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Cathy O’Leary | Editor
Kids at the tipping point ... in WA we have young kids, some aged only six or seven, suffering anxiety, depression or self-harm to the point where they – or their parents – need emergency mental health support.
When I was growing up in a family of four kids born in quick succession, there was plenty of angst. Sibling rivalry, frequent door slamming and claims of “it’s not fair” were standard fare. It was tense but short-lived and no one was scarred for life (I think). But revelations that in WA we have young kids, some aged only six or seven, suffering anxiety, depression or self-harm to the point where they – or their parents – need emergency mental health support is hugely worrying. This is not teenage hormones in overdrive, it is children who haven’t yet hit puberty. This month we hear how an emergency telehealth service within our child and adolescent mental health services is stepping up to meet the increased calls for help, often from parents, GPs and teachers. And Perth Children’s Hospital is enlisting the help of GPs to get a better handle on the rising rates of food allergies. But the story of five-year-old Lincoln’s nearmisses with his dairy allergy shows we still need to do better. We also look at concerns that children have been on the COVID-19 strategy backburner for too long, amid surging cases in Indonesia, including deaths in underfives. On a lighter note, children in the UK have been trying to use a devious way to get out of school, according to the BBC, by using soft drink to create false positives from COVID-19 lateral flow tests. It seems their efforts have been thwarted but who said kids aren’t ingenious?
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MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
AUGUST 2021 | 1
CONTENTS | AUGUST 2021 – CHILD & ADOLESCENT HEALTH
Inside this issue 10
16
12 24
FEATURES
NEWS & VIEWS
LIFESTYLE
10 Q&A:
1
58 Car Review:
Dr Mark Duncan-Smith, President AMA (WA)
12 Young children’s mental health crisis
16 Walking the tightrope of food allergies
24 Close-up:
4 6 20 39
Dr Randolph Dobson
Editorial: Kids at the tipping point – Cathy O’Leary
Singing in the rain (with BMW) – Dr Mike Civil
In the news In brief COVID impact on children Powers of effective gender-diverse care – Dulasi Amarasingha
60 Swan dives into print 61 Wine Review: Domaine Naturaliste – Dr Louis Papaelias
62 Laughter – just what the doctor ordered
40 A GP’s guide to paediatric anxiety – Dr Andrew Leech
43 Who thinks of the children? – Dr Joe Kosterich
Wine Review See page 61 for Dr Louis Papaelias' review of Domaine Naturaliste wines and enter the competition. Dr Andrew Christophers is the lucky winner of the Aravina Estate Doctors Dozen.
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EDITORIAL TEAM
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Family History of Breast Cancer Dr Pamela Thompson
Soft tissue pathology in the adolescent patient Professor Camile Farah
Burns are more than skin deep Professor Fiona Wood
Reproductive genetic carrier screening Ms Jillian Kennedy
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Hepatitis C – Destination Elimination Dr Donna Mak
Complex airway management Dr Hayley Herbert
Paediatric Obstructive Sleep Apnoea Dr Paul Bumbak
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Improving childhood brain cancer treatment Professor Nick Gottardo
Djaalinj Waakinj Ear Health Program Dr George Sim
Video laryngoscopy in small infants Professor Britta Reglivon Ungern-Sternberg
Infantile tear duct management Clin/Assoc Professor Geoffrey Lam
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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The myopia generation Dr Jessica Mountford
GPs’ role in the concussion pathway Professor Melinda Fitzgerald
Immediate action – delayed consequences Enore Panetta and Daniel Spencer
Healing the airways to breathe better Dr Thomas Iosifidis
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AUGUST 2021 | 3
Lead author Dr Cele Richardson
Sleep baby sleep
sleep problems ranging from unsettled newborn babies to restless teenagers.
A study by researchers at the University of Western Australia and Flinders University has found a serious lack of expertise in health professionals when it comes to treating sleep problems in children. The research, published in Sleep Medicine, surveyed 263 Australian health professionals and revealed a significant shortfall in the knowledge, understanding and skills to identify manage and prevent paediatric sleep disorders. Sleep disorders are common in Australian children, with studies indicating up to 30% of children may experience
Music to the ears Researchers at Murdoch University’s Centre for Healthy Ageing are working to identify how music can be used to manage dementia. Previous research suggests listening to or singing songs could provide emotional and behavioural benefits for the estimated 472,000 people living with dementia in Australia. The new project will investigate the effects of personalised music on their quality of life. The centre’s director Associate Professor Hamid Sohrabi said aged-care facilities faced challenging behaviours associated with dementia such as agitation, depression and anxiety. “Typically, these symptoms are treated with antipsychotic and sedative medications, but they have limitations in helping people with dementia,” Prof Sohrabi said. “Personalised music delivered via headphones can moderate symptoms of dementia, with daily music exposure appearing to have at least temporary positive impact on the moods and behaviours. 4 | AUGUST 2021
Lead author Dr Cele Richardson, from UWA’s Centre for Sleep Science, said health professionals received little training in sleep medicine during their degree and it was likely this lack of training adversely affected their clinical practice. “We found about one-third of the health professionals were not routinely screening for sleep disorders in paediatric patients and many were not routinely recommending evidence-based treatments,” she said. “One common reason for not screening for sleep problems was the belief that parents would report poor sleep if it were a problem.”
“What we’re exploring is the ideal dosage and duration of music intervention.”
Funding ahead Professor Camile Farah and his team at the Australian Centre for Oral Oncology Research and Education have been awarded $2.2m by the Federal Government’s $20 billion Medical Research Future Fund to continue its work into the genomic profile of head and neck cancers. The project, evaluating clinically relevant biomarkers to improve early detection and treatment of head and neck cancer, will be carried out with colleagues at the Peter MacCallum Cancer Centre, Genomics for Life, Icon Cancer Centre, and CSIRO.
Snack attacks in lockdown Not surprisingly, Australians have turned to comfort food to ease the pain of COVID lockdowns, a new study in Appetite shows.
English and Australian professors compared notes about experiences in the UK and Australia to warn about the effect of extended pandemic lockdowns on our waist-lines. Their study confirmed that the small luxuries, from sweets and chocolate to salty treats, have helped to lift our spirits – and kilojoule intake – during lockdowns. Despite having more time at home to prepare healthy food, the intake of high-energy density food has risen for many. Top of the list of lockdown snacks are chocolate, cake, ice cream and pizza. But while more than half of respondents reported increased snack intake, 26% reported decreased intake and 20% reported no change to the amount they ate during the lockdown.
Support for sugary drinks tax Silver Chain Group is supporting calls for a tax on sugary drinks to encourage people to make healthy choices. CEO Dale Fisher said it was continued on Page 6
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Family History of Breast Cancer Breast cancer is common, with a lifetime risk of one in eight for women. It is usually the result of chance and ageing with lifestyle and environmental factors also contributing. Five-year survival is greater than 90% due to early detection and advances in treatment. In 5% of cases, there is an underlying genetic fault with either maternal or paternal inheritance. Red flag features in a particular family include multiple close relatives with breast or related cancers, cancer diagnosed at a young age (under 40) and more than one related cancer occurring in the same person.
Risk categories Risk is estimated by assessing a woman’s first- and second-degree relatives with breast or ovarian cancer using the Cancer Australia publication Advice about familial aspects of breast and epithelial ovarian cancer. Alternatively, a validated risk assessment tool can be used. Category 1 (average risk) comprises 95% of women. The lifetime risk of breast cancer is 1-1.5 times average (<17%). Category 2 (moderately increased risk) comprises less than 4% of women. The lifetime risk of breast cancer is 1.5-3 times average (between 17% and 30%). Category 3 (high risk) comprises less than 1% of women. The lifetime risk of breast cancer is greater than 3 times average (>30%). iPrevent is a breast cancer risk assessment and management decision tool for clinicians and patients accessed at www.iprevent. net.au. It calculates a woman’s risk of breast cancer and facilitates prevention and screening discussions. The CanRisk Web Tool found at www.canrisk.org is a comprehensive algorithm for use by clinicians to calculate patients’ risk of developing breast or ovarian cancer and their likelihood of carrying a genetic mutation.
Dr Pamela Thompson MBBS (Hons), FRACGP, DRANZCOG, DCH, Breast Physician Pamela graduated from UWA and began her medical career as a rural General Practitioner with a special interest in women’s health, obstetrics and paediatrics. Since 2013, she has been practising as a Breast Physician. She has a public appointment at Fiona Stanley Hospital and is in the multidisclipinary team at Perth Breast Cancer Institute.
Managing Women at increased risk Lifestyle factors such as breastfeeding, healthy diet and weight, minimising alcohol and regular physical activity are often underestimated in importance. Hormonal contraceptives and menopause hormone therapy may increase risk and should be carefully considered on an individual basis. Breast surveillance comprises breast self-awareness, clinical breast examination and surveillance imaging.
Risk reducing bilateral mastectomy may be appropriate for some high-risk women, particularly those who carry a genetic fault. Referral to a Breast Surgeon for further discussion is important to allow women to make an informed decision. Some genetic faults also confer an increased risk of ovarian cancer and gynaecological-oncology referral may be required to discuss risk management options. Ovarian surveillance with ultrasound or serum CA 125 is not recommended.
Mammography reduces breast cancer mortality and morbidity through early detection. The age of commencement and frequency of screening depends on a woman’s individual risk category. Women at average risk usually commence two-yearly screening at age 50. Mammography should start earlier and be performed more often (annually) for women in a higher risk category.
Genetic testing
Additional surveillance such as breast MRI or ultrasound may be required for women at higher risk. Breast MRI should be considered as part of an overall high-risk management strategy in a designated breast clinic, as specific MBS criteria apply.
Referral to a genetic counsellor is important. Private testing is available for women who do not qualify for MBS funded testing, although the result may be uninformative.
Prevention of breast cancer Chemoprevention may be prescribed to women at moderate or high risk. Tamoxifen is on the PBS for this indication and results in a risk reduction of at least one third when taken daily for five years with benefit lasting at least 20 years. The potential risks need to be carefully balanced against the benefit for each individual by an experienced doctor.
MBS-funded genetic testing may be accessed if there is a greater than 10% chance of identifying a gene fault using a validated risk calculation tool. Initial testing (mutation search) is ideally performed on an affected family member with predictive testing offered to blood relatives if a pathogenic mutation is found.
High-risk breast clinics These operate at both tertiary public and private breast clinics. A detailed assessment of a woman’s family and personal history is performed with implementation of personalised risk management strategies. Referral for genetic testing can also be made if indicated.
PBCI Breast Clinic Suite 404, Level 4, Hollywood Consulting Centre 91 Monash Ave, Nedlands, WA 6009 Healthlink EDI: breastci Telephone: 6500 5576 Fax: 6500 5574 Email: reception@bcrc-wa.com.au www.bcrc-wa.com.au MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
AUGUST 2021 | 5
Respiratory medicine physician and regional and remote health services researcher Professor Graeme Maguire is Curtin University’s new Associate Dean of Medicine. WA-based laboratory animal supplier Animal Resources Centre is set to close within 18 months. The major supplier of rats and mice for Australia's biomedical research says it is winding up because it is unable to operate in a financially selfsustaining manner, as required by legislation.
IN THE NEWS
continued from Page 4 time for Australian authorities to consider a tax to help save lives and millions of dollars in healthcare costs. “We’ve long known that sugary drinks such as soft drinks have no nutritional value, we don’t need them in our diet,” Ms Fisher said. “Overseas jurisdictions that have introduced a tax on sugary drinks have found that it does result in reduced consumption of drinks. The tax also resulted in manufacturers reformulating more of their products so there was a greater choice of reduced-sugar drinks and non-sugar drinks.”
A tax on sugar-sweetened drinks has been championed by organisations including Diabetes Australia and the Australian Medical Association.
Fish oil takes on superbugs For the first time, Australian scientists have confirmed a link between the role of regular fish oil to break down the ability of ‘superbugs’ to become resistant to antibiotics. The discovery, led by Flinders University, found that the antimicrobial powers of fish oil fatty acids could prove a simple and safe continued on Page 8
Perth-based medicinal cannabis producer Little Green Pharma has acquired a production facility in Denmark in Europe, and has received a $15 million commitment from one of Australia’s largest mining and resources companies, Hancock Prospecting. WA’s newly-created Older Person Health Network has appointed Dr Nick Spendier as its inaugural Clinical Lead. He is WA Country Health Service’s director of geriatric medicine. Edith Cowan University has appointed Aboriginal cultural advisers – Aboriginal Productions and Promotions – for its city campus project. It says recognition and celebration of Noongar people, culture and history will play a key role in the design. GPs caring for older palliative patients living at home or in residential care can now access the smartphone app palliAGEDgp for information on terminal prescribing. The Global Cardiovascular Research Funders Forum has been founded by 11 leading research funders from across Europe, the United States, Canada, Australia and New Zealand, including Australia’s Heart Foundation.
6 | AUGUST 2021
Hollywood Private Hospital Clinical Nurse Manager Adam Coleman with his International Congress on Innovation in Nursing award.
Rapid response rewarded Research into rapid response teams at Hollywood Private Hospital is gaining international traction. A study of the non-technical skills of medical emergency teams was led by Dr Rosemary Saunders and conducted by researchers from Hollywood and Edith Cowan University’s School of Nursing and Midwifery. Hollywood Clinical Nurse Manager Adam Coleman shared the research at the recent International Congress on Innovations in Nursing in Perth and won the Best Oral Presentation Award. The study was published in the June edition of Australasian Emergency Care. Mr Coleman has also been invited to present the research in Zurich, Switzerland, in October. “Medical emergency teams are essential in responding to acute deterioration of patients in hospitals, requiring both clinical and nontechnical skills,” Mr Coleman said. “Our findings emphasise the importance of non-technical skills in resuscitation training and well-developed processes for medical emergency teams.” Mr Coleman is now making improvements in the processes of Hollywood’s medical emergency teams. The project was funded by the Hollywood Private Hospital Research Foundation. MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
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IN BRIEF
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AUGUST 2021 | 7
continued from Page 6 dietary supplement for people to take with antibiotics to make their fight against infection more effective. Microbiologist Dr Bart Eijkelkamp, from the Bacterial Host Adaptation Research Laboratory at Flinders, said studies indicated that a major antibiotic resistance mechanism in cells could be negatively impacted by the uptake of omega-3 dietary lipids. “In the experiments, and complementary supercomputer modelling, we found that these fatty acids in fish oil render the bacteria more susceptible to various common antibiotics.” The researchers said this chink in the armour of harmful bacteria was an important step forward in combatting the rise of superbugs that are developing multi-drug resistance to antibiotics.
funding by Healthway and the West Australian Future Health Research and Innovation Fund. Successful projects include a collaborative community program to support WA Culturally and Linguistically Diverse women experiencing domestic violence, measuring the use of e-cigarettes in young people, and reducing the risks of harm for Aboriginal and Torres Strait Island people using illicit drugs.
Predicting breast cancer risk For the first time, Australian women with non-invasive breast cancer will have access to an innovative test to help predict outcomes and inform personalised treatment plans.
Future funds
Almost 20,000 women are diagnosed with breast cancer in Australia each year, with Ductal Carcinoma in situ (DCIS) – a common form of non-invasive breast cancer – accounting for up to one in five cases.
A raft of health-based projects led by Curtin University have been awarded nearly $1.5 million dollars in
GenesisCare says combining the latest innovations in molecular biology with artificial intelligence,
Hospital milestones St John of God’s Subiaco and Murdoch hospitals recently held social functions to recognise their doctors and help break up the winter woes. SJOG Subiaco Hospital held an autumn tribute dinner at Fraser’s State Reception Centre on June 18 to pay tribute to specialists retiring from practice at the hospital after many years of service. Mr Steve Archer, Professor Lincoln Brett and Dr Erica Shellabear were recognised, with SJOG Health Care Group CEO Dr Shane Kelly and chief operating officer Bryan Pyne attending the event. 8 | AUGUST 2021
DCISionRT is a precision medicine test for women diagnosed with DCIS who have undergone breastconserving surgery. The test assesses the 10-year risk of DCIS returning or progressing to local invasive breast cancer and predicts whether radiation therapy will be of additional benefit to surgery alone.
Finding cancer early PanKind, the only foundation in Australia dedicated to pancreatic cancer, has launched an early detection initiative. Currently, there is no way to test or find pancreatic cancer early, and if you have inoperable pancreatic cancer, 80% of patients survive only 6-12 months. But screening all Australians for pancreatic cancer is not a viable option. PanKind has awarded $465,000 to two new research projects with QIMR Berghofer Medical Research Institute and the Jreissati Family Pancreatic Centre to increase the proportion of patients diagnosed with operable disease through early detection.
SJOG Murdoch Hospital celebrated its Annual Doctors Dinner at the Ritz Carlton on June 26. Attended by more than 200 doctors, partners and caregivers, the fire and ice themed event was a celebration of two years of hard work during the COVID-19 pandemic. Guests included former Governor of WA Kerry Sanderson, Dr Shane Kelly and British-born comedian Ben Elton. Photo left: SJOG Subiaco CEO Professor Shirley Bowen, Dr Erica Shellabear, Mr Steve Archer and Prof Lincoln Brett. Photo right: Dr Shane Kelly, Pauline Bremner, Dr Peter Bremner, Dr Erik Hagen, Margaret Grover, Kerry Sanderson, SJOG Murdoch CEO Ben Edwards, Dr John Gorter, Ms Eva Skira, and Trish Tebbutt.
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Soft tissue pathology in the adolescent patient Head and neck tumours are common in the adult population, with major attention paid to epithelial malignancies given the significant morbidity and mortality associated with these pathologies. In infants, adolescents and young patients, however, soft tissue tumours are more likely to be encountered compared to epithelial malignancies. Soft tissue tumours share overlapping clinical presentation, histogenesis and pathological profiles making definitive diagnosis difficult and nuanced. Given the age and growth profile of affected patients, in addition to the invasiveness of treatment approaches, it is important to achieve a correct definitive diagnosis. In many instances this is not possible on routine haematoxylin and eosin staining of incisional biopsy samples. In such circumstances, immunohistochemical staining for specific markers can help reveal the cell of origin of a particular tumour, with implications for appropriate therapy. An example of this approach is highlighted in the case below.
By Professor Camile S. Farah Oral Physician & Maxillofacial Pathologist, Nedlands BDSc, MDSc (OralMed OralPath), PhD, GCEd (HE), GCExLead, MBA, MAICD, AFCHSM, CHM, FRACDS (OralMed), FOMAA, FIAOO, FICD, FPFA, FAIM Prof Farah is a Consultant Oral & Maxillofacial Pathologist at Australian Clinical Labs. He is a dual registered specialist in oral medicine and oral pathology with sub-specialty training in oral oncology. In addition to private practice at Hollywood Medical Centre, he is Consultant in Oral Medicine at Fiona Stanley Hospital.
Key messages
Tumours and tumour-like lesions of the head and neck are commonly encountered in medical practice.
Presentation of a mass in the head and neck should be evaluated with care and examined in detail.
Soft tissue mesenchymal tumours are more likely to be encountered in infants, adolescents and younger patients.
Soft tissue tumours share overlapping clinical presentation, histogenesis, and pathological profiles making definitive diagnosis difficult and nuanced.
Definitive diagnosis often requires immunohistochemical assessment of an adequate tissue sample and expert pathological interpretation.
Figure 1. Soft tissue lump involving the dorsal tongue. Image supplied by Dr Jacinta Vu.
A 12-year-old female presented with a recent history of an intraoral lump. Clinically the patient presented with an asymptomatic raised 1.5cm firm
A Figure 2. Histopathology shows biphasic spindle cell proliferation. Incisional biopsy sample submitted by Mr Rob Wormald.
B
C
Figure 3. Immunohistochemistry shows strong and diffuse S100 expression (a) with scattered CD34 positivity (b) and no expression of SMA (c) in tumour cells. Desmin staining was negative (not shown).
submucosal nodule visible from the dorsal aspect of tongue, with normal appearing intact overlying mucosa (Fig 1). Clinical differential diagnosis included a granular cell tumour, schwannoma, or other mesenchymal soft tissue tumour. Histopathological examination of a biopsy from the lump showed a circumscribed, unencapsulated, submucosal mass displaying a biphasic hypocellular/hypercellular spindle cell proliferation. The hypercellular region displayed amorphous-looking, eosinophilic material between parallel groups of nuclei, suggestive of Verocay bodies, but lacking typical nuclear palisading (Fig 2). Histopathological differential diagnosis included schwannoma, myofibroblastoma or myofibroma. In this example, despite the presence of histopathological features of each of myofibroma, myofibroblastoma and schwannoma on routine haematoxylin and eosin stain, immunohistochemical staining revealed that the lingual tumour was of Schwann cell, and not of myofibroblastic origin (Fig 3), rendering a final definitive diagnosis of Schwannoma. Schwannoma is treated with local resection, with minimal to no evidence of malignant transformation. – References available on request Author competing interests – the author is an oral and maxillofacial pathologist at Australian Clinical Labs and has written a book on the topic.
Building Better Partnerships
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AUGUST 2021 | 9
Q&A with... Dr Mark Duncan-Smith, AMA (WA) president
The only way out of this pandemic and ongoing restrictions is vaccination. It is unfortunate that communications from the Federal Government and coordination with the State Government has been less than perfect.
MF: You certainly picked a quiet time in the health system to take the reins at the AMA (WA)! Is it a daunting time to be president and is Andrew Miller a hard act to follow? MD: A week before I took over as president, I did say to Andrew that I expected him to have everything sorted in the last week. Andrew has been tireless in his efforts to protect WA and our health workers from disaster. The Artania near-disaster was a succinct example of this. There were advanced plans by the State Government to offload COVID-19 positive patients to private hospitals including Hollywood, the Mount and Bethesda – all hospitals with no specific training or COVID-19 systems in place. This was occurring because the government did not want to use public hospital resources for overseas patients. The situation was typical of the blame game and poor collaboration between the State and Federal Governments – and would have been an unmitigated disaster. Andrew directly intervened resulting in the patients going to Joondalup Health Campus, a hospital which was trained with systems and protocols in place. To JHC’s credit, there was not a single transmission to a healthcare worker. Andrew and the AMA (WA) were attacked by the government over this. So yes, big shoes to fill and I have already estimated them to be size 20 gumboots. It is also very comforting to know Andrew is there as a resource for me and as the immediate past president. He has my back. MF: COVID-19 is obviously right up there on the agenda at the moment and the AMA has been very vocal on the issue. There’s been a lot of setbacks with the vaccination roll-out. What’s your view on the way forward? MD: The only way out of this pandemic and ongoing restrictions is vaccination. It is unfortunate that communications from the Federal Government and coordination with the State Government has been less than perfect. The second half of 2021 will see a rapid increase in vaccination rates with the greater availability of the Pfizer vaccine. There are 40 million doses expected by October. Approximately 25% of West Australians have had their first dose, but only 6-7% are vaccinated with the second dose. I have been pushing the message for those who have had the AstraZeneca vaccine and experienced no issues, that they should get the second dose at three months. The incidence of thrombotic disease is one-tenth of the first dose risk and there are currently no pathways to mix vaccines. MF: Do you support the use of incentives to encourage people to be vaccinated? What about financial incentives? MD: Marketing often refers to carrot or stick, or both as messaging. Guilt-type
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Q&A messaging will not be effective, and financial incentives are not likely to change vaccine behaviour. A positive marketing campaign should be undertaken along the lines of protecting yourself, your loved ones and especially elderly relatives. The message should also be about getting through this together as a community. A COVID-19 passport for travel is also a positive incentive and will probably be part of our future. Hopefully, both levels of government are working on this already.
new beds and the staff and facilities around them need to be built.
safety and quality of healthcare delivery.
A longer-term plan also needs to be developed with real implementable actions rather than a review that is at best a helicopter view, or possibly more close to a view from the international space station.
MF: What do say about criticism that the AMA is a doctors’ union, so its primary interest is its members and not patients, as is often claimed?
The role of primary care working hand in hand with tertiary care also needs to be solved. Mental health also needs to be assessed and workable solutions identified, funded and implemented.
MF: Is it worth keeping our passports valid and on the kitchen bench or should we be putting them in the storage box at the back of the wardrobe?
MF: Are you concerned about public loss of confidence in the public hospital system in the wake of the death of Aishwarya Aswath at PCH?
MD: My passport expired in August last year and I have not renewed it as I don’t expect to use it for a while yet. On expiry, you have two years to renew without needing to go through the whole application process again. I suspect I will be renewing mid-next year to avoid that process, rather than international borders being opened.
MD: This was an extremely unfortunate and tragic event, most importantly for Aishwarya’s family. I don’t think it was handled well at all by the Government.
MF: The issue running parallel to COVID in terms of importance has been the headlines of a health crisis, particularly in our hospitals. What are the big drivers of the overwhelmed system? MD: The primary driver is chronic underfunding. The WA Health Budget has been inadequate for the past five years. The government’s focus on finance has led to a shift from patient care and outcomes to cost-cutting and the concept of doing more with less. Essentially, the last drop of blood has been squeezed out of the health system stone and now we are seeing the consequences of that, with reduced capacity, hospitals full and record ramping. MF: What needs to be done shortterm and longer-term to address the capacity of hospitals? MD: It is multifactorial, but the most glaring statistic is that we are trying to deliver tertiary healthcare in WA with the least number of hospital beds per capita of any state or territory. We have 2.28 public (nonpsychiatric hospital beds) beds per 1000 head of population. To get us to the national average, we would need 440 beds tomorrow. In the short term, closed beds need to be opened. In the longer term,
The reporting of the two nurses and the doctor to AHPRA was unnecessary and very damaging to the morale of all healthcare professionals. The coroner could report them to AHPRA as part of a proper and more far-reaching investigation, and just because they were the last piece of Swiss cheese to line up does not mean they are to blame for all the other pieces of cheese lining up. Leaking of the Severity Assessment Code 1 (SAC1) report to the media was counterproductive and has essentially broken the SAC1 system, which needs to be legally privileged to ensure unreserved participation and, therefore, improved safety and quality at the delivery level. MF: You have already indicated that your views might be different to those of Andrew Miller’s, such as whether Roger Cook should have quit over Aishwarya’s death. Do you think the Minister has done a good job overall? MD: No, I don’t think the Health Minister has done a good job overall, but I need to work with him to try and improve the health system. In my opinion, there is a lack of overall strategy and policy for healthcare delivery in WA and I have already identified the problems with chronic underfunding. Morale is low with the use of fiveyear contracts as an IR tool, refusal to use ‘permanent’ contracts, and a fiscal/cost-cutting focus are eroding
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MD: The AMA is the industrial instrument of doctors in WA. In the Industrial Relations Act 1979, it is not called a union, but it does have that function. I would estimate three quarters of our time at AMA (WA) Council is spent on public health advocacy and is one of the main reasons I was so interested to be involved in the organisation. MF: You have been vice-president of the AMA (WA) for five years. Did you always aspire to serve as president one day? MD: Five years as VP did not mean a ‘fait accompli’ that I would be president. This for me has been a journey of self-development and challenge. I have recently completed a postgraduate degree in corporate governance and management, without which I think I’d have struggled to have had the skills to take up the role. I have undertaken a project evaluating the corporate governance of WA Health. The Health Services Act 2016 defines the corporate governance of WA Health and is required to be reviewed this year (as part of a five-yearly review). My conclusion was that an external expert or company should undertake a formal, transparent review of the corporate governance of WA Health. This is to ensure WA Health has the optimal framework to facilitate the best decisions about healthcare delivery, safety and quality. MF: As a plastics surgeon, you have been critical in the past of the marketing by “cowboy” cosmetic surgeons, particularly on social media. What harm does this cause? MD: A lot of it is about patient expectations and being realistic. Social media and Instagram can live in the superlative. What I mean by that is, the lips or buttock have to look the biggest for example and the more of a ‘superlative image’ they are, the more ‘likes’ they would have received. What the followers of some leaders in social media don’t realise is that it has taken a team of four people half a day to prepare for that ‘selfie.’
AUGUST 2021 | 11
Young children in urgent mental health need An emergency mental health teleservice for children and youth has been swamped by demand in its first year and as Cathy O’Leary reports, some are primary school aged.
When the headlines warn of surging mental health issues in young people, it is natural to think of troubled older teens struggling betwixt childhood and adult life.
Three-quarters of the calls related to children aged 11 to 15, while 17% concerned 16 to 18-year-olds. Overall, 70% of the calls related to girls.
But worryingly it is young children who are among the drivers of the increased demand for mental health services, with two recent cases in Perth of a six-year-old and a seven-year-old needing crisis mental health support.
Over the six months, the service carried out 180 mental health assessments of children via phone or video, as an alternative to the child attending PCH’s ED or another hospital ED.
This trend is reflected in new figures from WA’s Child and Adolescent Mental Health Service. CAMHS’ Emergency Telehealth Service, which was launched 12 months ago and operates out of Perth Children’s Hospital, fielded more than 1700 calls in its first six months between July and December last year – an average of 12 calls a day. While some calls to the ETS were made by young people themselves, the majority were from adults such as parents, GPs and other health and school professionals. 12 | AUGUST 2021
It also provided back-up support for PCH’s ED, doing another 102 mental health assessments at times of high demand or when the telehealth service had advised that a child needed to be taken to the ED. In total, the ETS carried out 21% of all mental health assessments for PCH. The service is led by Dr Alex Thompson, a consultant child and adolescent psychiatrist, who heads a team of clinical nurse specialists providing crisis support and mental health MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
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assessments between 8am and 2.30am, seven days a week.
COVID, “and the demand was just waiting for us”.
Exponential demand
“What we see is not the young adult cohort, this is children we’re talking about, and when it comes to mental health, we’re seeing younger and younger presentations, before puberty, so it’s not just the adolescent angst turned up to 11,” he said. “We’re seeing a lot of families in crisis, with children displaying symptoms at a high level.
Increasing numbers of children under the age of 18 have attended hospital emergency departments in WA due to self-harm injuries, with 1300 children presenting in 2013, increasing to 1551 in 2018. “Unfortunately, we haven’t seen any reprieve since the tsunami that was the post-COVID wave, and that’s been a government health-wide experience of ongoing pressure and increasing demands, Dr Thompson told Medical Forum. “And unfortunately, the resources are still taking time to come in, so it’s a real heart decision rather than head decision to keep going in this climate. Everyone who works in this space relies on each other’s compassion and motivation to keep going.” Dr Thompson said the service was born out of a grant from the Mental Health Commission to develop a telehealth service because of
“We’re seeing an overlap between mental health and children with neurodevelopmental differences such as young children on the autism spectrum or with ADHD who are now presenting with mental health difficulties too.”
School pressures Dr Thompson said there was a strong correlation between mental health presentations and the school calendar. “It goes up and down like the stock market and we see a reprieve when young people go on holidays but then escalates as the year goes
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on, and the busiest time for us is November, before the holidays start.” Dr Thompson said children could use the telehealth themselves but typically it was their parents, carers, health professionals such as GPs and schools who put in the call seeking advice and crisis support. The emergency telehealth service was a novel approach, not modelled on anything previously existing, but instead based on what was needed. He believes having the ETS has helped keep a lid on escalating mental health presentations at hospital EDs, including at PCH. He said the telehealth service also did virtual in-reach when young people presented at the general EDs, and that had seen increased demand too. “The opportunities to intervene in mental health are numerous but what we can’t escape is that at continued on Page 15
AUGUST 2021 | 13
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Young children in urgent mental health need continued from Page 13 the end of the day, in a crisis, you do rely on emergency services, whether that be in person at PCH, or other EDs, or via the telehealth service. “We’re seeing things like parent education videos, and that’s great, but we’re seeing the need for crisis response more often.” While the ETS is online from 8am until 2.30am, demand is highest after school and in the evening. The hope is to move to a 24-hour model.
Not a quick fix “We’re a relatively young service and keen to mould our service to the needs of the community,” Dr Thompson said. “Our ultimate aim is to replicate our face-to-face mental health assessment, but the reality is that a mental health assessment takes much longer than a traditional medical assessment, and then in child and adolescent land, their care system also needs time and space to be heard. “Telehealth takes just as long, if not longer, due to technical considerations that need to be overcome.
“And we know the crisis doesn’t happen in the emergency department – the visit to the ED is the reaction by the family, and so we offer an alternative by saying if you’re at home and experiencing a mental health crisis, call us instead and we can give you the care in your home.” The service has produced a poster for GPs to explain clearly how it can help them, whether it be urgent specialist mental health advice, or a mental health assessment which includes risk assessment and a discharge plan. The aim is to provide better care for young people experiencing a mental health crisis in the metropolitan area, including access to urgent mental health assessments in their homes and communities instead of presenting to an emergency department. Doctors agree the busy and sensory-overloading nature of EDs is not conducive to a young person’s mental well-being, particularly if they have to wait for an assessment. Dr Thompson concedes that in an emergency, the first response by GPs is to refer the mentally unwell patient to an ED but, where appropriate, a telehealth mental
health assessment can avoid that need for a young patient.
More options “We understand that GPs want to refer young people to ED when there is a crisis, but we would like to provide information on what they might consider doing next time,” he said. Sometimes callers only require advice and support, but other times the young person needs a mental health assessment, and that could result in them being referred to a community mental health service, being advised to go to PCH ED, or being admitted to an inpatient mental health unit. “In cases where it makes more sense to refer to another inpatient service, for example one of the older youth units, CAMHS ETS is able to share assessments and handover to the receiving hospital, which supports greater continuity of care during an acute presentation,” Dr Thompson said. “At the end of the day it’s about improving the quality of clinical care and the experiences of young people accessing emergency mental health services.”
Who can use CAMHS’s Emergency Telehealth Service
Young people up to the age of 18 in the
metropolitan area requiring urgent mental health support or emergency tele-mental health assessment while in a community setting. Young people up to the age of 16 presenting to PCH ED or other metropolitan EDs with mental health concerns. Young people, families and professionals such as GPs have direct access to the CAMHS ETS via the urgent telephone support line: 1800 048 636. In rural, regional and remote WA, the WA Country Health Service’s Mental Health Emergency Telehealth Service provides doctors and nurses with access to specialist clinicians 24/7, for patients of all ages.
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AUGUST 2021 | 15
FEATURE
Walking the tightrope of food allergies
For years, the mantra given to new parents was to avoid giving riskier foods like peanuts and eggs to young babies in the belief this would reduce the risk of allergies. But the messaging has evolved over the years, as research topped up the knowledge bank to suggest food avoidance can sometimes do more harm than good. While parents were once advised to avoid allergenic foods in their child’s diet until the age of three, Australian guidelines were walked back in 2016 by advising parents to introduce nuts and other allergens before 12 months. A recent study by Murdoch Children’s Research Institute suggests it was the right move after collecting data from about 2000 infants from 2018-19 and comparing the findings to a similar study 10 years earlier, under the old infant feeding guidelines. Researchers found that the changes to the guidelines had led to a 16% decrease in peanut allergies. However, the need for more research remains strong in Australia, which is often labelled the food allergy capital of the world, with an estimated one in 10 children developing a food allergy by the age of one. Although many children will grow out of allergies to cow’s milk, soy, wheat and egg, peanut allergies persist into adulthood for about 75% of childhood sufferers.
Services buckle under demand In Western Australia, food allergies are growing, putting pressure on primary health providers such as GPs and specialist allergy services, with long waiting lists for assessment. 16 | AUGUST 2021
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Managing food allergies in children is a balancing act for parents – trying to avoid dangerous reactions while not unnecessarily restricting diets, as Cathy O’Leary explains.
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It prompted the start of SmartStartAllergy, a project at Perth Children’s Hospital based on a successful pilot led by consultant immunologist Dr Michael O’Sullivan in partnership with Dr Alan Leeb, a GP and developer of SmartVax. It is enlisting the help of GPs to educate parents about food allergies in infants and encourage them to report allergic reactions through the use of automated SMS technology. Dr O’Sullivan said the parentreported reactions to food would also help provide a clearer picture of the rates of food allergies in WA children. It was thought 10% of children had a food allergy at 12 months of age, with about 8-9% having egg allergy, based on raw egg studies,
3% allergic to peanut and a similar number allergic to dairy. “A larger scale, observational research project means we can better report the incidence of food allergies as we don’t have any good measures of that at the moment,” he says. “Getting kids in and doing food challenges under supervision gives you an absolute answer, but it’s time-consuming and expensive, so we’re using a process that combines parents’ reported questionnaires and that's done with GPs.” Dr O’Sullivan said PCH received pilot funding through the PCH Foundation five years ago to promote what was, at the time, recent updates to infant feeding and allergy prevention guidelines to give infants peanut in the first year. At the time few infants were eating peanuts in the first year, and the
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trial used a health promotion tool, via an SMS message to parents, to collect data. The pilot showed parents were more likely to follow the guidelines if they were sent the messages.
GPs as a resource “We know that in the first year of life, an infant will see a GP more than any other health professional,” Dr O’Sullivan says. “It’s a good way to try to get a sense of what is actually happening at a community level, rather than what we see coming through emergency or specialist referral.” He said GPs carried a lot of expertise in family medicine, and they understood their families and how anxious they could be, so that expertise was relevant for early management of food allergy. “Rather than plucking kids out of an existing relationship with their GP continued on Page 18
AUGUST 2021 | 17
Walking the tightrope of food allergies continued from Page 17 who knows the family, and dropping them into a clinic as a one-off appointment and then sending them back to the GP, we want to tailor the approach,” he says. “Sometimes the GP might just need to ask a question, other times the child might need to be referred to see a specialist.”
Changing advice Dr O’Sullivan said there was explicit advice in the late 1990s to avoid peanuts until the age of three, and egg until after the age of two, and then there was a lack of any advice for a while. The change in advice now had been taken up well, but some families were reluctant about giving infants foods like peanuts. “If GPs get results back that show parents haven’t tried certain foods, they might have the opportunity to talk to them about that,” he said. “The general advice is to gradually introduce the foods without any prior testing because testing can create false positives and can delay introduction of food while they’re waiting for a specialist appointment. “Even when reactions occur, it’s still safe to try foods in young kids, because there’s been no fatalities from an allergic reaction in under two years. “Some people worry something terrible will happen, and yes there is a risk of a reaction, but the risk of anything terrible happening is very low.”
Results next year Dr O’Sullivan said he hoped that by early next year they would have fairly robust estimates of the rates of food allergies in one-year-olds in WA, and then expect updates every 12 months to see any trends emerging. “As we roll out more public health interventions around allergy prevention, it would be nice to get population real-time reporting through GPs,” he said Meanwhile, some allergy experts are campaigning to raise more awareness about potentially life18 | AUGUST 2021
threatening allergic reactions, or anaphylaxis, though the National Allergy Strategy (NAS). These reactions cause about 2400 hospital admissions and 20 deaths in Australia each year. Over 4 million Australians live with allergic disease, and that number is on the rise.
Costly mistakes The NAS says three mistakes people make when responding to anaphylaxis are assuming it is not a severe allergic reaction because there is no skin rash or facial swelling; delaying the administration of adrenaline; and allowing the person to walk, even to an ambulance, after having adrenaline. Ms Maria Said, co-chair of the NAS and chief executive of Allergy and Anaphylaxis Australia, says people need to access appropriate care at the right time and be properly diagnosed. “We still have people at risk of anaphylaxis who go to a GP but are
never referred on to see an allergy specialist, and that’s a critical issue, because when we look at fatal reactions, almost all of them are not under the ongoing care of an allergy specialist to keep tabs on them,” she says. “I can’t stress enough how important it is for people to be referred on, even though waiting lists are long, and I think the long waits deter some GPs from referring people. “Unless you see a specialist, you probably won’t know that, if you have asthma, you’re at a higher risk of a fatal reaction, and if you’re unwell, or drinking alcohol, and you eat something, you’re going to have a more severe reaction. “Unless you’re an expert in the field, you won’t be aware of all the current information.” Ms Said says she is frustrated after talking to a father whose 17-year-old son recently died from anaphylaxis.
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Lincoln's story Four years ago, Hayley McLean was doing everything by the textbook to reduce the risk of allergic reactions in her one-year-old son. She and her husband Jamen Oliver had found out a few months earlier that Lincoln was allergic to dairy products after his face swelled up when he tried yoghurt for the first time. They promptly removed all dairy foods from their home. But one day at work Hayley ate a small piece of chocolate and nine hours later when she kissed Lincoln on the forehead his whole head broke out in hives. Worse was to come a few years later when Lincoln was accidentally given a bottle containing cow’s milk instead of rice milk when he was in daycare. Hayley is still traumatised by the event. “I got a phone call saying something’s happened and get here straight away. They had called an ambulance, but no one had given him his EpiPen because he wasn’t really miserable, so everyone hesitated. “He was rushed under sirens and lights to Perth Children’s Hospital. My husband was working FIFO and I had to call him and tell him, and he had to hop on a plane not knowing what he was coming home to.”
him the EpiPen, but it was still another pretty intense hospital stay.” Hayley says Lincoln, now five, is becoming aware of what he can’t eat, and if people offer him food he will often say no, he has an allergy.
Hayley says there was a second close call at daycare when Lincoln was given a tuna sandwich and, unbeknown to the carer, the canned tuna contained dairy.
He has to be accompanied to birthday parties and the family take their own food.
“They did give him the EpiPen straight away and it was a very different story because he was treated without delay.”
“He always has back-up clothes at school, and if he has a touch reaction, which is once every week or two, he breaks out in hives or gets puffy eyes and he has to have antihistamines and change all his clothes.”
There was another incident in a restaurant which was predominantly vegan, but the grilled cheese sandwich given to Lincoln contained real cheese. “The symptoms were different, he was quite lethargic, and his grandma had done the training and she gave
“It’s the same story – kid not referred to see an allergy specialist, even though he’d had reactions. They weren’t severe, but he wasn’t given an EpiPen and the family wasn’t told that the next reaction could be a lot worse,” she says. “This isn’t an isolated case. When people sometimes disclose their allergy to me and I ask if they’ve ever seen a specialist, they say no but they’re just really careful. And I say to them I’m really careful when I drive my car but that doesn’t mean I’ll never have a car accident.
“Going out for the day has to be planned, we can’t just call in somewhere for lunch,” she says.
Hayley says many people do not appreciate that allergies can mean more than an uncomfortable rash. “They don’t realise that for some people it’s a life-or-death situation.”
“I’m not picking on GPs, and some manage these patients really well, but we need to be doing better to improve access to care.” Dr O’Sullivan says the ultimate aim of his project was to make food allergy management as uncomplicated as possible. “While it’s very important kids with severe allergies are safely and carefully managed, we might have created a level of anxiety around people with relatively mild allergies that exceeds what they need to be worried about,” he says.
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“But if parents think their child has an allergy that needs to be addressed, it almost doesn’t matter what we think, because that’s ultimately what drives behaviour and anxiety, and diet modification.” ED: Doctors wanting to be part of SmartStartAllergy should go to www. smartstartallergy.com.au For the latest allergy management guidelines go to the Australasian Society of Clinical Immunology and Allergy at www.allergy.org.au/hp/anaphylaxis.
AUGUST 2021 | 19
Are kids the missing COVID link? Mostly ignored since the start of the pandemic, children are now being considered an important part of the COVID-19 jigsaw.
Dr Karl Gruber (PhD) explains.
20 | AUGUST 2021
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FEATURE Since the start of the COVID-19 pandemic, our main concern has been the health impact on adults and the elderly. Children, however, did not seem to catch the virus or get seriously ill from it and have mostly been ignored when it comes to the health advice, including vaccine strategy and mask wearing for those under 12 years. But more than a year later, we have learnt a thing or two about COVID-19 and how it affects children and the findings are troublesome.
Children do get sick Fortunately, most children seem asymptomatic or have only mild presentations compared to other respiratory viruses. “Usually with respiratory viruses, children tend to become more unwell than adults, and are responsible for transmitting more illness, however, this doesn’t appear to be the case with COVID-19,” Associate Professor Asha Bowen, paediatric infectious diseases specialist at the Telethon Kids Institute and Perth Children’s Hospital, said in a statement. “We are seeing lower numbers of children infected compared to what we'd normally see with other respiratory viruses.” For more serious outcomes, data so far shows that only a small percentage of children infected by COVID-19 have died – about 0.3% of all COVID-19 deaths which translates to about 8,700 children. But children do get the virus and can pass it to others just as efficiently as adults. In Europe, studies suggest that schools were a significant driver for the socalled second wave of COVID-19 infections. Added to this is the problem of the virus going undetected in children, who don’t normally get tested or vaccinated. While the initial presentations of COVID-19 infection do seem to be mild in children, research is now showing that long-term effects may be a different story. One international study that surveyed the parents of children with long COVID (mostly from the UK and US) found multiple health issues were affecting children. Among 510 children, 87% experienced tiredness and weakness, nearly 80% complained of headaches and abdominal pain,
and muscle and joint pain affected over 60%.
the pandemic, compared to previous years.
"Symptoms like fatigue, headache, muscle and joint pain, rashes and heart palpitations, and mental health issues like lack of concentration and short memory problems, were particularly frequent and confirm previous observations, suggesting that they may characterise this condition," Sammie Mcfarland, one of the lead authors of the study and a founder of the community-led Long COVID Kids, UK, wrote in the report.
Due to COVID-19 restrictions during 2019, nearly 14 million children did not get any vaccines and it is estimated that about 80 million children under the age of one may miss out on life-saving vaccines. One specific example is with measles, with cases reaching 870,000 in 2019 across 26 countries, the highest in 23 years.
COVID-19 ripple effect Beyond the inherent health problems caused by COVID-19, there are many other detrimental consequences we don’t normally hear about. For example, data from the United Nations International Children’s Emergency Fund (UNICEF), shows that up to 7 million additional children under the age of five may have suffered from wasting or acute malnutrition during 2020. Likewise, stunting among poor children has been more than 2.4 times higher during
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Violence, exploitation and abuse is also likely to increase due to the pandemic, due to factors such as added stress, economic uncertainty, job loss, and social isolation. In some countries, the economic impact of the pandemic, school closures and interruptions in support services may have led to 10 million additional child marriages occurring before the end of the decade. “Thus, school closures such as those triggered by COVID-19
continued on Page 23
AUGUST 2021 | 21
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Are kids the missing COVID link? continued from Page 21 may, in effect, push girls towards marriage since school is no longer an option,” the UNICEF reports.
The path ahead What all studies are showing is that children should not be excluded from any effort to control the pandemic. While most children seem to experience only mild or no symptoms from the original COVID-19 virus, new strains are emerging.
What is becoming clear is that children need to be considered as an integral part of our efforts to control the COVID-19 pandemic. In the US, Canada and the United Kingdom, children as young as 12 are now being vaccinated.
11, the TGA granted a provisional determination to Pfizer Australia for their COVID-19 vaccine called COMIRNATY. Currently, COMIRNATY is provisionally approved for use in people 16 years of age or older.
In Australia, the Therapeutic Goods Administration is yet to approve either the Pfizer or AstraZeneca vaccines for use in children. On May
Whether this vaccine or any other COVID-19 vaccine will reach the arms of any children or teenagers in Australia remains to be seen.
Throughout the pandemic, the SARS-CoV-2 virus has evolved, accumulating genomic mutations forming troublesome strains such as the Delta strain (B.1.617.2) that is now widespread and seems to be more efficient at transmission. Other variants such as the Beta strain (B.1.351) seem more efficient at re-infection. Evidence so far shows that, while there is an increase in children affected by this virus, it is not clear that it is due to a specific variant. “There is no convincing evidence that any of the variants have special propensity to infect or cause disease in children. We need to be vigilant in monitoring such shifts, but we can only speculate at this point,” Dr Stuart Ray, vice chair of medicine for data integrity and analytics at Johns Hopkins Hospital, said in a statement. Dr Andrew Miller, an anaesthetist and immediate past president of the WA branch of the Australian Medical Association, explains that in the case of the Delta variant, it may be a case of both adults and children experiencing higher levels of infection. "The predilection [for the virus] to attack children is probably the same as it is in adults," Dr Miller said in a recent news report. "We don't have enough information yet that's reliable to say the disease [caused by the Delta strain] is more severe in terms of hospitalisation and death — but that will only come with time." MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
AUGUST 2021 | 23
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A clear view of regional eye health Junior doctor Randolph Dobson is seeing a different side of Western Australia as part of the Lions Outback Vision team.
They say our eyes are the mirror of our souls. For Dr Randolph Dobson, looking deeply into people’s eyes is taking him around Western Australia and giving him a crash course in country, health and culture. After finishing medical school two years ago and working at Fiona Stanley Hospital and Bunbury Hospital, Randolph is now six months into a job with the Lions Eye Institute as part of their Outback Vision team. Lions Outback Vision and their visiting ophthalmology services aim to address the unique challenges of delivering specialist eye health care to regional and remote communities around WA. They also work closely with the group’s Visiting Optometry Services. Randolph, 26, is a junior doctor on the Vision Van, a mobile eye clinic which completes several circuits around the State each year. It provides services in and around Albany, Esperance, Katanning, Kalgoorlie, Leonora, Laverton, Wiluna, Newman, Meekatharra, Roebourne, Karratha, Port Hedland, Onslow, Exmouth, Broome, Derby, Fitzroy Crossing, Halls Creek, Kununurra, Wyndham and Warmun. The doctors aim to build local capacity by up-skilling and training health workers during their visits and harnessing a strong partnership between community, corporate bodies and government to meet the increasing demand for eye health services. The van – which is more like a container on the back of a truck – has three consulting rooms fitted with specialist equipment. The travelling team consists of two drivers (who are also mechanics) and two junior doctors and a senior one who provide comprehensive ophthalmology care for cataracts, trachoma, glaucoma and diabetic retinopathy. It has been running since 2017 and is a free service. 24 | AUGUST 2021
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Randolph, right, with the Outback Vision team
Eye on eyes Initially, Randolph’s undergraduate work was in biomedical science with a major in immunology but after going to an interesting pathology lecture on the altering of genetic code and how that could help vision impairment, that changed his focus to eye health. After declaring several specialties – including ophthalmology – Randolph says he got lucky when Dr Angus Turner became his mentor. The associate professor is director of Lions Outback Vision, an associate professor at UWA and a clinical lecturer for the Rural Clinical School at UWA and Notre Dame. “I tried to learn as much as possible from him. Having that link to Lions Outback Vision and seeing what he was doing was fascinating and inspiring. Now in my third year I’ve been able to see the impact it is having on people’s lives. A 20-minute operation can help someone improve their vision for
decades. That’s life-changing,” he said. “The van can do almost anything you could get at a country ophthalmology practice so we try to take it to areas where there’s no permanent ophthalmologist and which don’t have access to such services.” The doctors see between 20 and 40 people a day. The work can include anything from a regular eye exam to injections, scans and backof-the-eye check for diabetes. “Some people drive for hours to see us. We try and connect with the local medical community so they can refer people as well. I’ve liked making those connections because when you come back to a town you don’t feel so isolated. “In places like Laverton, we have such great support from the community health centre that we’ve been able to help people who have slipped through the cracks. We also
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notice in some places we offer a service which local GPs don’t have time to deal with or don’t always consider in their diagnosis.” Travelling with the van has opened Randolph’s eyes to the gulf between care levels in Perth versus regional and remote areas. He says the ease of access – or lack of it – is clear.
Free to access “A good number of our patients can’t afford to pay to see an ophthalmologist. We’re a public ophthalmology service for country WA providing a service at no cost. That’s something I really love about it. “If it’s taking months to get to your GP, that’s broken up your care, so with us coming through regularly, hopefully we can be part of the care team and improve that.” While he’s working in one discipline, Randolph says he likes the fact that continued on Page 26
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A clear view of regional eye health continued from Page 25 when they roll into town, they never know what kind of issues they might be asked to deal with. “In places like Wiluna, a steady flow of people come to see us. Some days you think there’s only four or five people around and then suddenly 20 people will turn up. We try and see as many people as possible and usually stay in one place for two or three days.” As a kid, Randolph spent school holidays camping out in the regions and he particularly remembers a trip out on the Gibb River Road as a teenager. Since then, he’s loved exploring the State and this job has given him the opportunity to explore further when he’s not working. Hiking in picturesque places is a wonderful perk of the job. To date, one of the big highlights has been exploring the gorges around Kununurra which Randolph describes as mind-blowing. On his
26 | AUGUST 2021
wishlist is to hike Mount Augustus, the world’s largest monolith, 390km east of Meekatharra.
eliminate avoidable blindness as a national health issues has been pushed back to 2025.
“Some of the days are long but the reward is that you get to go adventuring as we’re away the whole time and don’t come back to Perth in between or for weekends. It can make you a little homesick but it’s busy and interesting.
“We can fix some of these problems in about 20 minutes – and that has shocked me the most. That’s why I try to give patients some health literacy, which can be life-changing for them. If there’s anything which has shaped my last six months, it has been that.
“You get to know some of the locals and you make new friends. I think like with every job, it’s the people you meet along the way who make it such a great experience.”
Seeing new ways Something he treasures is the opportunity to expand his understanding of Aboriginal culture by working with diverse groups as well as offering help for some of the chronic health issues present in regional communities. He’s also thankful to the people willing to teach him. “What has shocked me is to learn that the Closing the Gap target to
“You don’t see trachoma in the city, yet in the Kimberley it’s endemic and completely reversible. I’m proud that the work we do contributes to helping change those statistics.” There’s also the added challenge that avoiding eye contact is a cultural gesture of respect, which is difficult when you’re trying to look deep into someone’s eyes and examine them. “You really are up in someone’s business when you are looking at their eyes. It’s a challenging part of the job. I also saw one woman who believed she had lost her sight
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CLOSE-UP because of a cultural punishment. She was frail and in her 70s and we couldn’t convince her there was something else going on, which was reversible. Hopefully, we can see her again and work on that.”
Collaborators During one of their visits, the team were invited to a bush barbecue with locals in Laverton. They sat down with traditional owners, elders and community health workers to discuss how to improve Aboriginal health and the local traditions which impacted health and healthcare. Randolph says it was a special event and another opportunity to gain further understanding about the communities he’s working in. “It has been eye-opening to meet people from so many different cultural groups. It has felt like a crash course in just about everything, but I’ve really enjoyed that.” Working with the Vision Van has confirmed for Randolph that he always wants to have one foot in the public system while hoping to be accepted for further training in ophthalmology.
“It’s important for me to be part of a service where people don’t have to pay. I think that will always be part of my ethos – to provide access to people who don’t have it in rural and remote areas. I want to be able to do what I can. I think that’s one of the greatest strengths of the Australian health system.
in country areas has been a real eye-opener.
“It has definitely sharpened things for me in that I am seeing the issues first-hand that come with having a system of public and private services. The access to specialists
ED: Check www.outbackvision.com.au/ vision-van/ for van locations for the rest of 2021. For information and bookings, contact info@outbackvision.com.au or 9381 0802 or contact your regional health clinic.
“Everyday we work with people living far from the health care they need and we try and figure out how we can improve their access and give them tools to help themselves at the same time.”
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The myopia generation Dr Jessica Mountford from the Lions Eye Institute is putting new focus on near-sightedness in children. Rapidly rising in prevalence and associated with a growing socioeconomic burden, myopia, or nearsightedness, is now recognised as one of the world’s leading causes of distant visual impairment. To help explore the mechanisms involved in the development of early-onset myopia, we are using zebrafish as a model to screen myopia-associated genes, as well as closely following how COVID-19 lockdowns may influence the prevalence of early-onset myopia in school-aged children.
What is myopia? Myopia occurs when there has been excessive axial elongation of the eye, resulting in refractive error, as light entering the eye is focused in front of, rather than on the neural retina. Left untreated, high myopia (>-5.00 diopters) can lead to other visual disorders such as retinal detachment, retinal atrophy, myopic maculopathy, glaucoma and cataracts. Prevalence rates are as high as 97% in some countries (namely within East Asia) and at 17% here in Australia. The World Health Organisation has predicted 3.36 billion people worldwide will become myopic by the year 2030 and this is expected to increase to 50% by the year 2050, with 10% of those developing into high myopia. Therefore, it is a condition that is forecast to increasingly burden the healthcare system globally. Sadly, the fastest rise in prevalence is occurring in school-aged children as young as six years of age, whereby early-onset or juvenile myopia develops.
What causes myopia? There are several contributing factors attributed to the development of myopia, including both genetics and environmental determinants such as nearwork (reading, screen time and schoolwork) and time spent outdoors. 28 | AUGUST 2021
The rise in early-onset myopia and high myopia prevalence, however, is occurring globally at a rate too rapid to be attributed to genetic variance or environmental factors alone, suggesting a compelling association between complex heterogeneous interactions in eye development and environmental risk factors, yet the fundamental causal mechanisms remain unknown.
Impact of school closures With global infection rates of SARS-CoV-2 virus still continuing to rise more than 18 months into the pandemic, many parts of the
globe are still implementing strict measures to help flatten the curve, including social distancing, mask coverings, border closures, curfews, stay-at-home orders and periods of lockdown. As a result, many educational institutions such as schools and universities have resorted to online learning. In fact, UNESCO has indicated that the pandemic has created the largest disruption of educational systems in history, affecting nearly 1.6 billion learners in more than 190 countries and all continents.
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GUEST COLUMN Closures of schools and other learning spaces have impacted 94% of the world’s student population, up to 99% in low and lower-middle income countries. Subsequently, these children have increased their screen time, using devices (such as iPads, tablets and laptops), whilst completing schoolwork at home, consequently increasing their environmental risk of developing early-onset myopia indirectly by limiting the amount of time they spend outdoors in natural light.
associated with pathological disease.
COVID-19 lockdowns and the prevalence of early-onset myopia.
Recent studies have identified novel genetic loci found to be associated with refractive error, however, our understanding of the mechanisms involved in this progress remain unknown. With the use of a highthroughput genetic screening platform in zebrafish (Danio rerio), I aim to determine which genes are involved in the progression of early-onset myopia and how light modulation effects the severity of the disease.
Given these predicted myopia rates during an increasingly uncertain time, investigating the mechanisms involved in the development of early-onset myopia will be significant and timely in combating an increasingly global socioeconomic burden.
End-game
Thus, it is predicted that diagnoses of early-onset myopia will escalate as a result. By investigating this association, protective mechanisms can be implemented into policy reforms in an attempt to lower the environmental risk.
These studies aim to develop a screening method to link functional myopic phenotypes with known myopia-associated genes, and test how environmental changes may affect this outcome.
Genes vs environment My research at the Lions Eye Institute focuses upon determining the role both genetics and environmental factors have on the development of early-onset myopia. The use of human epidemiological and genetic analyses is essential for identifying genomic regions
Hopefully this will allow for a targeted approach to encourage prevention, government policy change and personalised risk assessments. ED: Dr Mountford is the Lions Eye Institute’s Brian King Fellow.
Read this story on mforum.com.au
In addition to this, and with the help of collaborators, locally and abroad, we aim to gather translational information on myopia risk factors such as near work, time spent indoors and outdoors, eye health in a defined group of children living in populations affected by school closures during
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GPs’ role in the concussion pathway What is concussion’s knock-on effect to general practice, asks Professor Melinda Fitzgerald from Curtin University. While concussion is in the public eye due to its effects on highprofile sports people, only about 20% of concussions are sports related. Most concussions, also referred to as mild traumatic brain injury, arise from road traffic accidents, falls and assaults.
When a person experiences concussion they have a range of options as what to do. They can attend a hospital emergency department, either public or private. They can see a GP, including at after-hours medical clinics.
attended by a first aid officer, sports trainer and/or a sports medicine clinic or physiotherapist if their symptoms do not resolve. Unfortunately, there is a further option – to do nothing – and it appears that more people than we realise follow this path.
People who have experienced concussion playing sport may be
Based on recent studies of incidence rates it can be calculated that there are about 170,000 cases of concussion per year in Australia [Thomas et al Journal of Concussion (2021) 4: 1]. Coded presentations to hospital emergency departments amount to less than one tenth of this number. Our current research indicates that about 40% of people who seek medical care following a concussion do so through an ED. So, it follows that up to 80% of people who experience a concussion do not seek medical care, at least acutely. Good management of concussion helps in timely recovery. The lack of early medical care for the majority of people who experience a concussion is a concern, due to the potential for misdiagnosis and lack of care for the one in five people whose recovery is delayed. WA researchers have recently surveyed GPs to determine
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GUEST COLUMN their exposure to patients with concussion, their referral practices and their familiarity with guidelines. The results were reported in Thomas et al. BMC Fam Pract (2021) 22:46. A key finding from the study is that of the surveyed GPs, only 63% felt confident to manage a patient diagnosed with concussion.
that currently available guidelines are disseminated broadly. However, lack of confidence in managing concussion was not linked to awareness of guidelines, reflecting a lack of information on additional key particulars of how to advise patients on their recovery.
GPs who are not aware of concussion guidelines were less confident in concussion diagnosis.
Researchers around Australia and internationally are investigating how best to manage people who experience concussion, and more severe traumatic brain injury.
The length of time that symptoms persist is highly variable following concussion and depends on the nature of the injury. Good management practices incorporating graded return to activity in such a way as to not exacerbate symptoms is key to optimal recovery.
Connectivity: Traumatic Brain Injury is a new not-for-profit organisation working to raise awareness of concussion in the community. One way it seeks to achieve this is by linking clinicians and healthcare providers with researchers and new research outcomes via its website www.connectivity.org.au.
The GP survey identified that most respondents thought that a delayed recovery is symptoms or signs persisting after five days in adults and children. Current literature actually indicates that symptoms or signs commonly persist for 7-14 days in adults and 28 days in children.
I encourage all healthcare practitioners who manage people with concussion to visit the website and learn more about the latest research on best-practice management.
This data implies that GPs are expecting people with concussion to have recovered after five days and may be suggesting they can return to normal activity, including contact sport after this time. Return to normal activity that may expose a person to a second concussion risks recurrence of symptoms, repeated concussion and, at worst, the potentially catastrophic consequences of second impact syndrome. Even premature return to work or school may exacerbate symptoms resulting in delayed recovery. Given that diagnostic confidence in GPs is linked to awareness of guidelines, it is important to ensure
As knowledge evolves, there is a need for continually updated, nationally consistent concussion diagnosis and management guidelines. Ensuring these are relevant to concussion from all causes, and with a range of frequently encountered comorbidities will be important. The Mission for Traumatic Brain Injury, supported by the Medical Research Future Fund, features the development of such guidelines in its draft Implementation Plan. Once these are developed, they will be broadly disseminated. Additional research is planned to focus on developing prediction models for concussion and more severe traumatic brain injury and identifying new treatments to improve both short and long-term outcomes.
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The GP survey identified that most respondents thought that a delayed recovery is symptoms or signs persisting after five days in adults and children. Current literature indicates that symptoms or signs commonly persist for 7-14 days in adults and 28 days in children.
Ensuring GPs and other healthcare practitioners who manage people with concussion receive the most up-to-date knowledge of bestpractice, evidence-based care, is key to improving outcomes after concussion. Raising awareness in the broader community of the need to seek medical care after concussion will ensure that upto-date knowledge is delivered to those who need it most. ED: Professor Fitzgerald is jointly appointed by Curtin University and the Perron Institute, and is CEO of Connectivity. Her team has been awarded almost $500,000 in Federal Government funding to improve care for people with traumatic brain injury, including those in rural, remote and Aboriginal communities.
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ChestRad is a medical imaging practice in the Nedlands hospital precinct dedicated solely to cardiac CT and chest imaging Our staff and equipment were handpicked to provide an uncompromised patient experience and diagnosis. We recommend coronary C T to GPs as a first line test for CAD as it is more sensitive and at least as specific as other tests. Our pricing is set to make the test m o r e a v a i l a b l e t h a n e v e r. f a s te r, s a f e r, s i m p l e r, c o s t- e f f e c t i v e
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Immediate action – delayed consequences Lawyers Enore Panetta and Daniel Spencer argue that national health boards go too far in restricting practitioners under immediate action. Individual and organisational response to risk is intriguing. We only have to look as far as the response to the COVID-19 pandemic to gain an understanding of how entities (or jurisdictions) adjust (mandate) behaviour differently in the face of risk.
One of the critical things to remember about immediate action is that findings are not being made about the veracity of allegations and an appropriate disciplinary sanction imposed. These are interim measures designed to ensure the public is protected in the short term. By their very nature, they must be as least restrictive and do as little damage to the practitioner as is consistent with the maintenance of public safety.
The public is divided on the proportionality of these responses. Some people consider the measures necessary, while others consider them excessive. The reasons adopted for such measures can be perplexing and obscure. In the health regulation space, response to ‘risk’ by national health boards can be just as baffling. With the addition of the ‘public interest’ limb in the Health Practitioner Regulation National Law in August 2018 – which allows a board to take immediate action against a practitioner when it is ‘otherwise in the public interest’ – there appears to have been an increase in the most restrictive immediate action being taken, or at least proposed, against practitioners, albeit not necessarily relying on the new limb. Immediate action is a decision taken quickly, based on limited evidence, and generally consists of either suspension or imposition of conditions on a practitioner’s registration. Ultimately, the underlying allegations may not be proved. Prior to the addition of the new limb, the board could only (in addition to other rarely used circumstances) take immediate action in circumstances where it considered that a practitioner posed a serious risk to persons and it was necessary to take the action to protect public health or safety. The regularity with which boards put out proposals to suspend has become monotonous and predictable. Worse though, it has also become so destructive to the professional and personal lives of practitioners – reputationally and financially – while at the same time 34 | AUGUST 2021
doing little to afford the public the necessary protection it ‘requires’. Immediate action suspension restricts the practitioner from any practice and continues to have effect until it is revoked by the board. In our experience, some practitioners have been suspended for periods of six, 12 or even up to 18 months under the immediate action provisions of the National Law before any disciplinary proceedings are commenced against them. Further periods of suspension (or cancellation) are inevitably waiting for them at the conclusion of the disciplinary proceedings. The main gripe from these practitioners is the time taken from when immediate action is imposed to when the investigations are completed, often exacerbated by the regular turnover of AHPRA staff sapping its resources to expedite matters. When the time comes for a penalty in the disciplinary matters, board representatives argue that an immediate action suspension already served should not count for the purpose of any penalty agreed at the disciplinary stage. Why not? When is enough, enough? How many times ought a practitioner be punished? You cannot help but think there is an element of double jeopardy going on here.
Such considerations do not need to be applied in disciplinary proceedings and nor should they be, given their different mandate. While suspension is the obvious example of excessive action, one of the less recognised examples of the board taking disproportionate action against practitioners is when it imposes “gender-based restrictions” which prevent the practitioner from having contact with female patients, in lieu of a proposed suspension. Conditions regarding such restrictions are governed by an AHPRA-drafted protocol, adopted by the board as the gold (only) standard when imposing such conditions. Let’s consider a real example of when such action was taken. A registered health practitioner contacted a female patient via social media. The relevant board is informed and proposes immediate action by suspending the practitioner’s registration, despite no similar previous conduct or concerns regarding clinical care. A once-off where a practitioner has failed to maintain professional boundaries which, undoubtedly (and appropriately) will probably be the subject of a referral to a tribunal for professional misconduct and an appropriate penalty imposed.
continued on Page 37
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Healing the airways to breathe better Dr Thomas Iosifidis is working to develop safe and better treatments for childhood asthma. Despite common misconceptions, asthma remains a substantial global healthcare burden with around 330 million sufferers worldwide. Asthma costs the country $28 billion in healthcare costs, according to a report by Asthma Australia and National Asthma Council Australia.
different to children’s needs. Unfortunately, it is difficult to replicate asthma as seen in children in the lab to test these potential therapies, and so there is a need for the development of patient-specific complex airway models to fasttrack identification of new asthma treatments suitable for children.
Young children are arguably the most disproportionally affected. In fact, asthma is the most common lifelong breathing disorder in children, with one in six Australian children experiencing asthma. In addition, it remains one of the main causes of their hospitalisation.
that accessing the required tissues from the airways is challenging, particularly in children, due to the invasive nature of airway sampling.
The potential solution – organon-a-chip technology – has arisen through the collaborative efforts of bioengineering, cell biology and medicine disciplines. A strategic partnership between A/Prof Sean Murphy and his bioengineering team at the Wake Forest Institute for Regenerative Medicine in North Carolina, USA, and our local respiratory medicine research team, funded by WA Health, places the Wal-yan Respiratory Research Centre at the forefront of this field globally.
The team at Wal-yan has pioneered access to these precious samples and shown that the airway lining of children with asthma has abnormal responses to injury, and is inherently ‘leaky’ and inflamed, contributing to ongoing and worsening breathing problems.
Combining our access to paediatricderived airway tissues with the cutting-edge organ-on-a-chip platforms provide an ideal scenario to examine the biological processes underlying early-onset disease in culture models resembling patientspecific tissue environment.
A recent study found experimental and FDA-approved medications used to treat pain in children and adults could enhance repair and reduce inflammation in asthmatic airway epithelial cell cultures. This study has highlighted a potentially new class of drugs that targets a previously unknown disease pathway in asthma. More importantly, the data suggest that this treatment strategy may not only heal damaged airways, but also reduce recurrence and severity of asthma flare-ups in children.
Additionally, interconnected organ chip models (e.g., lung and liver) on body-on-a-chip platforms are facilitating our drug screening efforts to accurately identify human organ toxicity, not otherwise observed in animal models or conventional cell culture models.
The burden of asthma on our community is under-addressed by current treatments. Although asthma symptoms are manageable in most patients, these medications fail to alter lung function decline and may present unwanted side effects. Unfortunately, the most vulnerable group of all, children with ongoing asthma, remain at highest risk of having lifelong respiratory diseases such as severe chronic obstructive pulmonary disease. As such, there is a pressing need for new therapies that target the underlying disease processes of asthma in early life and not just treat symptoms. This is an area of intensive research being undertaken by a team of clinicians and scientists at the Walyan Respiratory Research Centre, a partnership between Telethon Kids Institute, Perth Children’s Hospital Foundation and Perth Children’s Hospital. The team has focused its research on the epithelium cells lining the airway surface, which form the lung’s first line of defence, a barrier against the outside environment, and are responsible for the initial responses to injury and infection such as viruses – one of the main triggers of asthma flare-ups. While studying the triggers of asthma flare-ups may seem intuitive, it is a surprisingly understudied, the reason being
However, to determine if these treatments are safe and effective to use in a clinical setting, new treatments need to undergo rigorous preclinical testing and human clinical trial assessments.
By using these complex human organ models and technology, we can find the best treatment candidates with strong safety and effectiveness profiles to be progressed into further clinical trials. The conventional drug development pipeline has provided minimal therapeutic options for vulnerable children with asthma, so it is time to upgrade the process and fast-track the delivery of better treatment options.
The standard drug development pipelines currently cater to adult asthma therapies, which are
ED: Dr Thomas Iosifidis is a postdoctoral researcher with the Wal-yan Respiratory Research Centre.
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Immediate action – delayed consequences continued from Page 34 But a suspension from practice? The only inference to be drawn from that decision is that the practitioner is such a ‘serious risk’ to all patients, irrespective of their age or gender, that he cannot be trusted to undertake any form of medical practice in the meanwhile. Respectfully, that is an outrageous leap of logic. Following a submission from the practitioner that a suspension may be excessive, the board imposes gender-based restrictions. Presumably, such restrictions (on their face) would simply prohibit the practitioner from treating female patients. But not only is the practitioner prohibited from consulting female patients, the definitions in the protocol are such that the practitioner is also prevented from:
• consulting a female child; • consulting a male or female child in the presence of their mother (or another female); • consulting a male in the presence of their female spouse or partner; • working at a medical practice or in hospital where females consult other practitioners; and • consulting a female patient via telehealth. Indeed, it would potentially be impracticable for the practitioner to continue to work under gender-based restrictions. When submissions are invariably made that the protocol is too restrictive, the same response is given – “that’s what the protocol says”. As well as protecting public safety, the boards ought to consider the identified risks that a practitioner poses and the practicalities of any immediate action restrictions to be imposed. If immediate action
is imposed in any form, regular reviews should be undertaken to determine whether a risk still exists. In many cases, the risk will decrease with the passage of time. Practitioner suicide (and threats) have resulted from situations where practitioners are at the mercy of ill-fitted draconian restrictions and protracted investigations. Striking and maintaining an appropriate balance is hard for the boards. However, they are obliged to do so in accordance with the guiding principles of the legislation under which they exist. Proportionality must play a considered role and the professional reputation of practitioners must be given value before and during the exercise. ED: Enore Panetta and Daniel Spencer are lawyers with Panetta McGrath.
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Powers of effective gender diverse care Dulasi Amarasingha from Youth Pride Network explains how GPs can help trans and gender diverse youth access health care. Primary care is often the first point of contact a LGBTQIA+ young person has with the health system and these early experiences may permanently shape their future engagement. Therefore, it is critical that these early encounters are productive, affirming and positive. Being LGBTQIA+ in itself is not a risk factor for poor mental health. It is the sociocultural expectation of cisheteronormativity (the expectation that everyone is heterosexual and cisgender) and accompanying social exclusion, stigma and systemic discrimination that negatively impacts mental health. This results in higher rates of psychological distress, depression, anxiety, suicidal ideation, suicide and self-harm. When seeking healthcare, LGBTQIA+ people may experience overt discrimination, subtle discrimination and the more pervasive knowledge gaps contributing to sub-optimal patientprovider communication. Conversely, GPs who are able to provide inclusive and affirming experiences for LGBTIQA+ young people are able to establish a lifelong positive relationship with the health care system. Only two-thirds of LGBTQIA+ youth receive professional diagnosis and support, and one-third do not use crisis support when needed due to anticipated discrimination. The COVID-19 pandemic has exacerbated the challenges and disparities faced by these youth, of note is mental health especially for young people in unsupportive households with limited contact to community support systems. Young people with variation of sex characteristics (also known as Intersex conditions) often receive substandard care due to lack of understanding and stigma. Intersex advocates have globally called for increased education of health professionals and many other health-related reforms in the Darlington Statement.
Aboriginal and Torres Strait Islander LGBTQIA+ youth face exclusion and discrimination in both Queer and Indigenous communities. As is highlighted in many studies, including a recent report from ECU, Breaking the Silence, racism and heterosexism present significant barriers to care. It is important that health care providers understand diverse identity groups and have awareness of support services led by Aboriginal and Torres Strait Islander LGBTIQA+ people. This experience of ‘dual discrimination’ is also faced by LGBTQIA+ youth who are from a culturally and linguistically diverse background, refugee background, have a disability, from religious faith communities, living rurally or are in foster care. Discrimination, ignorance and poor communication make it difficult for LGBTQIA+ young people to have their sexual health needs addressed by GPs. This is especially prevalent in STI and HIV testing which must be accessible to youth without harmful stereotypes and assumptions. In particular, there is a lack of informed and respectful discussions surrounding safe sex practices for women who have sex with women and contraceptive options for transmasculine youth. Additionally, education surrounding PrEP and PEP for HIV is crucial to providing LGBTQIA+ youth with informed care. GPs can also play a vital role in discussing consent and healthy relationships, as LGBTQIA+ youth are at higher risk of abusive relationships mainly due to barriers to support. It is important to include trans and gender diverse young adults in preventative screening such as the cervical screening test. Avoiding gendered anatomy and using inclusive language (e.g. people with cervixes, people who menstruate) can improve communication during consultations. Explaining and reassuring confidentiality is
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critical to creating a safe space for LGBTQIA+ youth to ask questions. Trans and gender diverse youth face unique challenges in accessing primary care. This may include deciding whether to disclose their gender identity and having to explain terminology or justify their identity to practitioners. They may also be asked invasive, personal questions that are not clinically relevant to presenting issues due to a practitioner’s curiosity. Sometimes this may be wellintentioned, but it is not helpful to place the burden on the young person seeking healthcare to also educate. Staff making inappropriate remarks about LGBTQIA+ people’s bodies, identities and expression is actively harmful. Because of the lack of informed GPs, there are often long waiting lists and multiple barriers for young people accessing gender-affirming care. Given the opportunity, GPs should be informed of consent-based gender affirmation care and be able to educate LGBTQIA+ youth about safe practices for non-hormonal gender affirming care such as chest binding and genital tucking. Lack of accessibility can delay presentations for essential healthcare. It is incumbent upon GP to understand LGBTQIA+ inclusive health care is well within their capability to provide, and must be a standard across all health care, rather than viewed as a specialist area. The Youth Pride Network has recently released a version of the Australian Charter of Healthcare Rights with LGBTIQA+ specific examples and imagery to improve the accessibility and understanding of the Charter for LGBTIQA+ young people. This is a great place for GPs to start and is available on www.youthpridenetwork.net/ me-and-my-doctor ED: Dulasi Amarasingha is a committee member of the Youth Pride Network, with Hunter Gurevich, chair of Transfolk of WA, providing feedback for the article.
AUGUST 2021 | 39
A GP’s guide to paediatric anxiety Anxiety is considered the fastest growing childhood mental health issue in Australia. Dr Andrew Leech explains. GPs are the most used service provider when it comes to mental health of children. We are often the first point of contact for families, yet understandably do not feel confident in how best to manage this. Feeling anxious, stressed, angry or scared are normal parts of growing up and learning about the world. It can be challenging to figure out the exact moment in time where a child shifts from being anxious, to developing an anxiety disorder. For example, pre-school aged children may be anxious about changes in their routine, separating from parents and spending time with unfamiliar people, all normal. In the early school years, children can worry about the dark, monsters and ghosts. It is important to recognise the ranges of ‘normal feelings’ so that as health professionals we don’t over-label conditions.
Is anxiety increasing? Anxiety in children is a complex process. Infants and children, more than any other age group, are shaped and influenced by a range of social, biological and environmental factors, all of which go into making them who they are. Anxiety remains both environmental and genetic and there is often a strong family link. There are multiple theories on why paediatric anxiety might be increasing: • Anxiety is increasing in adults. Children learn their own coping mechanisms through watching how their parents deal with stress. • The COVID-19 pandemic has increased anxiety through the media and constant reminders of the threats related to the virus through lockdowns and changes at school. • Children are given less opportunity to take risks. Resilience is affected by this, and they are more sensitive to change and stress. • On the flipside, children are now rewarded for anything and 40 | AUGUST 2021
•
• •
•
everything. Children can be ‘over rewarded’ to the point they feel they have failed if they don’t get praise. Children’s diets are deteriorating. There is more fast food and sweet food on offer and less awareness of good food choices. The impact of devices and computer games. The pressure to be ‘perfect’ on social media. The longer periods of time spent playing with technology. Less sleep, less good food, less physical activity due to all the above factors.
What is an anxiety disorder? The DSM classifies anxiety for children in the same way it does for adults. The exception of this is PTSD and ADHD where children have their own criteria. Social anxiety disorder, obsessive compulsive disorder and phobias remain the most common childhood anxiety disorders. Anxiety disorders rarely exist alone, however, and can be linked to other neurodevelopmental conditions such as Autism Spectrum Disorder and ADHD. For this reason, it is important to take time when considering the diagnosis and follow families up over a few consultations. Enquire about that child’s overall development. When in doubt involve a developmental paediatrician.
What are the symptoms? Children present quite differently to adults when it comes to mental health. The breadth of symptoms can be wide and often warrant consideration of medical and psychological causes. Think about anxiety whenever a child presents with: • Increased irritability and behavioural outbursts • Butterflies or a sore tummy • Headaches and dizziness • Reports of being able to feel their heart beating • Difficulty concentrating at school,
avoidance of a particular place, person or experience • Resistance when separating from primary carers • Difficulty sleeping Clarify with parents the degree each of these symptoms is occurring by asking is the emotion pervasive, severe and persistent? A child mental health condition can be distinguished from a vulnerability by its intensity, duration and extent of its impact on the whole ecology of the child.
Discussing anxiety? Be aware that the child is sitting in front of you in the consultation room and overhearing a lot of this adult conversation. Start with positive questions to build rapport. Ask the child first about what is going well for them, what are their favourite hobbies or friends? Who do they play with at school? What are their hopes and dreams for the future? If this is ineffective, colouring-in and drawing also works well enabling the child to express themselves differently. Questions related to anxiety require child-friendly language that is easy to understand. Instead of the word anxiety, use words like, being scared, having a tummy ache or butterflies, or labelling the anxiety as something else like ‘the worry monster’. For younger children it can help to draw a human body shape and then ask the child to tell you where they feel these worries in their body. Normalising can be immensely powerful. ‘I’ve talked to other children before who get a bit scared at night when Mum and Dad put them to bed, does this happen to you?’ I will often leave parents with a screening tool to take home and email back to me. There are two useful tools when it comes to anxiety. https:// www.sdqinfo.org/py/sdqinfo/ b3.py?language=Englishqz(Austral) and the spence anxiety score https://www.scaswebsite.com/
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Medical screening Consider secondary medical causes of the anxiety. Perform a physical examination checking their height and weight. Examine their ears and throat, chest, and heart sounds. If there are bowel changes, consider constipation and examine their abdomen. Assess the need for blood screening, in particular iron, thyroid, a full blood panel, vitamins, and coeliac serology. When it comes to sleep, consider sleep disorders and ask if the child is snoring. A snoring child is never normal and warrants further review with an ENT or sleep specialist.
Teaching self-regulation The goal for most kids is not to eliminate anxiety completely. It is about giving them the skills to manage anxiety, so it does not get in the way of enjoying life. Discuss with parents their own coping strategies and encourage them to be consistent with how they help kids regulate. To acknowledge the difficult feeling they are experiencing and help them through that. Talk to parents about slowing down. A suitable time to do this is in the school holidays. Allowing the
child time to calm down, going for a walk with them, sitting with them, holding them, hugging them when they are angry or stressed, stating clearly and firmly that they are okay and that you are with them now.
Practical tips for parents • • • • • • • • •
Start by slowing down Make time to worry Climb that ladder Encourage positive thinking Have a go Model helpful coping Help your child take charge Be upfront about scary stuff Be brave, allowing children to take risks and learn from their mistakes • And finally, check your own behaviour Refer parents to the BRAVE program https://brave4you.psy. uq.edu.au/
Start with the basics • Sleep – discuss sleep hygiene and no screens after dinner. Melatonin can be useful for the difficult sleepers. • Diet – water should be the predominant drink. Avoid packaged foods. A diet lower in
added sugars and colours. Build around fresher foods, fruit and vegetables. • Physical symptoms – tummy aches, headaches, anxious feelings – daily mindfulness to slow down using the Smiling Mind app or bedtime explorer's podcast. Encourage children to label their emotion using an emotion chart, drawing and colouring. • School – encourage parents to talk to the teacher and let them know what is going on. Allow the child to take more regular breaks in the classroom if this helps. • Social – find a positive activity for the child to engage with on a regular basis, exercise is great for helping release serotonin. Follow up with the family and if not improving it can be helpful to refer to a child psychologist or occupational therapist with training in mental health, using the mental health treatment plan item numbers. If concerned about developmental conditions or autism, refer early to a developmental paediatrician as there are currently extended wait times. ED: Dr Andrew Leech is a GP with special interest in paediatric health and mental health.
BreastScreen WA opens a new screening clinic in Albany BreastScreen WA has opened a new permanent screening clinic in Albany at 2/2 Barnesby Drive. This clinic will give women in the Great Southern region year around access to screening mammograms. The clinic has free parking, easy access to public transport and facilities for women with disabilities. All asymptomatic women aged 40 years and over are encouraged to have a free screening mammogram every two years.
Women may book online www.breastscreen.health.wa.gov.au or phone 13 20 50 Medical Forum_Albany 2021.indd 1
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52 | APRIL 2021
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OPINION BACK TO CONTENTS
Dr Joe Kosterich | Clinical Editor
Who thinks of the children? The proverbial visitor from Mars would look at how our society treats children and form a view that there is some inconsistency. On one hand we say that the children are the future but, on the other, decisions are often made to the detriment of children and the benefit of adults.
Sleep apnoea is a condition we associate more with adults. However, children can be affected as well.
Whether one agrees or not with lockdowns, it is children who are most adversely affected through loss of education and the anxiety and fear from not being able to play with or see friends. As we know, young children tend to internalise matters and assume that whatever happens to them is because of what they have done. It is to be hoped that the long-term mental health problems will not be as bad as has been predicted and that for once when the cry of “who will think of the children” goes out there may be some action rather than hand wringing. On the positive side, as a cohort, children and teens are generally healthier than adults. In turn, health issues that do affect children can get less airtime and research dollars. This month we highlight work being done here in WA to improve outcomes from burn injuries and brain cancer. Use of video-laryngoscopy and the role of the complex airways team is something most of us outside the hospital system will not be familiar with and makes for fascinating reading. Research into genetic screening is also examined. Sleep apnoea is a condition we associate more with adults. However, children can be affected as well. Diagnosis and treatment are looked at, as is management of a common issue – blocked tear ducts. On all health indicators, Indigenous citizens do worse than the broader population and this also applies to middle ear infections. Untreated this can impact language development, education and future prospects in life. A project in the South Metro region is working to improve outcomes. Without fanfare they are getting on with the job and to use a footy term “kicking goals”. Despite political point scoring, the vaccine rollout is gathering pace and by year's end we will likely be at 60% or more. Where the UK is now shows that there is light at the end of the lockdown and mask tunnel. They used the AZ vaccine (mainly) in all age groups. Singapore is moving to reporting hospitalisations rather than positive test numbers. Australia did well. Other countries have caught up. We need to learn from what is working in other countries.
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AUGUST 2021 | 43
Burns are more than skin deep By Professor Fiona Wood, Director, Burns Service WA Working in burn injury is challenging seeing lives changed in an instant with lifelong consequences. Our children are especially vulnerable with those under age four most commonly affected. Some years ago, we treated a child who survived a major burn injury who subsequently lost the battle with cancer.
Key messages
Burns may have long-term impacts beyond the skin
New surgical methods are improving outcomes
Mental health and fitness also need focus.
I wondered if surviving the burn injury had an impact on the risk of cancer later? Western Australia is known for its data linkage expertise, and I was privileged to collaborate and build the team that explored the lifelong impact of burn injury. The answer is yes – burn injury does have an impact for life across many body systems.
our database of 34,000 requiring hospital admission for burn injury were not major burns. The questions now are, why is the response to burn injury changing the life trajectory, what is the underlying mechanism driving the changes in inflammation and the immune response, and who is vulnerable?
The most surprising thing in our published work was that 94% of the children and 86% of the adults in
It is clearly not simply related to the extent of the injury and the answers to those questions are vital in driving
forward innovative therapeutic interventions to mitigate against the impact of injury. In 2019, the Stan Perron Centre of Excellence in Childhood Burns was established at Perth Children’s Hospital (PCH), made possible by the support of the Perth Children’s Hospital Foundation. The centre drives and supports clinical excellence, research, education, and community engagement aiming to optimise care at all stages while driving forward the body of knowledge to continually improve. The centre has built on previous work (e.g., exploring the mechanisms underlying the risk of malignancy and vaccine amnesia) in collaboration with Telethon Kids Institute. The team has created a paediatric burn trauma biobank to obtain
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CLINICAL UPDATE biological samples with over 140 children already recruited. This will underpin studies using a systems biology to understand the systemic and long-term physiological impact of burn injury. The biobank alone has led to a number of collaborations and importantly supports a number of early career and higher degree scientists here in WA. Early results have shown changes in neurological pathways and immune responses, guiding further in-depth work. The More Than Skin Deep education program is another pillar being developed to improve the delivery of psychosocial care for children and young people and their families and the staff at the PCH Burn Service with the goal of improved patient outcomes and quality of life. In addition to improving long-term systemic health, including mental health, the centre is focused on developing new methods for surgery to reduce scarring and improve the appearance of scar for children with burns. We are developing a 3D bioprinter that will print cells and a gel (matrix) to promote wound healing and reduce scarring. Collaborations with Inventia and University of Wollongong to develop
this intra-operative printer aim to conduct the first human trials by the end of 2022. Point of care chemistry is the holy grail when supporting decision making in surgery and at the time of dressing changes to understand and monitor the healing processes. Working with Australian National Phenome Centre (ANCP), we are exploring the iknife technology building the library of knowledge around the chemistry of the skin, its surface and changes when injured and infected. How we can unscar the scar remains an area of intense activity with our laser and the research around understanding the changes in the cell phenotype. Data innovation systems established initially with Microsoft and Lotterywest grants are now embedded at PCH, ensuring that the Burns Service, comprising both the adults and paediatric units, is a seamless service that supports clinical and research excellence. The integrity of the clinical data is an essential, foundational piece of the work.
those around them to minimise the impact using a range of technologies such as multi-omics approach with cell biology, locally at the wound site and systemically. While striving for new knowledge and interventions, we have driven care with cell-based therapies and rapid surgery to reduce the time to healing to reduce ongoing inflammation. Connecting with the children in our clinics over time, we are collecting outcome measures highlighting needs such as fitness and exploring the role of exercise in limiting the ongoing inflammatory changes. It is a positive time with the capacity to answer questions with cuttingedge technologies and develop novel skin regenerative strategies. Acknowledgement: The author heads the Stan Perron Centre of Excellence for Childhood Burns at PCH thanks to funding from the Perth Children’s Hospital Foundation Author competing interests – nil
We want to best understand how we can treat the child as a whole and
Clear the path to diagnosis for patients presenting with seizure-like events. Seer Medical is Australia’s leading provider of at-home diagnostic testing for the investigation of suspected seizures.
Who is this for? Patients who benefit from Seer Medical’s diagnostic monitoring are those who present with: — — — —
Events with impaired awareness, unresponsive episodes or loss of consciousness Possible seizures occurring during sleep Checking control of seizures when considering driving To clarify nature of events previously controlled on medications
The Seer Medical diagnostic service is suitable for people from the age of four.
Contact us Paulette Kemp Business Development Manager WA +61 417 077 418 paulette@seermedical.com
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AUGUST 2021 | 45
Reproductive genetic carrier screening By Ms Jillian Kennedy, Associate Genetic Counsellor, KEMH Reproductive genetic carrier screening (RGCS) is testing offered to couples planning a pregnancy, or in the early stages of pregnancy for conditions inherited in an autosomal recessive or X-linked manner. The testing aims to identify those couples who are at risk of having a child with a serious childhood onset condition. Identifying these couples offers them information on which to base reproductive decision making. I To quote the RANZCOG: “Information on available reproductive genetic carrier screening should be offered to all women planning a pregnancy or in the first trimester of pregnancy. Options for carrier screening include screening with a panel for a limited selection of the most frequent conditions (e.g. cystic fibrosis, spinal muscular atrophy and fragile X syndrome) or screening with an expanded panel that contains many disorders (up to hundreds).” Genetic conditions are a major cause of death and chronic illness in children. Estimates suggest one in 50 Australian couples have an increased chance of having a child with a severe autosomal
Key messages
Reproductive genetic cancer screening should be offered to all women planning a pregnancy or in the early stages of pregnancy.
Reproductive genetic carrier screening is relevant for all couples regardless of family history or ethnicity
Further information and education (Cat.2 CPD activity) can be found at RACGP Beware the Rare website.
or X-linked recessive condition such as cystic fibrosis (CF), spinal muscular atrophy (SMA) or Fragile X syndrome. This equates to more than one in 400 children being born with one of these conditions. The impact on families cannot be overstated and nearly 90% of parents with affected children have no prior family history. The advent of genomic testing has focused on diagnosing those individuals who already have symptoms of genetic conditions. Known as the diagnostic odyssey,
the journey to a diagnosis can be both lengthy and challenging, placing additional burdens on the affected individual and their family. RGCS is relevant to all couples regardless of ethnicity or family history and offers the chance to get ahead of the diagnostic odyssey and be informed of their risk of having a child with a severe genetic condition before pregnancy, or during early pregnancy. This allows couples the opportunity to then make reproductive decisions in line with their own beliefs and values. Options such as IVF and preimplantation genetic diagnosis (PGT), early intervention and prenatal diagnosis are all open to couples. Genetic Services of Western Australia gladly accepts referrals, via the Central Referral System for couples where there is a family history of a known genetic condition; other couples can explore options available with their GP, obstetrician, or private genetic counselling services. As there are several providers of RGCS who offer a wide range of services, some of the issues to
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decision about whether or not to pursue RGCS is one for each couple to make once the above issues have been considered. Mackenzie’s Mission is a federally funded national research study investigating how to best implement a population genetic carrier screening program in Australia. Reproductive genetic carrier screening for approximately 1300 genes will be offered to more than 8000 couples nationwide free of charge. Issues such as health economics, ethical considerations, screening uptake, incidence of increased chance couples, gene selection and clinical considerations will all be assessed. In Western Australia, Mackenzie’s Mission is still looking for health care professionals (midwives, GPs, obstetricians, GP/Obst.) in northeast metropolitan Perth, rural and remote regions to recruit their patients. If you are interested in being involved, please phone 1800 466 466 or email the WA study team on mackenziesmissionwa@ perkins.org.au. For more information Mackenzie’s Mission | Home (mackenziesmission.org.au). Jonny, Rachael and Mackenzie Casella, whose legacy lives on in Mackenzie’s Mission – the national reproductive genetic carrier screening program.
consider when selecting providers and offering RGCS include: whether or not to test both members of the couple at the same time or sequentially, which panel of genes to select, how the samples are
collected (blood or saliva) and the cost of the test. The turnaround time for results and whether or not the couple are currently pregnant will impact the decision on whether or not to test at the same time. The
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ED: This article was written with the input of Dr Sarah Smith – KEMH Liaison GP and Ms Samantha Edwards –Project Officer and Associate Genetic Counsellor Mackenzie’s Mission Author competing interests - nil
AUGUST 2021 | 47
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Hepatitis C – Destination Elimination By Dr Donna Mak
The last year or so, one particular virus has been at the forefront of our minds. Meanwhile, in the background, another virus – hepatitis C virus – was being successfully cured by an increasing number of people, as the nation chips away at reaching the 2030 target of eliminating hepatitis C from Australia. It has been just over five years since direct-acting antivirals (DAA) treatments were listed on the PBS. DAAs were a breakthrough in eliminating hepatitis C, curing 95% of individuals who complete treatment in a shorter time frame than previous treatments, with less side effects and taken orally.1
What progress has been made? A total of 7,820 people, representing 41.9% of residents living with chronic hepatitis C virus (HCV) in WA, have initiated the new DAA treatment since it was introduced in March 2016. 2
What can GPs do? GPs are extremely well positioned in the community to be the champions of eliminating hepatitis C. Promisingly, DAA prescribing by GPs has been on an upward trend. 2 While approximately equal proportions of WA residents were prescribed DAA treatment by a GP or a specialist in the period of March 2016 to September 2016 (first reporting period by the Department of Health WA), 79% of DAA treatment between October 2019 to March 2020 (latest published reporting period) were prescribed treatment by a GP. 2 48 | AUGUST 2021
There was a 26% increase in the number of unique prescribers for DAA treatment in WA from the first reporting period to the latest published reporting period. 2 This highlights the essential role of GPs in the elimination of hepatitis C, a role that is only increasing in importance. The skills that GPs use every day fits well with those needed to find and treat patients with chronic HCV.3
How can we effectively test?
the pathology form: “If anti-HCV positive please perform a HCV RNA and genotype.” In this way, the HCV RNA and pre-treatment virology assessment tests can be collected at the same time as the initial screening.4 This will reduce the number of appointments and blood tests required for your patients and reduce the likelihood of patient attrition.1 PBS eligibility criterion for accessing DAA treatment requires documented chronic hepatitis C, that is, evidence of chronic hepatitis C infection (repeated HCV antibody positivity (anti-HCV) and HCV RNA positive).5
As most people living with chronic HCV are asymptomatic, opportunistic identification of people at risk is vital.4
What resources and supports are available?
Routinely asking the question “Have you ever injected drugs?” or identifying if your patient’s country of origin is from a high HCV region may detect many of those who require testing for HCV due to being at risk of having acquired the virus.4
The WA Department of Health is committed to the goal of eliminating hepatitis C as a public health threat by 2030, so that the infection no longer impacts on the lives of people living with chronic hepatitis C and on the WA health system.
Once you have identified that your patient should be tested, to ensure complete and timely diagnosis of chronic HCV, reflex testing is recommended following a positive hepatitis C antibody (anti-HCV) screening test.1
• The Department supports HepatitisWA to facilitate a project encouraging GPs to undertake a lookback for patients with hepatitis C and provide advice on treatment and monitoring. If you would like to speak to the hepatitis C GP Liaison Nurse at HepatitisWA, please call Kat on (08) 9227 9802 or email clinicnurse@hepatitiswa.com.au. • The Burnet Institute Practice Support Toolkit WA1 provides information and resources promoting hepatitis C testing, treatment and patient support. • The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) hepatitis C
Reflex testing involves requesting on the pathology form that a) if the blood sample is positive to hepatitis C antibody, to then test for HCV ribonucleic acid (RNA) and b) if the HCV RNA test is positive, that the pre-treatment virology assessment tests are also completed. A dedicated collection tube is required to undertake the HCV RNA.4 A good practice tip is to write on
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Donna Mak is a public health physician for the Department of Health, WA.
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Miracle of science by Dr Ric Chaney On a timescale that is little short of miraculous, managing hepatitis C in general practice has gone from being the province of the very brave GP to being simple, fail-safe and immensely professionally satisfying. No longer the nightmare of prolonged injected interferon plus ribavirin therapy, which not only made patients very sick, but failed more often than it succeeded, hepatitis C treatment has been replaced by the new era of shortduration, non-toxic, all-oral medications, with cure rates approaching 100%.
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It is difficult to imagine a more rewarding field of endeavour in general practice where, within a few short weeks, we can cure a disease that has blighted patients’ lives and damaged their self-esteem, often for decades. resources4 contains resources for general practitioners in eliminating hepatitis C and also hosts various training events. • Further information about hepatitis C testing and treatment is also available in the ‘Silverbook’ (Guidelines for managing sexually transmitted infections and blood-borne viruses)6, and Healthpathways.7
We are not practising medicine primarily with the aim of gaining patients’ gratitude, but there are few fields where it is more manifest. The Gastroenterological Society of Australia (GESA) has on its website a simple two-page guide to everything we need to know as GPs to manage hepatitis C. The key is to diagnose it in the first place: it really should be part of universal baseline screening in general practice, as there is a great pool of undiagnosed patients in the Australian community, many of whom do not have any of the traditional risk factors. Think hepatitis C! Ric has worked in the field of blood-borne viruses for over 30 years, and now does regular sessional work at the Sexual Health Clinic at RPH and at HepatitisWA.
References: 1. Burnet Institute Eliminate Hepatitis C Partnership. EC Partnership Practice Support Toolkit WA. Melbourne: Burnet Institute; 2018. Available online at: https:// ecpartnership.org.au/ toolkit (accessed May 2021). 2. Mitchell K, Mak D, Bastian L, Giele C, Bevan J. Hepatitis C treatment uptake in WA Uptake of antiviral treatment for chronic hepatitis C, October 2019 to March 2020 [Internet]. Perth; 2020. Available from: https://ww2.health.wa.gov.au/Articles/A_E/ Epidemiology-of-STIs-and-BBVs-inWestern-Australia 3. Baker D, Balcomb A, O'Loan J, Howell J. Eliminating hepatitis C Part 5. Practical steps in your practice. MedicineToday. 2019;20(9):36046. 4. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. Primary Care Providers and Hepatitis C [Internet]. Department of Health, Australian Government; 2016. Available from: https:// www.ashm.org.au/resources/PCP_and_ HCV_web_V10.pdf 5. The Pharmaceutical Benefits Scheme. General Statement for Drugs for the Treatment of Hepatitis C [Internet]. Australian Government Department of Health; 2021. Available from: https://www. pbs.gov.au/info/healthpro/explanatorynotes/general-statement-hep-c 6. Department of Health. Hepatitis C [Internet]. Department of Health, Government of Western Australia, 2021. Available from: https://ww2.health.wa.gov. au/Silver-book/Notifiable-infections/ Hepatitis-C 7. WA Primary Health Alliance. Healthpathways [Internet]. 2021. Available from: https://wa.communityhealthpathways. org/13454.htm
Consumer Perspective: Pete’s journey Pete, with Dr Chaney, successfully completed hepatitis C DAA treatment in 2017. What benefits have you experienced since being cured of hepatitis C? In general, patients are more likely to seek appropriate GP care when required after they’ve been cured of hepatitis C, instead of ignoring problems because of shame or fear. Personally, my general health has improved immensely, both physically and mentally, since being cured of Hep C. Being co-infected with HIV, my symptoms from hepatitis C virus (HCV) were greatly exacerbated. I felt 30 years older than I am, but now my quality of life since HCV treatment/cure is hugely improved. I feel like myself again. I am optimistic again. How did your relationship with your GP influence your treatment journey? Because I have been living with HIV for over 35 years, my GP and I have forged a relationship built on mutual trust and respect. He knows my journey, particularly the difficulties regarding loss, trauma and stigma. I implicitly trust him. He always explained treatment regimes, outcomes and the like with me in ways I could easily comprehend. I was able to relay my fears and hopes. Our honest relationship was the foundation on which beginning DAA treatment for hepatitis C was based. If you could give a message to GPs to encourage them to test and treat hepatitis C, what would you say? The testing and treatment are easy and straightforward for both patient and doctor. Nothing is time-consuming. It also adds a tangible layer of trust between physician and patient. Open, non-judgmental discussion between both parties is the key. This again underscores the building of trust.
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A team approach to complex airway management By Dr Hayley Herbert, Head of ENT Department, PCH The Complex Airway Team at Perth Children’s Hospital is the first and only team of its kind in Australasia. It commenced in 2006 bringing together a broad range of specialists to diagnose, treat and monitor children with complex airway problems modelled on the pioneering Airway Team at Cincinnati Children’s Hospital. The active multidisciplinary team draws on expertise and experience across different medical, surgical and allied health specialities aiming to formulate an individualised management plan for patients with complex issues who have generally been referred by a specialist looking after them. Members of the team include ENT surgeons, respiratory physicians, plastic surgeons, oral maxillofacial surgeons, paediatric surgeons, gastroenterologists and paediatricians. Allied health practitioners including speech therapists, clinical nurse specialists from respiratory, ENT, tech dependent (tracheostomy), dietitians and administrative staff Each fortnight about 15 complex babies and children with airway and swallow issues will be discussed in depth and a management plan will be agreed on. Airway and swallow functions are closely related, especially in young babies who are dependent on an adequate airway to develop a suck, swallow, breathe (SSB) synchrony. This co-ordinated rhythmic pattern is required so that infants are able to eat and breathe without choking. Swallowing in itself is a highly complex biomechanical function dependent on structural integrity and mature developed neuronal reflex and control of the oral, pharyngeal and oesophageal muscles. Safe swallowing is also dependent on protective sensorimotor reflexes around a patent airway. Swallowing can be disordered as a result of malformations, central nervous system control, 50 | AUGUST 2021
who monitor the baby’s progress – feeding, obstructive events and growth. They may intervene changing the baby’s sleeping position to prone or placing a nasopharyngeal airway (NPA). ENT surgeons will assess and discuss the child’s upper airway anatomy based on a flexible nasoendoscopy performed on all Robin Sequence infants. At this time, the NPA position may be assessed, and a Functional Endoscopic Evaluation of Swallow may be performed in conjunction with the speech therapy team.
Key messages
The PCH Complex Airway Team was the first of its kind in Australasia
The team approach allows inconsistencies to be reduced and communication enhanced
Outcomes are thus optimised. congenital or acquired infection, cardiovascular or respiratory compromise, prematurity, physiological or behavioural factors or a combination of these. In addition, paediatric swallowing assessment and management requires consideration of other health issues, parent-child interaction, and assessment of the child’s environment. The multifactorial aetiology of swallowing disorders means an interdisciplinary team is best for diagnosis and management of these problems. To illustrate the utility of the team, consider the journey of a child with Robin (also called Pierre Robin) Sequence. These children have a triad of small jaw (micrognathia), posteriorly displaced tongue (glossoptosis) and airway obstruction (with or without a cleft palate). Such children are frequently discussed at the meetings. Valuable input is sought from neonatologists
Speech therapists use this in addition to clinical swallow assessments to adjust factors that may improve the swallow of the infants. They work in collaboration with dietitians to optimise the baby’s growth. Objective assessments of obstructive events may be quantified by a sleep study performed by respiratory physicians who are involved with the majority of patients discussed at this meeting. Plastic surgeons also review the child in the neonatal intensive care unit. If the baby has significant obstructive episodes that cannot be remedied by a nasopharyngeal airway, they may consider a mandibular distraction to expand the lower jaw and in doing so improve the obstruction. CT scans of the child’s jaw may be discussed at the meeting with a radiologist who also regularly attends. If the child has a cleft palate the plastic surgery team will plan repair. Rarely, if the baby’s airway is obstructed at multiple levels, the team may recommend the ENT surgeons perform a tracheostomy. The highly effective collaboration and cohesive decision-making of this multidisciplinary meeting allows for world-class care for these fragile children with diverse and complex needs. Author competing interests – nil
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Understanding Paediatric Obstructive Sleep Apnoea By Dr Paul Bumbak, Paediatric ENT Surgeon, Nedlands Paediatric obstructive sleep apnoea (POSA) is a breathing disorder caused by repetitive episodes of upper airway obstruction during sleep, which result in the disturbance of normal respiratory and sleep patterns. It is one of a group of sleep disorders, termed sleep disordered breathing (SDB), which have been shown to negatively impact a child’s quality of life: in particular, there are physical, developmental, and cognitive consequences, if left untreated. The prevalence of paediatric SDB is up to 6% in children of all ages. Both girls and boys are equally affected before puberty, with the peak incidence of POSA occurring at the age of 2-8 years, during which tonsillar and/or adenoidal hypertrophy is common. With increasing societal affluence and the resultant rising prevalence of obesity, there is now a second peak incidence in children aged above eight years of age. The most common presenting complaint is snoring, mouth breathing and sleep disturbances. Concerned parents may notice apnoea or choking episodes and increased respiratory effort with retractions or paradoxical movement of the chest and abdomen. There are frequent night-time awakenings, enuresis and awakening unrefreshed in the mornings. Furthermore, as the day progresses, such children may present with hyperactivity, poor school performance or conduct disorders. Clinical assessment requires assessing both the size of the tonsils and adenoids as well as establishing if the child has nasal obstruction. Allergic rhinitis is also prevalent in the general population, and it can compound the problem in the child with POSA. Children with certain medical conditions are also more likely to have POSA, particularly those associated with muscle weakness, hypotonia, craniofacial
Key messages
Sleep disturbed breathing issues in children may lead to physical, developmental, and cognitive consequences if untreated
The three most common risk factors for POSA in children are tonsillar and/or adenoidal hypertrophy and obesity
The most common surgical treatment for POSA in children is Adenotonsillectomy. abnormalities including micrognathia, previous upper airway surgery including repair of cleft palate, and syndromes such as Down syndrome or Achondroplasia. The clinical findings alone are poor predictors of the severity of POSA. Studies have also shown that there is no correlation between the intensity of snoring and severity of POSA. A normal physical examination does not exclude POSA, and conversely, not all children with large tonsils have POSA. Thus, a sleep study (polysomnography) may be needed to aid in the diagnosis of POSA for those children with the aforementioned medical conditions, or if there is dissent between the parents. A recent meta-analysis has shown that the use of paediatric sleep questionnaire together with pulse oximetry is also effective for early detection of POSA. The first-line surgical treatment in children is Adenotonsillectomy.
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Often, this results in a marked improvement, however, studies have shown that about 15-20% of these children still have persistent POSA or a recurrence of symptoms. Treatment failure can result from obstruction at multiple levels, beyond enlarged tonsils and adenoids. These areas of narrowing in the nasal, retropalatal and retroglossal regions occurs more frequently in children with craniofacial abnormalities, Down syndrome and obese children, but it can also occur in otherwise normal children. These cases can be assessed by Sleep nasendoscopy and CINE MRI. Newer surgical modalities to include powered endoscopic inferior turbinoplasties and tongue base reduction procedures. Despite treatment, POSA may recur (or persist), especially in children with the underlying risk factors mentioned above. GPs play an important co-management role in the follow-up and screening for recurrent/residual POSA. As POSA has been shown to negatively impact quality of life, if left untreated, in the long term it can predispose the child to chronic problems such as heart disease and hypertension in adulthood. Therefore, early detection and intervention will reduce the morbidities associated with POSA, improve school performance, and reduce healthcare costs. Author competing interests – nil
AUGUST 2021 | 51
The quest to improve childhood brain cancer treatment By Professor Nick Gottardo, Head of Oncology and Haematology, PCH In recent years significant headway has been made to increase survival rates and decrease long-term complications for children with brain cancer and work being done in WA is helping to transform clinical practice globally. Brain tumours are the major cause of childhood cancer deaths and the most common solid cancers of childhood affecting approximately 200 children in Australia annually. Survival statistics for childhood brain tumours (unchanged for over two decades) remain well below that of other childhood cancers, including leukaemia. Improvement in childhood brain tumour treatment has been hampered by deficiencies in knowledge about the underlying biological causes. Over the past 10 years, advances in genomic technology and international collaboration means there is now the opportunity to personalise treatment by developing novel therapeutic approaches tailored to each molecular subtype of brain cancer. This can improve cure rates while minimising toxicities. Medulloblastoma is the most common childhood malignant brain tumour. Current therapy consists of surgery, craniospinal irradiation (CSI) and multi-agent chemotherapy. Only four drugs (which have been used for decades) are commonly used worldwide for upfront medulloblastoma treatment: cyclophosphamide, cisplatin, vincristine and lomustine. Despite improvements in survival, approximately 30% of children succumb to their disease. Those surviving are faced with lifelong side effects from their treatments including cognitive decline, developmental defects, endocrine abnormalities, and other cancers.
Brain Tumour Research Program The Brain Tumour Research Laboratory at the Telethon Kids Institute was established in 2009. 52 | AUGUST 2021
Our research harnesses the power of innovative model systems of childhood brain tumours, which we have developed to test the effectiveness of new treatments so that the most promising therapies can be taken through to the clinic. The Brain Tumour Research Laboratory has developed a comprehensive and robust preclinical testing pipeline using sophisticated childhood brain cancer models and cutting-edge technologies. This is now one of the largest programs in Australia specifically focused on childhood brain tumours bringing together clinicians and scientists with a focus on providing laboratory evidence that will more accurately inform new paediatric brain cancer clinical trials.
A pre-clinical pipeline to discover new therapies Many new cancer drugs exist that more precisely target the molecular abnormalities in cancer cells that drive tumour growth. For two major reasons, very few have improved clinical outcomes so far. Firstly, these new drugs were not fully evaluated in model systems that accurately reflect the disease prior to clinical trial. Secondly, the drugs were not adequately assessed for their ability to
penetrate the blood brain barrier (BBB) and effectively reach their target, the tumour. We have now reached a tipping point in choosing the right drugs. There are more new drugs to assess through clinical trials than patients available. We believe the answer to this conundrum is to increase the rigour of preclinical testing to identify and prioritise only the most effective drugs with the best chance of success for clinical translation. Our approach is to undertake this preclinical testing using sophisticated laboratory mouse models that we and our collaborators have developed. These patient-derived xenograft models (PDXs) were created by taking brain cancer cells from children at the time of surgery and immediately implanting them into the equivalent location in the brains of mice. These PDX models closely mimic the clinical characteristics of childhood brain cancers and enable testing of many more drugs than could be evaluated in the clinic. Ineffective drugs can be screened out, resulting in enrichment of the clinical trials pipeline for drugs that are BBB penetrant and truly active. In designing our approach, we
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Key messages
Childhood brain cancer treatment has changed little in decades
WA is at the forefront of new research
A pre-clinical approach can determine which drugs have better prospects of improving outcomes.
considered how to best incorporate new therapeutics in a clinical trial. Most new cancer drugs are tested in an early phase (I/II) clinical trial after patients fail all proven therapies. Outcome is dismal for patients at this disease stage because the tumours become highly treatment resistant. Moreover, no new therapies have been established as frontline standard of care for decades. Consequently, the strategy to cure children with medulloblastoma is to identify drugs that enhance the efficacy of current treatments and identify compounds that have potential to be included in a frontline clinical trial.
Using this approach we discovered a novel drug, called LY2606368 or prexasertib that had never been used before in children with brain cancer. Chemotherapy used for medulloblastoma treatment works by breaking DNA strands. However, this triggers a repair response involving enzymes called cell cycle checkpoint kinases (CHK1/2). Consequently, cancer cells can repair this damage and keep on growing and dividing. Prexasertib is a drug that stops CHK1/2 from inducing the DNA repair. When the cancer cells are treated with prexasertib at the same time as chemotherapy, they are no longer able to repair the DNA and the cells die. This significantly extended the survival of mice with medulloblastoma, and these findings have recently been published in Science Translational Medicine*. This pre-clinical data led to the design, approval and NHMRC MRFF funding for an innovative international clinical trial called SJ-ELiOT (NCT04023669), carried out at Perth Children’s Hospital in
partnership with St Jude Children’s Research Hospital (SJCRH) in the US. SJ-ELiOT is named in honour of four-year-old Perth boy Elliot Parish, who in 2011 lost a 15-month battle with medulloblastoma. In this trial, patients with certain types of recurrent, progressive or refractory medulloblastoma are treated with one of two combination therapies involving prexasertib. This international trial will provide important safety and initial data to explore if this treatment option can slow or reduce the growth of the medulloblastoma. SJ-ELiOT demonstrates the effectiveness of our pipeline to successfully translate pre-clinical findings into the clinic. ED: The author is co-head of the Brain Tumour Research Program at Telethon Kid’s Institute. He is funded by the Perth Children’s Hospital Foundation as the Stan Perron Chair in Oncology and Haematology. – References available on request. Author competing interests – nil
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Djaalinj Waakinj Ear Health Program: a national first By Dr George Sim, Paediatric ENT Surgeon, Nedlands Otitis media (OM) is one of the most common reasons why young children present to medical practitioners and winter is peak season. Approximately 75% of children have at least one episode of otitis media by school age. Those between 6-18 months of age are at a higher risk. The incidence of OM decreases after the age of six. Acute otitis media causes pain, fever, and occasionally perforation. The child will be irritable, and sleep may be disrupted. Treatment is usually symptomatic control with adequate pain relief and antibiotics orally may be required. Symptoms may take one to two weeks to resolve. Recurring middle ear infections of three episodes or more in six months may warrant further assessment. Otitis media with effusion or ‘glue ear’ is accumulation of fluid in the middle ear. These children may have hearing loss, speech delay, learning difficulties and imbalance. Common predisposing factors are
day-care attendance, frequent upper respiratory tract infections; exposure to cigarette smoke; bottle feeding; and use of pacifiers. Children with excessive middle ear infections not responding to conservative measures will need review by a paediatric ENT surgeon. An audiological assessment will be part of the examination. Surgery (usually grommet insertion and/ or adenoidectomy) may be recommended.
Djaalinj Waakinj Urban Aboriginal Ear Health program In Australian Aboriginal and Torres Strait Islander (hereafter respectfully referred to as “Aboriginal”) children, OM occurs at a younger age. The prevalence is higher and hearing loss and serious complications more common than in non-Aboriginal children. Most Aboriginal people live in urban centres. Despite this, data on the burden of OM and hearing loss in urban Aboriginal children is limited.
This project was initiated following a request from urban Aboriginal people who felt the focus on more remote communities often meant urban communities were forgotten. Djaalinj Waakinj (Noongar for listening talking) was initiated in 2017 by discussions with Aboriginal community members, and Aboriginal health researchers. It is an ongoing study being conducted in South Metropolitan areas of Perth on Noongar Boodja (country). Aboriginal researchers visit people’s homes to collect sociodemographic and environmental data at enrolment of babies under three months; otoscopy and tympanometry are conducted by an Aboriginal research assistant or a nurse at ages 2-4, 6–8 and 12–18 months, and full audiological assessment conducted at 9-12 months. This is the first cohort study of the prevalence and risk factors associated with OM in Aboriginal infants residing in an urban area.
Video laryngoscopy in small infants By Professor Britta Regli-von Ungern-Sternberg, Anaesthetist, PCH Tracheal intubation is a routine and sometimes lifesaving procedure which is often required in anaesthetised infants. There are increased risks of complications including neurological injury, cardiac arrest and death with repeated intubation attempts and unsuccessful tracheal intubations. The most popular tool used for tracheal intubation in infants is the standard Miller direct laryngoscope, where the clinician intubates with a direct line of sight. However, video laryngoscopes are becoming more widely used. These have a camera 54 | AUGUST 2021
at their distal tip that displays a magnified image of the airway on a monitor. An advantage of video laryngoscopes is that inexperienced operators can be guided by more experienced staff who can see the image on the monitor, allowing coaching and guidance, or intervention if needed, thus improving training of anaesthetists and safety for children being intubated. Video laryngoscopes are associated with a higher first-
attempt success rate than standard direct laryngoscopes in infants with difficult airways. Video laryngoscopes can have standard blades, similar to those on the traditional direct laryngoscopes or have non-standard blades which are acutely curved. The different blade designs have different learning curves and techniques for intubation. There is still some discussion around which type of laryngoscopy (direct or video) and which type of videolaryngoscope blade (standard or non-standard) allow the easiest
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poor mental health outcomes and job prospects later in life. Djaalinj Waakinj was born as a novel collaboration to provide essential ear surgery for Aboriginal children. The charity, the first of its kind in Australia, stands as an excellent example of public-private partnership, translation of policy into practice and health care benefits for these children.
Children ready for their ear surgery with Dr George Sim (left) and Mr Ben Edwards, SJOG Murdoch Hospital CEO (right) on St Michael’s children’s ward.
As at the end of February 2020, 125 participants have been enrolled – 39% of 71 children aged 2-4 months and 52% of 44 children aged 6-8 months had evidence of OM. The Djaalinj Waakinj project was the catalyst for a range of other Aboriginal ear health projects designed to translate research directly into policy and practice, including the evaluation of a telehealth program to reduce wait times for specialist treatment. The project has played a key role in the development of the WA Child Ear Health Strategy and will be provide the first prevalence and risk factor data for young urban Aboriginal children.
ENT clinic. CIH is a not-for-profit integrated health service established to meet the needs of the population in Cockburn and the surrounding communities. Telethon Kids Institute (TKI) and Moorditj Koort Aboriginal Health organises the monthly clinics. Telethon Speech and Hearing and Hearing Australia provide audiological support. The author and fellow ENT surgeon Dr Francis Lannigan clinically assess these children and those requiring surgery are referred to PCH.
Charity program
Children with OM are referred to the Cockburn Integrated Health (CIH)
The current wait-time for specialist treatment for OM can be lengthy. Hearing loss if not treated early can result in significant long-term issues with language, behavioural and educational development, as well as
tracheal intubation and which have the best first-attempt success rate in children. The optimum choice may be dependent on age and difficulty of intubation.
aged younger than 12 months, undergoing a non-cardiac procedure lasting longer than 30 minutes that required general anaesthesia, were intubated by an anaesthetist.
In order to resolve this uncertainty for infants, a recent study was conducted by the Pediatric Difficult Intubation Registry group (PeDIReg). The group is an international collaboration dedicated to assessing, understanding and improving the outcomes of children with Difficult Direct Laryngoscopy with the aim of making airway management safer.
In total 282 infants were assigned to each group – standard video laryngoscopy or direct laryngoscopy. Unsuccessful intubation with either device was rare with 93% of patients having a successful first attempt with standard video laryngoscopy compared with 88% in the direct laryngoscopy group. The number of attempts was lower in the video laryngoscopy group than in the direct laryngoscopy group. Fewer severe complications occurred in the video laryngoscopy group than in the direct laryngoscopy group.
This study was an international, multicentre, randomised controlled clinical trial at four children’s hospitals in the US and Perth Children’s Hospital in WA, which aimed to compare the firstattempt success rate using a video laryngoscope with a standard blade with direct laryngoscopy for orotracheal intubation. Children
The finding that video laryngoscopy was associated with fewer oesophageal intubations has important clinical implications.
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In 2019, the author and St John of God Murdoch Hospital collaborated with TKI to provide access for children needing grommet surgery at no cost to their families as nominated Charity of the Year. The program has been well supported by the hospital, caregivers and South Metropolitan communities. The program is now ongoing with 15 children per year benefiting. There have already been positive outcomes from Djaalinj Waakinj. The strong relationships established with the local Aboriginal community and organisations provide a solid foundation on which to conduct research now and in the future. Through community forums, attendance at local events and health promotion in schools there has been enhanced awareness about OM and its consequences. Author competing interests – the author is involved with the clinical aspect of the program
Assuming that 500,000 infants are orotracheally intubated annually worldwide, an improvement in firstattempt success rate from 88% to 93% will prevent 25,000 multiple intubations and 10,500 oesophageal intubations and their potential associated adverse events. Overall, it was found that, among infants presenting for elective surgery, the first-attempt success rate of orotracheal intubation in infants was higher using video laryngoscopy with a standard blade compared with direct laryngoscopy and was associated with fewer severe complications. The firstattempt success rate of video laryngoscopy was markedly greater than that of direct laryngoscopy for infants weighing 6.5kg or less. Author competing interests – the author was involved in the trial mentioned
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Infantile blocked tear duct management By Clin/Assoc Professor Geoffrey Lam, Ophthalmologist, PCH Blocked tear duct (BTD) is a common condition seen in the very young. Conservative management is the mainstay of treatment. Massaging of the tear duct is an effective treatment, but parents are frequently confused about the technique of tear duct massage. Most cases of BTD spontaneously resolve in the first year of life. Conservative treatments such as cleaning away the dried secretions and collections in the eyes and massaging of the tear duct are frequently employed. Antibiotics, in drops or systemic preparation, are reserved for conjunctival infection or peri-orbital cellulitis. One general misconception is that a tear duct massage is deemed successful when copious amounts of tears and pus are expressed from the tear sac into the conjunctival sac. This is in fact not the reason for massaging. The purpose of the massage is to pump the content of the tear sac to ‘break open’ the blockage.
Figure 1. Location of left tear duct
Figure 2. ‘Pinch’ technique of tear duct massage
Key messages
BTD usually spontaneously resolves by the age of one
The tear sac is the only accessible part for massaging
A ‘pinch and squeeze’ technique is suggested.
To understand how tear duct massage works and how to perform a proper massage, one needs to understand the anatomy of the tear duct. Referring to Figure 1, tears drain into the upper and lower lacrimal canaliculi through the two puncta in the upper and lower lids. The canaliculi join before entering the tear sac (outlined in red in Figure 1). Tears then flow downwards along the tear duct (drawn in blue dashes) and eventually drain into the inferior meatus under the cover of the inferior concha/ turbinate in the nose. The most common location of obstruction of the tear duct is at the lower end where there is a membranous obstruction at the inferior meatus. The tear duct (blue dashes in Fig. 1) is enclosed totally by bony structure (maxilla and lacrimal bone), so it is not accessible to be massaged. In essence, the tear sac is the only soft part of the system not enclosed by bony structure. Parents frequently run their massaging finger along the lower lid, or along the nose when they perform the massage. There is no benefit in this as they are essentially massaging bony structure of the face and nose. A simple but effective way of performing the massage is to ‘pinch’ the bridge of the nose adjacent to the inner canthus of the two eyes, where the tear sac is located, with the thumb and index finger across the nose and ‘squeeze’ the tear sac of both sides (Fig. 2). A few ‘pinch and squeeze’ motions will pump the content of
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the tear sac downwards to push open the obstruction downstream. This technique will work for single eye or bilateral BTD. This is best done whenever the child is being fed. The child is distracted by food, the massage can be done with minimal complaint. It is important to distinguished BTD from congenital glaucoma, which may also present with watery eyes. Glaucoma has the additional symptoms and signs of raised intraocular pressure, including hazy cornea from oedema, photophobia, and buphthalmos (enlarged eye). Ophthalmological intervention is indicated only when surgical intervention is needed. This is usually for recalcitrant cases when BTD persists after the age of one. Infrequently early surgery is done when there is dacryocystitis, or if the child has severe and frequent episodes of infection, causing the lids to be stuck together, frequently risking amblyopia or causing periorbital cellulitis. Probing of the tear duct is the surgery of choice. A metallic probe is passed down the tear duct through the punctum, to break the membranous obstruction at the inferior end of the tear duct. The procedure has a success rate of over 90%. The reason for failure is either scarring after surgery, or anatomical abnormal tear duct system such as absence of the puncta, agenesis of canalicular or tear duct. These cases will require reconstructive surgeries such as dacryocystorhinostomy (DCR), or lacrimal bypass tube insertions (Lestor Jones tubes insertion). Author competing interests – nil
AUGUST 2021 | 57
TEST DRIVE
Singing in the rain
It’s always a good feeling when the phone rings and you are offered the opportunity to review one of the cars from BMW. Squishing in the test before a planned locum in the Kimberley limited things to a damp weekend in Perth, but them’s the breaks. Wandering into the dealership to collect the car gave an opportunity to see the new, more aggressive front grill styling on some of the newer models. Gets my seal of approval. Our test vehicle (the BMW 235i xDrive Grand Coupe) didn’t have one, but still good to have seen the new look. Brief chat before driving off – apparently this is a popular choice for medicos – let’s see if we can figure out why. Interior fit-out is the usual high specification, the wide range of electronic wizardry is (again) very impressive, pop-up display, paired iPhone, all taken for granted. It has been a while since my last BMW test and my regular daily driver is a base model Toyota Prado, 58 | AUGUST 2021
so not overly loaded with electronic multi-functions. However, despite this long break, it was incredibly straightforward to understand how things worked and how to get the most from the various systems. I would almost go as far as to say that it was intuitive, which is great, given all my children left home some time ago. So well done BMW for not stretching the i-era needs of your test driver today. I had been warned that I would like the “exhaust note” and there was no disappointment there. Sounds great. The car was set in ‘Comfort’ mode and already it sounded purposeful, but I was looking forward to trying the ‘Sport’ mode. I’m always a little cautious as I drive away and I was rewarded on this occasion, as the keys were still with our sales rep at the dealership. A rep phoned and encouraged me to not stop the car, I returned to pick up the wayward keys. Take two: I had the car for the whole weekend, so it experienced some shopping duties first and immediately I felt at home driving in busy streets, parking in car parks. There was no need for time to build up a sense of the size of the
car or where the corners were. It was precise and responsive, rapidly imbuing a sense of confidence. On the Sunday morning, the weather gods had spoken – there was rain aplenty. Water, dirt and gravel all seemed to be joining the rush to get across the road in some sections. Clearly it would have been irresponsible to shift the car into Sports mode, so Comfort mode was the sensible choice for the moment, but then I never was particularly sensible. In Sports mode, everything seemed to sharpen a little more, that wicked exhaust note took on more purpose, and the smile across my face increased just that little bit more. Yes, the 4-Wheel-Drive did help, but this was really impressive in such appalling conditions. My ‘test route’ covered various types of corners and different qualities of tarmac and road service. The Grand Coupe took it all in its stride. This was on normal tarmac specification tyres (admittedly a good quality set), but they were clearly not a set of tarmac rallying ‘wets’ or even a ‘soft compound. Despite this, grip was always there, with no suggestion of having to over-correct, or having to back
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Dr Mike Civil takes the BMW 235i xDrive Grand Coupe out for a Sunday spin when the weather gods decided to put driver and car to a real test.
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that accelerator pedal off a tad. My ageing Evo 9 tarmac rally car would probably be a little quicker, but the BMW would allow my latte to stay in the cup and give a much higher level of comfort. Confidence built all the time, and nothing happened to shake that feeling, whether it was a sweeping left or right-hander, twisty bits with changing road surfaces, there was no hint of exploring the cars limits, even in the wet. With the ride over, it was a highly competent and thoroughly enjoyable
car to drive. Whip the back seats out, put a Roll Cage in it and go tarmac rallying – please! This Beemer really does bring the enjoyment in driving back to the driver. All the expected BMW luxuries are still there – the electronic wizardry has become more intuitive; the trim is the usual high standard. My lady wife particularly liked the neon blue subtle lights in the trim that pick up on the stitching, very smooth.
producer that is responsive to feedback from customers and keeps up with current tech. They have a range of electric vehicles coming out later this year and still have the desire to try bold styling changes (that new front grill) while not forgetting that passion for driving. It is hardly surprising that this particular model is popular with my medical colleagues and peers, in this price bracket, the BMW 235i xDrive is a hard car to pass on.
BMW remains a prestige car
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AUGUST 2021 | 59
BOOKS
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Swan dives into print Trained in paediatrics, Dr Norman Swan has become the go-to doctor for clear information about COVID-19. And on the side, he’s written a book.
By Cathy O’Leary The timing of broadcaster Norman Swan’s “ultimate health guide” is impeccable, given it promises to unpack medical myths as the world is bombarded with unprecedented information during the pandemic. And many Australians could well have some time on their hands to digest the A to Z of health advice from the country’s most trusted doctor as they face rolling lockdowns. So You Think You Know What’s Good For You? was written by Swan as he juggled commitments as the face of the ABC's coverage of the pandemic, including The Health Report that he's presented for 25 years and the daily Coronacast podcast.
because it provides any great detail or lightbulb moments, but because it doesn’t spruik narrow or restrictive paths to good health. He includes detailed referencing too, which can reassure readers his comments are not just thought bubbles. When it comes to diet, Norman stresses that “life is a package and diet is just one piece.” He offers this quick myth-bust: there is no Palaeolithic diet, it is romanticised. People in the Stone Age rarely lived past their early 30s which is hardly a glowing recommendation.
He also co-founded Tonic Media Network, a health channel that plays in GPs’ waiting rooms.
On the subject of antioxidant supplements, he says people should save their money and spend it on extra virgin olive oil and red, purple and orange vegetables.
Swan says that despite people being bombarded by health advice, it can be difficult to separate the wheat from the chaff. His book covers everything from nutrition to sex.
Likewise, he doesn’t mince words about vitamin and mineral supplements, saying it is a multimillion dollar industry based on very little science. “Largely a con,” are his words.
“No one’s got time to waste on stuff that doesn’t matter, is wrong or isn’t focused on your needs,” Swan says.
And Swan offers this simple explanation for rising rates of obesity that cuts through all the various diet advice: people just eat too much.
What he has produced is common sense advice – the type GPs could confidently recommend to their health-conscious patients, not 60 | AUGUST 2021
and with full-cream milk thank you, no trendy soy substitutes. He concludes that “coffee is actually pretty good for you.” Not surprisingly, his final word is on the pandemic, and he is philosophical. He says it’s not the first time that a germ has made history and changed human destiny. He argues genes and human behaviour through the ages create new diseases or mark the return of old ones. “We’ve just lived through the worst pandemic to hit humankind for more than 100 years, caused by a new virus that’s probably only existed for a year or two,” he writes. “COVID-19 has killed millions of people and will now likely be with us for eternity. “My observation is that the general community now understands far more about molecular and cellular biology than they – or me – ever imagined they would.” ED: So You Think You Know What’s Good For You? is published by Hachette Australia.
Yet he is no puritan, declaring himself a salt addict, and says he needs rather than wants his coffee, MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
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WINE REVIEW
Domaine Naturaliste Bruce Jukes began his professional career after studying agricultural science at UWA. The knowledge gained enabled him to properly appreciate and understand the concept of sustainable farming where emphasis is placed upon minimal intervention and encouraging a natural biosphere as much as possible. The practice of soil rejuvenation through natural composting and encouraging a natural carpet of grasses between the vines are good examples of this. Grape musts are allowed to ferment spontaneously with local wild yeasts. After working in California for five years at Coppola winery and then with Dr Michael Peterkin at Pierro, Bruce established his Domaine Naturaliste in Wilyabrup, the central sub-district of the Margaret River appellation. The soils here are typically gravelly loam, the natural habitat of Western Australian jarrah. Perfectly suited to producing quality grapes, with Cabernet Sauvignon and Chardonnay being the outstanding examples. The winemaking is careful and nurturing. Flavour and texture matter.
Review by Dr Louis Papaelias
2020 Sauvignon Blanc “Sauvage” (13%, rrp $30)
2017 Rebus Cabernet Sauvignon (13.8%, rrp $35)
Fragrant floral fruity citrus. Very appealing. Sourced from the cooler southern part of Margaret River. This has a bright, soft textural feel in the mouth with a lovely crisp and balanced finish. An outstanding wine.
Very pure Cabernet aromas of red fruits, dark chocolate and black olive. Oak very much in the background. Fruitiness predominates, balanced by ample tannins that soften with airing the wine. Will easily improve over the next few years.
2020 Artus Chardonnay (13.5%, rrp $49) Domaine Naturaliste’s flagship white, this is also made from southern Margaret River fruit. Naturally fermented and raised in oak, 45% of casks brand new. Attractive toasty peachy aromas (“Funky oak and butterscotch” according to the winemaker). Full of flavour but with a light footprint. Lovely balance and a deliciously long finish.
2017 Morus Cabernet Sauvignon (14%, rrp $89) Domaine Naturaliste’s flagship red. Matured 14 months in 55% new barrels. The term morus comes from Morus Australis, the botanical name for the mulberry and, yes, there are definite mulberry aromas present. So, too, are there blueberries, violets and spice. A generous and lush suppleness with ample soft tannins makes for a very fine example of what Margaret River Cabernet can achieve. Delicious.
MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
AUGUST 2021 | 61
r e t h g u La
– just what the doctor ordered When life is busy, it’s hard to remember to laugh and see the humour in things. Paul Montague tells Ara Jansen we should prescribe laughter to ourselves regularly.
When was the last time you laughed? Really laughed. When it exploded out of you, unbidden and without caring what anyone thought? If it has been a while, perhaps it’s time to prescribe some laughter and humour for your week. Paul Montague understands deeply the benefits of laughter and comedy. He grew up with bipolar in his family and household, as well as being a rare case of developing the condition at a non-typically early age. Stand-up comedy was his trade for many years, and he led workshops on writing and performing comedy. Not only did it and laughter help him with his own emotional balance, but like music, Paul believes uplifting comedy can change the way we see the world and ourselves. Let’s not forget, it’s just flat-out fun too. 62 | AUGUST 2021
MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
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LIFESTYLE
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LIFESTYLE He now wears two hats as a minister of religion at Wembley Downs Church of Christ and as a community educator specialising in mental health, communication and conflict resolution. You’ll also hear him regularly on the radio with his Pirate Church, Holy Heretic show. Those who hear his sermons – or reads them on social media – will know he eruditely mingles scholarship, faith, modern sense and humour in his teachings. “Laughter as medicine, as a life-giving discipline, is just as important for personal, relational and community health as it has ever been,” he says. “It literally helps us breathe and oxygenate. “It neurologically resets us and provides huge endorphin boosts. It helps sleep, digestion – all the important stuff. It’s free from cost, side effects and increases in efficacy the more you share it.” Living with bipolar, Paul is mindful of the double-edged sword of a “positive frame of mind”. When depressed, positivity of mind is a vital goal for getting through, for recovering and some days, survival.
Equally he’s wary of the unhelpfully excessive positivity that comes when feeling euphorically hypomanic or manic. Humour is the equaliser of both states for him. A humour-focused perspective dispels any illusion that he needs to take the world, ourselves or our circumstances too seriously. “A healthy dose of absurdism is great. Get some bathos in your pathos, people! Laughter brings inner peace and calm. In my experience, happiness is transient. While it’s a great daily goal, peace and calm are the foundation of wellbeing. Laughing at myself and the world resets my body to peace and calm – and my mind follows.” He loves the way kids just laugh so easily and do it largely without caring who sees or hears them explode into gales of giggles. They don’t judge the importance of it, the way adults often police themselves not to laugh, make too much noise or hope they don’t look silly. “Adults can fall into judging laughter as an optional indulgence or distraction, which is dumb as hell – a bit like deciding that getting a proper night’s sleep is optional.” Laughter does only good things and has positive physical, mental
and social benefits. Physically, laughter helps boost immunity, lowers stress hormones, decreases pain, relaxes muscles, burns calories and diffuses anger’s heavy load. Mentally, having a jolly good laugh adds zest to life, relieves anxiety and stress, improves mood and strengthens resilience. Humour helps you keep a positive and optimistic outlook on life amidst difficult situations. Even a smile – or smiling at someone else – can go a long way to making you feel better and can shift your perspective. Plus, laughter is thoroughly contagious! “Offering someone a smile or receiving and returning a smile is definitely uplifting. It’s regenerative. It’s the exact opposite of awkward social interaction, which is emotionally and energetically draining. Sharing a smile is socially harmonious – and that’s a gift in times of fractious community. “I absolutely notice when I’ve gone a length of days without really laughing, which reminds me that I absolutely should commit to a daily discipline around it. The days I laugh freely are my best days, in terms of health, productivity, mood and how warm and cooperative I am in my relationships. “I know how to make myself laugh. I can bring myself there with a practice somewhat like laughter yoga – making myself mimic the physical action of laughter until the laughter becomes genuine. I do that often with my five-year-old son in the car and we both love it.”
PAUL’S FAVOURITE LAUGHS Classics: Blackadder, Monty Python and Fawlty Towers Newer: Catherine Tate, Cunk on Britain and Fleabag
10 MOVIES TO MAKE YOU LAUGH:
The Castle Borat Anchorman Zoolander Groundhog Day
Bridesmaids This is Spinal Tap Patch Adams Some Like it Hot Duck Soup
Favourite stand-up special of recent years: Patton Oswalt’s Annihilation
MEDICAL FORUM | CHILD & ADOLESCENT HEALTH
AUGUST 2021 | 63
Margaret River Here we come! Opening soon, we are on the hunt for GP’s, Nurses and Administrative
Built To Care
Looking to sell your practice? For a cRQǓGHQtLDO Giscussion contact us tRGD\ Dr BrHQGD 0XUUison 0 418 921 73 ( %rHQGD 0XUUison@breckenhealth com au Damian Green 0 423 844 268 ( 'DPLDQ Green@breckenhealth com au
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