Aspirin and Paracetamol – Surely these “age old” painkillers are harmless?

With the increasing sophistication of clinical trials, the medical world and the better educated general public with easy access to Dr Google is becoming more aware of the potential complications and long-term side effects of chronic pharmaceutical therapy.

Also, with increasing longevity, many people are suffering chronic illnesses and require multiple therapies for relief and treatment of their underlying conditions.

One of the commonest medical problems in modern society is that of chronic pain. It is estimated that around 3 1/2 million people living in Australia suffer some form of chronic pain e.g. arthritis, back pain and headaches.

For many years, the only “go to” painkillers were aspirin and paracetamol. When I started medicine in the 1970s, we were just becoming aware of the pervasive effects of analgesic abuse with the use of Bex and Vincents powders, which, at times, led to chronic kidney failure, if taken regularly.

High dose aspirin therapy and moderate dose paracetamol were the mainstays of therapies for acute pain and in some cases were even used for chronic conditions to alleviate discomfort.

The Therapeutic Goods Administration will be meeting in mid-November to discuss limiting the access to paracetamol. The reason for this is that over the past 12 months in New South Wales and Victoria alone there has been around 7000 cases of paracetamol overdose.

Paracetamol is touted as a gentle to the stomach pain killer but many people do not realize that in doses greater than 2 to 3 g per day, there is a real and definite risk for liver disease.

A small but significant number of people also take a large dose to induce self-harm or potentially even commit suicide. Many groups are pushing for paracetamol compounds to be restricted to avoid people stockpiling the drug and also to try to limit access to stronger doses. Interestingly, over the last 10 years the rates of paracetamol overdose have increased by 98%.

I have attached the proposed amendments to paracetamol access.

Proposed amendments to the Poisons Standard

Option 1: Requirement for paracetamol to be sold in blister packs.

Option 2: Restrictions on paracetamol pack sizes.

Option 3: Restrictions on purchase of paracetamol packs.

Option 4: Prevent display and self-selection of paracetamol from non-pharmacy outlets i.e. require paracetamol to be purchased from behind the counter.

Option 5: Age restrictions on purchasing paracetamol.

Option 6: All modified release paracetamol should be rescheduled from Schedule 3 to Schedule 4 (prescription only), without change to maximum pack size.

Reprinted form SMH article-Nov 6th 2022


Analysis of a study of low-dose aspirin [only 100 mg and not in doses that would alleviate pain] examined 6703 Australians over the age of 70 followed for somewhere between 4 to 6 years in a placebo-controlled trial and found that 1400 of these people required hospitalization for a fall. Those taking low-dose aspirin were 10% more likely to suffer a fall during the trial.

I would suggest the reason for this statistic is not that aspirin increases your risk for falling but it certainly increases your risk for bleeding when you fall and thus necessitating the need for hospitalization.

Regardless, it is important to realize that all forms of pharmaceutical therapy have a potential risk. Even consistent doses of more than four standard 500 mg paracetamol per day may increase the risk for liver damage. Taking a lethal overdose may even induce liver failure.

Aspirin therapy, even in the dose of 100 mg daily, may induce significant gastrointestinal bleeding. The anti-inflammatory, pain relieving doses of 600 mg 2 to 3 times per day, makes the risk for gastrointestinal bleeding very significant.

There are multiple other potential side effects from these very commonly used painkillers, thus the need for medical supervision with anything other than occasional doses.

I'm certainly not in favour of the nanny state controlling all of our behaviors but do believe we need to have a strong debate about the use of all drugs and their potential risks. 

A few years back, all codeine containing pharmaceuticals were taken off the shelf and made prescription only in an attempt to minimize the risk of abuse from a very small proportion of the population. Although there was a reasonable argument to support this act, it meant that many people would have to make a doctor’s appointment to obtain a script for an ibuprofen-codeine combination to relieve acute pain. In my view, this made the busy GP’s life, even busier.

It has been said that “always the needs of the many outweigh the needs of the few”, but this certainly does not appear to be the case with the new legislation around all pain killers. I totally agree that we always need to minimize harm and risk but also feel the need for common sense around the debate when it comes to how we obtain painkillers for the very common conditions of acute and chronic pain.


Was Timothy Leary Correct?

Since the time of recorded history, human beings have been trying to alter their consciousness with a variety of legal and illegal substances. From opium dens, so common across the world at the start of last century, to the psychedelic age of the 1960s, highlighted by the work of American professor, Timothy Leary, with his experimentation around LSD, to the most recent scourge of the hideous drug Crystal Meth or ICE, I can't see this quest for altered consciousness stopping too soon.

We also need to mention the most commonly used mind-bending drug around the planet, alcohol, which has undone the lives of many families.

Also, sometimes related and often not related to mind bending substances, is the problem of mental health. But, who would've thought that one of these mind-bending substances may be one of the solutions for treating and alleviating mental health issues.

A recent study in the prestigious New England Journal of Medicine examines the effects of psilocybin, the active component of magic mushrooms, for the use of refractory depression. The study was conducted in 233 patients scattered across the US, Europe and Canada. Refractory depression is a serious condition where people often attempt suicide and typically have a sense of hopelessness around their life.

Also, typically they have attended numerous psychiatrists and mental health facilities with, at times, minimal success in alleviating the symptoms and the disease.

This study, that was not a placebo controlled trial, used between 1 to 3 doses of psilocybin with the participants being medically supervised for a 6 to 8 hour period after dosing. Present were two mental health experts guiding them through the hallucinatory experience of ingesting psilocybin.

Depressive symptoms were reduced in all groups in a dose related fashion and interestingly after three weeks close to 40% of the high-dose group had substantial improvement which had been maintained in 20% at three months.

Strikingly, this was with therapy administered on one occasion. Side effects of headaches and nausea were quite common but serious side effects, such as suicidal thoughts and desire for self-harm, were very rare.

It is important to note that these patients with extremely hard to treat depression had improvement after just one dose but it was a very intensive study that required medical supervision for eight hours after this single dose. (Or in other words-Don’t try this at home!) It is also important to note that there have been 180 studies of psilocybin and other psychedelics for a variety of mental health issues including depression, anxiety and PTSD.

America has been at the forefront of psychedelic drug use for medical conditions including the legalization of marijuana both for personal and medical, use in a number of states.

Oregon state legalized the use of psilocybin for medical conditions in 2020 and Colorado has also just voted to do the same. There are a number of other cities in America where its use has been legalized.

In Australia, the use of psilocybin to treat depression and other mental health issues is still illegal. I am on the scientific advisory board of Mind Medicine Australia, a group lobbying the government for this decision to be overturned.

My view is that severe endogenous depression, which is not a psychological disease, but a disorder of severe chemical imbalance within the brain needs many options for appropriate management. With the increasing evidence around the benefits of substances such as psilocybin, I believe it is now time that the government overturns its current position and allows medically supervised psilocybin therapy to be trialed in people with refractory depression.

Standard therapies such as anti-depressants, psychotherapy and cognitive behavioral therapy are important in the long term management of this condition, as is the newer technique of direct cranial stimulation, which I have highlighted previously. But, we need as many options as possible for the treatment of this dreadful condition. It appears from the current available evidence that Psilocybin is a viable alternative that needs to be considered by the relevant authorities.

Managing low back pain; what has changed?

Co-authored by Dr Stephanie Mathieson

Most people will experience low back pain in their life. For some of us, it feels like it is a daily occurrence, and there is a documented greater prevalence of low back pain with or without leg pain in persons 40 years and older.

Most cases of low back pain are considered to be non-specific, meaning there is no identifiable cause. Less frequent causes include back pain disorders with associated leg pain, like sciatica or herniated disc (5-10% of cases), or even rarer causes (less than 5%) due to serious pathology, such as vertebral fractures. Although uncommon, back pain may be a symptom of a more serious underlying disorder & if the condition does not settle with appropriate management, further investigations for systemic conditions need to be performed.

In general, episodes of low back pain have a favourable natural history with most cases resolving within 6 weeks. Unfortunately for some people, symptoms persist and become chronic (symptoms present for longer than 3 months).

What is new in the domain of low back pain research and clinical care?

There has been a shift from reliance on passive interventions, such as prescribing medicines, to more active management of the pain and individual, such as advice and exercise. A recent review found that individualized exercise therapy provided clinically important benefits at 3 months in patients with chronic low back pain3. While more modern applications of physical activity, e.g. virtual reality platforms, like activities using the Wii Fit Plus workout, found significant reduction in pain compared to using more traditional exercise in those with chronic low back pain.

Is there anything new? Well, there are new guidelines to manage people with low back pain in Australia. The Australian Commission released a new clinical care standard on Safety and Quality in Health Care (ACSQHC) which is part of the Australian Government  Department of Health and Aging, on the 1st of September 2022.

The Low Back Pain Clinical Care Standard5 describes the care you can expect if you go to a primary healthcare provider or a hospital emergency department with a new episode of low back pain

The standard contains eight quality statements. It describes things to expect in an initial clinical assessment and recommendations for patient management based on current evidence. Some recommendations include the following:

The standard includes two statements related to treatments.  One standard recommends that patients are offered physical and/or psychological interventions based on their clinical findings, and therapy is targeted at overcoming identified barriers to recovery. Examples of barriers could be not having the right strategies to manage pain.

Many patients benefit form mechanical therapies in the form of physiotherapy, osteopathy & a newer technique, Medkey, which is an electromagnetic device which delivers pulses into the affected area.

The other statement advises the judicious use of pain medicines and highlights that the role of analgesics is to enable physical activity and get you moving to return to normal activities, not to eliminate pain. The latter is a common misconception about pain medicines. This is important to acknowledge and help ensure people do not become reliant on them. Some medicines are advised to be avoided (e.g. opioid analgesics) because the risks are greater than the potential benefits, and some medicines are now not recommended at all for managing back pain (benzodiazepines (e.g. valium), antidepressants, and anticonvulsants (e.g. pregabalin) because their risk benefits ratio and recent evidence. For instance, pregabalin is no better than a placebo in reducing leg pain and back pain in patients with sciatica.

For general advice on managing back pain or if you have any questions, the Australian Commission on Safety and Quality in Health Care has made some resources available on their website to inform  people in the community.

Dr Stephanie Mathieson is a Research Fellow at the Institute for Musculoskeletal Health, University of Sydney.

References

1. Chiarotto A, Koes BW. Nonspecific low back pain. New England Journal of Medicine. 2022;386:1732-40.

2. Ropper AH, Zafonte RD. Sciatica. New England Journal of Medicine. 2015;372:1240-8.

3. Fleckenstein J, et al. Individualized exercise in chronic non-specific low back pain: a systematic review with meta-analysis on the effects of exercise alone or in combination with psychological interventions on pain and disability. Journal of Pain. 2022 Jul 29:S1526-5900(22)00364-9. doi: 10.1016/j.jpain.2022.07.005.

4. Brea-Gómez B, et al. Virtual reality in the treatment of adults with chronic low back pain: a systematic review and meta-analysis of randomized clinical trials. International Journal of Environmental Research and Public Health. 2021;18(22):11806.

5. Australian Commission on Safety and Quality in Health Care (ACSQHC) low back pain clinical care standard. https://www.safetyandquality.gov.au/standards/clinical-care-standards/low-back-pain-clinical-care-standard

6. Mathieson S, et al. Trial of pregabalin for acute and chronic sciatica. New England Journal of Medicine. 2017;376:1111-20.

A major risk factor for all diseases

Over the past (almost) three years, much of the medical debate has been centered around the COVID-19 pandemic. To this point, we are approaching 650 million cases of Covid with just over 6.6 million deaths from this infection.

But, the World Health Organization has estimated that 16% of all deaths around the globe are directly linked to pollution, representing many more deaths than the COVID-19 pandemic. Pollution, in the view of many health experts, should be considered a major risk factor for the vast majority of diseases.

When you think of air pollution, you typically think of the dreadful smog experienced in many highly populated cities. Pollution also includes indoor pollution, especially from the burning of wood for heating and cooking but also, strangely, noise pollution as well.

The cost in Europe from yearly exposure to cigarettes is around €500 billion per year whereas the combined cost of inhaled air pollution and noise is estimated to cost €1 trillion on a yearly basis.

A study from Europe examined the health consequences of being exposed to nighttime aircraft noise. it has been estimated that 70 million people living in Europe on a daily basis, out of the estimated population of around 750 million, suffer noise from traffic and aircraft greater than 55dB. This is considered the limit beyond which there is an increased risk for cardiovascular disease and hypertension.

It is suggested that this form of noise pollution accounts for a significant number of cases of hypertension, hospital admissions and premature deaths on a yearly basis.

The study of aircraft noise estimated that 3% of cardiovascular disease was directly related to night-time exposure to aircraft noise because of its effect of inducing sleep disturbances and the strong link with poor sleep & cardiovascular events. It was estimated that, as one example, endothelial dysfunction (the malfunction of the cells that line blood vessels) is linked to an increased risk for cardiovascular disease. This was clearly linked to aircraft noise. It was also demonstrated that noise pollution also led to the release of stress hormones leading to high blood pressure and disruption of the 24-hour circadian cycle.

A recent study published in the Journal “Neurology” examined the link between the common air pollutant PM 2.5., typically found in polluted air. It has been estimated that 90% of the world’s population live in areas which expose them to greater than the recommended level of pollution. This study was a meta-analysis of 17 studies in people over the age of 40. It examined 91 million people of which 5.5 million i.e. 6%, had dementia. The study was adjusted for age, sex, cigarette smoking and education. The study found that the risk of dementia was increased 3% for every one microgram per cubic millimeter of exposure to PM 2.5. The US environmental pollution agency has estimated that an average exposure of PM 2 .5 up to 12 µg per  cubic millimeter was safe and beyond that there were a variety of potential health issues.

Interestingly the researchers also reviewed exposure to nitrogen oxide which is the key component of smog, nitrous dioxide and Ozone and found that there was no real link to dementia in this particular study.

To date, pollution has been associated with a variety of cardiovascular diseases, dementia, respiratory diseases, increased risk for cancers, behavioral abnormalities in children and infertility, to name a few.

As I have stated on numerous occasions, the major issue on the planet is increasing population which leads to the flow on effect being pollution in the form of polluted air and excessive noise.

Albert Einstein once said, “we cannot solve our current problems with the same thinking we used to create them”. It is my opinion that we need a serious rethink about how we are all living our lives & especially how we continue to overpopulate the planet because the 16% of deaths directly related to pollution will continue to increase unless we don’t.

From the Harbour to the CBD, these are the 10 most luxurious hotels in Sydney

WHETHER YOU’RE TRAVELLING from afar or seeking a night of luxury locally, the city of Sydney is a beautiful place to spend an evening — or a few.

From the bustling energy of the CBD, to the quaint charm of The Rocks, to the effervescent spark of personality embodied by any inner-city suburb; there’s a plethora of nooks and crannies to delve into in the rollicking metropolis.

But at the end of those exciting days of discovery, you’ll need a place to rest your head at night — and fortunately for you, you won’t need to skimp on your standards, because Sydney is home to a number of truly luxurious hotels for you to take advantage of.

Best hotels in Sydney in 2022

Read on for our guide to the very best hotels to rest your head in when visiting Sydney — from harbour-side, world-class hotel chains, to one-of-a-kind boutique accommodations in charming inner-city suburbs.

This excerpt has been republished from Dani Maher's article for Harper's BAZAAR Australia.

CLICK HERE to read the full original article.

Chronic Traumatic Encephalopathy-A Hard end for the hardened sports star

The recent untimely and tragic death of the rugby league player and coach, Paul Green was yet another shock for the sporting world. The autopsy results were just released revealing that Paul had severe Chronic Traumatic Encephalopathy, better known by its acronym CTE.

These findings gave an explanation to the Green family as to why a man with so many achievements in his life including a stellar career in rugby league as a player and coach, a Harvard business degree, a helicopter pilot, a musician, but most importantly a devoted family man, would take his own life when earlier that day he appeared happy and cheerful.

There were no signs of depression which is a typical cause present in a person committing suicide. It was reported by his family that Paul had appeared, at times, somewhat more angry than his usual cheery and relaxed predisposition and this may be one of the signs of CTE.

Recurrent head injuries or even a severe blow to the head may lead to this condition. Many sports people over the years have suffered as a consequence of this condition, arguably the most famous being Muhammad Ali. Mr Ali had a combination of what appeared to be dementia and Parkinson's disease but, in reality, was almost definitely the end effects of CTE.

This condition can manifest as a variety of forms of depression, anxiety, anger and impulsive behavior but, regardless, is a serious condition with serious consequences to the sufferer and their family.

This raises many questions as to the current method in which sport is played and also the current rules around head knocks sustained during sporting activity. There are now calls for heading the ball in soccer to be banned (at least in children) with even some talk about it being banned across-the-board which would totally change the nature of this particular game.

Many parents are concerned about their younger children playing a variety of forms of football and with our increasingly careful society, we will almost certainly see changes over the next few decades.

The only benefit to come out of these tragedies is the ability of medical science to detect these conditions early and with increasing medical technology offer some form of therapy to either prevent, stabilize and possibly even reverse the disease.

My friend and colleague, Dr Adrian Cohen who is the boss of Headsafe has developed a device to assess the severity of concussion in athletes. There is also some preliminary work using medical cannabis as a form of therapy for this condition. With the increasing strides seen in stem cell therapy and other forms of regenerative medicine, at some stage in the relatively near future we may see possibly definitive therapy for this dreadful condition.

The vast majority of society either plays or enjoys watching some form of sport offering so many people hours of enjoyment and passion. Tragically, there are occasional serious consequences involved in this pursuit and, as always, we are forever trying to find the balance between following passions, the thrill of competition and the safety of all people involved.

Male infertility - Is it a big issue?

There is a registry known as the Australian and New Zealand Assisted Reproduction Database (ANZARD). Recently, their 2020 data was released suggesting that one in three cases of infertility were directly cause as a consequence of problems with the male.

Male infertility is related to having a low sperm count, sperm dysmotility (this is where the sperm are poor swimmers for some reason) or abnormally shaped sperm that typically have some chromosomal abnormalities.

There are many causes for these abnormalities of sperm including relatively uncommon genetic abnormalities, a prior infection such as mumps, testicular trauma or abnormal sperm production such as seen after chemotherapy for cancer. There are also obvious causes of a male’s inability to conceive such as those who have already undergone a vasectomy, failure of ejaculation, poorly timed intercourse and, of course, varying degrees of erectile dysfunction.

There are also hormonal issues such as marked reduction in testosterone or pituitary gland failure along with many chronic illnesses such as obesity, diabetes and drug use, including cigarettes, alcohol or illegal drugs. For example, smoking one joint per week in a male significantly reduces the chance of his partner getting pregnant.

I have seen occasional patients who were commenced early in their life (e.g. twenties) on statin drugs to lower cholesterol, who could not conceive until the statins were ceased.

We have seen the rates of infertility in males increase over the past few decades, possibly because of increasing environmental exposures such as the ubiquitous chemicals found in a variety of household goods, especially plastics, increasing air pollution and potentially an increase in electromagnetic radiation exposure from all of the appliances that we use on a daily basis, although the evidence for the latter is rather tenuous and sketchy.

For men who would like advice as to how to improve their chances of conceiving, there are many interventions that may be of some benefit.

1) For many years I have been discussing the five keys to good health and there is no doubt that men who practice these 5 keys will have a much greater chance of having healthy sperm.

2) Achieving ideal body weight, which is clearly related to the five keys of being healthy specifically improves a couples’ chance of conceiving.

3) There are a variety of supplements on the market which typically contain high quality multivitamins which may be of some benefit but the evidence base around this is not particularly strong. Regardless, these supplements are harmless and may enhance your chance of conceiving.

4) Any male with a history of sexually transmitted diseases may have experienced some damage to their reproductive organs with scarring in the vas deferens & epididymis. These tubes transfer sperm from the testicles into the prostate. Chronic prostatic infections may also be a factor in these cases.

5) Finally and probably most controversially is the modern trend to delay conceiving. If you think of it logically, our bodies were designed physiologically to live for 30 to 40 years, wandering around a jungle with a spear, dying from some infection or having a sabretooth tiger rip off your head.

Young girls would go through puberty in their early teens and conceive within a year or two and their grandmothers in their late 20s would help them look after the child in a very simple “top of the food chain” existence.

These days, it is more the norm than the exception to have a child over the age of 35 and regardless of the social acceptance of this concept, women conceiving beyond this age are at much higher risk for maternal complications and in children conceived to parents over the age of 35 (males & females), there are much higher rates of congenital abnormalities, schizophrenia, autism and ADHD.

The discussion around the world population crisis and pollution is for another time but without wishing to sound trite, if you are serious about having children, my strong medical advice is to “go hard and go early” rather than delaying until well over the age of 35. It is much more difficult to conceive beyond age 35 and if you do there are many more complications and often the need for assisted reproduction in this age group.

COVID-19, Is the treatment worse than the complaint?

Many aspects of our behaviour and life have been turned upside down by the COVID-19 pandemic. Interestingly, this disease has also caused a significant divide in the population with a small, but very vocal, minority of anti-VAXXERs and conspiracy theorists making very loud noises about the entire way this pandemic has been managed.

Recently, two major trials have brought into question the “go to” oral antivirals against SARS-CoV2. The first trial from the University of Oxford, known as the PANORAMIC trial enrolled just under 26,000 people with COVID-19 given the oral antiviral Molnupiravir, in a placebo controlled trial. After 28 days, 103 people given Molnupiravir had died compared with 96 in the placebo group. This is clearly not statistically significant but shows no significant benefit in reducing mortality using Molnupiravir in people with COVID-19.

The second trial recently published in the Journal of the American College of Cardiology examined the role of Paxlovid, another commonly prescribed anti-viral used in the treatment of COVID-19. This was specifically looking about the potential for any interactions between Paxlovid and cardiovascular drugs. It is well known that sicker patients with comorbid illnesses such as cardiovascular disease and more likely to succumb from COVID-19 or be hospitalised. Therefore, this group of patients are typically on cardiovascular medications.

The study showed drug interactions with commonly used cardiovascular medications such as blood thinning drugs, rhythm controlling drugs, antianginals, some statin drugs and some immunosuppressive therapies used widely in people who have undergone some form of transplantation, in particular, heart transplantation.

We must then ask the question, does this mean that these previously thought to be highly effective antiviral medications should no longer be used for the acute management of COVID-19?

My response would be that the problem is more with the interpretation of the research rather than with the drugs themselves. When COVID-19 first hit the planet, the initial Wuhan strain had around a 3% mortality rate. As the virus mutated around the world, although many of the new strains became more contagious, they became less deadly.

This may have been because the virus was mutating to a less serious strain or equally may have been due to widespread infection and vaccination, the so-called hybrid immunity.

Regardless, the mortality rate quoted in the PANORAMIC trial was around 0.4%, nowhere near the initial 3% mortality rate with the Wuhan strain.

When Molnupiravir was initially studied, this was around the time of the Delta strain which had a much higher mortality rate but was less contagious. Also, in the earlier phase of this trial, Molnupiravir was administered to much sicker patients & appeared to markedly reduce death rates & hospitalisation. As the PANORAMIC trial continued until the middle of 2022, the predominant strain was Omicron which appears less sensitive to vaccination and probably from this trial, to antiviral drugs.

In Australia, it is only suggested that those people over 70 or people with significant comorbid conditions take either Molnupiravir or Paxlovid.

This brings me to the second trial suggesting significant interactions with Paxlovid and cardiovascular therapies. This is very important information and suggests strongly that Paxlovid should be avoided in people with cardiovascular disease who are on medications. If this group of patients develops SARS-CoV2, they probably should be described Molnupiravir, for the reasons stated above.

We have known from early on in the pandemic that SARS-CoV2 tends to affect the very old, the very sick with comorbid conditions or the very overweight and it is my opinion that these are the groups that need booster vaccinations and aggressive antiviral therapy. But, it may well be that in the variants of Omicron, all of these therapies are less effective.

The typical mortality rates of standard influenza are around 0.5% and also appear to occur more commonly in the above groups I have just mentioned. It is my opinion we should now view COVID-19 infections in the same light as influenza.

From all of the evidence, vaccinations and antiviral drugs have some effect but are certainly not miraculous therapies, nor do they protect everyone. Although it appears that the pandemic has now finished, it may well be that like influenza, SARS-CoV2 and its multiple strains will become an endemic virus that we will need to learn to live with. Part of living with this virus, of course, requires ongoing research into developing more effective preventative vaccines and therapies not only to treat the acute illness but also to support and help the 10% of people who appear to be developing Long Covid.

Gaze upon frosted forests and sip on champagne aboard the Venice Simplon-Orient-Express

FOR A TRULY enchanting Christmas this year, A Belmond Train is offering a winter wonderland experience.

For the first time ever, the iconic Venice Simplon-Orient-Express is operating throughout December with 10 memorable one-night journeys. Usually, the opulent service runs across Europe from March to November.

Guests will get to gaze upon snow-topped views while sipping champagne — as they head to their preferred festive destination. One can start their Christmas voyage at one of Italy’s cultural epicentres; Venice, Verona or Florence and head towards Paris or vice versa. Aside from Belmond’s Italian routes, an additional itinerary has been planned between the City of Lights and arguably Europe’s most convivial city, Vienna.

Made up of 17 original midnight blue 1920sand 1930s carriages, the Venice Simplon-Orient-Express invites guests to first dress up for dinner upon boarding. French chef Jean Imbert, who spearheads Dior’s restaurant Moniseur Dior and boasts almost half a million Instagram followers, serves a seasonal four-course meal utilising local hearty ingredients.

This excerpt has been republished from Hayley Peppin's article for Harper's BAZAAR Australia.

CLICK HERE to read the original article in full.

Disney cruise line to hit Australian and New Zealand shores for the first time

IN NEWS Disney fans have been awaiting a long time, Disney Wonder, Disney’s cruise line, will be coming Down Under. The magical cruise will be departing from four home ports: Sydney, Melbourne and Brisbane, Australia, as well as Auckland, New Zealand.

Since its inception in 1998, the Disney Cruise Line has never sailed to Australia or New Zealand, opting instead to only sail out of North America and Europe. But now, antipodean Disnerds young and old will have the opportunity to set sail with Captains Mickey Mouse and Minnie Mouse and Goofy and Pluto, in addition to characters from the Star Wars and Marvel universes.

When is Disney Cruise coming to Australia?

The first of these cruises will set sail from Sydney Harbour on October 28, 2023, and Disney plans to run the cruises from Australia until February 2024.

Bookings will open to the general public from Thursday 29 September 2022 at 8am AEST / 11am NZDT.

This excerpt has been republished from Tessa Ogle's article for Harper's BAZAAR Australia.

CLICK HERE to read the original article in full.

Artificial sweeteners: Are they a healthier alternative?

For many decades we have seen increasing numbers of overweight and obese people with clear evidence that this results from excessive caloric intake and, in particular, the intake of processed carbohydrates, especially related to the variety of sugars added to food and beverages.

Although many people are sedentary, it has been estimated that our weight is typically related to calories in versus calories out. To give a good example, a brisk half an hour walk burns about 300 calories whereas a small piece of chocolate cake is about 300 calories. Thus, the system is more geared toward sin than it is toward penance.

Therefore, for many years, society has been living under the delusion that artificial sweeteners added to food and fluid are a healthier alternative than using the different types of so-called “natural” sugars available.

Although there is no dispute about the health detriments of consuming excessive sugars, such as sucrose (i.e. commonly used sugar), there has been mounting evidence over the years demonstrating artificial sweeteners are not much better.

A recent study published in the British Medical Journal reviewing the research from the French National Institute for Health and Medical Research examined the cardiovascular outcomes of 103,388 people over the age of 18, the average age being 42 years, of which 80% in this analysis were female.

The study assessed the intake of varying artificial sugars such as saccharin, acesulfame, sucralose, aspartame, stevia and xylitol.

A prior study from Harvard suggested that there was a link between artificial sweeteners, type two diabetes and weight gain.

In the BMJ study, a regular food questionnaire performed an analysis of demographic data such as age, sex and socioeconomic groups along with lifestyle factors including exercise. 37% of the group were regular consumers of artificial sweeteners with an average intake being about 42mg per day.

The end analysis showed that there were 346 cardiovascular events including coronary heart disease and stroke per 100,000 person-years examined versus 314 events per hundred thousand years examined in the non-users. This was statistically significant.

It appears that the three worst artificial sweeteners were aspartame, acesulfame and sucralose whereas there did not appear to be any increase in cardiovascular disease using the more natural sweetener, stevia.

It was also suggested that most of the deleterious effects of artificial sweeteners are through a pathologic change in the gut microbiome.

Regardless of the actual reasons for artificial sweeteners increasing cardiovascular risk, this evidence is strong support for the fact that we should be trying to avoid sweeteners, natural or artificial, as much as possible.

Unfortunately, the human palate has become very accustomed to anything sweet and humans often show ill-discipline in being unable to consume many different varieties of food or fluid unless it contains a sweet flavour. The bottom line here is, do so at your peril.

Seven of the best biopics and documentaries about Queen Elizabeth II

COUNTLESS BRITISH period dramas are based on royalty, or at least depict aristocracy. From The Duchess starring Keira Knightley as Georgiana Spencer, to The Other Boleyn Girl with Natalie Portman as King Henry VIII’s most famous (and ill-fated) wife, Anne Boleyn.

Even the fictionalised, Gwyneth Paltrow-fronted Shakespeare in Love saw a fantastic Judy Dench play Queen Elizabeth I in a few memorable scenes. As for Queen Elizabeth II, less biopics have been made about her — perhaps due to her visibility and prominence in modern society. The Crown creator Peter Morgan previously revealed he had a “20-year-rule” when it came to adapting historical moments.

“That is enough time and enough distance to really understand something, to understand its role, to understand its position, to understand its relevance,” Morgan told The Hollywood Reporter.

Whereas other directors may have been apprehensive to chronicle the Queen’s life as she continued to rule the UK. But since Buckingham Palace announced the death of the 96-year-old Queen on September 8, it’s likely more filmmakers may place a lens on one of Britain’s most successful monarchs.

But until fresh features are released, BAZAAR has rounded up some of the most insightful films, television shows and documentaries about Queen Elizabeth II to help you consider her extraordinary 70-year legacy. Unsurprisingly, season one of The Crown has already hit Netflix’s top 10 in the week since her passing.

This excerpt has been republished from Hayley Peppin's article for Harper's BAZAAR Australia.

CLICK HERE for the original article that lists the seven best biopics and documentaries about Queen Elizabeth II.