 2010; 107: 9483-9484.
              • 11. Hussey R, Weatherup C. Lessons from Wales — how to embed sustainability and prevention in health care. Med J Aust 2016; 204: 102-103. <MJA full text>
              • 12. Malik A, Lenzen M, McAlister S, McGain F. The carbon footprint of Australian health care. Lancet Planet Health 2018; 2: e27-e35.
              • 13. Hippocrates. On air, waters and places. In: The genuine works of Hippocrates. Translated with a commentary by Francis Adams. London: Sydenham Society, 1849.
              • 14. Sveiby KE, Skuthorpe T. Treading lightly: the hidden wisdom of the world’s oldest people. Sydney: Allen and Unwin; 2006.
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                Preparing medical graduates for the health effects of climate change: an Australasian collaboration

                Diana L Madden, Michelle McLean and Graeme L Horton
                Med J Aust 2018; 208 (7): . || doi: 10.5694/mja17.01172
                Published online: 16 April 2018

                Building a medical workforce that understands the impact of climate change on health and health services and will create change

                The Lancet has described action to address climate change as the greatest public health opportunity before us.1 However, to grasp this opportunity, health professionals, including doctors, must understand the impact of climate change on health and be competent to take action and advocate for change. Otherwise it will be a missed opportunity when an urgent and scaled response to mitigate and adapt to climate change is required if society is to avoid the most harmful consequences. Medical degrees (primary medical programs) in Australia and New Zealand are responsible for preparing doctors for entry into clinical practice and to care for patients and their communities. In response to the health threats posed by climate change, Medical Deans of Australia and New Zealand (MDANZ) has formed a working group, representing medical schools and medical student associations across both countries, to work collaboratively to develop curricula and resources to address this within primary medical programs. This article summarises this initiative.


                • 1 University of Notre Dame Australia, Sydney, NSW
                • 2 Australasian Faculty of Public Health Medicine, Royal Australasian College of Physicians, Sydney, NSW
                • 3 Bond University, Gold Coast, QLD
                • 4 University of Newcastle, Newcastle, NSW


                Correspondence: lynne.madden@nd.edu.au
                Competing interests:

                No relevant disclosures.

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                  Tackling the worsening epidemic of Buruli ulcer in Australia in an information void: time for an urgent scientific response

                  Daniel P O'Brien, Eugene Athan, Kim Blasdell and Paul De Barro
                  Med J Aust 2018; 208 (7): . || doi: 10.5694/mja17.00879
                  Published online: 16 April 2018

                  Understanding risk factors is key to defining the source and transmission route of Mycobacterium ulcerans

                  Mycobacterium ulcerans causes an infectious disease known internationally as Buruli ulcer, and also as Bairnsdale ulcer or Daintree ulcer in Australia. It causes severe destructive lesions of skin and soft tissue, resulting in significant morbidity, in attributable mortality and often in long term disability and cosmetic deformity.1 All age groups, including young children, are affected, and the emotional and psychological impact on patients and their carers is substantial (Box 1). Although treatment effectiveness has improved in recent years, with cure rates approaching 100% using combination antibiotic regimens such as rifampicin and clarithromycin,2 these antibiotics are not covered by the Pharmaceutical Benefits Scheme for this condition and are, therefore, expensive to patients. Moreover, these antibiotics have severe side effects in up to one-quarter of patients,1 and many people also require reparative plastic surgery, sometimes with prolonged hospital admissions. The disease thus results in substantial costs, averaging $14 000 per patient including direct3 and indirect costs (eg, transport, lost productivity and dressings) — it had an estimated cost to Victoria in 2016 of $2 548 000 (Paul Mwebaze, Research Scientist, Adaptive Urban and Social Systems, Land and Water, CSIRO, Australia, personal communication, June 2017).


                  • 1 Barwon Health, Geelong, VIC
                  • 2 Geelong Centre for Emerging Infectious Diseases, Geelong, VIC
                  • 3 CSIRO, Brisbane, QLD


                  Correspondence: DanielO@BarwonHealth.org.au
                  Competing interests:

                  No relevant disclosures.

                  • 1. O’Brien DP, Friedman ND, Cowan R, et al. Mycobacterium ulcerans in the elderly: more severe disease and suboptimal outcomes. PLoS Negl Trop Dis 2015; 9: e0004253.
                  • 2. Friedman ND, Athan E, Walton AL, O’Brien DP. Increasing experience with primary oral medical therapy for Mycobacterium ulcerans disease in an Australian cohort. Antimicrob Agents Chemother 2016; 60: 2692-2695.
                  • 3. Pak J, O’Brien DP, Quek TY, Athan E. Treatment costs of Mycobacterium ulcerans in the antibiotic era. Int Health 2012; 4: 123-127.
                  • 4. World Health Organization. Buruli ulcer — number of new cases of Buruli ulcer reported: 2016 [website]. http://apps.who.int/neglected_diseases/ntddata/buruli/buruli.html (viewed Nov 2017).
                  • 5. Steffen CM, Freeborn H. Mycobacterium ulcerans in the Daintree 2009–2015 and the mini-epidemic of 2011. ANZ J Surg 2016.
                  • 6. Centers for Disease Control and Prevention. Lesson 6: investigating an outbreak [website]. Atlanta: CDC; 2016. https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson6/section2.html (viewed Nov 2017).
                  • 7. Tai A, Athan E, Friedman ND, et al. Increased severity and spread of Mycobacterium ulcerans, southeastern Australia. Emerg Infect Dis 2018. doi:10.3201/eid2401.171070. [Epub ahead of print].
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                    The Lancet Countdown down under: tracking progress on health and climate change in Australia

                    Ying Zhang and Paul J Beggs
                    Med J Aust 2018; 208 (7): . || doi: 10.5694/mja17.01245
                    Published online: 16 April 2018

                    Australia is set to join a global initiative to track progress on health and climate change

                    When it comes to climate change and human health, Australia has, in many respects, an impressive track record. The late Professor Tony McMichael led the international community in research and advocacy on this issue.1,2 In 2016, the Royal Australasian College of Physicians Climate Change and Health Working Party released position statements on climate change and health and the health benefits of mitigating climate change.3,4 Scientific articles on Australian health and climate change have been published since the mid-1990s, including in the MJA.5


                    • 1 University of Sydney, Sydney, NSW
                    • 2 Macquarie University, Sydney, NSW


                    Correspondence: ying.zhang@sydney.edu.au
                    Acknowledgements: 

                    We acknowledge the current team members who are developing the Australian countdown report.

                    Competing interests:

                    No relevant disclosures.

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                    • 2. McMichael A, Githeko A, Akhtar R, et al. Human health. In: McCarthy JJ, Canziani OF, Leary NA, et al, editors. Climate change 2001: impacts, adaptation, and vulnerability. Contribution of Working Group II to the Third Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press, 2001.
                    • 3. Royal Australasian College of Physicians. Climate change and health: position statement. Sydney: RACP, 2016.
                    • 4. Royal Australasian College of Physicians. The health benefits of mitigating climate change: position statement. Sydney: RACP, 2016.
                    • 5. Jackson EK. Climate change and global infectious disease threats. Med J Aust 1995; 163: 570-574.
                    • 6. Beggs PJ, editor. Impacts of climate change on allergens and allergic diseases. Cambridge: Cambridge University Press, 2016.
                    • 7. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009; 373: 1693-1733.
                    • 8. Watts N, Adger WN, Agnolucci P, et al. Health and climate change: policy responses to protect public health. Lancet 2015; 386: 1861-1914.
                    • 9. Watts N, Amann M, Ayeb-Karlsson S, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet 2018; 391: 581-630.
                    • 10. United Nations Framework Convention on Climate Change. The Paris Agreement. http://unfccc.int/paris_agreement/items/9485.php (viewed Dec 2017).
                    • 11. International Energy Agency. IEA Atlas of Energy: CO2 Emissions from Fuel Combustion. http://energyatlas.iea.org/#!/tellmap/1378539487/4 (viewed Feb 2018).
                    Online responses are no longer available. Please refer to our instructions for authors page for more information.

                      Whole genome sequencing provides better diagnostic yield and future value than whole exome sequencing

                      John S Mattick, Marcel Dinger, Nicole Schonrock and Mark Cowley
                      Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01176
                      Published online: 9 April 2018

                      The integration of genome sequencing with clinical records and data from the internet of things will transform health care

                      There is a great deal of optimism about the potential of genomics to transform medicine and health care. That optimism is justified. Indeed, it is hard to imagine a future where personal genomic information is not consulted routinely at the point of care. Every one of us is different, with personal genetic idiosyncrasies and risks — of cancer, cardiac arrest, blood clots, emphysema, diabetes, arthritis or toxic reactions to medications, among many others; the list will only continue to grow. Knowledge of individual genetic variation will change medicine from the art of crisis response to the science of health management, with huge benefits, both individually and systemically. It will also create new enterprises at a time of rapid change in the largest and fastest growing industry in the world.


                      • 1 Garvan Institute of Medical Research, Sydney, NSW
                      • 2 St Vincent's Clinical School, UNSW Sydney, Sydney, NSW
                      • 3 Kinghorn Centre of Clinical Genomics, Garvan Institute of Medical Research, Sydney, NSW


                      Correspondence: j.mattick@garvan.org.au
                      Acknowledgements: 

                      We thank Howard Jacob for his comments on the manuscript. This work was supported by funding from the Kinghorn Foundation, the New South Wales State Government and the National Health and Medical Research Council of Australia.

                      Competing interests:

                      The Garvan Institute of Medical Research is the owner of Genome.One, which is clinically accredited (ISO15189) to provide whole human genome sequencing and analysis.

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