Medical Forum – July 2022 – Public Edition

The Warne effect Men’s Health | Hypogonadism, prostate health & gender in kidney disease

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Dr Fiona Langdon Obstetrician and gynaecologist, WA

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Cathy O’Leary | Editor

Men – heart to heart Since [Warne’s] unexpected death from heart attack in March, only days after another cricket great Rod Marsh also succumbed, middle-aged men have been going in their droves to have their own ticker checked out.

Are men as hopeless at going to the doctor’s as urban legend suggests?

Judging from the men I know, or I see waiting in GP surgeries or at the dentist, the male gender might be the victim of outdated typecasting.

What is unarguably true though is that the way people seek medical help, and what might trigger them to put their hand up, is very different for men, women and those who identify their gender in other ways.

So, it is not surprising that our men’s health story by Eric Martin this month has strong sporting references, with our cover sharing a poignant photo of Shane “Warnie” Warne bowing out, literally and figuratively.

Since his unexpected death from heart attack in March, only days after another cricket great Rod Marsh also succumbed, middleaged men have been going in their droves to have their own ticker checked out.

We tend to associate heart attack as the body’s sign of wearing out a bit in old age, so when it happens to someone in their 50s, 60s or even their 70s it seems premature.

And when it strikes someone who is fit and of sporting greatness, everyone really hits the panic button.

We are all well-versed in the mantra of following a healthy diet and exercising to reduce heart attack risk, but many middle-aged men are asking if there is anything else they could be doing to avoid becoming a premature statistic – through lifestyle or early detection.

And while we’re breaking down stereotypes, our story explains it’s not just the overweight who are at risk.

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CONTENTS | JULY 2022 – MEN'S HEALTH

Inside this issue 20

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52

FEATURES

IN THE NEWS

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Close-up: Dr Simon Towler Q&A with Dr Omar Khorshid Cover story: The Warne effect Ability on the big screen

LIFESTYLE 54 Winter flicks 55 Wine review: Evans & Tate

Editorial: Men – heart to heart – Cathy O’Leary

4 News & Views 6 In brief 10 EVOLUTION prostate

29 COVID biobank – Drs Dominic Mallon & Michael O'Sullivan

35 Skinny dipping?

– Dr Joe Kosterich

40 Advancing the plan – Andrew Allsop

cancer trial

– Dr Louis Papaelias

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New hope in locally advanced prostate cancer A/Prof Tom Shannon

Functional hypogonadism Dr Imran Badshah

Sex-based disparities in kidney disease Dr Rahul Mainra

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Minimally invasive BPH treatments Dr Manmeet Saluja

Pelvic venous congestion Dr Stefan Ponosh

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Surgery for metabolic syndrome Dr Krishna Epari

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On quokkas and growing membership John Van Der Wielen

Rehab needs a leg-up Dr Bruce Powell

Individualising the screening message Melissa Ledger

Doctors held to ransom Ajay Unni

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Boxing lending a hand to Parkinson’s A high intensity exercise program using non-contact boxing for people with Parkinson’s disease has been developed by a team from the Perron Institute and Edith Cowan University.

With the help of professional fitness trainer Rai Fazio, the team has developed the FIGHT-PD program.

A feasibility study involving community volunteers has shown that non-contact boxing could be helpful and safe for people with early-stage PD. The study was the first to use continual heart rate monitoring and ratified scales of exertion used by sports scientists. Training included balance and movement drills, high intensity aerobic bursts and sequences of punches using a Fightmaster training machine.

Participants showed improvements in fatigue levels, sleep quality and a commonly used score of PD severity.

Aboriginal post a first Aboriginal health service South Coastal Babbingur Mia has appointed Dr Talila Milroy to its team – the first Aboriginal GP to work there and thought to be the first to work in the Rockingham and Kwinana district.

The Yindjibarndi and Palyku woman is passionate about Indigenous social justice, health care education and research.

About 3% of the Australian population, or just over 760,000 people, identify as Aboriginal or Torres Strait Islander – and Dr Milroy is one of only about 600 Indigenous doctors in Australia.

She was the only Indigenous medical graduate in her class of 2015 at the University of Sydney.

What’s an emergency?

Many people are confused about what constitutes an emergency and when they need to call an ambulance or go to an ED, according to the results of Curtin University research.

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Perron Institute’s FIGHT-PD boxing study team Mitchell Turner, left, David Blacker, Travis Cruickshank and Rai Fazio.

Clinical Professor David Blacker, Perron’s medical director and consultant neurologist, is the study leader and has a personal perspective as someone living with Parkinson’s disease. Exercise, he says, has significantly helped to reduce his symptoms.

“Boxing movements, footwork and balance are excellent for PD because the postures and movements required are almost the exact opposite of what occurs in this disease,” Professor Blacker said.

Despite suggestions that people seek emergency help unnecessarily, the study found that many people downplayed potentially lifethreatening situations and felt they did not warrant a triple-0 call or trip to the ED. The research involved data from more than 5000 people who were asked to respond to a series of 17 medical scenarios. Researchers then quantified how often people were incorrect in recognising which scenarios warranted calling an ambulance or presenting at an ED. Senior lecturer and researcher Dr Brennen Mills said that while people were advised against unnecessarily calling an ambulance or attending EDs, particularly given ongoing ambulance ramping issues and over-burdened hospitals, it was still important they sought emergency help when necessary.

"While most Australians are able to correctly identify symptoms associated with a number of medical emergencies, there are some conditions in which recognition of being a potential emergency is poor,” Dr Mills said.

Among the scenarios were a child suffering a scalp haematoma (67% incorrectly thought an emergency response was not needed); potential

meningococcal infection (57%); box jellyfish sting (40%); paracetamol overdose (37%) and mild chest pain (26%).

Men were more likely not to seek emergency treatment when needed compared with women, and parents were no better than people without children at recognising the need for emergency care for head haematomas or potential meningococcal infection.

Be happy, avoid court Australian doctors are more likely to be sued for medical negligence if they are unhappy, overworked, working in rural areas or unwell, according to research from the University of Melbourne.

Published in the British Medical Journal, the Australian-first study also found that doctors with an “agreeable” personality were less likely to be sued.

The findings were more pronounced for male doctors than female.

The research team led by Dr Owen Bradfield and Professor Matthew Spittal analysed responses of over 12,000 Australian doctors to the continued on Page 6

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Leading urological treatment and care for men St John of God Subiaco Hospital provides high quality, compassionate and individualised care to support a wide range of urological conditions.

Our multidisciplinary team of urologists, oncologists, radiologists, registered nurses and allied health professionals work together to provide comprehensive urology services specific to patients’ unique clinical needs.

They are supported by state-of-the-art facilities and technologies, including the Da Vinci Surgical Robot, which has been used to complete over 2,800 surgeries.

Common urological conditions treated at our hospital include urinary tract infections, kidney stones, ureteric stones and incontinence.

Our specialists also treat benign and malignant prostate conditions, renal cancer, bladder/ urothelial cancer and penile cancer.

MEET OUR SPECIALISTS Urologists: bit.ly/Urology-Subiaco Urological oncologists: bit.ly/UOncologists-Subiaco

AMPLITUDE STUDY – CURRENTLY RECRUITING St John of God Subiaco Hospital’s leading care is informed by our comprehensive research program.

The AMPLITUDE study (a phase III trial) is trying to determine if the combination of niraparib with Abiraterone Acetate (AA) plus prednisone compared with AA plus prednisone in participants with deleterious germline or somatic Homologous Recombination Repair (HRR) gene-mutated Metastatic Castration-Sensitive Prostate Cancer (mCSPC) will result in improved survival outcomes.

The study is being led by St John of God Subiaco Hospital Oncologist Assoc/Prof Tim Clay, who has an interest in prostate and testicular cancer, among other areas.

For more information about the study: Clinical Trial Unit Ph: 08 6465 9204

For more information To learn about the expertise and interests of our specialists, visit bit.ly/FaS-Subiaco subiaco.cpd@sjog.org.au MEDICAL FORUM | MEN 'S HEALTH

(08) 6462 9689

sjog.org.au/subiacoGPs JULY 2022 | 5

Neurologist Professor Graeme Hankey is the inaugural Perron Institute Chair in Stroke Research at UWA. In other changes, barrister and solicitor Rob McKenzie has been appointed the new chair of the Perron Institute Board.

Gynaecologist and fertility specialist Dr Tamara Hunter will be the leading fertility provider at Monash’s recently acquired PIVET Medical Centre, which for decades has been the baby of WA’s IVF pioneer Dr John Yovich.

Tina Chinery starts as the new CEO at St John of God Subiaco Hospital on July 11. She moves from her role as CEO at Cairns Hinterland Hospital and Health Service but has previously worked for many years in the WA health system.

In Queen’s Birthday honours, child health expert Professor Donna Cross received the Medal of the Order of Australia in recognition of her service to youth mental health and wellbeing.

In other gongs, Telethon Kids Institute’s executive director Professor Jonathan Carapetis has become a Fellow of the prestigious Australian Academy of Science in recognition of his pioneering work in infectious diseases.

Professor Fiona Wood has been named the Australian Society of Medical Research 2022 Medallist.

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NEWS & VIEWS

continued from Page 4 Medicine in Australia Balancing Employment and Life (MABEL) survey between 2013 and 2018.

Just over 5% of the doctors reported being named in a medical negligence claim during this period.

Take no prisoners An international study of global progress in reaching World Health Organization goals in providing universal health care has found that many countries, including Australia, may be inflating their success by not counting people in prisons and youth detention in their data.

The review, led in Australia by Curtin University and the University of Melbourne, and published in The Lancet Public Health, analysed the way WHO collected global data and found that incarcerated people were currently excluded, despite the big concentration of health needs in custodial settings.

Lead Australian researcher Professor Stuart Kinner, from Curtin’s School of Population Health, said that particularly in countries with high incarceration rates, failure to include custodial settings in health care coverage calculations might not only result in overestimation of progress, but also mask important health inequalities.

“While Australia does have a 'universal' health insurance scheme – Medicare – in reality it's not quite universal because it excludes some of the most marginalised and unwell people in our communities,” he said.

ED milestone More than 5000 patients have presented to Hollywood Private Hospital’s emergency department in its first six months of operation.

The $67 million facility opened last November, becoming the second continued on Page 8

Take thirty Edith Cowan University has been awarded a $3 million grant to introduce a 30-minute infant health check which could have a profound impact on the lives of Aboriginal children.

Researchers will use the National Health and Medical Research Centre grant over five years to implement the Care for Child Development program which the World Health Organization and UNICEF have used internationally.

It adds just 30 minutes to regular infant health checks and sees health providers trained to offer advice to parents and caregivers on how they can improve and foster their child’s cognitive learning and speech and language.

Almost one in three Aboriginal children start school in WA with at least two developmental vulnerabilities.

ECU director of Aboriginal research Associate Professor Dan McAullay will lead the team, which includes experts from King’s College London, Telethon Kids Institute, King Edward Memorial Hospital for Women, University of Melbourne and Murdoch University.

“The long-term effects of having poor early child development means children don’t live up to their potential,” he said. “That then influences their educational attainments and their social and emotional wellbeing going into adulthood.

“Despite this, there has been no primary health care development programs starting in the first four weeks of life.”

ECU Kurongkurl Katitjin senior research fellow Dr Natalie Strobel said the program would be included in regular health checks run by health staff and Aboriginal health workers in a child’s first year of life, and would also support mothers’ mental health.

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IN BRIEF

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New Hope in Locally Advanced Prostate Cancer Surgery is the only curative treatment for prostate cancer. If we can remove every last cancer cell, we achieve cure, proven by an undetectable PSA. Life expectancy at diagnosis is now around 20 years and non-curative treatments may simply not last long enough. Subsequent lifelong ADT and chemotherapy are now known to be associated with significant complications and quality of life issues, previously under appreciated, such as: • Osteoporosis and increased risk of falls • Metabolic syndrome and increased cardiovascular mortality • Loss of libido and erectile dysfunction • Cognitive decline • Cancer-related fatigue • Decreased quality of life PSA testing gives men the best chance of being diagnosed at a curable stage, but the lack of clear guidelines means many men present with locally advanced disease or metastatic disease, once considered beyond cure. Combination therapy is now curing these men, provable by long follow-up with negative PSA tests. So how can we do this?

MRI – Very accurate local staging allows better patient selection and precise surgical planning.

PSMA – Significantly improves extra prostatic staging, Response to therapy can be accurately monitored and responders identified.

Neoadjuvant chemotherapy – Prostate cancer primaries contain many clones, which promote

Associate Professor Tom Shannon Consultant Urologist A/Prof Shannon is a graduate of the University of WA. He completed his Fellowship in Urology in 1999 and completed post-fellowship training in the UK and the US focusing on minimally invasive surgery and prostate brachytherapy. He was a pioneer of minimally invasive urological surgery in WA and is a leader in the development of prostate MRI. He is a strong advocate for men’s health and has been a board member of the Prostate Cancer Foundation of Australia (WA) for over 10 years.

treatment resistance, but ‘mets’ are oligo or monoclonal and are more susceptible to treatment at diagnosis. Responders can be offered resection of primary to reduce failure and in some cases even achieve cure. Chemotherapy resistance may come from new clones that develop after presentation.

Extended surgery – Robotics and increased experience have allowed us to safely resect cancers extending beyond the prostate. We regularly find cancers outside the prostate, invading seminal vesicles and into bladder. Previously unresectable cancers with extensive bladder invasion, rectal invasion, pelvic floor invasion or nodal metastases have been successfully resected with no increase in length of stay or complications. We have presented data at 5 years with only 8% of patients on ADT despite metastatic disease in nodes. Even without cure, by removing the primary and the bulk of the clones that develop resistance, we can fundamentally change the course of the disease.

Widespread nodal resection is difficult and time consuming but can achieve clearance in many cases.

Perth’s Prostate Cancer and BPH Centre

Adjuvant radiotherapy – In our hands, primary resection is achieved in over 90% of cases of extra prostatic disease. Adjuvant DXT can be used in the prostate bed, but more often is used later if a PSMApositive site is identified at PSA recurrence. Highly accurate external beam radiation can target these sites, avoiding the need for extended use of medication.

The future – Precision medicine offers the possibility of tailored chemotherapy to treat latent micro metastatic disease. This will need DNA of the ‘mets’, only available by surgical sampling. Theranostics hold the promise of delivering high doses of radiation directly to marker positive cancer deposits, no matter where they are located.

We are at the start of a revolution in high-risk prostate cancer. As a high volume, focused prostate cancer service, we will always be at the forefront of diagnosis and treatment to achieve the best results for all men with this serious and complex cancer.

It is time to expect more for men.

Phone: 08 9389 7696 Fax: 08 9386 1799 49 Hardy Rd, Nedlands, WA 6009

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NEWS & VIEWS

continued from Page 6 private ED in WA and the first north of the river.

Director of Medical Services Dr John Maxwell said the ED had been embraced by the community.

“People appreciate having a choice and are grateful to have the option of private emergency care,” he said.

The most common presentations to the ED have been chest pain, abdominal pain, shortness of breath and falls.

The ED is open to both private and public patients, who can either make their own way there or arrive by ambulance. Referrals are not needed but there is a $200 doctor’s consultation fee.

St John of God Subiaco also has plans to open an ED.

Funding reprieve NPS MedicineWise has won a reprieve from the new Federal Government after it faced having its funding axed next year.

The previous government announced in its 2022 Budget that from January 1 NPS MedicineWise would no longer be funded by the Department of Health to deliver ‘quality use of medicines’ functions.

Instead, the Australian Commission on Safety and Quality in Health Care would take on this role, while education programs for health professionals and consumers would move to contestable funding.

The decision was criticised by doctor and consumer groups, who raised concerns about the implications for people’s health. NPS MedicineWise argued that since 1998 its work had delivered a $1.1 billion saving to the PBS and MBS by promoting more judicious use of medicines and tests.

In the lead-up to the Federal election, Labor pledged to review the decision if it won office.

Cancer research boost The Harry Perkins Institute of Medical Research has received eight grants in the WA Research Excellence Awards 2022 program, some of which will fund research into hard-to-treat cancers and 8 | JULY 2022

Brain health recognised The Neurological Council of WA has welcomed the World Health Assembly’s decision to adopt a new Intersectoral Global Action Plan on epilepsy and other neurological disorders.

It is the first time that neurological disorders have been recognised as a distinct field by the WHO. Key features of the plan include the right to rehabilitation, the importance of brain health from birth to old age, reducing health inequalities, and an intersectoral approach to neurological disorders.

The plan is considered a major step toward improving access to care and treatment for people with neurological disorders, preventing new cases, and promoting brain health and development across the life course.

Neurological disorders are on the rise in Australia, with the estimated economic burden topping $74 billion. Nervous system disorders and diseases are the leading cause of disability-adjusted life years and the second leading cause of death worldwide.

There are more than 600 neurological disorders, which include epilepsy, stroke, migraine, dementia, neuropathies, brain and spinal tumours, neurofibromatosis, meningitis, ADHD, autism, Tourette syndrome and chronic fatigue, as well as motor neurone disease, Parkinson’s, Huntington’s, multiple sclerosis, cerebral palsy and muscular dystrophy.

Neurological Council CEO Etta Palumbo, pictured with her team, said that while many conditions were considered rare, as a combined disease group, neurological conditions were in the top five WA burden of disease groups for both fatal and non-fatal disease types.

rare disease gene discoveries.

The grants, worth $1.7 million, are part of the more than $10 million awarded to some of WA’s leading health and medical researchers.

The REA program supports highperforming early-and mid-career researchers and established researchers.

Cancer researcher Professor Ruth

Ganss said the funds would help expand a program to improve cancer immunotherapy.

“These funds will help us with our work in inducing clusters of immune cells inside some tumours,” she said. “We are one of only a few laboratories globally which have developed drugs to induce these immune clusters.

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Going green Watering your garden in your favourite gumboots might seem a far cry from a busy hospital theatre, but there is a close connection thanks to sustainability initiatives at Hollywood Private Hospital.

Staff are recycling masks, oxygen tubing and intravenous drip bags made from PVC to be turned into a wide variety of products, including gumboots sold at Bunnings.

Support services manager Jonathan Reynold said the recycling campaign started 18 months ago and PVC hospital waste was sent to a facility in Victoria, where

“This is a new and exciting area in modern medicine, and we hope to be able to put more resources into it and test more treatments that combine new therapeutics with immunotherapy.”

TB treatment safety Seven out of 10 pregnant women were cured of their multidrugresistant tuberculosis and delivered healthy babies after taking a medication that had previously been considered unsafe in pregnancy,

it was processed and sold as recycled PVC resin to manufacturers to make products such as garden hoses and playmats. So far about 275kg of plastic bags has been diverted from landfill.

Other sustainability initiatives at the hospital are battery recycling, reusable fabric hair nets, environmentally friendly catering equipment, compostable medication bags and reducing the use of anaesthetic gas desflurane by switching to sevoflurane, which is not as harmful to the environment.

In another positive move, the WA Health Department has signed up to the Pacific arm of the Global Green and Healthy Hospitals network, joining health departments in Victoria, Queensland and the ACT.

a new Curtin and Telethon Kids Institute study has found.

Published in JAMA Network Open, the study looked at the experiences of 275 pregnant women with multidrug-resistant TB living in South Africa, Peru, Brazil, Iran and Uganda.

Lead researcher Dr Kefyalew Alene said the study had found a medication used to treat multidrug-resistant TB – Linezolid – was associated with favourable pregnancy outcomes and high treatment success.

“This is the first comprehensive review of treatment outcomes for multidrug-resistant tuberculosis in pregnant women, who remain one of the most vulnerable groups among the half a million people living with the disease globally,” Dr Alene said.

“As many as 73.2% of pregnant women with multidrug-resistant TB gave birth to healthy babies and that the treatment had worked for 72.5% of the women, meaning they were cured from the disease or had completed the treatment successfully.”

MURDOCH PSYCHIATRY is looking for multiple psychiatrists to join our, dynamic MDT team of psychiatrists, nurses, TMS clinicians, registrar psychologists, and occupational therapists.

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Treatment-resistant depression clinic: a. CBT and DBT treatment b. rTMS powered by Modalis c. Esketamine approved site.

First responders’ clinics: DVA/ADF Drug and Alcohol Support Network: In liaison with Cockburn Wellbeing providing home detox and ongoing support.

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Work in your area of interest, closer to home, great financial incentives for private practice starters in competitively priced rooms. Consortium arrangement for established practices.

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Child and Adolescent clinics • Memory Clinic • Complex, neurodiverse development clinics • Civil Forensic Psychiatry • Rural and remote psychiatric clinics

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To express interest, or have a friendly chat please email tajsingh@murdochpsychiatry.org or call 0434 252 672

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Prostate cancer treatment’s Evolution Australian men are being recruited into a clinical trial for a potential treatment game-changer for aggressive prostate cancer.

Cathy O’Leary reports Australian medical scientists are leading the world in prostate cancer research, following the recruitment of men with incurable prostate cancer in a worldfirst phase II clinical trial which is testing the effectiveness of experimental therapy combined with immunotherapy.

Prostate Cancer Foundation of Australia chief executive officer Anne Savage said it had invested $1.6 million for the EVOLUTION Phase II Clinical Trial to test Lutetium-177-PSMA (Lu-PSMA) and immunotherapy for treatment of advanced forms of prostate cancer that have stopped responding to other treatments.

If the approach proves effective, it could establish a new global standard of care, giving tens of thousands of men access to a new form of treatment that will extend their lives by keeping the deadliest forms of prostate cancer in remission.

The treatment is not cheap, currently costing about $10,000 a round.

However, Ms Savage argues we are on the verge of a transformation in prostate cancer treatment.

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and better responses in prostate cancer,” Professor Davis said.

PCFA successfully lobbied the Federal Government for PSMA PET/CT scanning to be listed on Medicare, which started on July 1. It is still pushing for Lu-PSMA treatment to be made available to all men who need it, with no out-ofpocket costs.

More options

“This trial will go beyond where any other trial has gone before, exploring the next frontier in precision nuclear medicine for prostate cancer,” she said.

Lu-PSMA therapy, also known as Lutetium177 Prostate Specific Membrane Antigen therapy, is a treatment for prostate cancer that has spread outside the prostate to other parts of the body.

Ms Savage said the drug Lutetium on its own binds to the cancer cells while not affecting the surrounding tissue, like radiation and chemotherapy do. It is currently considered experimental in Australia, and is typically only used when other treatments have failed.

“The EVOLUTION trial goes one step further than Lutetium on its own, pairing it with immunotherapy,” she said.

“This new class of precision medicine treatments – theranostics – combines therapy and diagnostics to improve our understanding of each man’s prostate cancer, and how it can be most effectively treated.

“This new combination may lead to shrinkage or stabilisation of previously progressing tumours and hopefully stop or reverse the growth of the cancer.”

Medicare listing The ProPSMA study and TheraP clinical trials, previously co-funded

by PCFA, had already improved the standard of care available to men, most recently by resulting in the listing of PSMA PET/CT scanning on Medicare.

PSMA PET/CT scanning can help to identify whether a man’s prostate cancer has spread beyond the prostate, using nuclear medicine to pinpoint the prostate cancer cells, while the CT scan uses x-rays to create a 3D image of the body MEDICAL FORUM | MEN 'S HEALTH

that can be used by specialists to get a more complete picture of each man’s situation.

The trial found this method of imaging to be 92% accurate in detecting deadly tumours, compared to only 65% accuracy for CT and bone scans combined.

If the cancer has spread to other parts of the body, doctors use a special nuclear medicine radiotracer that attaches itself to the PSMA and deploys a form of targeted radiation to find and destroy the killer cancer cells.

The radiotracer is Lutetium and is usually given in intervals of six weeks, with between four and six cycles of the treatment recommended.

In the EVOLUTION trial, Lu-PSMA will be given in conjunction with two immunotherapy drugs – ipilimumab and nivolumab – which are commonly used in cancer treatment.

PCFA is partnering with the Australian and New Zealand Urogenital and Prostate Cancer Trials Group for the 12-month trial of 100 men across Australia, who are now being recruited.

ANZUP chairman Professor Ian Davis said that while cancer immunotherapy was already used to treat many types of cancer, it has so far not proven successful in helping treat prostate cancer.

“The reasons for this are not known, but we believe it could be made more effective if we think creatively about how it is given,” Professor Davies said.

“Radiotherapy has been shown to help boost the immune response in other settings, so it is possible that combining radiotherapy with immunotherapy might lead to more

While 70-year-old Perth man Ian Simmonds is thankful he is not at a stage where he needs the type of drug being trialled, he could benefit from its findings.

Mr Simmonds was diagnosed with an aggressive prostate cancer in 2018 and underwent surgery at Hollywood Private Hospital soon after.

“I had the surgery and it all looked clear for a while but last year my PSA had crept up a bit, and although it wasn’t that high, it was increasing aggressively each month,” he said.

“So, I had radiation for six weeks and by May this year my PSA had gone down a bit, so I’ve been told by my urologist I don’t need to be seen for 12 months.”

Mr Simmonds is chairman of the community-based exercise program PROST! which encourages men to play light sport and do weight exercises in the gym, while also catching up socially to discuss their prostate cancer journey.

“Exercise is so important for anyone, but particularly if you’ve got cancer,” he said.

“Prostate cancer does play on your mind a bit, and you don’t really know you have it until you don’t have it, because a lot of the repercussions and symptoms occur once you’d had it taken out.

“The new drug in the EVOLUTION trial, or any treatment that they’re finding or working on, is absolutely fantastic because it gives people a lot more options and confidence that there are more treatments down the track.”

ED: For details of the PROST! group go to www.prost.com.au.

JULY 2022 | 11

It’s in the blood Clinicians and administrators working closely together is just one of the deep-felt causes intensive care specialist Dr Simon Towler staunchly advocates.

Ara Jansen reports

Dr Simon Towler never thought that getting to know a number of Jehovah’s Witness members would lead to a world-first rethink around unnecessary blood transfusions.

The veteran clinician discovered that the Western Australian health system was suffering because unnecessary blood transfusions were depleting stocks.

Jehovah’s Witnesses believe it is against God’s will to receive blood or to sustain their life with another creature’s blood and therefore refuse blood transfusions.

“I was working with a number of Witnesses and I had to think how we could legitimately support them to have a successful outcome,” says Simon.

“Having worked in the UK and the US, my experience told me we could do it differently.”

As a result of the reform in blood management and implemented programs now in WA, we’ve not only lowered the amount of unnecessary blood transfusions, saving blood needed for life-saving situations, but we’ve made massive shifts. For example, people having a hip replacement would routinely be given two units of blood. Now in the best programs, less than 1% of patients are transfused.

“With something like voluntary assisted dying we’re giving people a choice.

Why is blood transfusion different?” Simon argues.

“These experiences really tested my views around the fact that a clinician needs to acknowledge and provide the best possible care taking into consideration people’s convictions. How do we provide care without angering them and support how they face their illness as they make life choices?

“The idea was to change the focus from the products to the patients, while looking at a comprehensive approach to care.”

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Simon with his granddaughter at Rottnest

Simon has worked as a clinician in intensive care for most of his career and is currently an intensive care staff specialist at Fiona Stanley Hospital.

A ‘ten-pound Pom’, Simon came out to Australia when he was six-and-a-half. His grandfather lived in Melbourne but by the time he was 21 the family had moved 14 times.

Medicine calls Good at school and always “profoundly interested” in biology, he also really wanted to fly planes but was hampered by being red-green colour blind. His grandmother suggested he look at medicine instead.

She was influential enough that he did.

After doing his degree at Monash University, Simon’s internship was at the Alfred Hospital in Melbourne.

Considering a career in surgery it became clear that his colour blindness meant surgery was a closed path.

He went on to focus on physiology in practice and eventually found his way to anaesthesia and intensive care because they offered a lot of opportunities and procedural work.

“It was a perfect balance between what I would prefer to do and what my make-up would allow me to do. I would have been a truly miserable paediatrician.”

Simon’s father was a civil engineer and was offered work linked to the Muja Power Station, east of Collie. His parents came west, which ultimately led him here too.

After completing a fellowship in anaesthesia and working at St Bart’s in London (in his first overseas trip as an adult), Simon arrived in Perth in 1986 to start work as a senior registrar and pursue a career in intensive care medicine. Alongside the expected trauma resuscitation, he says snake bites were something reasonably common, with a parade of regular offenders getting themselves bitten.

“With something like voluntary assisted dying we’re giving people a choice. Why is blood transfusion different?...

These experiences really tested my views around the fact that a clinician needs to acknowledge and provide the best possible care taking into consideration people’s convictions.”

continued on Page 15

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JULY 2022 | 13

WORRIED ABOUT A LOVED ONE’S ALCOHOL OR DRUG USE? IT HELPS TO GET HELP. Confidential. Supportive. Professional.

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It’s in the blood continued from Page 13 While he moved around a bit Simon has always kept his hand in emergency and intensive care work, but always with an eye to open and informed care. He admires the pioneering work of his mentor Dr Geoff Clarke and Professor Teik Ho, who Simon says wrote the handbook on intensive care.

Ultimately, working in intensive care has become his passion, with his work greatly facilitated by machines “that go ping and give you information”. It’s also very much a team game, so he refuses to take all the credit.

He worked as an intensive care specialist at Royal Perth Hospital from 1990 to 2014 and is currently at FSH where he was also a medical co-director during the hospital’s commissioning.

Teamwork Undoubtedly a seasoned specialist, Simon has also dedicated significant chunks of his career advocating for better care and bringing clinicians and administrators together to improve how health care is delivered.

The list of his work in this arena is a dizzyingly impressive one but notably has included being executive director of health policy and clinical reform at the Department of Health in 2005 followed by a stint as WA’s Chief Medical Officer from 2006 to 2012.

He was responsible for initiating and promoting a model of statewide networks linking clinicians and patients in delivering more responsive, evidence-informed care.

His appointment in 2017 and ongoing work as the clinical lead of the Futures Program in the South Metropolitan Health Service included developing the Clinician Engagement Strategy, establishing the first Institute for Health Care Improvement Chapter in WA and championing the implementation of innovative approaches to end-oflife care and sepsis management.

A former local president of the AMA, Simon has been an active and vocal part of numerous committees and commissions into MEDICAL FORUM | MEN 'S HEALTH

Simon with his wife on holidays in Victoria

improving and sustaining health care in WA including 2001’s Health Administrative Review Committee and was deeply involved in the subsequent Reid Review of 2004.

Part of the expert panel which developed WA’s Voluntary Assisted Dying legislation, he has been a clinical lead in a project to increase the use of My Health Record for keeping end-of-life planning documents. He served six years on the Council of the National Health and Medical Research Council – Australia’s peak health policy and research funding body – is currently a board member of Palliative Care WA and adjunct professor at two universities.

“At a certain point, my colleagues told me I was losing my edge and said I needed to do more clinical work or get out completely,” Simon says. “I believe one of the most significant failings of the health system is the failure of the clinical staff and administration to work together more effectively. There are failings on both sides of that equation. I have always believed there’s a critical role for clinicians who understand management and for people even to have a toe in both camps.”

Doctor to patient All Simon’s personal experience advocating for improved patient care and better communication across the board was put to the test when he was diagnosed 10 years ago with

head and neck cancer caused by HPV. Overnight he became a patient, getting a box seat to appreciating the challenges patients face and the importance of a true patient-focused approach to the delivery of health services and healthcare.

Unlike the saying about doctors making terrible patients, Simon was the opposite. He says he did everything he was told to do, which helped and healed him.

Around the same time, he and his wife of 23 years separated. Being a workaholic clearly had a cost.

“My wife was right! I did nothing but work and my work-life balance was non-existent. My cancer diagnosis was a wake-up call,” he says.

While he’s far from done, he says if he has one regret, it’s not continuing to practise anaesthesiology. But he takes heart knowing his career to date has been “filled with extraordinary opportunities and experience”.

He’ll continue to use his voice and knowledge to advocate for the causes and issues he believes in, work to bridge the clinicianadministration gap as well as treat patients in intensive care.

Now remarried, Simon and his wife have eight children and five grandchildren between them. An enthusiastic gardener he’s up for the challenge of transitioning to a four-day working week.

JULY 2022 | 15

The health system tipping point, and need for reform After two years in the job, Perth orthopaedic surgeon Omar Khorshid is stepping down as national president of the AMA, a role which demanded more of his time than he ever imagined – courtesy of COVID. He talks to Medical Forum about the current state of the health system and the challenges ahead.

MF: In recent months we’ve seen hospital systems around the country operating dangerously over-capacity and many EDs unable to take more patients. What has gone wrong?

OK: There are several major issues from the AMA’s point of view, the first being a built-in lack of investment and capacity in the public hospital system, and that’s been present for many years.

Since the Rudd-Gillard reforms we’ve had activity-based funding, which has really held hospitals to account as to the cost of the services they provide, and they’ve become more efficient as a result. But the problem is that the national efficient price is calculated on the average cost of doing the service, and costs can vary greatly. As more hospitals become efficient, the average cost goes down and they’ve had to become even more efficient.

MF: So, you’re saying there is a perverse disincentive to do well and become more efficient and leaner, because more and more is expected?

OK: Yes, driving prices down is OK up until a point, but then hospitals just don’t have any fat left and you start to cut capability out of the hospitals, and that’s where it’s at now. A few smart people in Canberra agree that activitybased funding has perhaps run its course and needs to be balanced out a bit.

In WA, there has been a deliberate decision to cut health spending, or at least limit the growth to 1-2% a year, and we’re reaping the consequences of that.

There have been some funding announcements, but It’s all smoke and mirrors as to what’s really going on and, in my view, there hasn’t been a real fix to our hospital system from this government.

MF: What other issues are biting hard?

OK: The second issue is clearly COVID and its impact on the workforce, in particular, through the waves of Delta and Omicron in the east, and now Omicron in WA, which is knocking out so many health care workers. That just piles on top of the already overstretched system. Last winter we had over 5000 hours of ramping in August, and we had no COVID and no flu, and elective surgery was cut too. So, we were in for a bad year this year, with COVID and the flu coming back.

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Q&A The other issue is that we haven’t had investment and reform in general practice, so people are turning up at hospital who perhaps didn’t need to be there.

Governments use this as an excuse not to invest in public hospitals – they say we’re going to do primary care better, but they don’t and then wonder why hospitals are struggling.

So, right now, we need a massive investment in hospitals right across the country, and we need to do the promised reforms in general practice.

MF: Record ambulance ramping seems to have become a political football, and we know it’s reflective of overcrowded EDs and the wards, not just ambulance resources.

What’s the way out of this?

OK: There’s no easy solution, you have to fix the hospital system either by increasing capacity or reducing demand, and neither is easy to do. Things like the free flu vaccines are a good idea. And while I think there was some money in the budget to specifically look at ambulance ramping, that’s about the Government trying to get bad news out of the newspapers. It’s not a commitment to fix the problem because the problem is the capacity in the broader system. That big picture stuff means big dollars and long lead-times to fix them. You can’t, with a stroke of a pen, make ambulance ramping go away, and if you hide the problem by creating quasi-waiting areas you’re just creating an unsafe environment.

MEDICAL FORUM | MEN 'S HEALTH

An obvious way to create capacity is to find a solution for the longstay patients who we’ve been told don’t need to be in hospital but are waiting on aged care placements or NDIS packages.

And it’s not about the impact of COVID. It’s the fact that we’re keeping people alive longer, those with cancers, heart disease and all sorts of conditions that used to kill people but are almost chronic diseases now because of incredible medical advances.

MF: So, there’s a price to pay for our longevity?

OK: Yes, we have all these people that continue to need care. Ultimately, we need to build hospitals, beds and theatres, and understand that governments have underestimated the need for medical care.

MF: What about medical workforce shortages and lack of training opportunities?

OK: Health care worker training is a pipeline, it’s not just university undergraduate places, it’s about taking them from start to finish. You need activity to be happening in public hospitals, and an environment that supports training, because if it’s overloaded and stressed there’s no time for people to teach.

We don’t need more interns – we need resident medical officers and registrars who are a couple of years on from interns, because that’s where we have real shortages. They seem to be leaving the profession or going elsewhere.

In the short-term we’re still dependant on the skilled migrant intake, while recognising major ethical issues in poaching doctors from other countries.

MF: In terms of COVID, (lucky you, taking on the AMA role just as the pandemic was hitting our shores), how would you rate Australia’s and WA’s management of it?

OK: There have been bumps along the way, and plenty of criticism thrown around, but our Federal Government did act for Australia very quickly, and while they needed some nudging, so did Mark McGowan to take the steps he did.

On the whole, I think governments have been responsive, although I would add that if we’d had a Centre for Disease Control, with a more nationally consistent approach, we wouldn’t have seen the State border issues and fighting among the premiers.

We saw big problems with the Ruby Princess in Sydney, but don’t forget we had the Artania in WA, where our State said our beds were not continued on Page 19

JULY 2022 | 17

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18 | JULY 2022

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Q&A

The health system tipping point continued from Page 17 for foreigners, even though our hospitals were ready and trained to take on those patients. I felt quite ashamed of our State’s response to be honest. Since when do we not treat sick people just because they come from another country?

The mandates might have overshot a little, especially in WA, but if you sit back and look at the result, we have among the lowest mortality rate in the world. We’re not out of the woods yet, because there’s possibly more curve balls ahead, and we don’t know enough about longCOVID and how often we’re going to get infected with Omicron.

But the health system has responded faster, with things like telehealth services, than we ever thought possible, and on the whole, it’s been a great national success.

MF: It’s been all hands-on-deck to get as many people vaccinated quickly but how do you see pharmacists’ role as we start easing out of the pandemic?

OK: There’s no doubt the Pharmacy Guild has the idea that pharmacy should be at the centre of primary care delivery, and we fundamentally disagree with that model. We think the medical home has to be with the doctor and in general practice.

There needs to be teamwork, and we respect the role of pharmacists and that the separation of prescribing and dispensing supports safe practice. But with pharmacists trying to move into this primary care place, they’re fragmenting that care and confusing patients, and we’ll end up paying the price in the longer term.

It doesn’t mean pharmacists can’t do vaccinations safely, but is that the model that delivers the best overall health outcome? We’d suggest the answer is no. Particularly for things like childhood vaccinations or teenagers. These are opportunities for a family to come into a general practice where something other than vaccination might take place. GPs might notice someone is overweight or anorexic, or there are signs of domestic violence – things that a GP can do that a pharmacist in a retail environment simply cannot do and is not trained to do.

MEDICAL FORUM | MEN 'S HEALTH

We have a vision where you have a pharmacist, nurses and other types of practitioners in GP clinics, so you have all those skills available to the patient, and the doctor is not doing everything. We’ve got to get out of this silo mentality and change the model of primary care.

MF: Has it been a tough gig being national president of the AMA during a pandemic, especially for someone based in WA? OK: Yes, it has been tough, but it’s been a huge privilege to take on this role. I had a prominent role early on in assisting the Federal Government to convince the public that what they were doing was right. Some people questioned why the AMA was being so ‘nice’ to the government. But the last thing we needed was anyone undermining governments when they were making tough decisions on mandates, lockdowns and vaccinations.

MF: It’s interesting that you say there is an expectation that the AMA should have an antagonistic approach to government decisions, and that sometimes it’s important to have one clear message to the public. Do you have to pick your fights?

seemed more important to me than whether we absolutely agreed with everything the government was saying.

MF: As we ease out of the pandemic, what is the major challenge facing the health system?

OK: Sustainability, and paying for health care, are going to be our biggest problems going forward. My baby boomer parents are aged 75 and 76, and when they (hopefully) get to 85 or 90 – and substantial numbers will live that long – their health needs are going to be enormous.

We’ve got better survival from diseases, and we’ve possibly got long-COVID issues to deal with, and all this adds up to increased demand amid a shrinking tax base.

We have to have that conversation as a community, so that people understand that if we value our health care, we may need to pay more tax. If we don’t want to provide that high level of health care, then we have to become more selective.

OK: Yes, especially during a pandemic, when a consistent voice JULY 2022 | 19

Warne sparks a ripple effect in heart checks The ‘Warnie effect’ has raised awareness of heart disease risks in middle-aged men and sent many off to their GP.

Eric Martin reports

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The sudden death of Shane Warne, the King of Spin, from a massive heart attack on March 4 this year sparked a global outpouring of sorrow, with tributes flowing in from celebrities as diverse as UK singer Elton John to former NBA star Michael Jordan.

“We were anecdotally hearing from GPs and nurses that more people were booking a heart health check, and now the actual data has come through from the MBS which shows the highest ever recorded number of monthly heart checks billed,” she said.

Professor Bu Yeap, an endocrinologist at Fiona Stanley Hospital and president of the Endocrine Society of Australia, said that the lessons Australian men could take from their deaths were the importance of healthy living and prevention.

That same day, just hours earlier, another Australian cricketing legend, Rod Marsh, was also struck down, succumbing to the impact of heart failure suffered the week before. It seems poignantly ironic that Warne’s last social media post had been to reach out with a tribute of his own.

“It's great to see that Australians have used this as a wake-up call to get back on track with their preventative health.”

“Every man should be living as healthily as possible to protect their future,” Professor Yeap said.

“Sad to hear the news that Rod Marsh has passed. He was a legend of our great game & an inspiration to so many young boys & girls. Rod cared deeply about cricket & gave so much-especially to Australia & England players. Sending lots & lots of love to Ros & the family. RIP mate.”

While Australia mourned both men, grief was especially keen for Warne, who was only 52 when he died while holidaying with friends on Koh Samui in Thailand.

His state funeral, held at the MCG on March 30, was a momentous affair, with over 50,000 fans in attendance, joined by a ‘who’s who’ of distinguished guests including the current and two former prime ministers, Anthony Albanese, Scott Morrison and John Howard.

Picture: Philip Brown, Reuters

Yet, to quote the Dalai Lama, ‘Tragedy should be utilised as a source of strength’, and as a silver lining for the nation’s health, their deaths have inspired thousands of Australian men to check up on the health of their hearts – a trend which has been dubbed the ‘Warnie effect.’

According to the Heart Foundation, sudden cardiac arrest affects 20,000 Australians each year and 90% of people who suffer a sudden cardiac arrest will die, 2,000 of them under the age of 50.

Screening boom Natalie Raffoul, the foundation’s health care programs manager, said that during the period following Warne and Marsh’s deaths, traffic to its website doubled, and in March, more than 12,000 Australians booked a Medicare-funded heart health check with their local GP – a 70% increase on February.

MEDICAL FORUM | MEN 'S HEALTH

In many respects, Warne and Marsh were the opposite of everything international athletes are meant to be, partying just as hard as they played – neither looked that fit and one was a heavy smoker while the other was always known to have a beer in hand.

Rodney ‘Bacchus’ Marsh was just as famous for his legendary drinking competitions as being one of the best wicket keepers in the world, such as the herculean effort of drinking 45 cans of beer during a flight home from the UK. Warne always lit up a cigarette before going on the field.

Their passing has left many men looking at their own lifestyle choices and wondering if they too might be at risk.

Cardiologist Dr Stephen Gordon said that his initial reaction to the cricketers’ deaths was a sense of tragedy that they had both died prematurely, “when they still had much to offer their professional lives, their families and their sport.”

Age no barrier “The ‘Warnie effect’ has been a wake-up call, a strong reminder that death from heart disease is not exclusive to the elderly but carries significant risk in middle age and sometimes even younger patients – it is not a rare condition in middle age,” he said.

“It involves a recognition that coronary artery disease is the single commonest cause of death in Australia, and that modern lifestyles may be significantly contributing to that risk.”

“It just goes to show that once you get to middle age, you are vulnerable, and that may be the case even if you've been very fit and healthy beforehand. But if you look at the statistics, as a nation, we are still becoming more overweight and that's not a good sign.”

Like many men his age, Warne was regularly engaged in a battle with the bulge, and just a few days before he died, shared an old picture of himself at peak fitness, posting that he wanted to get back into shape by the end of July – something he called ‘Operation Shred’.

He’d already managed to drop 14kg but wanted to lose four more to get down to his ideal weight of 80kg, something he’d almost managed to achieve while dating British actress Elizabeth Hurley back in 2011.

Dr Gordon explained that even though weight was a factor, the incidence of cardiovascular disease and myocardial infarction was largely determined by the interaction of multiple lifestyle and risk factors, and while the elevation of a single factor alone might carry only a modest increase in risk, the interaction of multiple factors carried a synergistic increase.

“Similarly, prevention of cardiovascular disease will generally not come from pursuit of a single health lifestyle factor, but rather the combination of multiple lifestyle factors and treated risk factors,” Dr Gordon said.

continued on Page 23

JULY 2022 | 21

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Warne sparks a ripple effect in heart checks continued from Page 21 “The major issues are determining an individual’s risk of having a cardiac event and then effectively pursuing the lifestyle and treatment of risk factors that may significantly reduce that risk.”

Common sense Professor Yeap said that when he talks to people, he uses the same message no matter if the person is overweight, or has diabetes, or cardiovascular risk factors.

“It's a very common-sense message – don’t smoke is number one, followed by healthy eating, avoiding energy dense and heavily processed foods, and eating as much fresh greens as you can and keeping as active as possible.”

Smoking was Warne’s Achilles’ heel, with him smoking up to 50 a day throughout his 22-year sporting career, and he was regularly pictured lighting up - famously photographed smoking next to Adam Gilchrist at the Ashes in 1997 at the height of his career.

He was such a heavy smoker that even the offer of $200,000, made in 1999 by the nicotine replacement company Nicorette, was not enough to entice him to quit, with Warne caught smoking in a Barbados bar just before the sponsorship ended.

The Heart Foundation states that sudden cardiac arrest costs the Australian economy nearly $2 billion annually and is priceless in terms of the cost in grief and in some cases, where there are no warning signs, shock as people suddenly and tragically die in front of their loved ones.

“The whole thing about latent heart disease is presenting as, or being, asymptomatic, then your first symptom is a major cardiac event.

And that is occurring more and more. The tricky thing is what to do about it,” Professor Yeap said.

“If these high-profile deaths are a wakeup call, if it engages men, if it gets them interested, then yes, that's an opportunity that we [as doctors] can do something about on an individual scale.

MEDICAL FORUM | MEN 'S HEALTH

“And it comes down to a question of how beneficial is screening lowrisk people because of the cost and the potential side effects?

“You want to identify men at ‘intermediate risk’, where stratifying that risk more closely would actually change your management above and beyond optimising their lifestyle.”

Dr Gordon advised that online and desktop risk calculators can estimate the risk of a cardiovascular event once data on lifestyle and risk factors including diabetes, smoking status, dyslipidaemia and blood pressure have been attained.

Refining risk “Further refinement of risk may be obtained by performance of a Coronary Calcium Score obtained

by CT scan,” he said, adding that recent NHF guidelines also suggest that the greatest additional value of calcium scoring is in patients who are estimated to be at intermediate risk.

“Such scores have become widely available but are not covered

by Medicare, and while they have generally been endorsed by cardiologists, there are some caveats.

“Firstly, there is still some uncertainty as to how often a calcium score will significantly change a patient's risk stratification obtained by risk calculator, and patients at high risk by calculators probably ought to be treated as high risk.

“Lower risk patients may benefit from calcium scoring, particularly where factors that may enhance their risk are not incorporated into current risk calculators.

“These include metabolic syndrome, CKD, chronic inflammatory conditions (e.g. psoriasis, rheumatoid arthritis), premature menopause, familial hypercholesterolaemia, elevated triglycerides, elevated Lp(a), elevated ApoB, and family history of premature CVD. “Furthermore, there are very few studies yet to indicate how much interventions based on calcium scoring actually reduce cardiac event risk, though there is little doubt that the demonstration of calcium in coronary arteries is a very potent motivating factor for patients to alter lifestyle, and if necessary, accept pharmacotherapy.”

However, Professor Yeap warned that men should not go to their GP and request a coronary calcium score.

“When men present to their GPs for consultation, that's an opportunity for the GP to take a holistic assessment of their patients’ health than looking at cardiovascular risk in isolation.

By investigating someone's physical activity, sleep habits and stress levels, and screening for things like depression and sleep apnoea, doctors could learn a lot about their health and risk status.

JULY 2022 | 23

On quokkas and growing membership As he leaves after five years at the helm of HBF, John Van Der Wielen reflects on his efforts to make the organisation more relevant, and the challenges ahead.

“Health insurance plays an important role in the health system and participation has grown since the pandemic.

But there are considerable headwinds, with rising interest rates and cost of living pressures on household budgets.”

As chief executive officer, you are only ever the custodian of an organisation for a short time. If you leave a business in a better state than you found it, you can say you have done a good job – and I believe I have achieved that at HBF. When I started in 2017, HBF was a great West Australian brand with a strong capital position but dated technology and a steadily declining market share.

HBF needed to attract younger members to reduce the average age of its portfolio. Its premiums were not competitive and service levels were not where they needed to be.

Fast forward five years and HBF has increased its market share, with younger members and a growing membership on the east coast. We’ve kept average premium increases lower and payout ratios higher than our major competitors, expanded into health services such as dental and physio, improved our service levels as seen by our low complaint ratios and top-ranked app, and continued to support the community.

I saw the main challenge as building the belief internally that we could reinvent ourselves by growing nationally and transforming our technology, while remaining true to our origins.

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GUEST COLUMN

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GUEST COLUMN My first major project was a potential merger with HCF, enabling two similar organisations to become a national not-for-profit health insurer of scale. While the deal was closed, it never came to fruition, so we had to dust ourselves off, realise we were competing against strong competitors like Medibank, nib, Bupa and HCF, and acknowledge that to penetrate the east coast market we would need an innovative brand and new technology.

In developing our strategy, we knew that to attract young members and be successful outside of WA, HBF had to stand out from the rest. Our digital applications would have to lead the market, our pricing needed to be keen and, most importantly, the brand had to stand out from the rest – now you can see why we have the cheeky quokka.

We also knew that high commissions to brokers and comparison sites led to higher lapse rates and lower margins, which is why HBF decided to market directly to consumers and use innovative technology and branding to achieve growth.

HBF is one of only a few insurers not available on broker and comparison sites and we are proud that we are achieving growth without them. In addition to organic growth plans, HBF has been looking to merge with or acquire other not-for-profit funds and we’re particularly pleased with

our successful acquisition of CUA Health in Queensland.

Today, HBF has more than 1.1 million members and 20% of this membership base now lives outside WA. A technology upgrade has been gathering steam, with the leading app in the market, a new provider search engine, and the ability for members to store their member card in their phone’s digital wallet.

Our diversification into health services through the launch of HBF Dental and the acquisition of Life Ready is about providing greater value to members.

Looking back, the achievements I’m most proud of are our bold quokka marketing campaigns (they have been a real winner and helped make HBF a truly national brand), expansion into health services, and how we supported our members through the COVID-19 pandemic by being the only major fund to fully cancel our 2020 premium increase and the first to announce we were returning COVID savings to our members.

Looking at the health ecosystem more broadly, the fundamentals remain strong when comparing Australia to similar countries but there is no denying the public system post-pandemic remains under pressure. Even though private health insurance participation has increased, the growth in the number of people

presenting to public hospital emergency departments has increased well above the rate of population growth.

Health insurance plays an important role in the health system and participation has grown since the pandemic. But there are considerable headwinds, with rising interest rates and cost of living pressures on household budgets.

I have always been a strong believer that those who can afford health insurance should do so to free up the public system for the more vulnerable. We need to find ways to incentivise young people, in particular, to take up and retain health insurance; salary packaging of private health for people under 40, within appropriate income limits, could be an option.

Being CEO of this 81-year-old organisation has been a privilege and a big but an enjoyable task. I look forward to watching what the future holds for HBF.

Read this story on mforum.com.au

Everybody wants to know who they are and where they come from. Thousands of people are searching for their biological relatives through direct-to-consumer DNA testing. If any member of your extended family does a test, for whatever reason, there is a good chance your donor conceived child can find you, and that other members of your family may be contacted.

A voluntary Donor and Offspring Register managed by Jigsaw DNA Connect and funded by the Department of Health is available for you to securely enter your details. If there is a match on the register, all parties will be contacted and their wishes established.

NO identifying information will be given without the consent of each party.

Retrospective legislation to release identifying information about donors has already been introduced in Victoria and a committee is being set up to discuss in WA. For more information visit www.jigsawdna.org.au or talk to our staff on (08) 9228 2647 or email jigsawdna@jigsaw.org.au

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JULY 2022 | 25

Rehab needs a leg-up Rehabilitation services have been neglected during the pandemic and must return in force to create equity for patients, argues Dr Bruce Powell.

Through the long months of COVID isolation, health services in Western Australia have witnessed cracks widening in our ambulance services, aged care facilities and theatre waiting times.

But hidden beneath these familiar fault lines lies another group that has been profoundly affected by the pandemic.

Australian Rehabilitation Outcomes Centre (AROC) data indicates that 60% of the 143 inpatient rehabilitation services across Australia and New Zealand that responded to the survey have been affected by COVID.

Simple factors such as visitor limitation has reduced access to family support and impacted on mental wellbeing.

The brain injury community, along with many other acquired injury groups, require rehabilitation to return to a new and meaningful life. Without intense inpatient and community support, thousands of patients will be more reliant on costly government services. Their carers face a new career in home nursing, rather than returning as taxpayers to their preferred professions.

Is rehab too expensive?

Peer-reviewed data from the UK and the US demonstrates that intensive rehabilitation saves rather than costs money. Moreover, the most money spent on the most seriously injured yields the largest benefits.

AROC’s data reveals rehabilitation’s ability to increase partnerships between public hospitals and an impressive agility of rehabilitation

And 40% of impacted rehabilitation services have been closed or repurposed, and insufficient specialist FTEs have led an inability to meet patients’ complex care needs.

Tellingly, there is also a trend to allocate staff to non-specialist areas such as COVID clinics and emergency departments.

Consequently, rehabilitation units are unable to provide enriched environments, with the loss of gym and kitchen facilities for breakfast groups and meal preparation assessments. Group therapies and patient socialisation have also been impacted by isolation requirements.

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GUEST COLUMN

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GUEST COLUMN staff to move between in- and outpatient services.

Yet through COVID we have seen the political and health bias for acute services over rehabilitation resources. If we are not careful, those who would profit most from rehabilitation will become “acceptable collateral damage” as our health services strive to recover.

Rehabilitation is not just a medical term. It is a familiar and generous everyday word that reflects our community’s belief in a “fair go”.

Long-COVID may leave millions needing assistance and support to realise their potential. That is in addition to the 500,000 who already rely upon the NDIS. Yet politicians have it in their sights as an unsustainable and ill-judged ideological giveaway.

Not a charity The NDIS is not a charity, nor a handout. It is a pragmatic, community-spirited scheme designed to allow people to live their most productive life. Of course, the NDIS isn’t perfect.

Politicians and financiers rue the scope for rorting and escalating

costs, while patients and their carers lament the yawning gap between acute hospital care and the funding of resources for a successful discharge. Patients witness our carers carry us, while simultaneously bearing their own trauma and grief.

Now that the election storm has passed, there is an opportunity to change the language around the funding of rehabilitation and chronic care.

What now?

The NDIS should be regarded as a vote-winner, not a millstone to hang around the neck of our latest Prime Minister. The next Minister for the NDIS must celebrate its fiscal rewards, not suggest its funding is insatiable and unsustainable.

Politicians should be queueing up to claim ownership of our rehabilitation sector, shoulder to shoulder with advocates and clinicians to share the good news.

The next minister must reinstate hospital rehabilitation resources to their pre-COVID levels. They should increase funding further in the future, in partnership with the WA Government.

Look at the funding from a pragmatic viewpoint, just like we do with organ transplantation.

The process saves lives, creates optimism and saves money.

Similarly, intensive investment in an individual’s rehabilitation is regenerative and potentially longer lasting. Both are profound expressions of our humanity and community commitment to each other.

Increasing rehabilitation services and the simpler, faster funding of chronic health care are crucial parts of any community’s commitment to itself. Without these services, our hospital beds will remain gridlocked, and our ambulances ramped at the entrance.

Rehabilitation is not a dumping ground, but the light that reveals the path to a new life. With the advent of a new government, perhaps we might create a new generous culture of communitybased rehabilitation and rebirth.

ED: Dr Powell retired as an anaesthetist after being seriously injured in a cycling accident in 2018.

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MEDICAL FORUM | MEN 'S HEALTH

JULY 2022 | 27

The Audi end of financial year sale has been extended Take advantage of outstanding offers on a wide range of Audi models, in stock now at Audi Centre Perth. For a limited time, receive complimentary:

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COVID biobank unlocking data A biobank in WA will be invaluable in researching how the immune system responds to COVID-19, according to consultant immunologists Drs Dominic Mallon and Michael O'Sullivan.

The WA COVID-19 Immunity Collaborative Biobank that was set up in 2021 is an internationally unique biorepository that is already kicking goals.

It will allow researchers to examine and compare immune responses to SARS-CoV-2 infection and different types of vaccines in adult and paediatric populations within the State’s virus exposure.

When the WACIC Biobank was planned in late 2020, limited community spread meant that WA was well-placed to contribute to COVID immunity research and knowledge.

Being able to study COVID vaccineinduced immunity in a population which had not previously been exposed to the virus was an opportunity not able to be replicated in many other locations.

Donations welcome People recovering from a SARSCoV-2 infection, their close contacts, and those receiving or having received COVID-19 immunisations, have donated blood and saliva samples at various times to help answer questions about how immunity to the virus develops after infection or vaccination.

The samples will also help to discover how long immunity lasts, and aid in the development of diagnostic laboratory tests to show whether someone is immune to COVID-19.

The aim is to understand what immune factors are critical for protection against COVID, and support translating this knowledge into practice.

The WACIC Biobank study is supported by PathWest Laboratory Medicine, and the integration of research with a statewide public pathology provider has been key in streamlining sample collections from Broome to Albany.

MEDICAL FORUM | MEN 'S HEALTH

Together with the PathWest biochemistry and immunology laboratories, a robust biobanking workflow was set up, which uses the automated aliquot system to create and sort multiple aliquots for storage and has the capability to be used for large-scale biobanking applications.

The aim of the biobank is to be a unique collaboration between experts in public health, diagnostic laboratory medicine, specialty clinical practice and basic science, drawn from government and health service providers, medical research institutes and universities.

It will allow research outcomes that will achieve the greatest benefit for the broader community.

Hundreds of samples In just seven months, the WACIC Biobank team has recruited more than 300 adult and paediatric participants, and more than 550 sets of blood and saliva samples have been stored at partnering laboratories at Murdoch University, the University of Western Australia, and PathWest at Fiona Stanley Hospital.

Recruitment is ongoing, with a focus on those who are immunocompromised, people who have had a COVID-19 infection, and children and adolescents receiving or having received COVID

immunisations. More than 100 immunocompromised patients have been enrolled from clinics at Fiona Stanley Hospital and Sir Charles Gairdner Hospital, including those receiving chemotherapy for cancer and organ transplant recipients on immune suppressive therapy.

Samples and information collected from these participants will be key in understanding immune responses in these highly vulnerable populations.

Border-line effects With the opening of the WA border earlier this year, we are now in an exciting position to study the effects of locally transmitted SARS-CoV-2 infections due to the currently circulating Omicron variants in a population with high rates of immunisation with vaccines developed against the original SARS-CoV-2 virus.

Samples and data held in the biobank are available to all WAbased researchers and diagnostic laboratories for projects relevant to COVID-19 immunity. Researchers can apply to gain access to the biobank’s data and specimens and more information is available at www.pathwest.health.wa.gov.au/ WACIC. ED: Dr Mallon and Dr O'Sullivan are Consultant Immunologists at PathWest at Fiona Stanley Hospital.

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Individualising the screening message More needs to be done to encourage Aboriginal people to take part in bowel cancer screening, argues Melissa Ledger.

The National Bowel Cancer Screening Program, which sees kits sent to eligible Australians aged 50-74 every two years, has huge potential to reduce the burden of bowel cancer.

was a great success, with the material generating much online discussion among Aboriginal people.

While participation is hovering at around 43%, some priority populations face additional challenges to participate. One of these groups is Aboriginal and Torres Strait Islander people, with the latest data indicating a participation rate of 27%.

Aboriginal people face a range of barriers, including language and health literacy challenges, remote and regional access to postal and health services, and lack of tailored and culturally appropriate program resources. Aboriginal people in WA also show poorer bowel cancer outcomes than the general population, including a higher positive faecal occult blood test rate and longer colonoscopy waiting times following a positive test result.

Strategies have been employed to boost Indigenous participation rates, including an alternative pathway pilot program. The pilot ran for 12 months from November 2018 to October 2019, and saw encouraging increases in engagement with bowel screening and kit completions.

While we await its national roll-out, the question remains as to how to raise the profile of the program and start conversations among Aboriginal people.

Designing campaigns to reach particular priority populations presents opportunities to collaborate and co-design.

Using funds bequeathed to Cancer Council WA, our bowel team has worked closely with the Aboriginal Health Council of WA and Derbarl Yerrigan Health Service to develop an awareness campaign for bowel cancer screening among MEDICAL FORUM | MEN 'S HEALTH

Comedian Mary G in action

WA’s Aboriginal population and encourage participation in the NBCSP. We engaged our Aboriginal advisory group and elders, staff at Aboriginal Medical Services and community members across the state to fine-tune the campaign.

Initial campaign planning saw the development of a number of videos featuring Mary G, a well-loved Aboriginal personality, educator, and radio presenter, to raise awareness of bowel cancer, and her humorous delivery was a great way to broach such a sensitive topic.

In the early planning stages, these campaign materials were to be used across WA. However, as community consultation continued, the feedback highlighted the importance of running local, targeted campaigns, and ensuring that the materials used in each region resonated with the local community.

In addition to the Mary G materials, which were ultimately used only in the Pilbara and Kimberley, the campaign also featured local Aboriginal people from across the regions, delivering their own personal message about the importance of screening to their community.

Engagement with both the Mary G campaign and the local bowel screening champions campaign was high. Social media posts saw comments from community members encouraging others to take part in screening and noting how easy the test was to do. Importantly, it also generated comments which shared community members’ personal stories of taking the test, and the positive outcomes of that action.

We know peer encouragement is so important in creating health-related behaviour change.

We’re excited to run the campaign again this year. We’ve sought out a few new faces for the campaign, and this year its running over the cooler months, encouraging people to do the test when it arrives, particularly in the hot regions in WA where kit samples can be damaged due to the heat.

As with last year, we’re hoping for the same positive engagement with the campaign, and that people are motivated to do their kits when they come in the mail or to reorder a free replacement.

GPs influence their patients – you can identify why they aren’t screening and encourage them to do the test. Why not start the conversations today with your eligible patients? Even if they feel well, check if they’ve got a kit at National Cancer Screening Register, order them a replacement and start the conversation.

It could save their life.

ED: Melissa Ledger is Cancer Council WA’s director of cancer prevention and research.

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SPONSORED CONTENT

Precision & care Three of WA’s most respected orthopaedic surgeons, Drs Peter Campbell, David Colvin, and Hari Goonatillake have enhanced their Subiaco practice, to include advanced research and development alongside their trusted excellence in clinical care.

West Coast Orthopaedic Centre, as the practice is now known, welcomes Drs Will Blakeney and David Graham to their ranks. Both come with exceptional CVs. Dr Blakeney is a local graduate who completed fellowship training in shoulder and sports knee surgery in France, followed by a year in Canada on a fellowship in hip and knee replacement.

He is an Associate Professor at UWA and head of orthopaedic research at Royal Perth Hospital.

Research is a passion of his.

“With improvements in precision technology such as robotics and three-dimensional planning software, we are now able to match an implant to the patient’s individualised anatomy and alignment,” he says. “The ultimate aim is to give the patient a ‘forgotten joint’, where they can’t tell the difference between a prosthetic joint and a healthy native joint.”

Dr Graham is also a UWA graduate who completed his orthopaedic surgery training in WA before fellowships at the Fortius Clinic in London and the Melbourne Shoulder and Elbow Centre, with particular focus on arthroscopic techniques for shoulder reconstruction and modern techniques for joint replacement surgery.

The addition of Drs Blakeney and Graham complements the existing team, with Dr Campbell’s expertise in shoulder surgery, Dr Colvin’s interest in ACL reconstruction, rotator cuff repair, and shoulder and knee surgery for sports injuries, and Dr Goonatillake’s focus on knee and shoulder surgery and limb reconstruction.

As fitting the new direction that acknowledges the skill and innovation of its local team, West Coast Orthopaedic Centre has looked to some ancient wisdom, commissioning Noongar elder Peter

Farmer to design a new logo for the group.

Dr Campbell says the logo combines the iconic red and green kangaroo paw, endemic to Perth and the South-West, with the Noongar representation of the sacred Wagyl that created the local waterways.

It is important for the West Coast Orthopaedic Centre team to acknowledge the traditional custodians of the land on which they live and work.

“We want to extend that recognition of country to continue that tradition of caring, through our own work with patients who need our help,” he says.

The team is based centrally at the St John of God Clinic Subiaco and offers a range of orthopaedic treatments undertaken with signature care and precision.

St John of God Medical Clinic Suite 213, 25 McCourt Street, Subiaco WA 6008 Peter Campbell 9489 8777 William Blakeney 9489 8733 David Colvin 9489 8788 Hari Goonatillake 9489 8722 David Graham 9489 8744

www.wcortho.com.au

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Doctors being held to ransom To pay or not to pay – cyber-security specialist Ajay Unni explains how to avoid paying ransomware and what’s at risk if you don’t.

Transmitting health information and maintaining patient records digitally is now a mainstay of the medical industry. In turn, these systems have become a lucrative target for cybercriminals, increasing the importance of cybersecurity.

Ransomware, in particular, is a huge concern for the medical industry.

These malicious types of software are designed to block access to a computer system until a specific amount of money is paid. Since any downtime can put lives at stake, practices may choose to pay the ransom and move on as quickly as possible.

By paying the ransom, medical businesses might also believe they’re protecting sensitive data from being exposed or lost forever, which makes sense when you consider the huge amount of valuable personally identifiable information (PII) used in the industry.

Paying a ransom is often seen as a simple business decision: if the costs to recover from a ransomware attack exceed the ransom payment, some may choose to pay the ransom amount. Some medical practices will also choose to quietly pay a ransom rather than report it to officials and risk reputational damage.

Paying may not work Paying the ransom to regain access doesn’t completely eradicate the risks. Hackers could easily install other types of malware that could be activated later in order to launch new attacks. Victims might even suffer repeat attacks if other criminal groups learned that they made a ransom payment.

Even if a business makes a ransom payment, there are no guarantees that attackers will return the data or that the decryption key gets data back where it was before the attack.

In many cases, a single payment MEDICAL FORUM | MEN 'S HEALTH

may evolve into multiple payments.

For example, the first payment gives victims a decryption key, while a second payment may be requested to ensure that sensitive data isn’t released to the public.

Making the payment could also get medical practices in serious legal trouble. Depending on the nationstate the hacker group operates out of, paying ransomware attackers could even be seen as funding terrorism.

However, there are several steps that businesses can take to avoid paying ransomware in the future.

Some operating systems even offer specifically-designed ransomware protection, so make sure you enable this function to protect your devices.

Update your device and turn on automatic updates. Cybercriminals take advantage of known vulnerabilities to hack your devices.

Regular system updates have comprehensive security upgrades to patch these vulnerabilities.

Security ID Multi-factor authentication (MFA) is another important must-have.

MFA means there are two checks in place to prove your identity before you can access your account. For example, you may need to supply an authentication code from an app and your password. This makes it

more difficult for someone to access your files or account.

Set up and perform regular backups.

A backup is a digital copy of your most important information that is saved to an external storage device or to the cloud. The best recovery method for a ransomware attack is a regular offline backup made to an external storage device and a backup in the cloud. Backing up and checking that backups restore your files offers peace of mind. You can set up automatic backups in your system or application settings.

Finally, make sure you implement access controls. Controlling who can access what on your devices is an important step to minimise the risk of unauthorised access. It will also limit the amount of data that ransomware attacks can encrypt, steal, and delete. To do this, give users access and control only to what they need by restricting administrator privileges.

The ultimate goal is to embed cybersecurity awareness into the heart of your practice. That way, with the right protections in place, your practice should never be forced to make that impossible choice of whether to pay or not pay.

ED: Ajay Unni is founder of cybersecurity mitigation company StickmanCyber and was part of the NSW Government’s cyber security taskforce in 2020.

JULY 2022 | 33

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Dr Joe Kosterich | Clinical Editor

Skinny dipping?

As you read this we will be in the middle of winter – which is shaping up grey and wet.

Up until 2019, each year there were predictions around Easter that the upcoming flu season would be the worst on record.

As the COVID tide goes out we are learning about the health of the health system.

History records that some years are worse than others and that severity of illness and numbers of cases are not only not synonymous but can tend to move in opposite directions. To state the obvious, this year will be fascinating. The push to increase flu vaccinations, with State Governments providing free shots until June 30, was based on higher case numbers earlier than usual.

The question is whether cost is the barrier to people getting a flu shot.

My suspicions are that those not under the Federal program or having one at work likely don’t regard themselves as being at risk or think that getting a shot is too inconvenient and time-consuming. We will hopefully know the answer after winter. This can then influence future policy.

On virtually all health parameters, males fare worse than females. Life expectancy, while increasing, is still two years less. There are higher rates of smoking, excess alcohol consumption, obesity, heart disease and suicide to name but some. Males are less frequent users of health services and less likely to engage with lifestyle programs. On the plus side, younger males (millennials in particular) are more interested in their health.

This month’s articles are a potpourri where, among others, we look at functional hypogonadism BPH, kidney disease, bariatric surgery, the role of medicinal cannabis (for the record I am medical advisor to Little Green Pharma) in PTSD, and minimally invasive gastric surgery.

The quote of when the tide goes out you learn who has been swimming naked is attributed to Warren Buffet. Necessarily he was referring to businesses and investors who looked like they were performing well but in reality, were not.

As the COVID tide goes out we are learning about the health of the health system. Despite predictions to the contrary, COVID has not overwhelmed health systems in Australia and certainly not in WA. With periodic cancellation of elective surgery, some have argued the load has been lowered.

The tried and true WA tactic of blaming the Feds will be harder with Labor being in power at both levels. There is more to a health system than reporting COVID numbers and closing borders. The question is, has anyone been swimming naked?

MEDICAL FORUM | MEN 'S HEALTH

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CLINICAL UPDATE

Functional hypogonadism

By Dr Imran Badshah, Endocrinologist, Hollywood Male hypogonadism is diagnosed by specific symptoms of androgen deficiency and low testosterone levels.

Hypogonadism that is caused by structural, destructive, or congenital pathological process of hypothalamic pituitary testicular axis is known as organic hypogonadism. In contrast, functional hypogonadism presents in middle-aged men (defined as aged above 50) with obesity and co-morbidities, low testosterone with normal gonadotrophins without intrinsic pathology of HPT axis.

Patients with organic causes will need testosterone replacement almost always whereas a more holistic approach is required to manage patients with functional hypogonadism.

In males with functional hypogonadism, levels of testosterone are modestly reduced and usually fluctuate around the normal range. In large observational studies, males with confounding co-morbidities may not confirm androgen deficiency as per stringent criteria, although they may have low testosterone levels. Functional hypogonadism does not warrant TRT as there is evidence that weight loss and lifestyle measures have a reversible effect on it.

In a large US-based observational study, after 15 years of follow-up, over 50% males remitted because either their symptoms resolved, or testosterone normalised.

In European male ageing study, prevalence of functional hypogonadism was 13-fold increased with obesity and ninefold in males with co-morbidities.

It was a rare finding in males who were lean and healthy.

It leads to another discussion whether low T level leads to obesity and poor health resulting in poor outcomes. Low testosterone may be maladaptive, neutral or even a beneficial state but it’s hard to say without any clinical trials.

In observational studies, obesity, and co-morbidities such as MEDICAL FORUM | MEN 'S HEALTH

Key messages Men with symptoms consistent with androgen deficiency and low T levels should be thoroughly investigated for organic causes.

Do not assume their presentation is due to age and co-morbidities Lifestyle measures and weight loss should be the first management in treating functional hypogonadism In selected patients, TRT may be concomitantly started with lifestyle measures where management of co-morbidities or cessation of offending medications may be difficult. diabetes, obstructive sleep apnoea and chronic use of opioids was associated with reduced testosterone levels with normal luteinising hormone levels.

Incident of chronic disease such as diabetes or 4-5kg/m2 increase in BMI is associated with decline in testosterone comparable to 10 years of ageing.

Lifestyle medicine Targeted approach to address lifestyle changes and chronic disease management other than testosterone replacement in functional hypogonadism has shown improvements in the testosterone levels and general health of the individuals.

Weight loss can also improve erectile dysfunction. In a metaanalysis of four RCTs, weight loss was associated with clinically meaningful increase in the international index of erectile dysfunction score. However, this increase was less than the PDE5 inhibitors. Bariatric surgery has reported similar results. In a twoyear follow-up of 64 males who underwent gastric bypass and with 30% weight loss improved testosterone by a 10.8 nmol/L. Functional hypogonadism is more common in middle-aged men who are not physically active

and engaging in physical activity leads to weigh loss associated increase in testosterone levels and overall improvement in the cardio metabolic health and comorbidities.

Diabetes and OSA are the two most common diseases associated with functional hypogonadism. HbA1c level is inversely proportional to the testosterone levels. Improvements in HbA1c has been shown to increase the testosterone levels.

Continuous positive airway is associated with improvements in erectile dysfunction and quality of life, but studies have not shown improvements in testosterone levels with CPAP therapy. More studies are needed long term to see any effect on the testosterone levels with CPAP.

Testosterone and functional hypogonadism Above measures are advocated in the management of functional hypogonadism. However, in certain patients these measures are not practically achievable such as cessation of methadone or putting morbidly obese patients on exercise programs. In a selected group of patients where contraindications have been excluded, concomitant testosterone therapy with lifestyle measures may be trialed with clear goals and close follow-up.

Symptoms should improve in three to six months of commencement on TRT and should be ceased if no clinically meaningful improvement is seen.

In a majority of patients with functional hypogonadism, general measures to improve lifestyle, overall health and targeted management of the chronic disease should be the mainstay of management. However, in a selected group of patients concomitant testosterone therapy may be trialed. Therapies other than testosterone and above measures should not be used due to lack of clinical evidence.

Author competing interests – nil

JULY 2022 | 37

It’s our 10th anniversary WE ARE CELEBRATING THIS MILESTONE OF EXCELLENCE, AND TEAM POGU IS GRATEFUL FOR YOUR CONTINUED SUPPORT! Perth Obstetrics and Gynaecology Ultrasound is a specialist practice offering comprehensive ultrasound services in both Obstetrics and Gynaecology. Our clinic has state-of-the-art equipment with high-end imaging capabilities using 2D and 3D/4D ultrasound technology.

Our team takes pride in providing the highest standard of care for our patients in a friendly and professional environment. We strive to provide quality service to our referring clinicians and are readily accessible for discussion and urgent requests.

Dr Anjana Thottungal, owner and director of POGU and the staff members of our clinic would like to thank all our referrers, clinic staff, supporters and patients as we mark this wonderful milestone.

Our key Obstetrics and Gynaecology services include: Early Pregnancy Scan First Trimester Screening 12-14 weeks Early Anatomy Scan 19-20 weeks Anatomy Scan Growth Scan Pelvic Ultrasound (Including 3D Imaging) Sonovaginography and detailed assessment of Endometriosis HyCoSy (Tubal assessment) Saline Infusion Sonography

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PERTH OBSTETRICS AND GYNAECOLOGY ULTRASOUND 38 | JULY 2022

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CLINICAL UPDATE

Sex-based disparities in kidney disease

By Dr Rahul Mainra, Nephrologist, Sir Charles Gairdner Hospital Chronic kidney disease (CKD) is diagnosed based on the presence of a reduced estimated glomerular filtration rate (eGFR) and/or albuminuria that has been present for at least three months. An important feature of this definition is the impact on patients’ health as this differs based on the stage of CKD. Generally, an eGFR of <60ml/ min/1.73m2 has the potential for health implications and is a commonly used definition for CKD. Worldwide, the prevalence of CKD stage 3-5 (eGFR <60ml/min/1.73m2) is approximately 10% in adults ≥20 years with variations in sex, age, race and in low vs high income nations.

Females have a higher prevalence of CKD, however more men are treated for end-stage kidney failure (ESKF) with dialysis and/or transplantation.

The underlying reasons behind these sex-based disparities are complex and not fully understood or accepted.

Numerous studies have tried to elucidate the differences in CKD and ESKF prevalence between females and males. The most commonly used equations to determine eGFR based on the serum creatinine include sex as a variable in that a 60-year-old, non-African American with a serum creatinine of 120µmol/L will have an eGFR of 42ml/min/1.73m2 if they are female and 56ml/min/1.73m2 if they are male.

This bias in eGFR calculations may lead to an over-diagnosis of CKD in females calling into question the appropriateness of this variable.

There are other explanations that have been discussed to explain these differences. Women live longer than men and the natural age-related decline in kidney function may lead to a higher prevalence of CKD. However, this survival advantage is negated in late stages of CKD and in ESKF suggesting a larger negative impact on mortality for women compared to men.

Many studies document a more rapid decline in kidney function in men MEDICAL FORUM | MEN 'S HEALTH

Consistent with the greater numbers of men on dialysis, they are also more likely to receive both deceased and living donor kidney transplantation. However, various disparities exist along the transplant pathway for women with ESKF that are not explained by this numerical imbalance.

In fact, the proportion of women who are activated on a transplant waitlist and/or receive a deceased or living donor kidney transplant is lower than men. This is particularly more evident in females over the age of 60.

Key messages The epidemiology of CKD differs between men and women Men with CKD progress to ESKF faster than women Gender-based disparities exist in all aspects of kidney care, negatively affecting women.

compared to women thus leading to a higher rate of ESKF. Although there are potential biological explanations for this difference, such as the renoprotective effects of sex hormones, gender-based disparities deserve discussion.

There is data to suggest that women are less likely to receive renal replacement therapy (RRT) suggesting that more of them choose conservative care over dialysis therapies. One must also consider if access to appropriate CKD care is equitable between sexes.

Fewer women are aware that they have CKD and are referred to a nephrologist later than men and start RRT with a lower eGFR. Whether these factors lead to the lower numbers of female patients receiving RRT is unknown.

Kidney transplantation is the treatment of choice for most patients with ESKF resulting in improved quality of life and life expectancy.

A commonly cited reason for this disparity is the pregnancyinduced sensitisation that leads to the development of anti-HLA antibodies. The disparity in access to transplant between men and women equalizes when HLA incompatibility is excluded. However, women’s sensitisation status is a barrier in living donor kidney transplant as they may be incompatible with their intended donor if it is their spouse or child.

Kidney-paired donation programs can match incompatible donorrecipient pairs resulting in successful transplantation. This strategy has the potential to reduce inequities in transplant rates for sensitised females. Culminating these inequities is the higher number of living donors that are female and the declining number of males donating. This may be explained by the better health of women. However, social factors likely play an additional role.

Sex-based differences in kidney disease have been well known for over two decades. Biology may be the single most important factor explaining this, though it is the physician’s responsibility to care for groups that are marginalised and to work to identify and remove these disparities.

– References available on request Author competing interests – nil

JULY 2022 | 39

Opening of a new era of minimally invasive BPH treatments

By Dr Manmeet Saluja, Urologist, Hollywood Benign Prostatic Hypertrophy (BPH) is a prevalent problem, largely discounted as a “symptom of growing older”. Effective management can lead to an immense improvement of quality of life.

Along with conventional medical and surgical strategies, novel minimally invasive treatments can now be offered. These have similar efficacy and durability in a selected group of patients with minimal risk of sexual dysfunction.

BPH is an enlargement of the prostate due to stromal and epithelial proliferation of the prostate transition zone. This can cause a dynamic and mechanical compression on the urethra, causing bladder outflow obstruction. Prevalence increases

with advancing age. On autopsy findings this can be as high as 5060% in men in their 60s and 8090% in men over 70 years of age.

Key messages Newer minimally invasive surgical techniques are now available for BPH

Management is largely based on symptoms and complications arising from BPH. Men with minimal or non-bothersome LUTS can be safely kept on watchful waiting, but approximately 30% of these patients will progress to needing treatment over the next two years.

Alpha blockers relax the smooth muscle in the prostate and bladder neck often leading to improved flow and LUTS. Uroselective agents are less likely to cause systemic side effects such as postural hypotension but can still lead to ejaculatory dysfunction.

These agents show a synergistic improvement when in combination

These have similar efficacy as standard procedures (TURP), with almost no change in erectile and ejaculatory function These are especially useful for younger patients with mildmoderate BPH, wanting to preserve sexual function and avoid medications. Older comorbid patients may also benefit. with 5-Alpha reductase inhibitors (finasteride, dutasteride), though can cause sexual side effects and an artificial decrease in PSA levels.

Compliance with these medications can be as low as 30% in the long term.

Novel surgical strategies are now available in the management of BPH and can potentially replace the use of long-term medications.

The two most performed minimally invasive surgeries include UroliftTM and RezumTM. Both techniques have shown significant improvement in flow rates, symptom scores and quality of life.

Figure 1: UroliftTM appearances before and after surgery

These procedures almost eliminate

We need to advance the plan Start the conversation now about advance care planning, says Andrew Allsop, director of clinical operations for Silver Chain’s palliative care in WA. Death and the end of life are difficult topics to discuss. It is widely accepted within the health care industry that the best time to discuss advance care planning is when a person is still medically stable, rather than leaving it until their health is rapidly deteriorating.

40 | JULY 2022

You don’t need a life-limiting illness to start talking about your wishes.

Like making a will, advance care planning is simply a part of planning for the future.

While this planning process may seem daunting and confronting,

having an advance care plan will go a long way to alleviate stress and uncertainty for the patient and their family down the track.

I have the privilege of being a part of these conversations regularly.

The process involves talking about MEDICAL FORUM | MEN 'S HEALTH

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Figure 2: RezumTM procedure mechanism Table 1: Data extracted from pivotal studies for UroliftTM and RezumTM

UROLIFT TM

REZUMTM

Change in IPSS score (% change)

8.8 (41%)

10.1(46.7%)

Qmax improvement

4.2 (62%)

4.2 (49.5%)

QOL improvement

2.4

2.0

Retreatment at 5 years

13.6%

4.4%

M – Malignancy and Hyperplasia

N – Not otherwise classified

N – Not otherwise classified

the risk of sexual dysfunction caused by more conventional surgeries such as TURP, Greenlight or Holmium laser prostatectomy.

Additionally, these could be useful for patients preferring procedures with a lesser risk of bleeding, earlier recovery and shorter hospital stay.

Patients with comorbidities could also benefit, as these procedures offer shorter anaesthetic time and reduced complication rate.

Australia they are commonly done under a general anaesthetic.

Generally, these procedures offer a slightly reduced efficacy compared to TURP and are mainly limited to prostate size under 80cc. They are considered durable with follow-up data available for at least five years.

These procedures can potentially be office based and performed under sedation. However, in

Patients may report mild postoperative urgency and dysuria, which tends to resolve in three to five days. Compared to TURP, symptom scores and flow rates are slightly inferior, and it is associated with a 13% five-year retreatment rate. More recent studies have shown that median lobes can also

values, beliefs and preferences with family and doctors. This helps them make decisions about care when the patient is no longer able.

• Thinking about what matters most now and what will matter most when the individuals can no longer communicate clearly their choices, with input from family, friends, carers and the GP. • Writing your preferences down, making a will, nominating substitute decisionmakers to cover financial and medical or lifestyle decisions and deciding if organ and tissue donation is an option.

• Sharing that information with family, friends, carers, the GP and other health professionals so that information can be easily located when needed. My Health Record is also a way of storing this information.

With more than 20 years’ experience in palliative care, I cannot understate the positive impact advance care planning can have in easing these difficult transitions.

Palliative care services can provide information on how to have these conversations, based on the individual’s preferences and values, which can be written down using the template provided by each State and territory, in WA this is an Advance Health Directive.

The key steps to advance care planning are: MEDICAL FORUM | MEN 'S HEALTH

Urolift is the transurethral deployment of an implant that retracts the obstructing lobes and creates an open voiding channel. It has demonstrated a main benefit of not impacting sexual function.

This could be performed as a day procedure without the use of an in-dwelling catheter (see figure 1).

TM

be safely and effectively treated with this procedure.

RezumTM utilises stored thermal energy (steam) to de-nature and ablate prostate adenoma. The water vapour thermal energy is injected transurethrally into the transition zone. This is most commonly a day procedure and patients are typically discharged with an IDC in situ for up three to five days (see figure 2).

Patients’ symptoms improve gradually and gain a maximal benefit at three months following surgery. Patients commonly report dysuria for a few weeks following procedure. Surgical retreatment rates are up to 4.4% in five years, however there are no direct comparisons made in prospective trials with TURP. Trials are also undergoing evaluating other novel techniques such as aqua ablation, iTIND and prostate artery embolisation for BPH. Minimally invasive prostate surgeries have already been adopted extensively around the world and are here to stay.

Author competing interests – nil

• Advance care planning with people living with dementia is an area requiring much greater understanding and awareness.

Supported decision-making approaches recognise that individuals experiencing cognitive changes must be actively involved to the greatest possible extent in decision-making about their preferences and choices.

It is never too early or too late to have these conversations with loved ones, but it is better to do it before people urgently need to do it.

Details and forms can be found at www.advancecareplanning.org.au

JULY 2022 | 41

Pelvic venous congestion

By Mr Stefan Ponosh, Vascular & Endovascular Surgeon, Hollywood “If only I had found out earlier” is an all-too-common lament made by patients presenting with often years of “investigated” chronic pelvic pain (CPP) when the diagnosis of Pelvic Congestion Syndrome (PCS) is made.

CPP affects between 15-43% of 18-50 females worldwide, comprising 10-20% of all outpatient gynaecologic visits and up to 40% of gynaecologic laparoscopies. CPP has significant physical, emotional and quality of life implications. PCS is estimated to account for 30-40% of CPP. CPP is a challenging, often multifactorial diagnosis with multiple possible differential (mainly gynaecological) diagnoses.

Over a third of patients following investigation are left with chronic pain with mild arguably asymptomatic gynaecological pathology or labelled as “chronic pain patients”.

PCS in simple terms is the development of ‘varicose veins’ in the pelvis. It can be associated with intermittent, often cyclical but sometimes persistent chronic abdominal and pelvic pain lasting over six months. Common in women of reproductive age (parous more than nulliparous), PCS is also associated with secondary venous complications after menopause.

Key messages PCS is an underdiagnosed, underrecognised, underappreciated, and often ignored common cause of CPP PCS is relatively easily diagnosed and has a low risk and successful treatment Better awareness and clinical suspicion for the specific symptomatology of PCS may speed up PCS diagnosis and treatment.

sensation to pelvis or perineum and genitals, bloating, dyspareunia, lower abdominal pain, stress incontinence and irritable bowellike symptoms.

Outside the pelvis there may be varicose veins (vulva, groin, buttock, lower limb), leg swelling or heaviness and chronic venous symptoms (e.g. eczema pigmentation). Symptoms can be variable in nature and position and are often worsened by menstrual periods due to hormonal influences on pelvic venous dilatation and worsened by increased abdominal pressure (e.g. lifting, prolonged standing).

The primary pathophysiology is associated with incompetence of the ovarian (uni or bilateral, left more than right side) and pelvic vein plexus. This does not affect the localisation of patient symptoms.

In the vast majority of cases this is associated with ovarian vein incompetence. However, in some cases it can be associated with internal iliac vein incompetence.

This incompetence can be congenital (nulliparous women), but pregnancy is strongly associated with secondary incompetence.

This incompetence results in pelvic venous hypertension and dilated congested pelvic varicosities involving the uterus, rectum, bladder, vagina, and secondary lower limb pressurisation causing inflammation and the constellation of PCS symptoms.

Rarely, pelvic venous hypertension can be associated with extrinsic venous compression caused by a May-Thurner Syndrome (iliac vein compression between iliac artery and spine) or a Nutcracker Syndrome (renal vein compression between aorta and superior mesenteric artery).

Specialist pelvic ultrasound utilising transvaginal imaging has been

Pelvic congestion syndrome symptoms inside the pelvis include pelvic pain, ‘heaviness’ or ‘dragging’

Varicose veins

42 | JULY 2022

Ovarian vein embolisation – incompetent ovarian vein (right) and OVE (left)

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venography have some role but should not be used initially due to a low specificity. In most cases it should be utilised as interventional planning imaging or to assess for compressive syndromes.

May Thurner Syndrome

While medical treatment options exist, the mainstay and gold-standard treatment in ultrasound confirmed or clinically suspected PCS is minimally invasive interventional abdominal venography and endovascular ovarian vein embolisation (OVE). This is an extremely lowrisk, percutaneous day-case endovascular procedure under local anaesthesia and sedation in which the abdominal and pelvic venous anatomy is definitively assessed and treated in the same procedure if found to be abnormal.

demonstrated as the most sensitive for identifying pelvic varicosities and dilated ovarian veins to suggest PCS as well as to exclude other primary gynaecological pathologies. In CPP or suspected PCS, a pelvic transabdominal and transvaginal ultrasound should be undertaken. CT or MR

In the vast majority of cases this consists of bilateral or unilateral ovarian vein coil embolisation to occlude the incompetent ovarian veins depressurising the pelvic venous hypertension and varicosities. Adjuvant techniques such as intravascular ultrasound (IVUS) or DYNA CT (interventional CT venography) can also be used

to assess for rare causes of PCS (e.g., May-Thurner or Nutcracker syndromes) which may require additional intervention such as stenting.

OVE is associated with a reported 68.2-100% improvement of symptoms with a reported significant reduction in symptoms on Visual Analogue Scale (VAS) of 5.7. The complication rate is extremely low at 0.85% of which all were minor such as groin haematomas.

Recurrent symptoms post-OVE are reported at approximately 2%, meaning very low re-intervention rates. Improvements of symptoms were reported over one to 90 days. The commonly used platinum coils are benign and inert. The other concern often raised regards fertility post-OVE. Evidence suggests management of PCS is likely associated with improved fertility and no reported adverse effects to fertility have been documented.

– References available on request Author competing interests – nil

Stimulating pathways to recovery Modalis specialises in MRI-guided Transcranial Magnetic Stimulation (TMS) which can improve the treatment options in pain management, psychiatry (depression, OCD, PTSD), neurology, rehabilitation and other areas of medicine, such as treatment of tinnitus. TMS therapy has advantages over other treatments including: • • • • •

non-invasive with a superior safety profile drug-free comparable success rates to pharmacological therapy good tolerance with few side-effects quick, convenient sessions on an outpatient basis

Visit modalis.com.au to find out more about our services, locations, referral pathways and screening process. The referral template for rTMS services at Modalis will be available on Best Practice software from May 2022.

08 6166 3733

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tms@modalis.com.au

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Endoscopic submucosal dissection – a new solution to an old problem

By Dr Niroshan Muwanwella, Gastroenterologist, Hollywood Gastrointestinal (GI) malignancies are a leading cause of morbidity and mortality throughout the world. According to the latest medical literature, gastric and colorectal malignancy are the third and fifth leading cause of death respectively (Global cancer statistics 2020).

If detected at early stages, these malignancies are curable with complete resection. Early malignancies confined to the mucosal layer of the GI tract can be resected by endoscopic methods forgoing the requirement for invasive surgery.

This endoscopic technique is called endoscopic submucosal dissection (ESD).

The technique was pioneered in Japan at the National Cancer Centre Hospital in the late 1990s.

Subsequently, it has been widely adopted and now serves as the most advanced endoscopic procedure to remove early malignancies and complex lesions.

Key messages GI malignancies are a leading cause of death worldwide ESD is one of the most advanced and effective endoscopic resection techniques for early malignancies When a suspicious lesion is identified, regardless of the histology, it is important to refer to a specialised centre for further evaluation. as narrow band imaging (which is a light source with different wavelength to white light), most lesions can be readily identified by any endoscopist.

Thereafter, using the endoscopic knife, mucosa is incised outside the markings to ensure all the dysplastic tissue is included in the resection, thus ensuring complete resection. The submucosa is continually expanded by injecting fluid. See Fig 2.

The latest European guidelines recommend against imaging modalities such as computed tomography (CT) in such lesions and recommend proceeding directly to ESD. Therefore, ESD serves as the most accurate method of staging a particular lesion as well.

Once the peripheral incision has been made, using the knife the submucosa is continually dissected by entering the submucosal plane with the endoscope. A special instrument called coag grasper is utilised to cauterise blood vessels that are encountered in the submucosal plane. See Fig 3.

Technique

While these classification systems are essential to determine the staging of the lesions, an in-depth knowledge of these is not required for diagnosis. By careful and adequate visualisation of the whole segment being examined, utilising available technology such

The ESD procedure is done under general anaesthesia, starting with identifying the lesion and carefully determining the margins of dysplasia.

This is ideally done using a zoom endoscopy system where 130+ magnification can be achieved.

Figure 2

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Once the lesion is marked, a fluid cushion containing a blue dye (indigo carmine in most instances) is injected into the submucosal layer of the lesion expanding it from the muscularis propria using an injection needle. This blue dye helps differentiate the submucosal layer from the muscle layer as the muscle layer does not take up the dye thereby helping the endoscopist prevent muscle injury and perforation.

Using the available classification systems, a fairly accurate prediction can be made of the type of GI malignancy as well as the risk of submucosal invasion and nodal spread. The lesions which have a high pre-test probability of being a T1a (confined to the mucosa) are suitable for resection with this method.

The key to utilising the ESD technique is to identify suspicious lesions early.

There are multiple classification systems to describe lesions seen at endoscopy and colonoscopy. These classification systems help categorise lesions according to their gross morphology and surface attributes and aid in estimating the depth of invasion, thus determining the stage of the malignancy.

Figure 1

Once the margins have been determined this is marked with diathermy using an endoscopic knife which is generally 1.5-2.0mm in length and about 0.5mm in width, inserted through a channel in the endoscope. See Fig 1.

Figure 3

Advantages of ESD technique over surgery can include: • Considerably lower surgical morbidity especially for gastric cardia, oesophageal and distal rectal lesions • Lower length of hospital stay • No external surgical scars • Suitable for patients who are poor surgical candidates Disadvantages of ESD can include: • Requires referral to a highly specialised unit • Can only be deemed curative in T1a (intramucosal lesions) • Regional lymph nodes cannot be sampled.

Author competing interests – nil

JULY 2022 | 45

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Surgery for metabolic syndrome

By Dr Krishna Epari, Upper GI & Robotic Surgeon, Murdoch Metabolic syndrome (MetS) is characterised by abdominal obesity, insulin resistance, hypertension and dyslipidaemia.

Its incidence parallels the rising incidence of obesity and results in increased risk of developing type 2 diabetes (T2DM), non-alcoholic fatty liver disease (NAFLD) and cardiovascular diseases (CVD).

The pathophysiology is complex and not yet fully elucidated.

Genetic, epigenetic, lifestyle (high calorie foods, sedentary lifestyle) and environmental factors are involved. Visceral adiposity is an important trigger and insulin resistance, chronic inflammation and neurohormonal activation are involved in the progression of MetS and transition to CVD and T2DM. Diagnostic definitions of MetS require three or more of the following criteria: increased waist circumference (a central obesity measure strongly correlated with insulin resistance), impaired glucose tolerance, high triglycerides, low HDL and hypertension.

Bariatric and metabolic surgery (BMS) has been shown to be the most effective treatment to achieve substantial and sustained weight loss in morbidly obese patients with significant reductions in CVD cancer, and mortality.

Traditionally bariatric operations were classified as being restrictive and/or malabsorptive, however, we now understand that physiological changes in the gastrointestinal tract are important in the mechanism of action of metabolic surgery.

These include alterations in bile acid signalling and receptors, gut microbiome, gut hormones and circulating exosomes, which lead to improved glycaemic control, insulin sensitivity, lipid metabolism, energy expenditure, weight loss and improvement in obesity related comorbidities including MetS and T2DM. Multiple RCTs show BMS in obese patients with T2DM to be more effective than medical MEDICAL FORUM | MEN 'S HEALTH

Surgery should also be considered for patients with T2DM and BMI 30.0-34.9 if hyperglycaemia is inadequately controlled despite treatment with oral or injectable medications.

Tailor individually Sleeve Gastrectomy is now the commonest procedure in Australia.

It has good weight loss outcomes, is less complicated to perform than bypass procedures and has fewer long-term complications, although patients can be more prone to gastro-oesophageal reflux.

Key messages Metabolic syndrome consists of central obesity, insulin resistance, hypertension and dyslipidaemia and leads to cardiovascular disease and type 2 diabetes Bariatric and metabolic surgery produces physiological changes in the gut which improve metabolic syndrome and type 2 diabetes Consider bariatric and metabolic surgery in management algorithms for type 2 diabetes and metabolic syndrome. management. One 10-year follow-up reported 37.5% (BMS) maintaining diabetes remission at 10 years compared to 5.5% in the medical arm.

Although the relapse rate seems high, all but one of those patients maintained an HbA1c <7.0 with minimal or no medication. All had diabetes for at least five years and 50% were on insulin before intervention. There was lower CVD, better renal function, reduced medication use and lower diabetesrelated complications after surgery.

In 2016, a joint statement

by International Diabetes Organisations advised that metabolic surgery should be recommended to treat T2DM in patients with class III obesity (BMI >40) and class II obesity (BMI 35.0-39.9) when hyperglycaemia is inadequately controlled by lifestyle and optimal medical therapy.

Roux-en-Y Gastric Bypass (RYGB) has been the dominant procedure worldwide for much of the past 50 years and is more effective for T2DM and MetS. However, it has specific risks (dumping syndrome, hypoglycaemia, marginal ulceration, internal herniation). Patients must also avoid NSAIDs and be aware that alcohol metabolism is impaired.

Biliopancreatic diversion (BPD) demonstrates the highest remission rates for T2DM but with higher risks (e.g., protein malnutrition and micronutrient deficiencies) due to the extreme proportion of intestine bypassed.

Modern variations of gastric and intestinal bypasses known by many names and acronyms including single anastomosis gastric bypass (SAGB, MGB) and single anastomosis duodenal switch (SADI, SIPS) are increasingly popular. They aim to leverage the more powerful metabolic effects of intestinal bypass, whilst reducing side effects and complications of traditional bypass procedures.

The SADI/SIPS procedure preserves pyloric function reducing dumping, glucose variability and marginal ulceration. The single anastomosis has much lower risks of internal herniation and the longer common channel reduces the risk of severe protein malnutrition and micronutrient deficiencies. continued on Page 51

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PTSD: role of cannabinoids in fear-extinction learning

By Dr Matthew Moore, GP, Dunsborough I understand the hesitancy of prescribing an unapproved medication for something as potentially serious as PTSD. However, my belief is that we have a responsibility to act now to avoid more lives being lost to suicide.

Like many doctors, I am passionate about mental health, but never more so than after meeting and caring for my veteran patients. These men and women are the reason we live care-free. It’s about sacrifice and commitment to have put their lives on the line for us, without consideration. But unfortunately, it comes at a cost.

PTSD is a mental health condition that affects millions of Australians, not just veterans. This extreme form of anxiety occurs after exposure to a stressor or traumatic event, which results in intrusive symptoms, avoidance of stimuli, negative changes in cognition and mood, and alteration in arousal or reactivity.

According to the DSM-V criteria, the above symptoms must have lasted for more than a month and create

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Key messages 12% of Australians develop PTSD in their lifetime First-line therapies may not effectively treat PTSD, leading to poor quality of life, substance use, increased hospitalisations and suicidal ideation Cannabinoids, specifically THC, can aid in the fear-extinction process in the forebrain.

distress or functional impairment not otherwise explained by medications, substance use, or illness.

Traditional treatments include both pharmacological and psychological support.

There are several potentially helpful psychological modalities including trauma-focused cognitive behavioral training (TFCBT), eye movement desensitisation and reprocessing (EMDR), and exposure therapy (ET).

Often, pharmacologic management

is needed alongside the above therapies. These include treatments like SSRI/SNRI, TCA, MAOI, benzodiazepines, or anti-psychotics.

But when this fails, where do we go from here?

Preliminary research shows the potential for the endocannabinoid system (ECS) to play a role in treatment of this resistant condition by facilitating the extinction of fear. This occurs through the ECS’s majority receptor, CB1, in the amygdala, ventromedial prefrontal cortex, and hippocampus. Our own endogenous cannabinoid, anandamide, pairs with this receptor as do plant cannabinoids, CBD, and THC. Therefore, the hypothesis of therapeutic benefit with cannabis and the research backing its use has begun.

Initial mice-model studies show that activation of these receptors allow maximisation of treatment effects of exposure-based therapies. When continued on Page 51

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Joining forces to increase LGBTIQA+ cancer screening

Australia is a world leader in the prevention and early detection of cancer. The national cancer screening programs target specific age groups and populations where evidence demonstrates screening to be most effective.

Screening programs increase the likelihood of detecting abnormalities or cancer at an early stage, leading to significantly better outcomes. The survival rates for breast cancer at 5 years are 92%¹, bowel cancer 98%² and almost all cervical cancer can be prevented through regular screening. Improving participation in cancer screening programs is vital for better health outcomes, however screening rates amongst the LGBTIQA+ community are lower than the general population.

WA cancer screening programs for breast, bowel and cervical have joined forces to develop campaign resources for the LGBTIQA+ community with the message that ‘Screening saves lives’. Members of WA’s LGBTIQA+ community volunteered to be the ‘heroes’ of the campaign. Images and personal quotes have been developed into a suite of resources to raise awareness of and increase participation in cancer screening programs.

Campaign resources include a DL flyer (pictured right) to provide easy reference of eligibility criteria for each screening program and a stakeholder communications toolkit with posters and social media tiles with key messages to reinforce the importance of cancer screening participation in the LGBTIQA+ community. These resources will be used at significant dates and events in the community calendar and by key stakeholders to promote through their social media channels.

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GPs play a vital role in raising awareness about the benefits of regular cancer screening to ensure better health outcomes for members of the community. Join us and start the conversation about the importance of regular cancer screening with your LGBTIQA+ patients.

For more information or to order these resources email: breastscreenwa@health.wa.gov.au

1 sourced: https://www.canceraustralia.gov.au/cancer-types/breast-cancer/statistics 2 sourced: https://www.bowelcanceraustralia.org/prognosis

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PTSD: role of cannabinoids in fear-extinction learning continued from Page 49 these receptors are blocked with antagonists, mice display symptoms not unlike those phenotypes that are CB1-receptor deficient. This suggests that CB1 receptors are critical for successful extinction of fear memories.

In 2019, a small randomised, doubleblind, placebo-controlled study in humans was performed where a THC dose of 7.5mg duplicated these exciting animal-model results.

THC may be beneficial for patients with PTSD, helping them regulate memories and memory retrieval, improve sleep and decrease the physical and emotional response to flashback memories.

From a risk and harm reduction standpoint, medicinal cannabis is safer than our first-line therapies for PTSD. To me, considering cannabinoids as a treatment option is a no-brainer even if we are not familiar with medicinal cannabis, exactly how it works, and that the research data does not yet fully support it.

Medicinal cannabis is worth a trial of treatment after first-line treatments have been unsuccessful based simply on the lack of toxicity and dependency (see charts). Of the psychoactive medicines, cannabis is by far the least toxic (death occurring at 20,000 doses as opposed to eight doses with heroin). And with regards dependency, it’s less addictive than coffee and alcohol.

Given that the patient doesn’t have an increased risk of harm to themselves or others, there is no history of psychosis, nor any substance use disorder or significant liver dysfunction, doctors can have confidence that your slow and steady titration initially of this treatment modality will at the very least help them to sleep better.

– References available on request Author competing interests – nil

Surgery for metabolic syndrome continued from Page 47 Most primary and revision procedures can be performed using minimally invasive surgery with relatively low morbidity and short inpatient stay. Robotic surgery has additional advantages especially for more complicated bypass procedures, with emerging data showing decreased complications.

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Consider patients for surgery before development of end-stage complications of T2DM and MetS place them at unacceptably high perioperative risk. Poor glycaemic control (HbA1c > 8.0) should be optimised before surgery as it increases the risk of infective complications, poor wound healing and anastomotic leaks.

BMS alone does not guarantee success and still requires healthy

food choices, good eating behaviours combined with regular exercise to achieve optimal results.

Ongoing vitamin and mineral supplementation and annual monitoring is recommended to reduce the risk of long-term micronutrient deficiencies.

– References available on request Author competing interests – nil

JULY 2022 | 51

Casting a fascinating Shadow

The annual Revelation Film Festival always brings together a thought-provoking cinematic collection. This year it includes a brave and captivating debut from a theatre company featuring people with intellectual disability – both actors and those behind the camera.

By Ara Jansen

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FILM FESTIVAL

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FILM FESTIVAL

When their overseas performances were cancelled overnight because of the pandemic, the Back to Back Theatre company decided to take matters into their own hands as a way to keep working.

Not able to have audiences come to the theatre, they decided to take their ability to the world by making their debut film, entitled Shadow, despite not knowing a lot about how to do it.

Based in Geelong, Back to Back is one of Australia’s leading contemporary theatre companies committed to creating new forms of theatre with an ensemble of actors who have disability or identify as neuro-diverse.

Directed by Bruce Gladwin, Shadow is a darkly humorous based on the company’s internationally award-winning stage play The Shadow Whose Prey the Hunter Becomes. The cast adapted the play to make a film using a combination of dramatic and documentary-style elements.

Shadow is the story of a group of activists who hold a public meeting on the future impacts of artificial intelligence only to discover their own prejudices are their biggest obstacles to saving the world.

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What begins as a polite discussion quickly descends into bickering and chaos as one of the often overlooked and underestimated activists explodes while trying to unite the group, only to wonder if their message may already be lost.

As they couldn’t travel or perform live, the company wanted to find alternative models of story creation and storytelling. Shadow was created through conversation and improvisation over two-and-a-halfyears.

“Our objective is always to make great art and engage with audiences and explore themes relevant to contemporary audiences,” says Gladwin, who also wrote the film.

“The by-product of that is around inclusiveness and diversity.

“Our ensemble is made up of people with intellectual disability and who are neuro-diverse, and we’re interested in finding other representations of them outside stereotypes or what you expect.

“Maybe there is an expectation that we are going to represent a group of disability advocates where they are more holy than holy, but they are just as human as everyone else. We need to represent people in ways that are human but also be really clear there’s still misogyny or racism presenting in these characters.”

The performers are also the film’s co-authors with 95% of those onscreen being people with disability.

The company also created a model where the majority of the crew roles were fulfilled by interns who identify as people with disability. As some of them had no previous experience in their roles – like camera crew or make-up artists and wardrobe – they were supported by professional mentors.

“For some of the crew, their understanding of how film production works is based on watching TV. So, we brought in amazing experts and experienced crew to support them learning.”

Gladwin calls this community filmmaking as the theme and its philosophical approach to the process of creation are intrinsically linked.

Specialising in adventurous theatrical works, Gladwin personally hit a steep learning curve moving into film. He says having the energy of 30 people in the room was exhilarating and exploring the subtleties of film, which are so different from live theatre, was incredibly exciting.

Shadow screens as part of the Revelation Perth International Film Festival in July. There are films screening in cinemas and online. Tickets and information at revelationfilmfest.org

JULY 2022 | 53

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WINTER FLICKS

Fast and mysterious reasons to go back to the cinema Grab the popcorn, there is a string of winter flicks and some blockbusters on the big screen to warm you up. By Ara Jansen

Destined to be a speedy hit over winter is Bullet Train. This fun action thriller from Deadpool 2 director David Leitch stars Brad Pitt as the seasoned assassin, Ladybug.

This trained killer wants to give up the life but is pulled back in by his handler Maria Beetle (Sandra Bullock) to collect a briefcase on the bullet train running from Tokyo to Kyoto.

Of course, he’s not the only one on the speeding train as he painfully discovers an eclectic crew of fellow assassins all with connected yet conflicting objectives. Set against the backdrop of a non-stop ride through modern-day Japan, it’s filled with iconic and quirky Japanese imagery and objects. Keep an ear out for the funky cover of Staying Alive, complete with Spanish and English lyrics, in the trailer.

The cast includes Joey King, Aaron Taylor-Johnson, Brian Tyree Henry, Andrew Koji, Hiroyuki Sanada, Michael Shannon, Zazie Beetz and Bad Bunny. Apparently a very physically active cast, Pitt apparently did almost all his own stunts and fighting and the rest of the cast did much of their own stunt work too.

The film was originally intended as a violent action film, but during the development phase it turned into more of a comedy. The movie 54 | JULY 2022

is based on a book called Maria Beetle by Kotaro Isaka. The awardwinning Japanese author writes mysteries and has released more than two dozen novels and 14 short story collections in Japanese since 2000. Bullet Train is his 14th film adaptation.

Bullet Train is in cinemas August 4.

Another movie based on a book to hit cinemas next month is Where the Crawdads Sing. Drawn from the bestselling debut novel

by Delia Owens, it’s a captivating mystery and drama.

Where the Crawdads Sing tells the story of Kya (Daisy EdgarJones), an abandoned and resourceful girl who raises herself to adulthood in the dangerous marshlands of North Carolina.

For years, rumours of the Marsh Girl haunted Barkley Cove, isolating the sharp and resilient Kya from her community.

Drawn to two young men from town, Kya opens herself up to a new and startling world, but when one of them is found dead, the community immediately makes her the main suspect. The evidence in the case against Kya seems insurmountable but as events unfold, what actually happened becomes increasingly

Win! We have 10 double passes to give away to each movie. To enter go to www.mforum.com.au and click on the competitions tab. unclear, threatening to reveal many of the secrets that lie in the marsh.

Where the Crawdads Sing also stars Taylor John Smith, Harris Dickinson, Michael Hyatt, Sterling Macer, Jr. and David Strathairn.

A champion for the book as part of her famed Reese’s Book Club, the film is co-produced by Reese Witherspoon, who described the novel as a truly moving page-turner with an endlessly fascinating female heroine at the centre.

The project sits perfectly with her media company Hello Sunshine’s mandate to promote female-driven projects. That includes movies like Gone Girl and television shows like Big Little Lies, The Morning Show and Little Fires Everywhere.

Singer-songwriter Taylor Swift says she was totally mesmerised by the book and just had to be part of the film. She wrote and performed the haunting and ethereal original song Carolina.

Where the Crawdads Sing is in cinemas August 18.

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WINE REVIEW

Evans & Tate – quality control

Review by Dr Louis Papaelias

The Evans & Tate story began in 1971 when John Evans and John Tate planted vines in the Swan Valley. In 1974, they planted the Redbrook vineyard in Wilyabrup, just over the road from Moss Wood and Woodlands.

With the introduction of the Semillon Sauvignon Blanc blend in 1987, which Evans and Tate named Margaret River Classic, a new trend was born. With its fresh and fruity appeal, it became an instant success. In 2007 management control passed to the McWilliams Wine Company followed by the Fogarty Wine Group in 2012. Despite the changes in ownership there has been stability where it really counts. Both senior winemaker Matt Byrne and chief viticulturist John Fogarty have been with the company for 21 and 20 years respectively.

Their efforts in the vineyards and cellar have been recognised industry wide with a host of gold medals and trophies. In 2017 and 2018, Evans & Tate won gold medals with 11 different chardonnays.

Reader special Evans & Tate is offering a 20% discount for Medical Forum readers on the Fogarty Wines website www.fogarty.wine/collections/evans-tate The code is MedForum

2018 Redbrook Estate Chardonnay (13% alcohol, rrp $40)

2020 Single Vineyard Shiraz Cabernet Sauvignon (14.5% alcohol, rrp $35)

Awarded three gold medals. A multi-vineyard blend made from selected sites in Margaret River. Wild yeast fermentation in new French oak puncheons (500 litre casks).

Barrel maturation for 7-10 months according to each component’s characteristics. Drinking beautifully now, it has a lovely bouquet of creamy fruit and toasty oak. Palate is gentle, flavoursome and persists with flavours of delicious stone fruit and spice.

From the 50-year-old Redbrook vineyard. The shiraz fruit underwent whole bunch fermentation, the cabernet, whole berry fermentation after destalking. Fermentation began naturally with wild yeasts.

Maturation took place in old French oak puncheons. The result is a wine with a highly perfumed bouquet and depth of flavour that old vines can produce. There is the spicy plum fruit of Shiraz and the elegance and complexity of Cabernet Sauvignon.

Tannins are firm but fine-grained keeping in check the abundant fruit.

It will age easily for 5+ years.

2020 Single Vineyard Malbec (14.5% alcohol, rrp $35) From the Carter vineyard in the heart of Wilyabrup. Cold soaked for five days after picking. Partially wild fermented and then matured in French oak puncheons, 15% new. A deep red colour. On the nose a riot of aromas – satsuma plum, spice and a touch of violets. Generous and mouth filling, the fruit flavours stand out above a background of fine tannins This wine will no doubt age for 5+ years but makes for very attractive drinking now. It is uncommon to see a straight Malbec coming out of Margaret River. Hope there are more to come! A real beauty.

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'S EWER I V E R

PICK

2018 Redbrook Estate Shiraz (rrp $40) Predominantly Wilyabrup fruit with a small parcel from Karridale. Coldsoaked with some whole bunch fermentation. Aged for 12 months in new and seasoned French oak.

Displays uplifted aromas of spicy plum fruit and pepper. A lively generous and finely textured palate.

Fruity yet savoury and a persisting length. A beautifully balanced wine from a great vintage. Will age 5+ years easily. Awarded four gold medals.

2018 Single Vineyard Chardonnay, (13.5% alcohol, rrp $35)

From the Bridgelands vineyard at the cooler Karridale, whole bunches were cooled and gently pressed into oak barrels where fermentation took place with wild natural yeasts.

The wine stayed in the cask for 11 months and then further matured in a stainless-steel tank resting on lees for another year. Attractive grapefruit and pear aromas. Clean and crisp, the fine and generous palate has an exciting touch of minerality and long finish that makes the wine sing. Beautifully crafted, with oak well integrated.

JULY 2022 | 55

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