Western Nurse Magazine May June 2017

May – June 2017

incorporating western midwife

Your western nurse now also digital!

Go to iFolio and read it on any device.

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western nurse is the official magazine for ANF members in WA

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Secretary's Report May-June 2017

State Secretary, Mark Olson

FEATURED

May – June 2017

incorporating western midwife

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Life After Nursing

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Awards: Nurses and Midwives Recognised

12 New Digi Issue!

on the

cover Your western nurse now also digital!

Go to iFolio and read it on any device.

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25 Tanzanian Nurses Visit WA

FAVOURITES 14 Internet Watch 18 ANF Out ‘N’ About 20 Across the Nation 26 Around the Globe 30 Research Roundup 31 ANF Contact Details

Life After Nursing

HOLIDAY ANF 13 ANF Super Deal Margaret River 32 ANF Super Deal Kalbarri

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8 Nurses and Midwives Recognised

31 Win one of 20 boxsets containing four classic 1960s films! Also five copies up for grabs of The Barefoot Investor: The Only Money Guide You'll Ever Need.

CLINICAL UPDATES 6 Yellow Fever 16 Rheumatoid Arthritis – An Update 22 Alcohol Withdrawal Syndrome

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29 Treatment of Chronic Hepatitis C Infection

I normally don’t focus on individual awards because I feel the vast majority of our nurses, midwives and carers do a great job every day under increasingly difficult conditions. However, May was a big month for our members in local, national and even international awards. So in a special awards spread in this edition, we recognize the winners of the WA Nursing and Midwifery Excellence Awards, the 2017 HESTA Australian Nursing & Midwifery Awards, and the Florence Nightingale Medal – congratulations to you all.

Moving from recognition of past deeds into the future of the ANF, you’ve probably noticed that we’ve revamped this magazine in the past year, and as of recently, we have also rolled out a digital version of western nurse on your iFolio. In this edition we also announce we have an ANF App in the works. We see the digi issue and app as trimmings that can top up your quite incredible iFolio system, which I’ve spent years building with our hardworking IT team.

Unlike many other similar organisations that have social media promotion as their major IT consideration, the ANF’s top priority has always been to build a system that could deliver what our members needed. This is why you now have an iFolio where you can do anything from book one of nearly 80 ANF holiday units, to getting your CPD requirements completed with our clinical updates, to downloading a CPD evidence record that lists everything AHPRA asks for. This emphasis on substance over self-promotion has also meant we have a secure iFolio that protects your information, which has become essential in a modern world of cyber attacks. We’ll be collecting as much input from you our members, before we launch the new ANF App so we can develop it with the features you want, so stay tuned for surveys in coming months.

Yellow Fever

May–June 2017 western nurse |

3

New Life

After Nursing After more than four decades of nursing, one of our senior country nurses is taking on new challenges – including a trip to Machu Picchu in Peru.

Trip to Machu Picchu in Peru.

When Jeanette Hancock recently wrote to ANF State Secretary Mark Olson to say she’d retired from Geraldton Regional Hospital, her email was rather more celebratory than sombre.

ship M.S. Expedition and sail round Svalbard, Greenland and Iceland,” the former general ward coordinator added. “This is the same ship on which we went to Antarctica in January 2016.”

“After 44 years of nursing since graduating from Fremantle Hospital, I am now enjoying travelling, grandkids and doing all the things I've never had time for (such as) more caravanning,” the senior clinical nurse said, emphasising more leisure time with a photo in her email captioned: “Last year ...... camping on the Antarctic Continent”.

Jeanette started nursing with training at Fremantle Hospital in January 1972, which she completed in January 1975. The following year, she married Graham, and then moved north to a cattle station to live and work, 150km out of Meekatharra.

Jeanette also informed Mark matter-of-factly, that living near Dongara, 351 kilometres northnorthwest of Perth, she has “travelled 1.2 million km and gone through 10 cars”.

“Quite a feat when I look back on it. Only ever hit one roo in all those years of travelling in the dark,” she added.

After reading Jeanette’s letter and seeing she’d travelled to the South Pole, western nurse thought we might enquire about coming travels. She wrote back a few weeks ago – during a caravan trip to Kununurra for the Kimberley Moon Festival – saying she and her husband Graham fly to Russia in August “to cruise the river from St. Petersburg to Moscow”.

“Then to England for eight days, then onto Svalbard in the Arctic Circle to join the Expedition

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Jeanette in her early years of nursing

“Then we went to a sheep and wheat station/farm at Mingenew (where) I assisted as an ambulance volunteer,” she said. “We bought our own small farmlet at Dongara, and I did a refresher course at the Western Australian School of Nursing in 1986, commencing at Geraldton Regional Hospital on the 17th of March, 1987.

“I became a clinical nurse there in surgical nursing and loved orthopaedics. After having bilateral hip replacements myself – the first 19 years ago, and the second 11 years ago – I was able to show my ‘not so enthusiastic’ patients just how beneficial rehab could be! I took up bike riding as part of my rehab, and ride nearly every day and also in bike hikes like the Freeway Bike Hike for Asthma.”

Jeanette also became the only stomal therapy nurse at the regional hospital from 1991 until her retirement – “a very interesting and challenging job, which I enjoyed”. A stoma is a surgically created opening that helps drain body products –

such as a colostomy. “Unfortunately I could never find anyone interested enough to take this job on, despite many years of lecturing and demonstrating stomal therapy,” she said.

Dear Mark, I am writing to let you know that I retired from Geraldton Regional Hospital on the 11th Dec. 2016 after 29 years & 9 months there! 2 other long term CN's and a long term EN from Paeds also retired during 2016......, over 120 years of experience walked out the door that day. :( 2 of us still had our original uniforms, so dressed up for our last day.

Since I live near Dongara, I have travelled 1.2million km and gone through 10 cars! Quite a feat when I look back on it. Only ever hit 1 roo in all those years of travelling in the dark.

44 years of Nursing since graduating from Fremantle Hospital, I am now enjoying travelling, grandkids and doing all the things I've never had time for.

More caravaning. Last year....camping on the Antarctic Continent.

Jeanette said she has seen “many, many” changes in nursing over the last 44-plus years – “some good, some not so good”. She told western nurse: “Uniforms have changed dramatically – for the better, though I am not a fan of scrubs, and have never worn them. I felt that as a ‘profession’ we should not be wearing PJs to work!

After almost 30 years at Geraldton, and at 63 years of age, it was time to retire and travel to some more remote places in the world as well as see this beautiful country of ours. I will miss the work, the patients and my colleagues, but certainly not the politics that rule our workplaces these days.”

In her letter to Mark, Jeanette said she finally left Geraldton regional on December 11, 2016, “after 29 years and nine months there!” and that two other long term CNs and a long term EN also retired during 2016 – so “over 120 years of experience walked out the door that day”.

“Two of us still had our original uniforms, so dressed up for our last day,” she wrote Mark, illustrating with the photo of her with registered nurse Liz Gates, and advanced skill enrolled nurse Ruth Criddle.

She also told Mark: “I would like to thank you for all your constant hard work for nurses and our conditions, and for all your visits to Geraldton over the years. Thank you for your camera courses, lectures, the iFolio, and so much more, but mostly for your unwavering support of me and my colleagues. I cannot imagine the ANF without you at the helm.”

In recent years, Jeanette’s adventures have included: Machu Picchu in Peru, Easter Island in Polynesia, and a river cruise in Europe, from Amsterdam to the Black Sea, as well as local trips, such as driving Great Ocean Road in a van, and a caravan trip to Darwin. The ANF wishes Jeanette well in all her future travels, wherever they may be.

I would like to thank you for all your constant hard work for nurses and our conditions, and for all your visits to Geraldton over the years.

Thank you for your camera courses, lectures, the ifolio, and so much more, but mostly for your unwavering support of me and my colleagues.

I cannot imagine the ANF without you at the helm.

Thanks for everything.

Jeanette Hancock.

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May–June 2017 western nurse |

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update: Yellow fever

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

INTRODUCTION Yellow fever is a mosquito-borne viral disease of the flavivirus genus.1,2 It is an arbovirus, similar to other concerning viral diseases, including Zika virus and dengue fever (see Box 1).1 Yellow fever is spread by the Aedes and Haemogogus mosquitoes, which are found in urban and jungle settings in Africa and South America.1 Although a vaccine is available, immunisation rates in high-risk areas remain low.3 Since December 2015, Angola, West Africa has been suffering from the largest outbreak of yellow fever in recent history. As a result, global stockpiles of the vaccine are running dangerously low.3 Box 1. Arbovirus

“Arbovirus” is a term used to describe a large group of viruses, which are transmitted through arthropods, including mosquitoes and ticks. Arboviruses that cause significant human disease include Zika virus, yellow fever virus, dengue and West Nile.

GEOGRAPHIC DISTRIBUTION There are 44 countries in Africa and Latin America with endemic yellow fever and more than 900 million people at risk.1 The current outbreak raises concerns that the virus will continue to spread throughout the provinces of Angola, and into neighbouring countries.3 The greatest risk is in jungle areas where the reservoirs of monkey and jungle mosquitoes are high. There is also a potential for the virus to spread to urban areas resulting in large- scale outbreaks, similar to those seen with other arboviruses including Zika virus.3 Some experts fear a potential spread into Asia. Despite an ideal climate, Asia has never been affected by yellow fever and at present, the risk remains uncertain.3 The Center for Disease Control and Prevention provides maps of countries with yellow fever.4

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TRANSMISSION Yellow fever may be transmitted in three ways. Sylvatic (jungle) yellow fever spreads from infected monkeys to humans through wild mosquitoes in the forest or jungle.

Intermediate yellow fever occurs in urban and non-urban settings. Wild and domestic (household) mosquitoes spread the virus between monkeys and people in more densely populated areas. Urban yellow fever is responsible for large epidemics. In Africa, the Aedes mosquito transfers the virus between infected and non-infected individuals in highly populated areas.1,2

SIGNS AND SYMPTOMS The incubation period for yellow fever may last up to six days. Acute infections are characterised by fever, muscle aches, back pain, gastrointestinal upset, and loss of appetite, lasting between 3-4 days.1 A small proportion of patients may experience a resurgence of worsening symptoms within 24 hours of initial remission. Symptoms of this second, more toxic phase include fever, jaundice, abdominal pain, vomiting, and internal or external bleeding.1 Patients with severe symptoms may die within two weeks. However, those who recover, tend to return to normal functioning.1

IDENTIFICATION Yellow fever may be difficult to differentiate from other conditions including malaria, leptospirosis, viral hepatitis, and other haemorrhagic fevers. Antibodies may be detected in blood samples. New methods of rapid diagnosis are under development and will hopefully be available in the near future.2

TREATMENT There is no cure for yellow fever. Without treatment, approximately 50% of severely affected individuals will die from their infection.1 Treatment includes symptom management and supportive care. Dehydration from gastrointestinal losses must be reversed and opportunistic bacterial infections may be treated with antibiotics.1

PREVENTION A multi-faceted approach to yellow fever prevention is required to reduce the risk of infection and prevent epidemics in highrisk areas. Techniques for prevention include

epidemic preparedness, mosquito control, and vaccination.1 Epidemic preparedness relies on effective disease reporting. Unfortunately, many countries lack the basic mechanisms to ensure accurate disease detection and reporting. The World Health Organization recommends at least one national laboratory that can perform blood tests for yellow fever and identify an increase in the number of confirmed cases in all high-risk areas.1 Mosquito control is essential to prevent the spread of all mosquito-borne illnesses.

Basic interventions include the use of nets and removal of mosquito breeding sites.

Insecticides may also be used to help halt disease transmission, especially in urban areas.1 Above all else, vaccination is the most important prevention tool for yellow fever.1 The yellow fever vaccine is safe, affordable, and highly effective at inducing life-long adaptive immunity.1,2 Despite this, vaccination coverage remains too low to prevent outbreaks in many regions.1,3 Mechanisms to increase vaccination rates include mass immunisation campaigns, protection for travellers to endemic regions and routine vaccination for children in highrisk areas.1

REFERENCES 1. World Health Organization. Yellow fever [Internet]. Geneva: WHO; 2016 Mar [cited 2016 Apr]. Available from http://www.who.int/ mediacentre/factsheets/fs100/en/ 2. Monath TP, Vasconcelos PF. Yellow fever. J Clin Virol. 2015 Mar;64:160-73.

3. Butler D. Fears rise over yellow fever’s next move.

Nature. 2016 Apr 14;532:155-56.

4. Centers for Disease Control and Prevention, 2015. http://www.cdc.gov/yellowfever/maps/

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OUR NURSES AND MIDW WA WINNERS

Amy Wallace has taken out WA’s 2017 Nurse/Midwife of the Year Award among numerous other local ANF members who won State, national and international prizes this year.

Graylands Hospital nurse Amy Wallace says her achievement at the WA Nursing and Midwifery Excellence Awards is “for all mental health nurses out there making a difference to people’s lives”.

Amy, who won WA 2017 Nurse/Midwife of the Year on May 6, said it is an ”amazing honour” and she felt “very privileged” to be chosen out of all the finalists, who are all doing “amazing things” for the nursing and midwifery professions.

This award to me signifies a “ long overdue recognition for mental health nursing and the challenging role we undertake,

”

“This award to me signifies a long overdue recognition for mental health nursing and the challenging role we undertake,” Amy told western nurse. “Although I am the recipient of the award, this is for all mental health nurses out there making a difference to people’s lives every day.”

This is the 14th year of the awards, which were held at Perth Convention and Exhibition Centre, and are hosted annually to coincide with International Day of the Midwife on May 5, and International Nurses Day on May 12.

Amy, who was the inaugural Physical Health Care Clinical Nurse Specialist at Graylands in 2015, with the aim of integrating physical health care into the wellbeing of people with mental illness, also won the Excellence in Registered Nursing award.

Left to Right: 1. TED DOWLING 2. PRUE ANDRUS 3. ELENA ADAMS 4. RACHEL BARNES 5. ASHLEIGH JOY 6. PROFESSOR DI TWIGG 7. PREMIER HON MARK MCGOWAN 8. AMY WALLACE 9. SUSAN DUGAY 10. KAREN COYLE 11. TARRYN SHARP 12. DI BARR 13. DR FENELLA GILL

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western nurse May–June 2017

WIVES RECOGNISED Other winners included Tarryn Sharp for Excellence in Midwifery; Ted Dowling for Excellence in Aboriginal Health; Rachel Barnes for Excellence in Residential Care; Karen Coyle for Excellence in Rural and Remote Health; and Susan Dugay for Excellence in Enrolled Nursing. Graduate of the Year was Ashleigh Joy; while Elena Adams won the Consumer Appreciation awards; Prue Andrus was awarded for Excellence in Education; and Dr Fenella Gill took out the Excellence in Research award. Professor Di Twigg, was given a Lifetime Achievement Honour; and Excellence in Leadership was awarded to Di Barr.

Amy, 34, said she had been inspired to start nursing because nurses had helped her so much in her life. “Since the first time I can remember I have always been physically

unwell. I have had multiple gastric surgeries and suffer from Rheumatoid Arthritis,” she said. “I clearly remember as a little girl waking up from surgery in pain and so scared, and it was the nurse who took my hand, wiped my tears and reassured me my mum was on the way. I quickly learnt how much such nurturing and kindness could make a difference to how a person heals.”

Premier Mark McGowan congratulated all winners and finalists and thanked them for their commitment. Health Minister Roger Cook said: “Western Australia’s 38,000 nurses and midwives play a critical role in the State’s health system and are at the forefront of ensuring compassionate, safe and cost effective care”.

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OUR NURSES AND MIDWIVES NIGHTINGALE MEDALS FOR LOCAL NURSES Two WA nurses are among only 39 worldwide from 22 nations who this year received the highest international nursing honour.

WA Australian of the Year for 2016, and ANF member, Anne Carey, well known for helping lead the successful charge against Ebola, has now won a Florence Nightingale Medal.

Fellow WA nurse Catherine Fry joins her in achieving this prestigious international honour, after they were selected by a commission comprised of the International Committee of the Red Cross, the International Federation of Red Cross and Red Crescent Societies, and the International Council of Nurses.

After announcing the award on May 12 – International Nurses Day and also the birthday of Florence Nightingale, who established the world’s first professional nursing school at St Thomas’ Hospital in 1860 – the Red Cross said: “Anne Carey is a nurse who helped in the Red Cross response to contain the Ebola epidemic in Sierra Leone. She has also worked in Darfur, Sudan and in a refugee camp on the Sudan/Kenya border.”

Cathy Fry in Darfur

The organisation said of Catherine: “After a career in remote area nursing around Australia, Catherine Fry coordinated the delivery of health care in Darfur, Sudan for children and mothers. On top of providing access to health care across frontlines, Catherine also played a critical teaching role in her missions, including in Liberia, Uganda and Afghanistan.”

“Kindness is never mentioned in lists of key performance indicators. It, however, underlies the whole purpose of healthcare. We have to remember what healthcare is about. It is basically there to bring care to the suffering.

It is an outcome of our innate compassion and kindness that is part of being human.”

The pair were characteristically humble – Anne telling western nurse: “I was surprised when a colleague rang me up from a remote nursing post to tell me … I found myself reflecting after the call on what it meant. It is to me a recognition not so much of anything I have done, as on the work of the teams I have been part of.

Catherine said there were five recipients from Australia this year, and she had been “fortunate enough” to work with all the other four through the Red Cross at some stage.

“None of us achieve anything much in health care unless we are part of a team. (And) teams do not achieve much unless they have an essential quality for health workers, the courage to overcome fear, the courage to be honest and most importantly, the courage to be kind.

Anne Carey with her award

“For me personally the award is a tribute to many people who have influenced my life,” she said. This tribute should include her grandfather, who was a prisoner of war with Sir Weary Dunlop, who had shared “his stories of the difficulties they endured”, and the tribute should also extend to “the support and encouragement of my family who must find it stressful when I am in conflict zones, to my friends who welcome me home and listen to my stories , the wonderful colleagues overseas who mentor me, and the local staff who allow me to carry out my work, and then the WA Health Department which lets me slide back into work here back in my normal life – it is always a team effort”.

Anne Carey fighting ebola

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RECOGNISED NATIONAL WINNER A WA nurse won Outstanding Graduate at the 2017 HESTA Australian Nursing & Midwifery Awards on May 10.

Bec Rich’s life ambition is to help break down the stigma surrounding mental health.

The 25-year-old nurse, who won Outstanding Graduate at HESTA’s Australian Nursing & Midwifery Awards in Brisbane last month, especially has a passion for adolescent mental health.

“I strongly believe if we can reach people early and increase awareness and acceptance of mental illness, prevention and early intervention is achievable,” Bec told western nurse soon after winning her award.

“During adolescence, we want to build resilience, promote wellbeing and positive health behaviours that will increase their opportunities for the future. If we can teach healthy, effective coping strategies, self-management and interpersonal skills early, I think we have a real chance in reducing hospitalisation including number of admissions and time spent in hospital, and the impact of mental illness on people's lives both short and long term.”

Bec, who works at Perth Clinic, a private psychiatric hospital in West Perth, said she has been fortunate enough to “do something I love and am so passionate about”, let alone “to be recognised for this, and to receive an award”.

“It means the absolute world to me and will continue to motivate me in the future,” she said of the award. Bec studied two and a half years of a psychology degree, before completing her nursing degree at Curtin University in 2015. She

began the Perth Clinic graduate program in 2016, and finished in February 2017. “I now work predominantly on the adolescent ward at Perth Clinic, and have branched into dialectical behaviour therapy – assisting to run groups and doing individual sessions,” she said.

Bec, who said she has been brought up in the “most amazing and supportive family”, wants to work with patients with mental illness, because “it is often unseen and silent, adding to the stigma and other difficulties people face during their recovery”.

She added: “I believe the conversation around mental health needs to be louder and I want to help with this.

It is also truly rewarding having the opportunity to walk beside someone on their mental health recovery journey.”

She will use her $10,000 prize money to visit hospitals around Australia, to research how others treat mental health and personality disorders.

Judges of the awards said Rebecca was “recognised for her commitment to achieving patient-centred care in mental health nursing”.

Bec Rich at the HESTA Awards, with her fiancée Daniel Young.

May–June 2017 western nurse |

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DIGITAL ISSUE AND REVAMP JUST THE BEGINNING

After years of developing and honing what we believe is the best collection of services of any union in the nation, the ANF is topping up the iFolio with some extra trimmings for our members.

The brand new digital edition of western nurse – recently launched on the iFolio – and the facelift to the magazine in the past year, have been among the first stages of moving our communication tools from being purely efficient towards the polished aesthetics they deserve to promote them properly.

From now on all the great features, clinical updates and latest ANF news that comprise your western nurse, will be available online, and accessible from any device.

You can choose from two digital options – and either read the magazine online, turning pages like a paper publication, or you can download a copy.

Your quality gloss western nurse magazine will still arrive in the mail, unless you opt out of the delivery, in the ‘my account’ section of your iFolio.

We are also now in development phase of a special ANF App, which, as ANF State Secretary Mark Olson stated in this edition’s editorial, will mean we will be seeking input from you, our members, as to what exactly that app should deliver.

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western nurse May–June 2017

“It’s going to be quite an undertaking for me and the IT team, because we’ve spent the past decade setting up so many services on the iFolio that simply don’t exist in any other state of the ANF or any other union in Australia,” Mark said. “We’re going to listen to our members, and then cherry pick the favourites to create an app that works as fast and delivers the goods in the way members have become accustomed.

“But as our members know, the iFolio is nothing like the normal simple union websites you see. It has become a onestop shop for our 30,000-plus members.”

Mark said members have come to expect that they are able to go to one site and be able to plan their holidays and book the ANF’s heavily discounted quality holiday units in Margaret River and Kalbarri, and then at the same time also be able to get all their Continuing Professional Development fulfilled through our terrific quality Clinical Updates, while also downloading a complete record of their CPD achievements, so they can provide information AHPRA might request.

“That’s just a small taste of what’s on the iFolio, as anyone who’s used it knows, never mind the courses and appointments and tutorials, also possible from one place,” Mark said. “But, as always, we’ll figure out, and you’ll get an app that does your iFolio justice. We are, however, going to need your help, so over coming months when we have surveys or emails requesting input, make sure you play a role so you can get the app you want and deserve.”

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The Moron Test The fun and frustration of The Moron Test is back in the second version. This has become a classic and seriously addictive game. There are new puzzles, themes, animations and more. Get a puzzle wrong and you’re back to the beginning. Just like Snakes and Ladders plus side splitting laughs. $0.99

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western nurse May–June 2017

YouTube Music YouTube Music lets you watch and listen to a massive catalogue of streamed music. Enjoy music for free with ads, or get YouTube Red. Every video starts a non-stop station or you can personalise the station according to your own tastes. Access concert footage and live recordings. Free or $10 per month

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Which character was responsible for this quote: ‘Better Hufflepuff than Slytherin.

There’s not a single witch or wizard who went bad who wasn’t in Slytherin’? https://www.hp-lexicon.org/

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May–June 2017 western nurse |

15

update: Rheumatoid arthritis – an update Read this article and complete the online quiz to earn 1 iFolio hour

Rheumatoid arthritis (RA) is a systemic autoimmune disorder that affects up to 1% of the adult population worldwide.1 It is more prevalent in Australasia than other regions, and affects more women than men.2 Symptoms of RA include inflammation, stiffness, joint deformity, pain, progressive disability, fatigue, weight loss, and general malaise.1,2 Although there is no cure, individuals with RA may achieve remission through early intervention and compliance with ongoing therapy.1

PATHOGENESIS Rheumatoid arthritis is characterised by joint swelling, autoantibody production (see Box 1), cartilage and bone destruction, and systemic complications.3 The onset and progression of the disease involves a complex, multistep process with interaction between environmental and genetic factors.3 Environmental factors are thought to play a significant role in RA. However, conclusive links between most exposures and disease onset have yet to be determined.

Smoking is the only well-established environmental factor known to increase the risk of RA. Other potential risk factors include infectious diseases such as EpsteinBarr virus, cytomegalovirus and Escherichia coli, periodontal disease, air pollution, coffee, alcohol, hormones, and variations in the bacterial composition of the gut.1 Box 1. Autoantibodies1,3

An autoantibody is an antibody produced by the immune system in response to one or more of the body’s own tissues. Autoantibodies associated with rheumatoid arthritis include rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA). Not all patients with RA have autoantibodies. However, their presence may help support a diagnosis and is often associated with a more severe prognosis.

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Genetic factors influence RA through regulation of the immune system.3 More than 100 genetic risk factors have been identified in the pathogenesis of RA.1 The most significant link is between variations in the human leukocyte antigen HLA-DRB1 gene and the onset of RA in patients with autoantibodypositive serology.3

DIAGNOSIS In 2010, the American College of Rheumatology/ European League Against Rheumatism released new classification criteria for the diagnosis of rheumatoid arthritis (see Table 1). The criteria were designed to diagnose RA in individuals with unexplained single or multi-joint swelling.

A score of at least six is required to confirm RA.4 If rheumatoid arthritis is suspected, the individual should have blood tests checking inflammatory markers, rheumatoid factor and full blood picture, and an x-ray of affected areas to assess joint condition. 5

STAGES OF RHEUMATOID ARTHRITIS

Pre-rheumatoid arthritis is a general term used to describe individuals with RA prior to the onset of symptoms or in the very early phases of disease.1 It may include individuals at risk, those with systemic autoimmunity (without symptoms), as well as those with mild to moderate symptoms, unclassified arthritis or a new diagnosis of RA.1 Early rheumatoid arthritis is found in individuals with a disease duration of less than a few years.1 Current best practice suggests that early identification and treatment is ideal, as there may be a “window of opportunity” where remission may be achieved through altering the disease process early on.1 This window is thought to be narrow and ideally treatment should be commenced within weeks of symptom onset.1

Table 1. The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis.4

CLASSIFICATION CRITERIA FOR RA

WEIGHTING

DESCRIPTION

Joint involvement 1 large joint

0

2-10 large joints

1

1-3 small joints (with or without large joint involvement)

2

4-10 small joints (with or without large joint involvement)

3

>10 joints (with at least 1 small joint)

5

Large joints are the shoulders, elbows, hips, knees, and ankles Small joints include the metacarpophalangeal, proximal interphalangeal, 2nd-5th metatarsophalangeal, thumb interphalangeal, and wrist joints.

Serology Negative RF and negative ACPA

0

Low-positive RF OR low-positive ACPA

2

High-positive RF OR high-positive ACPA

3

Autoantibodies may or may not be present in individuals with RA.

Acute-phase reactants Normal CRP*** AND normal ESR****

0

Abnormal CRP OR abnormal ESR

1

CRP, C-reactive protein, and ESR, erythrocyte sedimentation rate, are inflammatory markers, which may be elevated in response to inflammation in the body.

Duration of symptoms Less than 6 weeks

0

Greater than or equal to 6 weeks

1

According to patient self-reporting.

RHEUMATOID ARTHRITIS Section view of PIP joint

Table 2. Overview of treatments for rheumatoid arthritis.5 Bone Synovial swelling Erosion

Joint capsule

Normal Arthritic Outline indicates normal position of thumb

Metacarpophalangeal (MCP) joint Proximal interphalangeal (PIP) joint

SPECIFIC TREATMENTS

EXAMPLES

Disease-modifying anti-rheumatic drugs (DMARDs)

Methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, azathioprine, cyclosporine

Glucocorticoids

Cortisone, Fludrocortisone Hydrocortisone

Biological agents (bDMARDS)

Tumour necrosis factor antagonists (e.g. adalimumab) Interleukin-6 inhibitor (tocilizumab) Chimeric anti-CD20 monoclonal antibody (rituximab) T-cell co-stimulation moderator (abatacept) Janus-associated kinase (JAK) inhibitor (tofacitinib)

SYMPTOM CONTROL

EXAMPLES

Simple Analgesia

Paracetamol, Codeine

Ulnar drift

Boutonniere deformity of the thumb

Redness at MCP joints from inflammation

Cyst

Non-steroidal Diclofenac, Ibuprofen, anti-inflammatories Indomethacin, Ketorolac (NSAIDs) Naproxen COX-2 Inhibitors

Swelling

Established rheumatoid arthritis is characterised by synovitis in distinct joints including the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints.1 Synovitis is an inflammatory condition caused by synovial hypertrophy and fluid collection that creates swollen joints, which are warm and soft to touch. As the disease progresses, synovitis may spread to the feet and ankles, and other major joints. Eventually, chronic inflammation results in visible joint deformities and functional disabilities.1 Rheumatoid nodules are a symptom of wellestablished, active RA. They may be identified in up to 35% of patients.1 Risk factors for their presentation include smoking, RF factor, and the use of methotrexate. Nodules generally present in the joints, but may also be found outside of the joints in the lungs, eyes, soft tissue, bone periosteum, or blood vessels.1 Most often, nodules are painless and do not require treatment. Surgical removal is often possible, but subsequent regrowth may occur.1

EARLY INTERVENTIONS The introduction of early, effective interventions has transformed the management of RA. Few patients now manifest symptoms of well-established disease. Rather, the goals of treatment are to contain or reverse the condition, induce remission and limit the complications of treatment.1 Any patient with unexplained persistent synovitis should be urgently referred to a specialist, such as a rheumatologist or immunologist, for diagnosis and treatment.5 Early non-pharmacological

interventions include patient education and a multidisciplinary approach to care.

Coordinated, patient-centred care may help to improve quality of life by ensuring that all aspects of life with RA are addressed.5 Pharmacological interventions for RA include specific treatments and symptom control (see Table 2).

Specific treatment for RA aims to suppress the body’s overactive immune system and prevent damage to the joints.6 Most therapies are associated with a range of side effects and potential toxicities. Risks and benefits should be weighed prior to commencing treatment. First line therapy for newly diagnosed patients include a combination of two DMARDs (methotrexate and one other) and glucocorticoids.5 A short course of glucocorticoids is used to alleviate symptoms during the initial onset of disease and during acute exacerbations. The long-term use of glucocorticoids is only recommended for patients who have tried alternative interventions, including biological agents and are well-informed of the chronic complications associated with use.5 Biological agents are used in combination with methotrexate to treat patients with severe RA. Best available evidence suggests they are likely to reduce the number of tender joints, limit pain, and prevent disability.6 Patients who continue to experience pain and symptoms despite optimal pharmacotherapy may benefit from surgical interventions, such as synovectomy, arthroplasty and arthrodesis.5 Early referrals are recommended to help improve quality of life and reduce long-term disability.

Celecoxib, Etoricoxib, Melocoxib, Parecoxib

CONCLUSION Rheumatoid arthritis is a common, progressive inflammatory condition that has no cure.

Advances in early identification and treatment have resulted in opportunities to halt the disease course and achieve remission. Patients with rheumatoid arthritis benefit from the early introduction of comprehensive therapies including extensive patient education, multidisciplinary care, pharmacological and non-pharmacological interventions. Severe RA, which fails to respond to therapy, may require surgical intervention.

REFERENCES 1. Emery P, editors. Atlas of rheumatoid arthritis.

London: Springer Healthcare Ltd; 2015. 257p.

2. Cross M, et al. The global burden of rheumatoid arthritis: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis doi:10.1136/ annrheumdis-2013-204627.

3. McInnes IB, Schett G. The pathogenesis of rheumatoid arthritis. N Engl J Med. 2011;365:2205-19.

4. Aletaha D, et al. Rheumatoid arthritis classification criteria: an American College of Rheumatology/ European League Against Rheumatism collaborative initiative. Arthritis & Rheumatism.

2010 Sep;62(9):2569-2581.

5. National Institute of Health and Clinical Excellence (2009, updated 2015) Rheumatoid arthritis in adults: management. NICE guideline (CG79).

6. Singh JA, et al. Biologics for rheumatoid arthritis: an overview [Internet]. London: The Cochrane Collaboration; 2009 Oct [cited 2016 Apr]. Available from http://www.cochrane.org/ CD007848/MUSKEL_biologics-for-rheumatoidarthritis-an-overview-of-cochrane-reviews.

May–June 2017 western nurse |

17

ANF Out ‘N’ About

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This edition of western nurse’s Out ‘N’ About showcases our members at ANF lunch time visits at St John of God Midland Hospital, Fremantle Hospital and Osborne Park Hospital.

We want to publish a few more editions worth of happy snaps before we award some fabulous prizes to the workplace where we get the best photos – so you’re still in the running. See you when we come by!

B

D C

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western nurse May–June 2017

F A. Osborne Park Hospital operating theatre group B. St John of God Midland Hospital - Erin Monaghan and Melissa Murray C. Fremantle Hospital - Irene Hall and Danielle Dornan D. Fremantle Hospital - Donna Brown and Linda Breen E. Osborne Park midwives - Mandy Wood, Adele Mercier, Kay Fraser, Justine Huggins and Linda Ellis F. Osborne Park Hospital staff at ANF lunchtime visit.

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Out ‘N’ About Learn Jamie’s tips for cooking from scratch, time saving tricks + cooking on a budget, from $10 per class* Edith Cowan University Joondalup 270 Joondalup Dr, Joondalup WA 6027

For more information and to book: jamiesministryoffood.com.au *$10 per class for a concession card holder, $70 for total 7 week course

May–June 2017 western nurse |

19

AcrossTheNation NEWS, VIEWS AND GOSSIP FROM ALL OVER AUSTRALIA

NSW WORLD-FIRST: GUT-BUSTING BBQ BRISTLE Scrubbing your barbecue with a wire bristle brush can land you or one of your guests on the operating table.

A 39-year-old man on the New South Wales Coffs Coast who accidentally swallowed a stray bristle at a barbecue has had to have it surgically removed from his pancreas more than a week later.

The patient went to Coffs Harbour emergency department four times with “vague abdominal pain” that became severe when he tried to eat. After being sent home three times on painkillers, he was finally given a CT scan on the fourth visit, which revealed the bristle protruding from his duodenum into his pancreas, and then sent into surgery.

Dr Rafael Gaszynski, the general surgery trainee who made the finding, told ABC News in May: "This is the first case that has ever been reported in the world. Because it's such a rare occurrence, nobody really thought about it. Initially I thought it was going to be a fish bone … then I went back to have a look at this black thing and I pulled it out ... to my surprise it was a barbecue bristle."

While this is the first pancreatic injury from a barbecue bristle brush reported, warnings about the utensil have been issued in the US and Canada, because of mouth and throat injuries.

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western nurse May–June 2017

WA FOOTIE CONCUSSION CONNECTION TO DEPRESSION

NSW ICE ADDICT SERPENT IN PRISON REHAB

Getting hit in the head while playing football is being linked to depression.

A python hooked on methamphetamine is in a NSW jail alongside about 250 other animals.

Notre Dame University researcher Sarah Harris, who conducted a two-year study into the issue, told Perth’s The Sunday Times that senior team players experiencing concussion are “eight times more likely to have depressive symptoms”.

A police raid of an ice lab found the jungle python which had absorbed the meth through its skin, according to senior overseer at the John Morony Correctional Complex in Berkshire Park, Ian Mitchell.

Ms Harris asked 69 players at a WA Football League club to report head trauma incidents. Within a fortnight of concussion, 40 per cent of players had depressive symptoms. Even those who had a significant head knock not diagnosed as concussion were “14 per cent more likely to feel depressed”. And players who sustained multiple hits in a twoweek period were more at risk than those who got hit once – with some footballers having five head knocks in a fortnight.

“With research emerging from the US regarding NFL (National Football League) players, further research needs to be completed in the AFL (Australian Football League) and WAFL to see if our players are exposed to the same risks,” said Ms Harris, who has eight years’ experience as a trainer with a WAFL club. She said long-term effects might include “decreased concentration, memory loss, and cognitive impairment”.

The snake needed six weeks of detoxification at the prison's wildlife care centre – its addiction meant it was extra confused, erratic and aggressive, ABC News reported in April.

The python was found by police during a raid on a crystal meth lab. CSNSW

"It just takes time for the drug to leave the snake's system, but through our assistance, we managed to calm it down after several months and bring it back to its routine feeding patterns," Mr Mitchell said.

Other animals seized during police raids include bearded dragons and blue tongue lizards. Injured animals are also brought in for rehabilitation from agencies, such as turtles, wallabies, possums, kookaburras, emus, cockatoos and wombats, which are among about 250 animals normally kept there.

But the wildlife centre doesn’t only help wildlife – it also gives about a dozen minimum-security prisoners the chance to complete a certificate II in animal care, while they look after the animals.

brews, told ABC News: “This gives us a way to tailor things. So, for example, if you're interested in a low carb beer for beer drinkers that don't want the calories, then you may be able to tailor your malt earlier on to make your beer less fattening”.

WA SENIORS AT RISK BECAUSE NOT GETTING PNEUMONIA JAB WA GROUNDBREAKING GENETIC WORK COULD LEAD TO HEALTHIER BEER WA scientists have played a major role in cracking the genetic code of barley – which will innovate the development of new and improved varieties of the cereal.

Murdoch University Professor Chengdao Li said an alliance between Murdoch and the WA Department of Agriculture and Food was among the elite group of international scientists who mapped the complete barley genome – with the locals helping to map two of the seven barley chromosomes.

Professor Li said on the Murdoch website the “barley genome map pinpointed genetic information, from which molecular markers and genomic breeding tools could be developed to enhance future barley varieties”.

“Mapping the barley genome effectively provides a ‘dictionary’ from which genetic ‘words’ and ‘sentences’ can be produced that identify the genes that control traits, such as yield, adaption to climate, quality and pest and disease tolerance,” said Professor Li, Director of Western Barley Genetics Alliance.

University of Adelaide’s Professor Rachel Burton, whose team were given an early copy of the reference genome and have already used it to experiment with barley that better ferments and more efficiently

Only 46 per cent of Australian seniors have had free immunisation offered by the Federal Government for lethal pneumococcal pneumonia.

This contrasts with 93 per cent of Australian children having had the vaccine – and a Perth respiratory physician is extremely concerned many older people are leaving themselves vulnerable to the potentially deadly bacterial infection that attacks the lungs.

Sir Charles Gairdner Hospital’s Professor Fiona Lake told The West Australian in May that most people aged 65 and older understood flu vaccines are needed. But few realise “the seriousness of pneumococcal pneumonia”.

Professor Lake said pneumonia is a big cause of death and hospitalisation, but many older people “believed only very unwell people were at risk”.

“All West Australians aged 65 and over are at increased risk due to their age alone, and many more have existing chronic medical conditions or lifestyle factors that place them at heightened risk,” she said.

WA WINTER CURE FOR LACK OF VITAMIN D People with Vitamin D deficiencies won’t have to suffer through winter because of a lack of sun – the solution might be as easy as eating a couple of eggs or some fish.

This is significant because while normally 17 per cent of West Australians lack vitamin D, that figure rises to a whopping 28 per cent in winter, according to Curtin University researcher Rachel Cheang. Risks include developing soft, thin and brittle bones.

Fellow researcher Eleanor Dunlop’s dietary pilot study found two large cooked eggs provide enough vitamin D for the day – based on the five micrograms daily allowance recommended for people aged one to 50. And though oily fish such as salmon has the most vitamin D, 100g of cooked white fish such as barramundi, basa, hoki or king dory provides about half the recommended daily intake.

“Based on our findings, either two eggs, or one egg and a serve of white fish, may allow many Australians to get their vitamin D intake for the day,” Ms Dunlop said.

Ms Cheang said the most at risk group includes people aged 18-24, those born in Asia, and people who are overweight or obese, and smokers.

“Most of us think we might get the flu, because everyone seems to get it at this time of the year, but most of us don’t think we’ll get pneumonia.”

She warned even if people recover, they are often never the same, and researchers believe they subsequently have an increased risk of heart problems.

May–June 2017 western nurse |

21

update: Alcohol withdrawal syndrome Box 1. Characteristics of Autonomic Hyperactivity1

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

Alcohol withdrawal syndrome (AWS) is an acute condition which may occur when individuals with alcohol use disorder abruptly reduce or cease alcohol consumption.1 It is a common cause of presentation to emergency departments and may complicate acute treatment in adult inpatient settings.

PATHOPHYSIOLOGY Chronic alcohol consumption alters central nervous system (CNS) functioning through interference with neurotransmitter pathways including gamma-aminobutyric acid (GABA), glutamate, and noradrenaline. As a result of changes to the CNS, sudden cessation of alcohol leads to an acute neurotransmitter imbalance and the onset of symptoms including autonomic hyperactivity and hallucinations (see Box 1).1

SYMPTOMS Alcohol withdrawal syndrome is a potentially life-threatening condition.1 Symptoms generally present within six to 24 hours of alcohol cessation, and may last up to 10 days.1 Approximately 50% of individuals with alcohol use disorder will experience symptoms such as autonomic hyperactivity, agitation, nausea and vomiting, and visual, auditory or tactile disturbances.1 Risk factors for severe alcohol withdrawal include recurrent episodes of withdrawal, concomitant use of CNS-depressant agents or illicit substances, excessive blood alcohol levels, increased autonomic activity, medical or surgical illness, severe alcohol dependence and male sex.1 Severe alcohol withdrawal is characterised by general tonic-clonic seizures and delirium tremens. Delirium tremens is a psychotic condition with the potential to cause hallucinations, hyperthermia, hypertension, seizures, a fluctuating mental status, coma, and death. Effective treatment requires early identification, continuous monitoring, non-pharmacological and pharmacological interventions, as indicated.

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Tremors • Irritability • Anxiety • Hyperreflexia • Confusion • Hypertension • Tachycardia • Fever • Diaphoresis • Insomnia

IDENTIFICATION The revised version of the Addiction Research Foundation’s Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is one of the most commonly used tools to assess the severity of alcohol withdrawal. Clinicians use the 10-point scale to regularly assess the presence of withdrawal symptoms in individuals at risk (see Table 1). Scores may range from less than 8 (mild), 8-15 (moderate) or greater than 15 (severe withdrawal).1 Table 1. CIWA-Ar, adapted from Sullivan, et al. See original scale for full description of all scores 0-7 for each of the 10 symptoms.2

Other assessments that may be indicated for individuals with AWS include regular blood tests to determine blood alcohol concentrations, full blood count, electrolytes, renal and liver function tests, glucose levels, and toxicology screening.1

TREATMENT Goals of treatment for AWS include minimising the severity of symptoms, preventing deterioration of condition, ensuring patient and practitioner safety, and improving individual quality of life.1 Non-pharmacological interventions, such as offering support, reassurance and re-orientation, and reducing excessive sensory stimuli may help to prevent deterioration.1 Other useful therapies include rehydration, reversal of electrolyte imbalances and hypoglycaemia, and supplementation of thiamine and B-complex vitamins (see Box 2).1

SYMPTOMS

SCORE

Nausea and Vomiting

0 Nil 4 Intermittent, dry heaving 7 Constant, dry heaving, and vomiting

Tremor

0 Nil 4 Moderate, with arms extended 7 Severe, even without extension

Paroxysmal Sweats

0 Nil 4 Beads of sweat on the forehead 7 Drenching sweats

Anxiety “Do you feel nervous?”

0 Nil 4 Moderately anxious, guarded 7 Panic state

Agitation

0 Nil 4 Fidgety, restless 7 Pacing, thrashing

Tactile Disturbances “Do you have itching, burning, or feel bugs crawling on your skin?”

0 Nil 4 Moderately severe hallucinations 7 Continuous hallucinations

Auditory Disturbances “Are you more aware of sounds around you? Are you hearing things you know are not there?”

0 Nil 4 Moderately severe hallucinations 7 Continuous hallucinations

Visual Disturbances “Is the light bothering you? Are you seeing things you know are not there?”

0 Nil 4 Moderately severe hallucinations 7 Continuous hallucinations

Headache, Fullness in head 0 Nil “Does your head feel different or tight?” 4 Moderately severe 7 Extremely severe Orientation to person, place and time Clouding of sensorium

0 Oriented and can do serial additions 1 Cannot do serial additions or uncertain of date 2 Disoriented by no more than two calendar days 3 Disoriented by more than two calendar days 4 Disoriented for place or person

Box 2. Thiamine.1,3

Thiamine is an essential vitamin for energy metabolism. Deficiency is common in individuals with alcohol use disorder and increases the risk of Wernicke syndrome and irreversible dementia.1 Treatment for all patients with AWS should include 100300mg of thiamine daily.3 Moderate to long acting benzodiazepines, including lorazepam, chlordiazepoxide, and diazepam, are the “gold-standard” pharmacological interventions for acute withdrawal.1 They act by stimulating GABAA receptors in order to mimic the CNS effects of alcohol. They effectively manage withdrawal symptoms and reduce the risk of severe AWS and associated mortality.1 More severe cases of AWS may also require adjunct therapies, such as barbiturates and propofol for continuous sedation, alpha2-agonists, beta-blockers, and neuroleptic agents to alleviate symptoms, and anticonvulsant agents for the treatment of seizures.1 Pharmacological interventions for AWS may be administered as fixed doses or titrated in response to symptoms. Patients who require intensive care are often treated with a fixed-dose approach, with high doses of benzodiazepines administered up to four times a day, and tapering with improvement. Many other institutions use CIWA-Ar scores to guide the dose and frequency of treatment. This method

of symptom-triggered benzodiazepine administration may be beneficial for reducing the total pharmacological treatment required and overall duration of treatment for patients at low risk of complications.1

SPECIAL POPULATIONS Unique populations that may be affected

by AWS include adolescents, older adults, pregnant women, and severely ill individuals.

Pregnant women going through withdrawal may benefit from specialist antenatal and obstetric care, as well as drug and alcohol services. Older adults, especially those with reduced liver metabolism, may require shortacting treatments to prevent excessive sedation and respiratory depression.1 Is it estimated that excessive alcohol use is associated with up to 20% of admissions to intensive care and 60% of trauma presentations.4 Best practice guidelines for the identification and treatment of AWS in critically ill patients have not been established.

The CIWA-Ar scale has limited applicability in this population as assessment is limited by invasive treatments such as mechanical ventilation. Further, the safety and efficacy of pharmacological interventions in critically ill patients has yet to be determined. General recommendations suggest titrating treatment to identifiable symptoms, based on extent of alcohol use and severity of withdrawal.4

ONGOING TREATMENT Alcohol use disorder is a complex, chronic relapsing condition, which requires long-term

interventions. Identification and treatment for AWS provides an opportunity for clinicians to discuss prolonged interventions to prevent relapse. Potentially effective long-term treatments include counselling, self-help, rehabilitation, and long-term pharmacological therapies.5 Patient-centred management plans, with structured patient support networks, should be introduced prior to discharge following any inpatient treatment for AWS.

REFERENCES 1. Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, et al. Identification and management of alcohol withdrawal syndrome. Drugs. 2015;75:353-65.

2. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale. Br J Addict. 1989;84:1353-57.

3. Latt N, Dore G. Thiamine in the treatment of Wernicke encephalopathy in patients with alcohol use disorders. Int Med J. 2014;44:911-15.

4. Awissi DK, Lebrun G, Coursin DB, Riker RR, Skrobik Y. Alcohol withdrawal and delirium tremens in the critically ill: a systematic review and commentary.

Intensive Care Med. 2013;39:16-30.

5. Australian Government Department of Health and Ageing. Guidelines for the Treatment of Alcohol Problems. Barton (ACT): Commonwealth of Australia; Jun 2009. 255p.

May–June 2017 western nurse |

23

PROFESSIONAL INDEMNITY INSURANCE

Are you a student member of the ANF? Your ANF membership includes Professional Indemnity Insurance (at no extra cost). So we’ve got you covered even at prac time.

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western nurse May–June 2017

Rear: Armadale Hospital Associate Midwifery Manager Philippa Reppington and midwife Jody Weller.

Front: Tanzanian nurse midwives Chiku Hamisi and Johari Kishegena, with mother Hayley Wilson and her baby Georgia Bell, born in April in Armadale Hospital.

Crosscultural helping hand WA midwives are helping to improve maternity care in Africa.

Being so short on hospital space that two new mums have to share one bed, is just one of the challenges faced daily by Tanzanian midwives who visited WA recently to study our maternity system.

Hilda Kweka, one of the six nurse-midwives who visited in April, compared her normal workplace with WA, saying: “In WA, husbands and partners have more support during a woman’s labour, and are able to stay with the mother for the whole birth.

“In Tanzania there is no room for the husband as the labour ward is very crowded. Sometimes there are two mothers to one bed so they take turns to use it while the other mother sits on the floor.”

Nurse-midwife Chiku Hamisi, said: “(At home) three midwives per shift will deal with between 70 and 90 births each day. There is more automated equipment here than in Tanzania. In Dar es Salaam (Tanzania’s biggest city) hospitals, midwives take blood pressure manually. I want to go home and use what I have learnt to help my colleagues and teach them about best practice maternal care.”

The three-week study tour took them to maternal and neonatal facilities at King Edward Memorial Hospital, Fiona Stanley Hospital, Armadale Hospital, Bunbury Regional Hospital and Kalgoorlie Regional Hospital.

Organised through the Health Department’s Global Health Alliance of WA, and Rotary International, they also visited Curtin University and Edith Cowan

University, where they saw how midwifery education is delivered in WA, and participated in obstetric and neonatal simulations and scenarios.

The Health Department said the aim was to “support knowledge advancement, specifically in maternal and neonatal care, and to embed a sustainable program in maternal and neonatal care in Tanzania through a ‘training-the-trainer’ initiative”.

“On completion of the program, it is expected that the Tanzanian nurse midwives will return to their country and act as role models and champions in maternal and neonatal care,” the department said.

The WA Nursing and Midwifery Office said once back home, the Tanzanian midwives will work alongside expert Australian volunteers to deliver a Maternal and Neonatal Care Course. Also, two Tanzanian midwives will deliver the foundation unit to midwives in the Masaki district in July. Monitoring will be ongoing and the transition will be evaluated yearly until the program is handed over to the Tanzanian health ministry.

Armadale Hospital associate midwifery manager Philippa Reppington – who in February delivered training in maternal and neonatal care to nurse-midwives in Tanzania, as an expert volunteer – said the midwives who came over are “some of the top-performing students from the course”. And after observing maternity wards in WA, and attending masterclasses and leadership training, they are equipped “to take the knowledge they have gained back home to educate their peers”. 

May–June 2017 western nurse |

25

AroundtheGlobe WORLD NEWS

SUSHI WORMS! As dining on raw fish in sushi and sashimi increases in popularity worldwide this could lead to more cases of belly worms, researchers are warning.

Their paper “Anisakiasis: a growing cause of abdominal pain!” – published in BMJ Case Reports in May – describes a “previously healthy man, aged 32 years” being “admitted with severe epigastric pain, vomiting and lowgrade fever since the previous week”.

The patient said he “recently ate sushi”. Lab tests revealed mild leucocytosis, and an upper gastrointestinal endoscopy “showed on the gastric body, a filiform parasite firmly attached to an area of swollen and hyperaemic mucosa, with its end penetrating the gastric mucosa”.

STONE AGE DENTISTS “Fillings” in human teeth dating back 13,000 years show dentists were likely causing pain even in the Stone Age. The teeth from Neolithic people found at Riparo Fredian, in the mountains of northern Tuscany in Italy, appear to have had cavities scraped out and coated with a mixture of bitumen, vegetal fibers and hair.

This is according to University of Bologna researchers, who recently published their findings in the journal Physical Anthropology, saying “Here, we report the second earliest probable evidence for dentistry in a Late Upper Paleolithic hunter-gatherer”.

After the larva was removed, “the patient's symptoms resolved immediately”, and microbiological analysis showed the larva was an anisakis type of parasitic worm.

The Portuguese researchers said “Owing to changes in food habits”, anisakiasis – a parasitic disease caused by worms that attach to the wall of the oesophagus, stomach, or intestine, “is a growing disease in Western countries, which should be suspected in patients with a history of ingestion of raw or uncooked fish”.

Patients can have allergic symptoms such as angioedema, urticarial and anaphylaxis, and gastrointestinal symptoms including abdominal pain, nausea and vomiting. Complications such as digestive bleeding, bowel obstruction, perforation and peritonitis are possible. 

aspects suggest anthropic manipulation. Residue analyses revealed a conglomerate of bitumen, vegetal fibers, and probable hairs adherent to the internal walls of the cavities”.

These results were “consistent with tool-assisted manipulation to remove necrotic or infected pulp in vivo and the subsequent use of a composite, organic filling”.

This means it is likely early man had a basic understanding of biomedical knowledge and practice “long before the socioeconomic changes associated with the transition to food production in the Neolithic”. 

They said the sample labelled “Fredian 5” was from “between 13,000 and 12,740 calendar years ago”.

The researchers said: “Both pulp chambers were circumferentially enlarged prior to the death of this individual. Occlusal dentine flaking on the margin of the cavities and striations on their internal

INVENTION TO MAKE CATHETER SAFER AND MORE COMFORTABLE A device that makes wearing a catheter more comfortable and reduces chances of contracting a urinary tract infection has been invented by Indian nursing academics.

Designed by faculty members of Manipal College of Nursing, the Urosac Comforter “eases unobstructed flow of urine through the catheter, and prevents traction when patients are mobile”, The Times of India reported in May. The washable and reusable device, which is to be sold to hospitals across India, is described as a “non-slippery, adjustable and comfortable system that can easily be secured to a patient's thigh”.

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western nurse May–June 2017

Photography: Stefano Benazzi

It uses “two inches of stiff cotton bandage, with a cotton ring being used to tie around the Urosac bag”. The back has an adjustable Velcro strap that is fastened around the thigh.

“Since the device is made entirely of cotton, skin is spared of any irritable feeling. The patient will be more comfortable with the device," said Manipal College of Nursing Dean Dr Anice George.

The teachers were inspired by the common occurrence of catheter associated urinary tract infection (CAUTI) among patients. "A large number of CAUTI cases can be prevented by properly managing the indwelling catheter and the urine collection bag,” Dr George said.

“Securing the catheter and the bag to the body helps in flow of urine.”

NURSE SICKIES MORE LIKELY AFTER 12-HOUR SHIFTS Nurses take time off sick more often after 12-hour shifts than other work periods, English researchers say.

In the three years up to March 31, 2015, University of Southampton researchers examined an acute care general hospital trust of about 800 beds in Wessex, among 32 adult inpatient general wards.

They looked at 543,719 shifts, worked by 1,997 staff members – comprised of 1,312 registered nurses and 685 healthcare assistants – said the paper titled: The association of nurses’ shift characteristics and sickness absence.

The researchers found “working ≥12 h shifts is associated with an increased likelihood of calling in sick” and commented that “nurses may prefer them, but at what cost?”

The Nursing Times in the U.K. reported of the study: “In particular, if nursing staff had exclusively worked 12-hour shifts in the past seven days, they were 40 per cent more likely to call in sick compared to those who had worked no 12-hour stints”.

Consequences for patients of the resulting absenteeism was shifts covered by agency nurses and the paper questioned whether that was “safe”. It said the consequence of the long shifts for nurses was “decreased wellbeing”, and the National Health Service was also likely hit by higher costs, with “sickness absence” costing the NHS £2.4billion ($4.19 billion AUD) yearly. 

HUMAN HEAD TRANSPLANT

BY NEXT YEAR?

Medical University, a close friend of mine and an extraordinarily capable surgeon. The operation will be conducted in Harbin."

The world’s first human head transplantation will be performed by the early months of 2018 in China – an Italian neurosurgeon claims.

He dismissed scepticism about the key problem of reconnecting a severed spinal cord in a way that restores bodily function. “This problem has now been solved,“ he said. “In the September 2016 issue of the scientific journal Surgical Neurology International (we) outline how we succeeded in fully restoring the functionality and motor activity of entirely severed spinal cords in mice using a fluid called Texas-PEG ... in other words, the mice were able to run again, as the nerve cords were restored.”

Professor Sergio Canavero, from Torino, also told German magazine Ooom, that the world’s first brain transplant will occur within three years, and that we will enter “a new era” that holds hope for many people in wheelchairs.

“The world’s first human head transplant will be conducted in less than ten months, ” said Prof Canavero in Ooom in April. “The Chinese team of doctors is led on site by Dr. Xiaoping Ren of Harbin

QUESTIONS OVER MEDICAL STUDIES Lots of medical studies are of “questionable value”, says a veteran science correspondent.

“Many studies can't be reproduced in other labs. Academic scientists face perverse incentives – what's best for their careers is often not what's best for science,” said the reporter Richard Harris, of NPR (National Public Radio), an American privately and publicly funded not-for-profit membership media organisation.

But Harris, who has written a book “about why a lot of biomedical research is of questionable value”, told western nurse while he focuses on US science in his book – “that’s where the data to date are strongest” – that “this is a worldwide phenomenon”.

“(And) we are currently planning the world’s first brain transplant, and I consider it realistic that we will be ready in three years at the latest.”

“Clearly the funding crunch caused by the US National Institutes of Health budget doesn’t apply to other countries, but many of the other pressures do,” he told western nurse.

But he also said on his LinkedIn page that “the good news is efforts are afoot to improve the biomedical research enterprise”.

NPR’s Morning Edition show in April interviewed Harris about the book – which is titled: Rigor Mortis: How Sloppy Science Creates Worthless Cures, Crushes Hope, and Wastes Billions – and revealed a “surprising medical finding” that caught Harris’s eye in 2014.

A scientist from a drug company reviewed the results of 53 studies originally thought to be “highly promising – findings likely to lead to important new drugs”.

But when the scientist tried to replicate the promising results, he “could only reproduce six”.  May–June 2017 western nurse |

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Are you an ANF member who does humanitarian volunteer work?

VOLUNTEER FUNDING

ANFIUWP Humanitarian Aid Volunteers Fund provides financial help to ANF members who are undertaking humanitarian volunteer work in Australia or overseas. The closing date for applications is the 15th December 2017.

The fund may be used for planned or completed volunteer work.

For more information about the fund or to get a copy of the application form and selection guidelines, call the ANF office on 6218 9444, email anf@anfiuwp.org.au or log on to iFolio.

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western nurse May–June 2017

update: New medicines for the treatment of chronic hepatitis C infection Read this article and complete the online quiz to earn 0.5 iFolio hour

may be used to treat all HCV genotypes and offer an up to 90% cure rate, with a lower risk of viral resistance.4

INTRODUCTION

MECHANISM OF ACTION

As of January 2017, seven new medicines for the treatment of chronic hepatitis C virus (HCV) have become available on the Australian Pharmaceutical Benefits Scheme (PBS). These second-generation direct-acting antivirals (DAAs) offer significant improvements on previously available treatments.1-4

DAAs prevent non-structural proteinsynthesis, required for HCV replication. Each agent targets a specific point along the protein synthesis pathway.3,4

Table 1. New medicines for chronic hepatitis C available on the PBS.1

Daclatasvir (Daklinza®) Ledipasvir with sofosbuvir (Harvoni®) Sofosbuvir (Sovaldi ®) Ribavirin (Ibavyr ®) Paritaprevir with ritonavir, ombitasvir and dasabuvir (Viekira Pak ®) Paritaprevir with ritonavir, ombitasvir, dasabuvir and ribavirin (Viekira Pa-RBV ®) Grazoprevir with elbasvir (Zepatier ®)

NS5A inhibitors (e.g. daclatasvir and ledipasvir).

HCV NS5A is an essential protein for RNA replication and virion assembly. Inhibitors bind to the protein and prevent viral RNA synthesis.

Daclatasvir is the most potent NS5A inhibitor, with efficacy against multiple HCV genotypes.4 NS5B polymerase inhibitors (e.g. sofosbuvir).

NS5B RNA-dependent RNA polymerase is an enzyme required for HCV RNA synthesis.

Inhibitors competitively bind to HCV RNA during synthesis, prevent enzyme activity, and cause premature chain termination.4 NS5B polymerase inhibitors are similarly effective across all HCV genotypes and are resilient against viral resistance.4 NS3 serine protease inhibitors (e.g. paritaprevir).

EVOLVING TREATMENTS FOR CHRONIC HEPATITIS C Historically, non-specific antiviral treatments including injectable peginterferon and oral ribavirin were the standard of care for treating chronic HCV.2,3 The benefits of these therapies were limited by poor tolerance, contraindications, and high rates of treatment failure.4 In April 2013, first generation DAAs, such as boceprevir and telaprevir, became available on the PBS. However, treatment required complex medication regimes, with multiple daily dosing and was restricted to individuals infected with HCV genotype-1, in specialist in-patient facilities.3 While combination therapy with non-specific antivirals and first-generation DAAs increased the cure rates for HCV genotype-1, they also potentiated side effects.3,4 Second-generation DAAs are more effective and better tolerated, with a shorter treatment course.1-4 Most require once or twice daily oral dosing for as little as 8-12 weeks.1,2 New agents

Protease enzyme activity is essential for nonstructural protein synthesis and HCV RNA replication. NS3 serine protease inhibitors bind to the protease active sites on the polyprotein involved in HCV RNA replication and prevent protein cleavage. First generation protease inhibitors, including boceprevir and telaprevir, were only effective against genotype-1 and were prone to viral resistance. Newer agents, such as paritaprevir, inhibit different active sites across all HCV genotypes and are less prone to resistance.4

SIDE EFFECTS New HCV treatments are generally well tolerated. Combination therapy that includes second generation DAAs and ribavirin or peginterferon may be associated with mild to moderate adverse effects, including anaemia, fatigue, headache, skin irritation, and insomnia.3

CONTRAINDICATIONS DAAs have the potential for significant drugdrug interactions. A full review of an individual’s

other prescription and non-prescription medications is required prior to commencing treatment.2 Safety during pregnancy is dependent on the agent selected. Specialist advice is always indicated.1

ELIGIBILITY All adults, over the age of 18, with chronic hepatitis C are eligible for treatment.1 This includes people who inject drugs or who are currently in prison.1,2 Use of specific agents is dependent on the individuals disease genotype, severity of symptoms, presence or absence of liver cirrhosis, prior treatments and the professional opinion of the treating medical practitioner.1 Under the PBS, treatment may be prescribed by any medical practitioner, so long as they have consulted with an experienced gastroenterologist, hepatologist, or infectious disease physician.1

CONCLUSION New medicines for chronic HCV are promising interventions that may be used to treat any genotype, with limited complications.

Availability on the PBS helps to overcome barriers associated with cost and ensures that all individuals with chronic HCV in Australia gain access to potentially life saving therapies.

REFERENCES 1. The Pharmaceutical Benefits Scheme. Hep C medicines fact sheet for consumers [Internet].

Canberra; Australian Government: 1 May 2016 [cited 17 May 2016]. Available from: http://www. pbs.gov.au/info/publication/factsheets/hep-c/ factsheet-for-patients-and-consumers 2. Hepatitis Australia. Treatment for hepatitis C (internet). Woden; Hepatitis Australia Inc.: 09 January 2017 [cited 06 April 2017]. Available from http://www.hepatitisaustralia.com/hepatitis-cfacts/treatment-for-hep-c 3. NPS MedicineWise. Direct acting antivirals for hepatitis C: new developments [Internet].

Strawberry Hills; NPS MedicineWise: 8 May 2015 [cited 17 May 2016]. Available from: http://www. nps.org.au/publications/health-professional/ health-news-evidence/2015/new-therapieshepatitis-c 4. Aghemo A, De Francesco R. New horizons in hepatitis C antiviral therapy with direct-acting antivirals. Hepatology. 2013;58(1): 428-38.

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ResearchRoundup LATEST AND GREATEST FROM SCIENCE

FROG FLUID FIXES FLU Peptides in skin mucus on southern Indian frogs have been found to kill the H1 influenza virus.

Researchers found the peptides that defend the amphibians against bacteria have potential for antiviral drugs.

Anti-flu peptides could be “handy when vaccines are unavailable”, or “in the case of a new pandemic strain, or when circulating strains become resistant to current drugs”. This is according to a senior author of the study of the discovery, Joshy Jacob, PhD, associate professor of microbiology and immunology at Emory Vaccine Center and Emory University School of Medicine in Georgia, USA. Dr Jacob and his U.S. colleagues, along with researchers from the Rajiv Gandhi Center for Biotechnology in India, named one of the antiviral peptides Urumin, after a whip-like sword called urumi, used in southern India centuries ago.

Skin secretions from The Indian frog Hydrophylax bahuvistara contained the Urumin.

"I was almost knocked off my chair," Dr Jacob said in April, when the study was published in the journal Immunity. "In the beginning, I thought that when you do drug discovery, you have to go through thousands of drug candidates, even a million, before you get 1 or 2 hits. Here we did 32 peptides, and we had 4 hits.”

PLASTIC BAG ‘WOMB’ WHICH GREW A LAMB COULD SAVE PREM HUMAN BABIES Care for extremely premature babies could be transformed by a womb-like “Biobag” that mimicks the prenatal fluid-filled environment so well it allows fetal lambs to survive.

“Our system could prevent the severe morbidity suffered by extremely premature infants by potentially offering a medical technology that does not currently exist,” said Alan W. Flake, MD, leader of the study on the lambs, published in Nature Communications.

Dr Flake – the Director of the Center for Fetal Research at the Children’s Hospital of Philadelphia – and his colleagues tested their “extra-uterine support device” on eight fetal lambs, whose development resembles that of extreme premature human infants.

Lambs grew for up to four weeks in a “temperature-controlled, near-sterile environment, breathing amniotic fluid as they normally do in the womb, their hearts pumping blood through their umbilical cord into a gas exchange machine outside the bag”.

The researchers said neonatal care practices have improved survival of premature babies, but that survival came with “a 90 percent risk of morbidity, from chronic lung disease or other complications of organ immaturity” and “lifelong disability”.

“These infants have an urgent need for a bridge between the mother’s womb and the outside world,” Dr Flake said in April.

“If we can develop an extra-uterine system to support growth and organ maturation for only a few weeks, we can dramatically improve outcomes for extremely premature babies.”

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western nurse May–June 2017

CRAYFISH MAY SHOW WHY WE MIGHT DRINK MORE WHEN LONELY Drunken crayfish may give clues about alcohol abuse, say U.S. researchers.

The University of Maryland researchers speculate their experiments with crustaceans may contribute to theories that people drink more when socially isolated because they develop lower sensitivity to alcohol.

They kept crayfish either isolated or with others, and then moved the subjects to tanks with alcohol in them.

Predictably, effects occurred much faster at the highest alcohol concentrations, including “walking aggressively on stiff straight legs, before switching to tail-flipping as they became more intoxicated, and finally losing control as they rolled on their backs like incapacitated humans”.

This took 20 minutes for crayfish that had been held in groups.

But crayfish that had been in isolation for a week before “were far less sensitive to the alcohol”, taking 28 minutes to become “inebriated and begin tail-flipping”.

“Although somewhat speculative at this point, it is tempting to suggest that the reduced sensitivity to alcohol we observed in socially isolated crayfish underlies the increase in drinking behavior that has been widely reported in socially isolated mammalian species,” the researchers said in the study, published this year in the Journal of Experimental Biology. “If social isolation causes a suppression of the alcohol-induced acute neurobehavioral response, it would be reasonable to expect that humans and non-human animals increase drinking after social isolation (or ‘exclusion’) as a result of the lower sensitivity to the cellular effects of alcohol.”

They conceded it is unclear whether these results “generalize to neural circuits and corresponding behavior in mammals”, but hoped they might contribute to developing better options for treating and preventing “negative c o n s e q u e n ce s o f alcohol abuse”.

WIN ONE OF FIVE COPIES OF THE BOOK THAT CALLS ITSELF “THE ONLY MONEY GUIDE YOU'LL EVER NEED”

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Scott Pape’s claim in the title of his book The Barefoot Investor: The Only Money Guide You'll Ever Need, is pretty bold considering the numerous finance books already for sale.

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WIN a special boxset containing four classic 1960s films WE HAVE 20 TO GIVE AWAY TO ANF MEMBERS ONLY! To Kill a Mockingbird (1962), starring Gregory Peck, shows life in an Alabama town in the 1930s, but is also a powerful illustration of race relations in much of the American Deep South at that time.

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May–June 2017 western nurse |

31

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