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A PREVENTATIVE HEALTHCARE FOCUS Treating & Preventing Gestational Diabetes Mellitus Out with the old in predicting cardiovascular and kidney disease New glaucoma test to prevent blindness
FOREWORD Prevention – a power word in health and medical research as the sector’s mission is quite simply about prevention of ill health for all people.
lthough this publication was developed before t h e o n s e t of C OV i D -19, public health responsiveness and communicable diseases is clearly an area that research has much to offer and indeed lead.
Never before has the need for strong evidence-based research been more necessar y to guide populations through such health threats. While the current focus is on vaccines to deal with COViD-19, research in other areas to develop these potential lifesaving and life-changing interventions continue and I am proud to be part of a research community whose mission to improve the health and wellbeing of us all. I know there are Australian research teams actively engaged in the search for global solutions. I particularly commend the work done by the Doherty Institute at Melbourne University for successfully growing the novel coronavirus from a patient sample and efforts by researchers the from University of Queensland who are racing against time to produce a vaccine. To these and other global efforts, “Go teams go”. Beyond the pandemic, we all know that non-communicable diseases (NCDs) such as hear t disease, diabete s, chronic re spirator y diseases, and cancer are the leading c ause s of de ath a nd dis abilit y worldwide, representing around 60 per cent of all deaths. Worryingly, disease rates from these conditions are accelerating globally, advancing across ever y region and pervading all socio-economic classes. All of these diseases are linked to preventable causes, and it is, therefore, vital to understand the best strategies for their prevention. In addition, interventions such as vaccines can of fer a compelling a p p r o a c h to t a c k l i n g c h r o n i c 2 INSPIRE 015 | 2020
infectious diseases. By developing and implementing successful, costeffective interventions, it is possible to reduce people’s risk of developing and dying from major diseases. Many of these chronic diseases come with a significant cost to healthcare services. As we always say "a healthy population means a healthy economy". Our risk of developing chronic diseases depends on certain aspects of our lives which we can control, our genes and also our environment. The health behaviours that contribute to developing disease include physical inactivity, poor diet, smoking, and alcohol consumption. In addition, environmental factors such as air pollution and UV exposure are risk factors for disease and can be considered preventable causes. But how do we translate this knowledge of risk factors into actions that will prevent disease? How do we implement interventions that are successful at preventing diseases? How do we identify the current gaps in our approach to preventative public health?
The answer lies in more research. Large-scale, multidisciplinary approaches that evaluate these interventions can indicate which prevention strategies to implement, and whether they are successful or not." I was fascinated to see the work that Flinders University and QIMR Berghofer are doing in the area of prevention of blindness. With glaucoma affecting 76 million people worldwide their world first genetic information is being used to develop a test to identify individuals at risk of developing glaucoma. See their article on page (see page 14)
Research Australia is so pleased there is a National Obesity Strategy in development in Australia and we are inspired by the potential impact that could be achieved through implementation of agreed, evidence informed obesity prevention actions. It’s always encouraging to hear about the findings from research trials and see real world evidence being collected and used to improve health outcomes. It’s also terrific to hear more about the work researchers at Black Dog Institute are doing to harness the power of data to create a clear picture of where suicide attempts and deaths occur – and what could be done at a local level to help prevent them. The LifeSpan data team led by Mathew Phillips were highly commended in the Data Innovation Category at our 2019 Health & Medical Research Awards. Prof David Currow from the Cancer Institute NSW makes the point in our ‘Last Word’ the critical importance of investment in health and medical research. We absolutely agree – it is imperative we dif ferentiate between research being a cost and a burden to an investment. Advocating for smarter investment in the sector is a key objective for Research Australia and we are committed to ensuring it is a priority fo r g ove r n m e n ts, f u n d e r s a n d philanthropists alike. Given where we are today, ensuring this is a shared view for our tomorrow is even more significant. For now I I wish you and your colleagues and families good health in this difficult time.
Nadia Levin CEO & Managing Director
Awards Gala Dinner Four Seasons Hotel Sydney Tuesday, December 8
NOMINATIONS OPEN APRIL 20 Visit researchaustralia.org Peter Wills Medal Advocacy Award Griffith University Discovery Award Frontiers Award Sponsored by Australian National University Data Innovation Award Sponsored by Bupa Health Foundation Philanthropy Award Health Services Research Award Health Services Award Sponsored by the NSW Government
CONTENTS Australian Health & Medical Research
Research Australia Forum Overviews
EDITH COWAN UNIVERSITY
ST VINCENT’S INSTITUTE
The eccentric side of cancer treatment
Preventing obesity in Australia
Using data to unlock life-saving suicide prevention solutions
BLACK DOG INSTITUTE
Prolonging good health throughout the ageing process
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Improving breast and cervical screening participation rates amongst high risk and priority target groups
UNIVERSITY OF NOTRE DAME
'Out with the old, in with the new'...
Research improves the early detection of sepsis
Treating & Preventing Gestational Diabetes Mellitus
UNIVERSITY OF WOLLONGONG
Publisher Research Australia Ltd
New glaucoma test to help prevent blindness
Art Direction Matthew Ware p +61 403 844 763 or e email@example.com
For Advertising enquiries please contact the Research Australia office on p 02 9295 8546 or e firstname.lastname@example.org
Rethinking how type 1 diabetes is diagnosed
JUVENILE DIABETES RESEARCH FOUNDATION
Managing blood pressure
Co-designing a Learning Health System Framework:
THE LAST WORD: Optimising research funding
CANCER INSTITUTE NSW
One of Australia’s leading foundations
BUPA HEALTH FOUNDATION
INSPIRE ONLINE issuu.com/researchaustralia INSPIRE is a publication of Research Australia Ltd ABN 28 095 324 379 CHRISTOPHE KEREBEL CHRISTOPHE Twitter : @chriskere 384 My Victoria Street KEREBEL Darlinghurst NSW 2010
My Twitter : @chriskere
Who can submit articles? Any current member of Research Australia who would like to share a relevant story that affects their organisation including, philanthropic donations and their outcomes, research findings, and any other related health and medical research topic that affects the Australian population. Submission guidelines & deadlines For information regarding how to submit and publishing deadlines visit the Research Australia website. Disclaimer The opinions expressed in INSPIRE do not necessarily represent the views of Research Australia. Whilst every effort has been made to ensure accuracy, no responsibility can be accepted by Research Australia for omissions, typographical or inaccuracies that may have taken place after publication. All rights reserved. The editorial material published in INSPIRE is copyright. No part of the editorial contents may be reproduced or copied in any form without the prior permission from Research Australia. © Research Australia 2019.
OVERVIEW OF RECENT FORUMS HEALTH ECONOMICS ROUNDTABLE The University of Melbourne kindly hosted the last Health Economics Roundtable for 2019. The Chair of the Roundtable, Associate Professor Annette Schmiede introduced Professor Shitij Kapur, the Dean, Medicine Dentistry and Health Sciences and Assistant Vice-Chancellor of the University of Melbourne who welcomed attendees with a provocative presentation about health improvements over time and a sobering, yet not surprising, perspective of how we can improve health by tackling behavioural issues that undermine health. (Professor Kapur is also a Research Australia director.) Continuing the engagement with government approaches for evaluating policies and programs, the Roundtable heard inspiring speakers including Allyson Essex from the Commonwealth Department of Health and John King from the Victorian Department of Health and Human Services about where their Departments are at in developing and implementing evaluations to improve policy and program development and implementation. Professor Anthony Harris from the Centre for Health Economics at Monash University shared his views on what we are good at in evaluations, namely evaluating the health benefits of pharmaceuticals, and what we’re not so good at, examining programs to make them better. He also explained that we can learn a lot from evaluations of social programs, which is where the Victorian Department of Health and Human Services has commenced their evaluations.
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Addressing the HERT objective for be more health economics in evidence-based policy in health, Professor Henry Cutler provided insights about the barriers and challenges to embedding health economics into the policy cycle. He highlighted the challenges for researcher health economists to engage in government procurement processes, citing the differing approaches and timelines of research and consultancy projects, and suggested ways government can assist by enabling access to data and encouraging pilots for testing new programs. He also explained the opportunities to encourage more health economist representation in government bodies and advisory groups. This year Research Australia continues to advocate for health economics to drive evidence-based policy and in government evaluations of policies and programs. Research Australia’s Health Economics Roundtable will continue its strong focus on policy themes for the sector.
My Twitter : @chriskere CHRISTOPHE KEREBEL
UNIVERSITY ROUNDTABLE The final University Roundtable for 2019 on December 5 was kindly hosted by The University of Canberra. The opening address and welcome were provided by Professor Leigh Sullivan, Deputy Vice Chancellor, Research and Innovation, University of Canberra. Along with expressing appreciation for the hosting opportunity, Professor Sullivan was extremely complimentary toward Research Australia on the critical role it plays in supporting and promoting Australian HMR and building relationships across the whole of the HMR and health innovation sector.
A HOSPITAL ON CAMPUS- THE HOW AND WHY
Left: A/Prof Annette Schmiede & Nadia Levin - Research Australia Below: Prof Anthony Harris, Monash University Centre for Health Economics. Below right: Dr Henry Cutler, Macquarie University Centre for Health Economy.
The presentation by Professor Nick Brown, Professor of Allied Health Research at the University of Canberra explained the history of the new University of Canberra Hospital, and how it aligned with the University’s broader strategy (‘An Educated Life’) and the needs of Canberra Health. He also placed it in the context of the other health services offered from the University of Canberra campus (the Health Hub and the Icon Specialist Cancer Centre) and the plans for a future Residential Aged Care facility in partnership with Moran Aged Care. Professor Brown explained some of the benefits for the university in terms of providing more student placements across 14 health disciplines and the opportunity to engage the hospital staff and patients in research.
NHMRC RESEARCH PROGRAMS
Professor Anne Kelso AO, CEO of the NHMRC provided her observations on progress with the new NHMRC Research Grant programs. Professor Kelso expressed concerns about apparent breaches of confidentiality by peer reviewers in talking about individual applications and specific panels on social media. Professor Kelso outlined some plans for minor changes to the Program in the second round.
BETTER SHARING OF GOVERNMENT DATA WITH THE RESEARCH SECTOR
Ms Deb Anton, Interim National Commissioner, and Mr Phillip Gould, Assistant Secretary, Office of the National Data Commissioner gave a presentation to the Roundtable. Deb explained the origins of the current legislative reforms in the Productivity Commission’s Report on Data Availability and discussed some of that report’s key recommendations.
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The Government is currently developing a new Data Availability and Transparency Act to implement some of the recommendations of the Productivuty Commission’s re p or t of Data Ava il a bili t y, including improv ing researcher’s access to the Government’s datasets.
IDEAS, INVESTIGATORS AND THE DIRECTION OF RESEARCH IN AUSTRALIA
There was a further discussion following on from Professor Kelso’s presentation on Investigator Grants. It was initiated with a presentation by Professor Mike Ryan, drawing on data about Investigator Grants and Peer Review from Monash, and supplemented with data from other sources. There was also a discussion about the experience with the MRFF and NHMRC. Research Australia agreed to do some further work on the questions of transparency and the MRFF selection processes.
Research Australia provided a review of recent policy developments including MRFF funding announcements and establishment of the Health and Medical Research Office within the Commonwealth Department of Health, to support the MRFF.
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Greg Mullins provided a brief policy update, touching on the relatively large number of new MRFF funding opportunities. He also noted current consultations being undertaken by Government, including: ● Data Availability and Transparency legislation; ● Treasurer’s call for Pre- Budget Submission; ● Productivity Commission into Mental Health; ● Senate Autism Inquiry;
FOCUS VS INTEGRATION- THE PROS AND CONS OF INTRAMURAL AND AFFILIATED INSTITUTES IN HMR
Professor Graham Mann gave a presentation on the topic from his perspective as the current director of the John Curtin School of Medicine and as a former director of the Melanoma Institute Australia. Graham presented data on the number of independent medical research institutes and the amount of variability in their size and resources and he also discussed the different types of research structures and the relative merits of different governance structures, including their different operating models, with some very collaborative and others more self-contained.
My Twitter : @chriskere CHRISTOPHE KEREBEL
TELSTRA HEALTH & RESEARCH AUSTRALIA – DATA OVER DRINKS! Foundation member Telstra Health hosted the first forum for 2020 to discuss the role of digital technology in a changing health system. Research Australia members and Telstra Health partners networked over a drink and shared their views on the subject. Professor Mary Foley AM and Nadia Levin gave speeches from their positions on the transformative power of data and technology on the health and medical research sector and encouraged an interactive questions session in conclusion.
Above: Professor Mary Foley AM & Nadia Levin Below: A/Prof Annette Schmiede & Dr Lara McClements Bottom left: Christopher Ladds & Alex Denison
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THE ECCENTRIC SIDE OF CANCER TREATMENT: A GLOBAL CORPORATE DONATES A SOLUTION! Exercise medicine is established as highly effective therapy for all types of cancer, stage of disease and even when undergoing difficult treatments.
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Twitter : @chriskere Third, the Biocircuit guides the patientMythrough their cce ntr ic exe r cis e is a spe cif ic moCHRISTOPHE da lit y KEREBEL CHRISTOPHE requiringKEREBEL minimal supervision by an which has potential to be more effective for exercise prescription suppressing tumour growth while requiring less exercise physiologist so it represents a very cost-effective effort and energy expenditure by patients - however way to provide high-quality yet still tailored exercise medicine for a very wide range of patient populations. eccentric exercise can be difficult to implement.
Technogym, a multinational innovator in exercise equipment has donated their latest robotic machines to the Exercise Medicine Research Institute at ECU for research into exercise medicine as treatment for people with cancer. Originally developed by NASA for keeping astronauts healthy in zero gravity, the potential for cancer patients is exciting.
The Biocircuit uses a computer-controlled electronic server motor to provide resistance for the patient to work against; it is essentially a series of robots. The machines adjust automatically to each individual patient so they are optimally positioned for each exercise. Through a series of sensors in each machine a wide range of parameters including force output and work done are measured and uploaded to cloud-based data storage for the patient to check their exercise performance and the clinician or researcher to monitor the patient precisely. Why then is the Biocircuit so attractive as a potential exercise therapy for people with cancer? First, the ability to automatically and ubiquitously monitor every exercise session allows us to detect any changes in the patientâ€™s exercise capacity and behaviour. This has the potential to be an important tool detecting subtle changes in the patient to flag potential disease progression or increasing treatment toxicities. We are investigating whether changes in exercise pattern, perhaps detected using artificial intelligence, can provide an early warning sign to automatically generate an alert to the patient and their physician for further follow-up. Second, cancer patients experience so many demands on their time due to medical appointments, and various treatments, often while still trying to work and care for family. The provision of exercise medicine needs to be as effective and efficient as possible, minimising time commitment while eliciting the most appropriate mode and dosage to address the major health issues facing the patient. The high intensity interval training provided by the Biocircuit is very effective for achieving this. Combining aerobic and resistance training into a single workout, the machines can provide overload to all the major muscle groups of the body, using contractions which are known to produce the greatest increase in muscle size and strength. The exercise also drives the release of hormones and cytokines that have proven anti-tumour effects, while also enhancing the immune system to seek out and destroy cancer cells.
The exercise physiologist can focus on monitoring and supporting the patient rather than operating the equipment and recording the exercise performance. Being essentially a computer-controlled robot, various resistance profiles can be programmed, for example constant load or constant velocity, to achieve specific functional outcomes. It can even reduce the amount of load being applied when it senses that the patient is struggling to complete the repetition.
WHY ECCENTRIC EXERCISE?
Eccentric exercise is a mode of training whereby the eccentric or lowering phase of the movement is emphasised. A good example is lowering your body down to a seated position during which your muscles are said to be acting eccentrically. It has been well-established in numerous patient populations that eccentric exercise provides a strong stimulus to muscle growth, requires less energy than concentric exercise (e.g. lifting the weight) and drives very favourable biochemical changes and chemical signalling within the body, which have been demonstrated to improve metabolic health, including insulin responsiveness. Our team is very interested in exploring this mode of exercise using the Biocircuit with cancer patients.
The Biocircuit has the capacity for us to prescribe accentuated eccentric exercise whereby the eccentric phase of the movement involves a much higher loading than the concentric phase". Accentuated eccentric exercise may prove particularly effective for cancer patients exhibiting muscle loss and cachexia (overall loss of body mass) because it may preserve or even increase muscle mass whilst not exacerbating the energy deficit experienced by the cancer patient. Technogym has been exceedingly generous in providing this system for us to conduct a series of research trials in cancer patients. Using this highly programmable system with extensive measurement inbuilt, we will not only be able to improve recommendations for exercise prescription but also study the underlying biological mechanisms by which different modes and dosages of aerobic and resistance exercise suppress cancer cell proliferation, increase apoptosis and inhibit metastasis. Author: Professor Robert U. Newton, PhD. Exercise Medicine Research Institute, Edith Cowan University.
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ʽOUT WITH THE OLD, IN WITH THE NEWʼ... A
s a small boy, Associate Professor Jock Campbell remembers sitting in the kitchen watching his grandmother unwrap a skinned rabbit wrapped in brown paper. After gutting the rabbit, she would take the lungs and insert a straw into the trachea. She would then inflate the lungs and show Jock how they floated in a bowl of water. “My grandmother’s early experiments opened my eyes to the mechanical nature of the heart and lungs,” says Jock, who went on to complete a medical degree, then a PhD. “Like most scientists, understanding how things work has been a big driver for me both in the lab and with my patients.” Jock’s grandmother was one of only six women to graduate from Melbourne Medical School in 1911. She had six children, three of whom became doctors and two, nurses. It’s no wonder that Jock followed in her footsteps. According to the Heart Foundation, cardiovascular disease (CVD) includes heart, stroke and blood vessel diseases, and is a major cause of death in Australia; 41,8491 deaths can be attributed to cardiovascular disease in Australia in 2018. The condition is one of Australia’s largest health problems, killing one Australian every 13 minutes1, and despite improvements over the last few decades, it remains one of the biggest burdens on our economy.2 Cardiovascular disease prevalence increases with age, with 35% of Australians aged 55-64 reporting a long-term 12 INSPIRE 015 | 2020
CVD condition, increasing to 66% for Australians aged 75 and over.3 The proportion of people with heart disease generally increases with age. In 2017-18, the proportion of people with heart disease was less than 5% under 55 years of age, then steadily climbed to one in four (25.8%) Australians aged 75 years and over with heart disease in 2017-18.
What has frustrated me for a number of years is that the current practices to identify people at risk of heart and kidney disease are based on decadesold practices that perform poorly in the Australian population. With the help of a Vanguard Grant from the National Heart Foundation of Australia, I hope to change that,” says Jock. SCREEN-HF STUDY
To that end, Jock aims to improve approaches that identify people at risk of heart and kidney disease, using two unique Australian-specific resources. The first is serum samples from the SCREEN-HF study, Australia’s largest longitudinal study of heart disease, in which more than 4,000 people aged 60 years and over participated. Extensive baseline and follow-up clinical information
A/Prof Duncan CHRISTOPHE KEREBEL
were collected along with plasma and serum; and heart attacks, strokes, heart failure, and procedures to unblock coronary arteries and coronary artery bypass surgery were recorded over a period of 6-7 years. Chronic kidney disease is a major contributor to cardiovascular disease; most patients with chronic kidney disease die of cardiovascular disease before they develop end-stage kidney disease. Jock plans to measure changes in serum creatinine levels (creatinine is a waste product produced from the normal wear and tear of muscles) in SCREEN-HF participants, in order to develop a prediction model that identifies individuals at risk of accelerated decline in kidney function. The SCREEN-HF cohort is a uniquely valuable resource for the study of biomarkers that improve risk prediction. Jock credits much of the study’s success to the participants who contributed their time to the study over many years. “Without the willingness of the community to be involved, it wouldn’t have been possible for me to do this research. It’s great to see so many people willing to contribute in such a personal way, to help us develop new ways to prevent cardiovascular and kidney disease.”
VIFM HEART TISSUE COLLECTION
The second ‘Australian’ resource that Jock is accessing is heart muscle from people who died suddenly, obtained from the Victorian Institute of Forensic Medicine. “This unique collection of heart tissue samples from individuals
My Twitter : @chriskere CHRISTOPHE KEREBEL
who experienced sudden death offers exciting new possibilities for therapies that may not only reduce the incidence of heart attacks and sudden death, but also, heart failure. If we get the outcomes I am hoping for from this study – new tools to improve the prediction of CVD and kidney disease risk in older Australians – we will be able to say, ‘Out with the old, and in with the new’ and they will get the advice and treatment they need to prevent CVD and kidney disease sooner, rather than later,” says Jock. Note: The SCREEN-HF study was funded by the Heart Foundation, as well as by BUPA and the National Health and Medical Research Council of Australia. It was a collaboration between SVI, St Vincent’s Hospital Melbourne, The University of Melbourne, Monash University and Baker IDI. 1. Australian Bureau of Statistics 2018, Causes of Death 2017, ABS cat. no. 3303.0, September. 2. A ustralian Institute of Health and Welfare 2011. Cardiovascular disease: Australian facts 2011. Cardiovascular disease series. Cat. no. CVD 53. Canberra: AIHW. 3. Australian Bureau of Statistics, 2016, National Health Survey: First results, 2014-15, ABS cat. no. 4364.0.55.001, March. Data customised using TableBuilder.
Author: Associate Professor Duncan (Jock) Campbell, Head of the Molecular Cardiology Unit at St Vincent’s Institute. 2020 | INSPIRE 015 13
GLAUCOMA TEST TO HELP PREVENT BLINDNESS
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ew research led by Flinders University and QIMR Berghofer Medical Research has made diagnosis of glaucoma, easier and more accurate via a new predictive test using a single blood or saliva sample. Affecting about 76 million people worldwide, glaucoma is the leading cause of irreversible blindness globally. Researchers have identified 107 genes that increase a person’s risk of developing glaucoma and have now developed a genetic test to detect those at risk of going blind from it. The research has been published in the international Nature Genetics journal. In a world first, genetic information from tens of thousands of people around the world has been used to develop a test to identify individuals at risk of developing glaucoma.
Once accredited for use, the test will improve doctors’ ability to predict and prevent vision loss from glaucoma. It will also guide the age at which screening for glaucoma should start, and the level of risk to other family members.
The researchers are now hoping to recruit 20,000 people with a personal or family history of the disease to join the Genetics of Glaucoma study so they can identify more genes that play a role in the condition. “Glaucoma is a genetic disease and the best way to prevent the loss of sight from glaucoma is through early detection and treatment,” says Associate Professor Stuart MacGregor, head of QIMR Berghofer’s Statistical Genetics Group and co-lead author on the new paper.
Our study found that by analysing DNA collected from saliva or blood, we could determine how likely a person was to develop the disease and who should be offered early treatment and/or monitoringˮ.
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“One in 30 Australians has glaucoma, but most people CHRISTOPHE KEREBEL only find out they have it when they go to the optometrist because they are losing vision, or for a general eye check”. “Early detection is paramount because existing treatments can’t restore vision that has been lost, and late detection of glaucoma is a major risk factor for blindness”.
Glaucoma can arise at any age but most of those affected are in their 50s or older, so our ultimate aim is to be able to offer blood tests to people when they turn 50 so they can find out if they are at risk, and then hopefully act on itˮ. “In most cases, glaucoma can be treated easily using simple eye drops, but this test is likely to be helpful in identifying those who would benefit from more aggressive intervention such as surgery. “There is no single definitive test for glaucoma, and diagnosis involves assessing a range of features including visualising the optic nerve and testing peripheral visionˮ. “With these results, we can now quite accurately assess an individual’s genetic risk ‘score’ for developing glaucoma, similar to other tests in development for cardiovascular disease, breast and prostate cancer,” Professor Craig says. Early diagnosis makes it much easier to maintain good vision using a range of treatments, and we have shown that people with high genetic risk scores are more likely to need invasive treatments such as surgery to control their disease. The research has been funded by the National Health and Medical Research Council (NHMRC). The paper, ‘Multitrait analysis of glaucoma identifies new risk loci and enables polygenic prediction of disease susceptibility and progression’ (2020) by Craig, J.E., Han, X., Qassim, A. et al was published in Nature Genetics in January.
“Importantly, unlike existing eye health checks based on eye pressure or optic nerve damage, the genetic test can be done before damage begins so regular screening can be put in place. “Having a high-risk score doesn’t mean you will definitely get glaucoma but knowing you could be at future risk allows people to take the necessary precautions.”
PREVENTION THROUGH SCREENING AND EARLY DETECTION
Clinical lead researcher and Chair and Academic Head of Ophthalmology at Flinders University, Professor Jamie Craig, says the study results provide hope that mass screening for glaucoma could be offered in the future. “There are Australians who, if they’d had appropriate treatment a few years earlier, wouldn’t have gone blind,” says Professor Craig, who is also a consultant ophthalmologist.
Associate Professor Stuart MacGregor, head of QIMR Berghofer’s Statistical Genetics Group © QIMR Berghofer Medical Research Institute
Authors: Tom Symonds Flinders University & Professor Stuart MacGregor, QIMR Berghofer.
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RETHINKING HOW TYPE 1 DIABETES IS DIAGNOSED By the time the physical symptoms of type 1 diabetes (T1D) appear, the autoimmune attack on the body’s beta cells is already well underway.
ow, r e s e a r c h i s d r i v i n g a s h i f t i n the diagnostic paradigm towards a preventative model that could save lives. Type 1 diabetes (T1D) is one of the most common chronic diseases in children, affecting more than 120,000 Australians.
Even before physical symptoms develop, the early stages of an autoimmune response can be identified by circulating autoantibodies to islet antigens, which indicate pancreatic beta cell or islet autoimmunity. Most children who develop T1D have detectable autoantibodies to at least two islet antigens before the age of 5.
There is no cure, and diagnosis is made based on the classic triad of physical symptoms – increased urination, excessive thirst and weight loss. But this diagnosis comes too late for many families, with up to 30% of newly diagnosed children in Australia experiencing diabetic ketoacidosis (DKA) due to unchecked blood sugar levels.
Islet autoantibodies are a key indicator of T1D risk – 75% of children with two or more islet autoantibodies before age 3 will develop T1D by age 10. This risk is even higher in younger children, and in those with certain high-risk HLA class II haplotypes. The subclinical stage between the emergence of islet autoantibodies and diagnosis of T1D can last for years, presenting a unique opportunity for early intervention and management.
Now, an opportunity exists to change the way we diagnose T1D. Rather than waiting for physical symptoms to appear, research is driving a shift to a preventative risk screening model. By screening for risk and intervening early, it’s hoped that we can dramatically reduce rates of DKA and bring about better long-term outcomes for people with T1D.
HOW T1D SCREENING WORKS
T1D is caused by an autoimmune response that destroys the insulin-producing beta cells in the pancreas. This leaves the pancreas producing little or no insulin, meaning that people with T1D must monitor blood sugar levels and replace insulin through either injections, or an insulin pump. 16 INSPIRE 015 | 2020
THE BENEFITS OF EARLY INTERVENTION
One of the most immediate benefits of T1D screening is a potential reduction in the rate of DKA – a serious build-up of toxic ketones in the blood due to unchecked blood sugar, often occurring as one of the first symptoms of T1D. In addition to causing significant psychological stress for families, DKA leads to poorer long-term outcomes, and can be fatal. The Fr1da study of an autoantibody screening program in Germany showed that among 90,632 children, less than 5% developed DKA – a markedly lower rate than the 20% normally seen in Germany.
My Twitter : @chriskere CHRISTOPHE KEREBEL
Additionally, there is a promising pipeline of immune therapies in development for T1D. Many of these are more effective at early stages of disease, when functioning beta cells are still present in the pancreas.
WHAT’S PLANNED FOR AUSTRALIA?
In 2019, a milestone clinical trial of teplizumab – an anti-CD3 monoclonal antibody – was the first ever T1D study in humans to show a delay in disease onset. Among children with multiple islet autoantibodies but without an official T1D diagnosis, teplizumab delayed disease onset by a median of 2 yearsˮ.
In February, JDRF announced a new pilot study to screen children in the general population, without a family history, for islet autoantibodies. The pilot, led by Dr Kirstine Bell from the Charles Perkins Centre at the University of Sydney, will gather crucial data on the benefits and feasibility of general population screening in Australia, as well as attitudes of healthcare professionals and the T1D community.
A similar clinical trial is being planned in Australia for the rheumatoid arthritis drug baricitinib, which has shown promise as a way of delaying, or even reversing beta cell loss in mouse models. It’s only through early identification of risk that people can be given the opportunity to enrol in these trials and benefit from the therapies in development. Once preventative immune therapies are ultimately approved for wider use in T1D, the value of screening programs and risk identification will only increase further.
Australia already has an islet autoantibody screening program – Type1Screen – for people who have a firstdegree relative with T1D.
If the pilot is successful, it’s hoped that autoantibody screening can one day be offered to all children in Australia – a major step on the pathway towards making T1D a preventable disease. This research is supported by JDRF Australia, the recipient of the Australian Research Council Special Research Initiative in Type 1 Diabetes.
Author: JDRF Australia is the leading supporter of type 1 diabetes research in the world. We drive innovation, demand action and stand with everyone facing life with T1D. We know that research is the key to destroy T1D.
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PREVENTING OBESITY IN AUSTRALIA Obesity is the product of the many interactions between our biology, our culture and the environment in which we live.
t impacts many facets of our lives, from stigma about being over weight through to chronic disease; reducing our capacity to work and live independently. Here, we explore the systemic issues that must be addressed to significantly reduce the negative impacts of obesity in Australia. All Australians can play a role in calling for the low hanging fruit – those interventions that we know can work and have been implemented elsewhere – to be a part of our new national obesity strategy.
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Two-thirds of Australian adults, and one quarter of children, are overweight or obese. This is a large increase over time, up from just over one third of adults in 1980. Obesity is experienced more by those Australians who face greater social and structural disadvantage, with particularly large differences in the level of obesity in regional and remote Australia, compared to metropolitan areas. The growing prevalence of obesity could increase our preventable health burden and widen existing health
inequalities. The health risks associate with being overweight or obese, range from diabetes and heart disease to cancer, musculoskeletal diseases and Alzheimer’s disease. In addition, obesity impacts our lives through stigma and discrimination and affects our capacity to work and live independently. Preventing excess weight gain throughout the life course needs to be a key focus of Australian health, economic and social policies.
In 2007, a UK report captured the many interconnected systems that affect our likelihood of excess weight gain, including our physiology, our physical activity, our diet, our psychology and the social, economic, political and structural environments that influence our behaviours. The general concept of that original systems map remains a useful guide to explore the systemic issues we should address to significantly reduce the negative impacts of obesity in Australia.
WE KNOW WHAT TO DO ABOUT OBESITY
In 2015, an exper t round table of public health professionals, representing a range of organisations, convened to develop the key agreed evidence-based components of a national obesity prevention strategy. This consensus document, Tipping The Scales, endorsed by a range of academic, public health, consumer and other groups, identified areas for action across the food system, the urban environment, and our health and education systems. Similar combinations of actions are recommended by international and global bodies, such as the recent World Health Organisation’s Commission on Ending Childhood Obesity report. With a national obesity strategy now under development in Australia, the timing is ideal to reflect on the potential impact we could achieve through implementation of agreed, evidence informed obesity prevention actions. As is clear from the evidence reviews done to inform the national obesity strategy there are many interventions that that have been shown to work at a population level to improve diets, increase physical activity levels and reduce excess weight gain.
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savings and 1.5 times higher KEREBEL health benefits in the most CHRISTOPHE disadvantaged socio-economic group compared to the least disadvantaged group.
The NOURISHING database also demonstrates that over 40 countries have implemented policies to ensure mandated health standards for food procurement by government related bodies (such as schools, hospitals, and local councils). In Australia, while there is guidance available, monitoring and enforcement is patchyˮ. There is an opportunity to build an expectation for healthy food offerings in all places where children and adolescents gather, starting with schools, sports and recreation centres and hospitals. Research emerging from studies with food service retailers demonstrates that changing their offering to healthier food and drink can be economically feasible as well as driving healthier food purchasing. However, large barriers to implementation remain, including the need for strong leadership support, adequate supply and increased technical expertise and capacity. Preventing excess weight gain throughout the life course requires substantial systems transformation. The proposed national obesity strategy is an opportunity for robust government policy. At the same time, many sectors, and citizens, will need to come together to support these policies to align our food system, health system, education system and built environment to best support healthy weight gain.
In addition to the findings from research trials, real world evidence is now being built, demonstrating the implementability and likely health impacts of these interventions.
FOOD MARKETING AND AVAILABILITY OF UNHEALTHY FOOD In the UK, the NOURISHING database has been built to capture real world implementation of government policies intended to improve population diet and activity levels around the world. From this, we can see that over 20 countries - unlike Australia - have policies restricting the marketing of unhealthy food and drink to children and adolescents. Introducing stricter regulations on television advertising in Australia is likely to be both costeffective and equitable, with 1.4 times higher total cost-
Author: Professor Anna Peeters (pictured above). Professor of Epidemiology and Equity in Public Health & Director of the Institute for Health Transformation at Deakin University.
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USING DATA TO UNLOCK LIFE-SAVING SUICIDE PREVENTION SOLUTIONS Every death by suicide is a unique tragedy, and the causes are immensely complex.
“Local analysis of suicide data can reveal important information that can’t be gleaned by looking at Australiawide or even state trends alone,” said Dr Michelle Tye, Research Fellow at the Black Dog Institute.
Researchers at the Black Dog Institute are harnessing the power of data to piece together our clearest picture yet of where suicide deaths and attempts occur – and what could be done at a local level to help prevent them.
“SPIS incorporates multiple data sets, acquired through robust par tnerships with data custodians across emergency services, the Coroners and other government agencies. By bringing these disparate threads together, we are able to draw meaningful insights and make sense of the data for local communities.”
uicide is the leading cause of death amongst Australians aged 15 – 44 years, and men have a three-fold higher rate of death by suicide. More than 3040 Australians died by suicide in 2018, according to the Australian Bureau of Statistics’ annual Causes of Death data.
In collaboration with the Australian National University (ANU) and SAS, Black Dog has developed the Suicide Prevention Intelligence System (SPIS) to gain insights that help local communities develop more targeted and evidence-based suicide prevention initiatives. The System is currently being deployed as part of Black Dog’s ground-breaking LifeSpan trial – Australia’s largest scientific suicide prevention trial – in four NSW locations and the ACT. Key learnings from the core LifeSpan research trials are also being shared with sites nationally through Black Dog’s support for the National Suicide Prevention Trials.
TAKING THE GUESSWORK OUT OF SUICIDE PREVENTION
A major challenge hampering existing suicide prevention efforts has been a lack of detail about the full scale and extent of the issue. 20 INSPIRE 015 | 2020
FROM DATA TO INSIGHTS TO ACTION
The SPIS data are visualised, depicting the concentration of suicide deaths occurring in local areas. These are overlaid with geospatial mapping of available services and population density to identify gaps, with recommendations and reports on how best to respond fed back to suicide prevention teams within Primary Health Networks (PHNs), Local Health Districts (LHDs) and local councils.
As governments quite rightly are putting more resources towards mental health services and suicide prevention, we need the data and the data analytics to determine the resources are being properly targeted,” said Scientia Professor Helen Christensen AO, Director and Chief Scientist at the Black Dog Instituteˮ.
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“The Importance of Spatial Resolution” Using the correct Spatial Resolution for your data can be critical to gaining meaningful insights and results when analysing or interpreting spatial information.
Professor Helen Christensen AO
“We can provide Primary Healthcare Networks (PHNs) and local councils with information about what’s happening in their district, who is at risk, and where the danger spots are in their own communities so that they can target their prevention activities. “SPIS is helping to identify risk areas and populations, as well as health service gaps, to inform public safety and health care opportunities.”
BUILDING A SAFETY NET FOR LIFESAVING CHANGE
Though the initiative is still in its early trial phase, it is already proving an invaluable tool for proactive prevention planning on the ground.
Thanks to data analytics, a high-risk location within the North Coast NSW LifeSpan site was identified, leading to means restriction activities including a new lookout and culturally appropriate signage following consultations with National Parks and Wildlife Services, Lifeline and local area coordinatorsˮ. Similarly, in the Murrumbidgee LifeSpan trial site, data was used to identify vulnerable groups and individuals, who were targeted with a new promotional campaign via traditional and social media, as well as evidence-based training delivered at community forums.
Dr Michelle Tye
In a testament to the project’s life-saving potential, the Black Dog Institute’s LifeSpan Data Team were named Highly Commended finalists in the Data Innovation Award category at Research Australia's 2019 Awards. “SPIS looks at the micro level, teasing out significant learnings and providing tailored solutions that work for each trial site community,” said Matthew Phillips, LifeSpan Data Manager. “While the journey is only just beginning, it is our hope that, along with the help of our communities and health networks, we can use the data to develop intricate yet robust safety nets.”
B l a c k D o g I n s ti tu te’s S u i c i d e Preve nti o n Intelligence System (SPIS) wouldn’t be possible without substantial corporate support from SAS, ANU, data custodians across governments, coroners, police and ambulance, and generous philanthropic support for LifeSpan from the Paul Ramsay Foundation.
Author: The Lifespan Data team led by Matthew Phillips from The Black Dog Institute.
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RESEARCH IMPROVES THE EARLY DETECTION OF SEPSIS Sepsis is a blood-borne infection that triggers a potentially fatal response by the body’s immune system, damaging organs. More than 5,000 people die from sepsis every year in Australia.
ore than from prostate cancer, more than from breast cancer. It can affect anyone, from the very young to the elderly, the fit and the infirm. The best defence against sepsis is the early detection of people at risk. Supporting and improving the ability of hospital staff to do this has been the priority of Associate Professor Ling Li from the Australian Institute of Health Innovation, Macquarie University. Associate Professor Li’s research is the first to compare the performance of commonly accepted tools for the early detection of sepsis in adult inpatients on hospital wards.
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Now and as a result of findings, Associate Professor Li warns against adoption of the internationally recommended Quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) for early detection of suspected sepsis in hospital patients. qSOFA was developed by a team from the International Society of Critical Care Medicine and the European Society of Intensive Care Medicine and while not yet widely used in Australian hospitals, it is recommended by the international taskforce of the Third International Consensus Definition for Sepsis and Septic Shock (2016). “qSOFA has been put forward as an effective tool for early detection of sepsis however our research shows it is not adequate. Instead, we are calling on all Australian hospitals to use SEPSIS KILLS Adult Sepsis Pathway (ASP) to improve the timeliness of detection,” Associate Professor Li said. ASP was devised to prompt nurses and doctors at a patient’s bedside to consider certain criteria, such as changes in blood pressure, respiratory rate and consciousness, in assessing the possibility of sepsis.
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For a patient with sepsis, every hour of delay in the commencement of treatment with antibiotics significantly reduces their chance of survival,” Associate Professor Li explained. THE RESEARCH
Associate Professor Li’s research was conducted using more than 10 million clinical records from over 130,000 patient admissions in 34 healthcare facilities across metropolitan, rural and regional locations in NSW. The aim was threefold: •
Evaluate the ef fectiveness of dif ferent sepsis recognition tools for the early detection of sepsis in adult inpatients
Develop algorithms to utilise big data collected from the electronic health record for scenario testing
Optimise an electronic clinical decision support system to be rolled out in NSW hospitals
In evaluating the effectiveness of tools, research results led to the recommendation that hospitals use ASP, which was developed in NSW and implemented by the Clinical Excellence Commission, ahead of qSOFA.
The study found for two thirds of cases in the study, qSOFA would not have triggered a warning of sepsis prior to the patient’s death. On the other hand, ASP would have triggered a warning for more than 90% of cases who died in hospital and the warning would have been triggered 8 days before death for half of cases.
ASP is a paper-based system and Associate Professor Li says the future will be in developing automated systems. Recently, Associate Professor Li and a team from the Australian Institute of Health Innovation completed an evaluation and optimisation of automated clinical systems to improve early sepsis diagnosis and rapid treatment. The optimised electronic decision support system increased the chance of sepsis patients being recognised early by 35%. Associate Professor Li presented this published research at the 17th World Congress of Medical and Health Informatics (a worldwide key event in digital health) in August 2019. This research has been adopted by the Clinical Excellence Commission and eHealth NSW for future rollout in NSW. The research was published in the Internal Medicine Journal , Studies in Health Technology and Informatics (book series), and on the Clinical Excellence Commission Website. This article was co-authored by Chrissy Clay, Research Outreach Coordinator, Australian Institute of Health Innovation. Author: Associate Professor Ling Li, Australian Institute of Health Innovation, Macquarie University.
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PRESSURE IN RESOURCE POOR SETTINGS
A health worker delivering education about hypertension to people with hypertension living in a village in Andhra Pradesh, India. © Oduru Suresh 24 INSPIRE 015 | 2020
CHRISTOPHE KEREBEL CHRISTOPHE KEREBEL Hypertension has emerged as a major threat to public health in low and middle-income countries.
n rural India, where more than two-thirds of India’s population reside, there are significant barriers to accessing health care, partly because doctors are in short supply. Innovative approaches to managing hypertension are needed to overcome the barriers. Hypertension is an emerging epidemic in India. Rural residents are particularly vulnerable to poor control of hypertension as: •
awareness of risk factors is poor;
doctors are in short supply and are located large distances from many villages; and
the costs of accessing private health care are often prohibitive.
These factors have critical health implications, as people who do not have their hypertension managed are much more likely to suffer a heart attack or stroke than those whose hypertension is well-controlled. To overcome some of the difficulties in accessing health care in rural and disadvantaged regions, the Indian government established a National Rural Health Mission aimed at providing every village with a trained healthcare worker to act as an interface between the villagers and the public health system. These health workers are chosen by a rigorous process involving health and village community groups. Their remit has been targeted at maternal and child health to deliver first-contact care, improve health literacy, and mobilise the community to increase their use of existing health services.
A TRIAL USING EXISTING HEALTH WORKERS
In three very different rural regions in India, researchers from Monash University, the George Institute for Global Health and collaborators from India who led the Controlling Hypertension in Rural India (CHIRI) trial decided to use this existing system of health workers to manage hypertension. The researchers involved community members to help shape the intervention program, which included focus group discussion with people who had hypertension, feedback on the content of a pilot training program from health workers and local clinicians, and a workshop with policy makers and clinicians to co-develop the intervention in-line with the country’s health programs. The study, which was in the form of a cluster randomised controlled trial, involved 637 participants with hypertension from 5 clusters who were recruited and randomised to the intervention, and 1,097 with hypertension from 10 clusters who were recruited and randomised to usual care.
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The researchers taught these health workers, who had a minimum level of Grade 8 education, how to educate villagers about self-managing their hypertensionˮ. Health workers then arranged education sessions with groups of villagers who had hypertension, taught them about the condition, and how to manage it. This was done at 6 fortnightly 90-minute sessions delivered over 3 months using flipcharts as education aids, and handouts for people to use at home. The training materials and resources are freely available online. The health workers also measured the residents’ blood pressure at each group meeting to enable participants to determine whether their strategies were working.
When compared to other villages, where there were no group-based educational meetings, the average blood pressure declined by 5/2 mmHg more in the villages where the educational sessions were given and control of blood pressure improved. This large reduction in blood pressure has the potential to reduce the risk of heart disease and stroke in low-resource settings. This novel group-based low-cost education and monitoring program overcomes many of the limitations in access to healthcare in disadvantaged settings. It uses a workforce that is already available in sufficient numbers and is embedded within the community, and provides them with basic training. This approach to managing hypertension could be introduced in many settings where doctors are unavailable and distance to health services is great. The next steps are to test the scalability of the program for the more than 100 million people with hypertension in India, and to modify the approach for people living in other disadvantaged regions globally.
Authors: Professor Amanda Thrift is Head of the Stroke & Ageing Research group at Monash University. A/Prof Rohina Joshi is from the George Institute for Global Health, UNSW. Professor Roger Evans is from the Department of Physiology, Monash University. This work was supported by the NHMRC through the Global Alliance for Chronic Diseases.
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CO-DESIGNING A LEARNING HEALTH SYSTEM FRAMEWORK: Learning Health Systems: Learning together for better health
here is a growing interest in how best to use evidence and health data to inform decision making in care delivery. With a seemingly endless amount of data now available, systems are needed to ensure the most relevant and current information guides decisions related to healthcare delivery. Improved health outcomes require better decision making at all levels of healthcare delivery, from the chief executive to the clinician and patient consultation. Improving the ability to access, understand, quickly visualise and compare data related to patient care is known to improve health outcomes. The Learning Health System (LHS) provides a framework for incorporating best practice and takes a systems approach. Monash Partners (MP) is one of seven NHMRC accredited Advanced Health Research Translation Centres. The Centres bring acute and community health services, primar y care, research institutes, universities and government together to translate research into best practice to improve patient care and health outcomes. A strategic priority of MP is data-driven health care improvement. In 2019 we gathered evidence to create a framework to support a network of sustainable LHSs in Australia. The evidence offers learnings for a system for 26â€ƒ INSPIRE 015 | 2020
co-developing LHSs with inter-disciplinary members that are sustainable and provide the environments needed to shape the healthcare of the future.
SYSTEMATIC REVIEW, INTERVIEWS AND CO-DESIGN WORKSHOP
The LHS framework was informed by a systematic review of academic and non- academic sources, then matured through a series of interviews and a workshop with national and international stakeholders.
LEARNING HEALTH SYSTEM
Evidence synthesis of the review, interviews and codesign workshop has produced a LHS framework. A key feature is the integrated team of frontline clinicians, researchers and community members, embedded in healthcare. This is critical for the purpose of using data from clinical encounters and other sources to generate new knowledge to continuously inform and improve health decision making and practice. A strong foundation is needed in stakeholder partnership, clinical leadership, community engagement and priority setting. A LHS combines people with relevant workforce capacities and people with capabilities in analytics to make sense of the complex data arising from complex
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health systems. Community involvement ensures the improvement cycle focuses on areas of unmet need, public interest and priorities. New evidence is integrated and captured in a LHS. Evidence can come from inside the LHS (e.g. outcomes from patients with similar conditions and characteristics) and from outside (e.g. guidelines). The synthesised evidence then informs algorithms and standards to guide practice, with agreed core outcomes to measure care.
To have direct health impact, a LHS must provide timely access to data as well as analysis of that dataËŽ. Access to integrated real-world data is often impeded by governance and regulatory systems as well as technical, quality and interoperability issues. These issues can be addressed within the LHS continuous improvement process, supported by strategies including natural language processing to improve data quality. Feedback of benchmarked data to those making healthcare decisions at all levels drives a LHS to deliver impact. Existing clinical registries can be embedded into a broader LHS, and doing this had produced healthcare
impact in six international LHSs studied by this project. Whilst this is all potentially feasible in developed health systems, the silos that separate the community, healthcare provision, clinical research, guideline development, data access and governance, data analysis and feedback, implementation science and organisational quality improvement, fly directly in the face of an integrated LHS. Given that ultimately the community are the funders and beneficiaries of health care, these silos must be integrated in the interests of the community to drive improvement and the LHS offers an ideal system level approach to this challenge. We propose that a LHS will iteratively drive evidence into practice and generate new knowledge, to shape and deliver the healthcare of the future. Academic Health Science Centres that integrate healthcare, research and education are ideally positioned to underpin and support this LHS.
Authors: Enticott, J1,2, Johnson, A1, Jones, A1, Teede, H1,2
Monash Partners Academic Health Science Center, Melbourne, Australia 2 Monash Centre for Health Research & Implantation, School of Public Health, Monash University, Melbourne, Australia 1
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PROLONGING GOOD HEALTH THROUGHOUT THE AGEING PROCESS
With ageing populations booming globally, extending illness – and disability-free years is vital to the quality of life of individuals, and to reducing spiralling health budgets.
onash University’s School of Public Health and Preventive Medicine is home to major studies exploring whether two commonly prescribed medications – aspirin and statins – have a role in prolonging good health in the healthy elderly. When the primary findings of the Aspirin in Reducing Events in the Elderly (ASPREE) were released in 2018 they created waves across medical and consumer media around the world. Released in three papers published simultaneously in NEJM,1,2,3 the findings showed that the risks of daily low-dose aspirin outweighed the benefits in healthy older people who had not already experienced a stroke or cardiac event. 18 months down the track and one of the most gratifying legacies of ASPREE is the rapid changes the findings have generated, including incorporation into American Heart Association/American College of Cardiology guidelines around aspirin use. Such fast and decisive translation of research results into clinical practice is rarely seen. Based on high quality evidence from the ASPREE trial, millions of otherwise healthy older people around the world now have one less tablet to take, saving them money, reducing the health risks associated with aspirin, and reducing the health risks and quality of life burdens associated with polypharmacy. 28 INSPIRE 015 | 2020
While aspirin-ef fects may have been the primar y endpoint, ASPREE researchers have only scratched the surface of the wealth of data collected. The dataset has already provided an up-to-date prevalence of depressive symptoms among healthy, older, community-dwelling Australians, and given clinicians insights into warning signs that may improve early detection. And it’s provided the first reference ranges for sex steroids testosterone and estrone in older women, findings that will undoubtably have great impact on our understanding of healthy ageing in women.
It is also of interest to understand the legacy effects of prior aspirin use. Meta-analyses4,5,6 have reported protective effects against colorectal cancer, but the studies included didn’t focus on older peopleˮ. TRIALS CONTINUING
The ASPREE-XT follow-up longitudinal study aims to fill this knowledge gap, and to date 15,000 ASPREE participants in Australia and the US are taking part. They continue to provide data that will explore those health impacts and elucidate the effects that medical conditions, lifestyle, the environment, genetics and other factors may have on health and ageing.
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Australian ASPREE and ASPREE-XT study Principal Investigator Professor John McNeil AO says ASPREE is unique because “no data set internationally has accumulated this level of detail from such a large cohort of elderly individuals.”
Study lead Professor Sophia Zoungas says, “Definitive, high quality trials involving healthy older adults such as STAREE are imperative to identifying preventive strategies that improve overall health and well-being when all possible benefits and risks are considered.”
The success of ASPREE has fuelled our anticipation of the Statins in Reducing Events in the Elderly (STAREE) study. Based on a similar study protocol, STAREE is a double-blind placebo trial exploring the risks and benefits of preventive statin use in a healthy elderly population. The study has already consented over 9,000 participants, recruiting through a national network of over 3,000 General Practitionersˮ.
An area of great interest to many are the pleiotropic effects of statins, or effects other than those for which the drug was developed. There is evidence that statins may delay Alzheimer’s Disease, and reduce vascular dementia. Other studies have suggested anti-hypertensive effects, antiinflammatory effects and improvements in bone density.
There is already good evidence that statins effectively lower ‘bad’ cholesterol in the order of 18-55%. They are the most commonly prescribed drug in Australia, and population level data suggests approximately 30-40% of Australians aged 70 and over take them. Despite this, the drugs have developed a divisive reputation, with previous unsubstantiated negative press creating fear in the community, despite a lack of evidence. Much of the research previously undertaken focusses on middle-aged cohorts.
It’s a complex balancing act, and STAREE aims to tease apart the many components to determine whether the beneficial effects of statins on death and disability are enough to warrant the risks in healthy older people. The results of this trial are expected to have a similar or even greater impact on the prescribing of statins in this age group as ASPREE has had with aspirin.
Authors: Professor Sophia Zoungas and Professor John McNeil AO
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Improving breast and cervical screening participation rates amongst high risk and priority target groups Significant disparities exist in health outcomes and behaviours of women in Australia.
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hese are influenced by several factors, two of which are Aboriginality and ethnicity. Breast and cervical screening participation rates by Indigenous and CALD women continue to be lower than national and state averages. To find out more about these disparities, The University of Notre Dame Australia undertook a project with BreastScreen NSW Greater Southern with an aim to raise Indigenous and CALD women’s awareness of breast and cervical screens, identify barriers which impact on their participation in screening, and increase participation rates. A variety of qualitative research methods were used.
Ninety-two women, including 28 Aboriginal (Indigenous) and 64 CALD women (from 13 countries), attended 11 information sessions to raise their awareness of breast and cervical screens. The information, developed in consultation with local Indigenous and multicultural organisations, was presented by BreastScreen NSW staff and a Women’s Health Nurse to separate groups of Indigenous and CALD women. Each Indigenous session was attended by an Aboriginal Health Worker and each CALD session, by an interpreter. Time was allowed for questions and answers. From the information sessions, 47 women agreed to participate in focus (‘yarning’ or ‘discussion’) groups to identify barriers. Analysis of the data revealed that many barriers facing these women are similar, regardless of cultural background. “There was no evidence that any ethnic group had a specific cultural belief which was a barrier to having breast or cervical screens. Rather, each woman had her own beliefs which either hindered or enabled her to participate in health screens.” The barriers identified in every group included: lack of awareness and information; lack of health literacy; communication problems; cultural beliefs, shame and embarrassment; competing health/life priorities; difficulty navigating the health system; and fear of screening procedure and/or results. Despite most women indicating that they had some fear of the screening procedure or what the screen might reveal, 46 of the 47 women agreed that it was better to have the screens, get the results and find any problems early. A review of the literature, which focussed on women in Australia and other countries, consistently identified similar barriers which impact on Indigenous and CALD women’s participation in health screens. Several researchers point out that “variations will occur within and between
cultures, based on factors such as cultural beliefs and practices, religion, and level of acculturation” (Ussher et al. 2012). Henderson and Kendall (2011) also highlight the importance of conducting qualitative research into specific cultural groups in order to provide insights into subtle differences. Likewise, in a systematic review of literature regarding migrant women in industrialised countries, Gagnon et al. (2009) suggest that the diverse definitions of migrants used in the studies limit the conclusions that could be drawn and call for further research which uses “clear, specific migrant definitions”. Two key points, however, must be made. Firstly, despite the cultural diversity of the women studied (both in our research and the literature), many barriers are similar. Secondly:
Culture is an evolving concept – variations will occur, not only between different groups, but also between individual women regardless of their cultural background.” To define any ethnic group according to a ‘clear or specific definition’ has the potential to stereotype in a way which may be unhelpful for the individuals within the defined group. The barriers which prevent Indigenous and CALD women from accessing breast and cervical screens are complex and reflect the different beliefs, values and attitudes of each woman. It was evident in the current study that the choice to screen or not to screen was a personal choice rather than being related to any specific cultural heritage. So, while culturally competent and sensitive approaches to interventions and strategies are necessary, they may not be as critical to reducing disparities as some researchers believe. Indeed, more progress may be made towards the reduction of disparities which exist in the health outcomes of women in Australia, if less focus is placed on the differences between cultural groups, and more focus is placed on the similarities of the barriers facing individual women. Arguably, this approach would offer greater guidance for the design of health screen practices that could increase participation rates for a greater number of women, regardless of their cultural backgrounds.
Author: Dr Dianne Jonasson, Dr Alexa Seal. Notre Dame, Rural Clinical School (Wagga Wagga)
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TREATING & PREVENTING GESTATIONAL DIABETES MELLITUS
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With a passion for exercise, nutrition and health, Dr Francois’ research is in optimising exercise for therapeutic health, with a focus on pregnancy and diabetes.
ith NHMRC funding awarded late in 2019, her team is aiming to improve the care of women diagnosed with diabetes in pregnancy (Gestational diabetes mellitus [GDM]). There are currently no guidelines for physical activity in women with GDM, and many pregnant women do not meet the current physical activity guidelines, which for most, are similar to the traditional guidelines of 30-minutes moderate exercise on most days of the week. “Ultimately my research program seeks to improve glucose control and prevent the complications of diabetes with simple but effective lifestyle therapies. A particular focus is to provide evidence-based guidelines for physical activity and nutrition for GDM,” says Dr Francois. Dr Francois is testing exercise and nutrition interventions for women with GDM, at risk of developing GDM, and in the postpartum period. For example, to lessen post meal surges in blood glucose they are testing whether short periods of physical activity after meals can stimulate glucose uptake into skeletal muscles which can lead to more levelled glucose levels across the day. Regardless of hormone levels, muscle contractions help to lower the blood glucose after eating, and current research suggests a 10-min stroll may be beneficial.
We believe exercise, or as we call it activity or movement is medicine.”
hand how stressful the management of GDM and the postpartum period can be. “During pregnancy women are repeatedly told of the many risks of GDM for mother and child, and that being induced is a possibility. However, what we are not told is that many of the risks are due to, and based on, studies in women who were not previously treated. With my work I was confident (or at least hopeful) I could control it (GDM) with diet and physical activity. Fortunately, we had no complications and she was born at term weighing 2.9 kg.” Gestational diabetes is the fastest growing subtype of diabetes; approximately 1 in 7 women are diagnosed with GDM on the NSW south coast and they have a 50% chance of developing type 2 diabetes later in life. The team at the University of Wollongong is well positioned to tackle the rising incidence of GDM in this area, and ultimately, these strategies will be implemented across Australia and worldwide. In collaboration with the Illawarra Shoalhaven Diabetes Service and the University of Wollongong, Dr Francois and colleagues are also trialling a community ‘walk and talk’ program to improve the health of women following pregnancy. The goal of the program is to promote physical activity, nutrition and wellbeing in order to lower the future risk of diabetes.
H o w e v e r, f u r t h e r r e s e a r c h i s n e e d e d b e f o r e recommendations can be made.
“Using the framework from other popular ‘walk and talk’ programs we are hoping to get the community together in supporting women during this overwhelming and selfless time.”
“This research is based on our previous work in patients with prediabetes and type 2 diabetes, both of which have impaired glucose tolerance. Other strategies we are trialling include whether a bedtime snack (supper) controls overnight glucose levels. This is part of a multi-site trial on low-carbohydrate breakfasts as a way to eliminate the breakfast morning glucose spike.”
Dr Francois and her team aim to use the results from trials such as these to develop community-based lifestyle interventions for treating and preventing GDM and future diabetes.
Together, the hope is that this work will provide clinicians with a larger lifestyle tool kit, one that may be used to lower glucose at specific times of the day. Having recently had her first child, and diagnosed with diabetes during her pregnancy, Dr Francois knows first-
Whilst there are still many questions regarding the treatment and diagnosis of GDM, healthy physical activity and nutrition habits are important for women.
Author: Dr Monique Francois, University of Wollongong, Faculty of Science Medical and Health (SMAH) (NHMRC Investigator Grant)
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THE LAST WORD
OPTIMISING RESEARCH FUNDING
esearch is a crucial part of any community that wishes to improve the lives of the people who live in it. Too often today research is portrayed as a cost to the community rather than as an investment by communities in their wellbeing. Framing research as an investment is particularly important (but difficult) in strained financial times.
When made properly, the investment in health research should have dividends for every member of a community, but especially for those who are most marginalised and those with poorest outcomes. There are potentially two reasons for research being seen as a cost: the community perceives little direct benefit from the investment that it sees in research; and researchers have failed to position their research in a way that the community can adequately understand the returns on investment that are being delivered. Considering research as an investment has led to a rapid evolution in the relationship between funders and researchers. Where once research funding may have been simply a grant, this is much less common these days.
Funding research is an investment – be it from a philanthropist, a non-government organisation or from government itselfˮ. Such an investment requires a partnership between researchers and their funders to jointly agree upon the work that will be done, ensure that it is policy, practiceor research-ready, and that it will deliver the tangible benefits that the funder seeks. Such a process in no way diminishes the role of investigator initiated studies, but does ask that their potential outputs and benefits can be articulated to potential funders in ways that can engage those funders. 34 INSPIRE 015 | 2020
Shifting from being a grant recipient to someone in whom a third party is investing is a mind shift. This requires real discipline for researchers in ensuring that there is an adequate focus on what their research is going to achieve and how that research is going to impact the future. In health, specifically, how will the impact of the research be experienced across the community? Although research may not have an impact on the whole community, it will need to have a clear target: practice, policy or further research. How the benefits are quantified will also depend on the conversation between funder and researcher, often influenced greatly by the peer reviewers who are advising the funders. Indeed, the ability to communicate with peers and colleagues is one crucial facet when successfully seeking funding for a project. Research will continue to preferentially attract the interest of funders that is: ● already looking to the next question; ● already looking to how the findings can be applied; and ● designed to address problems in the communities in which the work is conducted. In communicating the potential of research there needs to be a level of reality. Some researchers are incredibly good at communicating what is a potential outcome five, ten or twenty years down the track, knowing that they are outlining a best-case scenario that is highly unlikely to come to fruition. Some researchers are good at getting publicity for such long term goals but this may be to the detriment of the research community more broadly. Such lofty long term ambitions are laudable, but given the very low success rates of predicting research outcomes decades hence, funders are likely to be sceptical, and the community more broadly is likely to be left with a feeling that the promises of research outcomes are rarely delivered.
My Twitter : @chriskere CHRISTOPHE KEREBEL
Researchers need to ensure that we are honest about the timeframes and the likelihood of positive outcomes from our research. Only then can we foster the community discourse of research as an investment worthy of an additional proportion of the resources of the communityˮ. Ultimately, as a communit y, there is a ne ed for continued investment in research. To optimise the likelihood of that occurring, the research community has real opportunities to contribute to the public’s understanding of what research entails, the realistic timeframes for quality research to be done, and the outcomes that may reasonably be expected to accrue for the community. Absolute honesty in this area will help foster the public’s support for research as an integral pillar of any community. Consider our wicked problems. As a country, our water and food sovereignty is paramount, and yet how much do we invest in ensuring the basic substrates of existence are predictably available? In health, the disparity in outcomes by socio-economic status, ethnicity, rurality and by other
identifiable sub-groups continues across our community. Such disparities should not exist. As we look to the future, there is an opportunity for each of us to change the conversation to research as an investment. As we encounter family and friends, colleagues, politicians and the community more broadly, how can each of us better advocate for improved research spending? An honest appraisal of what research is offering and will continue to offer into the future is crucial if we are to ensure that research remains a fundamental part of our society.
Author: Professor David Currow, Chief Cancer Officer and Chief Executive Office Cancer Institute NSW
2020 | INSPIRE 015 35
The Bupa Health Foundation partners with health and medical researchers to address the health needs of the Australian community. Our approach to partnering includes investing in research that improves health through changes to policy practice band behaviour; collaborating with researchers across the academic, industry and healthcare sectors; advocating for those that are improving health and developing the capabilities, skills and networks of the health and medical research community. The Bupa Health Foundation is one of Australiaâ€™s leading foundations dedicated to health, investing over $33 million since 2005.
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As the voice of the health and medical ecosystem, we continually emphasise that all health and medical research is driven by a shared passio...
Published on Apr 1, 2020
As the voice of the health and medical ecosystem, we continually emphasise that all health and medical research is driven by a shared passio...