Private EDs ramp up
Cardiovascular Health | Hearts & COVID, lung cancer screening, stroke, donor hearts
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April 2021 www.mforum.com.au
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EDITORIAL BACK TO CONTENTS
Cathy O’Leary | Editor
Will private EDs fly? Many will watch with interest once Perth has three private hospital emergency departments within the next year or so. What will be the take-up, and will they ease pressure on the public system?
It’s the pointy end of medical care – the part we hope to avoid as much as possible but still want to know is there for us, just in case. Even with after-hours GPs and urgent care centres, the emergency department is still the place to go when things are really heading south. Traditionally that’s meant a visit to the nearest public hospital but more people seem prepared to pay a few hundred dollars to go private and bypass ambulance ramping and the stretched public health system. Many will watch with interest once Perth has three private hospital emergency departments within the next year or so. What will be the take-up, and will they ease pressure on the public system? What we know with certainty is that a frequent visitor to any ED is the patient with chest pains, and this month Medical Forum looks at local research trying to keep us, and our hearts, well away from the emergency department. Patients might also hope their medical records will be there for them in an emergency, and this month we track the progress of My Health Record to see why some doctors are not onboard and why many patients don’t even know their data exists. And for a quirky Perth connection to a baby grand piano used in silent movies starring Charlie Chaplin, read our profile piece on a colourful Perth cardiologist. Never say medicine isn’t entertaining.
SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission. DISCLAIMER Medical Forum is published by Medical Forum WA as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.
MEDICAL FORUM | CARDIOVASCUL AR HEALTH
APRIL 2021 | 1
CONTENTS | APRIL 2021 – CARDIOVASCULAR HEALTH
Inside this issue 14 18 30
24
FEATURES
NEWS & VIEWS
LIFESTYLE
14 Special Report:
1
64 Happy heart, happy life
The Rise of Private Eds
18 My Health Record update 24 Living (to the max) with T1DM
Will private EDs fly? – Cathy O’Leary
– Dr Johan Janssen
4 In the news 6 In brief 10 COVID-19 report card
30 Keeping hearts healthy
– Dr Paul Langton
12 Q&A WA and COVID
66 Gin promotion 67 Wine Review: 3 Drops – Dr Louis Papaelias
68 Kate Ceberano: Inspiration 68 Chess the Musical
– Dr Andrew Miller
35 Heart risk tool for GPs 47 Heart of the matter – Dr Joe Kosterich
63 Hollywood Cancer Centre opens
Win... We have wine, gin and three copies of Kate Ceberano’s new CD Sweet Inspiration to give away. Click on the competitions tab on www.mforum.com.au or enter via our new Medical Forum Weekly newsletter, delivered to your inbox.
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CONTENTS
PUBLISHERS
Clinicals
Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au
ADVERTISING Advertising Manager Andrew Bowyer 0403 282 510 andrew@mforum.com.au
EDITORIAL TEAM
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Anticoagulant therapy in patients with thromobocytopenia Dr Simon Kavanagh
Restless legs: The untold story Dr Luke Matar
Cardiac manifestations & COVID-19 Dr Susan Kuruvilla
Lung cancer screening with Low Dose CT Dr Conor Murray
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Novel therapy for familial heart disease Professor Livia Hool
Diabetes and heart attack Professor Girish Dwivedi
Acute Ischaemic Stroke Management Update Dr Darshan Ghia
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Increasing the use of donated hearts Dr Warren Pavey
Abdominal aortic calcification & CVD A/Prof Joshua Lewis
Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Journalist Dr Karl Gruber (PhD) 08 9203 5222 journalist@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Clinical Services Directory Editor Karen Walsh 0401 172 626 karen@mforum.com.au
GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au
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Consumers weigh in on heart health Clare Mullen
Are we really this miserable? Dr Martin Whitely (PhD)
Eyes on newborn’s hearing Philippa Hatch
COVID-21 – the next phase Dr Sarah Newman
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APRIL 2021 | 3
IN THE NEWS
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Women up front Ramsay Health Care has recognised the importance of gender equity in the workplace, arguing it is good for business and employees. Chief People Officer Colleen Harris said the company was a significant employer of women in Australia, with women making up 59% of its facility CEOs and 60% of its regional executives. “Providing a flexible, family-friendly environment for all employees is a vital way to achieve these targets and helps improve the wellbeing of our people,” she said. Glengarry Private Hospital Chief Executive Officer Leonie Gardiner leads an all-female executive team at the hospital and is a strong advocate for a diverse workplace.
Urgent care centre The first of four new St John WA Urgent Care centres has opened in Cannington. Urgent care and dental services have been added to St John’s Cannington GP practice, which has relocated to Beckenham. Another urgent care centre is due to open in Midland this month, adding to the network of existing centres at Armadale, Cockburn and Joondalup, with more centres due to open in Osborne Park and Mandurah early next year. They are part of a Federal Government-funded trial to deliver urgent, but non-emergency care to patients who may normally go to a hospital emergency department for treatment. The $28 million Federal Government initiative is aimed at developing and evaluating the urgent care model. The new Cannington centre includes GP and general dental services, pathology, X-ray and plaster casting.
Glengarry Private Hospital executive team Director of Finance and Support Services Bernadette Carreira, CEO Leonie Gardiner and Director of Clinical Services Karen Cunliffe.
“I have been in the health industry for 40 years and it’s been amazing to see the role of women in the workforce change and I look forward to seeing how it progresses further in the future,” she said. A
mother of four, Ms Gardiner said she felt grateful to have enjoyed an amazing career as well as raising a family.
a report by the AIHW. It found that more than a quarter of these hospitalisations were caused by bee stings, and the majority were due to allergic reactions. Bees and wasps were responsible for 12 of the 19 deaths related to venomous bites and stings. Spider bites accounted for one-fifth of presentations while venomous snakes were responsible for 17%.
the best of 20 international entrants in the ‘Innovation in Surgical Site Infection’ category of the Journal of Wound Care & World Union of Wound Healing Societies Awards. Dr Sandy-Hodgetts’ research has drawn attention to the importance of predicting at-risk patients, the accurate assessment of wound infection after surgery and whether infection is at play, while also providing a new diagnostic tool for clinicians. Her research calls for clinicians to change how they view and predict surgical wound complications such as dehiscence in patients before surgery. Dehiscence is where the edges of a surgical wound come apart. The risk assessment tool provides health care providers with the opportunity to identify and manage the risk of surgical wound dehiscence before a patient undergoes surgery.
Public health jobs plea Bee very careful
Wound care gong
It’s not snakes or spiders you have to worry about, it’s bees. They are responsible for most venomous bites and stings presenting to hospitals in Australia, according to new research. Over 3500 Australians were hospitalised due to contact with a venomous animal or plant in 2017–18, according to
A leading researcher in wound healing from the University of Western Australia has been awarded a prestigious international award for innovation in treatment of surgical wound complications. Dr Kylie Sandy-Hodgetts, a senior research fellow at UWA’s School of Biomedical Sciences, was judged
4 | APRIL 2021
A new study by researchers at the University of Western Australia has found a large rise in students graduating with public health qualifications in Australia over the past two decades. The study, published in the Australian and New Zealand Journal of Public Health, continued on Page 6
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Anticoagulant therapy in patients with thrombocytopenia Anticoagulant therapy is used in a number of cardiovascular conditions including atrial fibrillation (AF) and prosthetic heart valves. Excess bleeding is the most common serious adverse effect of anticoagulant therapy, whether this be with direct oral anticoagulants (DOACs), unfractionated/low molecular weight heparins or warfarin. Multiple scoring systems (e.g. HEMORR2HAGES and HAS-BLED) aid in estimation of bleeding risk. They vary in complexity, but both named systems consider all-cause impairment of platelet function as a risk factor. Such impairment is commonly qualitative (e.g. due to anti-platelet agents) though quantitative defects, independent of platelet function, are also a risk factor for bleeding. Thrombocytopenia is a common problem and, when defined as a platelet count of <150x109/L, has been reported in 11.4% of patients with AF in the Italian START registry. The bleeding risk attributable to thrombocytopenia depends on factors including tempo of onset, severity, duration and platelet function. Bleeding risk is generally proportional to degree of thrombocytopenia though the platelet count, in isolation, is a poor predictor for spontaneous haemorrhage. Bleeding risk is compounded by concurrent anticoagulation/anti-platelet therapy and presence of anaemia. When thrombocytopenia is identified in a patient on anticoagulant therapy, consideration must be given to whether treatment may be safely continued. The presence of bleeding typically warrants anticoagulant cessation
By Dr Simon Kavanagh MBBS FRACP FRCPA Dr Kavanagh is a clinical and laboratory haematologist in Perth, WA. Following admission to the RACP and RCPA in 2015, he completed a two-year fellowship, specialising in the research and management of acute leukaemias and myelodysplastic syndromes. He maintains an active interest in the targeted treatment of these conditions in addition to various aspects of general haematology. Simon currently sees patients privately at St John of God Hospital Subiaco and works as a laboratory haematologist for Australian Clinical Labs.
(+/- reversal) and concurrent investigation and treatment of thrombocytopenia. This is particularly true when bleeding is present at a critical site. In the absence of bleeding, mild thrombocytopenia (platelet count ≥100x109/L) generally does not warrant interruption of anticoagulant therapy. Where thromobcytopenia is severe but anticipated to be of short duration (e.g. following cytotoxic chemotherapy) platelet transfusion support may allow ongoing anticoagulant therapy when thrombotic risks are deemed unacceptably high. Chronic transfusion is generally not feasible in those with persistent severe thromobcytopenia. Formal data for moderate/ severe thrombocytopenia in anticoagulation for cardiovascular indications is lacking. Guidance, in the form of expert consensus, exists for patients with venous thromboembolism and thrombocytopenia due to malignant haematological disease. Anticoagulation with low molecular weight heparins is considered safe for platelet counts ≥50x109/L. A dose reduction of 50% is recommended when the platelet count lies between 30-49x109/L.
Anticoagulation cessation is generally advised with a platelet count <30x109/L. This balance is particularly challenging in those with a mechanical valve prosthesis, particularly in the mitral position, as valve thrombosis has a high shortterm morbidity and mortality. A cautious reduction in anticoagulant intensity is appropriate but anticoagulation may need to be continued well below the thresholds stated above. Ultimately, the decision to continue, temporarily interrupt or cease anticoagulation in the context of thrombocytopenia hinges on the clinical context, presence of additional risk factors for thrombosis and bleeding and the potential consequences of either outcome. Any decision represents a tradeoff – anticoagulation increases the risk of bleeding while omission increases the risk of thrombotic complications. The balance of risk needs regular re-evaluation with updated platelet counts and clinical review. Wherever possible, the cause for thrombocytopenia should be identified and treated. Patient involvement in the discussionmaking process is important.
Building Better Partnerships
1300 367 674 | clinicallabs.com.au MEDICAL FORUM | CARDIOVASCUL AR HEALTH
APRIL 2021 | 5
Online appointment booking and directory service HealthEngine has been chosen to build the booking platform for the federal government’s COVID-19 Vaccination Information and Booking Service.
Cancer Australia has released the first evidencebased information about the COVID-19 vaccines for people affected by cancer. The responses to 25 frequently asked questions from people with cancer and those affected by cancer are based on the latest evidence from around the world. Details at www.canceraustralia.gov.au/ covid-19-vaccine-and-cancer
A global philanthropic organisation has backed an Australian-led bid to develop a Strep A vaccine which could save millions of lives around the world, contributing US$5.3 million. The trial is coordinated by the Australian Strep A Vaccine Initiative, a partnership between the Telethon Kids Institute and the Murdoch Children’s Research Institute.
The RACGP is inviting GP and GP Registrar researchers to apply for a college Foundation Grant. The program enables general practice research, providing an evidence base to inform and improve practice and patient outcomes. The RACGP will distribute up to $450,000 and applications close on May 3. Apply at foundation.racgp.org.au/ grants
The Therapeutic Goods Administration has started publishing reports each Wednesday into suspected side effects or adverse events from COVID-19 vaccines.
6 | APRIL 2021
IN THE NEWS
continued from Page 4 calls for greater investment in public health to provide job opportunities commensurate with the growth in capacity. Co-author Dr Ian Li, from UWA’s School of Population and Global Health, said Australia had fared comparably well internationally in its public health response to the COVID-19 pandemic. “This has resulted in relatively strong population health and economic outcomes, which can be attributed to the efforts and expertise of Australia’s public health workforce and other frontline health staff,” Dr
Li said. “We should leverage the public health capacity and expertise of our graduates, and make deeper investments in the public health workforce. This will boost the wellbeing of the Australian population and economy in the long-term and see us through future health challenges.”
Medicinal cannabis QoLs A major longitudinal study is underway in Australia to assess changes in quality-of-life outcomes for patients prescribed medicinal continued on Page 8
Prof Davina Porock
Aged care missing out Many aged care residents are being denied proper end-of-life care, according to a Perth academic. Professor Davina Porock, who is director of Edith Cowan University’s Centre for Aged Care Research, believes that while elderly people hope for a ‘good death’, many of those in residential aged care miss out on end-of-life services. Writing in The Conversation after the release of the final report of the Royal Commission into Aged Care Quality and Safety, she said it was logical to expect aged-care homes to provide superior end-of-life care. But palliative care options were often better for those living outside residential aged care than those in it. More than a quarter of a million older Australians lived in residential aged care, but few chose to be there, few considered it their ‘home’ and most would die there after an average 2.6 years. “These are vulnerable older people who have been placed in residential aged care when they can no longer be cared for at home,” she said. Professor Porock said the royal commission had heard the clarion call for attention to ensure older Australians had as good a death as possible, as shown by the fact that a dozen of the recommendations reflected the need for quality end-of-life care. She said advanced care planning made a significant difference in the quality of end-of-life care by understanding and supporting individual choices through open conversation. It gave the individual the care they wanted and lessened the emotional toll on family. MEDICAL FORUM | CARDIOVASCUL AR HEALTH
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IN BRIEF
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RESTLESS LEGS: THE UNTOLD STORY Restless legs syndrome (RLS) is a poorly understood but relatively common condition that increases in prevalence with age (5-15% incidence). RLS typically causes an uncontrollable urge to move the legs to reduce uncomfortable sensations. Symptoms most commonly appear shortly after laying down/resting at night. Patients often have difficulty describing the unpleasant sensations associated with RLS. Terms used include creeping, crawling, pulling, throbbing, aching, itching, ‘electric shocks’, night cramps, twitching, or uncomfortable legs. Symptoms usually occur in both legs but can be worse in one and may also involve the upper limbs/body. Moving the legs temporarily eases the unpleasant feeling but the restlessness can disrupt sleep, not only for the RLS sufferer but also their sleeping partner. This often leads to fatigue and daytime sleepiness, poor concentration, reduced work performance and relationship conflicts. Sleep deficiency is also associated with increased depression, anxiety, heart disease and obesity. RLS is frequently neglected by patients and usually goes undiagnosed by doctors. The international RLS (IRLS) rating scale is a validated screening tool that can be used in clinical practice to diagnose RLS and monitor response to treatment. Untreated RLS can lead to significant impairment in quality of life, especially if severe. Reported negative outcomes versus control patients include:
Tired (35% vs 20%), Pessimistic (16% vs 10%), Prefer to be alone (34% vs 22%), Stressed (37% vs 21%) Angry (15% vs 6%) during a typical day.
Whilst many doctors are familiar with the need to order iron studies (mostly normal), very few are aware of the
by DR LUKE MATAR Dr Matar is a dual-qualified Radiologist and Phlebologist. His personal and family history with varicose veins fuels his ongoing passion for offering the most effective varicose vein treatments available. As medical director of The Vein Clinic in Perth he has pioneered several innovations in vein treatment and offers a highly tailored and targeted approach to treating venous insufficiency, the cause of varicose veins and a frequent cause of restless legs. need to order CVI studies (frequently abnormal). Despite several published studies showing a strong association between RLS and CVI, this knowledge remains largely unknown outside the phlebology and vascular surgery communities. In one study, 89% of patients reported significant improvement in RLS symptoms postCVI treatment and 31% had complete symptom relief. Another study found that 40% of CVI patients suffered from RLS and that >80% of these patients had symptoms improve following treatment. Forty per cent of our own CVI patients presenting for treatment have RLS. Often this is first diagnosed on completing the IRLS rating scale. Over 90% experience significant RLS improvement following treatment, often going from the severe to mild category. The majority of RLS sufferers in the community go undiagnosed and untreated, only 2.5% having symptoms severe enough to prompt them to peruse medical assessment/ intervention. Unfortunately, very few RLS sufferers get investigated for CVI, denying them a chance of a potential drug-free cure for their RLS by treating underlying venous reflux (CVI) if present. Simple lifestyle changes may provide relief for mild-to-moderate RLS – maintaining good sleep hygiene, regular exercise, leg massage, warm baths and magnesium supplements. Drug therapy
is not always effective and not without potentially serious side effects. For this reason, it is best reserved following negative investigations and failure of conservative measures mentioned above. From personal clinical experience, hundreds of RLS sufferers have been successfully treated using a combination of minimally invasive treatments including endovenous laser ablation, ambulatory phlebectomy and ultrasound-guided foam sclerotherapy. My team and I are undertaking ongoing research in this area and look forward to contributing to the scientific literature to further recognition of the importance of treatable CVI as a cause of RLS in the medical and wider community. In summary, RLS is a common condition that is usually neglected and remains undiagnosed and untreated leading to avoidable impairment in quality of life for many people. Medical doctors in general and especially those involved in primary care, respiratory medicine, and psychiatry should display increased vigilance for RLS and utilise the IRLS rating scale. CVI ultrasound is now the primary first line investigation prior to deciding on treatment. The Vein Clinic is proud to be at the forefront of increasing this awareness and looks forward to helping relieve the avoidable suffering of RLS in our community. References available on request.
Perth's Only Dedicated Varicose Vein Clinic 6/28, Subiaco Square Road Subiaco WA 6008 (08) 9200 3450 | veinclinicperth.com.au
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APRIL 2021 | 7
continued from Page 4 cannabis. Researchers at the University of Sydney have launched The QUality of life Evaluation STudy (The QUEST Initiative), a wideranging, longitudinal study for medicinal cannabis patients. The study will seek to recruit at least 2100 patients by June this year, with potential to extend this study internationally. “What makes our study unique is the comprehensive suite of patient-reported outcomes – or PROs – being assessed in patients prescribed medicinal cannabis,” said study lead Associate Professor Claudia Rutherford. The QUEST Initiative will assess changes in patient conditions and symptoms using self-reported quality-of-life outcomes. Information on patient mobility, functionality, pain or discomfort, anxiety and depression, medication requirements and ongoing health costs will be collected and analysed.
Brain protein marker A unique brain protein measured in the blood could be used to diagnose Alzheimer’s disease decades before symptoms develop, according to new Edith Cowan University research. Published in the Nature journal, Translational Psychiatry, the study is the first to find that people with elevated glial fibrillary acidic protein (GFAP) in the blood also have increased amyloid beta in the brain, a known indicator of Alzheimer’s disease. GFAP is a protein normally found in the brain, but it is released into the blood when the brain is damaged by early Alzheimer’s disease. Alzheimer’s disease affects more than 340,000 Australians and more than 35 million people worldwide. Current diagnosis involves a brain scan or spinal fluid tests. The study’s lead researcher Professor Ralph Martins said the discovery offered a promising new avenue for early diagnosis. The GFAP biomarker could be used to
develop a simple and quick blood test to detect if a person was at very high risk of developing Alzheimer’s, allowing time for medical and lifestyle interventions.
Spooky research People with aphantasia, or the inability to visualise mental images, are harder to spook with scary stories, a new University of NSW Sydney study shows. The research, published in Proceedings of the Royal Society B, tested how aphantasic people reacted to reading distressing scenarios, like being chased by a shark, falling off a cliff, or being in a plane that’s about to crash. The researchers were able to physically measure each participant’s fear response by monitoring how much the story made a person sweat. This type of test is commonly used in psychology research to measure the body’s physical expression of emotion. According to the findings, scary stories lost their fear factor when the readers couldn’t visually imagine the scene, suggesting imagery may have a closer link to emotions than scientists previously thought.
Jab for heart patients
Suan Kim See, Dr Andrew Crocker, Dr Ross Ireland and Lizzy Inman
End of an era The first plastic surgeon to work at St John of God Murdoch Hospital has retired. Mr Andrew Crocker has retired from operating at St John of God Murdoch Hospital after 27 years helping patients across Perth with reconstructive surgery. As a plastic surgeon specialist, he has helped thousands of people to restore normal function and appearance. Mr Crocker said he was the only plastic surgeon operating at Murdoch Hospital when it opened in 1994 but there were now several. 8 | APRIL 2021
The Heart Foundation is urging the estimated 4 million Australians with cardiovascular disease to get vaccinated to avoid the risk of severe complications from COVID-19. Its Chief Medical Adviser, cardiologist Professor Garry Jennings, said Australians should feel very confident that only those vaccines that met high Australian safety standards were being rolled out. “We encourage people with cardiovascular disease, which includes heart disease, blood vessel disease and stroke, to get vaccinated as soon as possible as they are at higher risk of severe complications from COVID-19,” Professor Jennings said. “This includes people who have heart disease and heart failure, as well as people who have previously had a heart attack or stroke,” he said. People whose blood pressure was high and those with diabetes were also encouraged to get vaccinated as soon as it is available to them.
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IN THE NEWS
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GUEST COLUMN
COVID-19 mid-term report card
This is an attempt to plot the COVID-19 pandemic – my view of where we have been, what we have learnt and where next.
Initial Response December 2019 saw reports of COVID-19 from Wuhan. By February, international cases exploded and Italian hospitals were overwhelmed. WA needed to close down to give us time to prepare, and we saw rapid planning, increased potential beds and ICU capacity. Thankfully, aggressive lobbying by many (led by AMA WA) prompted a border closure on March 16. We were all anxious, initially. Luckily, we had time to prepare and respond. After that initial response, however, ongoing promotion of ‘fear’ was Machiavellian (“a leader should be both feared and loved”, “but such emotions are difficult to simultaneously inspire. If you need to choose one, choose fear”). In part, ongoing border closures reflect the failure to upscale our control measures. 10 | APRIL 2021
Transmission and PPE “Watch what they do” was more reliable than “Listen to what we say”. Wuhan used full gown, glove, KN95 and goggles. They knew it was airborne transmission. Like SARS, spread is mostly droplets +/- surface but we saw early examples of aerosol super-spreading (such as singing). Ideally you use N95/FFP2 masks especially in high-risk scenarios such as COVID wards, aerosol procedures, and hotel quarantine. Surgical masks are probably adequate for use outside of these high-risk scenarios – noting eye protection should also be used. Pending vaccination, the best PPE should be available to all highrisk workers but shortages have not been fully resolved.
Lockdown in retrospect We saw businesses pivot to work from home and private schools moved to virtual classrooms. Lowincome manual workers were those most affected by retrenchments. Education Minister Sue Ellery did a great job by implementing distance learning in public schools.
Dr Kempton Cowan led the JHC response to 81 infected Artania passengers, with no transmission to healthcare workers. Dr Robyn Lawrence successfully led hotel quarantine of more than 38,000 individuals, with only one worker infected and no community transmission.
COVID-19 indirect effects Health: we have daily numbers but lack metrics of community consequences. Lockdowns and anxiety led to less health care, and telehealth is a partial substitute. Blood pressure monitors sold out as quickly as toilet paper. There’s no substitute for a physical examination. Locally, we’ve seen a reduction in influenza, but it will be years before we know how many more mental health, cancer, and cardiovascular deaths we face. In contrast, systems such as EuroMOMO reliably track and quantify ‘any cause’ excess deaths.
Vaccines & borders With early control measures, life in WA quickly returned to a new-
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It’s 15 months since COVID-19 first raised its ugly head and academic physician and cardiologist Dr Paul Langton has been tracking its course.
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GUEST COLUMN
normal. Most healthcare workers will be vaccinated in phase 1b (due March 22, pending the implementation plan). Extra groups are agitating to be in 1a, but it is hard to justify. Many are speculating that one vaccine is more effective than another. Individual trials were done in different populations and times (recent trials have included COVID-19 variants) and cannot be easily compared. Without head-tohead data this is just speculation. To date, all vaccines prevent serious disease and death. To help global equity, CSIRO is manufacturing the ChAdOx (Astra Zeneca) vaccine in our region. But until we have a global roll-out, new dangerous variants will arise in un(der)-vaccinated communities. In the medium term, will vaccination passports be sufficient for politicians to allow travel? New variants may be just ‘scariants’. The ‘abundance of caution’ response dissolves with experience. New variants can be controlled by
existing measures but the effective implementation of these measures is a greater question. • B.1.1.7 (UK) is outrunning others in Europe and USA. It remains vaccine-responsive, is more serious and about 50% more transmissible. • B.1.351 (SA), P.1 (Brazil) & B.1.526 (NY) are partial immune evaders, hence 30-40% reduction in vaccine response, and risk of re-infections.
Politics of fear We elect politicians to make political decisions, but they have been misusing ‘best medical advice’ (which is always qualified) for political gain. In most cases, prolonged state border closures have not been well justified. NSW has shown that COVID-19 can be managed with the combination of hotel quarantine for returned travellers, hygiene, social distancing and well implemented test, track and trace. Victoria was the opposite end of the spectrum (hotel quarantine outbreaks, prolonged
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lockdown and 89% of Australia’s deaths); and WA was mid-range.
Scientific bullying Finally, thoughts on the scientific process. Science evolves, in this case in a rapidly changing landscape. Individuals will struggle to keep on top of all the new information. And we can all have slightly different interpretations of studies and personal views. Some will be speaking for organisations, others influenced by political bias. But an overriding consideration is that we should be able to have mature debate of the issues. However, recently some people have been bullied about their perspectives on COVID-19. We don’t have to necessarily agree with their views, but we should absolutely oppose any non-scientific debate. Please be mindful of this, particularly on social media.
APRIL 2021 | 11
Q&A with... Dr Andrew Miller One of the loudest voices in WA’s efforts to control COVID-19 has been that of the Australian Medical Association WA president.
MF: Many West Australians follow your advice and believe you have been a consistent voice during the COVID-19 pandemic. Was that a gap you felt you needed to fill? AM: I speak to hundreds of experts on the ground every month and hear from many more. The emergency response to the pandemic was necessarily command and control at the outset, but in our culture where people cooperate more if reasoning is explained to them, that left a vacuum. There was a real thirst from the community for explanation and context that the government was unable or unwilling to supply in a timely manner. Our members were, for the first time in their careers, going to work not knowing what the risk to them and their families would be, and they had a lot of issues with the response and lack of information. Still do. If we had not been in a position to put their point of view openly and honestly, then there would have been a lot more anxiety, and if there had been a large outbreak it would have been an unmitigated communications and implementation disaster, as we have seen around the world. Governments, no matter how well intentioned, just have no idea what it is like, or what will work, at the coal face.
12 | APRIL 2021
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Q&A MF: There has been a review of the hotel quarantine program in WA and the State Government has conceded to changes. Do you remain concerned that this is still an area of significant vulnerability? AM: The (Tarun) Weeramanthri report is excellent. He is the first Australian government expert to take the issue of airborne spread seriously; to call it out for what it is and recommend changes to prevent it. It was always our view that ‘hotel quarantine’ is an oxymoron, but with appropriate administration, workforce and engineering changes to ventilation, buildings that used to be run as hotels can be repurposed with sufficient resources and will. We have COVID-19 variants of concern, some that may even evade the first vaccines, and we are having an increased number of COVID-19 positive returning passengers so quarantine will remain our Achilles heel for a long time. MF: We need good uptake of COVID-19 vaccines but there is still some hesitation among sensible people. What do we need to do to get them over the line, and would you ever support a punitive approach? There are three main groups in my view – those who will always have a vaccine, those who never will (less than 2% are true antivaxxers) and the hesitant. Usually emphasising the enormous success of previous vaccines, the safety profile that is growing rapidly in the real world with the new vaccines is helpful, but the reality that COVID-19 infection is a much worse option is the main point. This is a nasty virus and a growing group of ‘Long Covid’ patients is showing that death is not the only bad outcome from the infection. MF: Are you concerned that many people don’t really understand what the currently available vaccines can do – which is to limit serious disease – with many wrongly believing the vaccines prevent infection? AM: It is a scientific nuance that the disease can still be spread by the vaccinated and as such not many lay people understand this or the importance of it in a partially immune population. This especially holds true until we have
children vaccinated. What we hope is that time will show the vaccinated spread the disease a lot less than others, while protecting the vaccinated, and the mRNA candidates in particular look promising in that regard. MF: Are governments putting too much weight on vaccines as the way out of the pandemic? AM: No, the vaccines really will be our way out of COVID-19, but they are making some assumptions that will be tested over time. We hope most people in Australia will comply soon with common sense as usually they do, but some safety incident or supply problems with the program could slow that down. WHO estimates that it will take seven years at least for most of the world to have some sort of COVID-19 vaccine and in that time variants of concern will continue to arise as will long-haul infected patients. Some of these will evade the early vaccines so a successful long-term vaccine strategy will be required, hopefully with local manufacturing of a wide range of effective and nimble vaccines. Some sort of vaccine passport will also be necessary as an administrative aid to travel and employment. MF: Are you concerned that other aspects of health care are languishing while all eyes are on COVID-19, creating a “syndemic” or perfect storm for rising rates of non-communicable diseases such as obesity and type 2 diabetes? AM: The excess death rate measure in countries that have large COVID-19 outbreaks shows higher mortality from all the noncommunicable diseases as a flowon effect. We would expect that here we will do better, of course, but we are no doubt building up a larger long-term burden of disease as a result of the distraction of the pandemic. GPs will again bear the brunt of trying to care for this, even as the MBS review cynically tries to reduce their resources by targeting dollars without addressing outcomes. The narrative of the doctor scamming the system needs to be forgotten and community practice valued for the amazing asset that it is in Australia.
WA has not so much dodged the COVID-19 bullet by its hard border approach but merely delayed the inevitable. What is your view? AM: The political tussle between NSW and the border control/ elimination states has moved to a new footing with the arrival of vaccines. The roll-out is simply being used as another lever by NSW to posture about border control. As it stands, hopefully the vaccine program will be effective enough on both transmission and disease to keep us safe for the medium term from big case numbers, which is just as well as our state health system would collapse quickly into lockdown in those circumstances, just like Victoria did in 2020. MF: What remains WA’s greatest weak spot when it comes to COVID-19? AM: Quarantine arrangements and ports are our weak entry spots, along with the lack of PPE and ventilation required to prevent airborne spread in all the places it happens in large outbreaks. We have good fomite and droplet controls, leaving airborne as the weak transmission point. We need to fix this, starting with quarantine but also in aged care, which has all the other issues of staffing too, healthcare, and all workplaces. Our previous slack workplace safety culture in healthcare has left us very vulnerable. No mine site would be allowed to operate the way we run healthcare. We need health and safety reps, proper training, hierarchy or risk controls and literacy in occupational health and hygiene in all facilities. Carbon dioxide monitoring with readings under 600ppm are the modern version of the Nightingale wards, where the windows would always be open to fresh air.
Read this story on mforum.com.au
MF: There is an argument that
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The rise of private EDs Patient demand for private hospital emergency care is surging in Perth, as the number of beds is set to more than double.
Cathy O’Leary reports.
Perth’s emergency medical care landscape will be reshaped over the next 12 months, and new figures suggest plans to open up more private capacity is on the money. With 24-hour emergency departments due to open at Hollywood Private Hospital and St John of God Subiaco Hospital, the number of private ED beds will be boosted by more than 60%, increasing from 20 to 54. Figures obtained exclusively by Medical Forum show there is already strong appetite in the community to bypass the overloaded public hospital system and use private EDs, even with a non-refundable fee of about $200. It comes as Perth’s public EDs, despite having relatively low rates of respiratory infections as a welcome by-product of COVID-19 precautions, struggle to see even the most seriously ill patients within recommended times, causing record ambulance ramping.
14 | APRIL 2021
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SPECIAL REPORT
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SPECIAL REPORT St John of God Murdoch Hospital – currently the only operator of a 24/7 privately-run ED – treated more patients last year compared to 2019, despite being plunged into four months of low activity because of the pandemic. Data shows that last year the ED treated 21,674 patients, or an average of 59 patients a day, which was more than the 21,564 patients treated in the pre-COVID year 2019. Back in 2015-16, there were about 18,500 presentations.
Record number of ED cases The last four months of 2020 was its busiest on record. In December, the ED saw an average of 77 patients a day and broke its daily record for the highest number of patients treated, seeing 109 patients in one day. Murdoch ED’s director of emergency medicine Dr Jason Fitch told Medical Forum that, so far this year, the number of presentations was even higher than last year, averaging 68 a day. “When Fiona Stanley Hospital opened, we experienced a drop off in presentations to our ED, however, we are currently exceeding pre-FSH presentation numbers,” Dr Fitch said. Patients pay a $195 attendance fee and there can be other fees for imaging and pathology but the hospital says it is trying to reduce the costs by placing price caps on those services. Dr Fitch said many of the patients who used the Murdoch ED were “repeat customers” who used it as their preferred provider of emergency medical care. The top reasons for presentations were abdominal pain, chest pain, falls, shortness of breath and postoperative care. Dr Fitch said he expected minimal impact on patient numbers once the new EDs opened in Nedlands and Subiaco, given 80% of Murdoch’s cases came from the local area.
Time is right After a bumpy 12 months because of the COVID-triggered downturn
in elective surgery, private hospitals now believe offering emergency care is part of their road to recovery. They argue the time is right for more private EDs, with more patients keen to avoid lengthy waiting times for treatment at public hospitals. Construction has already begun on Hollywood Private Hospital’s $67 million ED, which is expected to open in mid-October this year. The 14-bed facility will have a resuscitation room, plaster/ treatment room, consultation spaces and three 30-bed wards to accommodate emergency patient admissions. SJG Subiaco Hospital’s 20-bed ED will open at the end of the year or early in 2022 and is expected to initially open 12 beds before scaling up as demand increases. Both hospitals expect to charge a similar fee to that billed by SJG Murdoch – about $200. Hollywood’s CEO Peter Mott said primarily it was about offering a purposebuilt private emergency service north of the river. Mr Mott, who is vice president of the Australian Private Hospitals Association, is confident three private EDs are viable in Perth, including two in the western suburbs. “We know that with an increase in, and the ageing of, the population, the demand for emergency care is increasing and will continue to do so,” he said. “Compared to most other states, in WA we are under-represented in private emergency departments, so we’re confident that based on our approach to timely patient care, our ED will be well utilised by people north of the river in Perth.” SJG Hospital Subiaco CEO Professor Shirley Bowen agrees, citing cities such as Adelaide and Brisbane which have more than one private ED.
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“With the ageing of the population, even just in the catchment of Nedlands, Subiaco and other western suburbs, I think (there is enough work for two units),” she said.
Captive audience It is no secret that the attraction of opening private EDs is not necessarily the units themselves –which are often barely financially sustainable – but rather the flowon effect to the whole hospital in terms of increased inpatient admissions, testing and surgery. As one hospital insider said, private EDs create a “captive and financially lucrative pool of patients”. At Murdoch, about 40% of patients who come through the doors of the ED end up being admitted to the main hospital or its short-stay unit. Mr Mott said based on modelling of other Ramsay hospital EDs on the east coast, Hollywood was planning for the expected influx of patients from the ED into the hospital. “To accommodate that anticipated demand we are building an additional 90 inpatient beds over three wards immediately above the ED, which will be commissioned as part of a staged approach to meet the needs of the ED,” he said. “Patients who choose the Hollywood ED will have access to timely care overseen by an emergency trained physician and in the event the patient requires admission to hospital, Hollywood has more than 200 regularly admitting specialists in a variety of specialties.” Professor Bowen said the main reason for the Subiaco hospital going into emergency care was because it was what its patients now expected. “The rise of the private ED in Perth is because patients with private health insurance now want an endto-end journey – they don’t want a bit in public and a bit in private,” she said. “We’ve become more than just places to have elective surgery.” “With the ageing of the population, we’re seeing people who have been to us for surgery before who then become people with cardiac continued on Page 16
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The rise of private EDs continued from Page 15 concerns or cancer, so they want to come here. “Most of our consultants work across public and private hospitals but there are still limited records in the middle of the night, so that means patients are being asked what type of cancer they have, what treatment have they had, so it can be very hard for them. “We have a massive oncology service, and those patients can become ill any time of the day or night, and at present, without us having an emergency department, if they phone for an ambulance at 2am they’ll end up in a public hospital. “We think it will be so much better to be able to provide that emergency service here.” Similarly, with unexpected complications after surgery, she said it made sense for the hospital to be able to take back patients easily at any time of the day.
Murdoch ED's Nurse Manager Gail Chambers and Jane Dobbs
Private hospital catch-up Private hospitals have undoubtedly needed to get on the front foot in WA, after a five-year-long infrastructure spending spree across the public hospital system, courtesy of successive state and federal governments. A recent national report published in Health Expectations highlighted that positive attitudes to public hospitals had risen significantly, with a 2018 survey finding that Australians were mostly satisfied with the system, although the need for more doctors, nurses and other health workers remained a major concern. Conversely, a report by the Melbourne Institute of Applied Economic and Social Research found that formerly strong growth in the use of private hospitals had eased, with this shift compounded by the drop off in elective surgery last year because of the pandemic. While national data released last month suggests some recovery, with the number of patients seeking care in private hospitals beginning to bounce back, administrators 16 | APRIL 2021
An artist's impression of the planned ED at Subiaco
know they need to be offering a bigger point of difference to the public hospital experience. Professor Bowen said the physical amenity offered in public hospitals such as Fiona Stanley, Midland and Joondalup was of a very high standard so private hospitals had to “renew and refresh”.
“But a building doesn’t make good health care, it’s the people, the timeliness of the service and we think that’s what we can give people,” she said. “If you look at the waiting times at Sir Charles Gairdner Hospital, and the people who go to Royal Perth, and you look at how
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SJOG Murdoch
busy Joondalup is, this is a large catchment and there’s enough work for all of us.”
Downside of public EDs Avoiding long waiting times at public EDs – either ramped on ambulance trolleys or just waiting to be seen by a doctor – is a major advantage drummed home by private hospital EDs. This is especially so when Perth is experiencing record ambulance ramping times – the term used when hospitals take longer than 30 minutes to take over the care of patients from paramedics. So far this year, ambulances have been ramped outside Perth public hospitals for an average of 728 hours a week, compared to the weekly average in recent years of 465 hours. Last month, it was not unusual for public EDs to be treating only 75% priority 1 life-threatening cases within 15 minutes – well below the target of 90%. On some days, only about half of priority 3 patients were seen within the recommended 60 minutes, well below the target of 90%. Professor Bowen said patients in private EDs could expect more timely treatment and more choice
for consultant-led care: “It’s a senior doctor seeing you, not an intern, and you have faster service and better access to tests like MRIs, and hopefully wrapped around with our culture of service and compassion as well,” she said. While no one disputes public hospitals mostly provide high quality emergency care, private EDs also have another benefit which is less about medical treatment and more about the experience. They are far less likely to have the aggressive, drunk and drugaffected patients and visitors, which are now a routine part of life for the big public tertiary sites, often requiring a significant security guard presence. “The experience in a public emergency department is potentially chaotic and there are a lot of drug-related injuries and issues presenting, and the reality is that can be quite unpleasant for people who are unwell, particularly older people,” Professor Bowen said. Mr Mott said it also made sense to think that additional emergency department capacity would take pressure off existing public hospital EDs, given a significant proportion
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of patients attending public EDs had private health insurance. “We are liaising with Sir Charles Gairdner Hospital and St John Ambulance to ensure that we can work together as part of the health care system's emergency capability and hopefully take some of the pressure off public hospital EDs,” he said.
Doctors are keen Professor Bowen said a survey of its doctors showed that many younger consultants and those involved in emergency, trauma, orthopaedics and other specialties were keen to have the ED. “I think our doctors can see that people with private insurance don’t want a segmented experience, so they’ve really come on board with the concept in the last couple of years, and they realise it’s time,” she said. “It’s about providing high level inpatient care all the time and providing complex care to complex patients. Private health insurance is expensive, especially when times are tough, so people really want value for money, and emergency care is something we should be offering.”
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My Health Record: the good, the bad and the path ahead It hasn’t been all smooth sailing for Australia’s most ambitious digital health information system, as Dr Karl Gruber (PhD) explains.
My Health Record is a nation-wide scheme that hopes to serve every Australian, providing quick and secure access to virtually every type of health-related information. It aims to be an online repository for everything related to a person’s health. Today, according to official statistics, about 23 million My Health Records have been created and more than 2.5 billion documents are being stored in this system. There are currently 187,000 documents uploaded by GPs and viewed by other approved users; 322,000 documents uploaded by public hospitals and viewed by other healthcare providers; and 271,000 documents uploaded by public hospitals and viewed by other approved users. But, despite the impressive stats, not all GPs are on board and not all patients are happy or even aware that their information is on the system.
The vision Launched more than nine years ago, My Health Record (MHR) is the Australian Digital Health Agency’s 18 | APRIL 2021
(ADHA) effort to centralise everyone’s health information into one online database. The system contains a wide range of healthrelated documents from patients, their healthcare providers and Medicare. Documents can include a patient’s medical history, a list of medicines prescribed, currently and in the past, test results such as pathology tests, referral letters sent by doctors, and any other information relevant to a patient’s health. The vision behind the database is to create a one-stop health hub that doctors and other healthcare providers can easily access to get up-to-date information about a patient’s health history. Ultimately, the goal is to help the patient get the best treatment possible. The promised benefits of implementing this system include reducing instances of adverse drug events or duplicated services, enhancements of a patient’s ability to manage their own health information, and an improvement in the time it takes to gather a patient’s health information.
The Good Dr Steve Hambleton currently acts as independent clinical adviser to the ADHA, providing clinical advice on the MHR. According to Dr Hambleton’s own experience, MHR can make a big and positive difference in the treatment of some patients. He recalls an event involving his mother, who suffers from dementia, who one day developed chest pain and was taken to the hospital. “When she got to the hospital, they would have said, ‘how are you?’ She would have said, ‘I'm fine’. And if they asked, ‘did you have any chest pains?’ she would have said ‘I’m fine’. She would not have been able to give a history and she certainly wouldn't have been able to tell them anything about her past history,” Dr Hambleton said. continued on Page 21
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My Health Record continued from Page 18 Luckily, this is not what happened, as all of his mother’s medical records were available to hospital staff, providing all the information they needed about her past medical history. It is very likely that many other patients would have similar experiences, benefiting from having their health information online, ready for a health care provider to use it in a time of need.
The Bad Despite good intentions, MHR is not everyone’s cup of tea. For some GPs the decision to avoid MHR is as simple as having no need for it. Some practices have already invested significant time and resources in their own medical software, which meets their every need. So why change? For other GPs, the reason to optout from MHR goes deeper, into the heart of good medical practice. Between July and October of 2018, MHR took an “opt-out” strategy, where all Australians were automatically enrolled in the system, and those who didn’t want to be had to “opt out” and actively request MHR to remove their information. While this approach might make sense when your goal is to enrol as many participants as possible, there is a crucial element missing. According to one Perth-based GP, MHR fails a fundamental pillar of medical practice: informed consent. “I don't use it because patients have not given their informed consent in the majority of cases,” he said. “It should have been more a patientcentred model rather than a blatant day grab central model.” However, the “opt-out” strategy might have been a necessary evil. “As a consumer advocate it can feel risky to be supportive of optout rather than opt-in strategies. However, the opt-in strategy was given a (very) long lead time with little result, whereas since the opt-in more than 22 million Australians now have a My Health Record,” says Pip Brennan, executive
director of Health Consumers Council WA. But among these vast number of records, it is likely that a significant number of Australians are unaware of their own record. “Our best guess is that many people with My Health Records don’t realise they have one. There are impressive stats on the number of documents that are uploaded, but what this actually means for patient care is questionable,” Ms Brennan said. Another issue raised by doctors is that MHR is not a comprehensive medical history, but a collection of key documents made since the date of creation of the record, and maybe only a summary is shared by your GP. However, this may reflect the need to better understand what can go into MHR and from where. According to Dr Hambleton, whatever health documents are uploaded into MHR are available to subsequent health care providers and the owner to peruse. In the case of the record owner, they can even restrict or prevent access to it, as they see fit. Security and privacy have also been raised as concerns. MHR keeps track of all access to your
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record, with all accessions being recorded in the record history and patients can get notifications via email or SMS whenever their record is viewed. However, while MHR is only accessible by a patient (and their nominated or authorised representative) and health care providers, it is not 100% clear who exactly is looking at your record. “When I look at my health record, there are many interactions with a doctor I’ve never heard of who reviews pathology tests. It doesn’t paint a very clear picture of my health care team,” Ms Brennan said. Dr Hambleton said there were strict penalties for privacy violations including up to five years’ jail and loss of registration. Ms Brennan raised consumer concerns that notations such as a drug and alcohol history, a blood-borne virus, mental health diagnosis etc. could negatively impact the care they received. While she acknowledged that this was not the fault of MHR, “stigma is a very real concern and can’t be cured by technology.” In this regard, Dr Hambleton says that details about drug or mental health issues would only come from GP-shared health summaries. “The GP that shares the health summary is someone who knows the patient well and a GP will generally be very sensitive to what continued on Page 22
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My Health Record continued from Page 21 they share. Similarly, those who author discharge summaries are aware that the information will be shared with both the patient and the patients’ health care providers,” he said. “I have discussed this with my mental health patients and explained that the only person authorised to look at a MHR is the person providing contemporaneous health care. That information has provided them with comfort.” What this means in practice is that patients can and should discuss with their GPs who can have access to sensitive information. Patients should also be informed that, at any time, they can restrict or delete any of their records. However, sharing information such as a blood-borne virus is in the best interest of a patient’s care. “Not knowing someone carries
a blood-borne virus or who is immunosuppressed could be at substantial risk from something as simple as a shingles vaccine, which could be lethal,” Dr Hambleton said. Overall, MHR was certainly a better alternative than paper-based records. “With the current paper-based system, we have absolutely no idea when our record is being accessed. There is obvious potential for My Health Record to better protect privacy,” Ms Brennan added. Instead, with MHR, you have the option to manage your record, invite someone you trust to manage it and decide who has access to your documents. There might be security risks, as with any complex system, and maybe the opt-out approach was a bit arbitrary but, at the end of the day, Australians now have total access to important information about their health, Ms Brennan said.
“Section 8.4.6 of the AMA’s good medical practice guidelines notes the importance of ‘Recognising patients’ right to access information contained in their medical records and facilitating that access.’ Arguably, My Health Record aims to do just that,” she said. Work remains, however. For example, improving the way data is added to the record. Ms Brennan recalls her own experience trying to get a test result uploaded. “There was no box to tick to say I did want it on My Health Record. The sonographer told me to ask reception staff, but I was advised that it wasn’t possible,” she said. Another important change involves aged care. Today, more than 1.2 million Australians live in aged care facilities, according to Australian Institute of Health and Welfare. Medical Forum asked various aged care facilities in WA about their use of MHR, and all of them had the same answer: they don’t use it.
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Implementation of MHR into aged care facilities should avoid these medications errors and provide an accessible system to obtain vital information about their residents when they need it the most.
More specifically, this recommendation requires that all aged care facilities implement a system that used My Health Record by 1 July 2022. By this date, every approved provider of aged care delivering personal care or clinical care should: • use a digital care management system (including an electronic medication management system) meeting a standard set by the Australian Digital Health Agency and interoperable with MHR • invite each person receiving aged care to consent to their care records being made accessible on MHR • on consent, that person’s care records (including, at a minimum, the categories of information required to be communicated upon a clinical handover) are kept up to date.
These concerns with aged care are reflected in the final report of the Royal Commission into Aged Care Quality and Safety released in March. Among its 148 recommendations was: “Universal adoption by the aged care sector of digital technology and My Health Record”.
Ms Brennan says she would like to see the record evolve from a ‘drop box’ of PDFs into an actual digital record. “Imagine having an easily accessible graphical depiction of your bloods so that you can track any improvement that lifestyle changes may be making to your liver function, for example,” she said.
This needs to change, Dr Hambleton said. “You would be horrified by the number of medication errors that occur in transitions of care from residential aged care facilities to hospitals and back again,” he said. “The main reason for these errors involves multiple medication lists. “There's a list of the patient’s medications at the facility, another at the pharmacy that looks after the facility and there's a third list that is in the software at the GP surgery. All three of those are often different and that is a recipe for chaos.”
“It would also improve public confidence if there was a specific My Health Record app (created by a non-commercial organisation like CSIRO). Not a web-based link to My Gov or one of the three current third party apps that may be harvesting, packaging, and reselling data in unspecified ways and that are not contributing to research and improved health outcomes.” There are two apps that can show users what information is in their record. One is called Healthi and the other is Healthnow. “Both apps have passed strict privacy requirements,” Dr Hambleton explained. “No data that is viewed is stored on a patient’s mobile phone. It disappears as soon as the app is shut down.” My Health Record has some important work ahead before this ambitious system can become the promised panacea of data, able to efficiently store the health information of all Australians – and make everyone happy.
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Living (to the max) with type 1 diabetes A diagnosis of type 1 diabetes hasn’t held back Bec Johnson, in fact it’s shaped her life, as she tells Cathy O’Leary.
What Bec Johnson doesn’t know about type 1 diabetes is probably not worth knowing. The 37-year-old arguably knows as much about the precarious relationship between blood glucose and insulin as an experienced endocrinologist — because she’s made it her business. However, her expertise is not gleaned from textbooks but rather the nitty gritty of living with an autoimmune condition that she knows, if left to its own devices, could prove deadly. It hasn’t been an easy ride, juggling a daily tightrope of tracking blood sugars, insulin and carbohydrate intake but she says that from the time she was diagnosed 20 years ago, it was a choice of sitting on the sidelines or diving in headfirst. After being told the long list of things she probably wouldn’t be able to do, Bec decided to do many of them anyway, but only after doing her homework. Today she is never far from water, particularly the ocean. This openwater swimmer can count four solo crossings in the annual 19.7 km Rottnest Channel event to her name.
Person + pancreas “It’s my job to be both a person and a pancreas,” she says. “I’ve always 24 | APRIL 2021
wanted to understand type 1 on a very granular level because if I don’t, it’s going to be hard for me to function day to day, let alone do those big goals like swimming to Rottnest.” Other “big goals” she has managed to tick off include sailing across the Atlantic and becoming a scuba dive guide – activities she was warned would be nearimpossible. When she is not swimming, she is often found at the Type 1 Diabetes Family Centre, which she helped establish in Perth five years ago. She works as its chief executive, helping young people and families get their head around managing the condition that affects about 170,000 Australians. Her motivation for the centre was borne out of her own struggle with the lack of social support. “The first conversations I had when I was diagnosed were about the risks and the challenges, and there was quite a negative frame around that diagnosis,” she says. “In my 20s I didn’t know anyone else with type 1 diabetes, and I remember going to work on a boat
and getting a medical which said I couldn’t sail more than five miles offshore, and my job was to deliver yachts across the Atlantic. “And when I wanted to scuba-dive I had to jump through a hundred hoops to do that, and those barriers really drove me to find the answers or formulas.”
Adaptation Ocean swimming is one of the most difficult sports to manage around diabetes because cold water immersion impacts blood glucose levels and strenuous exercise. Eating and absorbing carbohydrates is a major challenge, as is keeping track of blood glucose when you’re out in the ocean and can’t prick your finger to do a test. “But the Freestyle Libre (glucose monitoring) technology was released about four years ago in Australia, which has a sensor that runs on radio frequencies, so now I can just put the little receiver in a waterproof phone case down the back of my togs and then I’m totally self-sufficient out in the ocean,” she says. “One of the things that has always been really important to me is
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CLOSE-UP that when I see something that I’m told is too hard, whether it’s scuba diving, or swimming or sailing, or working in remote locations, I systemically go after them, just to show I can do them. “That philosophy is what we’ve built into the family centre.” Bec’s business CV is as impressive as her swimming achievements. She was winner of the 2020 Business News 40 under 40 People's Choice and HBF Community/Non-Profit/ Social Enterprise awards, and she holds qualifications in Law and Arts, a master’s degree in Public Health and a diploma in business governance. She is also an Associate Fellow of the Australasian College of Health Services Management. Bec believes having type 1 diabetes has shaped who she is, and she respects that. “Type 1 diabetes has given me a powerful sense of purpose and drive, and I think that when you live with type 1 you spend a lot of time feeling uncomfortable or unwell, and grinding through anyway, she says. “So, when you take on a big challenge and you can stick with it, feeling uncomfortable but doing it anyway, it builds resilience. “People with type 1 juggle 180 decisions every day on top of their normal daily decisions just to manage their blood sugar. And they show up for life, sport, travel, schools and partners, and I think that’s extraordinary.”
Bec at work at the Type 1 Diabetes Family Centre
Life-absorbing Still, type 1 takes up a lot of bandwidth, and when it’s not stable, a lot of energy goes into constantly trying to manage sugars in a very tight range. Bec does not sugar-coat the complexity of that. “You’re not only physically impacted, you’re mentally fatigued,” she says. “Some days it does overwhelm me, and feels too hard, but I’m committed to not only sharing the
triumphs and the successes, but also the low points because we’re all human.” Bec said the family centre not only helped support people with type 1 diabetes but its online community of 1000 people had developed into a valuable knowledge base for clinicians. “This disease is something that people live with 24 hours a day and they become experts in their own diabetes very quickly, and we have this opportunity to work in partnership with the clinical community, as consumers,” she says. “We can elevate our own knowledge as a community, working with clinicians who are interested in that interplay between the patient and the provider, in a very different partnership model. “What I love is that people with diabetes will question and challenge the status quo in pursuit of better managed blood glucose because we get this instant biofeedback, and we feel better when something goes right for us and we want to share it. “We have people in the type 1 community experimenting with continued on Page 27
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CLOSE-UP
Living (to the max) with type 1 diabetes continued from Page 25 totally novel approaches, such as food for example, with low carbohydrate diets, or DIY closed loop automated insulin delivery systems, which is pushing the commercial system harder. “The type 1 community is doing it for themselves, and there’s a whole movement globally called “We are not waiting” and it’s around changing diabetes technology to better suit the needs of people with type 1, and not waiting for commercial systems to catch up. “It’s a community that is pushing the boundaries, and that’s very exciting.” Bec never shies away from the serious and deadly complications from unmanaged type 1 diabetes, and how easily that can happen even in someone very much on top of their condition. “It remains a daily experience, and there are 42 factors that have been identified that influence and impact blood glucose levels, it’s so much more complex than carbohydrates and insulin as the input, but that’s the formula we have to work with.
Night dangers “I’m usually pretty good through the day because I’ve got my eye on it, but it’s during the night when things can go wrong and you can’t pay much attention to it, and that’s where things like the continuous glucose monitoring subsidies that the government brought out for people under the age of 21 have been amazing. “We’d love to see that extended to all adults because it’s such an important safety net. “To be able to have something that will set off an alarm during the night and wake me if my sugars are trending low could prevent a few sketchy moments.” Bec says she is fortunate that the number of scary moments she has experienced can be counted on one hand. Everyone makes bad decisions, but for people with type 1 diabetes that can be life-impacting. “Diabetes takes a lot of careful attention, and when your head is
full because you’ve had a big day, and you make a snap decision or accidentally take the wrong insulin, you have to pick up the pieces for hours or a whole day,” she says. “Twice in my life I’ve had low blood glucose where I’ve needed assistance from somebody else, and that’s very scary being in a state where you can see what’s happening, but you can’t help yourself, and that’s really motivated me to do what I can to manage my diabetes. “In the type 1 community, 20% have an assisted hypo once every six months, so it’s a very real thing that can happen with a miscalculated carbohydrate amount or a tiny mistake on insulin. “We’re always walking on a tightrope.”
Taking control For a long time Bec was afraid of going out for dinner with friends and the consequences of what food she chose. These days she takes it in her stride. “I’d love a day off from all the planning and dissecting menus and the calculations, which can all be exhausting, but it’s my normal,” she says.
which is rich and interesting and makes me happy. Food shouldn’t be all about numbers, it’s got to be about joy and community.” Bec would like to see more continuing education of health professionals, including GPs. Half of all diagnoses are in adulthood and many of these people are not getting the support they need. She would like to see more holistic care. “It’s not just a medical model, it’s also about more education, family and peer support, and practical know-how to managing diabetes,” she says. “GPs are very important in the management of type 1 diabetes because people end up in front of a GP far more often than they end up in front of their endocrinologist. It’s important they’re looped in, because they’re helping to manage complications, screening and referrals, so they can really be a hub in diabetes management. “People with type 1 are also prone to mental health issues so it’s important GPs do that check-in with their patients, because no one else might be doing that part of the puzzle.” www.type1familycentre.org.au
“I focus on what I’ve got, rather than what I haven’t. I have a diet
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Keeping young at heart Dr Karl Gruber (PhD) reports on home-ground research kicking goals for heart health.
A love song can help with a broken heart, but major lifestyle changes are needed to fix an ailing one. As we age, our body starts to do things we rather it didn’t – our hair turns grey (or falls out altogether), our joints ache, our skin wrinkles and our eyes and ears don’t work as well as they did. It is all part of growing old, some say. But there is one affliction of ageing that should never be dismissed as normal: an ailing heart. Heart-related problems are the number one cause of death worldwide, killing nearly nine million people in 2019. In Australia, heart-related problems caused 41,800 deaths in 2018, mostly due to coronary heart disease and stroke, the two most common forms of heart disease. The good news is that, for most people, heart-related conditions are preventable. Changes in lifestyle such as improved diet and more exercise can have a positive impact on the functioning of the heart.
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FEATURE
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FEATURE With these issues in mind, two Perth-based research teams are looking for the best way to improve heart health. Researchers, led by Professor Daniel Green, Professor of Exercise and Sport Science at the University of Western Australia, were recently awarded a major grant from the National Health and Medical Research Council (NHMRC) to examine whether exercising at a young age could have lasting benefits in heart health.
Starting early A 2017 study in rats showed that juvenile rats exercising five times a day for four weeks had a 36% increase in the number of heart cells. “This study showed that exercise resulted in a substantially larger number of heart cells (20 million more) and 15% larger heart size in later life,” Prof Green said. Finding that exercise can lead to such large increase in heart cells is a big deal as the current dogma is that we have, from birth, a fixed number of heart cells. “Although we knew that heart cells could increase in size with exercise training, the heart was previously considered incapable of growing new cells after birth,” Prof Green said. “If true in humans, it would have profound implications for lifelong heart function and health.” If these results hold for humans, there are significant implications for public health policy.
incredible commitment and generosity of the participants,” Prof Green said. “It is richly characterised, including adiposity, fitness, nutrition, sedentary behaviour and other risk factors across the lifespan of the children, who are now approaching 30 years of age.” Today, the Raine Study has amassed data from gen1, as well as from their children and grandchildren. Even the parents of gen1 have been studied. This massive and unique dataset is now fuelling Prof Green’s project over the next three years as well as other projects.
Risk profiles “Our project uses retrospective data and newly acquired data,” he said. “The retrospective cohort data will be used to determine what risk factor profiles in young people are related to (predict) the echo measures of adult heart structure and function that we will collect.” More specifically, this new project will address questions such as how accurately foetal growth can predict the health of an adult’s heart and arteries; whether engaging in physical activity during childhood and/or adolescence results in improved heart and artery health; and at what stage of life is it best to intervene with exercise to optimise adult health outcomes. While this project gets off the ground, Prof Green and his team have identified a simple way to improve the health of arteries without the need of drugs: exercise. In a study published last month, in the journal Hypertension, he reports that exercise can directly boost artery health.
In this new project, Prof Green is taking advantage of the Raine Study’s significant dataset.
In this study, the team addressed whether exercise alone was sufficient to improve artery health in middle-aged men. The study also evaluated whether low-dose testosterone supplementation provided significant benefits to artery health and function. Previous studies have suggested that testosterone supplementation may help improve health outcomes in middle-aged men, but not everyone is on board with this observation.
“The Raine Study possesses in utero and longitudinal developmental data of the gen1 offspring, with a high ongoing participation rate based on the
“Earlier studies showed that men who had higher testosterone levels and who were more physically active had better health outcomes. However, that could have been
According to Prof Green, this research raises important questions. For example, when is the best time to apply early health interventions for CV prevention? Or how is the health of your heart influenced by environmental factors during childhood or even in utero.
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because those men were generally healthier at the outset,” said Professor Bu Beng Yeap, from the UWA Medical School, who co-authored the study.
Testing testosterone “We needed to do a randomised controlled trial to find out whether giving men a combination of testosterone treatment and exercise training would improve artery health more than either alone, or neither,” he said. The study recruited 80 men, aged between 50 and 70 years, with no history of heart disease and with low-to-medium levels of testosterone. The men were assigned to four groups, either i) receiving a testosterone supplement and exercising for 12 weeks, ii) doing exercise without the testosterone supplementation, iii) receiving only testosterone or iv) neither receiving testosterone nor exercising. After analysing their data, the team found that only the participants who exercised had artery health benefits, with participants exercising without testosterone supplementation having the highest improvement: artery function improved by 28% in this group. “Our key findings were that exercise training improved artery health, but testosterone treatment did not. We were surprised, as we had expected that men receiving both testosterone treatment and exercise training might have the largest improvement in artery health, but testosterone didn’t add anything to the benefit of exercise,” Prof Yeap said. The findings of this study send a strong message to men aged 5070 with a waist circumference of 95cm or more: they can improve the health of their arteries by doing regular exercise. The recommendations are in line with official guidelines from the Australian Department of Health (DoH), which warn that “for men, waist circumference of 94cm or more indicates an increased risk of chronic disease.” continued on Page 33
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FEATURE
Keeping young at heart continued from Page 31
Lifestyle matters Beyond exercise, following a healthy diet is another key aspect affecting heart health, especially in people with early signs of heart disease. Jonathan Hodgson, Professor of Nutrition and Epidemiology at the School of Medical and Health Sciences at Edith Cowan University, is a director of the WA Cardiovascular Research Alliance, which was set up in 2019 to unify heart, stroke and vascular disease researchers. He is leading a study that aims to improve the diet and lifestyle of older Australians. High intake of fruits and vegetables as well as regular exercise are well established ways to prevent cardiovascular disease. For adults, the DoH recommends a bit over five servings of vegetables a day (alongside other healthy foods). For exercise, official guidelines recommend 2.5 to five hours of moderate intensity physical activity a week or 1.5 to 2.5 hours of vigorous intensity physical activity. But the reality is that only a small number of Australians follow these guidelines. “Increased fruit and vegetable intake and physical activity are regarded as cornerstones of lifestyle approaches for cardiovascular disease (CVD) primary prevention. However, only one in 20 Australian adults meet current fruit and veg recommendations, and over twothirds are sedentary or have low levels of physical activity,” Prof Hodgson said. In his new study, Prof Hodgson will test a new strategy to encourage people to improve their diet and lifestyle. The plan is to provide patients and their GPs with information about the health of their arteries, measured as levels
Prof Green researches accessing artery health
of abdominal aortic calcification or AAC. His goal is to provide people with a visual representation of their own level of AAC which is a marker of damage on their arteries and risk of future CVD events. With this knowledge, Prof Hodgson hopes people will make long-lasting positive changes in their diet and lifestyle.
Knowledge power? “AAC is a safe, low cost and specific marker of structural CVD that can be identified routinely in almost any individual using widely available bone density machines. AAC strongly predicts CVD deaths and all-cause mortality, independent of CVD risk factors,” Prof Hodgson said. “Our primary aim is to determine if providing an individual with knowledge of their AAC can lead to improved diet quality and levels of physical activity.” Prof Hodgson’s study is underway and expected to be completed by mid-2022. Participants of this 12week randomised controlled trial are randomly assigned to either receive information about their AAC levels at the start of the trial or at the end. Both groups receive standardised diet and lifestyle counselling via videos and after the 12 weeks participants will be evaluated to determine how well they followed exercise and dietary guidelines.
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“This is the first study in a primary prevention setting designed to evaluate the impact of knowledge of a measure of advanced vascular disease on diet and lifestyle change,” Prof Hodgson said. While the AAC test is not routinely available at this time, it is possible to capture a lateral spine image using bone density machines at the time of bone density testing, Prof Hodgson explains, and in the future, accessibility to this test might improve. “If the value of providing the AAC test results to patients and their GPs is demonstrated, then it would be easy for GPs to order this test either at the time of the bone density test or independent of a bone density test,” Prof Hodgson said. Currently, the research team is developing an automated software to help doctors with the identification and assessment of AAC, which currently must be done by experts, said AAC study co-lead Associate Professor Josh Lewis. The take-home message here is that we need to increase our intake of fruits and vegetables, as well as increase our weekly exercise levels. That is, if we want to dodge the bullet of an early death from heart disease.
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NEWS & VIEWS
New heart risk tool for GPs The development of a heart risk tool will help GPs spread the word about good heart health.
West Australians who left school early or live in regional and remotes areas are more than twice as likely to have a heart attack or stroke in the next five years, according to new data from the Heart Foundation. People aged 45 to 74 who did not finish high school are 65% more likely to be at high risk than those who did and a higher proportion of people living in outer regional and remote areas are 15% more high risk than compared to Australians living in major capital cities.
GP toolkit The figures were released to highlight a new online toolkit for GPs that aims to integrate Heart Health Checks into routine patient care to identify people at risk of heart disease. The data identifies Australians with a high absolute cardiovascular disease (CVD) risk score, defined as greater than 15% risk of a heart attack or stroke in the next five years. The findings come from an analysis of ABS health survey results to derive absolute CVD risk scores among Australians aged 45 to 74.
Heart Health Check Toolkit
Is your heart feeling your age? It only takes 3 minutes to find out. The Heart Age Calculator can help you to understand your risk of heart attack or stroke. Visit: myheartage.org
For heart health information and support, call our Helpline on 13 11 12 or visit heartfoundation.org.au
Terms of use: This material has been developed by the National Heart Foundation of Australia (Heart Foundation) for general information and educational purposes only. It does not constitute medical advice. Please consult your healthcare provider if you have, or suspect you have, a health problem. The information provided is based on evidence available at the time of publication. Please refer to the Heart Foundation website at www.heartfoundation.org.au for Terms of Use. © 2020 National Heart Foundation of Australia ABN 98 008 419 761
The Heart Health Check Toolkit was developed with input from a primary care expert advisory group and general practice validation group with GP, practice nurse, practice manager and PHN representatives. The toolkit offers pre-populated assessment and management templates for Heart Health Checks that make it easier for GPs and practice nurses to collect CVD risk factor information and support patients.
Engaging patients It also includes a range of resources that can be used by GPs to engage patients in their heart health. Heart Foundation Risk Reduction Manager Natalie Raffoul said the data reinforced that disadvantaged Australians were worse off when it came to CVD risk.
“This, combined with our knowledge from primary care data that tens of thousands of eligible Australians are not having their CVD risk assessed in line with guidelines, shows that people at risk are falling through the cracks,” she said. Ms Raffoul said the toolkit also had a section on quality improvement and the PIP QI incentive launched by the Australian Government in 2019.
Incentives “The toolkit encourages a whole-ofpractice approach so that general practice teams can improve heart health outcomes for their patients while maximising the financial incentives they can receive via the PIP QI,” she said.
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“With better processes for engaging and recalling patients eligible for a Heart Health Check, we hope to boost CVD screening rates and reach more at-risk Australians.” The Heart Health Check is the first preventative health assessment MBS item to incorporate absolute CVD risk calculation and facilitate yearly assessment. Absolute CVD risk brings together the combined risk of multiple CVD risk factors to estimate a person’s chance of heart attack or stroke in the next five years. The burden of CVD remains high in Australia, causing one in four of all deaths, or one death every 13 minutes, and accounts for 1600 hospitalisations a day.
CVD burden in WA In WA, coronary heart disease is estimated to account for 7.2% of all disease burden – the leading cause of burden. Taking into account population growth and ageing, hospitalisations in WA due to CVD are estimated to increase by 50% to 66,739 in 2025. The largest increases are predicted to occur in the 65 years and over age groups for both men and women. ED: To download the Heart Health Check Toolkit www.heartfoundation.org.au/hhc-toolkit
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Consumers weigh in on heart health Clare Mullen, Health Consumers’ Council Deputy Director, shares her view on how to approach cardiovascular health in relation to weight. Obesity is associated with a number of co-morbidities, including cardiovascular disease. It is one of the leading causes of ill health in Australia, affecting about 67% of adults and 25% of children.
was his special interest in keeping up-to-date with the latest evidence and advice around comorbidities surrounding obesity that allowed him to accurately detect her heart condition.
Health Consumers’ Council (HCC) is working with the WA Department of Health and the WA Primary Health Alliance on implementing the WA Healthy Weight Action Plan 2019-2024 to ensure that work to change health services in the area of weight and obesity is informed by the diverse experiences of people in the community.
Rachel was thankful not to be told “just lose weight and you will feel better” and was instead directed to make personalised health choices that worked with her lifestyle. Her cardiac rehab was made easier because of the education and individual support she received, including around programs to learn what mattered to her. She cited a food label reading workshop which helped her make better food choices as one positive example.
In more than 750 survey responses, more than 40% of respondents had taken action to lose weight more than five times in the previous 12 months. When asked what strategies they’d tried, 16% of respondents said they’d worked with a GP, 9% had worked with a health team using a health care plan, and 9% had used clinical interventions such as bariatric surgery. Feedback from people with experience of obesity suggests the importance of a tailored, nonjudgmental approach – one that sees them as a whole person. When health professionals help people to understand their own specific health risks relating to their weight – rather than a general comment that “being overweight is bad for your health” – this can be the key ingredient in supporting people to take action. Trust is crucial for a successful patient-clinician relationship, which presupposes the absence of judgment. Also important is a health professional’s knowledge of services and supports that are specific to their patient’s particular circumstances, rather than a onesize-fits-all approach. Rachel Locke, a member of HCC’s consumer advisory group for the project, shared her experience with heart health and how a range of factors, including long-term obesity and family history led to triple bypass surgery.
HCC’s consumer advisory group member Rachel Locke
“I never ate healthy…I put on quite a lot of weight and led an unhealthy lifestyle most of my life,” Rachel said. Rachel took up marathon training in the hope of losing weight, but was unsuccessful. During the six-month wait for surgery, she worked with her GP to address her health behaviours and access services that were personalised to her. She attributes her post-surgery success to the GP that worked with her throughout her heart surgery procedure. “I was thankful my GP was part of Hearts West, a cardiac care centre,” Rachel said. “I don’t know if I’d get the same treatment from any other GP. I wonder if [any other GP] would have been able to pick up (my heart condition).” Rachel praised her GP for his knowledge around heart health and his involvement with groups and organisations outside of the immediate scope of his role in general practice. She believes it
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When asked the one thing she would like GPs to know about obesity and heart health she said, “know who your health professionals are in your area so you can give the right service to your patient. Come from a no-judgment, no-criticism, and supportive mindset, and help your patient want to change.” Rachel found her GP’s knowledge and up-to-date evidence reassuring and hopes every health professional comes from the mindset of “one size does not fit all”. With an issue as complex as overweight and obesity, it is important to treat every patient individually and provide person-centred care. More information on the Healthy Weight Action Plan, including consumer perspectives, is available at https://www.hconc.org.au/ issues/partners-in-change-obesitycollaborative/ References on request
Read this story on mforum.com.au
APRIL 2021 | 37
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Are we really this miserable? Mental health researcher Dr Martin Whitely argues in his new book that over-prescribing is driving Australia’s mental illness epidemic. Australia has been admirably successful in limiting deaths from COVID-19, but this achievement has come at a considerable cost. Shutdowns, particularly in hospitality, retail and tourism, have cost jobs and caused business failures, and for many Australians social isolation has meant just that – isolation and loneliness. Prominent Australian psychiatrists Professors Ian Hickie and Patrick McGorry predicted that these factors would result in a spike in suicides that would overshadow COVID-19 deaths. They called on governments, both state and commonwealth, to spend hundreds of millions more to fund mental health interventions. Their call for extra mental health funding would be justified if the care on offer actually helped people distressed by unemployment, financial hardship and loneliness. But sadly, as explored in my new book, Overprescribing Madness, what’s driving Australia’s mental illness epidemic, the evidence is that far too often the pill-dominant mental health care on offer, and other alternatives promoted by mental health leaders, do more harm than good. In 2018, roughly one in six Australians took at least one mental health drug and since then prescribing rates have risen. Our reliance on pills is not new. In both 2000 and 2015, Australians were the second largest per capita users of antidepressants of the 30 OECD countries surveyed. Only tiny Iceland, with its frozen, dark, miserable North Atlantic winters, had a higher per capita antidepressant prescribing rate. This invites an obvious question: is the lucky country really that miserable? I contend that our high prescribing rates have nothing to do with Australians being disproportionately mentally ill. Rather a combination of salesmanship, questionable
medical practice (overlooked by timid regulators) and cultural, commercial and political drivers see too many Australians hooked on a cycle of over-diagnosis and overmedication. In essence: 1. Australia has blindly followed America's flawed DSM model for (over) diagnosing psychiatric disorders, and turning sadness into depression, immaturity into ADHD. 2. A few local psychiatric thought leaders who promote and extend the medicalised model have dominated Australia’s debate about mental health. 3. Most prescribing (particularly of antidepressants) is done by GPs with limited training and few other tricks in their toolbox. 4. Patients and parents often demand quick fixes. 5. Australia's drug safety regulator, the Therapeutic Goods Administration, has (despite some recent improvement) been overly industry-friendly. 6. The media have uncritically promoted 'disease awareness' and a medicalised 'see your doctor for help' approach.
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There is no denying that for many people, mental illness can be debilitating, and that for a subset of these people, drugs – when used judiciously – are helpful. But too often the drugs that are used to treat psychiatric disorders create new disorders that are managed with other drugs. Often the withdrawal effects from psychiatric drugs are worse than the initial problems they were supposed to treat. This iatrogenic suffering is often blamed on the patient’s re-emerging mental illness, and doses are increased and/or new medications are added. The result is that many patients get locked into a vicious cycle of drugs creating harm, with more drugs added to address that harm; meanwhile medication sales soar and Big Pharma rakes in iatrogenic profits (profits caused by creating harm). Some of the revelations in Overprescribing Madness may seem unbelievable, many of them are inconvenient; but Australians really are spending an awful lot of money, time and energy, following very bad advice and taking drugs that too often make them sicker, sadder and madder. APRIL 2021 | 39
Eyes on newborn’s hearing Telethon Speech and Hearing’s head of hearing services Philippa Hatch explains the benefits and limitations of newborn hearing screening. It is important to understand newborn hearing screening – how it works, what happens if a baby misses out on it in hospital, how it is different from tests in older children and its limitations.
been hugely impactful in terms of its capacity to lower the average age of diagnosis for sensorineural loss from an average age of three years to well below 12 months, it does have limitations.
The hearing assessment for children from birth to 18 years differs greatly depending on the age of the child, their developmental capability, neurological development and the target condition being investigated. Testing models range from newborn hearing screening, visual reinforcement observation to play audiometry for children aged 0-10 years.
The test
Newborn hearing screening differs from traditional hearing tests as it uses electrophysiological rather than traditional behavioral approaches to estimate hearing acuity. Whilst newborn hearing screening has
In WA, the test is performed via Automated Auditory Brainstem Response (AABR) and is an electrophysiological indicator rather than a behavioural indicator of hearing in infants.
Newborn screening is conducted in both public and private hospitals and is universally offered across WA. Testing is noninvasive and typically takes up to 15 minutes, with parents receiving a pass or a refer result. A pass result rules out all but a mild hearing loss. Abnormal results are termed ‘refer’.
Some children may fail the AABR due to fluid in the middle ear, neurological abnormalities and maturational issues. Following a refer (abnormal) result, infants are then offered a series of tests including a diagnostic auditory brainstem response test (ABR), tympanometry and otoacoustic emission testing to assess individual ear thresholds and site of lesion.
Who is it for? It is aimed at infants from 36 weeks gestation to about three months of age. Infants need to be asleep so testing can become more difficult as they age. Diagnosis is calculated from an algorithm of expected neurological results considering intensity and latency and is influenced by neurological integrity and maturation.
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Key messages
The hearing assessment of children from birth to 18 years differs depending on age, developmental capability, neurological development and the target condition.
The standard test for infants from 36 weeks gestation to three months is a newborn hearing screening.
A pass result at screening should not be considered a guarantee of normal speech and language development. Regular monitoring is recommended.
Parental understanding of typical listening behaviours of infants is inconsistent and parental anxiety often influences requests for hearing assessments.
If in doubt, an audiological assessment can rule out a range of ear health concerns and should include counselling around the typical development of listening and speaking in infants and young children.
Where infants meet certain highrisk criteria, such as having a congenital abnormality (ie atresia), they do not undergo screening and instead are referred directly for diagnostic testing.
The limitations
neurological abnormalities and maturational issues. A pass result at screening should not be considered a reflection of normal hearing nor a guarantee of normal speech and language development, especially as a mild loss may not be detected.
Sensorineural hearing losses aside, some children also fail the AABR due to fluid in the middle ear,
This is particularly pertinent given that more than half of congenital sensorineural hearing losses worsen
over time, hence a mild undetected loss may be diagnosed as a moderate hearing loss later in life. Regular monitoring of children’s hearing is recommended to rule out worsening sensorineural losses, acquired hearing loss and conductive hearing loss due to paediatric otitis media.
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APRIL 2021 | 41
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Comprehensive cancer care is now available at Hollywood Private Hospital. The opening of the world class Hollywood Consulting Centre brings together leading experts to focus on the early diagnosis, treatment and post treatment care of a wide range of cancers, all under one roof. Complementing the existing cancer services available at the hospital, patients will now receive integrated cancer care with medical and radiation oncologists, haematologists, surgeons, radiologists, nurses and clinical trial researchers all on the one campus. Patients will also have access to Hollywood’s Cancer Care Navigation service, McGrath breast care nurses and prostate cancer nurses to guide them through their treatment journey - from initial diagnosis through to post treatment care.
With mental health support available onsite at The Hollywood Clinic and outpatient allied health also on campus at Ramsay Health Plus, the convenience experienced by cancer patients at Hollywood Private Hospital is now second to none. The Hollywood Consulting Centre features: ✓ The Perth Breast Cancer Institute and Breast Cancer Research Centre of WA ✓ Perth Radiological Clinic ✓ GenesisCare radiation oncology centre ✓ The Hollywood Endoscopy Suite ✓ 37 medical consulting rooms ✓ A 280 bay multi storey car park
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COVID-21 – preparing for the next phase Health workers have another year of challenges ahead and Dr Sarah Newman urges doctors to look to their own health as a priority. In early 2020, we anxiously awaited the COVID-19 pandemic, the brunt of which was averted in Western Australia. But the absence of community spread only partially alleviated the stress on the medical community – it was still a hard year for health workers across the public, private and training sectors. Last year highlighted the critical role of healthcare worker wellbeing in patient care. Although avoiding the worst-case scenario and preparation for further outbreaks, the downstream workplace, financial and other direct and indirect stressors of COVID-19 are leading to burnout, anxiety, depression and stress reactions. So, what will this year, an era of COVID vaccines look like? How do we prepare ourselves for the uncertainty of 2021? First, we need to do the basics, ensuring our own physical and psychological safety. If nothing else, get vaccinated against COVID-19 and influenza. We are only as good as our infection control. We need to have proper PPE when at work, to avoid work when unwell, and to get tested if we have any symptoms – multiple times if necessary. Have a plan for your household should you catch the virus. Sleep, exercise and diet are also important in preventative self-care.
maybe even write times for them in your diary. Also, consider how you might meet your self-care needs in a lockdown.
Psychologically, we need to feel open to discuss our concerns and fears, and workplaces need to be safe spaces for discourse. Peerto-peer discussion and mentoring may be useful. There are also online supports available specifically for healthcare workers, and our website lists some COVID-related doctors’ health resources.
Chronic conditions increase the adverse outcomes of COVID-19. We recommend annual health checks for all doctors – it’s never been easier to access your regular GP with telehealth. If you need some help finding a doctor, psychiatrist or psychologist, refer to our website’s Doctors for Doctors list.
Think about experiences and relationships that revitalise, invigorate and sustain you. These are more important than ever for burnout management. Include emotional, social, physical, spiritual and vocational elements into your schedule – plan them into the week,
If time-poor, consider outsourcing tasks to give yourself more breaks or leisure time – be it workplace or at home. Cleaning, meals, laundry and shopping are easy examples.
The public will look to doctors for advice and guidance and we need to encourage calm evidence-based care. Large volumes of data on COVID-19 are emerging every day. It can be overwhelming for doctors and patients alike, as fear of the unknown and misinformation breed stress and anxiety.
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Upskill in your role in the current vaccination phase. Seek education from accredited sources, and avoid anxiety-provoking lay press and social media. The RACGP and WAPHA offer credible resources for community clinicians. The way we think and act matters. Firstly, be kind to yourself, as stress is a normal reaction to upheaval and uncertainty. Concentrating on what we can control in our lives gives us mastery in the unknown. Focusing on the present moment deters worries and ruminations about uncertainty. Some people find mindfulness and meditation useful stress busters. Find gratitude in your day and demonstrate kindness with colleagues. We need collegiality because workplace incivility causes distress and harms patients.
continued on Page 45
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44 | APRIL 2021
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COVID-21 – preparing for the next phase continued from Page 43 Thinking in ‘black and white’ misses many useful perspectives. Self-reflection exercises may reveal or help develop personal or professional growth with COVID-19. If your feelings of stress, exhaustion, dismay or disengagement are uncontrolled, reach out for help early. Draw on your personal support network of friends, family and colleagues. We encourage your GP as a secondary resource. If you want to speak to a doctor for doctors, call our 24/7 anonymous, confidential advice line. There is also a free national confidential telehealth counselling service for doctors and medical students provided by DRS4DRS (drs4drs.com.au). ED: Dr Newman is assistant director of the Doctors Health Advisory Service WA www.dhaswa.com.au. 24/7 advice line is 9321 3098.
The public will look to doctors for advice and guidance.
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OPINION BACK TO CONTENTS
Dr Joe Kosterich | Clinical Editor
The heart of the matter There is an old joke where different parts of the body argue amongst themselves about which is the most important. The brain, lungs and heart naturally see themselves as being above the rest. The punchline is when the anus goes on strike to prove that the remainder can’t cope without it.
AIHW data shows coronary heart disease was the leading cause of death in Australian males in 2018 and the second leading cause for female deaths.
Jokes aside, the general definition of extinct life is when the heart stops beating. Thus, the cardiovascular system, whilst perhaps not more important than other body systems, does hold a particular place in the eyes of both the public and the medical profession. Chest pain does strike more fear into all of us than abdominal pain or leg pain. AIHW data shows coronary heart disease was the leading cause of death in Australian males in 2018 and the second leading cause for female deaths. Cerebrovascular disease is third for females and fourth for males. There is no doubt we have made progress over the years, but we can do better. This edition has a focus on cardiovascular health in a broad sense. We look at WA research into possible new markers for cardiovascular disease, treatment of hypertrophic cardiomyopathy and potential ways to reduce risk through improving management of diabetes. From a completely different angle, better utilisation of potential donor hearts for transplant is examined. When I was in medical school there was very little that could be done to treat strokes. Today we are in a whole new world with early treatment. Having recently had a patient undergo such treatment, the article on hyperacute strike management, including the development of algorithms, was fascinating. The cardiac implications of COVID-19 are examined and as a change of pace we look at lung cancer screening. Smoking of combustible tobacco (cigarettes) remains the biggest risk factor for heart disease and lung cancer. Sadly Australia’s smoking rates have largely plateaued since 2013. It is one year since COVID hit our shores in a major way with lockdowns and border closures beginning in early April 2020. At time of writing all state borders are (effectively) open. The vaccination program, which will be into phase 1b by the time you read this, will be the biggest program of its type ever undertaken in this country. The experience in the US is encouraging. The drop in cases there points to light at the end of the tunnel. Perhaps it will be ‘Italy here I come’ in 2022.
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APRIL 2021 | 47
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Cardiac manifestations and their evolving management in COVID-19 By Dr Susan Kuruvilla, cardiologist, Nedlands COVID-19 has taken centre stage amongst current medical challenges and now with the rollout of vaccines, the world wants to see the light at the end of the tunnel. Patients with coronavirus disease (severe acute respiratory syndrome) typically present with symptoms and signs of respiratory tract infection, but cardiac manifestations are common. Putative causes of myocardial injury include myocarditis, hypoxic injury, stress (takotsubo) cardiomyopathy, ischemic injury caused by cardiac microvascular dysfunction, small vessel cardiac vasculitis, endotheliitis, epicardial coronary artery disease (with plaque rupture or demand ischemia), right heart strain (acute cor pulmonale), and systemic inflammatory response syndrome (cytokine storm). Symptoms and signs of heart disease in a patient with COVID-19 may result from the acute disease process, haemodynamic demands in the setting of pre-existing heart disease or acute exacerbation of chronic disease. There is substantial evidence of association between pre-existing cardiovascular disease and the risk and severity of COVID-19 infection. Proposed mechanisms include impaired physiologic reserve, impaired immune response, augmented inflammatory response, vulnerability to SARS-CoV-2induced endothelial dysfunction and effects mediated by the angiotensin-converting enzyme 2 receptor. Hypercoagulability and thrombosis are postulated to be due to endothelial injury, stasis and changes in the prothrombotic factors.
Clinical presentations Most patients with COVID-19 with cardiac test abnormalities (e.g. cardiac troponin elevation and ECG abnormalities) lack symptoms of heart disease. Myocardial injury as detected by troponin elevation
Key messages
COVID-19 can have many cardiac manifestations
Management of COVID-19 clinical conditions are evolving and challenging
Close monitoring is required to determine clinical severity and escalation of treatments.
can be due to myocarditis, stress cardiomyopathy and myocardial infarction. Heart failure may be precipitated by acute illness in patients with pre-existing heart disease, acute hemodynamic stress or acute myocardial injury. Patients with a known history of HF may suffer an acute decompensation due to the development of COVID-19. Right heart failure secondary to acute cor pulmonale (acute pulmonary embolism or adult respiratory distress syndrome) has been described. Hypercoagulability leading to venous thromboembolism, pulmonary embolism or arterial thrombosis is seen in patients acutely ill with COVID-19. Cardiogenic shock has been described. Multisystem inflammatory syndrome (MIS) was initially described in children (Kawasakilike illness). Similar cases of MIS have been described in young to middle-aged adults presenting with fever, gastrointestinal symptoms, shock with vasoplegia, LV systolic dysfunction and elevated inflammatory markers. Cardiac arrhythmias can be secondary to myocardial injury, hypoxia, shock, electrolyte disturbances and QT-prolonging drugs. Fever can unmask channelopathies such as Brugada and long QT syndrome.
Investigations Cardiac troponin and natriuretic peptide are commonly elevated among hospitalised patients and are associated with increased risk
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of mortality noted in studies from Wuhan, Milan and New York. ECG findings include sinus tachycardia, atrial fibrillation, flutter, RBBB, localised ST elevation, T wave inversion, Q waves, ventricular tachycardia and Torsade de pointes. QTc intervals need to be documented and continuous monitoring or regular ECGs done if QT-prolonging drugs are commenced. Echocardiogram findings include right ventricular dilatation and dysfunction, LV diastolic dysfunction and LV systolic dysfunction. Femoral deep vein thrombosis was found in 12% of patients with right ventricular failure in one study. Myocardial histology and viral genome analysis can be utilised for diagnosis of inflammatory myocarditis and viral myocarditis. Other investigations relevant to cardiac outcome include metabolic panel, CK, CRP, prothrombin time and D Dimer.
Management Supportive cardiac care includes management of heart failure, therapy for arrhythmias and avoidance of cardiotoxins. Heart failure patients will need pharmacologic therapy, careful management of fluid balance and advanced therapy. Early treatment with glucocorticoids, especially dexamethasone, has resulted in better outcome in some studies in patients with fulminant myocarditis. Even though there is speculation that elevated ACE 2 levels caused by renin angiotensin-aldosterone system may impact susceptibility to SARS-Cov-2, there is no evidence so far that treatment with ACE-I or ARBs worsens clinical course, and treatment with them can be continued. Thrombo-prophylaxis is very important due to the hypercoagulability and risk of DVT and PE.
continued on Page 50
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Lung cancer screening with Low Dose CT – ready, set…go? By Dr Conor Murray, radiologist, Nedlands Lung cancer is the leading cause of cancer death in Australia, for both men and women, with new cases numbers rising each year. Lung cancer causes more deaths than breast, colorectal, and cervical cancers combined – cancers for which national population-based screening programs already exist. Survival rates from lung cancer are low because it is usually late-stage disease by the time of diagnosis. The key to improving the length and quality of life of Australians with lung cancer is to diagnose it earlier. In 2019, the Australian Minister for Health, Greg Hunt, requested that Cancer Australia inquire into the appropriateness, feasibility, and potential process of a national lung cancer screening program. From this, an evidence-based lung cancer screening program plan (the Program) was designed to maximise the benefits and minimise the harms of screening. It would mirror and complement the other national cancer screening programs. It was found that such a screening program would reduce lung cancer mortality in Australia by at least 20% in the screened population and improve the quality of life of Australians affected by lung cancer. It was estimated that in the first 10 years of such a program, more than 70% of screen-detected lung cancers would be diagnosed at an early stage (currently less than 20% are), over 12,000 deaths would be prevented and up to 50,000 quality adjusted life years would be gained.
False positives and negatives
Key messages
Lung cancer is the leading cause of cancer death
Following an inquiry, a screening program has been proposed
It could increase survival and quality of life for those with lung cancer. The recommendation for a program received widespread support in the medical and lay communities.
International experience Two large and well-designed trials of Low Dose CT-screened (LDCT) versus non-screened long-term cigarette smokers in the US and Europe both showed a substantial reduction in disease-specific mortality. In the UK, targeted LDCT screening programs have been introduced in Liverpool and Manchester. In the US, screening has been introduced at about 2000 centres, albeit with no national registry, generally relying on the American Thoracic Society and American Lung Association protocols. Lung cancer screening is also being trialled or implemented in Canada, Spain, Poland, South Korea, Brazil and Israel. Currently in Australia a modicum of “case finding” with LDCT is conducted by GPs and specialists. There is no organised population screening program for lung cancer. The Cancer Australia proposal would be a federal program delivered with the cooperation, input and support of state and territory governments.
Using volumetric (instead of a simple diameter) measurement of nodules in the more recent European trials reduced the rate of false positives substantially (only 1.2% in the largest European trial). Volumetric measurement will be required in the Australian program to reduce the false positive rate as well as unnecessary invasive procedures, biopsies and surgeries. The reported rates of false negatives in international trials are low (1%) and are therefore not considered a significant problem for LDCT screening. The current best estimate of overdiagnosis is 8.9% (11-year followup). In the Australian program, rates of overdiagnosis will be minimised using a risk assessment tool for eligibility, performing volumetric analysis in concert with advanced nodule characterisation techniques such as artificial intelligence, and utilising contemporary nodule management strategies. LDCT scans are purposed for nodule detection and not, for example, mediastinal pathology. They are typically less than 1.5mSv though with the most advanced technology substantially less. For comparison, annual background radiation is approximately 2.5mSv. Modelling of dose exposures indicates there will be only a minor risk of significant long-term biological harm to participants. The benefits of LDCT screening for lung cancer will far outweigh potential harms.
Cardiac management in COVID-19 continued from Page 49 Trials of IL-6 inhibitor Tocilizumab show a mortality benefit in severe COVID-19. Mechanical circulatory support including intra-aortic balloon pump and extracorporeal membranous oxygenation (ECMO) may be needed in some patients. 50 | APRIL 2021
Appropriate care should be taken during aerosol-generating procedures (e.g. nebulisation, bronchoscopy, intubation and suctioning). Torsades de pointes can be treated with IV magnesium. If the clinical presentation is suggestive of acute coronary syndrome, timely evaluation and intervention is required.
Paracetamol is the preferred antipyretic. Statins and aspirin can be continued. Remdesevir has shown to hasten time to recovery in patients with COVID- 19. – Refences available on request Author competing interests – nil
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for monitoring key outcomes, quality assurance and research purposes. It is expected that the radiologists’ LDCT readings will be complemented by artificial intelligence (AI) to improve accuracy for detection and characterisation of nodules. Incidental findings will be managed in accordance with contemporary clinical practices.
A 14mm (160mm3) lung nodule, not seen by radiologists but detected on artificial intelligence (red contour). Images courtesy of ChestRad, patient consent for publication obtained.
Other harms include morbidity or mortality from downstream investigations or treatments. The compelling international evidence supports the conclusion that such harms are uncommon and usually manageable and should be considered in the context of substantial improved survival rates.
Going forward The population cohort for the Australian program is proposed as current or former smokers aged 55 to 74 years. An internationally validated risk assessment tool, called the PLCOm2012 (Prostate, Lung, Colorectal, and Ovarian Cancer) model, will be applied to people on entry to the program to assess their suitability. This tool requires the age, ethnicity, education, personal and family history of cancer and smoking status and smoking intensity of each patient. This PLCO model has performed well in validation
studies and is promoted in most international screening guidelines. For most patients, the likely referral pathway will be through their General Practitioner. The referrer will be responsible for obtaining informed consent. Other entry points may be self-referral or organised entry (a potentially eligible participant is proactively identified from existing medical records).
It is anticipated that the human, machine, and other resources demanded by the program will be met by the existing workforce and infrastructure. The total program costs are estimated to be $127 million in the first year, reducing to $76 million by Year 4. The estimated cost-effectiveness ratio is $83,545 per QALY gained. This compares favourably to the other governmentsponsored screening programs. The prospect of screening Australians at risk of lung cancer with LDCT is heartening because, if implemented carefully and handled well, it could manifest a remarkable increase in the length and quality of life of sufferers, at a reasonable cost.
It was proposed that current smokers entering the program be encouraged to access a smoking cessation education program. There is evidence that trial participants who are educated at this opportunity have higher quit rates than the general population of current smokers.
As with other cancer screening programs, GPs will be central to the uptake and success. A successful program will also require dedication from multidisciplinary teams of specialists with adherence to national quality assurance guidelines as well as monitoring and reporting requirements.
The program will require radiology providers to adhere to national quality control standards and report data to a centralised register
– References available on request Author competing interests - nil
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A novel therapy to treat familial heart disease By Prof Livia Hool, Cardiovascular Electrophysiology Laboratory, UWA Cardiovascular disease is a global burden and the leading cause of death worldwide. In context, more than 18 million people die from cardiovascular disease each year while the COVID-19 pandemic has resulted in 2.5 million deaths to date. Sudden cardiac death is a tragic and devastating complication of cardiovascular disease particularly when it impacts the young. Sudden cardiac death accounts for about half of all heart disease-related deaths and structural heart disease such as familial hypertrophic cardiomyopathy (HCM) is the leading cause of death from cardiac causes in people aged 5-15 years. HCM is a primary disorder of the myocardium characterised by cardiac hypertrophy in the absence of other loading conditions such as hypertension and may be as prevalent as 1 in 500. It is an autosomal-dominant condition caused by defects in at least 12 genes for contractile proteins. Mutations in cardiac ß myosin heavy chain, cardiac myosin binding protein C, and cardiac troponin T account for approximately 80% to 90% of described cases of familial hypertrophic cardiomyopathy. The clinical course of the cardiomyopathy is variable, ranging from benign asymptomatic disease to a malignant phenotype with a high-risk of cardiac failure or sudden cardiac death. Treatment for familial hypertrophic cardiomyopathy includes ß-blockers or calcium channel inhibitors that target symptoms. Arrhythmias are managed with antiarrhythmic drug therapy such as sodium or potassium channel blockers or insertion of an implantable cardioverter defibrillator. Surgical myotomy or myectomy may be required to reduce left ventricular outflow tract obstruction. The challenge has been to prevent the enlarged heart from developing because the presence of hypertrophy is associated with
Key messages
HCM is the leading cause of cardiac deaths in the 5-15 years age group
Thus far no treatment has influenced its development
Novel treatments are being trialled at UWA.
increased risk of sudden death. Patients present with increased interventricular septal and posterior wall thickness on echocardiography and hearts are hypercontractile with normal or high fractional shortening. It is not fully understood how the heart becomes large and why the heart is hypercontractile and consumes so much oxygen. In the heart, mitochondria are responsible for meeting the cellular energy demands required to maintain excitation and contraction on a beat-to-beat basis. Calcium uptake is integral to mitochondrial function in order to maintain ATP production. A research program at the University of Western Australia is significantly impacting management of genetically inherited cardiomyopathies by closing an important gap in treatment using novel approaches.
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A novel mechanism by which a calcium channel regulates energetics in the heart has been identified. By targeting the calcium channel, the therapy reduces energy consumption and prevents the development of the hypertrophy. We are also optimising the treatment to reverse the hypertrophy once it has established. The therapy is estimated to enter phase 1 clinical trials in 24 months. It will offer an alternative to a small molecule inhibitor of myosin, Mavacamten that completed Phase 3 clinical trials last year and is now seeking FDA regulatory approval. Once efficacy is established, the availability of the novel calcium channel inhibitor will be welcome news for patients with a family history of hypertrophic sarcomere gene mutations because no therapy has been available that can prevent the development of the hypertrophy. ED: Professor Hool is head of the Cardiovascular Electrophysiology Laboratory and Faculty-at-Large Victor Chang Cardiac Research Institute, Sydney. Author competing interests – the author leads the research described
APRIL 2021 | 53
54 | APRIL 2021
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Diabetes and heart attack: what’s new to improve outcomes? By Professor Girish Dwivedi, cardiologist, Fiona Stanley Hospital Heart disease is a leading cause of death in people with diabetes mellitus. Despite improvements in treatment options, diabetes remains associated with excess risk of heart disease. This is particularly important in people with diabetes with recent heart attack as the risk of recurrent heart attack, heart failure and death are increased substantially. Previous studies have consistently demonstrated strong associations between high blood sugar in the immediate aftermath of heart attack and increased risk of recurrent heart attack, heart failure or death. Furthermore, studies in heart attack settings have shown that high blood sugar during inpatient admission is frequently overlooked and inadequately addressed. Recent large-scale studies suggest that a new class of diabetes medications, sodiumglucose cotransporter-2 inhibitors (SGLT2Is), improve outcomes in patients with type 2 diabetes and heart diseases especially the high risk patients such as those with heart failure. Indeed, in patients with type 2 diabetes and heart failure, SGLT2Is are
Key messages
Diabetes remains a significant risk factor for heart disease
Research shows that use of SGLT2Is can improve outcomes
Early treatment can be undertaken safely in stable patients. being increasingly prescribed by specialists and family doctors. The question that is often asked is can they be started early following heart attack in patients with diabetes? Despite the well-established benefits in heart disease patients especially those with heart failure, studies have shown that the perceived side effect concerns have precluded their widespread use especially when patients are still in the hospital following the heart attack. This is troublesome, as it is known that initiation of treatment prior to hospital discharge improve medication adherence and longterm outcomes. Preliminary small studies have shown that SGLT2Is can be
safely started in a majority of patients following a heart attack. Early treatment would improve medication compliance and also reduce chances of complications such as heart failure, stroke, kidney failure and death in these patients. Ongoing studies, including the study funded by Diabetes Research WA and being performed at the Fiona Stanley Hospital, will provide further evidence of the safety and usefulness of this drug in heart attack patients especially when started soon after the heart attack. Other pertinent questions are what are the possible side effects of SGLT2Is and should one temporarily stop taking this medication when feeling unwell? Uncommon but possible side effects of SGLT2Is include hypoglycaemia (low blood glucose – this usually only occurs if SGLT2 inhibitors are used in combination with other diabetes medicines), dehydration, an increased risk of infection such as thrush around the genitals and rarely observed effect of an increase of acid in the blood (diabetic ketoacidosis). If a patient has been told about an active foot ulcer or circulatory problem in a leg, they should discuss with a doctor before continuing this medication. If the patient is feeling unwell (vomiting, diarrhoea, fever, sweats and shaking), they should also temporarily stop taking this medication and seek medical advice. Author competing interests – the author is involved in research mentioned in the article
Overview of unfavourable and favourable effects of SGLT2Is in patients with diabetes and heart attack.
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or visit https://gpurologymasterclass.com.au 56 | APRIL 2021
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CLINICAL UPDATE
Updates in Acute Ischaemic Stroke Management By Dr Darshan Ghia, neurologist, Karrinyup The hyperacute management of stroke generally refers to treatment in the first 24 hours of onset of symptoms and focuses on minimising brain injury. This includes time critical reperfusion therapies: intravenous thrombolysis (IVT) as well as endovascular clot retrieval (ECR) for stroke due to large vessel occlusion (LVO).
Pre-hospital triage Selected hospital emergency departments administer the hyperacute therapies. Patients with LVO benefit from direct transportation to an intervention centre, while non-LVO stroke patients need rapid IVT in the nearest stroke centre. Numerous prehospital stroke scales have been developed to identify stroke patients with LVO in the prehospital setting based on their clinical symptoms. In Perth, hospitals variably can administer both IVT and ECR 24/7, IVT 24/7 and ECR during the daytime, IVT 24/7 or neither hyperacute therapy. A strategy covering such heterogeneity while avoiding the double handling of a stroke patient is challenging. Based on a previous Perth observational study, St John Ambulance staff will apply the FAST (Face Arm Speech Time) criteria to identify stroke in the community if it presents within eight hours. If positive, then RACE (Rapid Arterial oCclusion Evaluation) score is applied. This is a simple tool that can accurately assess stroke severity and identify patients with acute
Key messages
In patients experiencing signs of stroke call the ambulance for immediate transfer to hospital and potential hyperacute treatment
Administer dual antiplatelet therapy in all patients with highrisk TIA and minor ischaemic stroke after ruling out bleeding on neuroimaging.
stroke with LVO in a prehospital setting. The ambulance services have an algorithm allowing them to take the patient to the appropriate hospital based on the time of the onset, above scales, time of the day and the day of the week. Any patient presenting to the primary practice within the first 24 hours of the onset of stroke symptoms or time-last-well warrants calling an ambulance.
Intravenous thrombolysis For patients with potentially disabling ischaemic stroke within 4.5 hours of onset who meet specific eligibility criteria, intravenous thrombolysis with alteplase should be administered as early as possible after stroke onset. Screening for the strict eligibility criteria will be done by the stroke team. For patients with potentially disabling ischaemic stroke without LVO who meet specific clinical and brain imaging eligibility criteria, tenecteplase may be used as an alternative to alteplase within 4.5 hours of onset. In patients with potentially disabling ischaemic stroke meeting perfusion mismatch criteria or MRI FLAIRdiffusion mismatch criteria in addition to standard clinical criteria, IVT can be administered beyond the standard 4.5 hours based on the updated stroke guidelines.
Endovascular clot retrieval For patients with ischaemic stroke caused by a large vessel occlusion in the internal carotid artery, proximal middle cerebral artery (M1 segment), or with tandem occlusion of both the cervical carotid and intracranial large arteries, ECR should be undertaken when the procedure can be commenced within six hours of stroke onset. ECR should be undertaken when the procedure can be commenced between 6-24 hours after they were last known to be well if clinical and CT perfusion or MRI features indicate the presence of salvageable brain tissue.
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Eligible stroke patients should receive IVT while concurrently arranging ECR, with neither treatment delaying the other. In selected stroke patients with occlusion of the basilar artery, ECR should be undertaken. For patients with ischaemic stroke caused by occlusion in the M2 segment of the middle cerebral artery, ECR may be considered.
Antithrombotic treatment Aspirin plus clopidogrel (dual antiplatelet) should be commenced within 24 hours and used in the short term (first three weeks) in patients with minor ischaemic stroke or high-risk TIA to prevent stroke recurrence. Treatment should commence with a loading dose of 300mg aspirin and 300600mg clopidogrel followed by 100-150mg aspirin and 75mg clopidogrel daily for a total of 21 days and a single antiplatelet agent thereafter. Most cryptogenic strokes are likely embolic. This understanding is captured by a related concept, termed embolic stroke of undetermined source (ESUS), defined as a nonlacunar brain infarct without proximal arterial stenosis or cardioembolic sources. Subclinical and paroxysmal AF is associated with an increased risk of embolic events including ESUS. Consider long-term cardiac monitoring for AF detection in patients selected by stroke physicians after appropriate stroke work-up. Initiate direct oral anticoagulants (DOACs) in preference to warfarin for patients with non-valvular atrial fibrillation and adequate renal function. In patients under 60 with ischaemic stroke, where patent foramen ovale is considered the likely cause of stroke (after exclusion of other aetiologies by stroke physician), percutaneous closure of the PFO is recommended. – References available on request Author competing interests – nil
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CLINICAL UPDATE
The gift of life – increasing the use of donated hearts By Dr Warren Pavey, anaesthetist, Murdoch In 2019, around Australia there were 367 heart donors but only 112 hearts were transplanted. Improving the use of donated organs is an area of clear unmet need. Unlike brain-dead donors, some donors suffer a circulatory death (DCD), where the heart has ceased beating. Hearts from these donors have traditionally been considered too high risk to be transplanted and thought likely to yield poor recipient outcomes. In 2014, the St Vincent’s group in Sydney commenced a world-first program of using DCD hearts for transplantation from adult donors. Established DCD heart transplant centres report an overall increase in heart transplant activity of 20-40%. Furthermore, five-year survival is superior to conventional donor organs at 94%. Despite excellent results in a few specialised centres, significant hurdles prevent DCD heart transplantation from becoming a mainstream tool worldwide.
Method, complexity, cost and ethics The Sydney group preserves hearts using the Transmedics Organ Care System (OCS Andover, MA, USA). This device, which supports a warm, beating organ, has become a global standard but consumables are about US$40,000 per organ. Papworth Hospital in the UK performs Normothermic Regional perfusion (NRP) where after circulatory arrest, the aortic arch vessels are clamped to exclude the cerebral circulation. The donor is then placed on a heart lung machine to resuscitate the heart in situ for 45 minutes before it is placed on the Transmedics OCS or ice, for transport. NRP is not permitted in many jurisdictions. Further, a ‘standoff period’ is observed following the cessation of circulatory activity to allow for confirmation of death. This may be as little as 75 seconds or up to 20 minutes as required in Italy. Better community and clinician understanding of DCD transplant
Key messages
Improving the ability to utilise more donated organs is an unmet need
Using hearts from donors who have suffered a circulatory death (DCD) is now possible but complex and costly
Research and innovation simplifying DCD heart transplantation and organ assessment, may allow wider use of such hearts.
is required to allay anxieties about procuring stopped hearts to be restarted in a recipient. Heart function after transplantation is linked to the time it has spent warm and ischaemic. Donors must progress to death following withdrawal of life support within 30 minutes to avoid significant organ injury. Longer times may preclude organ use. Ironically, reperfusing the heart may also further damage it.
The future of DCD heart transplantation
novel ASIC1a inhibitor derived from Australian funnel web spider venom to reduce reperfusion injury. Our own group in Perth, the Heart and Lung Research Institute of WA (HLRI WA) in collaboration with Fiona Stanley Hospital, Murdoch Veterinary School and the UWAbased Hool Lab and supported by Spinnaker Health Research Foundation, is investigating gas and nebulised drugs flushed through the vessels of the heart rather than blood or fluid to reduce complexity and improve outcomes. HLRI WA is also investigating novel assessment tools to test heart health before implantation, allowing those previously considered unusable, to be safely transplanted. Continuing advancement in organ procurement, management and assessment may yet improve our ability to utilise more fully the gifts so generously given by organ donors and their loved ones. For more information on DCD heart transplantation visit www.hlri.org.au Author competing interests – nil
The Victor Chang Cardiac Research Institute (VCCRI) is working a
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Abdominal aortic calcification and cardiovascular disease By A/Prof Joshua Lewis, Heart Foundation Future Leader Fellow, ECU Arterial calcification is a stable marker of advanced vascular disease. High coronary artery calcification scores are recognised as an indicator of future cardiovascular risk and increasingly used to guide patient management and to prompt better adherence to frontline medications. However, the prognostic importance of vascular calcification in other beds such as the abdominal aorta is relatively underexplored. Abdominal aortic calcification (AAC) is commonly seen when imaging the abdominal or lumbar spine regions in older individuals and those with diabetes and chronic kidney disease. Modifiable risk factors for AAC include smoking, a sedentary lifestyle, poor diet, dyslipidaemia,
Key messages
AAC is commonly observed on abdominal and lumbar spine imaging but its clinical importance for future cardiovascular risk has been unclear.
AAC presence was associated with an increased risk of cardiovascular events and deaths in people with no known CVD
Providing these results to the patient without known CVD may prompt positive behaviour changes. poor glycaemic control and impaired kidney function.
The research We undertook a systematic review and meta-analysis that identified
52 observational studies of 36,092 individuals to determine the longterm risk of future cardiovascular events and prognosis in people with AAC. In studies with participants recruited from the general population, people with any or more extensive AAC had approximately twice the risks of future CVD events, fatal CVD events and dying from any cause than those with no or less extensive AAC. We also found the more extensive the AAC, the higher the risk of future clinical events. Importantly, when pooling the adjusted risk estimates from these studies, these increased CVD risks attributable to AAC were similar even after accounting for traditional CVD risks factors such as high
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CLINICAL UPDATE
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AAC information and results to individuals and their GPs leads to positive lifestyle changes as well as improved uptake and adherence to cardiovascular medications. The ultimate goal is to develop the evidence that providing AAC information to GPs and their patients can prevent future clinical cardiovascular disease events such as heart attacks and strokes. That is, early detection of high-risk individuals will ultimately lead to fewer heart attacks and strokes. blood pressure, smoking and lipid profiles. In people with chronic kidney disease, those with any or more extensive AAC had almost four times the risk of cardiovascular events compared to those with no or less extensive AAC. The findings of this study demonstrate that the presence and extent of AAC can serve as an “early warning” for patients and their GPs on the risk of future cardiovascular events. A 74-year-old community participant told us: “I think anyone my age would want to know (their AAC). I came away with; okay I
have an issue to sort out … I’ve got a challenge and so I’m very grateful to know (my AAC). So how can we use this information? Widely accessible bone density machines can quickly and cheaply capture images for AAC assessment at a fraction of the radiation dose of alternative imaging modalities such as computed tomography. We are currently undertaking a world-first, 12-week randomised controlled trial in 300 older men and women in Perth. Our aim is to determine whether providing
In summary, fortuitous identification of abdominal aortic calcification may serve as an early warning sign of future clinical cardiovascular disease risk. Consistent reporting and conveying these results to GPs and patients may improve existing public health and primary prevention strategies for cardiovascular disease. – References available on request Author competing interests – the author has been involved in the research described
BEST PATIENT OUTCOMES IS HOW WE MEASURE SUCCESS! Omni Corde is a dedicated Cardiology practice with a special interest in the care of patients with arrhythmias. Our motto is embodied by our name ‘Omni Corde’ which is the latin for ‘all heart’ reflecting the compassionate care we provide. The practice was founded in 2018 by A/Prof Kushwin Rajamani (Cardiac Electrophysiologist) with the core aim of advancing investigation methods leading to early diagnosis and treatment of arrhythmias especially atrial fibrillation (AF). A/Prof. Rajamani trained at the Cleveland Clinic, ranked #1 Cardiology Hospital in the USA and is the only current Cardiac Electrophysiologist in WA who has obtained training at this prestigious institution. He offers catheter ablation for select patients with atrial fibrillation and as a ‘cure’ option for some of the other arrhythmias. He has a trusted reputation for excellent outcomes with AF ablation with the majority of his patients requiring only a single procedure (no-gap fees). NEDLANDS Suite 32, Hollywood Specialist Centre, 95 Monash Avenue, Nedlands
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NEWS & VIEWS
Hollywood’s new treatment hub Perth has a new centre for cancer treatment and a lot more. Dr Karl Gruber and Cathy O’Leary report.
The headline for the recently launched Hollywood Consulting Centre is an advanced radiotherapy system to improve the fight against cancer but that is just part of the story. The Nedlands clinic also provides services including computed tomography, magnetic resonance imaging, nuclear medicine, realtime X-ray tracking, ultrasound, mammography, breast cancer research and endoscopy services. It hosts health care providers from a range of specialities including bariatric surgery, cancer care, endocrinology, general medicine, gynaecology, orthopaedics, neurology, urology, palliative care and plastic surgery. Hollywood chief executive Peter Mott said the opening of the centre was great news for people undertaking cancer treatment in WA, and the addition of 280 extra car bays aimed to make their medical treatment more accessible. The cancer centre was part of a significant expansion of the Nedlands hospital campus. Breast Cancer Research Centre WA chief executive Carmelo Arto said moving to the new integrated centre meant patients could be offered a suite of additional services at the one site, including access to clinical psychologists and geneticists. “With all the key players together in one centre we can track the patient’s journey to see if there are any gaps,” he said. “We’re looking forward to where this takes us.” Among the specialities offered at the centre, cancer treatment is the most prominent, and for good reason. Cancer is a leading cause of death in the state, representing three out of every 10 deaths. Every
year, more than 13,300 people are diagnosed with some form of cancer. The condition also kills a significant number of Western Australians. In 2017, there were 4,147 deaths due to cancer. At the heart of Hollywood’s anticancer strategy is WA’s most advanced radiation therapy system, the Elekta Versa HD, featuring a Brainlab ExaTrac Dynamic system. This new system, the only one in WA, promises the delivery of ultraprecise radiation doses targeting cancer cells, while sparing most of the healthy tissue nearby. GenesisCare radiation oncologist Dr Yvonne Zissiadis said it marked an exciting new development in using the latest precision technology to treat cancer.
to tumours of the brain, breast, prostate, neck, lungs, liver and spine. “The surface-camera technology provides thousands of reference points on a patient’s skin, allowing our radiation therapists to track movements in real-time with submillimetre accuracy and eliminating the need for permanent tattoos in many patients.”
“At the end of the day, it is all about patients, and we know that multidisciplinary led care improves patient outcomes,” she said.
One of the first patients to be treated at the new centre is cattle farmer Michelle Fowler from Mt Narryer station in the Murchison, who recently had four weeks of radiation therapy to treat early breast cancer.
“The technology combines revolutionary new thermal-surface camera technology with realtime X-ray tracking to deliver highly precise doses of radiation
Mrs Fowler said her treatment at the centre was seamless and had allayed a lot of her anxiety, and she felt fortunate to have had access to the “one-stop shop”.
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LIFESTYLE
Happy heart, happy life Dr Johan Janssen has been mending hearts for four decades and has written a book to help educate patients around cardiac health.
By Ara Jansen
While he enjoys a gin and tonic during the odd quiet moment, even semiretired Dr Johan Janssen seems to find it hard to sit still. After mending hearts for more than 40 years, he recently self-published a book called Your Heart Maintenance, an instructional manual on what your heart does and how to take care of it. Gleaned from his decades of seeing patients as a cardiologist, it reads like you’re sitting in his office and he’s explaining it all to you. Simple and direct, it starts with the mechanics of the heart and finishes with prevention and lifestyle tips. “I fix broken hearts, which is why I wrote this book for my patients,” he says. “I also wrote it to try and get people to have a partnership with their cardiologist and their doctor. I think it’s a fundamental part of being a physician. Though while concentrating on the heart, you can also notice if they have any other issues.” Written last year in the middle of the pandemic, the conversational tone helps simplify jargon and medical language for patients, explaining important things like how blood gets through your heart, clears up potentially confusing things like a cardiologist not being the same as a cardiac surgeon and suggests eating as much nonprocessed food as possible. Born in the Netherlands, Johan studied cardiology under Professor Hein Wellens, who was considered one of the founding fathers in the subspecialty of cardiac electrophysiology, which diagnoses and treats the electrical activities of the heart. Professor Wellens died just last year. Johan thought cardiology sounded exciting. He was introduced to the professor, who walked him into his office and asked his secretary when the 64 | APRIL 2021
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LIFESTYLE
next training course started. It was the coming Monday. And that was the end of it, though, really, just the start of a career that has taken the doctor and his family on various adventures, including four years of working in Saudi Arabia, setting up a cardiovascular service at a new hospital in Jeddah. He arrived in Perth with his wife Marie-Louise and their three children in 1995, a place they had been visiting since the 1970s because Marie-Louise’s sister lived here. A self-confessed style dinosaur because he continues to wear a white coat with his name on it, Johan speaks five languages and maintains he was never a brilliant student but one of his strengths has been a genuine interest in his patients, which he learnt from Professor Wellens. “They pay for someone who cares for them and if you do that you are going to be good, and then interested in figuring out what continued on Page 66
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LIFESTYLE
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Happy heart, happy life continued from Page 65 their problem is, and then trying to help them,” says Johan. “Being inquisitive is vital. “Did you know 30% of women are born with a slightly different electrical system? If you don’t know that, it’s hard to find, and lots of people get fobbed off by their doctor. I’ve had women crying in my office because I’m the first person who has listened and helped them solve their problem. I’ve found a lot of doctors in modern medicine don’t listen. “A doctor that is only a very smart nerd is not good for people – they need to listen and be empathetic too.” When asked for the best joke about a heart or a broken one, Johan says he reserves his best for the clients having angiograms because they are usually reasonably stressed when being poked at. He considers laughter great heart medicine and makes it a point to laugh as much as possible and encourages his patients to do the same. Until the last few years, Johan’s busy full-time working life included attendances at various clinics and hospitals around Perth and regularly flying to regional centres. Now semi-retired, he works a few days a week at his long-term home at Western Cardiology and hops on a plane to Kalgoorlie most
weeks thanks to a long-standing connection to the city. Being in constant motion is one reason he earned the nickname the Flying Dutchman from his colleagues. “I decided years ago that I would not call a vacation a vacation,” says Johan about his heart philosophy. “I see it as one day I’m here and another day I’m there, and I’m having a good time no matter what I’m doing. I make every day a happy day and I never feel grumpy because every day is a gift. “I had a car accident with my family in 1984 and spent two years in rehab. That leaves an impact and you realise there’s more to life than getting up to work. So, every day I get up with pleasure. We’re a closeknit family but that accident also
made us a happier family as a result.” That sunniness, positive attitude and willingness to listen to his patients is probably why several of them graciously keep him supplied with fresh fruit, vegetables and eggs. They’re also contributing to the recipes he’s creating for the interactive kids’ cookbook he’s writing. No doubt trying out the recipes on his grandchildren. He’s also able to spend more time working on his piano playing. Once again, a grateful patient gifted the instrument Johan plays two years ago. The baby grand came from a Los Angeles film studio and was used in numerous silent movies, including those with Charlie Chaplin.
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Win... For your chance to win one of three bottles, visit our website www.mforum.com.au and click on the competitions tab
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WINE REVIEW
3 Drops growth a triumph In 1998, Great Southern farmer Joanne Bradbury and her husband planted 2000 olive trees on their Mount Barker property for premium olive oil production. The property is situated on Wragg Road, south of Mount Barker. Like many other large estates in the Great Southern, vines came later, albeit only a year later in 1999. Initial plantings were of Sauvignon Blanc, Cabernet Sauvignon and Cabernet Franc. Riesling, Chardonnay, Semillon and Nebbiolo quickly followed, a total of 15ha in all. A wise decision was made in 2002 when the vines became productive to engage the services of Rob Diletti, the very talented and experienced winemaker at Castle Rock wines. Rob has an intimate understanding of the grapes, microclimates and soils of the Mount Barker and Porongurup regions and an impressive track record in the wine show system. In 2007, the former Patterson’s vineyard (planted 1982) was acquired adding mature Pinot Noir, Chardonnay and Shiraz to the mix. Overall, the wines tasted were exemplary in their purity and balance and considering the pricing, which varies between $25 and $32 a bottle, very good value.
3 Drops 2020 Riesling, $26 Classic floral aromas of citrus lime with a lovely clean and refreshing palate. None of the hardness that can be seen in some other Rieslings. Ideal aperitif and good with oysters and seafood. Will age for 10 years+ if desired. (13% alcohol)
3 Drops 2020 Rose Nebbiolo, $25 With a beguiling pale salmon colour, this rose impresses with the combination of fruitiness (strawberry) and savouriness so characteristic of the Nebbiolo grape. Very fresh and mouth-filling and pleasingly fine tannins that round out the finish. No need to age this wine. It is lovely right now. Great as aperitif and with most dishes. Ideal in an outdoor setting. (13% alcohol)
Review by Dr Louis Papaelias
3 Drops 2019 Chardonnay, $28 Enticing peach and grapefruit flavours masterly dressed with just a lick of oak. Very ‘juicy’ and crisp on the palate. Lighter in body than typical Margaret River chardonnays. Very enjoyable now but has the freshness of acidity to age and develop for a few years. Great with seafood and white meats. (13% alcohol)
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3 Drops 2019 Shiraz $26 From mature shiraz vines in the Patterson’s vineyard, this wine shows lifted ripe plum aromas with white pepper and spice. Palate is fruity, well-rounded and supple without any hard tannins evident. Ideal accompaniment to red meats and many spicy Indian curries. Will improve with age but is also delicious now. A lovely example of great southern shiraz and like all the above wines a tribute to both vigneron and winemaker.
3 Drops 2019 Pinot Noir, $32
'S EWER I V E R
PICK
Forced to pick a favourite, I will go with this Pinot Noir. It is a notoriously difficult variety in WA but successful in this instance. Deep ruby coloured. Fragrant ripe cherry bouquet. Lovely mouthfeel, attractive cherry, strawberry fruit rounds out the palate balanced by skilfully integrated fine tannins. Although this wine will age, it is delicious right now with its seductive primary fruit. A very good effort and well worth tracking down. (13.5% alcohol)
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MUSIC
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Inspiration is sweet and comforting Singer Kate Ceberano knew making an album during a pandemic might be tricky, but she never expected it to change her life quite like it did. By Ara Jansen.
Kate Ceberano thinks of her latest album as a collaboration between herself and a different version of herself. While that might seem a little esoteric, the popular Australian singer says the combined experience of making Sweet Inspiration and the coronavirus pandemic changed her. If it was ever the role of an artist to reflect the times – and their life in those times – then that version of Ceberano is it. Alongside two original songs, this lovingly chosen collection of covers are delivered in Ceberano’s smooth
pop-jazz style and are interpreted with her characteristic passion and compassion, like a soothing blanket which wraps effortlessly around the listener. “I didn’t want to release something that wasn’t contextually interacting with the world around me,” explains Ceberano. “A journalist wrote that this album is a break-up album. It is – a break-up with one world and a reconnecting with the world as it is today. I didn’t want to do anything that was artificial. I wanted it to be as you are, in a moment in history, and this is how you documented it.”
Known for expressively and beautifully translating other people’s songs to make them her own, Ceberano has had Top 10 albums across five decades – 80s, 90s, 00s, 10s and now with Sweet Inspiration, 2021. This puts her in a special class of ARIA artists joining AC/DC, Kylie Minogue and Midnight Oil. Sweet Inspiration features two new original songs, Hold On and the title track. The rest are renditions of some of Ceberano’s favourite songs such as So Far Away by Carole King, If It Be Your Will by Leonard Cohen, Elbow’s Mirrorball, You Needed Me
Queen Nat's musical gambit The musical Chess makes a rare stage appearance in June with some special visiting and homegrown performers. By Ara Jansen. As a teenager Natalie Bassingthwaighte and her best friend knew all the words to the song, I Know Him So Well. The 1984 song was a hit single and the big ballad from Chess the Musical and the pair sang along to the radio, hairbrushes were probably involved. Decades later when the Australian singer landed the female lead in an Australian production of Chess, the first person she called was that same best friend. Singing might have been involved. “For me it’s a very challenging score but also one of the most beautiful,” says Bassingthwaighte, 68 | APRIL 2021
who is playing Florence Vassy and has previously appeared in Chicago, Rent and Grease. “Elaine Page played her originally, so if I’m considered in that realm then it’s a dream.
Ulvaeus with lyrics by Ulvaeus and Tim Rice. Two hit singles – I Knew Him So Well and the pop track One Night in Bangkok were released two years before it opened in London’s West End.
“I don’t think I’ve ever been as moved by a song as much as this one. Even now, when I play the music and sing along, I get goosebumps.”
Bassingthwaighte says it’s the most challenging role she has ever undertaken and she’s thoroughly excited. In this semi-staged concert show she’ll be joined by ARIA chart-topping vocalist Paulini, New York Metropolitan Opera singer Alexander Lewis, last year’s The Voice semi-finalist Mark Furze, musical theatre favourite Rob Mills, opera singer Eddie Muliaumaseali’i and all-rounder Brittanie Shipway.
Chess is the story of a complex love triangle involving Russian and American chess grandmasters set against the political intrigue of the Cold War-era 80s of defections and manipulations. It features music by ABBA’s Benny Andersson and Björn
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MUSIC (a hit for Anne Murray and Boyzone) and Lennon and McCartney’s The Long and Winding Road.
and they all “held on like a raft in a storm and made these songs mean something more.”
It’s personal
With being together and studio time at a premium the singer says everyone threw all their love, frustrations and energy into the music and came out the other side feeling like so many more things were possible.
“The only criterium was that the songs had to have some emotional connection to me or familiar experiences,” says Ceberano, who also produced the album. “Sitting on a piano stool with Peter Allen and hearing his version of I Honestly Love You was amazing and memorable, and Dolly Parton’s I Will Always Love You – I truly feel is a part of me. There’s nothing quite like the original source.” Early last year, Ceberano began planning her 28th album but before there was time to start recording, she found herself in lockdown. “In that first week, two years of work just fell off the calendar, but it was the same for a lot of others, so it was hard to complain. I started writing on the piano and accompanying myself, using new skills and teaching an old dog new tricks. It proved to be the best therapy.” In between lockdowns in Melbourne, she and her band managed to sneak three days in a studio to record a dozen tracks. They used the same Melbourne studio where Ceberano recorded her 1989 debut solo album, Brave. No one had been able to play in the same room for a while
Taking care of the music will be 25 musicians from Perth Symphony Orchestra while CEO and artistic director Bourby Webster is co-producing the show. The production is part of PSO’s 10-year celebrations. Webster says Chess was a perfect choice when she was looking around for a musical that wasn’t overexposed but could reach new audiences, one of PSO’s goals. Chess fits the bill because of the ABBA connection and the music travels the breadth of styles. “That’s why we are doing it semistaged because it’s all about the music,” says Webster. “It’ll be more like a Rolling Stones concert. It’s on steroids as it jumps from opera to pop. All the songs have a different texture.
“The world turned suddenly upside down overnight with panic and unknowns and singing seemed too simple – inappropriate and indulgent in the face of the times. But Nina Simone says the artist must sing for the times, so that’s what I did.
Unhelpful thinking “I’d put myself in this space thinking I was only entitled to make a covers album. No one put me there, I did that myself. I started to wonder if my originals were no longer relevant. Then I realised it was a privilege to record and perform anything, anytime. It’s a service. With that, I rewired something which has been part of my menacing inner voice and has been very toxic to me.” The musician came out of the process unexpectedly stronger, more confident and with the second most important album of her life, after her debut Brave. Through her eyes and her life’s experience she distilled everything she had learnt to
date, letting that version of herself make the album. The song, Sweet Inspiration, was written by Ceberano and longtime friend Rick Price. Despite it being an original, Ceberano sees it as a cover. A version recorded by the woman she was last year during lockdown. The soulfully uplifting song is about Ceberano’s feelings for nature, especially when it was hard to be outside and how so much is at the whim of nature and the weather. Despite the potential dangers, it’s no less beautiful. “I feel very changed as a person since COVID. I feel that Sweet Inspiration is very much someone I used to be and it’s a gorgeous album. This is everything I wanted so I can move forward.”
Win... We have three copies of Kate Ceberano’s new CD Sweet Inspiration to give away, thanks to Sony Music. Visit our website www.mforum.com.au and click on the competitions tab
“It’s a musicians’ musical. As soon as members of the orchestra got wind that we were considering it, so many people said they were keen to be part of it.” Both women agree it feels like the game of chess is firmly back in the minds and on the lips of many, not only with the announcement of the show but also with the huge success of the miniseries The Queen’s Gambit. “With everything going on in the world and the popularity of The Queen’s Gambit I feel that even though Chess was set in the Cold War, it’s equally relevant now,” says Bassingthwaighte. Chess the Musical will stage at the Perth Concert Hall, June 3–5. Tickets from PCH or Ticketmaster.
MEDICAL FORUM | CARDIOVASCUL AR HEALTH
APRIL 2021 | 69
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