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Information on this page is general in nature and not intended to replace the advice of your professional medical staff
by Peter LavellePublished 15/06/2006
Are you planning an overseas trip? You're not alone. About 4.4 million other Australians go overseas for business or holidays every year. And many of them are on some medications for a chronic ailment. But if they're not careful they could be flying into some unforeseen trouble, says Nicholas Zwar. He's Professor of General Practice, School of Public Health and Community Medicine, University of New South Wales, and in the latest issue of Australian Prescriber, he has some tips for people about to travel.
While people spend a lot of time booking their itineray and packing their wardrobe, they tend not to give much thought to their health overseas - particularly, what they'll do about their medications. Often they assume they'll be able to replenish their supply while away. The problem is, those particlar drugs may not be available. Or they may be available but you wouldn't know - in a foreign country, brand names and preparations are often different, he says.
Or what's available may be counterfeit. In parts of Asia, Africa and South America for instance, anywhere between 10 and 50 per cent of prescription drugs may be counterfeit. These counterfeit operations are extremely sophisticated and the packaging is often impossible to tell from the real thing. Even medications bought from a pharmacist may be fake, he says. Take it and it may not work or it could be toxic.
It's a better idea to take enough with you for the trip, he says. It's simply a matter of working out with your GP how much you'll need and gettting the GP to write enough repeats to cover it. (Check the expiry date of your current supply and throw out those that are about to expire). The GP simply indicates on the prescription that the pharmacist is allowed to dispense the whole lot at once.
To read the complete article go to http://www.abc.net.au/health/thepulse/s1662847.htm
The human body has an immune system which serves to attack and destroy invaders. The system is particularly tuned to recognise foreign chemicals found on worms and micro-organisms. These chemicals, known as antigens, are presented to the immune system locked to chemicals of the individual which are unique to the individual. These chemicals are known as the major histocompatibility complex (MHC). These antigens are present on the membrane of many cells including the leukocytes (antigens known as Human Leukocyte antigens HLA). These antigens are many including A, B and DR. which is paired (total six). HLA antigens can be detected in individuals by setting up their leukocytes against a panel of antibodies. This will allow so called tissue typing to be carried out where A B and DR antigens can be attributed specific numbers. It is possible for a brother and sister or other siblings to have matching A B and DR loci being a perfect match but, parents to child at best, can only have three out of the total of six matches (one haplotype). Unrelated people may share some antigens and it is possible where a cadaver is a donor, for the organ to be well matched with the recipient by transporting the organ around Australia. This is particularly for the kidney as the kidney appears to be more likely to undergo rejection if there is a mismatch.
It is routine for blood groups to be matched for donor to recipient. In addition, the donor and recipient should undergo what is known as a cross match, where donor white cells are set up in an environment against recipient antibodies. If the recipient antibodies kill the donor white cells, this is known as a positive cross match.
In summary, a donor should have the same blood group as the recipient, there should be a negative cross match and the donor and the recipient should share some HLA antigens. My belief is the DR is the most powerful of the antigens in provoking significant damage even in the presence of our remarkable immunosuppression.
Courage has no limits.
This report is an extract of a paper presented at the Royal Australasian College of Surgeons Annual Scientific Conference held in Brisbane in May 2003.
A 40 year old mother observed that "just months after receiving a liver transplant I was strong enough to start swimming. After completing a swim of 50 metres I experienced a overwhelming sense of exhilaration and achievement". This swimmer joined Transplant Australia after transplantation and began her first experiences of competitive sport in her life. She has been selected to represent Australia and will compete in Nancy, France in July 2003. Our swimmer's success is a manifestation of her extraordinary courage, however, both she and the community recognise that her success is also based on her family support, her donor and donor's family, the volunteers and supporters of Transplant Australia and donations from State and Federal Governments. When our athletes compete, they contribute to their own well being, their family's confidence, the medical profession's insight, the public's knowledge of transplantation and the satisfaction of donor families. Also, these sporting activities provide opportunities to understand the benefits of transplantation and opportunities to promote a comprehensive lifestyle.
WORLD TRANSPLANT GAMES
Athletes have participated in track and field, swimming, squash, tennis, badminton, golf, cycling, road run, lawn bowls, ten pin bowling, table tennis, volleyball, kayaking, fencing, chess and rifle shooting. The World Transplant Games provides some special aspects for recipients. Age groups include Juniors, 18-29 Adults, 30-39 Seniors, 40-49 Super Seniors, 50-59 Veterans, 60 and over Super Veterans (but recipients with different organs compete against one another). However there are no concessions and the Games are not considered to be for the disabled as most of the athletes achieve a very high standard. There is donor family participation in medal ceremonies, administration, organisation and social activities. Educational seminars are provided and cultural and social programmes are integral components of the 10 day activities. Recently, the Winter Transplant Games have expanded the recipient participation particularly of the young (Nicholas Cup).
Australians have participated in all of the World Games this being the 14th. The Australian Team has finished in the top three places in the last eight Games. Australians hold a number of World Records mostly in swimming but also in athletics. World Record times are approximately 10% off Olympic times but we should recognise that an American athlete won a medal in the last Olympic Games eighteen months after a liver transplant.
Approximately 2000 athletes and supporters attended the Games in Kobe in 2001 and came from 50 countries. This was followed by an increase in organ donation rates in Japan. Australia won the Press Award, which is given for the country generating the most favourable publicity for organ donor awareness during the preceding two years.
Australia is sending a team to France, the members of which have been selected on strict criteria. Almost all athletes competed in the Australian Games which were held at the Gold Coast in 2002 and which were a great success. The Australian Games provided a great springboard preparation for the World Games.
Of course, the athletes will require a range of dedicated volunteers to be able to enjoy a high standard of facilities and competition. Support is provided by the athlete's families, organisers, sports administrators, starters, judges, timers, coaches, physiotherapists, doctors, nurses, ambulance officers, masseurs, police, security officers, fund raisers, accountants, lawyers, equipment suppliers, transport officers, babysitters, reporters, entertainers, photographers, council representatives, dressers, strappers, caterers, interpreters and DONORS.
We should anticipate that World Records will be broken in France. The Olympic Record (OR) for 100m track sprint is 9.87 sec and the Transplant Record (TR) is 11.08 sec. The male high jump in adult age group at the Olympics is 2.25 m and the TR 1.90m. The long jump OR is 8.55m and the TR is 7.00m. The 100m freestyle female adults OR 53 sec and transplant record 61 sec. The male backstroke 100m OR is 53 sec and TR 64 sec.
Studies of the transplant recipients reveal that heart transplant recipients are not disadvantaged in swimming and running events despite having no nerves supplying the heart. The athlete's high blood pressure diminishes with training and the fitter the athlete the fewer medications required. Recipients on cyclosporin have constriction of blood vessels under the skin. This prevents loss of heat in competition. This in turn leads to a delayed recovery after vigorous sport. The athletes prove to have very competitive spirits and highly developed senses of humour. The following quotes will exemplify their joy, like the flight attendant who asked "will my liver slip out if I compete in the high jump", or the African/Englishman who said "I am the fastest black man with a white heart on earth" or if my organ came from a 70 year donor, "can I participate in the super veterans age group" or the gold medal winner who said "this medal goes to my donor".
Training benefits the athlete by reducing weight, reducing blood pressure, improving diet discipline, reducing drug therapy and side effects, reducing drug costs, reducing depression, reducing bowel disturbance and eliminating diabetes.
Adverse events are rare. Sporting injuries are largely prevented by training and supervision. Cardiac events are prevented by screening. Dehydration is the most common preventable adverse event. Contagion (chicken pox) is a serious concern. Fortunately, this has not yet been a problem.
Feedback from the athletes include that doctors still do not give recipients encouragement to participate in sport. Athletes also recognise that being a recipient is not being a patient, is not being disabled.
Athletes recommend that potential recipients should be given very firm lifestyle directions (including sport) by healthcare givers and lifestyle changes require reliable incentives for recipients.
Sport provides strong incentives through providing goals (personal bests), support (coaches and team members) positive feedback, strict discipline, repetition, reinforcement and appreciation.
Participation in the Games provides an opportunity to meet donor families in a friendly environment, which encourages resolution of conflicts, which may arise from the circumstances surrounding the GIFT OF LIFE.
Observations by the clinicians of the athletes reveal common favourable characteristics of the athletes. The Australian athletes demonstrate predictable, stable, generous attitudes. They have an appreciation for their own health and that of others. They have a determination to continue to improve their health and contributions. They are capable of self-help and also show concern for others. They prove to be time efficient, being able to train and carry responsibilities. They show a strong community spirit.
CONCLUSION
Recipients can excel in sport for many years. Adverse events are rare. Sporting activities benefit the athlete and community. Donation rates will rise with favourable publicity (especially children). Heart recipients are not disadvantaged. Sport as a lifestyle discipline must be included in Transplant planning.
Further information available from Dr. Daryl Wall Medical Advisor Transplant Australia
e-Mail address is at janrosewall@iinet.net.au
Dr Daryl Wall
Medical Director, Transplant Australia
Recipients, their relatives and their doctors are determined to maintain optimal immunosuppression to prevent organ damage through rejection. The success of this strategy is evident in the current excellent success rate of transplantation and the very low mortality of transplant recipients. Recently there has been a very major shift in research interest to long-term quality of life, organ function and survival issues. Australia is very fortunate in having 40 years of data collection in the ANZ DATA Transplant Registry (Renal). A review of ANZ DATA shows the death rate per 100 patient years beyond 5 years post transplantation has declined from 4.5 to 3. During that time there was a 37% reduction in death due to cardiovascular disease and a 23% reduction in death due to malignancy. We should recognise however, that cardiovascular causes still account for 42% of recipients deaths, malignancy accounts for 24% and infection accounts for 19%. Recently statistical analysis gave evidence that some kidney function loss is due to calcineurin inhibitors such as cyclosporine and tacrolimus, which have a side effect, nephrotoxicity. This data supports the view that we must now look into improving recipient's lives by reducing or removing the effects of immunosuppressive agents such as cyclosporine and tacrolimus. In trying to improve recipient's quality of life we should not lose sight of the importance of life-style choices which remain as important as drug effects, - eg, good diet and plenty of exercise.
There are three approaches to reducing therapeutic agents used for immunosuppression once the recipient's well being has been established post-operatively. The first approach is to gradually, under supervision, reduce the dosages of the immunosuppressive agents (usually three in number), consisting of a cyclosporine or cyclosporine-like agent (eg, tacrolimus) an antimetabolite such as imuren or mycophenolatemofetil (abbreviated to MMF) and prednisolone. A second strategy is to carry out the transplantation using four immunosuppressive agents, the 4th agent may be a monoclonal antibody and then reduce the number of agents to three and then two, and then finally down to one immunosuppressive agent. The choice of the remaining agent for immunosuppression may depend on the individual's tolerance of the side effects and on the individual's risk of serious complications of the side effects. A third strategy in recipients who have had their organs for many, many years is to consider ceasing immunosuppression. This 3rd pathway is not recommended and will not be discussed any further; however, some recipients in Australia have had their immunosuppression stopped for specific serious reasons.
Almost all recipients will be enjoying the benefits of having a progressive reduction in the dose of their immunosuppression. This leads to reduced blood concentrations which in turn is associated with reduced short and long term side effects. The inherent risk of this pathway is that if the recipient overlooks a dose then the matter becomes much more critical as there is no reserve in the blood. Despite this risk, all recipients should confirm that their current regimen is minimal immunosuppression based on careful evaluation of the biological effects of the immunosuppression and the blood assays.
With respect to the second strategy of reducing immunosuppression agents, we must recognise that different recipients have different side effects from different agents. In some people, steroids may produce a moon-face, acne, fragile skin, psychological change, cataracts or weak bones. For people who are recognised as susceptible to the side effects of steroids, it is now possible to carry out what is described as a steroids-sparing immunosuppressive regimen. When required, it is possible to add to the minimum dose immunosuppression of cyclosporine or tacrolimus another therapeutic agent such as MMF and the steroids can be discontinued. The benefits of this include overcoming susceptibility to obesity, diabetes and the serious cardiac and vascular consequences of diabetes. Almost all recipients could maintain excellent immunosuppression with the combination of low dose cyclosporine or tacrolimus and MMF, thus allowing the recipient to enjoy a life free of steroids. We should recognise that the adverse effects of steroids will not accumulate in most people who are on a prednisolone dose of 4mgs a day, although there are some exceptions to this guideline.
A common and serious challenge to Australian recipients is the management of skin cancers. In future, the risk of developing skin cancer may not be altered at all by immunosuppression with the introduction of immunosuppressive regimens consisting of basiliximab in association with sirolimus. Not only will the recipients avoid skin problems, they will also avoid kidney damage. In a randomised controlled trial by Stewart Flechner of the Cleveland Clinic, USA, the results of the regimen above were inseparable from the results which were achieved with the best currently available therapy without the risk of skin or kidney damage. This new emphasis on avoiding long term adverse events will demand a change in the immunosuppressive regimens being used in the future. In the meantime recipients who have serious skin cancer concerns should ensure that the immunosuppression is minimised. Imuran or MMF should be avoided. Recipients with skin cancers should also be given the option to start neotigosan to facilitate skin repair.
Recipients and doctors are leaning to individualise the therapeutic regimen of immunosuppression. Strategies to eliminate the side effects of steroids, minimise the effects of calcineurin inhibitors, examine the disturbance of cholesterol and lipid metabolism and skin cancer development are all part of future care in transplantation. New immunosuppression regimens will hopefully end these concerns. Doctors are, however, ready to identify new and as yet unrecognised consequences of the otherwise favourable modern immunosuppressive agents.
It is essential that any changes to an immunosuppression regimen be done in consultation with your transplant physician - do not undertake changes yourself!
Transplant Australia is supporting the establishment of a Foundation to raise money for the late V8 Supercar driver Ashley Cooper's partner Casey and their young children Ella and Bailey.
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Click here to donate to the Transplant Australia Trust - Ashley Cooper Foundation.
Key members of the National Clinical Taskforce into Organ and Tissue Donation presented their final report to the new Labor Government on Thursday, February 14.
Transplant Australia has released the 2007 Annual Report.
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