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The Round Up Podcast

The Round Up Podcast

Episodes dropped fortnightly

The Round Up Podcast

Welcome to The Roundup, a north Queensland-based medical podcast offering local content for local clinicians. Listeners will hear from passionate and knowledgeable clinicians discussing the approach and management of a diverse range of medical topics of significance to our communities.

Join Dr Elissa Hatherly, a local GP based in Mackay, family planning clinician and Head of James Cook University’s clinical school in Mackay on Yuwi Country. Elissa has 20 years' experience as a doctor in the Mackay region. With clinical work spanning both general practice and the hospital environment, Elissa is particularly interested in preventative health care and improving health literacy in the community. Elissa is also a member of the Mackay Hospital and Health Service Board.

This podcast is currently focused on the region of Mackay and is a collaborative project between the Mackay Hospital and Health Service, local clinicians and JCU where they discuss a range of popular health topics with local experts in each episode. We would like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander peoples of this nation, their contribution to health care and the Traditional Owners of the lands on which we practise.  

Episode 1: Trouble-shooting IUDs

Intrauterine Contraceptive devices: when to use them, common concerns and how to best manage our patients.

Transcript

Episode 1 IUD The Roundup

Thu, 9/8 10:45AM • 33:55

SPEAKERS

Dr Elissa Hatherly, Dr Stephen Lambert

Dr Elissa Hatherly  00:02

Welcome to the roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. In this episode, Dr. Steven Lambert talks to me Elissa Hatherly about some common pitfalls with intrauterine devices and answering some common questions.

Dr Stephen Lambert  00:52

Good morning, Elissa. Just in general, in terms of women's health, I know as a male GP, it's probably an area where I'm probably giving okay care, maybe a standard of care but good quality health care, what's been your experience of, of good quality health care, particularly when it comes to sexual health, contraception, womens health?

Dr Elissa Hatherly  01:16

Yeah, we are really behind the eight ball. Unfortunately, we don't have quality sex education in the schools. We don't have good, respectful relationships, counseling, a lot of schools don't have any respectful relationships, counseling, or a lot of sex education at all, maybe as part of a health class. So the general health literacy in the area is poor. And when I talk to young people, particularly they are getting poor advice from their parents, even if they are bold enough to ask their mums and dads, because the mums and dads didn't have good quality advice. So if we can do better, that would be great for the community. Sex Education, contraception, counseling, emergency contraception, counseling, all of those things are not rocket science. But I certainly don't expect every GP to be as good at every aspect of medicine as every other. And certainly for the junior doctors who might be seeing women in emergency with an unplanned pregnancy or threatened miscarriage, or who I've just popped an IUD in, having a good idea about some of those skills that are needed with those patients is really important. It makes it easier for the doctor, and much nicer for the patient.

Dr Stephen Lambert  02:28

I think today we're going to be talking about contraception. I'm imagining contraception is an area where, you know, we're talking about the public in Mackay probably feel like they've got a lot of information about you know, you would have talked to your mom, you would have got stuff in schools, that kind of thing. What I'm hearing you sort of say is there's there's an opportunity for doctors across the board, you may not be practicing this type of medicine every day, in the same way that you are, but there's a role for all health practitioners, doctors, you know, GPS, interns, Junior Doc's to be where the opportunity presents itself to be increasing the literacy, health literacy. Yeah, that's

Dr Elissa Hatherly  03:14

right. So for example, I just saw a young woman for an intrauterine device insertion on Friday, she had a six week old baby. The last time I saw this young woman, I inserted an IUD, and I said to her what happened to the IUD that I put in and she said, my GP took it out because I have endometriosis and PCOS and the GP reassured me that I wouldn't fall pregnant. And that GP I'm sure, wasn't doing what they thought was wrong but it has made an enormous impact on this young woman's life that can't be underestimated. And

Dr Stephen Lambert  03:49

maybe that'd be helpful for today's conversation is exploring some scenarios and common scenarios, particularly in the general practice environment, probably the patients I'm seeing where I'm not doing Woman's Health everyday or providing contraceptive advice, but I guess there is a body of knowledge that I would need to deliver a high standard of safe quality care. Certainly when I was in medical school, oral contraceptive pool was what we focus most of the time on. Copper IUDs were around. It was kind of like oh yeah, there's this thing. That that there was a little bit of knowledge. And then I think, you know, long acting reversible contraceptives (our LARCS) have probably come to the fore in the last sort of 5-10 years

 

Dr Elissa Hatherly  04:34

or so women doctors  like me have been banging on about LARCS for a long time. So hopefully that message is really starting to filter out into the medical community. A long acting reversible contraceptive is our focus for all women of all age groups because they are much more effective at preventing a pregnancy. The contraceptive pill is an easy one for any doctor to prescribe, but it is not an easy one for women to use and use reliably. And even if it is being used reliably, we can only expect it to prevent a pregnancy in 98 times out of 100. And if you don't want a pregnancy 98 times out of 100 is not good enough. We want a LARC where we are getting contraceptive efficacy, almost 100% of the time. So we use the numbers of about 99.9% effective, statistically a LARC is a more reliable contraceptive method than sterilization.

Dr Stephen Lambert  05:33

With that sort of context, do you want to give us just a bit of an understanding of particularly in terms of intrauterine devices, so in terms of LARCS, yeah, different products there and then I guess even within the class of intrauterine devices, the various products with their pros and cons, so it'd be great to just get your thinking about when you would use which of those.

Dr Elissa Hatherly  05:57

So in terms of LARCS, we have the implanon etonogestrel rod that sits in the upper arm that lasts for three years and provides really good contraception. It can give some unpredictable bleeding in a small number of women, but it's a great starting point, particularly for young women and women who maybe are not sexually active. That's an easy one to learn to insert and to do regularly in your practice, and is a great starting point. They cost about $30 for anyone, which is great. Financially effective, economically viable contraception for young women. When we look at  uterine devices, we have two types. We have those containing a progesterone likely Levonorgestrel, so we have the Mirena which lasts for five years, and delivers a higher dose of progesterone and now we have the Kyleena, which is a fractionally smaller device, again, lasting five years delivering a smaller dose of progesterone every day. And then we have the copper IUDs which irritate the lining of the uterus and are equally effective at contraception. We have the Multiload, the T 375 and the TT 380, that last one will last for 10 years. The smaller IUDs containing 375 millimeters of copper will last for five years for contraception. The copper IUDs can also be used for emergency contraception if inserted within five days of unprotected sexual intercourse. So they are fantastic. For women who don't want any hormone they can go for a copper IUD. For women who don't want any hormone, they might actually benefit from an intrauterine device containing progesterone. Because the progesterone is really only being delivered into the uterus, it's not going into the rest of the bloodstream, it is unlikely to impact on their mood or their weight. The fantastic thing with those progesterone delivering IUDs is that they are quickly reversible, like the copper IUD. So if you try a progesterone containing IUD and don't like it, we can take it out and you go back to normal almost immediately.

Dr Stephen Lambert  08:09

So in terms of IUDs, we've got the those impregnated with Levonorgestrel and the copper IUDs. And in terms of choosing one or the other, am I hearing you say that's kind of patient choice? Or is there? How would you go about selecting?

Dr Elissa Hatherly  08:30

So the progesterone containing IUD's cost about $42 each, which is very different to the copper IUDs, which we can access for around $100, which is still really cost effective when they're used for five to 10 years. Unfortunately, a lot of pharmacies in our region don't stock the copper IUD. And so the women who want a copper IUD might have to ask for it to be ordered in so access is a little bit slower, but not inaccessible at all. The copper IUD as I said, irritates the lining of the uterus, so it does increase the heaviness and the crampiness of a period. That might just be for the first few months it might be for the lifetime of the copper IUD, but you wouldn't know unless you tried it. A lot of women who use copper IUDs are super happy with them. For the progesterone containing the Levonorgestrel containing IUDs, they thin the lining of the uterus, which tends to give women a much lighter, shorter, less crampy period than they might experience any day of the week. So they are a fantastic option for women who need contraception. They are also a fantastic option for women who have an unmanageable period or a period that's interfering with their lives, which can be really variable. I have women all the time who tell me that changing two pads a day is unacceptable for them and that's fine. I have women who are changing two pads every hour, which I think we can all agree is unacceptable. But it's down to the woman whichever way she wants to manage her period and IUD can be there to help.

Dr Stephen Lambert  10:09

So in terms of the progesterone containing IUD, it seems like there are two basic clinical indications that that you could use this for. So ones contraception, the other related to menorrhagia. Yes. We may as well start with sort of contraception and then maybe move to sort of menorrhagia. So I've got a 27 year old, so the lady who's come to get a prescription for the pill, shes got two children doesn't want any children anytime soon. Part of my usual practice, with a request for the oral contraceptive would be to do sexual health screen, obviously, rule out contraindications, but I've been trying to get better at going have you explored other alternatives for sort of contraception? Have you had that conversation in terms of making people aware of IUDs, the benefits, and then helping them weigh up the pros and cons?

Dr Elissa Hatherly  11:07

Yep. So for anyone who comes in, regardless of their age, or where they are in their family planning, I would talk about long acting reversible contraceptives, we know that intrauterine devices, for example, are perfectly acceptable for nulliparous women, so women who have not yet had a baby. And even I will insert them in women who have not become sexually active, if that's the right contraceptive for them. So if someone comes in for contraceptive advice, I will actually just hand write a list of all of the different classes of contraceptives available to them. Also talking about the cost, because that's important, talking about patient input, because that's important. If you can't remember to brush your teeth every day, then you probably shouldn't be remembering to take a contraceptive pill every day, we talk about whether or not people do shift work, whether or not they have multiple sexual partners, and then maybe shouldn't have an intrauterine device. We talk about other things that might be bothering them, like their weight, or their mood, and help walk through the different options to work out what is going to be most acceptable for that woman.

Dr Stephen Lambert  12:15

And so what I'm hearing you sort of say is as part of the counseling, particularly, you know, not just for the LARCS, but particularly with the IUDs, a good set of sexual health history would be sort of really sort of important as part of that consult. It's

Dr Elissa Hatherly  12:35

tricky, isn't it? It's hard to do that in a sensitive fashion without being too interested in the nitty gritty of someone's sex life. But we do recognize that women who are not looking after their sexual health are at higher risk of contracting chlamydia and gonorrhea, which are both really prevalent in our community at the moment. If you pick up chlamydia or gonorrhea, and you have no symptoms, then you might end up with tubal occlusion, and primary infertility or secondary infertility. And that is devastating for those women. So in women who I'm talking about intrauterine devices with,  I say to them, you know, it's incredibly important that we screen you for chlamydia, make sure you don't have an undiagnosed infection. And of course, use condoms with new partners. And that's a conversation I have with everybody, when talking about contraception, regardless of their marital history, or their occupation, or however many children they have, that reminder that condoms are always important with new partners cannot be overstated.

Dr Stephen Lambert  13:35

So in terms of, I guess, myself, I wouldn't be inserting sort of IUDs. Just I haven't had the training to do that. But I've got a young lady in front of me, and we're talking about contraception. I'd like your input, I guess, into I guess, a potential approach for others listening, who may not be in the position where they've had the training to insert IUDs. So I guess the one thing in the back of my mind, if I'm going to refer someone for an IUD, this is the right form of contraception for them, there's a potential of a gap where they might not be covered with contraception before from my consult to seeing you, and some, you know, some patients or a lot of patients just need time to sort of think through the pros and cons I've given them information I've printed information. So my practice would be to give them the pill, so they keep going, give them the referral, I'll often give them a script as well, to perhaps collect that and then come sort of see you knowing that they won't have it inserted on the first consult. Do you have some things or just in your experience? Just nuancing that approach a little bit what would be the best way in approaching that sort of consult where there is potentially a gap in contraceptive cover?

Dr Elissa Hatherly  14:56

so we don't ever want a gap in contraceptive cover, even if women promise that they'll use condoms, I'm always a little bit nervous because condoms require two dedicated partners to use condoms correctly. So we often prescribe what we call bridging contraception. So that might be using the contraceptive pill for a short time, you would want to start it on an active pill, so that it's into their system as soon as possible. Or you could use a depo provera injection, for example, or you could use a nova ring if that was most appropriate or a progesterone only contraceptive pill. We always encourage people to use condoms, as I said, but that bridging contraception is incredibly important. If someone is already using something like the contraceptive pill and has been using it for a long time, don't ask them to stop their pill, I would always want them to continue with that contraceptive pill for seven days after the insertion of the IUD. Because a levonorgestrel progesterone containing IUD will take seven days to become effective. We know that those those IUDs are effective straightaway as contraception if they are inserted at the time of the period as long as it's a true menstrual period. If someone's had a medical termination of pregnancy, for example, we're not 100% sure what recent bleeding might mean whether they have had a true period and whether that IUD insertion is going to be effective straightaway. And of course, if you send someone in for insertion of an IUD and something pops up in that history that we need to investigate a little bit further, or we think a different form of contraception might be nice for that woman, then we don't proceed with that IUD insertion, we might further delay that contraceptive commencement and have a need for further bridging contraception. So if someone's coming from outside, I would ideally like them to still be on active contraception. So when women are coming into family planning clinic, for example, they don't need a referral because we are GPs who run that clinic women can self refer and they don't need a paper referral from the hospital. And we will ask them to have a little bit of pain relief about half an hour before that appointment time to bring the device with them on the day, to bring a pad and maybe, particularly if they're young women who haven't had a pregnancy, we'd suggest they have a driver to take them home afterwards, because they can be super crampy and maybe even feel a little bit faint. But for the vast majority of women, even women who've only had caeserian section births, the difficulty or the discomfort with insertion is really short lived. And I don't think people appreciate that adequately, you might be really uncomfortable for a minute or two but women leave our rooms with some mild period pain and can happily go back to work or go about their business. It's not perhaps as big a deal as some people might consider.

Dr Stephen Lambert  17:59

That's awesome. That's good to understand, I guess the process from the family planning side so that, you know, I guess we can adequately plan.  Would you what would your approach be? So that let's assume this young lady's had her IUD, she comes back five, six months later. She's concerned that she's put on a little bit of weight. She's concerned that her moods have changed, and it may be related to the progesterone. I'm assuming this is not  infrequent.

Dr Elissa Hatherly  18:36

Everyone blames their contraception.

Dr Stephen Lambert  18:39

How do you approach that consult in the sense that I think a lot of us or hopefully know that that's fairly sort of rare, and that this is working locally. But at the same time, you know, patients do come with, it's in their mind that there was an event and this is cause and effect relationship. How do you approach that? Yeah.

Dr Elissa Hatherly  19:04

So we actually see all of our patients six weeks after insertion to make sure that the bleedings settling down that there's no evidence of infection or expulsion of the IUD, and that the unpredictable bleeding that you would normally get at the initiation of the progesterone containing IUD has pretty much settled down. We know that for the first three months or so with a progesterone containing IUD, you might get a higher dose of progesterone released, which might actually get into the systemic circulation so could potentially make women feel a little bit bloated. They might complain of headache mastalgia, their mood or they might be a bit more tearful than usual. Some of those PMT symptoms might be there in a mild in a mild they you know some of those symptoms might be mild. But, you know, I reassure people that if it is related to the IUD, but that that effect would be gone by the three month mark. If we're at six months and women are concerned that their bodies are substantially changing, then an important thing to do is look at what contraception they have used previously. So if people have used a contraceptive pill, for example, that has really suppressed ovulation, when they have their IUD, they might notice more cyclical mood changes as their ovary kicks back into gear, they might notice more ovulation pain at mid cycle, they may not know where they are in their cycle, because the Mirena has suppressed their period, but they might notice cyclical ovulation pain, they might notice that they have gained a little bit of weight or their mood is a little bit poor, because they've actually benefited from the contraceptive pill. Whereas now all we've done is not necessarily to introduce a mirena. But we have removed a contraceptive pill that they had a lot of benefit from, aside from the contraceptive effect. We call those the beneficial side effects of the pill, they are substantial.

Dr Stephen Lambert  21:08

That's really helpful for me in the sense that thinking through what a patient's presenting with, you know, we lump these contraceptives under contraceptive, without thinking that the different modes of action, there's there's actually substantial differences in physiology and how you're getting the contraceptive effect. But there are also other beneficial side effects  to these different forms. Once again, this comes down to the counseling side of

Dr Elissa Hatherly  21:36

Yeah, but keeping our patients engaged is incredibly important. So we need to acknowledge that that patient has those symptoms that they're experiencing, they may not be the side effect of the mirena they not may not be because we've withdrawn the contraceptive pill. But it's also important to ask about other things that are going on in their life have they recently had a baby have they recently returned to work, have they commenced some other medications like an SSRI. So as I said, we can always remove the IUD and give them a period of time without their IUD to see if their symptoms improve. More often than not, I will also give them a prescription for another IUD at that same consult and say look, I'll take out your IUD, if you find that things don't magically change without your IUD, then we can always pop another one in and you can with your GP explore causes for your other symptoms down the track.

Dr Stephen Lambert  22:30

So what I'm hearing is the key point here is the patients come in thinking, you know, they're focused on the IUD. Really important to take a biopsychosocial approach, not have that anchoring bias, where the patients come in this is the problem but rather to zoom out and do a thorough history examination for for other biological causes or their symptoms, all while acknowledging that what they're experiencing is valid and reliable. I think sometimes the message we give is not your IUD keep the IUD in sort of.

Dr Elissa Hatherly  23:02

That's the message I'm going through inside my head, but out of my mouth comes a much more compassionate approach. And of course, it's going to depend on how much sleep I've had the night before how many patients I have waiting in the waiting room, how hungry I am, did I bother to eat lunch today? Probably not. So you're only as good at counselling your patients as you are at managing all of those other things in your workplace from day to day as well.

 

Dr Stephen Lambert  23:31

We might sort of finish off with just one more scenario around IUDs, and then to  summarize some of the key points. So I guess the second scenario is a 45 year old lady who still requires sort of contraception, but in terms of your history, you've uncovered that their periods getting heavier and longer and it's actually impacting sort of life. What would your approach be to that sort of scenario?

Dr Elissa Hatherly  24:01

So it's incredibly important that we offer women at midlife contraception up until we are sure that they have passed through menopause. So women who have their last period before the age of 50, we need to provide them with contraception for two years, just in case they have an unexpected ovulation in that time. For women over the age of 50, we want to provide them with contraception for at least 12 months after their final period. So if someone is using a contraceptive, like the pill, for example, then they are going to be having a reliable withdrawal bleed every month. And we may not know when they are going to go through their last period. We might need to stop their contraception and ask them just to use condoms for a period of time so we can assess what's going on with menopause. So for most women at the age of 45, the average age of menopause being 51 in this country, so women at 45 will not infrequently have a heavier period, that doesn't necessarily mean there's anything nasty going on. And we often use the nice criteria to just establish whether or not we need to investigate that heavier bleeding more enthusiastically or not. For those women who have no concerning pathology on the radar at all the ones who are not making the hairs on your back of the back of your neck stand up, we would look at a contraceptive that's going to provide reliable contraception, but also help to make their life a little bit easier with a lighter, less crampy and maybe even shorter period and that's really where the progesterone containing IUDs come into their home. So when we are over the age of 45, we can provide women with a progesterone containing contraception for what we use extended what we term extended use, so we don't leave that IUD for five years. We actually leave it for seven years, as long as we've removed it by the age of 55. So anyone over the age of 45 would get their last IUD their last progesterone containing IUD and that would be removed 12 months after we are sure they've passed through menopause. With a mirena or a Kyleena, we can be sure they've gone through menopause just by measuring the FSH because that is not interfered with by that contraception. So if you have an elevated FSH in a patient, you would wait another 12 months before removing her IUD. If that FSH is particularly high, like 80, then you don't need to repeat the level. If the FSH is only marginally elevated, you would repeat it six to 12 weeks later to be sure that it was still elevated, and that that woman was in menopause. But it's important that we leave that contraception for 12 months after we suspect their last period so that we capture those women who might have an extra ovulation down the track.

Dr Stephen Lambert  27:02

So in terms of our history, we're suspecting a fibroid uterus in this particular patient and we're able to sort of confirm that with further investigation. Do you want to talk a little bit about the role of IUDs and managing.

Dr Elissa Hatherly  27:18

So when IUDs first became more popular in Australia, it was a common misconception that women who'd only had caesarians were inappropriate for an IUD, that women who had a fibroid uterus were inappropriate for an IUD, that women who were nulliparous were inappropriate for an IUD and we just know that that is not the case. So many women will have fibroids in the uterus. Many women will have small fibroids. A large fibroid might increase the risk of spontaneous expulsion of that IUD, but I will always suggest it to women as an option to try or women who have an IUD would be encouraged to examine themselves for the string of the IUD to be sure that their IUD is in the correct place. If you or your partner can feel the string, then you are reassured that your IUD is in the right place providing contraception. If that IUD improves that woman's period substantially, or insubstantially even, it's up to the woman to know whether that IUD is affecting her period adequately or not. So if we try an IUD for six months, and that woman finds her period is much improved, then we would leave that IUD. If we use that IUD and the woman's period isn't very much changed, or they are crampy, or the IUD is pushed a bit low in the uterus, then we might say, Okay, we've tried the mirena, it's not going to work for you for your period and look at other options for that woman. I'll always give Mirena a go.

Dr Stephen Lambert  28:55

So just to summarize the discussion today, some of the take home points that I've taken and feel free to add any in terms of your long acting reversible contraceptives. I've heard you say that they're more effective than sterilization. So very effective form of contraception. Yeah. Second thing is they're appropriate for any woman basically of any age or previous obstetrical gynecological history. There are some contraindications obviously to it. But in terms of when they initially were introduced, there were ladies excluded, that would no longer be excluded. So the IUD can be considered for anyone wishing to use it as a form of contraception, definitely. In terms of your copper IUDs versus your progesterone impregnated IUDs the mirena and Kyleena are the most available and accessible to ladies here in Mackay.

Dr Elissa Hatherly  29:56

That's right. They're the ones that we have in Australia and all pharmacies stock them, they are a similar cost, they are really cost effective for women of all ages, and really have made an enormous impact on women's quality of life.

Dr Stephen Lambert  30:10

In terms of good medical care around advice around contraception, or providing sort of options, like my takeaway from this is always to take a good biopsychosocial approach to these conversations, there are lots of factors that come into determining an appropriate form of sort of contraception or beneficial side effects from different forms of contraception. And once again, just I guess, good communication skills when counseling prior to, you know, insertion of an IUD, but also the follow up down the track where a patient may come in and go I think it might be my IUD causing these symptoms, just taking a really sort of thorough history and examination and balancing the science at the back of your head going unlikey, but let's let's explore this a bit further.

Dr Elissa Hatherly  31:07

That's right. So of course, the pelvis is a complex anatomical area, it's easy to write off a woman's pelvic discomfort or symptoms as related to an IUD. Often women are also constipated, or might have an appendix that's playing out or suffer with irritable bowel syndrome. There are lots of other things going on. Whilst you might have an IUD in place, that is not the axis of evil. There are other things at play always.

Dr Stephen Lambert  31:35

So once again, thorough history examination, investigation, don't, don't don't let your anchoring bias necessarily get in the way.

Dr Elissa Hatherly  31:45

That's right. And at the end of the day, we just need to do what is best for that particular patient.

Dr Stephen Lambert  31:50

Any final thoughts? If there was one take home that the listeners today needed to take home from this, what would it be?

Dr Elissa Hatherly  31:58

Use condoms. And remember, an IUD for all of your female patients, they can be really helpful, we're so lucky in Mackay to have an easy access pathway for women. But of course, they can always see one of the gynecologists either publicly or privately. And there are lots of GPS in town who are trained to do IUDs you need to be doing them frequently to be proficient, and I would encourage every doctor to consider IUDs in their counseling of their patients.

Dr Stephen Lambert  32:30

Fantastic. Thank you. Thanks for your time, and hope to catch up with the next topic sometime soon

Dr Elissa Hatherly  32:36

Thanks Steven. For more information about the round up or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice, and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 2: Burnout: in yourself and your colleagues

Hear from Psychiatrist Dr Paul Henderson about his personal experiences and tips for recognising burnout in ourselves and our co-workers. Take the time to test your level of burnout, and learn about ways to manage psychological pressure.

Sources

Burnout: In yourself and your colleagues podcast resources

The Burnout Scale (theburnoutproject.com.au)

Self report scale that can provide some guidance on whether you are burning out and if so how severely it is affecting you.

Burnout: A guide to identifying burnout and pathways to recovery by Gordon Parker | Goodreads

An excellent book on Burn out by teg Australian Psychiatrist who was one of the founders of the black dog institute.

TEN – The Essential Network for Health Professionals - Black Dog Institute

The online TEN Navigating Burnout program has been developed specifically for health professionals to reduce the impact of burnout in a way that is sensitive to the unique challenges they face.

The Thriving Doctor: How to be more balanced and fulfilled, working in medicine by Sharee Johnson | Goodreads

This is a book written by an Australian Psychologist who specialises in treating Doctors. It concentrates on the psychological aspects of self care and complements Gordon Parkers book. It isn’t a replacement for it as it doesn’t cover the really important aspect of how to approach your workplace to discuss a position that is burning you out.

Crucial Conversations: Tools for Talking When Stakes Are High by Kerry Patterson | Goodreads

This is a great book that can help guide you in how to maximise the likelihood that any negotiations with your managers/supervisors result in appropriate adaptations to a role that is burning you out.

The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth by Amy C. Edmondson | Goodreads

Psychological safety is a really important aspect of organisational culture that can protect against burn out. This book is by one of the pre eminent researchers in the field.

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework - Kathryn Turner, Nicolas JC Stapelberg, Jerneja Sveticic, Sidney WA Dekker, 2020 (sagepub.com)

Restorative just culture and its relation to critical incident analysis is another approach that can protect clinicians in an organisation against burn out. This paper describes its implementation specifically in relation to suicide but if you exchange suicide for any critical incident you will see it actually provides a generic template that is applicable across the board.

Clinician health - Caring for Colleagues

Transcript

Burnout in yourself and your colleagues

Thu, 9/8 10:32AM • 12:29

SPEAKERS

Dr Elissa Hatherly, Dr Paul Henderson

 

Dr Elissa Hatherly  00:02

Welcome to the roundup and North Queensland based medical podcast offering local content for local clinicians. I'm your host, Alisa hatherly. I'm a local GP and family planning clinician and head of James Cook University is Clinical School here in Mackay on Nui country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the lands on which we practice. Welcome to today's episode on burnout in clinicians with Dr. Paul Henderson. Paul, thanks so much for joining us, you are so experienced in this area as a local psychiatrist here in Mackay. And burnout in doctors is something you're really passionate about. When we think about burnout from trauma. Of course, the type one trauma where there's a particular event or type two where there's repeated long term exposure to a traumatic event, or vicarious trauma. Burnout is something that is incredibly prevalent, isn't it? I think

 

Dr Paul Henderson  01:17

yes, absolutely. Because of vicarious trauma. You know, in ourselves in first responders, we not only witness a great deal of direct trauma, so to speak, but we also bear witness to a great deal of trauma in other people's lives, we, unfortunately are in the position of having to give a lot of bad news, which is very traumatic. We're also in the position of treating people with conditions that we we can't find a treatment for that works, which is which is also very traumatic. So So yes, so you know, everything that applies for PTSD, and our patients apply to PTSD and us. But I think if I suppose I would, I would open it up to something which in my mind is much more prevalent, and in many ways, much more significant, which is burnout. And this is something close to my heart. Because I've written myself like twice in my career. So far, you didn't get to learn after the first time. And you think as a psychiatrist, I would have learned to learn to recognize the signs growing in me. But the last time was only about 18 months ago, and it was what it was what triggered my transition from public health into into private health to be honest. So you know, when you look at surveys that look at prevalence rates, it's it can be absolutely enormous and really astoundingly enormous, you know, usually the lowest figure that is reported is 30%. And the highest figure that I've seen is up to 70% in surgical residents in America. And that, you know, that is enormous because it is it can be such a devastating experience to be burnt out. And I suppose the things to be aware of is that, you know, the core symptom is fatigue, absolute exhaustion, and I suppose that's generally what we don't recognize, because we all work so hard, that we just expect to be fatigued. But when that fatigue stops lifting over the weekend, and becomes a permanent part of our day to day working life, you know, that's a sign that you're starting to creep into burnout, distance, you know, having a sense of distance from your job, or cynicism about your job, or distance from your patients. So compassion, fatigue, those are all common parts of burnout. And also having a having an increasing self doubt about your effectiveness as a doctor is a common part of burnout. And, you know, sleep disturbance is a really common potent part of burnout. Because of the exhaustion, distance feeling from your family and friends is a really common part of burnout, anxiety, you know, particularly anticipatory anxiety going into work, having really low mood and work. And unfortunately, it becomes a self perpetuating cycle, because you're so exhausted. And you know, it's hard to say, but you start to lose the ability to care about what you're doing, that really starts to constantly promote that self doubt.

 

Dr Paul Henderson  03:57

And, you know, I'm no longer practicing with my value set. Because when I came into medicine, I was highly conscientious, I was highly compassionate, I was trying my best for my patients. And now I just don't seem to care anymore. And that is such a source of shame. For doctors, that is a massive barrier for us seeking any help, because you have a sense that I can't reveal to anybody that I don't feel like I'm the doctor that I should be. And I know I experienced that. And you know, and I find it hard to reach out for help as well. But I think, you know, once you recognize that yourself, there's many different ways that you can go about trying to address it. But if you don't recognize it in yourself, it can continue to build and it's, you know, once you have enough doctors in the system or enough professionals in a system where burnout is common, then the whole system starts to burn out. And you know, once you understand the the impacts and symptoms of burnout, you know, you start to recognize that the you know, the person that you work with who just doesn't seem to care anymore. It's not because they're a bad person. It's because they're burnt out but you We'll also see that when there's a number of people that are sort of affected by that, and they're starting to engage in what would commonly be termed as presenteeism, so they're present in work, but nonetheless, they're still absent from work, because they're just doing the bare minimum, because they don't have the mental reserves to go any further, then it means works get shifted to other people, that that increases the chance that they will burnt out, or burn out, that increases the risk of their risk of resentment, it causes tension with in teams. And so it really, you know, it really sort of spreads across teams, unfortunately. So I think, you know, for our own well being, it's really important to recognize, but also for our patients, because, you know, sadly, the research shows that a burnt out doctor is not a doctor, that's that is that is working at their highest level of productivity, or efficiency, or compassion, or conscientiousness. And that, you know, we all want to be that doctor that is functioning in that way. But sadly, the system and it's not a reflection of us on the whole, it's a reflection of the system that we work in is massively overloaded, constant time pressure. And I think, you know, something that's really become apparent in COVID is moral injury and moral injury can be a significant cause of burnout, it can be a significant cause of PTSD as well, actually. And moral injury is when you are behaving away in a way or that when you witness behaviour, that is inconsistent with your value set. And, you know, you'll probably recognize and what I just described about burnout, that you start to experience increasing motor and injury, about your own behaviour, or potentially start to have increasing moral injury about your own behaviour as you burn out. Because you, you just simply can no longer practice in a way that is consistent with your value set, because you're so absolutely exhausted and emotionally numb.

 

Dr Elissa Hatherly  06:43

Gosh, okay, so we need to be a lot more aware of burnout in our colleagues and in ourselves, study percent of our colleagues up to 70% is a massive number. And as you say, in the light of COVID, that moral injury is enormous.

 

Dr Paul Henderson  07:01

Absolutely. And in the show notes, I've included a really fantastic book by a is an Australian psychiatrist called Gordon Parker, literally called burnout. And he is one of the psychiatrists was one of the founders of the Black Dog Institute. And that is a really fantastic exploration of how burnout affects people, particularly within the medical profession. I've also actually included a link to a self reported burnout scale, if anybody is concerned that there may be burning out and just want to have a sense of if that is the case. And it's a spectrum, you know, from subtle symptoms of feeling exhausted, but nonetheless, really recovering over the weekend, to absolute exhaustion, all the other symptoms, and simply not being able to turn up to work. And at the extreme end of this spectrum, because burnout, there's a lot of similarities to depression, but it's not depression. But at the extreme end of the expected spectrum, up to 30%, of people with burnout would go on to develop depression as well.

 

Dr Elissa Hatherly  07:55

Okay, so for doctors who are experiencing burnout, or other mental health concerns, like depression, they can always access the doctors for doctors, peers, or the peer support work through the hand in hand Foundation, can't they?

 

Dr Paul Henderson  08:12

Absolutely. And the black dog Institute also has something called 10, the essential network for professionals. And that is for any medical professional, who is concerned, they may have burnout or other mental health conditions. And it's, I suppose, a professional group that can signpost them or provide support. There's lots of sort of psycho educational material on in that part of the website, and more generally, in the Black Dog Institute website, and I'll put a link in the show notes to that aspect for them as well. And there's also a good book by an a, an Australian psychologist whose name escapes me now but who, who now solely devoted time to coaching doctors, particularly with burnout. And her book is, I think, called the thriving doctor, which I've put in the show notes as well. And that's a really in depth, sort of self help book for how you can concentrate on the psychological aspects of self care, I suppose, you know, to you know, self care work life balance is really important to try and limit the impacts of burnout. But there's two other aspects and these are really well documented in the book called burnout is you really have to, and this is really hard, you really have to think, hard and deep about the role that you're in. Because even with all the self care in the world, if you're in an unworkable role, and sadly, there are many other workable roles in health at the moment, the chances of you being able to stave off burnout, even with all the best self care in the world, are quite low. So you need to you need to think long and hard about the role you're in. And that doesn't necessarily mean that I'm going to change role. But at the very least, it means you have to understand why the role is having such an effect on you, and be able to hopefully talk to a manager that will listen to you and that isn't always the case or a supervisor that will listen to you about the impact of the role on you And what can be done to change the world. And the last thing is a personality characteristic that is that is highly correlated with burnout. And it's related to conscientiousness, which is perfectionism. So when we come into medicine, the more conscientious we are, the more we get praised, essentially. And that can for people that aren't already perfectionist, that can provoke perfectionism. And even in a role that is actually genuinely doable. If you're a perfectionist, you can simply drive yourself into burnout. So you know, sort of the three areas you know, when you're thinking about burnout, self care, thinking about the role you're in what can be done to change it, but also specifically thinking about if you have perfectionist qualities to yourself, and what can be done to address those as well.

 

Dr Elissa Hatherly  10:42

Oh, Dr. Paul Henderson, thank you so much for your time today. Burnout is something that we all need to be thinking about. In the lead up to are you a K day in September, recognizing in ourselves and in our colleagues that we are not okay is incredibly important. Dr. Henderson, thank you so much for your time, we really appreciate it and look forward to seeing the great work that you're doing in our community. Thanks, Paul. For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqth.edu.au forward slash roundup hyphen podcast, or contact us at nqth.mci@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 3: Neonatal Jaundice

Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life, making it a very common condition. Around 3% to 9% of the total neonatal population, may need treatment. Tune in to hear from Mackay Base Hospital Paediatrician, Dr Gopakumar Hariharan who talks to Dr Elissa Hatherly about the common causes of physiological neonatal jaundice, and how to manage this in the community or in a hospital setting.

Resources

 

Table 1. The differential diagnosis for neonatal jaundice1,2

 

Early jaundice

(Within 48hours of life)

Pathological

Intermediate jaundice

(Day 3-10 of life)

Common and mostly benign

Prolonged jaundice

(Beyond Day 14 of life)

 

●       Haemolysis

-          Rhesus/ABO incompatibility

-          G6PD deficiency

-          Hereditary spherocytosis

-          Alpha thalassemia

 

●     Intrauterine Infection

 

●     Sepsis

●   Physiological jaundice which may be exacerbated by/associated with:

-          Prematurity

-          Bruising

-          Cephalohematoma

-          Polycythemia

-          Delayed passage of meconium

-          Breastfeeding

-          Dehydration

-          Asian ethnicity

-          Infant of diabetic mother

 

●    Haemolytic causes

●     Breast milk jaundice

 

●       Sepsis

 

●       Hypothyroidism

 

●     Inherited deficiencies of glucuronyl transferase enzymes - very rare

 

●     Conjugated jaundice  Biliary atresia, neonatal hepatitis

 

Guideline: Neonatal jaundice (health.qld.gov.au)

 

 

Table 2. Pertinent questions on the history of a jaundiced neonate2

History

Risk factors for jaundice

Day of onset of jaundice

-    Always pathological if <24 hours of life

Antenatal  factors

-    TORCH infections (Toxoplasmosis; Other(Syphilis, Hepatitis B); Rubella; Cytomegalovirus; Herpesviridae)

-    Maternal diabetes

Maternal blood group

-    Blood group O and baby group A or B (ABO incompatibility);

-    RhD negative for rhesus related haemolytic jaundice

Birth history

-    Prematurity

-    Traumatic delivery: cephalohematoma, bruising

Neonatal feeding

-    Exclusive breastfeeding

-    Dehydration

Family history

-    Siblings with neonatal jaundice

-    Gastrointestinal disorders

-    Haemolysis

Stool and urine colour

-    Acholic stool and dark urine are concerning features of conjugated jaundice

RACGP - Prolonged hyperbilirubinaemia in a neonate

Transcript

SPEAKERS

Dr Elissa Hatherly, Dr Gopakumar Hariharan

 

Dr Elissa Hatherly  00:02

Welcome to the roundup a North Queensland based medical podcast offering local content for local clinicians. I'm your host Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the land on which we practice. Hi, and welcome to our podcast today with Dr. Gopan Hariharan. He's one of the neonatologist's at Mackay Base Hospital. We wanted to talk about neonatal jaundice today one of the most common conditions that requires medical attention in newborn babies, super common in general practice and we need to be confident managing these babies. Gopans also a senior lecturer with me at James Cook University here in Mackay. Welcome Gopan.

 

Dr Gopakumar Hariharan  01:09

Thank you for having me today.

 

Dr Elissa Hatherly  01:10

Oh, well, thanks for coming along. Let's start off with a really common case that GPs may encounter. I see these babies all the time. We had a little baby who was one week old, a little girl presenting for her routine seven day baby check. Her birth was pretty uneventful at term and uncomplicated vaginal delivery and the antenatal period was pretty unremarkable. Everything during the pregnancy had been fine. She had a normal morphology scan and maternal serology was all negative, there was nothing concerning there and her clinical examination from the paeds department prior to discharge was also normal. From memory, she was about 3.6 kilos when she was born, so that makes her a nice big baby. But on examination at day seven, she was quite jaundiced. She was otherwise fine, but the jaundice was quite remarkable. So I wanted to ask you today Gopan, just how common is jaundice?

 

Dr Gopakumar Hariharan  02:09

So approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life. So it's very common for babies to have jaundice. The question is, whether that requires treatment or not. Around 3% to 9% of total neonatal population, may need phototherapy as a treatment. There are a couple of reasons why babies are predisposed to jaundice. Firstly, the neonates have a larger red cell mass and a shorter lifespan. And we know that the bilirubin is a breakdown product of haem, and with a larger red cell mass, and a shorter red cell lifespan, a greater release of bilirubin occurs into the circulation. Therefore, predisposing to hyperbilirubinemia. Neonates also tend to have an immature liver function, and that can lead to slower metabolism of bilirubin. Another factor is delayed passage of meconium. Thereby there is increased reabsorption of bilirubin from the intestines. So these are the reasons why jaundice is relatively common in babies.

 

Dr Elissa Hatherly  03:30

Right that meconium isn't a factor I often think about So are there any groups of babies who are at higher risk of jaundice?

 

Dr Gopakumar Hariharan  03:38

Apart from the babies being predisposed to jaundice by their nature itself, there are some maternal and neonatal risk factors that predispose some babies for exaggerated jaundice. The maternal risk factors would include blood group incompatibility related to ABO or rhesus blood types. There are occasions when we come across minor red cell antibodies in a mother and that can also result in exaggerated jaundice but they would be predominantly pathologic jaundice which appear generally within first 24 hours of life. Babies born to families from particular ethnicity, for example, East Asian or Mediterranean tend to have a greater degree of jaundice. In a family if there is a previous jaundiced baby who required phototherapy, then the subsequent siblings are at higher risk. And it's very important to note this when taking a history, maternal gestational diabetes is a very important risk factor and that is attributed to the polycythemia that these babies have. A larger degree of red cell mass can result in a greater release of bilirubin into the circulation, thereby predisposing to hyperbilirubinemia. From a neonatal perspective, feeding is probably the most common condition that we see. Breast feeding itself puts babies at risk of increased jaundice and we refer to them as breast milk jaundice. Reduced intake can predispose babies to jaundice because of dehydration and increased enterohepatic circulation. If the baby have hematoma or bruising, probably from birth trauma, these sites can release bilirubin resulting in exaggerated jaundice. As you already mentioned, the polycythemia in an infant of diabetic mother is a significant risk factor. Then there are factors causing haemolysis example this expediate efficiency. Again that can lead on to the pathologic jaundice. They could present in first 24 hours of life, or they could present with prolonged jaundice. Bowel obstruction, infection, and prematurity are all other risk factors for jaundice. So it's an exhaustive list of causes and predisposing factors. It is important to recognize that late preterm babies are at particularly elevated risk of jaundice, and we have several admissions to the paediatric ward. The late preterm babies are found to have difficulties with feeding and related dehydration can cause them to have severe jaundice and getting re admitted. So it is important that we shouldn't be reassured that these babies are born closer to term. They are at risk. And it's important to remember that these babies are at risk of high jaundice levels.

 

Dr Elissa Hatherly  04:03

Right. And of course, those late preterm babies that would be at around 36, 37 weeks gestation when they're born. Is that right Gopan?

 

Dr Gopakumar Hariharan  07:17

Yeah, absolutely. So 35 to 37 weeks those will be the late preterm babies,

 

Dr Elissa Hatherly  07:24

okay. So, when would jaundice be considered pathological then from your point of view?

 

Dr Gopakumar Hariharan  07:30

the jaundice is considered pathological if it's onset is less than 24 hours. And as I already mentioned, conditions which can cause hemolysis, such as ABO or rhesus incompatibility can result in pathologic jaundice. Pathologic jaundice can also occur if it persists more than two weeks of life when we refer to them as prolonged jaundice. The other factors which raises possibility of pathologic jaundice include, if the baby is unwell raising the suspicion of sepsis or has an elevated conjugated bilirubin component or has pale colored stools. These require prompt investigation and management.

 

Dr Elissa Hatherly  08:15

Right. So what would those key components of the assessment of that jaundiced neonate be then Gopan?

 

Dr Gopakumar Hariharan  08:22

When we encounter a baby who appears jaundiced the relevant factors that needs to be taken into consideration are the age of onset, if the jaundice has manifested less than 24 hours, or if the jaundice has persisted more than two weeks, then they are considered pathological and needs further evaluation. Antenatal course is important, the presence of maternal antibodies, or intra uterine infections can predispose to babies having jaundice, presence of birth trauma from instrumental delivery, these babies could have cephalohematoma, or significant bruising and these could be sites where bilirubin is released into the circulation. Feeding is very important to look for. Breastfed babies have an increased risk of jaundice and referred to as breast milk jaundice. And if the feeding is inadequate, then it can lead on to dehydration and increased enterohepatic circulation leading on to significant jaundice. It's important to ask parents whether the baby has been passing dark urine that stains nappies or history of pale colored stools and that could suggest significant pathologies like biliary obstruction, which needs urgent attention. Presence of a setting for ABO rhesus or any other hemolytic condition also needs prompt attention. If the baby is unwell or febrile child then that could suggest a septic child, septic baby and needs further evaluation along those lines and urgent treatment.

 

Dr Elissa Hatherly  10:17

Yeah, okay. So we've assessed the baby now and so, as part of the examination, what particular things will we be looking at in the jaundiced neonate then Gopan?

 

Dr Gopakumar Hariharan  10:29

The key components important in evaluating a baby with jaundice would include a general examination, a general examination, looking at general tone and neurological examination. The idea is to detect whether the jaundice is highly elevated resulting in complications like kernicterus. So, that will be very important and if the baby has a shrill cry or abnormal tone, then that needs immediate attention and treatment. Hydration status will be very important, looking at capillary refill time, and also looking at mucous membranes. And that will give us an idea whether the breast milk is sufficient in the first place. Plethora from polycytemia would be an indicator that the baby has allowed the red cell mass, releasing greater bilirubin into the circulation. Looking for bruising and cephalohematoma would be important and hepatosplenomegaly in the abdominal examination would allow us to think differential diagnosis pertaining to primary liver conditions.

 

Dr Elissa Hatherly  11:43

Sure, so what's been the initial approach when we're investigating the baby with jaundice?

 

Dr Gopakumar Hariharan  11:50

Any baby who visibly looks jaundiced needs a serum bilirubin done. And what we're looking for is both the unconjugated fraction and the conjugated fraction of bilirubin. If there is high bilirubin, or once we once we get the serum bilirubin done, it's important to plot it on the gestation based specific nomogram that's freely available from the Queensland or statewide guidelines. And this is to determine whether a baby crosses the threshold for treatment with phototherapy or exchange transfusion. If the condition warrants, then further testing, like full blown examination and Coombs test, would be necessary if there is a suspicion of hemolysis.

 

Dr Elissa Hatherly  12:46

Right so, of course, it's really the GP then who's most likely to come across these babies between 24 hours of life and 14 days of life when they're most likely to get jaundice, what would be the most common causes, and then the relevant investigations needed for this group of normal jaundice in the neonates?

 

Dr Gopakumar Hariharan  13:08

Jaundice that occurs between 24 hours and 14 days of life is probably the most common presentation to the general practitioners, as you rightly say, because if it was pathologic jaundice, generally it gets managed within the hospital itself within the first 24 hours. The common differential diagnosis considered will include physiologic jaundice, which is the most common, breastfeeding jaundice, sepsis, hemolysis, breast milk jaundice or bruising from birth trauma. So the investigations will be targeted to rule out these possibilities. For example, if dehydration is a possibility from breastfeeding jaundice, then a serum sodium would be very important, because it will be quite elevated in case of dehydration. A blood sugar would be useful in order to detect hypoglycemia if the feeding has been grossly inadequate. CRP blood culture, urine culture, lumbar puncture as per sepsis protocol may be necessary for a baby who looks unwell and the suspicion is sepsis. In case of probable hemolysis then a full blood examination blood film, reticulocytes, neonatal blood group and typing, direct Coombs test would be important. A G6PD screen may be undertaken in certain high risk group for example, those coming from Asian ethnicity and further workup for hemolysis may be necessary depending on the clinical situation. If we are confident that it is physiological jaundice, then no further testing is necessary. No testing is necessary if we are confident that it is breast milk jaundice, or jaundice secondary to bruising.

 

Dr Elissa Hatherly  15:07

Good. Okay, so then for those babies in whom we think it is simply that physiological jaundice that you mentioned, what's the treatment then?

 

Dr Gopakumar Hariharan  15:18

The initial step in the treatment of hyperbilirubinemia is to establish that we are dealing with an unconjugated hyperbilirubinemia or are we dealing with a conjugated hyperbilirubinemia. In order to determine this, it's important to look at the conjugated fraction of the bilirubin and that should be less than 20 micromoles per liter, and the conjugated fraction is less than 20% of the total bilirubin. As I already mentioned, once we get the serum bilirubin, it is plotted into the bilirubin chart available from the statewide jaundice guidelines and if the baby's bilirubin level is above a threshold for phototherapy, then baby may require admission for that. It's also important to treat underlying condition if we can find anything. For example, if the baby is breastfeeding, and has lost weight, dehydration is a possibility and that might be contributing to exaggerated jaundice. In these situations, we generally involve maternal and child health lactation consultant, and sometimes speech pathologist to help mother with breastfeeding. Speech pathologist is particularly useful in late preterm babies where sucking and swallowing may not be entirely mature. And it's useful for speech pathologists to get involved in these cases. So also, if there is a consideration of significant tongue tie affecting breastfeeding, in these situations we also sometimes suggest formula feeds while the mother is having breastfeeding supported. That's that's not uncommon that sometimes we do recommend formula feeding if the mother is struggling with breastfeeding. If sepsis is a possibility, then we follow the statewide sepsis guidelines, investigate accordingly and treat with antibiotics. If hemolysis is a possible, possible underlying cause, then we get full blood examination G6PD, Coombs test, reticulocyte count, osmotic fragility, if hereditary spherocytosis is a possible possibility. And in some cases, we do seek hematology opinion in managing these babies. We also review maternal blood group for ABO and rhesus incompatibility. Probably that's the most common thing that we look in the first instance as I already mentioned, breast milk itself can cause significant jaundice, and that is due to factors which are transferred across breast milk, and which can inhibit the metabolism of bilirubin by the liver. It can also lead on to break down of conjugated bilirubin in the intestine and handle releasing excess and conjugated bilirubin into the circulation. These babies are generally well looking with adequate weight gain. If we find that the conjugated fraction is high, alongside having pale stools and dark urine that stains nappies then biliary atresia should be considered and urgent gastroenterology opinion should be sought.

 

Dr Elissa Hatherly  18:55

Right? Gopan can I just ask you to go back to the breastfeeding jaundice? If you could just clarify for me please the difference between the breastfeeding jaundice and the breast milk jaundice. What's the difference?

 

Dr Gopakumar Hariharan  19:11

So breastfeeding jaundice generally occurs in the first week of life when breastfeeding is just being established. Inadequate feeding can result in dehydration and increased reabsorption of bilirubin from the intestines resulting in hyperbilirubinemia. Inadequate intake sometimes also result in delay in passage of meconium which contains large quantities of bilirubin that is then reabsorbed into the infants circulation. Treatment is through supporting breastfeeding by involving lactation consultants, and child health nurse as needed. And at times, as I already mentioned, sometimes we do suggest formula feeding if the parents wish while breastfeeding is being established. This is a temporary measure. We are advocates for breastfeeding, but this is just to tide over that that phase when breastfeeding is being established. Some babies could have tongue tie which needs assessment by speech pathologist and lactation consultant and we facilitate that in the hospital. In addition to our clinical review, breast milk jaundice on the other hand, generally occurs in the second or later weeks of life and continues for several weeks. It's postulated that factors such as beta glucuronidase in breast milk, increases the breakdown of conjugated bilirubin in the intestines to unconjugated bilirubin. There are other factors such as lack of protein lipase and non esterified fatty acids in breast milk, which inhibit normal bilirubin metabolism. And these can predispose to breast milk jaundice. The only way to establish the diagnosis is by temporary cessation of breastfeeding for 12 to 48 hours. And if we can establish that there is a dramatic decrease in serum bilirubin with stopping breastfeeding, then the breast milk jaundice can be diagnosed. It is also important to remember that we have to investigate thoroughly and make sure that we are not missing any substantial diagnosis before coming to the diagnosis of breast milk jaundice. And these babies continue to be a bit jaundiced to around six weeks and and that is acceptable.

 

Dr Elissa Hatherly  21:49

Okay, so there's a lot of information here Gopan, I might just try and summarize that if I can. Our approach to jaundice between 24 hours of life and two weeks of life starts with that detailed history and clinical examination, particularly checking for the dark urine and pale stools of biliary obstruction. And the other things that we're looking at would be checking the total serum bilirubin and looking at the fraction of the conjugated bilirubin, which should be less than 20%. We need to check the maternal blood group for ABO and rhesus type, and any other minor blood group abnormalities that might pop up plus the full blood count, the direct Coombs test, the reticulocytes and the blood film in suspected hemolysis. And then the other things will depend on that clinical picture like the urea and electrolytes and liver function test, other things that might contribute to a high rate of hemolysis like G6PD deficiency and hereditary spherocytosis, there was a sepsis workup as well, looking for congenital infections. So that would be the torch screen, of course, and screening for inborn errors of metabolism, and things like that we will probably leave to the pediatricians as well as the thyroid function test, and other inborn errors of metabolism, like urine reducing substances and things like that. There's a lot to be thinking about Gopan. Are there any groups of babies who we should be particularly monitoring and really keeping under close surveillance when they're first discharged?

 

Dr Gopakumar Hariharan  23:39

There are a subset of babies that we do close surveillance, especially those babies who had pathologic jaundice, for example, from ABO incompatibility or rhesus incompatibility. They are at risk of continuing to have hemolysis and continue to be jaundiced. So they require very close surveillance. The other group would be those who had cephalohematoma. They are at risk of jaundice, and so are some babies who have bruising from the birthing process itself. So in a nutshell, babies who have predisposing factors for exaggerated jaundice, we do a very close surveillance and it's important to have a very close follow up.

 

Dr Elissa Hatherly  24:29

Okay, so the follow up required for babies who have received phototherapy. What should we be looking out for in those babies?

 

Dr Gopakumar Hariharan  24:38

So babies coming off phototherapy should have a repeat bilirubin after 18 to 24 hours to ensure that there is no rebound hyperbilirubinemia. A safe limit for stopping phototherapy is when the serum bilirubin has fallen less than 50 micromoles per liter from the threshold line for further therapy. In order to happen in order for this to happen, the baby necessarily doesn't have to stay in the hospital. Once the babies are discharged from the hospital, we have child health nurses who visit the family and make clinical assessments and decide on further testing. Those from private facilities may have their own processes. And in many of these cases, we find that the general practitioner will be very closely involved in following up these babies. At the time of discharge, we give a detailed verbal and written information on neonatal jaundice so that they are aware of what to look for. The statewide neonatal jaundice guideline is a great resource to refer while managing these cases.

 

Dr Elissa Hatherly  25:50

Yes, of course. So, what's the risk Gopan if babies are not identified promptly, who in fact need treatment?

 

Dr Gopakumar Hariharan  25:59

babies with the exceedingly high unconjugated bilirubin heart rate or increased risk of kernicterus and the kernicterus is a condition where excess unconjugated fraction of bilirubin crosses the blood brain barrier and get deposited in various areas of the brain, especially the basal ganglia. In significant cases, this could result in dystonic cerebral palsy and other morbidities could be hearing deficits and neurodevelopmental delays. And that is the risk posed by significant jaundice and if there is delay in treatment, and that risk is caused by any of the pathologic causes that can result in jaundice, for example, ABO incompatibility. A rapid rise in bilirubin example, more than 8.5 micromoles per liter per hour also puts a baby at particular risk. So it's it's not only the absolute bilirubin value, it's also the rate of rise, which is important to look at in case of evaluating a baby with jaundice.

 

Dr Elissa Hatherly  27:12

Okay, so now Gopan, let's go back to the baby that I was talking about at the beginning of this chat. You know, this baby too. When we looked at this baby born at term who was jaundiced at one week of age, when I examined her she was clinically well, but we sent her off to have her serum bilirubin check. And when you looked at it, and I suppose you would have plotted it on the age specific bilirubin chart, you found that the level was high enough for the baby to warrant phototherapy. What happened next?

 

Dr Gopakumar Hariharan  27:48

this baby got admitted to the pediatric ward because as you just mentioned, the the levels were quite high, above the threshold for phototherapy. We also noted that baby has had lost more than 10% of birth weight. And at that point in time, we did a serum sodium which was 148, which was elevated and that suggested dehydration. So in addition to the phototherapy, we involved the lactation consultant in the hospital to help the mother with breastfeeding. And the parents were open to trial some formula feeds at that point in time while the mother was establishing breastfeeding. We talked about other possibilities as well. At that point in time, there was no setting for hemolysis as mother's blood group was A positive and baby didn't have any particular features of sepsis. Baby was active otherwise, therefore no further blood tests were needed. With adequate feeding established, the bilirubin steadily dropped to safe limits, and we discharged the baby from the hospital after 72 hours. We ensured that the baby and the family was linked with a child health service in the community and a repeat bilirubin, which was done in 24 hours after discharge was in safe limit and baby had demonstrated good weight gain.

 

Dr Elissa Hatherly  29:21

That's a really reassuring end to the story, isn't it Gopan. So yeah, what would be your key take home messages from this story on neonatal jaundice?

 

Dr Gopakumar Hariharan  29:33

So the key points would be to ensure taking a thorough history, performing a physical examination to rule out any significant underlying pathologies and relevant investigations as necessary to treat a jaundiced neonate. It's important to pay particular attention to late preterm babies because of the risks that I already mentioned. It's also important to consider a wide range of differential diagnosis in babies presenting with jaundice even though physiologic jaundice is the most common cause. Pediatric referral is indicated for cases of early jaundice, that's jaundice appearing within 24 hours of life, conjugated hyperbilirubinemia, babies with pale colored stools, prolonged jaundice, or any other additional concerns.

 

Dr Elissa Hatherly  30:30

Oh look thank you so much for your time Gopan, we really appreciate you sitting down to talk through neonatal jaundice. I think next time we'll have to talk about prolonged hyperbilirubinemia where it's a little bit different, but thank you so much for your time. Thank you. For more information about the round up or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

Episode 4: Asthma in the post-COVID world

Take a look at how asthma is being managed in the post-COVID world. Hear from Dr Pranav Kumar, who talks to Dr Elissa Hatherly about new treatments for asthma patients and provides his tips and tricks on how to manage asthma in this new era.

Dr Pranav Kumar is a Consultant Respiratory Physician at Mackay Private Hospital and an expert with a broad array of experience in lung conditions. He has published research in major peer-reviewed journals and is a highly skilled clinician and proceduralist.

Available: Monday 3 October

Sources

Since the COVID-19 pandemic there were concerns that asthma patients could be at increased risk for SARS-CoV-2 infection and disease severity, it appears that asthma is not an independent risk factor for both. Asthma is not over-represented in hospitalised patients with severe pneumonia due to SARS-CoV-2 infection and there has been no increased risk of asthma exacerbations triggered by SARS-CoV-2 in that setting.  

There is accumulating evidence that asthma phenotypes are important factors in evaluating the risk for SARS-CoV-2 infection and disease severity, as findings suggest that Th2-high inflammation may reduce the risk of SARS-Cov-2 infection and disease severity in contrast to increased risk in patients with Th2-low asthma.

Regarding asthma medications, the use of ICS, despite early concern about immunosuppression, is safe. Furthermore, ICS do not increase infectivity or disease severity. In contrast, chronic or recurrent use of SCS before SARS-CoV-2 infection is a major risk factor for poor outcomes and worst survival. Biological therapy for severe allergic and eosinophilic asthma does not increase the risk of being infected with SARS-CoV-2 or having worse COVID-19 severity. These data emphasise the need for optimised management of asthma patients in order to achieve asthma control and avoid whenever possible the need for chronic or recurrent use of SCS. However, further studies are needed to answer still unresolved questions such as the relation between different asthma phenotypes and SARS-CoV-2 infection.

Busse WW, Lemanske Jr RF, Gern JE. Role of viral respiratory infections in asthma and asthma exacerbations. Lancet 2010; 376: 826–834

Branco ACCC, Sato MN, Alberca RW. The possible dual role of the ACE2 receptor in asthma and coronavirus (SARS-CoV2) infection. Front Cell Infect Microbiol 2020; 10: 550571

Zhu Z, Hasegawa K, Ma B, et al. Association of asthma and its genetic predisposition with the risk of severe COVID-19. J Allergy Clin Immunol 2020; 146: 327–329.e4

Yamaya M, Nishimura H, Deng X. Inhibitory effects of glycopyrronium, formoterol, and budesonide on coronavirus HCoV-229E replication and cytokine production by primary cultures of human nasal and tracheal epithelial cells. Respir Investig 2020; 58: 155–168

Yu LM, Bafadhel M, Dorward J, et al. Inhaled budesonide for COVID-19 in people at high risk of complications in the community in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial. Lancet 2021; 398: 843–855

RECOVERY Collaborative Group, Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with COVID-19. N Engl J Med. 2021; 384: 693–704

Transcript

SPEAKERS

Dr Elissa Hatherly, Dr Pranav Kumar

 

Dr Elissa Hatherly  00:02

Welcome to the roundup, a North Queensland based medical podcast offering local content for local clinicians. I'm your host, Elissa Hatherly. I'm a local GP and family planning clinician and head of James Cook University's Clinical School here in Mackay on Yuwi country. This collaborative podcasting project between Mackay Hospital and Health Service, local clinicians and JCU will bring you a different topic and guest in each episode. Before we begin, I'd like to respectfully acknowledge the Australian Aboriginal and Torres Strait Islander people of this nation, their contribution to health care and the traditional owners of the land on which we practice. Welcome to today's episode where I'm joined by Dr. Pranav Kumar, one of our respiratory physicians at the base hospital. Pranav has qualifications in respiratory medicine from not only Australia, but India, America and the UK. Thank you so much for joining us today.

 

Dr Pranav Kumar  01:00

Thanks, Dr. Hatherly. It's really nice. I'm really excited to sort of come to join this podcast.

 

Dr Elissa Hatherly  01:07

We wanted to talk a bit about asthma today and I suppose it's a particularly important topic in light of COVID. How big a problem has asthma been in the COVID era?.

 

Dr Pranav Kumar  01:19

 So, basically, we see that as is never been sort of a lesser problem. Prior to the COVID era, if you see, really, if we estimate the percentage of cases throughout Australia, so nearly 10% of the population which sort of diagnosed or sort of latent or cough variant the asthma is present, it is one of the top 10 diagnoses presenting to our emergency department. And overall, if we compare the whole degree of severe asthma in the post COVID era, it normally consumed about three to 5% of the total cases of asthma. So if you look at the whole, this whole data is Lex there got quite a mammoth problem at this moment. And what actually, we see is with the COVID-19, although there was a misconception that normally, as after COVID, we get more cases of asthma or exacerbation. It is partly true and partly untrue, which I'm going to explain you in a later discussion of the time. What I really want to put in here is it has intensified the stigma we had around the asthma cough. And we see that there was a very interesting survey which said that nearly 43% of Australians who  saw someone coughing and they, they, they thought it to be contagious, though they are, you know, just a mild cough, small cough-variant asthma. So overall, if you look at the whole data, I think the problem has gone and there has been more unmasking of the silent or cough-variant asthma to sort of become very persistent and see their form of asthma post COVID era.

 

Dr Elissa Hatherly  03:31

Right. So COVID is helping to unmask those patients who have silent asthma. Getting that reactive airways as a response to that inflammatory process. And yeah, that stigma around cough is really prevalent in our community. We've certainly noticed that in general practice, but three to 5% of the community is a big number. With asthma, then what increases the risk with COVID-19 in our patients, what are the sorts of things we need to be mindful of?

 

Dr Pranav Kumar  04:06

Well, you know, that doctor Hatherly we had this notion that was you know, the major drivers for all our, you know, asthma exacerbations, are the respiratory viruses and that holds true for time immemorial like every asthma exacerbation, if you look at the most of the data as we see nearly 80% or more of the cases from the all the respiratory viruses. And since after the COVID it was thought that look, this is one of the Coronavirus is going to be no different and then we're going to more and more number of increased severity or increased number of cases or exacerbations through the years. What normally we have seen that you know how the COVID they viruses they basically uses more angiotensin converting enzyme 2 expression. And that has also been contributed that, that they will be more severity of infection, there will be more infectivity, as is one of the viruses. But all the epidemiological data or studies, which we have so far has said that the incidence of these cases are pretty low, that there is no asthma doesn't sort of, you know, in these people cases hasn't gone up. And it has shown that the incidence of COVID 19, in people with asthma was pretty low. And the current evidence also supports that the notion that asthma does not increase the risk of COVID 19 was also true. But it all saying this, you know, the other aspect of it was severe COVID, which, which normally, we seen the people who had asthma, and has got an old age, or they had different comorbidities in form of cardiovascular disease, or diabetes, or obesity, they are the ones who are the most sufferers. And I also think that the there are two, or the two data, which I like to sort of mention here is one from the Belgian asthma registry or Sani which has got, they did a severe asthma network in Italy. They, they they said that and they found out through their you know, course of the disease, that severe asthma is not an independent risk factor for COVID-19. So, if you look at the whole picture, I think, what we thought initially, that, you know, we are going to have more and more, because it's one of the respiratory viruses, and then we're going to get more ACE2 inhibitor expression and increased infection and increased severity, which wasn't the case, but only the people who had severe COVID and asthma were the people who belong to the old age group or the people who had comorbidities in the form of obesity, cardiovascular and diabetes, who were the worst sufferers.

 

Dr Elissa Hatherly  07:32

Yeah, certainly, we learnt a lot in that first twelve months about COVID and respiratory disease. So with some asthma, I wonder if you could take us through some of the different phenotypes and relate that to disease severity, then please.

 

Dr Pranav Kumar  07:48

Yeah, that's a very interesting question and Dr. Hatherly, I recently had the European respiratory Congress, where they had a long debate about these phenotypes and the treatment part and that was really interesting. And they know the what we know till date is we got type two or Th2. So, there are two types Th2 high or Th2 low these are the two phenotypes, which normally we use and the difference between them is Th2 high is mostly the 50% of the formal asthma diagnostic diagnosis patients will have it and type two, before I sort of go further, I just say that they have this interleukin manifestation like IL4, IL5, 13 eosinophils pheno epithelioid barrier dysfunction, all these can cause a protective effect on the size of COVID-19 infectivity and severity Yes. So, this was very interesting that despite of the you know, there is expression of these they have poor risk, protective effect. And mostly if you see there was also some studies which has shown if you've got more eosinophils, they are more protective for this COVID 19 infection and severity, in comparison with Th2 type or more they will call Th2 low they have more neutrophilic infiltration and they are more mostly pauci-granulocytic inflammation where this is mostly non allergic type and they had common association with people who had obesity related or smoking related or other comorbidities related in there. The you know, as we know there was more severity there was more infectivity and much more mortality. Compared to IL 4, 5 they have if you see the biomarker, there were IL6 which was predominant. And as is noted in one of the studies, these obese people will have increased leptins, and the increased leptin will cause more Th1 pathway, and they will cause more severity and more infectivity.

 

Dr Elissa Hatherly  10:24

Right. So the higher the eosinophils, the more protective toward COVID. That's fantastic. And of course, would include a lot of our patients that we have here in our region. In terms of asthma medications, then do we need to be tailoring those a little bit more to those different phenotypes to better address that risk of COVID-19 and the disease severity?

 

Dr Pranav Kumar  10:51

That's a really interesting question. And that's really sort of generating a lot of interest in I think there will be a lot of a lot of studies has still to be carried out. But when we talk about the predominant as we know that inhaled corticosteroid (ICS) is one of the which, which is mainly used for the prevention and our protection as a as a preventer in asthma medication. If we think ICS per se, it says that it confirms some of the protections against the COVID. So there was initial when we had COVID, when we started to have COVID. And there was concerns that using people on a high dose corticosteroid or inhaled corticosteroid will give them instead of more mortality and more chances of severity of infection didn't come through on this study, we say that they causes a decreased expression of ACE2 although you know the where these, these viruses are binding. So they will be less a less than of their, you know, binding and less severity of infection. They also had some sort of biochemically protein seronase in the lung, they were also reduced and they helped in overall modify the risk or confers a kind of protection against the COVID. As we also know, Dr. Hatherly that all these ICS causes decrease inflammation. That's the main main job and, and in some studies, if you see there's very interesting that some of the anti inhaled corticosteroid in form of ciclesonide or Mometasone, they, they sort of suppress this virus per se as well. So there's still study going on. So but that was very interesting finding that some of these inhaled corticosteroid also suppress the SAR school or COVID-19 infections. And as you know, in our at the moment, when we're treating we're treating a lot of people with, with the when we say some sort of severity of the COVID, we do use, inhale budesonide drugs, which is a very common to give them like at least, you know, 12- to 16-hundred micrograms of budesonide. And that was based on a trial, which was the principal trial, and we say that the more inhale Budesonide you use, and they will decrease the symptom burden, and also helps us in the time of recovery, and also reducing the total hospital admission. So that was a really, really, very good trial. And that has prompted us to help us to sort of designed this, putting this budesonide as a routine kind of management for this COVID, which is not that severe, to decrease their symptom burden, as well as recover and reducing in the hospital admissions.

 

Dr Elissa Hatherly  14:13

Right. So those ACE inhibitors have that anti inflammatory effect as do the inhaled corticosteroids, which we've known for many, many years. Now. That's, that's interesting.

 

Dr Pranav Kumar  14:24

Yeah. There's another one, which was really sort of, we always thought that if you use systemic steroid in this group of patients, like if you use, they will have more severity of the disease, isn't it that will cause more while to sort of replicate. And there was a recent recovery trial, which did say that, if you've used the dexamethasone of like nearly six milligram per day, for nearly 10 days in those group of patients, it was found that 28 day mortality was very less, and also the rate of the decrease like rate of intubation in those group of patients. So that was really interesting finding and sort of still sort of worked out for all the severity cases in the what we get in the ICU.

 

Dr Elissa Hatherly  15:20

Yes, certainly important information for you to have before the COVID patients started to appear in our part of the world. Dr. Kumar can we ask about the biologics then too, so we know the ACE inhibitors, the inhaled steroids and the oral steroids are really effective. What about some of those newer biologics that we've been prescribing in the last few years?

 

Dr Pranav Kumar  15:41

Yeah, and that's very, very, I mean I'm really particularly very interested in like, biologics. Since we have biologics, it is really sort of I have patients here who, on a lot of them, like at least I know, five of them, who are my patients and on non-biologics, they most of the time, they presented to the hospital, got intubated and went to the ICU. And since they've been on biologics, they've been doing pretty well and sort of out of the hospital for most of the time. So that really sort of made me very interested. And I post COVID I've seen that we did have sort of a lot number of cases which has come up with increased severity and there was a sort of they being labeled as a long COVID. But in fact, they were the COVID, they were the asthma with a sort of gone into a severe kind of asthma which was not responding to any treatment. And in a couple of them, I recently put them on biologics, and they they are recovered on their, on the pathway of them. And so, if you see the types of biologics, we have, like anti-IGE, IL5 and IL5  receptor antagonist, we are mainly using here anti IL5 and anti IL5 receptor. And they normally they do is they blocked the type two, inflammation and confers a degree of protection against COVID as well, only thing, which was sort of contradictory that in one stage, we know that eosinophils are protective. These drugs basically they got, they have concerns of decreasing the tissue and the blood eosinophils. So, we thought that we will get more disease severity or increased severity in these cases. And there was a study which all eyes I think have done this in our talk earlier, that eosinophils are kind of more than 150 they normally give you a decrease mortality. But you said this was a contradictory finding at one at one stage, we were saying that if you've got a more eosinophils they are protective to overall confirms that I have you know less risk from the COVID. At the same time that we are using biologics, we say that they are providing a protection, though they are decreasing your eosinophil counts to a very significant level or even to the normal and there has been clinically evidence with so that this use of biologics are pretty safe. It is it has found that during the course of the follow up that they are not associated with increased severity or mortality. So, so since when this study has come up, I think we have instead of as soon as the patients are diagnosed and they are being they're being put on the biologics without any much of you know, risk of that, you know, you're using biologics in this group of patients. We don't we previously thought it to be very, very cautious and nowadays these study coming up, even though they have found out that they treat the severity cases and more morbidity and mortality are less though, it is quite safe to use the biologics

 

Dr Elissa Hatherly  19:17

Right. So particularly as you said, for some of those patients who might be experiencing what we thought was a long COVID symptom like persistent breathlessness. You think sometimes it can be undertreated breathlessness and the patient's need to be more fully worked up and more comprehensively treated then.

 

Dr Pranav Kumar  19:39

Yeah, and that's that's very important point as you said, in the post COVID They will have more like an array of symptoms in the form of shortness of breath, to chest pain to palpitation, and all so many kinds of symptoms. And most of the time if the people had COVID, and it persisted for nearly four weeks or more, we just term it as a long COVID. But if we sort of sticks seriously, because you know, if you see this group of patients, in some of them, if you do a lung function, if they got a very serious sort of airflow limitation in people who got a persistent sort of shadowing versus a perioheral area of consolidation, like organizing kind of pneumonia on the CT scan, they need to be treated, rather than labelling. So it's basically if the symptoms persist, there is nothing harm in doing some tests to confirm that we are not dealing with something which has been unmasked by the COVID, or is still the COVID long effect, because in there was recently a case with us, who has been labeled as a long COVID has a lung fibrosis that that chap, I think he left, he was in Indonesia. And then he when he came in and half of the lung was fibrosed, so he's finally getting lung transplant done. But it was initially labeled as a long as long COVID. So that does a few of the things which really sort of makes you wonder that you know, that of course, the long COVID will present with lots of issues and lots of somatic problems and health problems. But doing some investigation, before we label them will be a perfect way to deal with deal with this situation.

 

Dr Elissa Hatherly  21:41

Right. Okay, so for patients with persistent symptoms after COVID or worsening symptoms, it might be long COVID. But we need to be carefully ruling out other comorbidities like lung fibrosis, as you said, Is there anything else we should be looking for? Do you think?

 

Dr Pranav Kumar  21:59

I think it's, you know, if the patient has got, like, you know, the long COVID will have a array of symptoms. For the lung point of view, I would say that doing the chest X ray and doing a CT scan or lung function test, wont harm us, but actually help us to rule out the other causes which can sort of mimic and as a long COVID.

 

Dr Elissa Hatherly  22:27

Right, look Dr. Kumar, thank you so much for your time and your expertise today talking about asthma and the post COVID world I had no idea it was so incredibly prevalent, as you said, usually in the top 10 of our Emergency Department presentations and with severe asthma. Of course, in primary practice we can we can cope with that a little bit more enthusiastically, I suppose by making sure those patients are having their inhaled corticosteroids at maximum dose. And as you said, just ruling out other conditions with a chest X ray, a lung function test and maybe even a CT chest. Dr. Kumar, thank you so much for your time. We really appreciate it.

 

Dr Pranav Kumar  23:11

Thank you so much. I really do indeed a pleasure for me. Thank you so much.

 

Dr Elissa Hatherly  23:18

For more information about the Roundup, or to share your feedback and ideas for future episodes, visit nqrth.edu.au/roundup-podcast, or contact us at nqrth.mackay@jcu.edu.au. We also want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training hubs, or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. Northern Queensland Regional Training hubs is an initiative of the Australian Government's integrated rural training pipeline and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander health council, health services, Aboriginal community controlled health organizations, and general practice clinics.

For more information about The Roundup, or to share your feedback and ideas for future episodes, contact us at nqrth.mackay@jcu.edu.au 

We want to advise that the views and opinions presented in this podcast are those of the speaker only and do not represent the views and opinions of James Cook University, Northern Queensland Regional Training Hubs or Queensland Health. The content supplied in this podcast is not intended as medical advice and is for educational and entertainment purposes only. 

Northern Queensland Regional Training Hubs is an initiative of the Australian Government's Integrated Rural Training Pipeline (IRTP) and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council (QAIHC), health services, Aboriginal Community Controlled Health Organisations (ACCHOs) and GP clinics. 

NQRTH is an initiative of the Australian Government's Integrated Rural Training Pipeline (IRTP) and is facilitated by James Cook University in partnership with public and private hospitals, Queensland Aboriginal and Islander Health Council (QAIHC), health services, Aboriginal Community Controlled Health Organisations (ACCHOs) and GP clinics.

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