Western Nurse Magazine January February 2019

January – February 2019

incorporating western midwife

SPECIAL FEATURE FOR ANF MEMBERS:

QUEEN OF CLEAN

MARIE KONDO TALKS TIDYING TIPS PAGES 18-19

PLUS:

MIDWIFE OVERCOMES LIFE AND DEATH CHALLENGE PAGES 4-5

MEMBERS FIGHTING AGAINST SKIN CANCER PAGES 8-9 Photograph: The Telegraph / The Interview People

western nurse is the official magazine for ANF members in WA

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January – February 2019

FEATURED 3 4 8 14 18 28

Secretary’s Report Midwife’s Miracle Childbirth Members Fighting Skin Cancer Mark’s Q & A: Audit Approaches Marie Kondo Special Interview Recipe Corner

FAVOURITES 6 10 22 26 30

Internet Watch ANF Out ‘N’ About Across the Nation Around the Globe Research Roundup

HOLIDAY ANF 31 ANF Holiday Apartments

– book now!

WIN! 31 Win Barefoot Investor books and

Pitch Perfect Trilogy Blu-rays!

CLINICAL UPDATES 13 16 20 24

Wound culture techniques Hypothyroidism Molluscum contagiosum STI screening for women in primary care

Talk to us...

It’s your magazine. We want your feedback and story ideas!

Editor Mark Olson Phone Freecall Fax Email Web

08 6218 9444 1800 199 145 08 9218 9455 anf@anfiuwp.org.au anfiuwp.org.au

Australian Nursing Federation

Secretary's Report State Secretary Mark Olson

By the time you read this, the ink should be dry on the public sector pay and conditions agreement struck by the ANF. This deal includes real movement by the State Government towards having appropriate nurse-to-patient ratios in our public hospitals.

After months of resistance from the Government’s negotiators, they have agreed to establish a working party to investigate how ratios might work in our State.

We told those negotiators repeatedly there was no chance of a deal on their Government wages policy of a $1000 pay rise unless we obtained for our members several key outcomes, including the ratios working party.

Among other significant items we achieved is better access to leave entitlements for public sector nurses and midwives – with a provision that if a nurse or midwife is denied a leave request they cannot be forced to take holidays later on.

Cashing out leave will now also be more accessible, and you’ll also no longer have to complete mandatory online training in your own time – it is to be done in work time.

There are also measures to address the increasing levels of violence, bullying and aggression towards nurses and midwives in the workplace.

And new restrictions will protect night shift staff who are requested by employers to be rotated onto day shifts.

We have also written into the agreement a resolution to the disgraceful situation where people were being denied qualifications allowances because their previously accepted qualification was removed by bureaucrats from the relevant list. It is now a part of the public sector agreement that qualifications cannot be removed from the approved list unless the ANF agrees.

And the ratios working party is not pie-in-the-sky stuff. It will be looking specifically at what impact there’ll be on WA if we adopt legislated nurse-to-patient ratio systems that have already been established in Victoria and Queensland.

Yes, there are other ongoing battles in both the public and private sectors, including the negotiations to conclude the St John of God Health Care pay and conditions agreement.

But we have the numbers and the resources to ensure the ANF will get the best deal possible for nurses, midwives and carers in all those fights.

260 Pier Street, Perth WA 6000

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January–February 2019 western nurse |

3

Justine McFarlane nearly died when the birth of her fourth child went wrong – losing 80 per cent of her blood. Now, the local midwife wants to spread the message about seeking counselling after such trauma, if needed, trusting your instincts during pregnancy and the importance of blood donation.

Justine and baby Kalea

TALK TO SOMEONE It’s only just over a year ago that Justine McFarlane barely survived a caesarean delivery that came suddenly during the 35th week of her expected 38-week pregnancy.

A scan at 33 weeks had shown Justine had serious conditions – complete placenta praevia (where the placenta covers the cervix and thus the baby’s exit path) and signs of placenta accreta (where the placenta attaches too deeply to the uterine wall).

So a team was assembled at Joondalup Health Campus to deal with the complications, with a caesarean birth planned for the 38th week.

“But on week 35, I woke up at home on the morning of January 18 with a tense abdomen and my baby wasn't moving,” she said.

“I just felt really off. Then the severe headache started and spotty vision. I called the hospital and went straight in.”

In the very early hours of the next day Justine had a caesarean following a placental abruption (when the placenta separates early from the uterus).

She lost about 80 per cent of her blood during the birth because of the accreta, but both she and her baby Kalea survived.

Justine said she was lucky her midwives Jane and Marg also felt “things weren't right” and she was admitted the morning before the surgery – and therefore was in hospital rather than at home when she had the abruption.

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western nurse January–February 2019

“Had I stayed home and not listened to my body, who knows what would have happened,” Justine said.

“Please, please trust your instincts when you are pregnant. If you feel like something isn't right, please get checked out.

“And I am so grateful I had such amazing midwives and nurses looking after me. They are in the front line by your bedside – monitoring and caring for you, and also responding, reacting and alerting when things happen.”

After the delivery she woke up in recovery at JHC “in a world of pain”.

“I remember being told we had a girl and she was doing well on CPAP (continuous positive airway pressure) in the nursery,” she said. “One of my doctors, Cliff Neppe, removed the Bakri balloon (catheter) I had in to try to stop the bleeding, and the bleeding became visible – I was terrified.

“As Dr Neppe discussed hysterectomy and bladder and bowel involvement, I said 'Just do whatever you have to, just get me home to my babies’ – I have three more very young children at home.”

Justine stayed in the intensive care and high dependency units for three days. Then she and Kalea were discharged to a ward on the fourth day, where they spent two weeks.

But Justine’s next challenge had already started.

“The anxiety that came from Kalea's birth, including the threat of more

“Talking to other women who have been through similar experiences has really helped me, as well as counselling.

“I really hope by sharing my story, other parents know that they aren't alone and that anyone can be affected by their baby's birth.

“We will forever be grateful to the beautiful people who donated the blood that saved me and of course all the wonderful staff at JHC. “That includes the midwives, nurses, doctors, anaesthetists, paediatricians, and the theatre, recovery, ICU, HDU, special care nursery, radiology, pathology, blood bank and birthing suites staff, as well as the orderlies, kitchen staff, cleaners, and everyone else who helped me during those difficult days.

Justine and baby Kalea with the team from Joondalup Health Campus that saved their lives

surgery, was huge,” she said. “And I was unprepared to deal with it all – despite having been a registered nurse since 2001, a midwife since 2003 and having worked at Joondalup Health Campus for almost 17 years.

“A special thanks to midwives Jane, Marg, Kaylene, Denise, Carol, Marion, Annette, Michelle, Wendy, Tracey, Sue, Marissa, Caroline and Arlene, doctors Margo, Cliff and Jay, nurses Jess, Lesley, Anne-Marie, Nicola, Tracy, Carla, Chelsea and Steve, clinical nurse consultant Angie, and nurse unit manager Sandy.” 

“The midwives and my obstetrician Dr Margo Norman, as well as Dr Neppe, had to constantly reassure me that I would be going home. A lot of staff who looked after me came to visit me on the ward, to debrief with me.

“It is so important after any kind of birth trauma or unexpected outcome to debrief with the staff involved, so that you can understand what happened and why.”

But only when Justine got home could she start to really process the whole experience.

And since Kalea's birth, she has had multiple readmissions and more surgery.

“Dr Norman, Dr Neppe and Dr Jay Natalwala, who was on my initial surgical team, have been amazing, but both mentally and physically, it has been a long recovery,” she said.

“It breaks my heart thinking about what my hubby Ryan and our family went through during my surgeries and the days following.

“It is so important to talk about it. Don't pretend it's all ok if it isn't.”

She said the stress of the experience hit Ryan quite quickly. “But it took time for me, then the enormity of it all hit me like a tonne of bricks,” Justine said.

Maxine has a great caring but ‘no fuss’ approach for our son and I always know he is safe there. Daycare to the Max has a fabulous backyard, chickens, play equipment and space to run around. Caroline from Morley

Justine and baby Kalea, 1, with sons Kai, 8, (hugging Justine) and Bodhi, 5, and her daughter Amarri, 3

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January–February 2019 western nurse |

5

InternetWatch AMAZING APPS + ONLINE NEWS

Castbox Castbox is an easy to use platform for lovers of podcasts. Choose from a wide category of podcasts, or stream or download your favourites anywhere, anytime. A nifty way to store your podcasts in one place. Free

Qantas Wellbeing Here’s one from the folks at the Flying Kangaroo – earn Qantas Points for being active! Walked the dog? Went swimming? These activities and lots more can be tracked and rewarded. Used in combination with your wearable fitness device you can set goals and take part in group challenges. Free

Splitwise Oh how clever! Splitwise is a great way to share bills and make sure that everyone is paid back.

Use it to divide household bills with house mates, to figure out costs for a group holiday, or just to remember when a friend shouts you lunch. You can view your balances, track spending trends and set up email reminders for bills. Free

Sleep Sounds Insomnia? Trouble falling asleep? Shift worker? No worries, try Sleep Sounds. Choose from a selection of soothing sounds to settle you to sleep. This one works offline and has a timer, so the app turns off automatically. Free

Reddit

As a Redditor, get stuck into topics that matter to you, choosing from over 100,000 community groups. Your communities upvote and downvote posts to highlight the most interesting and relevant content. Share your passion for favourite books, movies, video games, and more. Free

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western nurse January–February 2019

Tik Tok Officially a fun time waster!

The idea is to record a story in 15 seconds of video. Of yourself. Or your cat. With a soundtrack and filters of your choosing. Discover awesome videos of funny and memorable moments. Keep to yourself or share with the world, it’s up to you! Free

Tomb of the Mask Get lost in a vertical labyrinth. You are in a tomb where you find a strange mask.

Of course, you put it on and suddenly discover that you can climb walls. As fun and addictive as any other arcade game around. Free

Body Language Psychology Secrets Non-verbal language is one of the most fascinating subjects in the world. To recognise what a person thinks and plans to do without exchanging a word is a useful skill. This app will take you through the basics of interpreting body language. Free

Grammarly Grammarly corrects your errors as you write in any app you use on your mobile device.

Whether you’re sending an urgent email, important WhatsApp message, or essential Instagram post, you can create with confidence. Free

ECG Basics Full Here you’ll find the e ss e n t i a l s o f E C G interpretation including normal sinus rhythm and arrhythmias ranging from the atrial to the ventricular – and everything in between. You’ll also discover the differences in paediatric electrocardiography. Free

FIVESuperSites Foodbank

Foodbank is the largest hunger relief organisation in Australia. They link the food industry’s surplus food with the welfare sector’s need to ensure all Australians have enough food to eat, including children attending the School Breakfast Program. Find out how you can help. www.foodbankwa.org.au

Dr Karl

His enthusiasm for science is totally infectious and no one is better able to convey the excitement and wonder of it all than Dr Karl Kruszelnicki. He has been popularising science on ABC radio stations across Australia for decades. Check out his website to see what’s happening in this amazing world of ours. drkarl.com

Maggie Dent

Maggie Dent is one of Australia’s favourite parenting authors and educators, with a particular interest in the early years and adolescence. Head here or the companion app for heaps of common sense advice and resources. www.maggiedent.com

Fast

It doesn’t get more basic than this - check the current speed of your Internet connection simply by navigating to the website. fast.com

Melanoma Risk Predictor

This validated tool is designed to provide an estimation of a person's risk of developing melanoma over the next 3.5 years. The information provided by the predictor is to be used as a general guide and not to be solely relied upon. It is highly recommended that you discuss your results with your doctor. publications.qimrberghofer.edu.au/ Custom/QSkinMelanomaRisk

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January–February 2019 western nurse |

7

SAVING LIVES FROM THE SUN

Our members work for the good of the community in so many different areas – June Walker and some of her friends decided they’d take on the scourge of skin cancer through volunteer work.

More than two decades ago registered nurse June Walker decided she needed to get involved in the battle against skin cancer – a disease that kills more than 2000 Australians each year.

It all started with some volunteer work for the Lions Cancer Institute, and she hasn’t stopped her efforts since – even after her retirement from nursing in 2017, with nearly 50 years in the profession.

“I was at the time (1994) doing a degree in Health Promotion at Curtin University and one of the recommendations was that we do some time of health promotion volunteering,” said June, who started her RN training at Fremantle Hospital back in July 1969.

“I started volunteering with the Lions Cancer Institute in 1994, when I was asked if I would help with a screening session, and it has all gone on from there.”

June quickly realised how important the screening work is and that she needed to do her bit – and more than 24 years later she is still travelling around WA screening people for skin cancer. She encourages others to get involved in such volunteer work.

But she added that regardless of whether people volunteer to help skin cancer efforts, West Australians need to look after themselves more when it comes to the sun.

“Australia has the highest incidence of skin cancer in the world.

Western Australia comes second to Queensland,” June said. “Two out of three Australians will develop skin cancer by the time they’re 70, and it can and does kill – get yourself checked regularly.”

She repeatedly sees first-hand the importance of screening. “I was screening at an Agricultural Show in the central Wheatbelt of WA in October last year,” June said.

June Walker (right) and Jan, whom June checked for melanoma during a visit of the Mobile Skin Cancer Screening Facility at North Fremantle's Port Beach.

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western nurse January–February 2019

“I did a full body screen on a young man. I saw on his upper back three lesions that I was very concerned about. I sent him as a matter of urgency to a GP who specialised in recognition and treatment of skin cancer.

“We as the Lions Skin Cancer Team do not diagnose, we can only tell people that they have a lesion we are concerned about.

“He went on to see the specialist GP and had the three lesions removed.

One was a malignant melanoma, and two were dysplastic naevi.

“He will have regular full body screens for the rest of his life. As should his siblings, parents and children when he has them.”

June said most of her volunteering is with the Lions Cancer Institute which raises money to fund cancer research and for screening the public for skin cancer.

“The Lions Skin Cancer Screening Team has been travelling in rural Western Australia for over twenty years, performing full body skin cancer checks,” she said.

“The team includes dermatologists, plastic surgeons and registered nurses. The team travels in specially designed screening vehicles in which people can be examined in comfort and privacy. Both vehicles have three examination rooms.

“In the last year (2018) I travelled to Brookton, Cunderdin, Denmark, Mt Barker, Coolgardie, Kalgoorlie, Broome, Derby, Newman, Tambellup and Gnowangerup, and my old home town of Quairading.”  More information is available at the Lions Cancer Institute Facebook and Web page: www.lionscancerinstitute.org.au

Survey Invitation

Reducing sedentary time in hospital inpatients

‘Two out of three Australians will develop skin cancer by the time they’re 70, and it can and does kill – get yourself checked regularly’

Are you an enrolled or registered nurse working in a sub-acute or rehabilitation setting?

Researchers from Federation University, Monash University and the University of Canberra are looking for nurses to share their experiences of helping patients to reduce their sedentary time.

Please complete this short, 10 min online survey:

https://bit.ly/2Q8Bw6R June checks one of her patients for melanoma.

Approved by the University of Canberra Human Research Ethics Committee (20180294).

January–February 2019 western nurse |

9

ANF Out 'N' About Good news, we’ve picked 60 winners for the 2018 Out 'N' About Photo Competition! We’ll bring you some of their photos soon – but more good news, the comp has restarted! This edition we feature members from Royal Perth, Fiona Stanley, St John of God Subiaco and Sir Charles Gairdner hospitals, as well as some of the winners of the ANF Futures Survey comp enjoying their prizes of dinner at their favourite restaurant.

SJOG Subiaco Anisha Regi, Alu Thomas and Limzy Philip

SCGH Ramil Crisostomo and Lester Lopez

Fiona Stanley Hospital Nichole Singleton and Diane Jones

RPH Ann Leong and Yi Yan

SJOG Subiaco Lirio Tagalog, Kerry Wheeler, Lucy Moras, Toni Lockwood-Hall and Anne Perry

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western nurse January–February 2019

SJOG Subiaco Kim Ng, Verity Hawyard and Karen Hadfield

Vivianne Lynn with husband Clive

WINNERS!

Marlenie Caballero and her mum Angelina Masacote at Epicurean Crown Towers

Sinead Coleman and daughter Sophie Nicholson at La Casetta

Seeking Trainer/ Assessor - Diploma of Nursing

ANF members receive 10% DISCOUNT on any online or instore purchase. Please enter or mention the code: ANF10.

The Institute of Health & Nursing Australia is a nationally Registered Training Organisation (RTO). We are currently seeking Full-time and Parttime Trainer and Assessors (Nurse Educators) to join our Academic Team to deliver the Diploma of Nursing program in our Perth Campus.

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Minimum skills and experience required · Bachelor or Master Degree in Nursing · Certificate IV in Training and Assessment - TAE40116 · Minimum one year's experience in a clinical setting, as RN Div 1

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Additional skills and experience advantageous for this role · Current experience in teaching nursing or other related health courses · In-depth understanding of ASQA/ANMAC regulatory guidelines and standards Candidates should submit expressions of interest to atif@healthcareers.edu.au

January–February 2019 western nurse |

11

NEW Member Offers for the whole family Up to 48% off cinema tickets, PLUS big discounts on theme parks across Australia, including Adventure World and Luna Park.

Just log onto your ANF iFolio, where you'll find the Member Offers section.

Then you're just a few clicks away from these and many more deals for you and your family – with great savings!

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western nurse January–February 2019

update: Wound culture techniques

Read this article and complete the online quiz to earn 0.5 iFolio hour

Wound cultures are used to determine the causative agent of an infection and guide the selection of the most appropriate antibiotic therapies. Samples are obtained through wound swabs or tissue biopsies. Research purports that tissue biopsy is the ideal method for sampling infected wounds, especially when there are concerns of antibiotic resistance.1 However, use in clinical practice is limited by cost, invasiveness and skills required. Wound swabs are more common, as they are minimally invasive and low-cost, with limited risk of complications.1 While wound cultures may seem easy to obtain, techniques vary and improper procedures may result in contamination and inaccurate diagnostic information.

Box 1. Potential differences in wound swabbing techniques between practitioners.1

• Area of wound sampled • Duration of sampling • The importance of applying pressure during sampling • Use of variable processing techniques including quantitative, semi-quantitative or simple surface swab analysis • Wound cleansing

WOUND SWABBING

Differences in wound swab collection may be limited by the use of standardised techniques, such as the Levine or Z-technique. The Levine technique is more effective at identifying the causative agent of infection in acute and chronic wounds because it allows for expression of fluid from the wound bed.2 The presence of debris on the surface of the wound has the potential to limit the accuracy of wound swab results. Cleaning or irrigating with non-bacteriostatic saline and the removal of necrotic tissue, eschar, purulent matter and wound drainage is important prior to swabbing to ensure an optimal sample.3

PERFORMING A WOUND SWAB With the Levine Technique; 1. Pre-moisten the swab with sterile 0.9% normal saline.

2. Apply the swab to a 1cm2 region in the middle of the wound bed.

3. Use gentle pressure for five seconds to ensure any fluid within the wound tissue is expressed and captured on the swab.2,4 The Z-technique is slightly different; 1. Pre-moisten the swab with sterile 0.9% normal saline.

2. Move the swab across the wound bed in a 10-point Z pattern (side to side, without touching the sides). Simultaneously rotate the swab between the fingers in a circular fashion.2 Following the use of either technique, swabs should be inserted into the appropriate culture medium and transferred to the laboratory at room temperature within 24 hours.

There are three alternative options to consider when sampling a wound; tissue curettage, tissue biopsy and needle aspiration.

Tissue curettage is the process of obtaining a tissue sample by scraping or scooping biomatter from the wound bed. It is performed across a wide surface area to ensure an adequate sample. The procedure yields similar results to wound swabbing but is more invasive and must be performed by an adequately trained health care professional.1 Tissue biopsies involve obtaining a tissue sample using a scalpel or punch biopsy instrument. The procedure can be invasive and painful. Prior to performing the biopsy, the site is cleaned and anaesthetised. Fullthickness punch biopsies require a deep sample of the skin, including the wound bed and underlying tissues. They are rarely required for small or superficial wounds and may not be appropriate for arterial ulcers. If the biopsy site is large, sutures may be required.4 Needle aspiration is used to obtain a sample of the fluid from within the wound bed. A 22-gauge needle is inserted into the tissue in

or around the wound and fluid is aspirated using a syringe. Needle aspiration only allows sampling of a small surface area and relies on the presence of infected fluid. It may be indicated for severe skin and soft tissue infections and surgical wound infections, but it is not routinely used for wound assessment.3 Tissue biopsies are regarded as the “gold standard” for the diagnosis and appropriate treatment of infected wounds. However, due to their significant practical limitations, wound swabs are more commonly used in most clinical settings. Research has demonstrated that in many types of wounds, swabs collected with optimal technique have equivalent reliability, and are less invasive, costly and skillintensive.1-3

REFERENCES 1. Smith ME, Robinowitz N, Chaulk P, Johnson K. Comparison of chronic wound culture techniques: swab versus curetted tissue for microbial recovery. Br J Community Nurs. 2014 Sep;19(9):S22-6.

2. Angel DE, Lloyd P, Carville K, Santamaria N. The clinical efficacy of two ssemi-quantitative wound-swabbing techniques in identifying causative organism(s) in infected cutaneous wounds. Int Wound J. 2011 Apr;8(2):176-85.

3. Drinka P, Bonham P, Crnich CJ. Swab culture of purulent skin infection to detect infection or colonization with antibiotic-resistant bacteria. J Am Med Dir Assoc. 2012 Jan 1;13(1):75-9.

4. Levitt J, Bernardo S, Whang T. How to perform a punch biopsy of the skin. N Engl J Med. 2013 Sep 12;369.11.

January–February 2019 western nurse |

13

Mark’s

In a few short months your Continuing Professional Development (CPD) hours will be due yet again. Given you can lose your registration if you haven’t fulfilled your CPD requirements and the Australian Health Practitioner Regulation Agency (AHPRA) audits you, we run this quick general guide annually because we know you’re busy and you might need a bit of a reminder. The ANF will also be visiting Perth suburbs in April and May to provide free 30-minute Audit Without Tears talks – in case you have more questions.

Q: When are my CPD hours due each year?

A: May 31.

Q: How many CPD hours am I required to complete annually?

A: Registered nurses (RNs) and midwives need to do a minimum of 20 CPD hours yearly. If you’re both a midwife and an RN you need to do a further 20 hours (40 hours total), though some CPD hours can count towards both nurse and midwife registrations.

Q: I’m a nurse practitioner or a midwife practitioner, how many CPD hours do I need?

A: You need an additional 10 hours on top of the CPD hours needed for your normal registration.

Q: I have scheduled medicines endorsement, how many CPD hours do I need?

A: You need an additional 10 hours on top of the CPD hours needed for your normal registration.

Q: I’m on maternity leave, long service leave or other leave, do I still need CPD? A: To retain your registration, yes, you need to complete normal CPD hours.

Q: I work part-time, do I still need CPD? A: Yes, you need to complete normal CPD hours.

Q: Where can I find and complete CPD modules easily?

A: ANF iFolio has hundreds of quickly accessible Clinical Updates (CUs) across a range of topics that fulfil your AHPRA obligations. western nurse magazine also contains CUs.

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western nurse January–February 2019

Q: How much does it cost to do ANF CPD units?

A: You don’t pay anything! CPD units are included as part of your local ANF membership in WA. Q: Is there an evidence record of my CPD I can show AHPRA if need be?

A: iFolio has a convenient downloadable evidence record that lists everything AHPRA asks for on CPD. This includes your identified learning need, activity undertaken and reflection on the activity. The ANF evidence record also details other relevant CPD activities on it, not just iFolio modules. If you attend ANF seminars, education sessions or legal talks, these are automatically updated on your ANF iFolio, so you receive CPD credit that you can show AHPRA, all in one location.

Q: I’ve been charged by the federal office for CPD units, why is that?

A: You signed up to the wrong provider! Save your cash – do your CPD with us, it’s free in WA with your local ANF membership.

Q: What other types of activities are valid as CPD apart from ANF iFolio modules and ANF activities?

A: Tertiary courses and other accredited study, conferences, short courses, workshops and even your mandatory competencies, as long as they are recognised as being related to your work, can count towards CPD and be recorded on your iFolio.

The information provided in this column is general advice only. If you want information specific to your circumstances you should contact the ANF Helpline or send us your questions by email.

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References 1 Garcia R, Jendresky L, Landesman S, Maher A, Nicolas F. Three years experience in implementing HICPAC recommendations for the reduction of central venous catheter–related bloodstream infections. Manag Infect Control. 2003;10:42–49. 2 Darouiche RO, Wall MJ, Itani KMF, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis N Engl J Med. 2010;362:18-26. 3 CareFusion Data on file as per Instructions for Use (IFU). * Central venous catheter. ** When compared to 10% povidone-iodine.

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January–February 2019 western nurse |

15

update: Hypothyroidism

Read this article and complete the online quiz to earn 1 iFolio hour

Hypothyroidism is an endocrine disorder characterised by low levels of circulating thyroid hormone.1 It is a common condition, affecting 1% of the population and 5% of people over the age of 60.1 There are several types of hypothyroidism including primary and secondary, clinical and subclinical hypothyroidism, and euthyroid sick syndrome (see Table 1).2 Primary hypothyroidism is particularly prevalent in women. The most frequently referenced long-term study conducted found that it was six times more common in women than men.3

PATHOPHYSIOLOGY The thyroid gland is responsible for the synthesis and secretion of thyroid hormone T4, which is converted into T3 in the tissues.

These circulating hormones are responsible for stimulating cellular oxygen consumption and energy production, and play an important role in the routine function of most organ systems.4 Production of T4 is stimulated by thyrotropin releasing hormone (TRH) in the hypothalamus and thyroid-stimulating hormone (TSH) in the anterior pituitary (see Illustration 1). T3 and T4 participate in a negative feedback loop with the pituitary, preventing or inducing the synthesis of TRH and TSH, as required (see Figure 1).4 In primary hypothyroidism, inadequate T3 and T4 levels, result in overstimulation of the pituitary gland and elevated levels of TSH, without subsequent thyroid hormone production (see Illustration 2).4

AETIOLOGY Primary hypothyroidism occurs as a result of damage to, or dysfunction of, the thyroid gland.5 Worldwide, iodine deficiency is the most common cause. In Australia, an iodinerich country, the primary cause is chronic autoimmune (Hashimoto) thyroiditis. In autoimmune thyroiditis, impaired immune surveillance leads to the production of antibodies that attack the thyroid gland (known as serum thyroid autoantibodies or anti-thyroid antibodies) leading to inadequate thyroid hormone production and secretion.6

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Table 1. Types of hypothyroidism1-4

Type

Description

Clinical hypothyroidism

Symptoms are present and hormone levels (TSH, T3 and T4) are outside normal range.

Subclinical hypothyroidism

Minimal (or no) symptoms are present. TSH levels are elevated, while T4 (and/or T3) levels remain normal.

Primary hypothyroidism

Inadequate thyroid hormone production occurs as a result of damage or dysfunction of the thyroid gland due to autoimmunity or a medical intervention such as surgery or ablation.

Secondary hypothyroidism

Failure to stimulate thyroid hormone production following damage or dysfunction to the pituitary or hypothalamus.

Central hypothyroidism

A type of secondary hypothyroidism caused by low levels of TSH as a result of hypothalamic or pituitary dysfunction.

Euthyroid sick syndrome

A syndrome diagnosed when T3 and T4 levels are low and TSH levels are normal or low.

Other causes of primary hypothyroidism include thyroidectomy and radioactive iodine therapy, commonly used for the treatment of thyroid cancer, and medication-induced hypothyroidism.5 Risk factors include female sex, personal or family history of autoimmune conditions, and family history of thyroid disease/hypothyroidism. Medications that have the potential to cause medicationinduced hypothyroidism include anti-thyroid drugs, iodine, amiodarone, lithium, interferons, thalidomide, and rifampicin.5

CLINICAL MANIFESTATIONS Hypothyroidism has the potential to affect most bodily functions, and if left untreated may be fatal.4 Common symptoms of hypothyroidism include fatigue, cold intolerance, weight gain, constipation, depression, hoarse voice, menorrhagia, myalgia, diastolic hypertension, bradycardia, and delayed return of deep tendon reflexes.1,4 Physical changes may occur such as dry, pale and yellowing skin, puffy face and eyes, and thinning of the hair and nails.1 Depending on the cause of hypothyroidism, individuals may also have an enlarged thyroid (goitre) as a result of increased circulating TSH levels.1 The severity of symptoms typically depends on the extent of the thyroid hormone deficiency and duration of onset. For example, autoimmune thyroiditis tends to arise

slowly, with symptoms developing over the course of several years. Other causes, such as thyroidectomy and radiotherapy, may result in the rapid onset of hypothyroidism with more severe symptoms early on.5

DIAGNOSIS Diagnosis is based on clinical symptoms and diagnostic investigations including serum TSH and free serum T4. A neck examination is used to rule out the presence of a goitre or thyroid nodules. Thyroid ultrasound is not indicated for all individuals with hypothyroidism. Rather, it is reserved for those with palpable thyroid abnormalities, including nodules.5 Primary hypothyroidism is characterised by elevated serum TSH and low levels of T4.1,4 Initial screening based on the first TSH level. If elevated, the test is repeated with a free serum T4 level to confirm the diagnosis. Free serum T4 levels may also be used to help rule out central hypothyroidism in symptomatic patients.5 The vast majority of individuals diagnosed with autoimmune thyroiditis have positive thyroid antibodies. Therefore, thyroid peroxidase antibody assays may be used to help diagnose the condition. 5 Additional investigations including full blood count, serum cholesterol, electrolytes, and creatinine kinase may also be recommended (see Illustration 3).5

Illustration 1: Anatomy of the thyroid gland

Illustration 3: Screening for hypothyroidism.5

Illustration 2: Pathophysiology

REFERENCES 1. Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. Editors. Current Medical Diagnosis & Treatment 2017. New York, NY: McGraw-Hill. https:// accessmedicine.mhmedical.com/Content. aspx?bookId=1843&sectionId=135718249 2. Nygaard B. Hypothyroidism (primary). BMJ Clin Evid. 2014;0605:PMC3931439. https://www. ncbi.nlm.nih.gov/pubmed/24807886

TREATMENT The treatment for confirmed primary hypothyroidism is supplemental thyroid hormone, levothyroxine also known as thyroxine, or T4.7 Treatment is generally required once daily, for life. If the underlying cause is transient or reversible, such as drug induced hypothyroidism, short-term treatment may be indicated.5 The optimal management of subclinical hypothyroidism remains controversial. Levothyroxine therapy may be recommended in some cases, although evidence to support improved clinical outcomes is limited.5 Thyroxine dosing is weight dependent and may be adjusted based on age and condition (average of 1.6mcg per kilogram body weight).

Individuals with unstable angina may require a lower dose as thyroid hormone increases the

amount of oxygen required by cardiac tissues.5 Low dose treatment is also recommended for frail individuals and older adults, greater than age 60 years.5,7 The half-life of thyroxine is approximately one week. It may take up to eight weeks for clinical benefits to be achieved after the initiation of treatment or dose titratration.5 Treatment failure may occur as a result of a variety of factors including poor compliance, comorbidities drug interactions, and variable gastrointestinal absorption. A medication review and medical follow-up may be indicated for patients who report compliance but fail to experience improvements in clinical symptoms or serum TSH levels. Doses may be adjusted every six to eight weeks, as required.

If clinical symptoms persist after a reduction in TSH levels to within normal limits, it may be necessary to investigate other causes.5

3. Vanderpump MP, Tunbridge WM, French JM, et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf ) 1995;43(1):55–68.

4. BMJ Best Practice. Primary hypothyroidism [Internet]. London: BMJ Publishing Group; 2016 Apr [cited 2017 Apr]. Available from: http://bestpractice.bmj.com.acs.hcn.com. au/best-practice/monograph/36/basics/ pathophysiology.html 5. So M, MacIsaac RJ, Grossmann M. Hypothyroidism: investigation and management. Australian Family Physician. 2012 Aug; 41(8):556-562. http://www.racgp.org.au/ afp/2012/august/hypothyroidism/ 6. Almandoz JP, Gharib H. Hypothyroidism: etiology, diagnosis and management. Med Clin North Am. 2012 Mar;96(2):203-221. https:// www.ncbi.nlm.nih.gov/pubmed/22443971 7. Australian Medicines Handbook 2017 (computer program). Adelaide: Australian Medicines Handbook Pty Ltd; 2017 Jan.

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17

QUEEN OF CLEAN COMES CLEAN ON CLEANING

Before all the recent Internet and TV hype, Marie Kondo had already had a best-selling book based around her ‘KonMari’ method of tidying.

Published in more than 40 countries, The Life-Changing Magic of Tidying Up: The Japanese Art of Decluttering and Organizing advocates her system where you gather together your belongings one category at a time, keeping only those things that “spark joy” (tokimeku in Japanese), and then choose a place for everything from then on.

A recent interview promoting her show reveals some of the 34-year-old’s fundamental tips for tidying and also her beginnings.

Q: So Marie, how did you start becoming a tidier?

A: I became interested in tidying when I was five years old and I somehow made it my life’s mission to tackle this question – we are always tidying our home, but we always rebound, we always return to clutter.

So how can I remedy that? I made it my life’s mission to figure that out.

Q: Did you grow up in a tidy home?

A: Not at all. Actually, my family home looked tidy on the surface, but when you pulled open those drawers it was a mess!

Photograph: The Telegraph / The Interview People

Q: Was there a sense that you wanted to feel the calm that you project now, or was it just that you figured there was a better way to do it (tidying)?

A: It’s not that I really hated clutter or a cluttered home. I was just genuinely curious and I was interested in tidying.

Marie Kondo is a Web sensation, best-selling author and the star of the new Netflix series: Tidying Up with Marie Kondo.

We go behind the story of Japan’s ‘queen of clean’, including her childhood.

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It was almost to me like an act of tidying was a game. So my mother would subscribe to periodicals about home-making and so on, and I was always reading their columns about tips and how to tidy homes, and I just always wanted to try them out.

Q: Your mom let you organise her house even from a young age?

A: This is something that I’m very grateful to my parents, because whenever they went out and it was just us kids in our home, I would just go about tidying the kitchen, the closet and by the time my parents came home, the kitchen would be perfectly bleached and sparkling, and they didn’t mind!

Q: The KonMari method, when did that develop?

A: … I’ve always been reading books on tidying and organising, so I was always researching and studying.

But when I turned 19 years old, I finally became a professional organising consultant. And through my experience with clients I gradually developed the KonMari method of tidying.

Q: Were there any parts of the process that you tried but didn’t work?

A: … it was trial and error, when I figured out that when you tackle sentimental items because my client wanted to at first, it will just end up getting them stuck.

So in the KonMari method you follow the right order of tidying (clothes, then books, paper, komono [miscellaneous items] and sentimental items). And the reason why we do this is throughout the process you are honing your sensitivity to joy.

‘Tidying is not about looking for things to discard, but rather to look for things that you want to keep in your life … things that you love’ You are developing your decision-making skills so that by the time that you get to the sentimental items you are able to figure out what you need, not only in that moment but looking on to the future.

Q: Where did the idea of sparking joy come into it for you?

A: When I developed the idea of ‘tokimeku’ in Japanese or ‘spark joy’, I was in the third year of middle school … at the time I was very influenced by this book with the title Skill of Discarding.

So I had that thought that tidying meant to let go of a lot of things.

And whenever I came home from school, even before I took off my school uniform, I would take out a trash bag and just rummage through the house looking for things to throw away … of course I was throwing away my personal belongings, but sometimes I would go through my siblings’ things or my parents’ things.

And when they found out, they were understandably very angry, to the point that they actually banned tidying for me … when I continued this way, tidying became more and more stressful for me, and when I reached peak stress, I think it was neurosis or something, I passed out.

So after I passed out and I woke up, my mind was clear, and I had this one odd instructive in my mind.

It was telling me to look closer at my things. And I intuitively knew the way that I was looking at things, there was something wrong about it and I needed to reconsider it.

And that’s when I knew that tidying is not about looking for things to discard, but rather to look for things that you want to keep in your life, things that you want to cherish, things that you love. Those are the things that I should be selecting. So that’s when I discovered what sparks joy for me.

Q: On your show the people are doing the work and the reveal comes when you return, and they really want your approval?

A: … what we’re trying to do is not simply tidying our home, it’s actually an opportunity for the client to just really move their hands and bodies on their own.

It’s an opportunity for introspection, to figure out how you want to live your life.

So it’s very crucial that the clients and families do it themselves.

Q: Are you intentionally sort of encouraging people to confront their relationship with buying stuff?

A: … gathering all of your clothes in one spot definitely is a confrontation with your own eyes.

It’s sort of like a shock treatment. In my experience we generally own three times as much as we think.

Q: What about you as a shopper ... do you buy something and think ‘I have to get rid of something’?

A: … rather than that, I make it a rule within myself that I only buy things that truly spark joy for me, from the bottom of my heart.

And in terms of letting go of clothes I know when I stand before my closet and I get a heavier feeling, or I feel that a certain piece has already served a role and it’s time for us to part ways. That’s how I know.

Q: What do you do if your partner isn’t as keen to participate in your method?

A: … set your partner aside, just forget about him or her for a while, and just focus on yourself first.

It’s quite uncanny, but when you are resolved within yourself that you are going to tidy and you are going to discover what sparks joy for you, I think my method of tidying is quite infectious.

So it’s very important that you don’t force that process upon a partner when they are not ready.

Another little trick that I have is once you’ve completely finished tidying your personal belongings and you find that your partner is still not interested, try folding their clothes perfectly. Everybody loves beautifully folded clothes. And that might convince them.

Q: What about moving house? Any tips on that?

A: Moving is actually a fantastic opportunity to tidy.

I recommend before you start packing away you do the ‘joy’ check of all your belongings and separate them into categories, and then you pack things that you really want to keep.

Q: What about clothes that don’t currently fit, but you’re hoping might fit again?

A: … when you hold that piece of clothing, how does it make you feel?

So when you hold the clothes does it make you feel really uplifted and positive like, ‘Yes, I’m going to lose a few inches from my waist!’ Or does it make you feel down on yourself and criticise yourself like, ‘I must lose weight.’

There’s a world of a difference even in a pile of clothes that you intend to wear later.

Q: Getting rid of books, there’s been a lot of debate on the Internet that there’s something sacrosanct about books?

A: … the point of the KonMari method is to figure out your sense of value, what do you hold most important?

So if your reaction is anger that you have to like all books, then that’s great as that means for you books are invaluable.

The idea is that if it sparks joy for you then you must keep it. Even if I go over to your home and say, ‘Do you really want to keep this book?’ If you feel that it sparks joy for you, keep it with confidence.  Extract of an interview by Lucy Allen / The Interview People

January–February 2019 western nurse |

19

update: A drug update: Molluscum contagiosum Read this article and complete the online quiz to earn 0.5 iFolio hour

Molluscum contagiosum is a viral skin disease caused by the molluscum virus, a member of the Poxviridae family. Infection of the human epithelium (skin) results in dome-shaped papule type lesions, which occur over a broad surface area of skin in children, and the pubic and genital areas of adults.1 The virus is highly contagious and easily transmitted through direct skin-to-skin contact, as in sexual activity, physical activity, and scratching or touching of an infected lesion.1 Infections predominantly occur in young children, sexually active adults and individuals suffering from immunosuppression (such as with those with human immunodeficiency virus, HIV).1,2 In healthy individuals, dermatological symptoms are mild and resolve independently over the course of several months. Unfortunately, those with underlying medical conditions have the potential to experience severe, persistent symptoms that are often difficult to treat.1

TRANSMISSION Infection with molluscum contagiosum begins with a breakdown in the epithelium, as in a skin tear or wound, which allows for the virus to enter the epidermis and replicate.2 Eczematous dermatitis at the site of infection causes itching and irritation which increases the likelihood of contamination in other areas.2 Risk factors for infection include contact with or between children and young adults, exposure to sexually transmitted infections, immunocompromised, and the use of topical corticosteroids and calcineurin inhibitors, which suppress the local immune response.2

SIGN AND SYMPTOMS The papules that arise on the skin as a result of molluscum contagiosum are typically small, approximately 3 to 5mm in diameter, skincoloured, waxy and filled with a whitish-grey purulent fluid (see Image 1).2 Mild infections are generally benign and associated with less than 20 papules over the surface of the skin. Severe infections are characterised by larger pustules, found in greater numbers, over a larger surface area of the body.2 In patients with HIV, infection with molluscum contagiosum may suggest deteriorating immune function.2 For those not known to be immunocompromised, the

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presence of more than 20 lesions suggests a need to investigate for underlying medical conditions such as sexually transmitted infections, HIV, or cancer.1

DIAGNOSIS Molluscum contagiosum is diagnosed with the identification of characteristic papules. In some cases, it may be confused with chickenpox or deep fungal infections. Laboratory tests including histopathology, molecular diagnosis by in-situ hybridisation, polymerase-chain reaction (PCR) and metagenomic sequencing may be useful for detecting the virus in complex cases.2

TREATMENT In most cases, molluscum contagiosum is self-limiting without any complications.1,2 Single lesions generally resolve within two months. Infections may take up to 12 months to completely clear.2 Potential complications associated with the presence of papules include inflammation, pruritus (itching), dermatitis and bacterial infection.2 In some cases, treatment may help reduce the spread of infection and limit the severity of symptoms. Treatment options include physical ablation, chemical agents, immune modulators and antiviral medications.2 Cryotherapy, curettage, podophyllotoxin and cantharidin have been demonstrated to rapidly remove lesions and are considered first line (see Table 1).1 Systemic and topical antiviral agents may be used to treat resistant lesions in immunocompromised patients. Cancer chemotherapeutic drugs and combination therapies may also be considered for severe infections.2

PREVENTION The spread of molluscum contagiosum may be limited by the use of contact precautions while lesions are present. This includes covering papules with clothing, dressings or bandages, avoiding bathing with others and maintaining single person use towels, clothing and other personal items.1 There is insufficient evidence to determine if condoms are effective at preventing the spread of infection. Therefore, abstinence is encouraged for all those with active infection.

REFERENCES 1. Chen X, Anstey AV, Bugert JJ. Molluscum contagiosum virus infection. The Lancet Infectious Diseases. 2013 Oct;13(10):877-88.

2. Ramdass P, Mullick S, Farber HF. Viral skin diseases.

Primary care: clinics in office practice. 2015 Oct; 42(4):517-67.

Table one. First line treatment options for molluscum contagiosum.1

Intervention

Description

Cryotherapy

Non-invasive procedure that involves the application of extreme cold (as in liquid nitrogen) to freeze and remove lesions.

Curettage

A medical procedure that involves the use of a surgical ‘scoop’ to scrape away unwanted tissue.

Podophyllotoxin

A topical cream, used to remove lesions and warts.

May be self-applied by adults twice a day. Has the potential to localised burning, pain, erythema and pruritus.

Safety and efficacy for use in children is presently unknown.

Cantharidin

A topical agent that causes blistering when applied to the skin.

May effectively remove lesions without scarring, but has the potential to cause localised burning, pain, erythema and pruritus.

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21

AcrosstheNation NEWS, VIEWS AND GOSSIP FROM ALL OVER AUSTRALIA

NSW PAIN FREE INJECTIONS WITH TINY NEEDLE-FREE DEVICE Vaccines will soon be able to be delivered directly to cells in the skin without needles – with a piece of biomedical polymer smaller than a postage stamp.

University of Sydney researchers are market testing the “one square-centimetre” Micro-projection Array Patch (MAP) – “embedded with 5,000 vaccine-coated micro-projections that pass through the skin’s outer layer to deliver a vaccine directly to thousands of immune-rich cells”.

“Delivering vaccines with this technology will be cheaper and easier than liquid vaccines delivered by needles because they don’t need to be refrigerated,” said Cristyn Davies from the university.

QLD MINI MUSCLES MANUFACTURED TO MANAGE MUSCULAR MALADIES Treatment of diseases such as muscular dystrophy will be assisted by the creation of functioning miniature human skeletal muscles by Queensland scientists.

The bio-engineered 1mm X 0.5mm skeletal muscles “flex and move like muscles in the body and grow and strengthen with exercise”, according to researchers at QIMR Berghofer Medical Research Institute.

The head of QIMR’s Organoid Research Laboratory, Dr James Hudson, said the micro muscles “would be an invaluable tool for researchers working on the development of new drugs and therapies for diseases like muscular dystrophy and muscle degeneration”.

“This would offer a significant advantage in remote locations, including in developing countries where refrigeration to keep vaccines viable is a major challenge.”

The university said the device “could boost vaccination rates since at least ten percent of people have been reported to avoid influenza vaccination due to fear of needles”.

“Further, the World Health Organisation estimates there are 1.3 million deaths each year due to needlestick injuries and cross contamination,” the university said.

“The technology has the potential to completely disrupt the vaccine industry, a $30 billion market” by eliminating needles and ending the need for cold chain storage of vaccines, said the university. 

“It gives us the ability to perform experiments on someone’s muscle in a petri dish,” Dr Hudson said.

“We created this micro muscle using a new method we developed.

We firstly cultured stem cells from a patient’s muscle, and then used bio-engineering devices and controlled culture conditions to turn them into human micro muscle tissues.

“So far the mini muscle functions and responds to signals in the same way as muscle in the body, making it a great model to accelerate research in muscle biology.”

QIMR post-doctoral researcher Dr Richard Mills – lead author on the paper of the study published in the journal Biomaterials – said the process has potential for developing “targeted, personalised treatments – where we can take cells from a patient, create hundreds of mini muscles and test which treatment is best for that individual”. 

VIC CUTTING EDGE NON-SURGICAL BRAIN TREATMENT MAY HELP EPILEPSY A tiny device that electrically stimulates the brain has been developed which in the future could treat conditions such as epilepsy and Parkinson’s disease – without invasive surgery.

Australian researchers found electrical stimulation can be delivered into the brain from a 4mm diameter “Stentrode” implanted inside a blood vessel.

This means treatments that have traditionally needed open brain surgery, such as deep brain stimulation for Parkinson’s disease and epilepsy, may be possible with just the Stentrode.

“Deep brain stimulation requires open brain surgery with an electrode implanted via burr hole surgery, where one or more holes are drilled in the skull so the electrodes

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can penetrate the brain,” said the University of Melbourne, which has scientists among the research team.

“The Stentrode can place electrodes in the brain via blood vessels through a vein in the neck.”

The university said the latest results expand on previous research showing the Stentrode could record brain signals and potentially control an exoskeleton in patients with paralysis. This latest study – published in the journal Nature Biomedical Engineering, and which also involves researchers from Florey Institute of Neuroscience and Mental Health, the Royal Melbourne Hospital, Monash University and the company Synchron Australia – shows the Stentrode “can also deliver targeted stimulation”. 

WA KOMBUCHA LIKELY NOT HELPING GUT HEALTH A study into 77 kombucha products available in Perth has found “there is no proof at all” that the fermented tea benefits gut health, reported The Sunday Times.

But a dietitian from the Cancer Council WA’s LiveLighter program, which ran the study, said the low-sugar tea was still a “great alternative” to sugary soft drinks.

The tea is fermented with SCOBY – a symbiotic culture of bacteria and yeast. “Touted health benefits include that it can aid digestion, colonise the gut with good bacteria and boost immunity,” said the newspaper.

VIC PATH TO CHILDHOOD ASTHMA CURE The key to preventing asthma in children may lie in the bacteria living in the lower respiratory tract of babies.

Melbourne researchers have found bacterial communities form in youngsters in their first two months of life, and “these bacteria interact with the immune system in ways that could potentially influence its development”.

“Although we don’t yet know how we could shape the lung microbiome of babies, data from our experimental models suggests

WA ALZHEIMER’S DELAYED BY MEDITERRANEAN DIET Alzheimer’s disease could be delayed by years by eating a Mediterranean diet.

Participants of an Australian study who ate the diet, which includes lots of vegetables, fruit, whole grains, fish and olive oil, were found to have significantly slower rates of Amyloid beta (Aβ) accumulation in the brain – a build-up linked with Alzheimer’s.

Edith Cowan University researchers, who made the discovery, said the good news was “you don’t have to be a lifelong adherent to the diet to get the benefits”.

“We found that by following a Mediterranean diet for just three years reduced the build-up of Aβ by up to 60 per cent,” said lead researcher Dr Stephanie Rainey-Smith.

“At this stage there is no proof at all that it does have benefits but it’s a growing research area so it may be something that comes out at a later date,” WA’s LiveLighter dietitian Gael Myers told The Sunday Times.

She said several approaches to “repopulating” gut health included increasing dietary fibre in food and “taking probiotic pills in conjunction with kombucha”.

“Our stomach is very acidic and it kills bacteria but probiotic pills are coated so they usually survive and get through to the gut. However, with fermented products such as kombucha and yoghurt, it’s variable as to how much of those bacteria go into your gut and help it,” Ms Myers said. 

this could be a powerful way of preventing asthma,” said Professor Ben Marsland, of Monash University.

“Looking towards the future, we aim to develop approaches that could help translate our current knowledge into strategies to reduce the incidence of childhood asthma.”

The study, led by Professor Marsland and published in the journal Cell Host and Microbe, differs from previous studies into the microbiota of the respiratory tract that relied on nasal swabs, because samples from the lower respiratory region require an invasive procedure.

In this study the researchers used samples from healthy babies and children among hundreds of newborns and young infants, who as part of their standard care were intubated in neonatal care units or during elective surgery. They found that the makeup of the bacteria in a twomonth-old was similar to those in a healthy adult. 

She also said while all aspects of the diet appear important for reducing Alzheimer’s risk, high fruit consumption was the feature most strongly related to a reduced build-up of Aβ and therefore “provided the greatest benefit”.

It is unclear exactly how fruit slowed accumulation of Aβ, but Dr RaineySmith said one possibility is the high concentration of Vitamin C in many types of fruit in the diet, such as citrus and strawberries, because the vitamin can “reduce the Aβ burden in mouse models”.

Another potential factor could be flavonoids present in fruit, because different types “have also been shown to be protective against Aβ accumulation in mouse models”.  January–February 2019 western nurse |

23

update: STI screening for women in primary care

Read this article and complete the online quiz to earn 1 iFolio hour

Sexually transmitted infections (STIs) are common in many areas of Australia, with the potential to impact fertility in both men and women. Women at high risk of infection include those aged 15 to 35 years of age, in communities with high rates of STIs. Women aged 15 to 19 years are particularly vulnerable, as are those who have had an STI or pelvic inflammatory disease (PID) within the last 12 months. Other risk factors include the presence of a new sexual partner in the past three months, more than one partner in the past six months, and behaviours like drug or alcohol misuse, which tend to indicate an increased likelihood of risky behaviour, such as sex with multiple partners or unsafe sexual activity. With all of this in mind, it is becoming increasingly important to perform routine STI screening and assessment in all primary health care facilities.

CONDUCTING A BRIEF FEMALE STI CHECK IN PRIMARY CARE When there is not enough time for a practitioner to perform a full STI check, a brief assessment may be used. This form of assessment includes sample collection, laboratory testing, and follow-up.

First, an appropriately trained healthcare professional collects two lower vaginal swabs, or instructs the patient to obtain swabs themselves through the self-obtained lower vaginal swab technique (SOLVs) (see image 1).

A first void urine sample may also be used, if required. If the patient is due for a Pap smear or a speculum examination is being performed, two endocervical swabs may be obtained instead. Samples are sent for nucleic acid amplification testing (NAAT) for chlamydia, gonorrhoea, and trichomonas and Gonorrhoea culture testing (see table 1).

Image One. Self-obtained lower vaginal swabs (SOLVs). http://remotephcmanuals.com.au/ publication/cpm/Self_collected_lower_ vaginal_swabs.html

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Table 1. Tests and swabs for STI assessment TEST

SWAB

NAAT – chlamydia, gonorrhoea, trichomonas

Aptima swab and tube or Dry swab

Gonorrhoea culture

Gel swab (amies transport medium) or Dry swab with charcoal medium

Microscopy, Culture and Sensitivities (MC&S) – thrush, bacterial vaginosis

Gel swab (amies transport medium) and glass slide

MC&S – GBS

Gel swab (amies transport medium)

NAAT - herpes, syphilis, donovanosis

Dry swab

In order to ensure appropriate follow-up, patients are encouraged to schedule a followup appointment regardless of the test results.

If findings are negative, practitioners must be careful not state that “they have the all-clear” or that “they do not have an STI.” Brief STI checks only screen for the most common STIs. If findings are positive, the patient must return to the clinic for treatment and contact tracing.

It is best practice to do a complete STI check at this point as well.

PERFORMING A FULL STI CHECK Annually, either as part of an adult health check or a community screening event, a full STI check should be performed. A full check may also be performed if the patient requests an STI assessment, complains of symptoms including vaginal discharge, pain on passing urine, or lower abdominal pain, has had a positive finding with a brief STI check, or is presenting for their first antenatal check.

Full STI assessments include a review of medical records, patient history, physical assessment, sample collection, laboratory testing, and follow-up. The practitioner begins by recording the date and results of the patient’s last STI check, as well as any treatment that has been previously offered and completed. Any use of contraception, the date and results of the patient’s last Pap smear, and their Hepatitis B immunisation status should also be discussed.

Next, a conversation is had about the patient’s last menstrual period to inquire after any abnormal bleeding. Practitioners should discuss whether the patient suffers from lower abdominal pain or pain during sexual intercourse, as well as whether there is any vaginal itching, discharge, soreness, sores, rashes, or lumps on their genitals. The patient’s sexual partners should also be discussed, to discover whether there are regular or casual partners, new partners within the past three months, and the total number of sexual partners had within the past six months.

The physical assessment includes a brief check for rashes around the genitals, hands, and feet, hair loss, mouth ulcers, and enlarged or tender lymph nodes around the groin. The groin, vulva, and anus should be checked for sores, other lesions, and rashes. All patients who are not currently taking contraception should also be offered a pregnancy test at this point.

COLLECTING SAMPLES FOR TESTING Initial samples are collected just as in a brief STI assessment. SOLVs or a first catch urine sample can be used to test for chlamydia, gonorrhea, and trichomonas. If a Pap smear is due or a speculum examination is being performed, two endocervical swabs can be collected instead. A low or high vaginal swab for MC&S should also be collected if there are signs of abnormal discharge.

In addition to these tests, blood is taken for HIV and syphilis serology. If genital sores are present, a dry swab at the base of the ulcer, sore, scab, or lump, or from fluid from the blister is taken. This sample is sent for NAAT for herpes, syphilis, and donovanosis. Finally, if the Hepatitis B status of the patient is not known or if there is no evidence of previous infection or immunisation, HBsAg, Anti-HBc, and Anti-HBs tests must also be performed. All pregnant women must be tested for Hepatitis B, regardless of their recorded status.

If the patient has presented with symptoms of an STI, the practitioner should immediately offer syndromic treatment without waiting for results. Where there are high rates of STIs, they may also consider immediate treatment even if no symptoms exist. Specific advanced treatment is required for related conditions such as pelvic inflammatory disease (PID).

All patients should receive education on STIs and safer sex while present.

PREGNANCY AND POSTNATAL CHECKS Pregnant and postnatal women are recommended to have STI checks on numerous occasions: at the first visit, 28 weeks, 36 weeks, birth, and six weeks post-natal.

At 28 and 36 weeks pregnant and the six week post-natal check, clinician collected lower vaginal swabs or a first void urine sample is collected and sent.

At 36 weeks, a combined anal and vaginal swab for Group B Streptococcus (GBS) test is performed.

A birth, a full STI check is performed, if not done previously. If the patient’s GBS status is unknown, the combined vaginal and anal swab is also taken.

A six weeks post-natal, syphilis serology is taken, if it was not performed at birth.

If any genital sores are present a dry swab at the base of the ulcer should be sent and immediate treatment should be offered.

REFERENCES 1. Tjukurpa, Minymaku Kutju. Women’s Business Manual, 5th ed (2014). 2014 Jun 30. Available online: http://remotephcmanuals.com.au/ publication/wbm.html 2. The Fertility Society of Australia. “Sexually Transmitted Infections (STIs).” Australian Government Department of Health and Ageing.

Available online from: http://yourfertility.org.au/ Sexually-transmitted-infections-STIs.pdf 3. Lucke, J.C., Herbert, D.L., Watson, M. et al. Arch Sex Behav (2013) 42: 237. doi:10.1007/s10508012-0020-x

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AroundtheGlobe WORLD NEWS

PETS IN EARLY LIFE CUT ALLERGIES LATER Children who are around lots of pets as infants have a lower incidence of allergies such as asthma, hay fever and eczema later in life, Swedish researchers believe.

“The prevalence of allergic disease in children aged 7–9 years is reduced in a dose-dependent fashion with the number of household pets living with the child during their first year of life,” said the researchers from University of Gothenburg in the journal PLoS One. This suggests “a ‘mini-farm’ effect, whereby cats and dogs protect against allergy development”, they added.

Two cohorts of children, both containing approximately equal quantities of males and females, were investigated. The first group comprised 1029

seven to eightyear-olds, and the second 249 children clinically evaluated for asthma and allergy by paediatricians from birth up to the ages of eight and nine years.

“A dose-response association was seen, with less allergic manifestations (any of asthma, allergic rhinoconjunctivitis, or eczema) with increasing number of household cats and dogs during the first year of life,” the researchers concluded.

Among the results, in the first seven to eight-year-old group allergy “decreased from 49 per cent in those with no pets to zero in those with five or more pets”. 

DOUBLE DIP CAN MAKE YOU SICK Legendary '90s TV sitcom Seinfeld made the point that when you double dip a chip “that’s like putting your whole mouth right in the dip” – and science pretty much agrees.

US food scientist Paul Dawson has conducted rigorous tests on double dipping and recently told ABC Radio Perth “that having a second swipe of communal dip with a halfeaten chip was riskier than he first thought”.

“We actually found there was 1,000 more bacteria per millilitre in the dip from when you

bit the chip than when you didn't," said Professor Dawson, of South Carolina’s Clemson University, who is co-author of food myth book Did You Just Eat That?.

“That's a significant amount. That's more like a person-to-person transfer like the common cold and other contagious diseases rather than the typical food-borne illness like E.coli and salmonella.”

Professor Dawson also tested the “five-second theory” by placing harmful bacteria on to tiles, wooden floorboards and carpet, and then dropping food on the surfaces, and picking it up after five seconds.

“It depends on the surface — if there is pathogenic bacteria on that surface, then no, it is not safe to eat,” he said. “But honestly, most surfaces are not going to have any kind of dangerous bacteria there.”

Surprisingly, carpet proved a safer place to drop food than tiles or floorboards, because “the carpet actually soaked up the salmonella we placed on it”. 

MORE HIP SURGERY WON’T SAVE ANDY MURRAY’S CAREER Andy Murray recently announced his impending retirement from tennis because of severe hip pain – with experts saying additional surgery likely won’t enable him to keep playing at the top level of the game.

His hip surgeon said it will be difficult for the Olympics and Wimbledon champion to continue playing even until the Wimbledon tournament in July, where Murray had hoped to finish his career.

Dr John O’Donnell, who previously operated on Murray’s right hip, is reported on The Guardian news website saying: “Andy has tried really hard and explored every option that has any real possibility of being helpful. Realistically I don’t think there is anywhere else to go to preserve his hip and get it better so he can continue to play.”

The Scottish sports star is considering hip resurfacing, said the New Scientist website. “(That would) suggest

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that he has quite severe osteoarthritis,” said Winston Kim, a consultant orthopaedic surgeon at Manchester Hip and Knee Clinic.

Instead of a whole hip replacement, resurfacing involves smoothing down the femur and covering it with a metal cap. Metal is also placed in the pelvic socket, so instead of bone rubbing against bone, causing severe pain, metal rubs against metal.

Murray is quoted on The Wall Street Journal website as saying the reason for having more surgery would be to have better quality of life.

“There are little things, day to day, that are also a struggle,” Murray said. “It would be nice to be able to do them without any pain, putting shoes on, socks on, things like that. That is the main reason for doing it.” 

BACKWARD MOTION IMPROVES MEMORY Backwards movement may be used to “improve short-term memories of eyewitness information, word recall and picture recall”, UK scientists have found.

They conducted six experiments to reveal “whether backward motion would promote recall in relation to forward motion or no-motion conditions” – with participants shown either a video of a staged crime, a word list, or a set of pictures.

“Then, the participants walked forward or backwards, watched forward or backward-directed motion videos, or imagined walking forward or backwards,” said a report of the experiments by the University of Roehampton London.

“At the end of the experiment, they answered questions about the video or recalled words or pictures.

“The results revealed that backward motion (whether real, induced or imaginary) improved the recall of details of a video, words or pictures.”

Dr Aleksandar Aksentijevic – who along with other colleagues from the university’s psychology department published the research in the journal Cognition – said: “The results demonstrated for the first time that motion-induced past-directed mental time travel improved mnemonic performance for different types of information.

“We have named this a ‘mnemonic time-travel effect’.”

Another of the co-authors, Dr Elias Tsakanikos, said: “There is a huge potential for developing this effect as a digital intervention for memory problems in older adults, and we are currently in discussions with app developers.” 

COMFIEST RUNNERS MIGHT NOT BE SAFEST Highly cushioned running shoes may put us at more risk of injury than conventionally padded ones.

This is because running in highly cushioned shoes can increase “leg stiffness” when landing and “amplify rather than attenuate impact loading”, Finnish researchers have found.

This might be similar to how “when transitioning from a hard surface to a more compliant surface, a runner’s leg becomes stiffer and compresses less to maintain the preferred spring-mass mechanics”.

To conduct their study, the academics recruited 12 healthy men aged from 27 to 32 years, with “several years of sports background and who ran with a heel strike pattern”.

They examined impact loading and the spring-like mechanics of running of the subjects while wearing a conventional control running shoe (CON) or a highly cushioned maximalist shoe (MAX), and at two training speeds – 10 km/h and 14.5 km/h.

“We found that highly cushioned maximalist shoes alter springlike running mechanics and amplify rather than attenuate impact loading,” wrote the researchers from the University of Helsinki and the University of Jyväskylä in the journal Scientific Reports.

“This surprising outcome was more pronounced at fast running speed (14.5 km/h), where ground reaction force impact peak and loading rate were 10.7 per cent and 12.3 per cent greater, respectively, in the maximalist shoe compared to the conventional shoe.

“We attribute the greater impact loading with the maximalist shoes to stiffer leg during landing compared to that of running with the conventional shoes.”

The researchers opined that the findings “may explain why shoes with more cushioning do not protect against impact-related running injuries”. 

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TOASTED COCONUT ICE CREAM Summer weather in WA seems to cry out for ice cream! This edition’s recipe delivers on all the expectations of this much-loved classic frosted dessert, but with a bit of a twist on the conventional ingredients – utilising flavoursome coconut cream and coconut milk and crispy toasted coconut flakes. So you get the smooth and creamy texture – with some extra crunch!

EQUIPMENT

INSTRUCTIONS

• Ice cream maker (optional)

1. Place coconut cream, coconut milk, glucose syrup, sugar and 1 cup of toasted coconut flakes in a saucepan over medium-low heat. Cook, stirring occasionally, for 3 to 4 minutes or until the mixture is smooth and just beginning to simmer.

• Electric hand mixer or stand mixer (to manually churn your ice cream) • Ice cream storer • Ice cream scoop • Large casserole or saucepan • Spatula (silicone or wooden) or whisk (stainless steel) • Small mixing bowl • Loaf pan • Cling film • Sieve or mesh strainer

INGREDIENTS • 1 can coconut cream • 1 can coconut milk • ¼ cup glucose syrup • ½ cup caster sugar • 1 cup and 2 tbsp toasted coconut flakes • 2 tbsp corn starch

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2. In a small bowl, add 2 tbsp of corn starch, along with 2 tbsp of the warm coconut mixture and mix until a smooth paste is formed.

3. While whisking, pour the corn starch mixture into the warm coconut milk. Increase the heat to medium and cook, stirring occasionally until the base has thickened enough to coat the back of a wooden spoon (similar to the consistency of a creme anglaise).

4. Pour the mixture into a large flat-sided tray, cover with cling film and leave to cool to room temperature before popping the tray into a refrigerator for at least 2 to 3 hours until completely chilled. Leave overnight for best results.

5. Once the ice cream base is completely chilled and slightly puddinglike in texture, strain the mixture, discarding the coconut and follow your manufacturer’s instructions on how to churn ice cream. (For manual churning, you can either use a hand mixer or stand mixer to churn your pre-chilled ice cream mixture. Ensure your mixing bowl is completely chilled to get a smooth ice cream. Churn as fast as you can.)

6. Once churned, transfer the ice cream into a freezer container and freeze for at least 4 hours before serving. Top it with some toasted coconut flakes and serve straight from the refrigerator.

And when you don’t have enough time and resources to make a nice, smooth, and creamy ice cream at home, this easy no-churn Snickersstyle ice cream recipe has your cravings covered – taking only 10 to 15 minutes to prepare! With just bananas, some leftover peanut butter, vanilla, and cacao powder, you can enjoy this yummy and sweet offering.

SNICKERS-STYLE ICE CREAM EQUIPMENT • • • •

Blender Spatula Measuring cups and spoons Coconut bowls

INGREDIENTS • • • • •

4 large frozen bananas ¼ cup smooth peanut butter 1 tbsp plant-based protein (optional) ½ tsp vanilla bean paste or powder 2 to 3 tbsp cacao powder

INSTRUCTIONS 1. Combine all ingredients (except cacao powder) in a high power blender, blend until smooth and creamy.

2. Transfer half of the mixture to your coconut bowls. Add cacao powder to the remaining mixture and blend.

3. Add the chocolate ice cream to the bowls. Top with peanuts, raw chocolate and/or cacao nibs.

Snickers-style ice cream recipe and image adapted from Coconut Bowls.

Both recipes supplied courtesy of Kitchen Warehouse.

January–February 2019 western nurse |

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ResearchRoundup LATEST AND GREATEST FROM SCIENCE

Lumberjacks studied also exerted themselves more “with the squat techniques (bending knees) than the stoop technique (straight knees)”, the journal said.

The editorial added: “The results from this study indicated that they (lumberjacks) preferred a movement strategy best suited to reduce the demand on the knee-extensor muscles … likely also to reduce the total work load and to save energy.”

LIVE YEARS LONGER WITH TENNIS People who play tennis can live nearly 10 years longer than couch potatoes.

But social interaction in tennis and other sports may also be key to the longevity, say the Danish and US researchers who examined life expectancy gains.

Playing tennis can improve life expectancy by up to 9.7 years compared with sedentary subjects, according to analysis of the Copenhagen City Heart Study – a population study of 8577 participants across 25 years.

Playing badminton can gain you 6.2 extra years; soccer can get you 4.7 years; cycling, 3.7 years; swimming, 3.4 years; jogging, 3.2 years; calisthenics, 3.1 years; and health club activities only 1.5 extra years.

Recent media reports about the Scandinavian editorial pointed to 2014 research at the University of Aberdeen, which said the mantra of “Bend your knees and keep your back straight” might “not work for everyone when it comes to back care”, but that the “shape of our spines is key to lifting correctly”.

“The curve of our lower backs is specific to each individual, a bit like a fingerprint. Interestingly, this affects the way we lift objects from the floor, so that those with ‘curvy’ spines tend to bend over, or stoop, to lift a box whereas those with straighter spines tend to bend their knees and squat,” Anastasia Pavlova, lead author of the Scottish research paper, said in 2014. 

PILL TO CURE OBESITY Eliminating obesity could soon be as easy as taking a pill.

A gene known as RCAN1 when removed in mice resulted in them failing to gain weight when fed, “even after gorging on high-fat foods for prolonged periods”.

“Interestingly, the leisure-time sports that inherently involve more social interaction were associated with the best longevity – a finding that warrants further investigation,” the researchers said in the US medical journal Mayo Clinic Proceedings.

Professor Damien Keating, of Flinders University in Adelaide, and his Texan co-researchers, who are researching the gene, hope a similar approach “will also be effective with humans to combat obesity and serious diseases like diabetes”.

“Sports such as badminton and doubles tennis do not typically require strenuous exertion, but do entail a great deal of social interaction.

“The findings in this study could mean developing a pill which would target the function of RCAN1 and may result in weight loss,” said Professor Keating, from Flinders Molecular and Cellular Physiology Laboratory at the College of Medicine and Public Health.

“Belonging to a group that meets regularly promotes a sense of support, trust, and commonality, which has been shown to contribute to a sense of well-being and improved long-term health.”

But the researchers added the best life expectancy gains “typically require interval bursts of exercise using large muscle groups and full body movements”, while sports “performed in a continuous manner showed less impressive life expectancy gains”. 

QUESTIONS ABOUT SAFEST WAY TO LIFT Conventional wisdom on lifting heavy loads is being challenged – with a European medical journal controversially stating “Lifting with straight legs and bent spine is not bad for your back”.

The Scandinavian Journal of Pain editorial claimed studies of lumberjacks had shown “the thighs and not the spine is the weak link during hard physical work including lifting”.

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Professor Keating said blocking RCAN1 helps transform unhealthy white fat (which stores energy) into healthy brown fat (which burns energy), “presenting a potential treatment method in the fight against obesity”.

“We have already developed a series of drugs that target the protein that this gene makes, and we are now in the process of testing them to see if they inhibit RCAN1 and whether they might represent potential new anti-obesity drugs," he said.

“The drugs we are developing to target RCAN1 would burn more calories while people are resting. It means the body would store less fat without the need for a person to reduce food consumption or exercise more.” 

W

WIN BESTSELLER BAREFOOT BOOKS!

WIN one of 30 copies of The barefoot investor for FAMILIES!

A recent Australia-wide number one seller, it’s Scott Pape’s guide to turning kids’ lives around, which will help parents and grandparents give their youngsters a solid start.

Pape outlines basic steps for making children more financially savvy, including setting up zero-fee/highinterest savings accounts, kids getting their first job and getting them three jam jars where they learn early on about how to save. “(It’s) more than a book – it’s a movement,” Pape told News Corp Australia.

“The most financially illiterate people in Australia are 18-yearolds leaving school. That needs to change. Every Aussie kid needs to learn about money before they finish school.” 

PERFECTLY PITCHED PRIZES! 30 copies of the Pitch Perfect Trilogy special Blu-ray pack are up for grabs!

Larger than life Aussie star Rebel Wilson showcases her talents on all three films in the series.

Relive the best moments with your favourite pitches! Triple the laughs, adventures and misadventures – and of course music with this collection.

The trilogy starts with Beca Mitchell (Anna Kendrick) arriving at her new college and finding herself not right for any clique, but somehow muscled into a group that she never would have picked – alongside mean girls, sweet girls and weird girls whose only thing in common is how good they sound when they sing together. 

To enter, just log on to your iFolio. The ANF Holiday Units Photo Competition is also on there!

FLEET NETWORK WINNER! Jade Melsom has won $500 cash in the Fleet Network’s ANF WA Members’ Competition!

Jade, a Graduate Nurse at Geraldton Regional Hospital, salary-packaged a car with Fleet Network during December, and automatically went into the draw.

“Purchasing my car through Fleet Network has been the easiest process,” Jade said.

“Being able to communicate via email, phone calls and text messages made the exchange of information for someone working full time easily accessible.

“I can’t recommend Fleet Network enough, they were so helpful I felt as if I did nothing but pick the car I wanted.”

Looking to salary package a new car? Call Fleet Network on 1300 738 601, or visit www.fleetnetwork.com.au/anfwa to view our special deals for ANF members.

ANF HOLIDAY APARTMENTS

PERFECT RIGHT NOW Low cost, high quality resort accommodation in KALBARRI and MARGARET RIVER

BOOKINGS AND INFORMATION

ifolio.anfiuwp.org.au January–February 2019 western nurse |

31

SPECIAL OFFER EXCLUSIVE TO bayswater mazda*

Special offer for Australian Nursing Federation WA: • Free 4 years/40,000 kms scheduled servicing • Free loan car for all routine servicing • Free $500 Caltex Fuel card for all new vehicle purchases • Free ongoing Roadside assistance when purchasing a vehicle

Salary packaging?

Ensure your Fleet Company contacts Bayswater Mazda to gain the full benefits of this offer.

*Special offer available to Australian Nursing Federation WA members. Vehicle must be purchased new from Bayswater Mazda and all servicing must be done at Bayswater Mazda. Servicing offer excludes Mazda 2, Mazda 3 and Mazda BT50. MD25174

Driving is better with Bayswater www.bayswatermazda.com.au/anfwa (08) 9783 9023 Cnr 374 Guildford & Garratt Road, Bayswater