Western Nurse Magazine Jan Feb 2017 by ANF WESTERN NURSE MAGAZINE

January â&#x20AC;&#x201C; February 2017

incorporating western midwife

western nurse is the official magazine for ANF members in WA

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Secretary's Report January-February 2017

State Secretary, Mark Olson

on the

cover

natal jaundice

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aemia, nation, babies3.

SPECIAL REPORT The ANF’s election campaign

FEATURED 4 I was a trainee nurse 50 years ago 8 The ANF’s election campaign is in full swing 14 ANF Out ‘N’ About Part I 18 Surveys working for members

Assessment should include any maternal or family history including patient24 andANF Out ‘N’ About maternal blood group, viral serology and any haemolytic diseases2. Enquire about the presence of symptoms including if the infant has been unwell, with any signs of dehydration, poor weight gain, birth trauma, 12 Internet Watch and/or dark urine or pale stools3.

Part II

FAVOURITES

Visible jaundice should be assessed 20 whenAcross the Nation the baby is naked and under natural 26 Around the Globe light by blanching the baby’s skin with a finger and observing the underlying skinResearch Roundup 30 colour1,4. Jaundice appears first in the face and progresses down to the trunk31 andANF Contact Details extremities4.

I was a trainee nurse 50 years ago Kramer recognised the cephalocaudal

HOLIDAY ANF

progression of jaundice with increasing total serum bilirubin levels and divided the baby into five zones, with a total serum 13 ANF Super Deal Margaret River bilirubin level measurement associated 3 32 asANF Super Deal Kalbarri with each zone . This became known Kramer’s rule and was traditionally used to visually assess the severity of jaundice. However visual estimation commonly lead to errors, especially in darker skinned babies, and babies who have already commenced phototherapy4. For this reason, a total 31 serumWin one of three Ziegler & Brown bilirubin level should be used if there areportable barbecue twin grills – concerns about jaundice and to assess thecomplete with their optional mobile 4 response to Out treatment . ANF ‘N’ About carts, ready for all your outdoor

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CLINICAL UPDATES 6 Oxybutynin 16 Bariatric surgery and the bone

22 Jaundice in neonates 29 Zika Virus

You have likely seen or heard some of the ads the ANF has been running in recent weeks in the lead up to WA State Election Our print and radio campaign for legislated nurse-to-patient ratios is a direct result of the members’ survey where you told us that you wanted certain issues highlighted in the lead up to the WA State Election on March 11. Our intention is to pressure politicians of all persuasions about the necessity for improving WA’s health system, particularly in terms of getting nurse-to-patient ratios in the law for hospitals, so your patients get the care they deserve. We have also approached political parties directly, had stories in the major newspapers and on TV, set up a website that has had thousands of hits from the community at large, and distributed various products about our cause. The campaign seems to be working – apart from all the feedback, to date we have been approached by several politicians whose initial support has ranged from strong, to room for negotiation. But I will inform you directly when we have names on the dotted line, because talk and promises fly around easily during a political campaign. We are not going to stop till we get what you want, but we will need your help. No matter when you read this, if there are days, hours, or minutes left before the election, and you haven’t jumped onto nomorethan4.com.au or contacted your local candidate in some other way, we encourage you to do so. We now all need to do what we do best when we have an important cause, we need to pull together and get involved, because the 30,000 voting members of the ANF are a formidable force.

Jaundice in neonates

January–February 2017 western nurse |

A Life

Well Lived Celebrating 50 fulfilling years of nursing has brought back fond memories for Patricia ‘Trinny’ Holgate – especially since she’s back at the hospital where it all first started.

Trinny Holgate and daughter Jane Callaghan

rinny Holgate had barely turned 18 when she arrived for her first day of general nursing training at St John of God Hospital Subiaco. Now 50 years later, after working around the world, she finds herself celebrating her gold career anniversary – back home at St John’s again. “I finished school at the end of 1966, there was no schoolies then. One was expected to finish school on the Friday, and commence a holiday job on the Monday until they either went to uni, teacher’s training or nursing,” Trinny recalled. “I commenced my general nursing training at St John of God Hospital Subiaco in February 1967, a few days after my 18th birthday, after having worked at Bethesda Hospital in Claremont as a nurse’s aide over the holidays. There were 23 in our group, three of them nuns. “My sister Jane was already at the hospital and was commencing her third year. I think that is why I went nursing, as she was full of stories and it all seemed so exciting and interesting.” Jane was Trinny’s senior on the ward during her training, and it was a very strict environment. “I had to refer to her as Nurse Holgate, and us juniors had to stand back to allow the seniors to enter the lift, or doorway before us,” Trinny said. “We had to stand with our hands behind our backs when being spoken to. “We commenced our training with 12 weeks Preliminary Training School. This was Monday to Friday, 8am to 5pm in the classroom, and mock ward, where we practised inserting nasogastric tubes on each other, making beds, learning how to do observations and removal of sutures etc. Thankfully we had a dummy to practise inserting IDCs (indwelling urethral catheters).” They had to wear full uniform consisting of a royal blue pinstriped dress with white bands around the arms, and a Peter Pan collar which

western nurse January–February 2017

Trinny Holgate First day at St Johns Hospital on 28/2/1967

was crossed over and pinned with their student nurse’s badge. “Over that we wore an apron with a bib, and all of it was starched, so much it could have stood up by itself,” she said. Trinny thought she was prepared for the wards after working at Bethesda, but walking onto the men’s ward was overwhelming. “Most of us were from private girls’ schools, and to look down the Florence Nightingale Ward, and see 20 men to the left and 20 men to the right, was quite scary,” she said. The training was job-orientated, and in rotations. “For example, we might be on pre-meds, with the ward sister to instruct us, and that meant getting everyone ready for theatre, inserting a nasogastric tube, IDC etc, and then giving them their pre-medication injection,” she said. “As there would be about 20 patients going to theatre a day, we certainly felt confident in those jobs by the end of the week. “Other rotations were, dressings, medications and observations, or the pan room, where we had to test all the urine – no dipsticks then, we had to put drops of urine into a test tube and then add a reagent or boil it. “In the afternoon, when the patients had their rest, or visitors, we sat in the handover room and made all supplies for the ward. We also did all our own sterilising, and while we did that, a tutor would choose a patient to tell us all about their disease.”

"We had a nun, Mother John, on guard at the front door, trying to get past her was like scaling the Berlin wall" There were no disposable syringes. “They were glass and we reused the needles,” she said. “So we had to decontaminate them, by boiling, and then test them to make sure they were patent, and draw the cotton wool ball over the end of the needle to make sure it didn’t catch and could be used again. We then sterilised all our equipment. Masks were another item we had to boil, as they weren’t disposable.” Trinny said the nuns were recycling “before it became the thing”. “We gathered all the old soaps and boiled them up until they were slimy and runny and used it for enema soap,” she said. After completing her training, Trinny moved to East Gippsland, Melbourne, Adelaide, and Port Moresby in Papua New Guinea. She also went to East Anglia in the UK, where she did a midwifery conversion course, allowing her to work in the UK as a midwife. She later worked as a private midwife in Lugano in Switzerland, Paris in France, Jersey in the Channel Islands and around London. She returned to Perth and St John's in December 2003, where she has continued to work in the labour ward. “As far as I know I am the only person from that original trainee group that is still working in hospitals, and certainly at St John's,” she said. “The nuns back then gave us wonderful training, not just in nursing but all aspects of life. In those days the matron ran the hospital, she did her rounds every day, and knew everyone, staff and patients. If the wards were busy she would take off her detachable sleeves, and bog in and help – every nurse was hands on.” Trinny said because they all lived in the nursing accommodation, the girls in the group became lifelong friends. “We weathered all the ups and downs,

Group Photo First day of training at St John's Hospital on 28/2/1967. Trinny is the blonde in centre of pic front row

our entire life for three years was all about nursing,” she said. “We sat in the evenings together and spoke about our day, and were a source of comfort to each other. We had to stay in in the evenings, because we weren’t allowed out after 22.00hrs. We had a nun, Mother John, on guard at the front door, trying to get past her was like scaling the Berlin wall. Once a week we were allowed out till midnight on our days off, and once a year till 2am to attend the hospital ball.” Trinny, who recently also celebrated her 68th birthday, said she has seen a lot of changes over the years. “When I started my first round of night duty, I carried a hurricane lamp. Now I have fingerprint ID on the computer,” she said. “My daughter, Jane Callaghan, is doing her nursing training at Notre Dame University, she has one semester to complete. I hope she finds in nursing, all the joy I have received from it. It has defined me since I was 18 years old, it has given me employment when I became a single mother, it has enabled me to meet and look after wonderful people, and travel the world. It will be hard to give it up.” 

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daycaretothemax@amnet.net.au Near corner of Wanneroo Rd and Reid Hwy Trinny Holgate at St Mary's Lindo Wing London aged 50 in May 2000.

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January–February 2017 western nurse |

update: Oxybutynin

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receptors at the detrusor muscle and inhibit acetylcholine, which leads to decreased muscle contraction and tolerance of greater volumes of urine in the bladder.1

EFFICACY Generic Name Oxybutynin hydrochloride Trade Names Oxybutynin Sandoz, Oxybutynin Winthrop, Oxytrol, Ditropan Drug Class Anti-cholinergic (Genitourinary)

INDICATIONS Oxybutynin is used in conjunction with physical and behavioural therapy for the management of urge incontinence (table 1).1,2 There are three main types of urinary incontinence: urge, stress, and overflow. Urge incontinence is the uncontrollable loss of urine after a sudden urge to void. It is caused by an over-active bladder. Stress incontinence is involuntary leaking of urine with the application of pressure on the bladder and overflow is incontinence due to outlet obstruction.1 Oxybutynin is reserved for the treatment of urge incontinence and may worsen the symptoms of other conditions.1 Table 1. Adjunct therapy for the management of incontinence2

Bladder diary

May help identify the type of incontinence and monitor any response to treatment

Weight loss

Weight loss for overweight and obese women may reduce the burden of incontinence

Reduced Reducing caffeine consumption caffeine may limit incontinence in intake patients with an overactive bladder Pelvic Primarily indicated for the floor management of stress exercises incontinence. May also contribute to treatment plans for those with mixed or urge incontinence. Bladder training

Bladder training is the gradual increase in times between voids. It is useful for residents in aged care facilities and women with urge or mixed incontinence.

ACTIONS Genitourinary anticholinergic agents reduce bladder muscle contractility and increase bladder function. They bind to muscarinic

western nurse January–February 2017

Approximately 1 in 7 people report an improvement in incontinence after a 12week course of an anti-cholinergic agent.2 The average patient may experience one less episode of incontinence within 48 hours, compared to placebo.1 After 4-6 weeks, a harm-benefit analysis should be performed with patients to determine overall efficacy. Oxybutynin should then be ceased in those with limited benefits.1

DOSING Oxybutynin is available on the Pharmaceutical Benefit Scheme (PBS) as a 3.9mg/24 hour patch or 5mg tablet.3 It may be prescribed by medical or nurse practitioners.3 It is recommended to start with a 4-6 week trial, at a low dose and gradually titrate up until reaching a therapeutic dose, with minimal adverse effects.1,2 Immediate or extendedrelease tablets may be administered once to three times daily, with a maximum dose of 20mg.1,3 Patches are effective for 3-4 days, and should be changed twice weekly.1 Table Two. Oxybutynin dosing1

Patient Dosage Population Children

2.5-5mg twice daily

Adults

5mg 2-3 times per day

Elderly

Start with 2.5mg at night, increased to twice daily with caution

(over 5 years)

(maximum 5mg twice daily) (maximum 5mg 4 times per day)

ADVERSE EFFECTS Anticholinergic adverse effects include urinary retention, blurred vision, dry mouth, constipation, and confusion.1 They are generally dose dependent and may be limited using the lowest effective dose. Patches and extended release tablets are less likely to cause dry mouth.1,3 However, patch formulations may cause local irritation around the application site, such as a rash, itch, or erythema.1 In large doses and overdose, anticholinergics may cause central nervous system complications, such as hallucinations, and potentially fatal conditions including cardiac arrhythmias, delirium, and seizures.1

PRECAUTIONS There are several concerns regarding the use of oxybutynin. Drugs with anticholinergic effects have the potential for additive therapeutic and adverse effects.1 Patients taking multiple medications should be wary of the potential for drug interactions. Elderly patients may be at greater risk of complications. Anticholinergic agents are not recommended for patients with dementia as they may worsen symptoms and interact with commonly prescribed medications.1 Avoid the use of oxybutynin in patients with urinary retention or bladder outlet obstruction. They may cause bladder complications including voiding dysfunction, hesitancy, and retention. Post-void residual volumes and monitoring for urinary retention may be required for patients at risk of obstruction.1

PRACTICE POINTS • Identify the type of incontinence prior to initiating treatment • Use anticholinergics in combination with adjunct therapies for the management of urge incontinence • Exercise caution with the use of oxybutynin in specific patient populations including the elderly and those with dementia • Monitor the efficacy of oxybutynin therapy and perform a harm vs. benefit analysis after several weeks of treatment • Cease treatment after 4-6 weeks if efficacy is limited • Consider extended-release formulations or patches in those who suffer from severe dry mouth as a result of oxybutynin1,2

REFERENCES 1

Australian Medicines Handbook 2015 (computer program). Adelaide: Australian Medicines Handbook Pty Ltd; 2015 July.

NPS MedicineWise. Managing urinary incontinence [Internet]. MedicineWise News. 2009 Dec 1 [cited 2015 Dec 14]. Available from http://www.nps.org.au/publications/healthprofessional/nps-news/2009/nps-news-66managing-urinary-incontinence-in-primarycare#Anticholinergics

Pharmaceutical Benefits Scheme. Oxybutynin [Internet]. Australia: PBS; n.d. [cited 2015 Dec 14]. Available from: http://www.pbs.gov.au/ pbs/search?term=oxybutynin

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SPECIAL FEATURE

2017 ANF STATE ELECTION CAMPAIGN Our recent election survey showed ANF State Secretary Mark Olson that members emphatically want him to serve their issues right up to all the political parties during the lead up to the State Election. The result is a strategy ensuring your voices are being heard LOUD and CLEAR. As soon as the pay deal negotiations for our public health members finished last year, ANF State Secretary Mark Olson looked around for other ways to improve the lives of our members and their patients. Emails he received from members before and after the Enterprise Bargaining Agreement campaign, made it clear many were extremely motivated about achieving goals including getting legislated nurse-to-patient ratios, and getting rid of annual performance appraisals. So when the State Election campaign started to kick off, Mark and the ANF were already prepared to launch our own election campaign – one that was not designed to help any particular party or candidate, only those who supported our members’ aims. A DV E RT I S E M E NT

THIS CORRIDOR SHOULD NEVER BE USED AS A HOSPITAL WARD. But that’s what happens when you don’t have nurse-to-patient ratios in the law. Both Liberal and Labor governments use a complicated formula that frequently results in too many patients and not enough nurses on a ward. But there’s no time for these complex calculations in a busy hospital when you’re seriously ill. You need clear rules, like there’ll always be one nurse per four patients in a general ward – and that’s that. Vote for the candidates and parties that want to make WA hospitals safer with legislated nurse-to-patient ratios. Authorised by Mark Olson 260 Pier St Perth WA 6000 for the Australian Nursing Federation Industrial Union of Workers Perth.

Across these four pages, you will get a good taste of what has been happening, and by the time you read this, much more will have occurred.

WHEN YOU NEED HELP FROM A NURSE IN A WA HOSPITAL YOU SHOULDN’T HAVE TO WAIT ... AND WAIT ... AND WAIT ... But nurses can’t look after you and your loved ones properly and quickly if there aren’t enough of us on your ward. We want standard nurse-to-patient ratios made part of WA law so there’ll always be enough nurses to keep you and your family safe.

Vote in the State Election for the candidates and the parties who want to make WA hospitals safer with legislated nurse-to-patient ratios.

western nurse January–February 2017

Contact your local candidates directly if you want to make WA hospitals safer. Go to: nomorethan4.com.au Authorised by Mark Olson 260 Pier St Perth WA 6000 for the Australian Nursing Federation Industrial Union of Workers Perth.

“We have bombarded the candidates and the community with full page adverts across the metro and regional newspapers,” Mark said. “Radio ads are blaring hourly about patients having to wait too long for care because nurses are being run off their feet looking after too many ill people at once. And thousands of stickers, badges and other products are being distributed as we speak. We’ve also been keeping up the pressure on both the Government and the Opposition with ads that certainly aren’t complimentary of either side of politics, and also news stories both in the major papers and on TV.” Mark said this combined effort is “pushing our members’ interests at a time when political parties are at their most vulnerable”.

ANF

Authorised by Mark Olson 260 Pier St Perth WA 6000 for the Australian Nursing Federation Industrial Union of Workers Perth.

nomorethan4.com.au “Our lethal weapon has been the No More Than 4 campaign, which refers to having a maximum of four patients in a general ward on a dayshift, and is about safe ratios across the whole system,” he said. “That has culminated in a website nomorethan4.com.au where all members of the community, not just our nurses, midwives and carers, can easily contact their local candidates to voice their concerns about achieving legislated ratios. ‘We had thousands of hits just hours after launching the website on the front page of The West Australian newspaper on February 23.”

January–February 2017 western nurse |

SPECIAL FEATURE

2017 ANF STATE ELECTION CAMPAIGN Cont.

“A complicated workloads formula is part of our wage agreement, not part of legislation, no matter what the politicians tell you. And governments have previously tried to water it down during EBA negotiations. We are fighting to ensure that patient safety is not negotiable – that safe nurse-to patient ratios are actually a law”

“

And we are going to fight this campaign right up to the last hours before the election, because safe nurse-to-patient ratios should be enshrined in the law.

Mark said though some politicians had indicated they would play ball on certain conditions we are seeking, he wanted to see action before he was convinced of their commitment, and before announcing it to members. “After all, at the end of the day, they are politicians,” Mark said. “We will still have a few days to go by the time you read this, and anything can happen in an election campaign in the last few days, as everyone around when we achieved that 14.7 per cent pay rise in 2013 will remember,” he said. “And we are going to fight this campaign right up to the last hours before the election, because safe nurse-to-patient ratios should be enshrined in the law.”

10 |

western nurse January–February 2017

”

Mark said current workload regulations are part of the EBA which means they can also be up for negotiation every few years when pay deals are being negotiated. “Politicians have been spinning the truth when implying ratios are already part of the law,” Mark said. “A complicated workloads formula based on nursing hours per patient day is part of our wage agreement, not part of legislation, no matter what the politicians tell you. And governments have previously tried to water it down during EBA negotiations. We are fighting to ensure that patient safety is not negotiable – that safe nurse-to patient ratios are actually a law.

A DV E RT I S E M E NT

The Australian Medical Association has released its annual health report card, saying inadequate funding has left Australian public hospitals and the dedicated health professionals who work in them in a "constant state of emergency". AMA ANALYSIS OF AUSTRALIA’S PUBLIC HOSPITAL SYSTEM (WA Performance - Summary)

Improvement in Emergency Department waiting time - urgent (category 3) 2015-16

MYEFO 2016-17 increased Commonwealth funding for 2016-17 over Budget 2016-17

Met National Emergency Access Target (NEAT) 2015+

Improvement in Elective Surgery Category 2 admission in 90 days

Improvement in Elective Surgery waiting time 2015-16

Met National Elective Surgery Target (NEST)+* 2015+

+ Targets are set on a calendar year basis; performance as reported by AIHW. AIHW reported elective surgery Category 2 performance for financial year 2013-14 but data for the period 2010-11 to 2011-12, and January to June 2013 has not been published. * Treating patients within clinically recommended time – Category 2 (within 90 days)

If you ask the Australian Medical Association, we're sure they'd also agree having too many patients per nurse is dangerous. But the reality is, that happens every day in WA public hospitals. WA Liberal and Labor governments have been putting West Australians in danger because there aren't nurse-to-patient ratios in the law. That's why nurses want you to vote in the State Election for candidates and parties who want to make WA hospitals safer with legislated nurse-to-patient ratios.

“We want ratios made part of the law like it is in Victoria and Queensland, so it will take a change of law to stop from having, for example, a maximum of four patients per nurse on a general ward during a dayshift. “Ratios in other sections will be even better than that, for example in high care wards where you may need one to one care. But with the current formula, when hospitals and the Government want to save money, they can manipulate the numbers so our members might be caring for up to 10 patients. That’s not good for our members, and is certainly not safe for the patients you try to care for as best you can.”

NO MORE THAN FOUR Authorised by Mark Olson 260 Pier St Perth WA 6000 for the Australian Nursing Federation Industrial Union of Workers Perth.

Mark said legislated workload ratios are key to patient care. “Legislated nurse-to-patient ratios should not be an item that can be used as a bargaining chip once every three years during EBA negotiations – we have told the politicians just that,” he said. “We would hope the politicians would agree that patient safety should not be negotiable. “We are seeking a commitment that nurse-to-patient ratios legislation be passed by the end of the first term of the next State Government, in order to ensure patient safety is protected.” 

nomorethan4.com.au January–February 2017 western nurse |

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western nurse January–February 2017

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Januaryâ&#x20AC;&#x201C;February 2017 western nurse |

ANF Out ‘N’ About

ABOUT

We’re always trying to figure out ways to get more photos of members in western nurse. With that goal in mind, we’ve decided to re-launch our pages of pictures at workplace visits, under the new banner of ANF OUT ‘N’ ABOUT. In fact, you may have already noticed that ANF staff have been getting really snap happy when they’re coming out to see you.

The neat thing is, if you flash your pearly whites for ANF pictures, not only do you get to be in your great magazine – and thus be the envy of your mates at work – but we’re also planning terrific prizes for the workplace where we get the best photos. So make sure you pick up and parade your ANF products when we come by. To get things rolling, we have two OUT ‘N’ ABOUT spreads this edition – turn to pages 24 and 25 for part 2, and enjoy our pics of you and your fellow nurses, midwives and carers, now and in coming months. See you on our visits! A. Sir Charles Gairdner B. King Edward memorial Hospital C. Brightwater Oats Street D. Bentley Hospital A

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Januaryâ&#x20AC;&#x201C;February 2017 western nurse |

update: Bariatric surgery and the bone Read this article and complete the online quiz to earn 1 iFolio hour

With the global rise of obesity, bariatric surgery has become an increasingly popular method for long-term weight loss. There are multiple surgical options to help patients with moderate to severe obesity to lose weight, improve most health outcomes, and enhance quality of life. However, these interventions are not without complications. Changes in diet, as well as altered mechanisms for digestion and absorption of nutrients, have the potential to cause nutrient deficiencies and altered bone metabolism. Adverse effects of bariatric surgery have only started to receive significant attention within the past five to ten years. As a result, the long-term consequences of bariatric surgery, particularly the risk associated with bone loss, remain poorly understood.

TYPES OF BARIATRIC SURGERY Bariatric surgery is indicated for patients with a body mass index (BMI) greater than 40kg/ m2, or greater than 35kg/m2 with at least one medical co-morbidity, such as type 2 diabetes mellitus or sleep apnoea.1 Possible surgical interventions include gastrointestinal diversionary procedures (for example, Rouxen-Y gastric bypass: see illustration 1) or gastric interventions, such as laparoscopic adjustable gastric banding or sleeve gastrectomy (see illustrations 2 and 3).1 Diversionary procedures are designed to induce malabsorption in particular areas of the gastrointestinal tract, while restrictive interventions aim to limit food intake.2 Weight loss following these procedures is substantial. After gastric bypass, patients can expect to lose up to 75% of their excess body weight, and maintain their reduced weight for more than 10 years.1 Weight loss with gastric banding and sleeve gastrectomy tends to be more delayed and slightly less dramatic, with an average loss of around 50% of excess body weight after 12-18 months.1,2

CHANGES IN BONE AND MINERAL METABOLISM AFTER BARIATRIC SURGERY Bariatric surgery has the potential to cause protein malnutrition and nutrient deficiencies including vitamin D, B12, folate, zinc, calcium,

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and iron deficiencies, as a result of poor diet, inadequate digestion and limited absorption.2 Optimal supplementation of calcium and vitamin D after surgery is yet to be determined.3 At a minimum, daily multivitamin tablets containing 1,200-2000mg of elemental calcium and at least 1000IU of vitamin D3 (cholecalciferol) are recommended.2 Vitamin D is essential for regulating calcium metabolism, sustaining serum calcium and phosphate levels, and maintaining adequate function of the parathyroid hormone.2 Vitamin D deficiency is common in obese patients and those who have undergone bariatric surgery. Without adequate vitamin D, calcium cannot be appropriately absorbed or managed, resulting in hypocalcaemia, increased parathyroid hormone production and bone breakdown.2 Patients may suffer from post-operative metabolic bone disease and an increased risk of hyperparathyroidism, osteoporosis, and osteomalacia.2 In order to prevent complications, patients with vitamin D deficiency require supplementation of greater than 2000IU per day.3 Bone mineral density (BMD) is a test that measures the density of minerals in the bone, as an indicator of their strength. It is used to diagnose osteoporosis and predict an increased risk of fractures. Potential causes of decreased BMD post-bariatric surgery include high levels of parathyroid hormone (PTH), decreased oestrogen levels in women, a reduction in plasma leptin and ghrelin levels and an increase in plasma adiponectin concentration (see box 1).3 Box 1.

Leptin, Ghrelin and Adiponectin Leptin, ghrelin, and adiponectin are plasma peptides that help regulate energy homeostasis. Ghrelin increases food intake and reduces energy expenditure, while leptin decreases food intake. Adiponectin increases energy expenditure and insulin resistance.8 These peptides may play an important role in bone mineral density. Adiponectin is negatively associated with BMD and reductions in plasma ghrelin concentrations may be related to increased bone loss.9 Current evidence to support a link between bariatric surgery and decline in BMD is limited by the potential for bias in research,

technical limitations, and inconsistent measurement techniques.1 Despite limitations, research groups have been able to identify a relationship between bariatric surgery and bone loss. Patients who have undergone Roux-en-Y gastric bypass are at greatest risk.2 Increased bone remodelling has been demonstrated in patients following Rouxen-Y gastric bypass, despite the routine use of nutritional supplements.1 Bone resorption and loss of BMD may start as early as 3 months post-procedure.1,2 When bone breakdown outweighs formation overall bone loss occurs. However, it is unknown whether bone loss is an adverse effect of bypass surgery or a physiological response to reduced weight bearing.1 The risk of nutrient deficiency is less pronounced for those undergoing other gastric interventions including gastric banding and sleeve gastrectomy. Preliminary research suggests that gastric banding has a limited impact on BMD within the first two years.1 Changes in BMD and bone loss have been documented following laparoscopic sleeve gastrectomy. One study noted a significant decline in BMD following the procedure, and another found bone remodelling and loss after as little as one year.4,5 In order to prevent potential complications, patients who have undergone laparoscopic gastric interventions are advised to follow the same dietary recommendations as those who have had gastric bypass.2

LINKING BARIATRIC SURGERY TO RISK OF FRACTURES Research in the field of bariatric surgery is evolving with the popularity of the procedure. Patients who have already undergone weight loss surgery may now be learning of newly discovered short and long term complications. Changes in bone and mineral metabolism following bariatric surgery may be associated with an increased risk of fractures. Researchers in the United States found that bariatric surgery (especially gastric bypass) was associated with a 2.3-fold increase in relative risk of any fracture. The most common fractures were found in the hand, leg, and foot, although many were also seen in osteoporotic sites, such as the hip, spine, humerus, and wrist.6 Alternatively, a study in the United Kingdom found no association

between bariatric surgery and an increased risk of fractures up to two years post-op.7 In that study the majority of patients underwent laparoscopic gastric banding. Authors noted a potential trend towards increased fractures in the longer term (up to 5 years post-op).1,7 Overall, evidence to support a correlation between bariatric surgery and an increased risk of fractures remains controversial. Patients and practitioners should be aware that gastric bypass surgery is likely to cause bone loss and a potentially increased risk of fracture, although the causes and implications of this have yet to be determined.1 Investigations to identify patients at risk of vitamin D deficiency, hyperparathyroidism, and osteoporosis may be beneficial.1,3

REFERENCES 1.

Brzozowska MM, Sainsbury A, Eisman JA, Baldock PA, Center JR. Bariatric surgery, bone loss, obesity and possible mechanisms. Obesity Reviews. 2013 Jan; 14(1):52-67.

Bikram SB, Finelli FC, Shope TR, Koch TR. Nutritional deficiencies after bariatric surgery. Nat Rev Endocrinol. 2012 Apr;8:544-556.

Viegas M, de Vasconcelos RS, Neves AP, Diniz ET, Bandeira F. Bariatric surgery and bone metabolism: a systematic review. Arq Bras Endocrinol Metab. 2010;54(2):158-63.

Pluskiewicz W, et al. Bone mineral changes in spine and proximal femur in individual obese women after laparoscopic sleeve gastrectomy: a short-term study. Obese Surg. 2012 Jul;22(7):1068-76.

Nogués, X. et al. Bone mass loss after sleeve gastrectomy: a prospective comparative study with gastric bypass [Spanish]. Cir Esp. 2010;88:103–109.

Nakamura KM, et al. Fracture risk following bariatric surgery: a population-based study. Osteoporos Int. 2014 Jan;25(1):151-8.

Lalmohamed A, et al. Risk of fracture after bariatric surgery in the United Kingdom: population based, retrospective cohort study. BMJ. 2012;345:e5085.

Sony, AC, Conroy MB, Mackey RH, Kuller LH. Ghrelin, leptin, adiponectin, and insulin levels and concurrent and future weight change in overweight postmenopausal women. Menopause. 2011 Mar;18(3):296-301.

Carrasco F, et al. Changes in bone mineral density after sleeve gastrectomy or gastric bypass: Relationships with variations in vitamin D, ghrelin and adiponectin levels. 2014 Jan;24:877-84.

January–February 2017 western nurse |

SURVEY

SUCCESS

We get results for you when you participate in surveys and other ANF activities because we are all working together.

We believe the members’ voices are the ones that count in the ANF. That’s why the results of member surveys have played a role in many important decisions at this organisation over the years, which in turn have also influenced key government policy to improve the health system. Just in recent weeks these surveys have again been breeding instant results. When the State Government recently announced it would not be opening the new Perth Children's Hospital before the March 11 State Election, that came after media pressure from the ANF – after our Princess Margaret Hospital members told us via our recent lead survey, that they would not work at the new hospital, until the lead there is completely removed.

“Surveys and other activities bring together the views of a group of members that is 30,000-strong. That is one loud voice when combined – no wonder we get results”

ANF State Secretary Mark Olson pointed out that just weeks earlier, another ANF survey of PMH members revealed nurses there were not getting leave and were getting fatigued to the point of being concerned about patient safety.

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“Following media inquiries and a story about the survey results, the State Government immediately announced it would make it easier for nurses to get leave,” Mark said. “We are still keeping on their backs about that promise. “The good news continues to be participate in surveys and other ANF activities as they are influencing work environments and the health system.” Mark said our current State Election campaign is the direct result of survey results. “We probed interest in issues repeatedly raised by members in emails during and after the State Government pay deal negotiations,” he said. “These included legislated nurse-to-patient ratios and the abolition of annual performance appraisals.”

Mark added: “Surveys and other activities bring together the views of a group of members that is 30,000-strong. That is one loud voice when combined – no wonder we get results.” 

WHAT CURRENTLY HAPPENS IN WA HOSPITALS

WHAT SHOULD HAPPEN

Too many patients per nurse is dangerous. Both Liberal and Labor governments use a complicated formula that frequently results in too many patients and not enough nurses on a hospital ward. But there’s no time for these complex calculations when you’re seriously ill. You need clear rules, like there’ll always be one nurse per four patients in a general ward – and that’s that.

Vote in the WA State Election for the candidates and the parties who want to make WA hospitals safer with legislated nurse-to-patient ratios.

January–February 2017 western nurse |

AcrossTheNation NEWS, VIEWS AND GOSSIP FROM ALL OVER AUSTRALIA

SCIENTISTS PRINT 3D HUMAN HEART TISSUE NSW Heart attack patients could soon be saved by a printer that creates 3D hearts. Sydney’s Heart Research Institute has announced it bought a 3D bio-printer to “engineer human heart tissue that can be stuck directly to a damaged organ following an attack”. “If we can make it work, we’ll be changing the lives of thousands of Australians and flipping the world of heart attack treatment on its head,” said Dr Carmine Gentile, HRI research fellow, who designed mini 3D hearts being used. The institute said “an urgent need for new treatments” led the HRI to investigate the benefits of printing out “unique 3D human mini hearts” called cardiac spheroids, “built from stem cells to be used as bio-ink to print cardiac patches”. The bio-printer will initially print patches for testing on animal models in the laboratory before being used on humans, as part of a trial of the technology to see if it works. “The idea is these patches will be grafted on to the heart after a heart attack, promoting muscle regeneration and returning cardiac function to normal,” Dr Gentile said. The technology may also be used to test new heart drugs and discover new molecular targets for future therapies. Heart attack kills about 24 Australians every day. 

CODEINE MEDICINES TO BE PRESCRIPTION ONLY

BIG VENEREAL DISEASE INCREASE IN WA

AUS Drugs containing codeine won’t be allowed to be sold over the counter at local pharmacies without a prescription.

WA The number of sexually transmitted infections in WA has risen dramatically in the past year – with more than 3,000 gonorrhoea cases from October 2015 to September 2016.

Australia’s Therapeutic Goods Administration has ruled medicines containing codeine will change from over-the counter (OTC) Schedule 2/3, to Schedule 4 prescription products, from February 2018. “People who wish to use painkiller medicines containing codeine will have to obtain a prescription from their GP or health care provider, or use an alternative OTC product such as paracetamol, ibuprofen or a combination of these drugs,” said the TGA in December. The TGA took into consideration “compelling evidence” of harm caused by overuse and abuse of OTC codeinecontaining medicines, and the fact the U.S., most of Europe, Hong Kong, Japan, the United Arab Emirates and several other nations have made codeinecontaining products prescription-only. The TGA said: “Misuse of OTC codeine products contributes to severe health outcomes including liver damage, stomach ulceration and perforations, hypokalaemia (low blood potassium levels), respiratory depression, and death”. Low dose codeine-containing medicines are not intended to treat long term conditions, but many consumers used such products to self-treat chronic pain, frequently leading to codeine addiction, according to the TGA. Yet little evidence exists showing low-dose codeine medicines are more effective for pain relief or cough than similar noncodeine medicines, the TGA said. 

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This compares with 2,170 in the same period the year before, according to ABC News, which also reported case numbers have more than tripled in the past five years. Syphilis cases are also increasing in quantity – rising from 139 to 308. Acting director of the Health Department's Communicable Disease Directorate Dr Donna Mak said the increase in gonorrhoea cases had been most dramatic in the Perth metropolitan area, among heterosexual people aged from 20 to 40. "That's a particular concern to us, because with gonorrhoea it can be passed from a mother to a child through the process of childbirth," she said. But she added that increases are occurring among “men, women, and people of various sexual orientation”. She said authorities would like people to have safe sex, but if they cannot, “to make sure they go to their doctor or get tested”. 

DRIVERLESS CARS AND PUBLIC HEALTH WA Using self-driving vehicles in public health will save money through accident prevention that can be redirected to scourges such as cancer and obesity. That is the opinion of Professor Simone Pettigrew from Curtin University’s

School of Psychology and Speech Pathology, writing in a recent edition of the Australian and New Zealand Journal of Public Health, who also said road capacity, global warming, and social inclusion would be improved by more use of autonomous vehicles (AVs). “Each year in Australia, around 1,200 people die in road accidents and another 34,000 are hospitalised with injuries,” she said. ”Road accidents cost developed nations such as Australia around 2 per cent of their GDP (about $18 billion). Almost all (93 per cent) road accidents are attributed to human error.” Professor Pettigrew said AVs can be programmed to obey speed limits, and have 360 degree vision and faster-thanhuman reaction times. She said moving to full vehicle automation potentially will avoid about 90 per cent of accidents. “(This) translates to a saving of more than $16 billion per year and the freeing up of thousands of beds in hospitals and rehabilitation facilities,” she said. “If the saved expenditure could be redirected to strategies designed to optimise other aspects of health (e.g. used to fund efforts to cure cancer and reduce obesity), the potential for national health improvements is even more substantial.” 

MILLIONS GIVEN FOR ASPIRIN TRIAL VIC Australia’s biggest ever clinical trial has received nearly $5 million among $483 million in Federal Government health and medical research grants. Professor John McNeil of Monash University, was awarded $4,796,724 for the ASPREE trial which will determine if a daily low dose of aspirin prevents disease in healthy older Australians – bringing total investment in the trial to over $10 million. ASPREE (ASPirin in Reducing Events in the Elderly) is a joint Australia/ US collaboration involving 16,700 Australians aged 70 and over and more than 2,000 Australian general practitioners. Regional areas are supplying 6,000 participants and a further 2,500 participants are in the U.S. “If aspirin is shown to be of overall benefit, millions of healthy older people

around the world will be advised to take aspirin,” said the ASPREE website. “If aspirin is shown not to be of benefit, then many older people will stop taking an unnecessary medication.” Recruitment closed in December 2014 with clinical research continuing until 2017, and results expected in 2018. More than 1900 researchers are sharing in the $483 million for a wide range of projects, and the new funding will support 601 grants across four National Health and Medical Research Council grant schemes. 

MILLIONS OF KIDS WITH WORMS COULD BE HELPED ACT Australian researchers have shown an expanded treatment strategy for intestinal worms could improve the health of millions of children in Southeast Asia, the Pacific and Africa. Senior researcher Dr Susana Vaz Nery, from Australian National University said global guidelines mainly recommended deworming treatment for children, but a new landmark ANU study has found worm prevention is likely more effective when the whole community is dewormed.

The research team is conducting follow-up research in East Timor. "We'll present our findings to the World Health Organization and advocate for new policies that will improve the health and welfare of people in the world's poorest communities," Dr Vaz Nery said of the research which was published in The Lancet medical journal in December. 

MCGOWAN PROMISES ‘DURESS ALARMS’ FOR NURSES WA Personal mobile duress alarms will be provided to public health workers at risk such as those “working at remote nursing posts”, under a Labor State Government. Health workers “doing home visits alone” will also get the alarms if Labor wins the March 11 State Election, according to WA Labor Leader Mark McGowan. Mr McGowan has also promised “antistab vests” that cover vital organs and reduce the risk of injuries from syringes and knives, will be provided to major public hospital security staff.

"This is the first time that researchers have shown that expanding medication programs to all community members will likely lead to improved control of intestinal worms in children," said Dr Vaz Nery, from ANU’s Research School of Population Health.

He said the initiatives will provide increased protection for health staff, who have seen a significant increase in assaults over the past four years, and that patients also need to be kept safe. Assaults on nursing staff have almost tripled compared with 2012 – to a “staggering 38 per month in 2015”, according to Mr McGowan’s office. Also, Code Black security incidents more than doubled from 10,069 in 2012 to 21,320 in 2015 – an all-time high, his office said.

January–February 2017 western nurse |

update: Neonatal jaundice

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

Jaundice, other wise known as hyperbilirubinaemia, occurs in up to 60% of full term babies, and is a common medical concern for new families1. Jaundice develops as a result of bilirubin deposits in the skin, which lead to a yellowish discolouration. Jaundice is considered prolonged if it persists for greater than 14 days in a full term baby (37 weeks gestation), or 21 days in preterm infants 1. In the majority of cases mild jaundice is harmless, however, prolonged or significantly elevated bilirubin concentrations can be detrimental if left untreated1. The identification, assessment and treatment of jaundice is not always straightforward. Depending on the skin tone of the child, early recognition of jaundice may be difficult1. Changes in skin colour may not be present until bilirubin concentrations are already significantly elevated2. The following is an overview of neonatal jaundice, including some of the recommended treatment options. Individual health service procedures should be referred to for specific guidelines and management of neonatal jaundice. CAUSES Bilirubin is a product of the breakdown of haemoglobin from red blood cells1. It is found in the body in two forms: conjugated and unconjugated bilirubin. Conjugated bilirubin has been metabolised in the liver and enters the gut for excretion in the stool1. Unconjugated bilirubin has yet to be broken down. In the bloodstream, it is largely bound to albumin. Unconjugated bilirubin has potentially neurotoxic effects on the neonatal brain and spinal cord1.

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There are many possible causes of elevated unconjugated bilirubin levels and jaundice. Physiological jaundice is the most common cause and is due to the immature neonatal liver, which metabolises conjugated bilirubin slower than the body needs leading to an increase in unconjugated bilirubin. Physiological jaundice usually resolves within two weeks. Breast milk jaundice is caused by certain enzymes in breast milk and may continue for many weeks, however breastfeeding cessation is not indicated. Other causes of jaundice include blood group incompatibility, sepsis, liver disease, bruising and metabolic disorders (see table one). Glucose-6-phosphate-dehydrogenase (G6PD) can cause severe neonatal jaundice, is hereditary and more common in specific ethnic groups. 2, 3 Risk factors for jaundice requiring treatment include preterm delivery, birth trauma, poor feeding, neonatal infection, previous history of siblings requiring treatment for jaundice and maternal antibodies. Blood group incompatibility, rhesus and haemolysis are also risk factors for severe jaundice3. ASSESSMENT Assessment for hyperbilirubinaemia, including patient history and examination, is an important aspect of care for all babies3. Figure 1- Neonate under phototherapy

Assessment should include any maternal or family history including patient and maternal blood group, viral serology and any haemolytic diseases2. Enquire about the presence of symptoms including if the infant has been unwell, with any signs of dehydration, poor weight gain, birth trauma, and/or dark urine or pale stools3. Visible jaundice should be assessed when the baby is naked and under natural light by blanching the babyâ&#x20AC;&#x2122;s skin with a finger and observing the underlying skin colour1,4. Jaundice appears first in the face and progresses down to the trunk and extremities4. Kramer recognised the cephalocaudal progression of jaundice with increasing total serum bilirubin levels and divided the baby into five zones, with a total serum bilirubin level measurement associated with each zone3. This became known as Kramerâ&#x20AC;&#x2122;s rule and was traditionally used to visually assess the severity of jaundice. However visual estimation commonly lead to errors, especially in darker skinned babies, and babies who have already commenced phototherapy4. For this reason, a total serum bilirubin level should be used if there are concerns about jaundice and to assess the response to treatment4.

Conjugated Hyperbilirubinaemia3

Unconjugated Hyperbilirubinaemia3

Sepsis

Exaggerated physiological response

GIT obstruction

Breast milk jaundice

Dehydration

Sepsis

Poor weight gain

Haemolysis

Haemolysis (usually as a result of Blood group incompatibility or red cell defects)

Birth trauma and bruising

Excessive destruction of red cells

Biliary atresia (or obstruction)

GIT obstruction or ileus

Neonatal hepatitis

Prematurity

Complication of total parenteral nutrition (TPN)

Hypothyroidism

Choledochal cyst

Metabolic causes including galactosaemia and fructose intolerance

Table 1 – Potential causes and contributing factors to the onset of hyperbilirubinaemia. Frequent re-assessment is required within the first 72 hours of life. Special attention should be given to neonates at high risk of jaundice4.

frequent and effective feeding1. Jaundiced babies should be fed more often, even if they need to be woken for feeds1.

For babies with suspec ted hyperbilirubinaemia, investigations including blood tests are required. Bilirubin levels, are taken urgently and repeated every 6–12 hours until resolved1,3. Serum bilirubin levels are always used for jaundice in the first 24 hours of life and preterm infants1. In some cases, bilirubin can be measured with a transcutaneous bilirubinometer to reduce invasive testing on neonates1. Elevated results will require confirmation with serum bilirubin levels1.

Many well babies are discharged from hospital with mild jaundice. They require early follow-up with their clinician to assess for adequate feeding and bilirubin levels as needed3. Parents should be encouraged to seek urgent review if the baby becomes lethargic, skin colour changes or feeding and weight gain are poor.

If jaundice requires treatment or baby is unwell, further investigations may be required. Frequently requested additional tests include a septic screen (including urine MCS), urea, electrolyte and creatinine levels, liver function tests, blood glucose, viral serology and thyroid function tests3. A direct antibody test and blood group can also be performed on the cord blood (obtained at birth) within the first few days after birth4. Ongoing assessment and management of hyperbilirubinaemia is guided by the identified type (conjugated or unconjugated) jaundice, bilirubin level and underlying causes1,2,3. INFORMATION FOR PARENTS AND CAREGIVERS Jaundice can be very concerning for new parents, especially those who are exclusively breastfeeding. Wherever possible, families should receive reassurance to continue breastfeeding, nappy changing and cuddling1. Breastfeeding mothers may need support and education in order to maintain

For babies who require treatment, detailed explanation of the necessary interventions and expected length of stay may help ease family distress1. THERAPEUTIC INTERVENTIONS Treatment for mild neonatal jaundice includes treating the underlying cause, ensuring adequate enteral hydration, increased breastfeeding or supplementation of feeds, and intravenous fluids if oral fluids are inadequate2. Therapeutic interventions for severe neonatal jaundice include phototherapy and rarely, exchange transfusions1,2,3. In cases of neonatal jaundice, the progression from frequent monitoring to initiating interventions is dependent on the infants age (in hours) and bilirubin measurements (total bilirubin, mmol/L)1. Phototherapy is the use of light to convert unconjugated bilirubin into a form that can be excreted in the baby’s urine and faeces2. (See Figure 1). It is a long-standing, low cost, effective intervention that can be optimised with blue light, at high intensity, large surface areas of exposed skin and close distances between the light and the child2.

In severe cases, bilirubin concentrations can rise quickly. Rarely, babies may require an exchange transfusion2. An exchange transfusion involves the removal of the patient’s blood and replacing it with donor blood in order to remove excess bilirubin3. This procedure is rare and associated with significant risks. It is generally only performed at tertiary centres3. KERNICTERUS If left untreated, the neurotoxic effects of unconjugated bilirubin may cause kernicterus. Kernicterus describes the permanent clinical symptoms that develop as a result of brain cell death caused by bilirubin toxicity2. It may result in spasticity, seizures, athetoid cerebral palsy, deafness, retardation and death2. REFERENCES 1. National Institute for Health and Care Excellence (2010) CG98: Recognition and treatment of neonatal jaundice. Clinical guideline. National Institute for Health and Care Excellence, London. 2. Department of Health, Victoria, Australia. (2014). Neonatal ehandbook: Jaundice in neonates. Retrieved January 2015 from www.health.vic.gov.au/neonatalhandbook/ conditions/jaundice-in-neonates.htm. 3. The Royal Children’s Hospital Melbourne. (2014). Jaundice in early infancy. Retrieved January 2015 from www.rch. org.au/clinicalguide/guideline_index/ Jaundice_in_Early_Infancy/. 4. Queensland Maternity and Neonatal Clinical Guidelines. (Nov 2009 – Reviewed Dec 2012). Neonatal jaundice: prevention, assessment and management. Retrieved January 2015 from www.health.qld.gov. au/qcg/documents/g_jaundice5-1.pdf

January–February 2017 western nurse |

ANF Out ‘N’ About The ANF conducts hundreds of workplace visits each year. Each edition we'll showcase a collection of photos from those visits in this brand new section. See also p14-15.

E. Northam Hospital F. Glengarry Private Hospital G. St John of GodSubiaco

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Januaryâ&#x20AC;&#x201C;February 2017 western nurse |

AroundtheGlobe WORLD NEWS

PRINCESS LEIA SPOKE OUT ABOUT MENTAL HEALTH WHEN OTHERS WOULDN’T

“

Carrie Fisher will be remembered for playing Princess Leia in the Star Wars films – but she also led the way among actors in helping to destigmatise mental illness. The star and accomplished writer, who died aged 60 from a heart attack on December 27, has been praised in the media as speaking out on the issue many times, “something almost unheard of in Hollywood at the time she began sharing publicly”.

I have a chemical imbalance that, in its most extreme state, will lead me to a mental hospital ... I am mentally ill. I can say that. I am not ashamed of that. I survived that, I’m still surviving it, but bring it on,” was how Fisher described her situation. Her view about dealing with mental illness was clear: “The only lesson for me, or for anybody, is that you have to get help. It’s not a neat illness. It doesn’t go away.”

“She gave honest testimonies of the trials and triumphs of battling addiction and bipolar disorder, displaying a no-holds-barred attitude when it comes to discussing the realities of mental health conditions,” said the Huffington Post soon after her death, listing her quotes on the subject over the years.

Fisher inspired fellow sufferers, saying: “In my opinion, living with manic depression takes a tremendous amount of balls. ... At times, being bipolar can be an all-consuming challenge, requiring a lot of stamina and even more courage, so if you’re living with this illness and functioning at all, it’s something to be proud of, not ashamed of”. 

DEMENTIA CURABLE SOON

“The younger generation will not need to worry about dementia, it will be much less of a threat because there will be treatments or cures, I am absolutely confident about that.”

Britain’s first director of the new UK Dementia Research Institute believes a cure for dementia will be found within 14 years. Professor Bart De Strooper, who was due to start the new position in January, has said on the British news website The Telegraph, it was possible cures for diseases such as Alzheimer’s already existed, but it would take several more years to prove their effectiveness in clinical trials.

He said people knew “basically nothing” about dementia 20 years ago, and “only a few dozen scientists” were working on a cure. “Now we have the resources and so much more knowledge,” he said. 

“I think we will be seeing a cure by the time I am 70, and I am in my late fifties now, so you can see that isn’t very far away,” Professor De Strooper, who is 56-years-old, said. Professor De Strooper, who before starting his post in January at the new £250 million ($425 million AUD) research institute at University College London, was previously leader of the Laboratory for the Research of Neurodegenerative Diseases at Belgium’s University of Leuven, added: “We are definitely now in the phase of a cure.

THE EPIDEMIC THAT KILLED Prince

The painkiller that killed music icon Prince is 50 times stronger than heroin – but is merely one part of an epidemic that claims more lives in the US than guns, transcending class, ethnic group and region. In April 2016, the time of Prince’s accidental lethal overdose of fentanyl, that drug was the “latest and most disturbing twist” in the epidemic of opioid painkiller addiction that has “crept across the United States over the past two decades, claiming close to 200,000 lives”, the guardian recently reported. The website added that Prince, like many of fentanyl’s victims, “probably never even knew he was taking the drug”. “The number of people overdosing is staggering,” Lieutenant Tracy Morris, commander of special investigations who manages the narcotics task force in Orange County, California, which has seen the drug flood across the Mexican border, told the guardian. “It is truly scary. They don’t even know what they’re taking.” The website also reported a fentanyl variant, carfentanil – which is 100 times more powerful and is used to tranquilise elephants – is now becoming popular on the street. 

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NORTHERN IRELAND NURSING SHORTAGE LEADS TO TREBLING OF STUDENT PLACES Northern Ireland will increase the number of student nursing places by 200 per cent by 2017/18 to address ongoing vacancies in western areas, according to the Derry Journal. “We have taken steps to increase the number of nurses qualifying from our local universities,” Health Minister Michelle O'Neill said. “In 2016/17 we increased the annual number of training places available by 100, and I have given a commitment to increase annual commissions by a further 100 from 2017/18. That means that next year we will have a total of 300 more nursing students than this time last year.

“By 2019 we will be seeing around 700 fully qualified nurses ready to enter the workforce and around 800 in 2020.” The website reported this is part of ongoing efforts to get more nurses to locate to the Western Trust area. “The Western Health and Social Care Trust are actively recruiting in respect of 78 current Nursing vacancies,” the minister said. “The Business Services Organisation has been commissioned by my Department to coordinate an international nurse recruitment campaign on behalf of all of the Trusts across the North. Six recruitment campaigns have already taken place during 2016 in The Philippines, Italy Greece and Romania.” 

MELANOMA DETECTOR TAKES GUESSWORK OUT OF SKIN CANCER CHECKS It will be easier to detect melanoma at its early stages because of new automated technology combining imaging with digital analysis and machine learning. This will save lives because even experts can have trouble discerning between malignant and benign growths, according to the researchers from New York’s The Rockefeller University, who developed the technology. “There is a real need for standardisation across the field of dermatology in how melanomas are evaluated,” said James Krueger, a D. Martin Carter Professor in Clinical Investigation and head of the Laboratory of Investigative Dermatology. “Detection through screening saves lives but is very

challenging visually, and even when a suspicious lesion is extracted and biopsied, it is confirmed to be melanoma in only about 10 percent of cases.” The new approach sees images of lesions processed by a series of computer programs that extract information about the number of colors present in a growth, and other data. This analysis generates an overall risk score, called a Q-score, indicating the likelihood of the growth being cancerous. A recent study published in the journal Experimental Dermatology, evaluated the tool’s usefulness, indicating the “Q-score yields 98 percent sensitivity, meaning it is very likely to correctly identify early melanomas on the skin.” 

JUNK FOOD ADS BANNED FROM CHILDREN’S MEDIA IN U.K.

media,” said the organisation. “Ads for HFSS products cannot appear in other media where children make up over 25% of the audience.

Tough new rules banning the advertising of high fat, salt or sugar (HFSS) food or drink in children’s media in Britain will come into effect from July. The Committees of Advertising Practice (CAP) recently announced the measures, which came after “a full public consultation” apply “across all non-broadcast media including in print, cinema and, crucially, online and in social media”, in media targeted at under-16s. “Ads that directly or indirectly promote an HFSS product cannot appear in children’s

“Ads for HFSS products will not be allowed to use promotions, licensed characters and celebrities popular with children; advertisers may now use those techniques to better promote healthier options.” “This significant change is designed to help protect the health and wellbeing of children,” the group said. “Bringing the nonbroadcast advertising rules in line with the TV rules, the new restrictions will lead to a major reduction in the number of ads for HFSS food and drinks seen by children. And it will also mean ads for HFSS products will no longer be allowed to appear around TV-like content online, such as on video-sharing platforms or advergames, if they are directed at or likely to appeal particularly to children.”  January–February 2017 western nurse |

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western nurse Januaryâ&#x20AC;&#x201C;February 2017

update: Zika virus

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Zika virus is an arbovirus transmitted by Aedes mosquitoes. It was first identified in Uganda in 1947 in monkeys and the first confirmed human case in 1952, with subsequent outbreaks in America, Asia and the Pacific.1 Between 2015 and February 2016, 33 countries in South America, Central America, and the Caribbean have reported transmission of the virus.3 Affected regions are steadily increasing; initial reports in northeast Brazil, have now spread east as far as Cape Verde (off the coast of West Africa) and north up to Mexico.3

“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.4 Box 1. Arbovirus

SIGNS AND SYMPTOMS Symptoms of Zika virus disease include mild fever, skin rash, and conjunctivitis, lasting between 2 to 7 days.3 Over the past year, rates of microcephaly in Zika affected areas has been increasing, prompting urgent studies.1,3-5 Microcephaly occurs when a child has a below average head circumference, which typically results from poor brain development in utero.2 It may occur in isolation or in conjunction with other conditions including seizure disorders, developmental delay, and feeding disturbances.2 In February 2016, the World Health Organization (WHO) declared that the recent increase in the rates of microcephaly and other neurologic disorders in Brazil constitutes a Public Health Emergency of International Concern.3 Maternal-fetal transmission of Zika virus has been documented throughout pregnancy and the virus has been detected in infants born with microcephaly.5

In April 2016, a causal link between Zika virus and microcephaly and other severe fetal brain defects was established.2 The link was established following a rigorous review of the evidence conducted by scientists at the US Centers for Disease Control and Prevention.2 Further studies are being undertaken to ascertain any causal link between other neurological disorders, such as Guillain-Barré syndrome (GBS).3,4

insect repellent, physical barriers including long clothes and screens to prevent insects indoors, and the spraying of insecticides, as indicated.1 Several affected countries have advised women to avoid pregnancy over the next six months to two years in order to prevent complications.4 Unaffected regions are also advising already pregnant women to postpone travel to high risk areas.5

Guillain-Barré syndrome is a progressive autoimmune disease that may arise following an acute infection.3,6 It affects the peripheral nervous system and causes sensorimotor impairment including altered sensation, bilateral ascending limb weakness, and paralysis.6 Severe cases may result in respiratory failure.6 GBS is thought to be associated with the Zika virus as several affected countries including Brazil, Colombia, El Salvador, Suriname, and Venezuela have also reported an increase in GBS over the past year (see table 1).3

Zika virus infection can be detected through venous blood sampling and polymerase chain reaction (PCR) testing.1 At present there is no specific treatment.1,3,4 Management includes bed rest and supportive care.4 Although there is currently no vaccine for Zika virus, there has been one recently approved for the related, dengue virus, which may potentially be adapted.4

Table 1. Annual rate of Guillain-Barré syndrome in Brazil and Colombia, past and present (as per the World Health Organization).3 GBS CASES

COUNTRY YEAR

(Confirmed & Unconfirmed)

Brazil

2014

1439

2015

1708

Annual average

242

Colombia

First 5 weeks of 86 2016 (January 2016)

TRANSMISSION AND PREVENTION The most common cause of Zika transmission is the Aedes mosquito.1 There is also evidence that Zika virus can be spread through unprotected sexual intercourse, and transmission via blood products (such as blood transfusion) is currently under investigation.1 Optimal protection occurs through the prevention of all mosquito bites and promotion of safe sex practices.1,3 Protective measures include the removal and modification of mosquito breeding sites, routine use of mosquito nets and

DETECTION AND TREATMENT

REFERENCES 1. World Health Organization. Zika virus [Internet]. Geneva: WHO; 2016 Jan [cited 2016 Feb]. Available from: http://www.who.int/mediacentre/ factsheets/zika/en/ 2. S A. Rasmussen, M.D., D J. Jamieson, M.D., M.P.H., M A. Honein, Ph.D., M.P.H., L R. Petersen, M.D., M.P.H. Zika Virus and Birth Defects — Reviewing the Evidence for Causality. N Engl J Med. DOI: 10.1056/NEJMsr1604338. April 13, 2016. Accessed 15 April 2016. http://www.cdc. gov/media/releases/2016/s0413-zika-microcephaly.html 3. World Health Organization. Zika situation report: neurological syndrome and congenital anomalies [Internet]. Geneva: WHO; 2016 Feb 5 [cited 2016 Feb 12]. Available from: http://apps. who.int/iris/bitstream/10665/204348/1/zikasitrep_5Feb2016_eng.pdf?ua=1 4. Fauci AS, Morens DM. Zika virus in the Americas – Yet another arbovirus threat. N Engl J Med [Internet]. 2016 Jan 13 [cited 2016 Feb 12]. Available from: http://www.nejm.org/doi/ full/10.1056/NEJMp1600297. DOI 10.1056/NEJMp1600297 5. Petersen EE, Staples JE, Meaney-Delman, D, et al. Interim Guidelines for Pregnant Women During a Zika Virus Outbreak — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:30–33. DOI: http://dx.doi.org/10.15585/mmwr. mm6502e1 6. Ansar V, Valadi N. Guillain-Barré syndrome. Prim Care Clin Office Pract. 2015;42:189-193

January–February 2017 western nurse |

ResearchRoundup LATEST AND GREATEST FROM SCIENCE

EXPERIMENTAL EBOLA VACCINE PREVENTS INFECTION An experimental Ebola vaccine has been confirmed to be “highly protective” against the deadly virus which killed more than 11,300 people during the 2013-2016 West African outbreak.

PETS OFFER PSYCH HELP

A major trial in Guinea has shown the rVSV-ZEBOV vaccine “is the first to prevent infection from one of the most lethal known pathogens”, announced the World Health Organisation on December 23.

UK researchers who interviewed 54 people diagnosed with a long-term mental health problem in North West and Southern England found that pets were “placed in the central, most valued circle of support”.

Published in The Lancet medical journal the day before the WHO’s announcement, the study findings add weight to early trial results published last year, according to the WHO.

“Pets were implicated in relational work through the provision of secure and intimate relationships not available elsewhere,” said the study published in the journal BMC Psychiatry in December.

The trial, conducted during 2015, involved 11,841 people in Guinea – with 5837 who received the vaccine showing no Ebola cases 10 days or more after vaccination. But among those who did not receive rVSV-ZEBOV, there were 23 cases. "While these compelling results come too late for those who lost their lives during West Africa's Ebola epidemic, they show that when the next Ebola outbreak hits, we will not be defenceless," said Dr Marie-Paule Kieny, WHO’s Assistant Director-General for Health Systems and Innovation, and the study’s lead author. 

TURNING BACK TIME Reversing the effects of old age is coming closer to reality. US scientists recently reprogrammed the cells of mice which had a premature aging disease – extending their lives by 30 per cent. Additionally, the Salk Institute researchers said their approach of an “intermittent expression of genes normally associated with an embryonic state” had also “prompted human skin cells in a dish to look and behave young again”. They said the early-stage research is insightful about “the cellular drivers of aging and possible therapeutic approaches for improving human health and longevity”. “Our study shows that aging may not have to proceed in one single direction. It has plasticity and, with careful modulation, aging might be reversed,” said Juan Carlos Izpisua Belmonte, a professor in Salk’s Gene Expression Laboratory and senior author of the paper containing the findings, published in December in the experimental biology journal Cell. The Salk researchers said “induction of epigenetic changes via chemicals or small molecules” might be the most promising approach for “rejuvenation in humans”. But they added that due to the complexity of aging, it could be up to 10 years before such therapies have clinical trials. 

30 |

western nurse January–February 2017

Pets have long been thought to contribute to the general wellbeing of their owners, but our furry friends may also be therapeutic for those with chronic mental health conditions.

“Pets constituted a valuable source of illness work in managing feelings through distraction from symptoms and upsetting experiences, and provided a form of encouragement for activity.” But the researchers, who are from the University of Manchester’s Division of Nursing, Midwifery and Social Work, and its Faculty of Biology, Medicine and Health, and the University of Southampton’s Faculty of Health Sciences, said despite these benefits, “pets were unanimously neither considered nor incorporated into individual mental health care plans”. They concluded pets “should be considered a main rather than a marginal source of support in the management of long-term mental health problems”. 

C-SECTIONS CHANGING EVOLUTION? The popularity of Caesarean sections may be leading to even more candidates for the procedure – because such infants and their mothers are surviving to pass on their genes. Austrian and US researchers have recently said “the regular use of Caesarean sections has reduced maternal mortality” and that a mathematical model they had used “predicts an evolutionary response of fetal or maternal dimensions, increasing the rates of fetopelvic disproportion”. Writing in the journal Proceedings of the National Academy of Sciences of the United States of America, the researchers said: “The strikingly high incidence of obstructed labor due to the disproportion of fetal size and the mother’s pelvic dimensions has puzzled evolutionary scientists for decades. We propose that these high rates are a direct consequence of the distinct characteristics of human obstetric selection.” They concluded: “Based on this model, we predict that the regular use of Caesarean sections throughout the last decades has led to an evolutionary increase of fetopelvic disproportion rates by 10 to 20 per cent.” 

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January–February 2017 western nurse |

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