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EDITORIAL BACK TO CONTENTS
Cathy O’Leary | Editor
Rest, insured! An omnipresent social media and a greater tendency for people to use these channels to share information means everyone has to stay on their toes.
For most doctors, medical indemnity is a nobrainer, like insuring your car. You hope you won’t have to use it, but it helps you sleep at night. In fact, according to MDA National president Michael Gannon, whose own speciality (obstetrics) is no stranger to medical litigation, few doctors could expect to get through their career without knocking on the door of their medical insurer at least once. Even the most vexatious claim needs to be answered, and if you can’t remember the case, your notes will need to fill in the blanks. This month we look at the increasingly complex environment for doctors to stay on the right side of AHPRA and Medicare regulators, and even their patients. An omnipresent social media and a greater tendency for people to use these channels to share information means everyone has to stay on their toes. If you need a drink after digesting all that, on a lighter note our lifestyle section has your tipple of choice – with or without alcohol. No one could accuse us at Medical Forum of being wowsers – we love our wines – but for those trying to moderate their drinking, Ara Jansen’s story about a local businesswoman promoting alcohol-free drinks will be a welcome tonic. Full disclosure before I get hate mail – no, they don’t taste exactly like the real thing but they are a far cry from the syrupy Ribena-type concoctions of the past. Cheers!
SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission. DISCLAIMER Medical Forum is published by Medical Forum WA as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with advertisers other than as publisher of promotional material. Medical Forum cannot and does not endorse any products.
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CONTENTS | OCTOBER 2021 – MUSCULOSKELETAL MEDICINE
Inside this issue 16
20
12 24
FEATURES
NEWS & VIEWS
LIFESTYLE
12 Medico-legal tightrope 16 Close-up:
1
Editorial: Rest, insured! – Cathy O’Leary
54 Alcohol-free and
In the news
56 Wine review:
Professor Jan Dickinson
20 Putting musculoskeletal under the x-ray
24 Secrets in our saliva
4 6 23 28
filled with spirit Fraser Gallop Estate – Dr Louis Papaelias
In brief Breaking bad Comprehensive DBT – Pauline Cole
35 GP tools to cut CVD risks – Natalie Raffoul
39 Move it, move it! 46 Grants for key determinants
Win On Page 56, Dr Louis Papaelias reviews wines from Fraser Gallop Estate in the Margaret River Wine Region and falls for its cabernet sauvignon. Head to the website at www.mforum.com.au (go to the competitions tab) or our weekly newsletter delivered to your inbox to be in the running for this month’s Fraser Gallop Estate doctors dozen. The winner of the Domaine Naturaliste dozen is Dr Biju Thomas.
Winemaker Clive Otto
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Clinicals
Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au
ADVERTISING Advertising Manager Andrew Bowyer 0403 282 510 andrew@mforum.com.au
EDITORIAL TEAM
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Investigating rheumatic and connective tissue diseases Dr Daman Langguth
Continuity of care for better patient outcomes Karen Gullick
Modern Management of common spinal complaints Drs Paul Taylor & Greg Cunningham
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When (not) to use tests in patients with joint pain Dr Hans Nossent
Treatment algorithm for chronic Achilles tendinopathy Dr Reza Salleh
A review of psoriasis Dr Harvey Smith
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A multidisciplinary approach to ACL injury Dr Ross Radic
Drinking plain water and muscle cramp Professor Ken Nosaka
Exercise app and type 1 diabetes Dr Vinutha B. Shetty
Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Journalist Dr Karl Gruber (PhD) 08 9203 5222 journalist@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Clinical Services Directory Editor Karen Walsh 0401 172 626 karen@mforum.com.au
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Thinking beyond organ donation Anne Cowie
Empowering consumers with chronic conditions Suzie Edward May
Telehealth critical for mental health care Dr Oleh Kay
What’s the future for Primary Health Networks? Learne Durrington
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IN THE NEWS
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Genetic link to dementia in Parkinson’s Dementia is one of the most debilitating symptoms of disease progression in people with Parkinson’s disease, with many experiencing some form of cognitive impairment over time. Now Professor Sulev Koks, who heads the Genetic Epidemiology Research group at the Perron Institute and Murdoch University, has been part of an international study to assess how genetic variation influences the progression of dementia.
Professor Sulev Koks
The pace of progression in Parkinson’s varies considerably between patients, and none of the existing therapies slows the underlying neuropathology as it advances from brainstem to the cerebral cortex.
The team discovered a genetic variant with a five times higher risk factor for predicting the progression of dementia.
Data from the lengthy longitudinal study has also been used to develop an innovative scoring system to predict the likelihood of developing dementia in Parkinson’s.
Gongs for health services Two WA health services are among the eight winners in the 2021 HESTA Excellence Awards for the allied health, aged care, community and disability sectors. The Earbus Foundation of WA won the allied health award for its work to reduce middle ear disease in young Aboriginal and Torres Strait Islander children. SHQ won the community services section for developing a clinician and consumer-endorsed screening tool to identify and support women at risk of, or have experienced intimate partner violence or reproductive coercion.
Tonsils vs POSA More understanding about risk factors is key to boosting safety and recovery for thousands of young tonsillectomy patients, says Perth Children’s Hospital consultant respiratory and sleep paediatrician Dr Mon Ohn. She has funding to colead the Nightowl project to assess the degree of obstructive sleep apnoea in tonsillectomy patients before and after their surgery. Dr Ohn said there are potential benefits for clinicians and families from the project because tonsillectomies are one of the most common surgical procedures performed in WA and 95% of these 4 | OCTOBER 2021
Prof Koks said the effects of 11 million genetic variants were analysed in the study involving almost 5000 Parkinson’s patients.
“The hope for the future is that disease-modifying drugs that target the genetic drivers of Parkinson’s disease progression can potentially turn fast progressors into slow progressors,” Professor Koks said.
surgeries are due to OSA rather than tonsillitis.
clinics. They will need to be fully vaccinated by November 1.
“We know that while parents generally see significant improvement in their children’s sleep following a tonsillectomy, we also know that kids with OSA have more breathing problems during surgery and in post-surgical recovery,” Dr Ohn said.
From November 1, health care workers will need to have had at least their first dose of a COVID-19 vaccine to access tier two facilities, which include all public and private hospitals. These workers will need to be fully vaccinated by December 1.
“Collecting respiratory and sleeprelated risk data about children before and during their surgery could pave the way for more personalised treatment of patients leading to fewer complications, faster recovery and potentially reduce the duration of their hospital stay.” About 60 children aged one to eight years will be recruited into the study.
No jab, no job It will soon be mandatory for all healthcare workers in WA to be fully vaccinated against COVID-19, with a staged implementation announced by the State Government. From October 1, health care and health support workers in public and private hospitals will need to have had at least their first dose of vaccine to access high-risk facilities such as ICU, high dependency units, respiratory wards, emergency departments and COVID-19
Health care workers include those who provide health, medical, nursing, pathology, pharmaceutical, social work or allied health services to a patient at a health care facility in any capacity.
Heart help Hollywood Private Hospital has become the only hospital in the southern hemisphere offering hybrid catheter ablation and surgical ablation (HyCASA), treating certain patients with long-standing, persistent atrial fibrillation. The aim is to interrupt the atrial fibrillation circuits and return the heart back to a normal rhythm. It combines endocardial radiofrequency ablation with epicardial ablation. Cardiac electrophysiologist Rukshen Weerasooriya and keyhole expert cardiothoracic surgeon Pragnesh Joshi underwent advanced training in the treatment continued on Page 6
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Investigating rheumatic and connective tissue diseases The immune system attacking self tissue is the basis of the immune process. The overlap of clinical features in many of the rheumatic and connective tissue diseases has always complicated the task of segregating disease entities. Autoantibody tests can help classification, though clinical assessment remains the cornerstone of diagnosis. Immune system attacking own body forms the basis of the autoimmune disease process, the end result being target organ damage. Most laboratory investigations are based on antibody detection as markers of autoimmune tissue damage, analogous to high blood pressure and vascular disease. Other basic investigations are also useful in the diagnosis and monitoring of disease activity such as CRP levels in rheumatoid arthritis (RA), though they are less useful in systemic lupus erythematosus (SLE).
Dr Daman Langguth FRACP FRCPA
About the Author Daman is a head of immunology at the Sonic Brisbane laboratory. He trained in rheumatology and immunology in Perth and Brisbane. Daman’s expertise is in auto-immune disease, allergy and immune deficiency.
Some connective tissue diseases commonly associated with RF
Rheumatoid arthritis Systemic lupus erythematosus (SLE) Sjögren’s syndrome Systemic sclerosis Mixed connective tissue disease
Investigations Rheumatoid Factor (RF): Rheumatoid factors are auto-antibodies directed against antigenic determinants on the Fc portion of IgG. Agglutination tests using IgG-coated particles (latex or erythrocytes) form the basis of most diagnostic tests. Interpretation: RF assays are not specific for RA. RF may be found in a variety of acute and chronic inflammatory diseases, most of which are associated with a broadly elevated level of gamma globulin. RFs are also found in low titre (5%) in normal individuals, with titre and incidence increasing with age. Positive RF is, however, a highly sensitive diagnostic tool for RA, with 80% of RA patients having positive results, though only 50% will be positive at time of diagnosis. The frequency of positive results increases with the duration of the disease. Cyclic citrullinated peptide (CCP) antibodies: The importance of antibodies directed against citrullinated peptides in the development of RA has allowed the subsequent production of commercial assays. Citrulline is a non- standard
ANA provides a rapid screening for SLE and related connective tissue disorders with a very high negative predictive value. A low titre (<1:160) ANA may have little or no clinical relevance, occurring in a wide range of diseases, and a percentage of healthy individuals. The ANA is positive, however, in 100% of patients with active SLE, in up to 90% of patients with RA, and in 50% of patients with systemic sclerosis.
Conclusion amino acid formed during cellular aging. CCP antibodies are present in a significant number (up to 70%) of RA patients. The antibodies may be present in those with a negative rheumatoid factor and are useful in combination with the RF assay. At present, tests for CCP antibodies are performed via an ELISA-based test and reported in numeric terms. The magnitude of the antibody level has not been reliably associated with clinical markers of severity. Antinuclear antibodies: Autoantibodies to a variety of cellular components are a frequent finding in connective tissue diseases. Antinuclear antibodies (ANA) were first detected when the LE cell phenomenon was discovered. This test was superseded by the ANA indirect immunofluorescence test. Human epithelial cell line cells are used for screening for ANA. This is a modification of the previous HEp2based ANA test so that SSA is also detected. In general, a negative ANA excludes active SLE.
Despite the lack of definitive tests for the diagnosis of rheumatic and connective tissue diseases, there are many pointers to their diagnosis. Rheumatoid factor assays, although moderately sensitive for RA, lack specificity. The use of CCP antibodies is a valuable tool. The ANA test remains a sensitive but not specific screening test for many connective tissue diseases. In combination, ANA for screening, and more specific anti-ds DNA and antiENA tests are helpful in the diagnosis of connective tissue diseases. A negative ANA, anti-ds DNA and antiENA excludes the diagnosis of SLE. Tests for antihistone antibodies are useful in diagnosis of drug- induced SLE. Testing for ANCA is useful in the investigation of patients with suspected small vessel necrotising vasculitis. Queries to Dr Mina John, Head of Immunology at Clinipath Pathology.
Interpretation: Standard testing for
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Military veteran and consultant psychiatrist Dr Richard Magtengaard will be medical director at the Bethesda Clinic in Cockburn, due to open in September next year. He will oversee specialist mental health inpatient and day programs for defence personnel, veterans and first responders.
Medicinal cannabis producer Little Green Pharma has been given approval by the WA Health Department to grow magic mushrooms for medical research. The ingredient psilocybin is being trialled as a psychedelic drug to treat depression and anxiety.
IN THE NEWS
continued from Page 4 in the US in 2018. Director of Medical Services Dr Andy Papa-Adams said Hollywood was one of the busiest providers of the procedure outside of the US, recently performing the 50th case. “Hollywood will be a significant centre for hybrid AF therapy and a potential proctoring site for the southern hemisphere,” he said. “We are set to become a training centre for the procedure, teaching surgeons and electrophysiologists across Australia, New Zealand and the Asia Pacific.” Dr Papa-Adams said most patients considered for HyCASA had persistent AF (lasting continuously for more than seven days) or previous pulmonary vein isolation procedures that had not been effective.
Mothers of children with autism who delayed their subsequent pregnancy by 2.5 to three years reduced the likelihood of their next child also being diagnosed on the spectrum, new research shows. The Curtin University research, in collaboration with the Telethon Kids Institute and published in Autism Research, investigated more than 925,000 births in Denmark, Finland and Sweden including more than 9,300 that resulted in a child later being diagnosed with autism spectrum disorder. Lead author Professor Gavin Pereira, from Curtin’s School of Population Health, said the research found a significant – and surprising – link between the time between pregnancies and a sibling’s chances of also being diagnosed with autism. “We found that the siblings of continued on Page 8
Pregnant pause Sports science start-up Levin Health, which is researching medicinal cannabis to treat chronic pain, has appointed business leader and hockey Olympian Jenn Morris as its first female board member.
WA faculty winners in the RACGP’s annual awards for achievement and contribution to community health are GP of the Year, Dr Charl Du Plessis; GP in Training of the Year, Dr Matthew Yeoh; GP Supervisor of the Year, Dr Rebecca Hunt-Davies; and General Practice of the Year, Ellen Health.
The National Drug Research Institute based at Curtin University will present latest findings from alcohol and illicit drug research at its 2021 symposium at the Perth Convention and Exhibition Centre on October 6. It will be followed by the WA Alcohol and Other Drugs Conference on October 7-8.
Dr Richard Alcock, Peter Mott and Dr Jon Spiro
On your bike When it comes to heart health, two cardiologists are practising what they preach. Dr Richard Alcock and Dr Jon Spiro are self-professed exercise enthusiasts who cycle regularly. Dr Spiro rides with local cycling group, the Frommers, which has more than 60 members. Dr Alcock said there had been a proliferation of cycling clubs in WA, but cycling did not make people immune to heart disease. The Frommers and other Perth cycling clubs had recently lost two members following cardiac episodes. “Both men were extremely fit and exceptional cyclists,” Dr Alcock said. In an effort to raise awareness about heart health, Dr Spiro and Dr Alcock recently presented a lecture to the Frommers at Hollywood Private Hospital. “Many of our members fall into the at-risk categories, which simply include being male and getting older,” Dr Spiro said. “The key messages are to see your GP, know what your heart risk is, and if you have any symptoms whilst cycling, get it checked out.” Hollywood CEO Peter Mott, who is a member of the Frommers, said cycling was the new golf, particularly among busy healthcare workers.
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IN BRIEF
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Continuity of care for better patient outcomes at Hollywood Private Hospital Continuity of care in healthcare takes on great importance when people require interprofessional care and interventions to treat chronic and complex health issues. Models for exemplary continuity of care describe regular and appropriate communication between various healthcare providers, sometimes across different settings, and for care to be provided in a coherent, logical and timely manner to the patient, considering their preferences.
By Karen Gullick – Director of Clinical Services Karen Gullick has extensive experience in the healthcare industry. She holds a Master of Science (Nursing) degree and is a Fellow of the Australasian College of Health Service Managers, as well as an Adjunct Associate Professor at both Edith Cowan University and Curtin University.
Stoma Therapy Nurse Delysia Tennant’s role is to care for and advise patients with a colostomy, ileostomy or urostomy before and after surgery.
Responsibility for continuity of care often begins where the person is diagnosed or first treated for an illness. Specialist Nurses such as breast cancer nurses, prostate cancer nurses and others can be critical in ensuring that there is a coherent pathway for patients, assisting both patients and families to develop an understanding of both the disease process itself, and the care and treatment options.
Prostate Cancer Specialist Nurses
Prostate Cancer Specialist Nurses Lucy Lyons, Lisa Ferri and Francesca Rogers
This support is vital for patients at a time when they are particularly vulnerable and helps sustain their relationships with healthcare team members. Hollywood has invested in a team of nurse specialists, including the only cardiac rehabilitation specialist nurse at a private hospital in WA, to support patient care. In addition, Ramsay Health Plus, an allied health service on Hollywood’s Nedlands campus, offers a team of physiotherapists and other allied health professionals who have specialist skills in prehabilitation and rehabilitation of people with Orthopaedic, Cardiology, Cancer and Neurology needs. The range of specialist nursing and allied health services at Hollywood encourages good collaboration within the interdisciplinary teams to benefit patients. There is evidence that continuity of care impacts positively on patient outcomes, including fewer hospital admissions and fewer visits to the emergency department.
In Collaboration with the Prostate Cancer Foundation, Hollywood has three Prostate Cancer Specialist Nurses – Lisa Ferry, Francesca Rogers and Lucy Lyons. From the time of diagnosis, throughout treatment and afterwards, these nurses provide information, support and coordination of care specific to individual needs.
Inflammatory Bowel Disease Specialist Nurse
Cardiac Rehabilitation Specialist Nurse Tracy Swanson
Cancer Care Navigator Therese Thompson is a specialist nurse who has had extensive experience in caring for people with cancer. She is the link between the multidisciplinary team to coordinate all aspects of a patient’s care and provide information and referrals to additional support services.
Breast Cancer Specialist Nurses With the support of the McGrath Foundation, Hollywood Private Hospital has two Breast Care Specialist Nurses, Dawn Johnson and Paula Melville.
Kate Willis is one of only two inflammatory bowel disease (IBD) specialist nurses at private hospitals in WA. Hollywood invested in an IBD nurse to provide support, education and a helpline to patients with IBD. Ms Willis supports consultants and helps patients with the ongoing management of conditions such as Crohn’s disease and colitis.
Cardiac Rehabilitation Specialist Nurse Tracy Swanson assists cardiac patients recovering from or trying to manage cardiovascular disease. Mrs Swanson’s goal is to guide patients on a heart-healthy path to lower the risk of future heart problems.
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continued from Page 6 children with autism were less likely to be diagnosed on the spectrum if there was a 30 to 39-month gap between both pregnancies,” Professor Pereira said. “Waiting for this time to conceive another child was considered the optimum timeframe, potentially preventing 5% of cases of autism in Denmark, 8% in Finland and 9% in Sweden, on average.”
Taking into account the six months to the end of June, we now estimate that figure has fallen to 290,000,” he said. “These are surgeries and other treatments that have been deferred but they will need to be done at some stage and include procedures like total knee and hip replacements or cataract surgery that impact a patient’s ability to move around or to see.”
Rare eye cancer hope Elective backlog ‘serious’ A significant number of patients are waiting for elective surgery, 18 months after the first COVID-19 enforced shutdown of procedures, new national figures show. Data from the Australian Prudential Regulation Authority show there were 978,797 episodes of care in private hospitals during the three months to the end of June this year – more than the previous quarter but still not breaching the gaps created by the various lockdowns around the country.
Perth researchers have helped discover a combination of drug treatments that show promise for an unusual and often fatal form of eye melanoma. Australia has the highest rate in the world of melanoma and 2% of patients suffer a uveal melanoma – the most common cause of primary tumours in the eye. Uveal melanoma mostly affects fairskinned Caucasians who have a light eye colour.
Australian Private Hospitals Association CEO Michael Roff said it would take some time before the backlog could be cleared.
Professor Jonas Nilsson, chair of Melanoma Discovery at Perth’s Harry Perkins Institute of Medical Research, has been researching ways to treat the disease with colleagues at Sweden’s University of Gothenburg.
“We have estimated there were 340,000 episodes of care ‘missing’ from private hospitals in 2020.
The Swedish team combined immunotherapy with the epigenetic therapy, Entinostat, a synthetic
drug which selectively inhibits certain enzymes and tumour cell growth, resulting in potent killing of uveal melanoma cell lines.
Angry bees best Angry bees produce the best venom for therapeutic benefits, Curtin University researchers have found. Behavioural and ecological factors have been known to influence the quality of bee venom, a product widely known for its effective treatment of degenerative and infectious diseases such as Parkinson’s and osteoarthritis. The study analysed protein diversity in bee venom produced by the western honeybee in the marri ecosystem in southern-western Australia. A compelling behavioural effect was revealed in docile and active bees. The researchers discovered that ‘angry bees’ that reacted intensively to stimulating devices produced a richer, more proteindense bee venom. Lead researcher Dr Daniela Scaccabarozzi, from Curtin’s School of Molecular and Life Sciences, said the research would be of substantial benefit to both human health and the lucrative beekeeping business, where bee venom is being sold for up to $300 per gram.
Green light for pandemic ward A major redevelopment of St John of God Subiaco Hospital will include a purpose-built pandemic ward to care for patients when outbreaks of highly infectious diseases such as COVID-19 occur. St John of God Subiaco Hospital CEO Professor Shirley Bowen, who is also a professor of infectious diseases helping to lead WA’s private hospital response to COVID-19, said the pandemic ward would be negatively pressured and allow the hospital to be prepared for future outbreaks of COVID-19 and other infectious diseases, when patients needed to be isolated.
St John of God Health Care CEO Dr Shane Kelly and Prof Shirley Bowen; and below an artist's impression of new clinical block
The redevelopment includes a new 24/7 emergency department, and a mother and baby unit with a neonatal intensive care unit. Bed numbers will also increase by 25% – from 550 to more than 700 – and an a la carte meal service will be introduced across the hospital, with 98% of rooms to be single.
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Why Mount Hospital... Mount Hospital is a leading acute private hospital in the Perth CBD providing medical and surgical services. We are delighted to support Orthopaedic Surgery, led by key “Valued Medical Officers”, who are supported by excellent allied health professionals, nurses, and on site radiology and diagnostic providers. To find out more please visit: mounthospital.com.au/services/orthopaedics Mr Peter Annear
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Thinking beyond organ donation While everyone appreciates the life-saving role of organ donation, few are aware of the benefits of bone and tissue donation, write PlusLife’s Anne Cowie.
For over 28 years, PlusLife has been at the forefront of managing tissue donations in Western Australia through the State’s only bone bank. We have played a part in providing human bone and soft tissue allografts for patients undergoing life-transforming procedures from complex joint surgery to the correction of spinal deformities and treatments for dental and facial bone loss. In some cases, allograft
donations have helped save children with cancer the distress of a limb amputation. It is extraordinary work in which every staff member at PlusLife feels privileged to be involved. Through its two donor programs, patients having a total hip replacement operation can donate the ball part of their hip, which is processed into a ground-up form and can be used as donated graft for others. And, like organ donation,
bone, tendons and ligaments can be donated after death with consent from the deceased person’s next-of-kin. Every donation is precious. Our expert technicians carefully retrieve, test, store and process each donated bone, tendon, or ligament to ensure that we produce allograft material that is fit for purpose and that there is no wastage. The COVID-19 pandemic has impacted heavily on the number of
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GUEST COLUMN tissue donations to PlusLife, but demand for allograft has risen. Our precautionary decision to stop accepting tissue donations during the height of COVID last year meant that our stores of allograft has diminished. At the same time, demand for our products has increased considerably. According to the Australian Orthopaedic Association National Joint Replacement Registry, around 50,000 hip replacement operations are conducted in Australia each year. In WA alone, 5852 hip surgeries were performed last year. Every one of these hip replacement patients could potentially be a living donor with the ability to improve the lives of others. While screening procedures preclude some people from making a donation, we encourage everyone who is about to have hip replacement surgery to speak to their surgeon about donating to PlusLife. Similarly, we urge doctors and surgeons to raise this as part of pre-surgery discussions to help us drive up tissue donation rates. Last year, 672 bone and tissue donations were made to PlusLife. Nationally, there were 3018 tissue donors, including 290 deceased donors who made 442 tissue donations. The majority were femoral head donations from hip replacement operations. But latest statistics show just 38% of West Australians are registered tissue and organ donors. Since its inception in 1993, PlusLife has provided more than 22,300 grafts that have helped in excess of 12,500 patients. One deceased tissue donor is able to improve the wellbeing, sight and mobility of up to 60 people through the donations of bones, tendons, corneas, heart valves and skin. As well as encouraging people to speak to their families about their organ and tissue donation wishes in an effort to increase the donor pool, PlusLife is investigating new ways of sourcing donor tissue. This includes expanding our operations into Bunbury and Busselton and engaging with interstate hospitals that do not currently have tissue donation programs. Over the years, we have been the conduit for thousands of allograft donations, which is life changing for recipients, some who have undergone spinal surgery that enabled them to walk without pain, cancer patients, who with a bone allograft have avoided amputation of a limb; and other inspiring stories like one young Perth girl who was able to resume her passion for dancing thanks to donor graft. It is these personal stories that provide critical insight into why we do what we do and why we must strive to promote awareness of tissue donation and drive up tissue donor rates to help meet the growing demand for Australian-produced allograft. ED: Annie Cowie is managing director of PlusLife.
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OCTOBER 2021 | 11
Doctors walk a legal tightrope A ubiquitous social media presence and more bureaucracy mean doctors are walking a complex regulatory tightrope.
Dr Karl Gruber (PhD) explains Imagine starting work just like any other day, and just as you finish seeing a patient mid-morning, a letter arrives from the Australian Health Practitioner Regulation Agency. A patient has complained about you and you need to respond – even if you think it is completely baseless. You continue to see patients for the rest of the day, but your mind is racing about having to respond to a complaint that at best will be time-consuming and annoying but at worst could jeopardise your career.
12 | OCTOBER 2021
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FEATURE The legal landscape According to the Australian Institute of Health and Welfare, 13,666 medico-legal claims were made in 2013-2014 about practitioners in the public and private sectors. This figure does not include claims from Western Australia, which did not report its claims for this period. More recent statistics from APHRA’s annual report show that, between 2018-2019, 13,006 health practitioners received one or more notifications. Among these, medical practitioners led the list, with 5,745 notifications, followed by nurses with 1,872, and dental practitioners with 784 notifications. Enore Panetta, who is managing director at Panetta McGrath Lawyers which specialises in defending medical, dental and allied health professionals, said the number of cases he has represented throughout his career is too many to count but a conservative figure would be about 100 a year. According to APHRA, the most common reasons behind notifications are clinical care (43.5%), medication-related issues (nearly 10%) and communication (7.2%). During 2018-2019, immediate action to restrict or suspend the registration of a medical practitioner was taken in 580 cases, and in 132 cases the notification ended up in a tribunal. In all of these 132 cases, a disciplinary action was taken. Mr Panetta says he has personally handled a wide range of different medico-legal problems. “I have dealt with the full gamut of complaints/claims against practitioners, including allegations of sexual misconduct and other boundary violations, misdiagnosis, inappropriate or inadequate treatment/management of patients, system breakdowns and follow-up failures and medication errors,” he said. “Others include failure to obtain
informed consent, communication issues, disrespectful behaviour, inappropriate social media usage, incorrect Medicare billing, selfprescribing, prescribing to friends and family members, infection control breaches, impaired practitioners (whether due to mental health, drugs and/or alcohol), and workplace conduct.” Medico-legal issues in Australia are initially handled by medical Indemnity companies and all doctors and other health practitioners are required to have indemnity protection. MDA National, one of Australia’s largest medical defence organisations with about 55,000 members, handled 9,303 medico-legal inquiries during 2019. According to Dr Michael Gannon, a WA obstetrician and gynaecologist and president of MDA National, it is common for doctors to face medicolegal issues at some point in their career. “It would be unusual for a doctor to go a whole career without calling on their medical defence organisation,” Dr Gannon told Medical Forum. Mr Panetta shares one case example of a doctor who shared
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controversial information on social media. The notification by AHPRA involved a GP who shared posts about Australia’s COVID-19 policies in his personal social media page.
Social media pitfalls “(The GP) had shared posts on social media from other persons questioning the effectiveness of COVID-19 testing and masking, urging an end to lockdowns and claiming that the Prime Minister was blackmailing Australia with threats that they must be vaccinated, which was an attack on liberty and rights,” Mr Panetta said. While this case is still under review, Mr Panetta points to some important issues to consider. Even if views or opinions are clearly personal, the Code of Conduct and various position statements published by the Medical Board extend to what a health practitioner can say in their personal capacity. “Personal posts fall within the board’s jurisdiction and, essentially, the board makes little distinction between a practitioner’s professional views and personal views,” he said. The logic behind this thinking is that patients and the general public often rely on whatever a GP says and will not distinguish between personal or professional views. If a GPs says something, many people will put great weight on those words. Mr Panetta says some practitioners view these regulations as a form of continued on Page 14
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FEATURE
Legal tightrope continued from Page 13 censorship that discourages robust debate on important issues. But there is an important take home message. “Any publishing on social media which may be inconsistent with public health messaging (by local, state or federal governments and their agencies) with respect to COVID-19 and vaccination will be subject to scrutiny by the board,” he said. In another case, Mr Panetta recalls a GP who shared a bit too much with a patient he found online. “While at home one evening, the practitioner was randomly searching on Facebook and came across the patient’s profile. The practitioner sent several flirty messages to the patient,” he said. The patient complained and the Medical Board took immediate action, restricting the practitioner from having any contact with female patients while it investigated the matter.
“Unsurprisingly, such restrictions make it very difficult for practitioners to remain in, or obtain alternative, employment,” Mr Panetta said.
Avoiding legal trouble Medico-legal issues can be hard to avoid, particularly in certain medical specialities. For example, surgeons are more likely to experience complications from an operation than a GP might from a consultation. When any complications or issues arise, they need to be reported immediately to medical defence organisations, according to Dr Gannon. “If you have a patient that has been returned to theatre, fell very unwell and had an unplanned ICU admission, or required a second major operation, you should report 14 | OCTOBER 2021
that. And that might be the last time you need to discuss it,” he said. So, how can you avoid legal trouble? According to Dr Gannon, the best approach is to be excellent in your practice. “A doctor who is less likely to get into trouble is a doctor who turns up to work healthy and well themselves, looks after patients in good conscience, takes time to listen to their patients, writes good notes, follows up their patients,” he says. “So, in other words, good medical practice is by far and away the most important way to avoid medico-legal trouble.” Another important issue is balancing the need to build trust
with a patient and how much personal information you share. For GPs, building effective doctorpatient relationships sometimes involve engaging with their patients and sharing some level of personal information. Dr Gannon said that he had recently spoken to many patients who have been reluctant to get the COVID-19 vaccine. For these patients, Dr Gannon shares his own experience getting his teenage children vaccinated.
Sharing v caring “That's an example of relating personal details in a clinically relevant way. And that's probably reasonable,” he said.
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“I have seen other factually similar cases where interim restrictions (including gender-based restrictions or even suspension) can remain ‘temporarily’ in place for over two years.
FEATURE upset, before you reply, before you think of anything like financial compensation, is to contact your medical defence organisation and they will guide you through the process,” Dr Gannon said. Avant Mutual is another big Australian defence organisation, which represents 78,000 health practitioners and medical students. According to Avant’s most recent annual report, it handled 4,347 claims last year. The top issues involved clinical records/ confidentiality, treatment, and patient relationships. The report noted that there was a significant increase for employment and Medicare-related queries, up 27% and 42% respectively from the previous year. “The increase in calls relating to Medicare reflects the need for advice on the wide range of Medicare compliance activities, as well as on the new COVID-19 telehealth item numbers," the report said.
The (safe) way forward Being careful in your practice, making good notes and offering a chaperone during a medical examination are all good practices that may help you get out of trouble one day, but, according to Mr Panetta, changes are needed in the way AHPRA manages complaints.
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“Practitioners are often left in limbo for up to 18 months, sometimes longer, during which time their conduct or performance is being investigated,” he said.
Doctors can also rely on a simple technique to avoid putting themselves in the conversation.
Regarding social media postings, Dr Gannon says doctors need to be very careful.
“They might talk about someone in the third person. So, for example, if they think of something from their own life that's relevant or relatable to a patient, they might say, well, ‘I've got a colleague’ or ‘I know this doctor’,” Dr Gannon said.
“The reality is that people across the board, including doctors, share deeply personal things on social media,” he says. “I think that doctors should be very selective about what they post. It's certainly an area of growth in in our work as a medical defence organisation.”
If you need to manage a patient regarding sensitive issues such as sexual health, or if the patient suffers from mental health problems, doctors should consider using a chaperone during examination. “It's very important to have good notes to support your version of events,” Dr Gannon said.
And even if a doctor does everything right, they can still end up in hot water but the first step, on receipt of a complaint, is to remain calm. “The first thing you should do before you say anything, before you get angry, before you get
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During this time, practitioners may see their ability to practise greatly reduced, potentially affecting their professional reputation, finances and mental health. “I have seen practitioners suffer severe mental health consequences as a result of these investigations, some of which have even contributed to practitioner suicide,” he said. “In my view, the disciplinary process is in need of significant overhaul in order to ensure that practitioners are not subject to such undue extended delays.”
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OCTOBER 2021 | 15
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Better lives for mums and babies Don’t dare call her a rebel – Professor Jan Dickinson won’t answer to that, but, as Ara Jansen discovers, she’s a trailblazer who has dedicated her career to better the lives of mums and babies.
Professor Jan Dickinson’s office is on the top floor of King Edward Memorial Hospital, facing the road. There are books everywhere, pictures of her much-loved boxer Jasper and a wonderful wooden chair she received after studying in the US. She’s well settled in this space. With a glint in her eye, the maternal fetal medicine specialist explains that she was born not far from her desk. And it’s not so many steps from the area where she also did her medical student training. She jokes – though not in a fatalistic way – this space is where they’ll find her one day at the other end. Jan wears many hats in her specialty, but most obviously she’s director of KEMH’s Maternal Fetal Medicine Service Gold Team, which is WA’s high-risk obstetric tertiary unit.
16 | OCTOBER 2021
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CLOSE-UP “I’m quite at peace with where I am,” Jan says. “I just tried to make myself a woman of science. I mean, obviously, one assumes that it’s kind of a coincidence that I was born here but that wasn’t necessarily a reason for becoming a doctor. Quite honestly, I’m not one of these people who had it as my life’s passion since I was a child. “It was something that gradually came upon me when I was a senior high school student. I didn’t feel a great passion to do medicine. I do now. Yes! But I didn’t then.
Too young to call “When I was in medical school, I think like a lot of medical students, you kind of just do what you do. I really didn’t know what it was about particularly much. But I did well at school and when you did well at school in the 1970s, you gravitated to that because women didn’t do engineering.” That decision led to a series of other choices which were not common for women at the time. “When I started doing obstetrics and gynaecology as a medical student, I believe that’s when I really became interested in women’s health. Until then, I hadn’t much of an idea about what I was going to do. I think that’s what happens when you take a 17-yearold from high school and plonk them in medical school. “So, I became quite interested in women’s health. It wasn’t particularly popular at the time – not very many people wanted to do obstetrics and gynaecology.” There were women trainees but like much of medicine, it was dominated by men. Today, Jan says 85% of the of the trainees in obstetrics and gynaecology are women. “I think it’s fantastic and appropriate that this area should be female dominated. That’s been hugely positive for the specialty as some of the older, more patriarchal approaches to women’s health that my mother experienced have disappeared with the increasing numbers of female trainees and males who are more positive towards the specific needs of providing women’s health. “In Western Australia, we’re fortunate to have some outstanding young obstetricians and
Jan at the Australia Day honours ceremony
gynaecologists who are doing so well because they listen to the women. I think there’s been a huge change in obstetrics and gynaecology and it has become a lot more caring, more femaleoriented, which is how it should be as women are our focus, and more tolerant to women’s issues and medical needs.
Lived experience “I had done a lot of deliveries, but I learned more at the delivery of my son because then I suddenly had insight into things like just how uncomfortable you are and what people would call the minor maladies of pregnancy, were actually a big deal.” Jan is professor of obstetrics and gynaecology (maternal fetal medicine) in the School of Women’s and Infants’ Health at UWA and recently joined Aurora Imaging, an ultrasound practice specialising in women’s ultrasound and prenatal diagnosis. Then there’s the teaching and mentoring of medical students, student midwives and trainee ultrasonographers as well as obstetricians, gynaecologists and upskilling GPs. Between 2011 and 2016, she was the first female editor-in-chief of the Australian and New Zealand Journal of Obstetrics and Gynaecology. Jan has also initiated and been
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involved in programs and projects across maternal fetal medicine, including being an obstetrician with the WA Preterm Birth Prevention Initiative and a long-term followup of children with congenital malformations. She was recognised in this year’s Australia Day Honours List as a Member (AM) in the General Division of the Order of Australia. Thrilled to be honoured, Jan didn’t realise how much it meant to her until she was presented with her medal. While she might have gone places other people haven’t – including training in maternal fetal medicine in Texas and Florida in the late ’80s and early ’90s – Jan Dickinson is much happier answering to trailblazer or pioneer than ever being called a rebel. As a resident and registrar, she became interested in high-risk obstetrics but, during that period, maternal fetal medicine wasn’t yet a subspecialty. She believes she rode the wave started by the likes of Professors Brian Trudinger, Warrick Giles and John Newnham, but her work still made her only Australia’s sixth maternal fetal medicine specialist.
continued on Page 19
OCTOBER 2021 | 17
Sports Imaging Experts Perth Radiological Clinic has WA’s largest team of specialist musculoskeletal radiologists.
Leaders in Medical Imaging
perthradclinic.com.au 18 | OCTOBER 2021
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A life of adventure and learning they may or may not need to optimise their pregnancy outcome. It’s important stuff that makes a difference. If the mother receives specific treatment based on her medical needs it provides her with the best opportunity for a successful pregnancy outcome.”
continued from Page 17 It’s a field which can cover everything from helping women with heart problems or organ transplants fall pregnant and have a healthy obstetric journey, through to looking out for a fetus which isn’t growing sufficiently. Some of those can be treated in utero, which became possible with the use of ultrasound, which Jan describes as a vital third hand, and the use of lasers in helping tiny bodies in the womb.
Another area Jan has worked tirelessly in and is very proud of, is the HIV in pregnancy service. It’s a multidisciplinary statewide service across several hospitals and involving a variety of specialists such as immunologists, infectious disease physicians, paediatricians, nurses and midwives to provide care for women living with HIV.
Tech helps “Now we can diagnose many disorders in the fetus, we can make a difference for the woman and her baby and we can treat some fetal conditions in-utero.” This kind of work led to Jan setting up the fetal surgical service in WA. It is especially relevant because of WA’s isolation and an inability to send women elsewhere for highly specialised medical care. She says for the size of our population we bat well above our weight in this area. One recent example was the use of placental laser ablation to treat Twin-Twin Transfusion Syndrome, where monochorionic twins sharing a placenta have blood flow imbalances such that one twin gets more amniotic fluid volume than the other. This means one baby doesn’t get enough nutrients while the other struggles with the overload. Using a tiny fetoscope and laser, the shared blood vessels on the placental surface are coagulated to help equilibrate the flow between the two babies, which hopefully leads to them developing more equally before birth. Alongside this busy multi-pronged professional life, Jan has been married to John, a mechanical engineer, for 40 years. Their Texanborn son Tim is an emergency medicine doctor.
to Scotland is next on the list) and have a small but well-appreciated art collection, including a series of bird paintings, favourites of Jan’s. She’s also a reader, with eclectic tastes. Two years ago, Jan stopped delivering babies and now concentrates on ultrasound consultations, running the hospital’s Thursday antenatal clinic and shares her clinical experience with junior medical staff and midwives. But like the monochorionic twins, she can still be called in for surgery.
Joy of the work Maternal fetal medicine remains fascinating to her because while it seems specific, it also runs a wide gamut, including women who have multiple sclerosis, heart issues or a chronic neurological disease and want to become pregnant.
Photos of boxer dogs are all over Jan’s office. One of them is her energetic dog Jasper, whom she loves to walk when she’s not working.
“I see a lot of women before they get pregnant, which is really helpful. We can attempt to facilitate medical and obstetric care for women who may have a physical disability or significant medical issues using a multidisciplinary team approach,” she says.
Jan and John like to travel (a trip
“We talk with them about what
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“We have an outstanding service looking after all women living with HIV in our state. This comprehensive service has resulted in an extremely low mother-child transmission. Whilst it is a small number of pregnancies each year, the lifelong health consequences for the woman and her baby are so important. Disease prevention is one of the best outcomes in medicine.” From geneticists to haematologists, one of the things Jan loves about maternal fetal medicine is it’s so multidisciplinary as it interacts with so many other specialties. There are very few specialties where that happens, so it’s something Jan relishes. Add to that, Jan has seen women through multiple pregnancies and then seen their daughters have their own children. “It has always been such a privilege. Honestly, I think I have fortunately gone into one of the most amazing professions. When I started, I didn’t know how wonderfully it was going to evolve with technology. “Human beings are incredibly brave and the human body is an amazing piece of bioengineering. I think a lot of people don’t appreciate just how wonderful each and every human is – or can be.”
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OCTOBER 2021 | 19
Putting musculoskeletal under the x-ray One medical condition takes the biggest bite out of Australia’s health spending, but as Cathy O’Leary reports, it’s not cancer or heart disease.
20 | OCTOBER 2021
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Musculoskeletal conditions are crippling in more ways than one, breaking not just bones, but also the bank – to the tune of $14 billion a year in Australia. A newly-released report from the Australian Institute of Health and Welfare found that more money was spent on musculoskeletal disorders such as osteoporosis and back pain than any other disease, condition or injury in 2018-19.
Bad backs, big bucks Of the $136 billion spent across the entire health system that year, musculoskeletal disorders consumed the most dollars, followed by cardiovascular diseases ($11.8 billion), cancer ($11.8 billion), and mental and substance use disorders ($10.5 billion). A separate report by Musculoskeletal Australia, based on a national survey last year, recently revealed that of the seven million Australians with a musculoskeletal condition, 93% said it had a significant negative impact on them. More than half reported their ability to carry out basic daily activities such as cooking and grocery shopping was affected by their condition, and almost-three quarters said it badly affected their sleep. And Musculoskeletal Australia predicts it will get worse, with the number of people living with one or more musculoskeletal condition expected to grow to 8.7 million people by 2032. Its CEO Rob Anderson said musculoskeletal conditions already affected a staggering one in three Australians, often seriously impacting on their daily lives. “This report reveals why so many are crying out for compassion, for understanding, for change, and the survey data now provides us with the opportunity to offer more support,” he said.
Global push Meanwhile, a new global effort involving Perth experts aims to put musculoskeletal conditions firmly on the map in terms of government awareness and funding. An international research team found that despite being the world’s leading cause of pain, disability and healthcare costs, the prevention and management of conditions such as low back pain, fractures, arthritis and osteoporosis remained under-prioritised. In response to a call by the Global Alliance for Musculoskeletal Health based at the University of Sydney, the team has identified key areas for improvement, including better access to medicines and technologies and more health care professionals working in the area.
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Project lead Professor Andrew Briggs from Curtin University said that globally more than 1.5 billion people lived with a musculoskeletal condition in 2019, which was 84% more than in 1990. Despite many calls to action and an ever-increasing ageing population, health systems continued to lag behind treating these conditions and catering for their rehabilitation needs.
Invisible conditions He said musculoskeletal disorders were not on the radar because they had a lower profile compared to other areas of medicine and were not commonly linked to death. Therefore, the presumed significance and societal relevance was considered to be lower. “But when you think about people having to live a long time with pain and disability, that’s also important,” Professor Briggs said. “Death is tragic of course, but living in chronic pain and not being able to work or go to school, that’s equally problematic to society.” He said many policies and funding were directed at conditions such as cancer, diabetes and heart disease, while musculoskeletal disorders languished. “Costs for cardiac disease are obviously high but typically episodic and in tertiary hospitals, whereas musculoskeletal conditions go across primary, secondary and tertiary care,” he said. “And when you scale up the cost by the number of people who have musculoskeletal issues, then it’s enormous compared to a smaller fraction of people that might have big costs but the net cost is much less.” While some conditions such as osteoporosis and osteoarthritis were more common in older age, autoimmune conditions such as juvenile arthritis and rheumatoid arthritis occurred much earlier in life and were life-long. “So, this idea that musculoskeletal diseases are an inevitable part of ageing is inaccurate because they can be lifelong and occur in children aged as young as five,” he said. “We’re trying to take a system view rather than a clinical one, so you have to consider financing, workforce, policy and service models, or in other words what needs to be done at a macro level to address this huge burden.” continued on Page 22
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Putting musculoskeletal under the x-ray
continued from Page 21 Professor Briggs said that while there was a pressing need to put musculoskeletal health care on the global map, there were varying levels of care and resources between low, middle, and highincome countries. “One of the limiting factors to reform efforts is that no global-level strategic response to the burden of disability has been developed until now,” he said. While WA led the world in policy and strategy for coordinated care for musculoskeletal conditions, he said it was disappointing the conditions were not a focus in WA’s Sustainable Health Review, given the data was clear that it was the leading cause of disability in Australia.
Hip fracture registry In other moves to improve how musculoskeletal conditions are managed, Perth doctors have helped develop the world’s first hip fracture registry toolbox to improve care for the more than one million people in Asia Pacific who fracture a hip each year. Developed by the Asia Pacific Fragility Fracture Alliance and the Fragility Fracture Network, the practical resource explains to other countries how to advocate for a national hip fracture registry. One in four patients who sustain a hip fracture die within a year, 22 | OCTOBER 2021
and less than half of those who survive regain their previous level of function. Tailored to clinicians, hospital administrators, healthcare systems and governments alike, the toolbox shows how to set up a registry, including getting ethics approval and patient involvement. Fiona Stanley Hospital consultant geriatrician Dr Hannah Seymour, who among her many roles is co-chair of the alliance’s hip fracture registry working group, said WA had been leading the way for some time when it came to hip fracture care through its tertiary hospitals and coordinated geriatric services. “A national hip fracture registry has been going in Australia for five or six years, and WA has been performing quite well,” she said. “But we can always do better, given the epidemic of osteoporotic fractures, and hip fractures are the most common types that come into hospital.”
Proactive care Dr Seymour said the registry aimed to measure and improve clinical care, such as time it took for patients to receive analgesia
in emergency departments. The toolbox was to help other jurisdictions learn from places like WA and develop their own models of care. “For some hip fracture patients, it’s about fixing them and getting them back to full independence, and then there’s a group in the middle who are frail older people at home and the aim is to get their lives back to as close as possible as it was before. “And then we have very frail patients coming from residential care, and some have dementia, and the reason we’re fixing hips is mainly for pain relief, and generally they do poorly.” Dr Seymour said a hip fracture could be life-changing for many people, and prevention was key so that they did not become a statistic on the registry. “An important message is to treat osteoporosis before someone has a hip fracture, so when people come in with a wrist or humoral fracture, there needs to be a path to treat their osteoporosis so they don’t end up with a hip fracture.”
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These boots are made for walking Perth Children’s Hospital is breaking new ground in treating young fractures, as Cathy O’Leary explains.
Until now, treating young children with lower leg fractures presenting at Perth Children’s Hospital inevitably meant a full-leg plaster cast, much to the dismay of parents. But a recent study by PCH’s emergency department has found that a far less unwieldy and inconvenient remedy – a walking boot – can be just as effective in the healing process in toddlers. The research, published in the Emergency Medicine Journal, found benefits in using a controlled ankle motion (CAM) walking boot to treat a toddler’s fracture compared with the more cumbersome full-leg plasters. Lead researcher and paediatric emergency consultant Dr Kate Bradman said the study has resulted in a new practice at PCH, which was making life far easier for parents managing this injury. All children aged between one and five years who present to the ED with a toddler’s fracture – a twisting injury which causes the child to stop weight bearing – are now treated with the CAM boot instead of the full-leg plaster. “The CAM boots are far easier for both parents and toddlers to manage, particularly with negotiating car seats and highchairs, and they can be adjusted and removed for bathing, dressing and toileting,” Dr Bradman said. She said that witnessing friends and patients manage the difficulties of a young child in a leg plaster prompted her to question whether an injury would heal just as effectively if it was immobilised in a below knee walking boot instead of a plaster. More than 80 parents took part in the trial which tracked fracture healing, pain and interaction with
Dr Kate Bradman with Leo and his mother Jodie Bowles
daily activities when the fracture was treated with a plaster cast instead of a CAM boot.
but I was inspired by the prospect of creating positive change through this project,” Dr Bradman said.
Jodie Bowles was one of the trial participants, who managed a plaster cast for her one-year-old son Leo following an accident. Leo’s plaster was recast on seven occasions within a month due to breaks in the plaster.
The study was run in partnership with the Orthopaedics Department and was funded through a grant from the Perth Children’s Hospital Foundation.
“I’m delighted we participated in this study, which has had an amazing outcome,” Ms Bowles said. “It’s fantastic to know other toddlers with a similar fracture to Leo’s no longer have to endure the pain and stress of plaster.” Dr Bradman said she was pleased the outcome of her study had resulted in a change in practice at PCH ED that benefited parents and toddlers with this type of injury.
Perth Children’s Hospital Foundation CEO Carrick Robinson said the research was making a real-world difference for children and their families. “The impact a fracture can have on the day-to-day activities of a young child can be difficult to navigate for the whole family,” Mr Robinson said. “This research is not only improving lives for these families in the everyday but is improving long-term outcomes for these children.”
“I had never been interested in leading my own research project until I commenced work at PCH,
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OCTOBER 2021 | 23
NEWS & VIEWS
Will saliva become the new gold standard in children’s medical research, asks Dr Karl Gruber (PhD).
There are many ways to assess health, but emerging research suggests that much can be gleaned from a simple drop of saliva. And this can be particularly helpful when it comes to children, who are not the easiest to study, particularly for epidemiological research requiring blood or other biological samples, as no one wants to volunteer their child for invasive sampling or procedures. Now a new generation of salivabased biomarker testing is changing the landscape of biomedical research in children and adults.
Secrets of saliva Saliva is a complex solution produced by several glands located inside the mouth. While saliva is mostly water, it also contains an interesting mix of molecular and bacterial compounds, such as electrolytes, proteins, mucus, and enzymes. Some of the compounds found in saliva can change when a person 24 | OCTOBER 2021
suffers from a disease. Hence, saliva can be used as a diagnostic tool to gain information about a person’s health. From a clinical perspective, saliva is a great study substance because it is easy, economic, safe and stress-free to collect from a patient. Professor David Wong, from the University of California, in Los Angeles, spoke of the potential at a recent conference. “Saliva has long been considered a ‘mirror of the body’ that reflects the state of overall health,” he said. “Systemic diseases, such as diabetes and Sjögren’s syndrome, have oral manifestations that clinicians can encounter in patients at various stages of disease development.”
Saliva and children In recent years, researchers have been focusing on biomarkers found in saliva to learn about children’s medical conditions. For
example, a recent study found that biomarkers found in saliva could detect differences in BMI, diet and physical activity levels in schoolage children. In this study, researchers found that C-reactive protein (CRP), insulin, IL21b and pro-inflammatory biomarkers could be used against the BMI, diet and physical activity levels of 129 children. Their results showed that insulin levels were correlated with all the three factors studied – positively correlated with BMI and negatively correlated with diet and physical activity. In other words, by just analysing saliva, it could be determined if a child was overweight, details of their diet and levels of physical activity. Other studies have shown that salivary markers in children can provide a broad range of health information, such as predicting significant traumatic brain injury and dental caries, diagnosis of
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Saliva yields its gold mine of secrets
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NEWS & VIEWS hypertension or appendicitis, and other conditions. Saliva-focused research is producing some exciting results, not only for children, but for all Australians.
Australia at the forefront This year, CSIRO organised SALSA 2021, a science symposium that focused on saliva and other noninvasive diagnostics and healthrelated technologies. The online symposium brought together a large number of brilliant researchers and amazing topics. International researchers reported on how saliva biomarkers could be used to detect different cancers, such as head, neck, lung and oropharyngeal cancers. Other presentations highlighted the potential of biomarkers found in saliva to aid with in-vitro diagnostics, predict heart failure and detect liver fibrosis. Other researchers showed how saliva-based diagnostics could be used to help with management of Alzheimer’s disease and dementia, detection of early type 2 diabetes, detection of the human papillomavirus, or for assessing the health of athletes and predicting their performance.
Screening programs One of the presentations, led by Associate Professor Chamindie Punyadeera, from the Saliva and Liquid Biopsy Translational Laboratory at the Queensland University of Technology, is using saliva for the early detection of heart failure and oropharyngeal cancer. Notably, her team has developed a protocol to detect salivary human papillomavirus-16 and made the world’s first discovery of occult HPV-driven oropharyngeal cancer in an asymptomatic individual. “Our research now provides the long-awaited scientific evidence to start a screening program for oropharyngeal cancer,” Prof Punyadeera said.
Heart failure biomarker A team led by Dr Xi Zhang, also from QUT, presented research showing how salivary proteins can be used to diagnose systolic heart failure. Using healthy controls and a group of patients with heart failure, Dr Zhang compared levels of proteins/peptides – Kallikrein-1,
CSIRO's Wayne Leifert, Maryam Hor, Maxime Francois
Protein S100-A7, and Cathelicidin antimicrobial peptide. Their results showed an overall diagnostic accuracy of 82% for the prediction of patients with heart failure, which may serve as the basis for a diagnostic test.
New applications Dr Greg Warner, from US life sciences company Quanterix, showed the application of saliva biomarkers through the lens of their SIngle MOlecule Array (Simoa) technology. Simoa is an ultrasensitive immunoassay technology that allows detection of proteins and nucleic acids at extremely low levels. Dr Warner highlighted the use of this Simoa technology for the detection of biomarkers correlated with the progression of Alzheimer’s, cancer, diabetes, and infectious diseases. “Simoa technologies have been used to prognosticate development of disease, to predict patient response to therapy and to discriminate different patient populations,” he wrote in his presentation abstract.
From bench to bedside Dr Jill Maron is a Professor of Pediatrics and Obstetrics and Gynecology at Tufts University School of Medicine and the Executive Director of the Mother Infant Research Institute at Tufts Medical Center, among other roles. Her work is focused on bringing salivary diagnostics to patients in hospitals or clinics.
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Her goal is to use saliva as a diagnostic tool for monitoring the health of patients and assessing the efficacy of treatments particularly in the neonatal population.
POC testing Guozhen Liu is an Associate Professor of Biomedical Engineering at the Chinese University of Hong Kong (Shenzhen), and an Honorary Associate Professor at the University of New South Wales. Her research is focused on using saliva to detect levels of cytokines – soluble proteins secreted by the certain cells that are core indicators of the functional status of the body, particularly of the immune system. However, clinical detection and quantification of cytokines is difficult, which has made its use in diagnostics challenging. Now Prof Liu and her team have developed both fluorescence and electrochemical biosensors for the efficient and sensitive detection of cytokines and they are working towards developing point-ofcare paper test strips, using this technology, to detect cytokines in saliva. For more information about the topics presented at this symposium, contact A/Prof Wayne Leifert, wayne.leifert@csiro.au or Dr Maxime Francois, maxime.francois@csiro.au.
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Empowering consumers to help themselves Suzie Edward May shares insights into how health professionals help her manage musculoskeletal conditions. Living with a musculoskeletal disease is both complex and demanding of both health professional and consumer. It requires both to work together as they strive to reduce pain and limitations and increase function. It is often accompanied with complex comorbidities which means treatment teams become multidisciplinary. This adds to the complexity and need for coordinated care, effective communication and shared decision making. As a consumer who has lived with chronic rheumatoid arthritis and multiple comorbidities for 19 years, I experience uncertainty, frustrations and physical pain every day. I constantly navigate our health system to ensure it gives me what I need, fortunately with a dedicated and skilled health care team by my side. My ability to successfully navigate the system has required me to learn and understand how the different parts of the system work together. I have learnt over two decades that the best way of achieving this is to be as informed and empowered as I can, working with my health-care team every step of the way. What is an empowered health consumer? Health consumers who understand their diagnosis and treatment options; who are engaged in shared decision-making with their healthcare team; and actively use selfmanagement strategies to live the best life they can. When you live with an unpredictable condition such as a musculoskeletal disease, it can be incredibly disempowering as you lose a sense of control over your body. For the first 10 years of living with rheumatoid arthritis, I felt a tremendous sense of loss of control over how my body felt, how it reacted to everyday situations including stress and exercise, and what challenges it was going to throw at me next.
There seemed to be no pattern to my pain, inflammation and limitations, making it hard to plan my days, activities and longer-term goals. However, the more educated I became about my condition and how to manage it, the more confident I felt to live my life with my health challenges. What role do medical professionals play in empowering health consumers? With the current pressures on our public and private health systems, it is important that doctors play a key role in empowering consumers to self-manage their condition (to the extent to which the person is able). This is particularly important for consumers with chronic conditions such as musculoskeletal diseases and related comorbidities, as their needs often require significant resources. As a medical professional, you can help consumers by: • increasing their health literacy by teaching them (in plain language) about their health condition/s, treatment options, prognosis, what their pathology and other test results mean and helping them understand how the health system works so they can navigate and connect with the services they need • engaging in shared decisionmaking by giving them choice over medications, methods of taking medications, treatments, specialists, exercise and other important decisions
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• assisting them to set and reach achievable goals by taking time to understand who they are, what is important to them, what they want to achieve and help them achieve it • facilitating self-management skills by encouraging them to undertake self-management courses*, be compliant with medications and other treatments, understand and practise good nutrition and exercise regimes with guidance and support, and understand the importance of preventative health care. How can medical professionals do this? Developing open, honest, trusting and mutually respectful working relationships is the key to genuine shared decision-making and effective self-management by consumers, leading to better health outcomes. Using effective communication skills with patients is essential – active listening, clear concise language, empathy, compassion and respect. Consumers with chronic diseases need a team of skilled professionals around them to educate, encourage and empower them. This powerful role played by medical professionals is essential to consumers becoming ‘experts’ in their own care, reducing their demand on our health system, and feeling more confident to be fully informed and engaged in the management of their health. *See Arthritis and Osteoporosis WA www.arthritiswa.org.au/services/selfmanagement-courses/ ED: Suzie Edward May is former deputy chair of the East Metropolitan Health Service board; a member of the Australian Orthopaedic Association Board ethics committee; a lecturer at UWA and Notre Dame medical schools, and a consumer representative and advocate in musculoskeletal disease and medical research.
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Comprehensive DBT can work wonders Psychiatrist Dr Pauline Cole explains why government funding for Dialectical Behaviour Therapy is urgently needed. Marsha Linehan first developed Dialectical Behaviour Therapy (DBT) in the 1980s and 1990s. Original research was with people who had severe emotional dysregulation or self-harm behaviours, but it is now widely regarded as a transdiagnostic treatment. DBT is a multi-modal treatment underpinned by a biosocial theory of emotional difficulties, a set of guiding principles and the three key paradigms of acceptance, change and dialectics. The model of therapy contains four key modes of treatment: • skills training group which has a key role to teach DBT skills • individual therapy, which has
a key role for assessment of problem behaviours and individual assistance to apply skills in the real world • telephone coaching between sessions to allow someone to assist the person to apply skills when it counts • team consultation, which promotes adherence to the principles and practice of the treatment and provides support to therapists. The consultation team mode is something above and beyond clinical supervision. It is using many brains to help resolve an individual’s difficulties. The emphasis on adherence minimises the risk of ineffective therapy.
The three paradigms of acceptance, change and dialectics each have various principles embedded within them. The acceptance paradigm encourages both therapist and patient to engage in the present moment. Reality acceptance skills include the invitation to respond willingly and effectively to the situation at hand, even when we don’t like the situation that we are in. Acceptance allows us to tolerate the reality without staying miserable or doing things that make the situation worse. Acceptance IS NOT approval, liking, condoning, giving up, or resignation. It is a necessary precursor to change.
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GUEST COLUMN The change paradigm encourages clarity about the behaviours that are being targeted and assists with commitment to goals. Analysis of the function of maladaptive behaviours, maintaining persistence with effective actions over time and following skills instructions ‘to the letter’ are considered essential. The dialectics paradigm assists with resolution of polarities including the seeming opposition between acceptance and change. It helps people get unstuck when conflicts arise, and it takes a systemic viewpoint that seeks to find the complex transactions that are at play in any given situation. The troublesome thing is that very few people in WA are able to receive comprehensive DBT because those services are not available. Many therapists deliver DBT-inspired approaches, however, these are not the same as comprehensive DBT. Linehan states that if there is no consultation team, then it’s not DBT. There are many people here in WA for whom quicker access to comprehensive DBT could turn unbearable suffering into tolerable pain.
A significant number of people who access something called ‘DBT’ are only receiving DBT skills training. Treatment ‘dismantling’ studies show that the skills group is vital, however, individual therapy and access to phone coaching is often needed for those people with complex difficultto-treat disorders such as borderline personality disorder. Everyone can gain from DBT-type skills. Some do benefit from only DBT skills training or solo individual therapy, but it is inaccurate to call it DBT. This sets people up to say that DBT has failed when in fact they haven’t actually received DBT. It is heartbreaking to hear people who gain from using DBT skills say, “I wish I had learnt these strategies earlier.” Thankfully there are researchers in the US taking DBT skills training into schools. The DBT in Schools developers lament the ‘Waiting to Fail’ scenario – where schools wait until someone develops extreme symptoms before intervening, which really doesn’t make sense. There are significant problems in WA that need urgent solutions. People with complex mental health conditions and atypical responding
patterns are getting stuck in EDs and hospital beds. This is exactly the cohort that DBT was developed to treat. Funding more beds isn’t what is needed – that just helps people remain stuck in the cycle of suicidality and hospitalisation as a way of life. We have people with potentially good prognoses languishing untreated or undertreated. There is a definite ‘postcode lottery’ for comprehensive DBT within the public sector. And, in those areas where a form of comprehensive DBT is available, we have people dying by suicide while on long waiting lists. Unfortunately, comprehensive DBT is not easy to establish in the private sector because Medicare and health fund rebates are inadequate to cover the necessary duration of service. A government funded statewide DBT service is urgently needed to facilitate the delivery of this lifesaving treatment in WA. ED: Dr Cole is a consultant psychiatrist specialising in DBT at the Marion Centre.
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A love letter to Mt Lawley Construction is due to start on a luxury residential development in Mt Lawley, on the back of the strongest sales in apartments in Perth in the past five years.
Leading Perth developer Willing Property has confirmed it is about to start construction on its $40.5million luxury residential development – No. 7 Field Street – which is now 60 per cent sold. Growing confidence in off-the-plan sales, combined with more owneroccupiers investing in high-quality homes, has seen Perth apartment sales surge to the highest levels since 2016, according to property consultancy Urbis. No. 7 Field Street is a unique collection of 24 residences and six townhomes designed by Hillam architects and award-winning heritage architects Griffiths Architects. It offers an unprecedented level of luxury by combining heritage design with contemporary architecture and lifestyle features. Willing Property Managing Director Tim Willing said it had been designed in response to buyer feedback and demand. “With so few apartments of this quality in the area, No 7. Field Street is an ideal option for local downsizers seeking a luxury residential option in a neighbourhood with which they are familiar,” he said. “We have designed the residences in response to demand for a home in Mt Lawley that doesn’t compromise on space, gardens, quality or amenity.
“The 30 luxuriously-appointed residences have been meticulously considered, planned and designed to appeal to a wide range of homeowners and lifestyle needs.” The residences are almost 50 per cent bigger than comparable apartments on the market, with no two floorplans the same. They feature quality craftsmanship, lush green private grounds and a low-maintenance, lock-up-and-leave lifestyle. The 6-green-star building delivers on amenity and technology, with features including a heated outdoor pool, private gym, yoga studio and sauna, dog wash room, resident concierge-style mail room and three elevators. The residences, which are only a 200-metre walk to Beaufort Street, are surrounded by a private park featuring expansive landscaped gardens and shared social spaces
by award-winning Tim Davies Landscaping. The homes themselves feature high ceilings, crafted cornicing and skirting, timber flooring, wool carpeting, underfloor heating, generous-sized verandahs, and premium appliances and fittings. Mr Willing said the price of twobedroom apartments start from $869,000, while three bedrooms are from $1,289,000. Townhomes are from $1,599,000, with fourbedroom penthouses at $2.7m. He said there was nothing like it on the market in WA, and inquiries had exceeded all expectations, with many buyers from Perth and the Eastern States keen to secure a property. It is the second luxury development for Willing Property in Mt Lawley in the last 12 months, following the successful Clifton + Central project.
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Telehealth critical for mental health care Video telehealth is key to making mental health services more accessible in regional WA, says psychiatrist Dr Oleh Kay. Until recently, mental health service provision in rural and remote Australia has long suffered from chronic staff shortages, inadequate access, long wait times and limited Medicare funding. The pandemic, alongside a growing mental health crisis, has only heightened the challenges facing patients and practitioners alike. The figures speak for themselves. The most recent statistics from the Australian Institute for Health and Welfare reveal that the number of psychiatrists, psychologists and mental health nurses per capita is rapidly declining in regional and remote areas. There are 3.5 psychiatrists per 100,000 people in remote regions compared to 13 in major cities. This, matched with vastly higher rates of suicide and self-harm in areas outside major urban centres, has created a growing crisis.
Challenges of distance The obstacles facing people in rural and remote areas trying to access adequate mental health support begins at the first step - accessing a psychiatrist or psychologist in close proximity. And even when there is a practising mental health practitioner, waitlists can be long. If patients take that first step to reach out for help but are told the services are either unavailable or a wait time counted in months, there is a risk they’ll give up, further exacerbating an already crisis-level situation. Mental health practitioners in these areas also face issues like burnout and high levels of stress as a result of high demand and limited resources.
Using video telehealth COVID-19 lockdowns forced many healthcare practitioners to change the way they operated, and this was no different for the mental health sector. My team and I at PsychPlace had to climb a steep learning curve during the first lockdown in March
2020, and during the subsequent snap lockdowns, which forced us to implement a telehealth strategy. Prior to which, our experience with telehealth technologies was zilch, largely due to a lack of Medicare or Department of Veterans' Affairs rebates. Video telehealth enabled us to continue seeing patients. Not only that, it enabled the practice to extend its reach to communities in rural and regional WA, helping us provide more support to those who need it. Prior to the pandemic, patients had to travel from places such as Exmouth and the South West, driving or flying kilometres for appointments. Some had to fly a 1,800km round trip. The introduction of rebates for psychiatric and psychology telehealth services has been a game changer for patients and practitioners alike. The video element of our telehealth service is crucial for our practice and our patients. It enables visual engagement between practitioner and patients, creating a closer connection, all without the need to travel. Telehealth has enabled mental health practitioners to not only maintain the health and safety of our patients during the pandemic but also more easily reach new patients – those who can so easily
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slip through the system can now more easily access mental health support online via telehealth.
Long-term vision As the government continues to build its post-pandemic healthcare strategy, mental health services and telehealth funding should be a priority. The Federal Government’s pledge to fund a $2.3 billion mental health package, combined with the extension of telehealth until December 2021, is a move that has been welcomed by mental health practitioners and advocates. However, rebates for mental health appointments via telehealth need to be affordable and we’re still unclear how this is going to look after December. In fact, this is essential if we want a mental health system that is accessible for anyone and everyone that requires care. Telehealth can be a critical lifeline for those struggling with mental health conditions in regional and remote areas, as well as those who are unable to travel due to health issues. In areas in which there are a limited number of practitioners, telehealth offers greater flexibility for patients, allowing them to avoid long journeys to the nearest psychiatrist or psychologist and overcome many of the obstacles preventing them from accessing care. continued on Page 33
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What’s the future for Primary Health Networks? WA Primary Health Alliance CEO Learne Durrington explains the role ahead for the PHN program in WA. The extraordinary circumstances of 2020 and 2021 highlighted the important role that primary health care providers and Primary Health Networks should play during a crisis. But while there is much goodwill and commitment from primary health care providers, they struggle to maximise existing capabilities for response, relief and recovery if they lack coordination, leadership and support. This highlights a more systemic challenge for the sector – one which PHNs of the future are keen to support. In 2015, the Australian Government’s PHN Program established 31 PHNs across Australia to strengthen primary health care and improve service integration. In Western Australia,
WA Primary Health Alliance was selected through a competitive tender process to oversee the three WA PHNs – Perth North, Perth South and Country WA. The PHN program was independently evaluated in 2018 and found to be well progressed in achieving early outcomes against the initial objectives. Through increased understanding of local health needs, the development of effective partnerships fostering integration (particularly with health service providers and State/Territory equivalents) and innovative ways of commissioning evidence-based primary health care services, the PHN program demonstrated it could influence the efficiency and effectiveness of medical services.
Subsequent reviews have shown PHNs are taking a leadership position within their communities to foster the development and performance of the primary health care sector and working strategically towards integration across primary, acute and aged care sectors. The recent addendum to the National Health Reform Agreement 2020-2025 redefines the strategic objectives of PHNs: • identifying the health needs of their local areas and development of relevant focused and responsive services • commissioning health services to meet health needs in their region • improving the patient journey through developing integrated and coordinated services
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GUEST COLUMN • providing support to clinicians and service providers to improve patient care • facilitating the implementation of primary health care initiatives and programs • being efficient and accountable with strong governance and management PHNs feature prominently in the National Health Reform Agenda. Their role is central throughout the Primary Health Reform Steering Group’s 20 draft recommendations to inform the National 10 Year Primary Health Care Plan, the Productivity Commission’s Inquiry Report into Mental Health and the 2021/22 Federal Budget Aged Care priorities. Primary health care is a vital part of Australia’s healthcare system, and never more so than during a crisis. Although Commonwealth and State agencies have overall responsibility for on-the-ground disaster management during natural disasters and health emergencies, PHNs can coordinate a strong primary health care response where and when needed, reducing pressure on the acute sector.
It is essential that disaster management is integrated and coordinated between all key stakeholders and the role of primary health care and PHNs is supported by all levels of government. WAPHA continues to be a key contributor to the vaccine rollout in WA, having supported 583 general practices statewide to take part in the rollout, with many now providing both Pfizer and AstraZeneca vaccines. This includes 14 Commonwealth Vaccination Clinics (also known as GP Respiratory Clinics), which deliver COVID-19 vaccines as well as crucial assessment and testing of
COVID-19. Considering the evolving outbreaks in other states, these clinics play an increasingly critical role in keeping our communities safe. WAPHA is also assisting the Australian Government in the coordination, planning and delivery of COVID-19 vaccines to residents and staff of residential aged care facilities across WA. Close engagement with GPs, practice teams and peak organisations will continue to be at the forefront of WAPHA’s COVID-19 response strategy.
Telehealth mental health care continued from Page 31 However, telehealth should go hand in hand with building local mental health capacities and services, as both play a pivotal role in creating more equitable access for more Australians. ED: Dr Oleh Kay is a consultant psychiatrist at PsychPlace. Silvia Pfeiffer, CEO and co-founder of video telehealth platform Coviu, provided input.
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OCTOBER 2021 | 33
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GP tools to cut CVD risks A new toolkit is helping GPs calculate CVD risks in their patients, as the Heart Foundation’s Natalie Raffoul explains. An estimated 340,000 West Australians live with cardiovascular disease. On average, 150 people are hospitalised each day with heart, stroke and blood-vessel disease and nine people die from these conditions. In outback North-West, hospital stays for heart attack are more than double those of the Wheatbelt – just one of the differences in heart health outcomes seen in WA. But, while the challenges in addressing CVD are big, so are the opportunities to detect and manage those at risk. Too many times we hear of people who think they’re fine but don’t realise they’re a ticking time bomb. For many, it is not uncommon for a heart attack or stroke to be the first sign of something seriously wrong. Modifiable CVD risk factors account for 90% of heart attack risk, reinforcing the fact that CVD is largely preventable. We know that high blood pressure and high cholesterol are two of the biggest risk factors for heart attack and stroke. These conditions are often silent or symptom free but are largely preventable and treatable if they’re picked up and managed. In WA, more than 600,000 adults have hypertension, more than 730,000 have high cholesterol, 1.2 million are living with obesity, 1.5 million are not active enough and more than 255,000 smoke. General practice teams, not only in WA but right across the country, play a pivotal role in the fight against CVD. The impact of COVID-19 on chronic disease prevention remains untold, but data shows that many Australians postponed health services in the past 18 months, from emergency treatment of acute conditions to preventive health assessments like Heart Health Checks. The Heart Health Check is the first preventative health assessment
MBS item (699 or 177) to incorporate absolute CVD risk calculation and facilitation of yearly assessment. This absolute assessment brings together the combined risk of multiple CVD risk factors to estimate a person’s chance of heart attack or stroke in the next five years. General practice staff have many tasks to juggle and require simple and practical tools when it comes to assessing cardiovascular risk and managing it, which is where the Heart Foundation’s Heart Health Check Toolkit comes in. The toolkit was developed with involvement of a national primary care expert advisory group, while a broader general practice validation group tested and reviewed the resource to ensure it was both practical and relevant. It is a combination of online tools to support the systematic implementation of Heart Health Checks via a whole-of-practice approach. Including: • Templates: Pre-filled assessment and management forms make it is easier for GPs and practice nurses to collect CVD risk factor
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information and support patients to manage their risk in line with clinical guidelines. • Recall guidance: Patient invitation templates, a receptionist’s guide and data recall recipes help general practice teams to identify and reach out to at-risk patients. • Patient resources: Waiting room posters, animations and brochures are available to engage and motivate patients about their heart health. • Quality improvement tips: Kickstart continuous activities relating to CVD risk as per the PIP QI program and gain financial incentives. By making the Heart Health Check easier to plan and implement, the toolkit aims to encourage the integration of these checks into routine patient care to help lower the sickness and death from CVD in Australia. ED: Natalie Raffoul is the Heart Foundation's National Risk Reduction Manager. She acknowledges the assistance of co-ordinator Sophie Gohl in the writing of this column.
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HBF launches no-gap joint replacement trial: places now open HBF, South Perth Hospital and HFRC are offering a unique pilot program that aims to reduce costs and speed up recovery. Places for suitable HBF members are open now. Patients needing a knee or hip replacement often have two key concerns – the out-ofpocket costs, and how long they’ll need to spend in hospital. “At HBF, our members have told us that they want to be with their family as they recover and get on with their lives, rather than being in hospital or having to regularly travel back to hospital for rehabilitation for weeks on end,” says Dr Daniel Heredia, HBF Executive General Manager – Health. “Our members have also raised concerns about out-of-pocket costs and hospital excess charges in addition to paying for outpatient rehabilitation services – on top of paying their health insurance premiums.”
Refer a patient now
To find out more or request an appointment contact: Murdoch Orthopaedic Clinic (08) 6332 6332
38 | OCTOBER 2021
delivered by a multidisciplinary team, who will also oversee the patient throughout their admission for surgery at South Perth Hospital.
Key messages • New pilot program for hip and knee replacements • Reduced out-of-pocket costs and less time in hospital
To address this, HBF, South Perth Hospital and leading rehabilitation provider HFRC have teamed up to provide an innovative pilot program, designed to reduce costs and facilitate faster recovery.
3. Rehabilitation at home. Following surgery at South Perth Hospital, participants will undertake a six-week rehabilitation program delivered by HFRC. This combines face-to-face home visits and telehealth, overseen be a rehabilitation physician. Participants will have access to a nurse, exercise physiologist or physiotherapist, and 24-hour telephone support.
How the program works
What does it cost?
The pilot program is open to HBF members only, and is made up of three stages:
Participating HBF members will not be charged a gap by their surgeons, and any hospital excess will be waived.
• Available for HBF members.
1. Pre-operative assessment. An orthopaedic surgeon will assess the member to determine if they are clinically suitable for the program.
HBF will also cover the cost of providing rehabilitation in the home.
2. ‘Joint school’ education program. Patients who are deemed suitable will then take part in an education program
Participating surgeons include: Ben Jeffcote
Gerald Lim
Mark Hurworth
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OPINION BACK TO CONTENTS
Dr Joe Kosterich | Clinical Editor
Move it, move it! This is the second year running (excuse the pun) that the City to Surf has been cancelled. I will never break any land speed records but it is certainly an annual goal to extend my runs up to 12km in the lead up to late August. Reaching the finish line is always a boost to the spirit. Increased training in any physical activity can remind us of muscles we haven’t thought about for a while.
Exercise has been shown to be beneficial for both physical and mental health. As doctors, we are also prone to stress and perhaps never more so than in this ongoing pandemic. It is a cliché, but we do not always look after our own health as well as that of our patients. Regular exercise is something we can all incorporate into our schedules, and it can be as simple as a walk.
Statistics tell us that many presentations in primary care are related to the musculoskeletal system. It may be sore backs, arthritic joints, sports injuries, or generalised soreness. It is estimated that one in five Australians live with chronic pain and a significant percentage of these people have musculoskeletal pain. Despite this prevalence, this body system often gets less attention and less research than others. This month we look at approaches to assessing and managing ACL injuries, scoliosis, and Achilles’ tendinopathy. We are increasingly aware of the downside of too many tests, so the piece on when not to investigate joint pain is timely. Muscle cramps are a common problem and there is a surprising factor that may make these more likely. Exercise is important for all. It can be tricky for those using insulin to control their diabetes. A new app being developed here in WA looks to solve that problem. For something different we also look at new ideas in management of psoriasis. Exercise has been shown to be beneficial for both physical and mental health. As doctors, we are also prone to stress and perhaps never more so than in this ongoing pandemic. It is a cliché, but we do not always look after our own health as well as that of our patients. Regular exercise is something we can all incorporate into our schedules, and it can be as simple as a walk. After one of the coldest and wettest winters in decades, spring offers us the opportunity to get outside and be active in the fresh air. We should all commit to using our muscles more. Lastly, as the vaccination rates increase, we edge closer to being reunited with friends and family who don’t live in WA. We can even dare to dream of wandering around in faraway places!
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OCTOBER 2021 | 39
Management of common spinal complaints By Dr Paul Taylor & Greg Cunningham, Spinal Surgeons, Murdoch Spinal pain is one of the most common musculoskeletal problems managed in primary care as one in six people have back problems (ABS data). Around 3% of all GP appointments are for the management of this issue increasing to approximately one in three males or one in four females aged 55 to 64. Rates in those aged under 25 is significantly lower but results in the highest rate of hospitalisation for any age group – possibly reflecting a more sinister aetiology.
New Clinical Care Standards for low back pain, currently under consultation, will help guide management.
Adult Degenerative Scoliosis The development of scoliosis in patients aged over 60 is not uncommon (prevalence reported from 2% to 30%). This may be only an incidental finding on a chest or abdominal radiograph requiring no specific management. In some it is the fundamental cause of their increasing back pain, sciatica, and declining mobility.
These patients are usually complex, and consideration of concurrent lower limb arthritis and cardiovascular pathology is necessary. Spinal CT or MRI imaging can identify specific nerve root impingement and illustrate the deformity. First line management involves self-guided exercise; 20 minutes walking in water three times per week is a good start that most tolerate. Physiotherapy and guided epidural steroid injections can be helpful. Onward referral can be necessary if pain is recalcitrant, or the deformity is progressing clinically or radiographically. Surgery to treat adult spinal deformity is a demanding task, even utilising the most modern, minimally invasive techniques. Many are too frail to be considered candidates. Most over age 75 or with significant medical comorbidities are more safely managed with a pain medicine specialist. Advances in surgical techniques and technology, particularly 3D intraoperative imaging, are increasingly affording safe deformity corrections. These treatments are usually comfortably offered to patients in their 60s with progressing deformity and significant pain symptoms. Decision making for the treatment of those with only moderate symptoms but significant deformity in a younger age bracket (50-60) is more complex. For some surgical treatment preventing a predictable deterioration is favourable before they become too frail for major surgery and its rehabilitation.
Adolescent Idiopathic Scoliosis
Severe adolescent idiopathic scoliosis with subsequent surgical correction
40 | OCTOBER 2021
Present in approximately 5% of females, this common diagnosis can provoke significant anxiety and concern. The idiopathic aetiology is only confirmed once specific diagnosis including syrinx, tumour
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Key messages
Adolescent Idiopathic Scoliosis often requires referral with both public and private services available
In adults, age and co-morbidity significantly influence treatment decisions
Pars fractures in adolescent athletes require prompt diagnosis and treatment.
or an underlying syndrome is excluded. Curve magnitude as measured by the ‘Cobb angle’ and the degree of skeletal maturity as measured by the ‘Risser grade’ are key to guiding management. Skeletally immature patients (typically under age 14) with a cobb angle more than 10 degrees usually require referral as they may benefit from treatment to guide their spinal growth and minimise the scoliotic deformity. Those with cobb angles more than 40 degrees warrant prompt surgical referral given the
predictable worsening of deformity in time.
as cricket, football and soccer are typically causative.
Historically, in WA, this surgery was solely performed in the public sector. There is now a private hospital option for these patients that some may not be aware of. A specific scoliosis physiotherapy clinic can also provide treatments. Older, skeletally mature (Risser grade >4) patient with a cobb angle <40 degrees are typically well managed on a specialised physiotherapy pathway, rarely if ever requiring surgical treatment.
Initial management of a suspected pars stress fracture is cessation of all sport until a diagnosis and treatment plan is made. A GPreferred Lumbar MRI for patients under 16 can attract a Medicare rebate. The 3D-VIBE MRI sequence can be performed if requested to yield equal diagnostic accuracy to a CT scan in identifying a pars fracture. There is no role for CT in the adolescent lumbar spine.
Pars fractures Stress fractures through the pars are common incidental findings on up to 7% of lumbar imaging, rarely requiring treatment in the adult population in the absence of sciatica or major spinal deformity. Pars stress fractures in the adolescent athlete are the opposite, needing aggressive management for optimal outcomes. Approximately half of adolescent athletes with low back pain will have a spondylolysis. Sports involving lumbar extension such
If a pars fracture is identified without anterolisthesis, treatment with a specialist sports physician is recommended to guide the safe rehabilitation and return to sports, aiming to heal the fracture and prevent recurrence. A mismanaged acute pars stress fracture can result in significant impairment and inability to return to sports. Authors competing interests – nil
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DCISionRT® – a new biological profiling test for breast cancer DCISionRT® is a new risk assessment test for women diagnosed with ductal carcinoma in situ (DCIS) of the breast. DCIS is the finding of abnormal cells confined to the milk ducts of the breast. In Australia, about 1600 women are diagnosed with DCIS each year. DCIS is most often detected on routine mammographic breast screening as it does not usually present as a lump or change. While not considered initially life threatening, those with DCIS are four times more likely to develop invasive breast cancer compared to those without the diagnosis. At five years post diagnosis, the risk of invasive cancer is 5.3%. Most women are recommended for breast-conserving surgery as the treatment of choice. Mastectomy is also appropriate for a small proportion of patients. There is level 1 evidence that postoperative radiation therapy (RT) to the breast further reduces the risk of both invasive cancer and DCIS by approximately 50%. As DCIS comes with varying risks of recurrence, the challenge facing clinicians is how to select patients with a low recurrence risk for whom surgery alone is sufficient and how to select those high-risk patients who will obtain a significant absolute benefit from the addition of adjuvant RT. DCISionRT® is a precision medicine tool which assesses an individual tumour’s 10-year risk of recurrence of both ipsilateral breast events (DCIS + invasive carcinoma) and invasive carcinoma alone. It also predicts the additional benefit from adding breast RT to breast conserving surgery. It is the only predictive test developed specifically for this purpose and can assist clinicians to more confidently make
a treatment recommendation based on an individual tumour’s molecular protein expression signature in addition to the traditional clinical and pathological factors. The test uses seven immunohistochemical markers to calculate a protein expression signature which is combined with clinicopathological factors to generate a recurrence score from 0-10. The risks can then be discussed with the patient so that a more informed treatment decision can be made. International validation studies have been completed in over 3500 women. Interestingly, the studies demonstrated that initial treatment decisions changed in 30-50% of cases due to the results of the DCISionRT® test. For example, among women whose DCIS was initially thought to have a low risk of recurrence or progression, two in five had their risk reclassified as elevated when assessed with DCISionRT®, revealing a potential need for RT after surgery. Furthermore, in women less than 50 years of age who are generally considered to have an elevated risk of recurrence, and for whom RT would usually be recommended, DCISionRT® found that almost one in two were classified as low risk, indicating that surgery alone may be appropriate. Genesiscare is proud to be partnering with PreludeDX to provide access to the DCISionRT® test to women across Australia. A national registry project has been launched to prospectively follow up these patients.
Dr Yvonne Zissiadis Radiation oncologist
About DCISionRT® • DCISionRT® is a predictive test to assess the recurrence risk and benefit of the addition of radiation therapy to surgery in women with ductal carcinoma in situ of the breast. • The test was developed and validated in over 3,500 patients across six distinct patient cohorts. • The test can be applied to the breast biopsy or surgical sample; no additional procedure is required. • The cost of the test included in a bundled payment for radiation therapy offered by GenesisCare if radiation is required • If no radiation therapy is needed at the time of the results, there is no cost to the patient. – References are available upon request. Dr Zissiadis is a consultant radiation oncologist with GenesisCare who subspecialises in breast cancer and Chair of the Australian Breast Tumour Reference Group for GC.
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Our centres Bunbury • Hollywood • Fiona Stanley Hospital Joondalup • Mandurah • Wembley Tel: 1300 977 062 | connection@genesiscare.com www.genesiscare.com 42 | OCTOBER 2021
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When (not) to use tests in patients with joint pain By Dr Hans Nossent, Rheumatologist, Nedlands Joint pain is a frequent presenting complaint. Many physicians order a panel of antibodies in patients with musculoskeletal complaints screening for a rheumatic disorder. Traditionally this includes testing for presence of Rheumatoid factors (RF), antibodies against Citrullinated Cyclic Peptides (ACPA or anti-CCP) and antinuclear Antibodies (ANA) and sometime HLA-B27 and ANCA tests. This strategy is expensive (approx. $150 to the taxpayers) and inappropriate when there is no clinical evidence of joint inflammation. Arthritis is a clinical diagnosis with typical examination findings of synovial inflammation (i.e., swollen, tender, sometimes red and warm joint(s) having reduced range of motion). Most patients with arthralgia will not have arthritis/ synovitis and following examination will not require further investigations for arthritis (Figure1).
Key messages
RA is a clinical diagnosis RF and ACPA testing are not needed to diagnose RA and there is a high risk of false positive
These autoantibodies have only a limited role in delineating disease severity in patients with a clinical diagnosis of RA.
Table 1. Conditions associated with a positive RF Rheumatic diseases
Frequency in %
Rheumatoid arthritis #
50-90
Systemic lupus erythematosus #
15-35
Sjøgren’s syndrome #
75-95
Systemic sclerosis #
20-30
Polymyositis/dermatomyositis #
5-10
Cryoglobulinemia #
40-100
Mixed connective tissue disease #
50-60
Infection
contribute to the maintenance of immune tolerance. The isolated finding of increased levels of autoantibodies in the circulation thus does not suggest the (impending) presence of autoimmune disease. As illustrated (Figure 2), healthy people with findings of an autoantibody are considered to be in a state of (? increased natural) autoimmunity but only a minority will progress to a state of autoimmune disease.
Bacterial endocarditis #
25-50
Hepatitis B and C #
20-75
Tuberculosis
8
Syphilis #
Up to 13
Parasitic diseases
20-90
Leprosy#
5-58
Viral infection #
15-65
Rheumatoid Arthritis (RA) is defined and diagnosed by the presence of chronic, usually symmetric synovitis involving wrist, MCP, PIP and MTP joints. These clinical findings are sufficient to diagnose RA, as there is no specific laboratory test for diagnosis
This progression, through a complex and poorly understood processes of antibody maturation by somatic mutations, is impossible to predict or even prevent. Thus, positive autoAb results in patients without clinical evidence of synovitis do not indicate a current or future inflammatory joint disease.
Natural autoantibodies circulate in healthy persons where they
Autoantibodies and RA Rheumatoid factors (RF) are polyclonal
Figure 1
Pulmonary disease Sarcoidosis #
3-33
Interstitial pulmonary fibrosis
10-50
Silicosis
30-50
Asbestosis
30
Miscellaneous diseases Primary biliary cirrhosis #
45-70
Malignancy #
5-25
Age > 70 years
5-25
antibodies directed mainly against modified sites of the Fc portion of IgG. The origin of this antibodyagainst-antibody response is not well understood, but most likely results from a durable or strong stimulus (e.g., smoking, infections) leading to alterations (glycosylation, phosphorylation) in the molecular structure of IgG, which then provokes a humoral immune response with activation of RF producing B cells. The possible useful functions of RF include clearance of the resulting Ig-IgG immune complexes. RF activity can be mediated by antibodies of all Ig subclasses, but most clinical laboratories traditionally only measure IgM-RF, with RF from IgA, IgG, IgD and IgE subclasses mainly used in research projects. continued on Page 45
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OCTOBER 2021 | 43
Treatment Algorithm for Chronic Achilles Tendinopathy By Mr Reza Salleh, Orthopaedic Surgeon, Subiaco Achilles tendinopathy is a relatively common condition affecting up to 2% of the population. The cause is usually repetitive intense activity as can be seen in athletes or may also be degenerate in nature. It is most commonly seen in the midsubstance of the Achilles tendon as well as at the insertion into the posterior calcaneum. The diagnosis can usually be established by clinical examination with focal tenderness and swelling over the mid-substance or swelling at the posterior heel often from an insertional enthesophyte. Pain can be reproduced by tendon loading activity such as a single heel rise. The first priority of clinical examination, however, is to exclude a complete rupture and a calf squeeze test has excellent validity for this.
pain scores, poorer function and prolonged symptoms.
Key messages
Chronic Achilles tendinopathy is easily treated in general practice.
Many conservative treatment options can relieve most tendon pain
Most failing to respond to conservative care will find relief from surgical treatment.
The main role of imaging is to exclude an associated tear that can alter management and prognosis. Ultrasound scans are useful and colour doppler demonstrates increased blood flow. In a normal Achilles tendon, blood flow is generally not detectable. Abnormal blood flow is linked to greater
Patient presents with Achilles tendor pain
Begin eccentric exercise programme 6-12 weeks
Respond Continue maintenance exercises (1) Continue eccentric exercises Modify load, consider GTN patch 6-12 weeks
(2) Continue eccentric exercises, add biomechanical assessment +/- orthotics Continue GTN patch 6-12 weeks (3) eccentric exercises, add pain-relieving adjuncts such as Lithotripsy, steroid iontophoresis 4-6 weeks (4) Night splint, Camwalker 8-12 weeks
(5) Surgery
44 | OCTOBER 2021
Conservative treatments Many treatments are available for chronic Achilles tendinopathy but there is often little scientific evidence for most conservative and surgical treatments. Nevertheless, conservative treatment is recommended as the initial strategy, involving a multifactorial approach including rest and activity modification, and alteration of shoes and orthotics. Eccentric musculotendinous training exercises lengthen the muscle unit with an external force and alter tendon pathology in the long term with a positive effect on Type 1 collagen production and increasing tendon volume over time, thus increasing tensile strength.
Exclude rupture, evaluate peritendinous structures
Not respond
Ultrasound scans have limitations in detecting more proximal partial thickness ruptures closer to the myotendinous junction and differentiating between older partial ruptures and intra-tendinous degeneration. Hence MRI scanning may be more accurate in determining the extent of partial thickness tearing as a percentage of the crosssectional area of the Achilles tendon.
Repetitive stretching and lengthening of the tendon unit may also increase capacity to effectively absorb load. Studies show that a 12-week program of eccentric training can successfully reduce symptoms in approximately 90% of those with mid-substance Achilles tendinopathy, but in only 30% with insertional tendinopathy. The application of topical Glyceryl Trinitrate directly onto the tendon theoretically helps by increasing local blood supply to stimulate a reparative response, and also through the action of nitric oxide to stimulate collagen and tendon healing. There are potential side-effects of hypotension and headaches, and it is thus best to initially use Glyceryl Trinitrate when sleeping. Extracorporeal Shockwave Therapy has been shown to reduce pain by
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CLINICAL UPDATE Local corticosteroid injections around the Achilles tendon and associated bursae do have a lower but still significant risk of causing a tendon rupture. As such iontophoresis is perhaps a safer method of delivering corticosteroids.
High-grade partial thickness tear on background of chronic Achilles tendinopathy
Night splints have been shown to be an effective intervention to help to stretch the tendon unit and overcome associated gastrocnemius contractures. Immobilisation fully weight-bearing in a Camwalker can have similar effects as well as preventing overload of the tendon during walking.
probably promoting regenerative processes in the Achilles tendon.
Surgery
Short-term effects of corticosteroid injections reduce pain and swelling. However intra-tendinous injections are contra-indicated because of the catabolic effects of the steroid which can cause tendon ruptures. Corticosteroids reduce inflammation and inhibit production of granulation tissue and adhesions.
Surgical treatment is indicated for those who fail to respond to conservative treatment. It includes percutaneous or open tenosynovectomies which can result in long-term improvement with 75% of patients reporting good or excellent results after 18 months. More controversial treatments include
percutaneous or open tenotomies to stimulate a healing response. Of more concern is a partial thickness tear which can potentially result in a full thickness tear. This is increased by corticosteroid injections and medications such as Fluoroquinolones. There is also the risk of spontaneous conversion to a complete rupture. Once over 30% of the cross-sectional area has commenced tearing the risk escalates. In these patients’ debridement and Achilles tendon repair can lead to excellent results in terms of pain resolution and preventing complete rupture. – References available on request Author competing interests – nil
When (not) to use tests in patients with joint pain continued from Page 43 There are multiple assays in use for the detection of IgM-RF (agglutination test of sensitised sheep red blood cells, latex fixation test (LFT), turbidimetry, radioimmunoassay, enzyme-linked immune-absorbent assays (ELISA) and as RF testing is unfortunately not standardised, results are not per se comparable from one WA laboratory to the other. In addition to these technical issues, multiple population-based studies have found that the presence of RF often is part of the natural
autoAb repertoire with less than 10% specificity for RA (Table 1). Taken together it comes as no surprise that the high rate of false positive results makes IgM-RF useless as a screening method for RA. In short, RF testing cannot replace joint examination.
and a range of citrullinated proteins (e.g., vimentin, fibrinogen) can trigger an antigen-driven maturation of B-cells to produce anti-CCP Ab. This immunological process is essentially similar to what underlies RF formation.
Antibodies against artificially produced cyclic citrullinated peptides (anti-CCP Ab) arise when citrullination of proteins occurs during a post-translational conversion of arginine to citrulline residues by peptidylarginine deiminase enzymes (PAD). Such citrullination can occur during inflammation of multiple tissues
Anti-CCP Ab can be detected in up to 5-10% of healthy individuals and is thus not recommended as a screening method for RA. In patients with evidence of synovitis, anti-CCP Ab are as sensitive as RF and more specific (around 70%) for confirming RA. Anti-CCP Ab also associate with genetic risk factors for RA and delineate a subset of RA patients with more severe disease. Importantly, ELISA based anti-CCP Ab testing is largely standardised.
Autoimmunity (pos. Auto Ab findings) is not a disease
Most patients presenting with joint pain will not have synovitis on joint examination and, in this setting of low pre-test probability, there is a high risk of false positive results (especially with RF) and unnecessary spending of health dollars. These patients are better served by allied health assistance with their underlying degenerative joint problems (osteoarthrosis) or soft tissue pains than a referral to a specialist based on the incidental finding of RF or ACPA. – References available on request
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A review of psoriasis By Dr Harvey Smith, Dermatologist The Lancet, when not retracting bogus MMR research papers or trying to ‘out-woke’ the NEJM, still produces comprehensive and reasonable updates of interest to the general reader. This is a personal commentary on Psoriasis (Griffiths, Christopher E M et al. The Lancet, Volume 397, Issue 10281, 1301 – 1315, April 03, 2021). I once worked for one of the authors in what a medical geologist might call the PreBiologic era.
External factors linked to the development of psoriasis remain largely limited to a small number of drugs and streptococcal pharyngitis precipitating widespread small plaque pattern termed ‘guttate’. It seems that around 40% of guttate cases progress to chronic plaque psoriasis. Classification includes acute small plaque, chronic large plaque, pustular and erythrodermic. Some quaint terms still exist for rarer variants, which can be safely filed by the general reader. Of interest though is that 90% of cases are
chronic overall, most will have scalp involvement, with 50% having nail involvement.
Fascinating as all this is, it remains that a biopsy of psoriasis is not required for diagnosis.
Looking at a section of psoriatic skin, we would see too much of everything. Too many keratinocytes, too many lymphocytes and other workers of the skin immune system. If one delved into the key immune pathway’s cytokines such as TNF-α, IL-17 and IL-23 would emerge as key players revolving around a manager: the Th17 lymphocyte subset of skin bound memory cells.
Associated non-skin pathologies are dominated by arthritis. Around 30% of patients will suffer this, sometimes before the onset of a rash. The patterns vary from oligoarthritic, asymmetric small joint and spondyloarthropathy. In severe psoriasis a modestly increased risk (x 1.3) of cardiovascular disease and NIDDM are noted. While this may relate to a genetic linkage for the conditions
Grants for research projects Ramsay Hospital Research Foundation has launched a new grants program, thanks to a $25 million injection from the Paul Ramsay Foundation. It aims to fund high quality, innovative research projects that improve patient outcomes and address key determinants of health. Funding will be offered every year for the next five years and will 46 | OCTOBER 2021
focus on four clinical areas: cancer, mental health, cardiovascular disease, and orthopaedic surgery and musculoskeletal injury.
Grants are open to universities and medical research institutes to do research within or outside of Ramsay Health Care.
Paul Ramsay Foundation CEO Professor Glyn Davis said projects needed to address a specific determinant of health, such as health literacy, social and lifestyle risk factors, or the effects of climate change on health.
Expressions of interest can be made via RHRF’s new online portal, the Research Ethics, Governance and Grants System, or REGGS.
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Psoriasis affects 2-3% of the world population with the majority developing the condition before 40. The genetic basis continues to be discovered. From each psoriasis linked gene an immune pathway flows opening the possibility of targeted therapeutic intervention.
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Key messages
Psoriasis is a major world health issue
Joint involvement can occur without skin lesions
Biologic therapies are often successful in clearing severe disease. it remains at present an association not causation. The potential for psoriasis to be linked with depression is now emphasised within the literature. Treatments have significantly changed over the past 20 years. Inpatient treatment with tar, dithranol and Psoralens UVA phototherapy are gone, with topical corticosteroid being the mainstay for most patients. UVB phototherapy has a strong track record of safety only limited by the ability of patients to access a brief treatment two to three times per week for at least 8-12 weeks. Conventional oral treatment has consolidated around ciclosporin, methotrexate and acitretinoin with 40-60% of patients being controlled by these interventions over a three-month period. However, what has really changed are the options for a patient with severe psoriasis – an extensive area of body involvement and failure to respond to conventional oral treatment. These patients now
have access to biologic therapies through a closely controlled PBS eligibility system. These agents are in general engineered monoclonal antibodies to key receptors or cytokines involved in the psoriatic immune cascade. Given by injection at regular intervals and with a high degree of patient tolerance, it is not an overstatement to say this has revolutionised the treatment of patients who had life-ruining disease. They are often now totally clear of the condition. The costs of these drugs run into the tens of thousands. With some biologics now off patent in Australia, it will
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be interesting to see if accessibility alters. However, compared with other drugs, biologics are high cost to produce and the savings from generics may be constrained. Despite considerable improvements to our knowledge of the immunology of psoriasis, basic answers to questions such as the distribution of plaques remain. One hypothesis is proposed by this paper: the distribution reflects the distribution of memory T cells within the skin. Author competing interests - nil
OCTOBER 2021 | 47
A multidisciplinary approach to ACL injury By Dr Ross Radic, Orthopaedic Surgeon, West Perth To facilitate successful return to sport, ACL injury management requires multidisciplinary approach involving the patient's GP, physiotherapist, sports physician and sports orthopaedic surgeon. ACL ruptures remain a common injury sustained by young, athletic individuals, with a peak age of 15-19 for females and 20-24 for males. Accurate diagnosis is key, with detailed physical exam and MRI to assess for concurrent injuries, particularly to menisci, chondral cartilage and ligamentous structures. Each treatment program is tailored to promote the highest chance of successful return to sport and activity.
Case example A 20-year-old representative level netballer landed awkwardly during a competitive netball game and felt her knee give way with severe pain. The knee swelled immediately. On review, Sarah had sustained a ruptured ACL and MCL damage, confirmed on subsequent MRI, with associated large medial meniscus tear. Given her young age, high level sporting commitments and the complex nature of her knee injury, Sarah is undergoing a period of ‘prehab’ with an experienced sports physiotherapist. Prehab is followed by reconstructive surgery with meniscal preservation and a comprehensive post-operative
rehabilitation program supervised by her orthopaedic surgeon, sports physiotherapist and strength and conditioning coach.
Additionally, an index of suspicion or diagnostic uncertainty also warrants referral for specialist opinion and/or further imaging.
It was previously acceptable to delay diagnosis of a sports-related knee injury; apply RICE (Rest, Ice, Compression and Elevation), clinically assess the knee, and apply a soft-structured treatment program. With advances in MR imaging quality and availability, as well as surgical sub-specialisation, early diagnosis of soft tissue injury is now the standard.
Surgical versus non-surgical options for ACL injury management are topical. Patients are inundated with information from practitioners, peers, and even social media. As such, patients may query not ‘when,’ but ‘if’ ACL reconstruction is warranted.
Patient awareness of ‘ACL rupture' and ‘knee reconstruction’ is also growing, prompting increased presentation for specialist advice and treatment soon after injury.
Imaging indications and management There are key features in clinical assessment which should alert the clinician to the need for additional investigation and imaging (MRI). These include: • Injury was sustained from a noncontact, pivoting manoeuvre or awkward landing (at least twothirds of ACL injury are noncontact injuries) • Initial inability to weight bear • Hearing a ‘pop’ at time of injury • Early knee swelling • A feeling of instability in the knee • Previous instability episodes, and • Similar occurrences or previous injury to the other knee
NEW SS RE ADD AME & N iously
Best management depends on patient factors and associated injuries to the knee joint. For some, early surgery after a period of prehab is the evidence-based pathway for return to best function. The younger the patient, the more likely they are to benefit from reconstructive surgery. Similarly, the higher their level of sports participation, the more beneficial reconstructive surgery can be. Critically, associated meniscal and chondral cartilage injuries warrant surgical intervention for stabilisation and prevention of injury related joint degeneration. On the contrary, patients who have ‘pure’ ACL injuries (with no meniscal, chondral or concomitant ligamentous injury), do not suffer from instability, swelling or mechanical symptoms and are generally those who play social as opposed to competitive pivoting sports are candidates for a nonoperative approach. If there is progression or nonresolution of symptoms, surgery can always be considered later.
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Key messages
Accurate diagnosis is key – knee swelling, instability episodes and traumatic sporting injuries warrant referral for MRI and specialist review Multidisciplinary input including evidence-based rehabilitation is critical to recovery Surgical treatment decisions depend on associated injuries and patient factors. A multidisciplinary approach when managing ACL injury, regardless of whether opting for operative or non-operative treatment is important. Usually, the patient spends most of their treatment time with their physiotherapist working on proprioceptive control, followed by strength and conditioning. There are circumstances where early surgery is indicated, primarily due to a structural issue blocking movement (classically a bucket handle meniscal tear) or more complex injury pattern. However, a period of prehab focusing on swelling management, restoring
range of motion, gait normalisation and initial strength recovery is crucial in setting the patient up for a successful return to sport after treatment. In most instances, allowing the knee to ‘cool down’ and getting the patient comfortable with the knee is an important goal to achieve prior to undergoing any surgical treatment.
Successful return to sport This is one of the most frequently asked and most difficult questions to answer. In practice, the actual return to sport will vary widely from patient to patient. After ACL reconstruction, patients can theoretically return to running at three to four months, sports specific training at six months and full return to sport from nine months. However, complex injuries and the addition of meniscal or chondral pathology add time to a treatment plan. The importance of a steady, evidence-based rehabilitation program, which is especially important in young (particularly skeletally immature) and elite level athletes, is increasingly recognised.
I often talk about satisfying three people when considering a return to full sport: 1. The physiotherapist / exercise physiologist who often has an intimate knowledge of the physical recovery. 2. The surgeon, or sports physician – it’s important there is no overt instability in the knee, recurrent swelling, or loss of motion. 3. The patient – needs to feel ready to return to the rigours of their chosen sport. This includes both physical and psychological readiness, with research demonstrating each one is as important as the other. ACL injuries are common, particularly in young athletes. History and examination findings can alert the practitioner to the possibility of ACL injury and warrant further investigation with MRI and specialist opinion. Input from all members of the multidisciplinary team with a structured ‘prehab’ and ‘rehab’ program provides the patient with the best chance of successful return to sport. Author competing interests – nil
Has your patient been injured at work or in a motor vehicle accident ? Guardian Exercise Rehabilitation’s allied health clinicians provide treatment and prescription of therapeutic exercise-based programs for individuals afflicted with injury or illness, principally under a compensable-injury policy.
Experienced team of mobile Physiotherapists and Exercise Physiologists Industry leaders in clinical exercise interventions Outcomes focused with self-efficacy for clients Video consultations where required through
A useful free e-resource for chronic pain www.guardianexercise.com.au/painbook
Our clinicians consult clients across a broad spectrum of injuries and illnesses, with significant experience in both musculoskeletal injuries and mental illnesses. We consult clients throughout their recovery journey, from early intervention through to chronicity management. We adopt a biopsychosocial approach with emphasis on collaboration, education and empowerment. Our programs optimise function and healthy re-engagement in work, as well as everyday and recreational activities. Referring to Guardian Exercise Rehabilitation will ensure your patient receives the most appropriate treatment required for the stage and complexity of their injury or condition. E-Refer now at guardianexercise.com.au
T. 1800 001 066 F. 1800 001 077
E. admin@guardianexercise.com.au
MEDICAL FORUM | MUSCULOSKELETAL MEDICINE
Mobile services: Physiotherapy | Exercise Physiology
OCTOBER 2021 | 49
Complex non-melanoma skin cancer patients? Refer cases to the Non-Melanoma Skin Cancer Advisory Service for multidisciplinary review The benefits of a multidisciplinary approach to patient management are well known. The Non-Melanoma Skin Cancer Advisory Service (NMSCAS) has been established to enhance the care of patients with complex non-melanoma skin cancers. To submit cases to the NMSCAS for advice or management either: •
Send a detailed referral letter with images and pathology
•
Or visit genesiscare.com/au/refer-a-patient then click on Refer to the WA non-melanoma skin cancer advisory service to download the referral forms.
Case information must be received no later than 1 week prior to the scheduled meeting.
•• NMSCAS meets every third Thursday of the month
Clinipath Pathology 310 Selby Street North Osborne Park WA 6017
NMSCAS specialist team: Dermatology Dr Kate Borchard Dr Judy Cole Dr Glen Foxton Dr Qadir Khan Dr Louise O’Halloran Dr Jamie Von Nida Dr Yee Tai Pathology Dr Trevor Beer Dr Gordon Harloe Dr Joseph Kattampallil Dr Stephen Lee Dr Ben Ryan Plastic surgery Dr Adrian Brooks Dr Sharon Chu Dr Brigid Corrigan Dr Mark Hanikeri Dr Daniel Luo Dr Linda Monshizadeh Dr Remo Papini Radiation Oncology Dr Eugene Leong Dr Susan Mincham Dr Evan Ng Dr Kasri Rahim Dr Craig Wilson Dr Yvonne Zissiadis
Referrals and all enquiries to: mdtskinwa@genesiscare.com 50 | OCTOBER 2021
0419 610 298
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CLINICAL UPDATE
Drinking plain water makes muscle more prone to cramping By Professor Ken Nosaka PhD, School of Medical & Health Sciences, ECU Muscle cramp is a painful, involuntary muscle contraction which can occur in any muscle, with calf and foot cramps being most common. Muscle cramp itself is usually harmless, but the pain and discomfort caused can be significant and affect other aspects of life, such as sleep. Whilst the exact cause is still unknown, many factors appear to play a part. Some studies show muscle cramp is caused by an imbalance between excitatory drive from muscle spindles and inhibitory drive from Golgi tendon organs to the alpha motor neurons. However, the involvement of dehydration, muscle condition (e.g., fatigue, stiffness) and electrolytes such as potassium and sodium in muscle cramp cannot be ruled out. Muscle cramp induced during or after exercise is referred to as exercise-associated muscle cramp (EAMC). Given the prevalence of EAMC among participants of many sports – 39% in marathons, 52% in rugby, 60% in cycling and 68% in triathlons – we focused on EAMC in our studies. To quantify muscle cramp susceptibility, our previous studies used electrical stimulation to induce muscle cramp in participants by increasing the electrical stimulation frequency. The threshold frequency (TF) that induced muscle cramp was used as an indicator of how susceptible each participant was to muscle cramps. Dehydration equivalent to 2% of body mass was induced by running in 35-36C heat. We found ingesting plain water after the exercise increased muscle cramp susceptibility assessed by TF, however TF increased when oral rehydration solution (ORS) was consumed, indicating decreased muscle cramp susceptibility. These results suggested that plain water intake after dehydration made muscles more susceptible to muscle cramp, but ORS reduced susceptibility.
6.0Hz) in the same period. Hct and Hb did not change significantly for either, but osmolarity only decreased if consuming water. Serum sodium and chloride concentrations decreased (under 2%) immediately after running – again, only after drinking water. These results suggested ORS intake during exercise decreased muscle cramp susceptibility.
Key messages
Muscle cramp is induced by drinking plain water after dehydration Muscles become immune to cramp after electrolyte water is ingested Dilution of electrolytes, especially sodium and potassium, appears to be a factor in muscle cramps.
In a subsequent study, we compared changes in TF of calf muscles before and after running in 35-36C heat. During exercise, participants consumed either plain water or ORS containing sodium (1150mg/L), potassium (780mg/L), magnesium (24mg/L), chloride (1770mg/L), glucose (18,000mg/L) and others (e.g., phosphorus) while exercising. Seven days later, they repeated the test but consumed the other fluid. Calf muscle cramp susceptibility was assessed by TF before, immediately after, 30 minutes then 65 minutes after running. Blood samples were taken before, immediately after and 65 minutes after running to measure serum sodium, potassium, magnesium and chloride concentrations, haematocrit (Hct), haemoglobin (Hb), and serum osmolarity. The average (±SD) baseline TF (25.6 0.7Hz) was the same between water and ORS. Drinking plain water decreased TF (3.8 2.7 to 4.5 1.7Hz) from the baseline value immediately to 65 minutes after running, while ORS intake increased TF (6.5 4.9 to 13.6
MEDICAL FORUM | MUSCULOSKELETAL MEDICINE
TF measures do not provide cramping intensity and duration, nor the extent of pain associated with the muscle cramp. Importantly, no one had muscle cramp during the exercise in the study. One study limitation was a control condition of no fluid ingestion during exercise was included. However, our previous study showed TF did not change significantly immediately after running from the baseline without fluid intake during exercise. Thus, it seems likely no significant change in TF would have been observed, if a no fluid ingestion during exercise condition had been included. TF increased after ORS intake by 3.7Hz at 30 minutes and 5.4Hz at 60 minutes, respectively. It is important to note the ORS contains glucose and serum electrolyte concentrations were not largely different from the baseline values and between conditions. Thus, it might be the TF increase was more due to glucose than electrolytes. We need to add the same amount of glucose to plain water to examine the effects of glucose on muscle cramp in a future study. It is also interesting to investigate the effects of ‘salt’ water without glucose on muscle cramp. From the completed studies, we concluded intake of electrolytes, especially sodium and potassium, could reduce muscle cramp. It will be interesting to investigate further whether the electrolytes’ intake can reduce other types of cramp, such as nocturnal muscle cramp. – References available on request Author competing interests – nil
OCTOBER 2021 | 51
App making exercising safer for young people with type 1 diabetes By Dr Vinutha B. Shetty, Endocrinologist, PCH & TKI Managing the blood glucose levels around physical activity remains one of the most challenging aspects of living with type 1 diabetes (T1D). There is a need to develop an easily accessible exercise intervention to help young people with T1D take appropriate action to optimise glucose levels during and after exercise. Type 1 diabetes (T1D) is a chronic autoimmune condition caused by a loss of the ability to produce insulin. It affects around 1200 children in Western Australia, with approximately 160 new diagnoses every year. Exercise is a vital part of managing T1D in childhood, as well as into adulthood, resulting not only in a stronger heart but also
improved strength, fitness and mental wellbeing, reduced insulin requirements – and importantly, fewer life-limiting complications in adulthood. Despite the many physical and psychological health benefits of regular exercise, many do not meet physical activity recommendations of at least 60 minutes/day of moderate to vigorous activity, with only 40-50% of individuals with T1D achieving a physically active lifestyle. Cardiovascular disease is the most common cause of shortened life expectancy in T1D and is clearly linked to key modifiable factors, including exercise. Physical activity, however, presents unique challenges for young people with T1D, especially the risk of
hypoglycaemia, which is frequently reported to be a barrier to an active lifestyle. Inadequate patient and health care provider knowledge about exercise-related diabetes management is another significant barrier. Exercise management for young people with T1D is complex and one approach does not fit all. Many factors influence an individual’s glycaemic response to exercise including the exercise type, intensity and duration, fitness levels, insulinaemic state, environmental conditions, and anxiety and stress levels. Despite the technological advances in diabetes management, such as insulin pumps and continuous glucose monitoring (CGM) systems, which have aided in the
WESTERN ORTHOPAEDIC CLINIC WELCOMES DR ABHIJEET GHOSHAL TO THE PRACTICE DR ABHIJEET GHOSHAL
A/PROF GERARD HARDISTY
DR ALEX O’BEIRNE
MBBS, BMEDSCI, FRACS, FAORTHA
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SPINE SURGEON
Dr Aba Ghoshal is a fellowship trained spinal surgeon with experience in navigation assisted spine surgery. His special interests include degenerative, paediatric deformity, trauma, spinal infection and spinal tumour.
A/Prof Gerard Hardisty is a fellowship trained orthopaedic surgeon with a special interest in arthroscopic and replacement knee, foot and ankle surgery. His research interests are in regenerative medicine, autologous tenocyte and chondrocyte grafting, as well as total ankle arthroplasty.
Dr Alex O’Beirne is a fellowship trained orthopaedic surgeon specialising in upper limb surgery including hand, wrist, elbow and shoulder. He also has a special interest in peripheral nerve surgery, brachial plexus injury and surgery and neurological reconstruction.
Wexford Medical Centre – MURDOCH | Hollywood Medical Centre – NEDLANDS
Tel 6166 3778 | Email admin@wocwexford.com.au
52 | OCTOBER 2021
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CLINICAL UPDATE
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CLINICAL UPDATE management of T1D, managing blood glucose levels around physical activity remains one of the biggest challenges to overcome due to the often-unpredictable nature of exercise and its effect on blood glucose levels. Key professional societies and organisations have published recommendations for the prevention of exercise-related hypoglycaemia based on previous clinical studies and expert opinion. However, these recommendations can be challenging to follow and are often located in medical journals, not readily accessible to the general T1D community. Therefore, adolescents and young adults with T1D may benefit from having access to decision-support aids to effectively contextualise a blood glucose result and take appropriate action to optimise glucose levels during and after exercise.
“acT1ve” app The Children’s Diabetes Centre at Telethon Kids Institute and Perth Children’s Hospital aims to address the exercise-related challenges
faced by adolescents and young adults with T1D by developing a digital educational exercise intervention in order to support them to exercise safely and more frequently. The development included multiple components. Firstly, we conducted focus groups with adolescents and young adults with T1D to identify barriers and facilitators in managing blood glucose levels around exercise. Next, we engaged them in co-designing an exercise intervention mobile health application (app) and finally testing the functionality, efficacy and safety of the app before translation and implementation to clinical practice in Western Australia, nationally and internationally. Features include: • Personalised insulin dose and carbohydrate advice for exercise lasting up to 60 minutes based on the user’s input on the type, intensity and duration of physical activity they are about to complete, duration since the last insulin bolus and their current blood glucose levels • Information on hypoglycaemia
treatment, pre- and post-exercise insulin, and carbohydrate advice • Educational food guide that highlights the importance of low and high glycaemic index (GI) foods in the context of exercise management. In an early pilot trial, acT1ve was found to be informative, functional, acceptable and to attract high user satisfaction, making it a promising intervention for exercise management. The app was amended based on the feedback from the pilot trial. The current phase of this program involves testing the efficacy and safety of acT1ve to obtain regulatory approvals before translation and implementation of this app into routine clinical practice, as a valuable supplement to diabetes management around exercise for adolescents and young adults with T1D. ED: Dr Shetty is a Clinical Researcher at the Children’s Diabetes Centre, Telethon Kids Institute. Author competing interests – the author was involved in the app development
Perth’s comprehensive vascular and vein treatment destination
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ponoshvascular.com.au
Hollywood Consulting Centre T: 08 9386 6200 F: 08 9689 2222 HL: stponosh
OCTOBER 2021 | 53
Alcohol-free and filled with spirit A Perth woman decided it was time to give up alcohol and the journey led her to start two businesses which support and embrace sobriety.
By Ara Jansen
Sarah Rusbatch woke up one morning and decided she wasn’t feeling her best. Looking back on it, she’d been feeling like that for a little while – and it was getting worse. In 2017 she started questioning her relationship with alcohol, and while she genuinely didn’t consider herself an alcoholic, she certainly had a dysfunctional relationship with drinking. When she examined it, so much of her life revolved around drinking – a drink at home to wind down from work, drinks out with friends on the weekend and more Sunday barbecue drinking. “I’d set myself rules and limits and break them,” says Sarah. “I’d always been a drinker. That had been my story and it had never really affected me that much physically. I was proud that I never got hung over.” When she hit 40, she started to feel really average after a night of drinking. She’d wake up at 3am, couldn’t get back to sleep, was low on energy and started having panic attacks. Not unexpectedly, her mental health started to suffer. “I had really negative self-talk, everything just felt bad and I was worrying about things I would never otherwise be concerned about. I’d have a few drinks, feel OK and then I’d go back to drinking again. I just never felt my best.” She visited her doctor because of the anxiety, was prescribed antidepressants but was never asked about her drinking habits.
54 | OCTOBER 2021
MEDICAL FORUM | MUSCULOSKELETAL MEDICINE
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LIFESTYLE
LIFESTYLE
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women, redefine their relationship with alcohol and, in most cases, giving up. “The more people I talked to, the more I realised there were a lot of people who didn’t like their relationship with alcohol. If 10 on the scale is an alcoholic, then I work with people who are around a five or six, feel they have a dysfunctional relationship with alcohol and are worried about what might be coming. “I want to work with people before they get to 10, so they can solve their issues before they get to rock bottom.”
“I knew I couldn’t mix the two and she never told me to stay off the booze. I never took them because I knew there must have been something else I could do.
showed her how many non-alcoholic alternatives were available. Until recently in Perth, alternatives have been rarely available and close on impossible to find.
“After a particularly big night out with my girlfriends I decided to do a detox and see how it made me feel. I started with three weeks and ended up doing it for three months. I couldn’t believe how good I felt. Apart from when I was pregnant, I had never taken a break from drinking.
So, as necessity became the mother of invention, Sarah and a business partner started Free Spirit Drink Co, an online home delivery company stocking alcohol-free alternatives to beer, wine and liquor. They deliver around WA and across the country.
“For the first time in my adult life, I was alcohol free. I’d had a glimpse of how good it felt, I’d lost some weight and was feeling really good.” Sarah realised she had also built her social life around drinking. Her friends thought her not drinking was a phase. After a few missteps, Sarah has now been alcohol-free for 2½ years. During that time a return trip to the UK
Over the past few years, the quality and taste of no-alcohol drinks have improved markedly. Better yet, they’ve become tasty in successfully mimicking their alcoholic counterparts and don’t make you feel like you’re missing out or are relegated to sugared-up soft drinks. Sarah wanted to find a way to keep enjoying socialising with her friends and this is how she’s been doing it. Now her drinking includes Giesen Sauvignon, Lyre spirits and sparkling wine – but just all alcohol-free. A therapist helped Sarah understand why she drank and in another mother-of-invention moment, she retrained from being a career coach to become a women’s health and wellbeing coach. She is one of Perth’s first accredited Grey Area Drinking Coach, helping others, particularly
MEDICAL FORUM | MUSCULOSKELETAL MEDICINE
A few months ago Sarah realised a dream and threw an alcoholfree cocktail party at a local pub. Invitees were drawn largely from the 5000-strong Facebook group called the Women’s Wellbeing Collective for those who want to change their relationship with alcohol and the Meet-Up group, Perth Sober Socials, set up specifically for women who want to socialise in no-alcohol environments. “I want people to know they can choose to live a life without alcohol, which can be great. It’s a foreign concept to so many people. Life is so much better without it. “When I started getting sober, I was in a Facebook group of about 100 women started in the UK. They got me sober. They were welcoming, supportive and with women supporting women, it was very empowering. That’s what I wanted to create here.” The expanding choice of nonalcholic beverages means you can have a gin and tonic, or a beer from the team at Heaps Normal and Mornington, or even a more meatier stout from Upflow, on a Friday night and know that Saturday morning will dawn bright and clear. A range of alcohol free wines extends from sparklings to still wines, with Geisen Sauvignon and Edenvale and Henkell leading the charge.
Read this story on mforum.com.au
OCTOBER 2021 | 55
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WINE REVIEW
The Fraser Gallop finesse It was interesting to revisit the Fraser Gallop wines since my review last year. Margaret River has had some cracker vintages recently, the standout being 2018. Not surprisingly, my pick then was the 2018 Parterre chardonnay. This is a quality estate with excellent viticultural sites in the heart of Wilyabrup. Important to note here is that the vines are dry grown, which means that irrigation is not relied upon. From a purist’s perspective the wines therefore are, I believe, more of a true reflection of the site’s terroir. The viticultural team is headed by Mike Bolas. Mike has extensive experience worldwide – Geisenheim Germany, Bordeaux as well as in the Swan Valley, Great Southern and more recently in Margaret River. In the well-equipped cellar, vinification is carefully nurtured by winemaker Ellen Tritt under the watchful eye of chief winemaker Clive Otto. Clive’s reputation is second to none in the region, having been responsible for many internationally acclaimed wines over the years.
2021 Estate Semillon Sauvignon Blanc Lifted aromas of white flowers, hints of tropical and passionfruit. Partial barrel fermentation adds a note of intrigue to this delightful wine. Very easy to gulp on a sunny spring day. (12%, $24)
Review by Dr Louis Papaelias
2019 Parterre Chardonnay
2019 Estate Cabernet Merlot
Naturally fermented with nine months barrel maturation. Not as intense as the 2018 but, again, expertly crafted. Seamless balance of fruitiness, acidity (freshness) and tannins (oak). Not high in alcohol (12.5%), it caresses the palate without being forceful. Whilst very enjoyable and drinkable right now, it will shine brightly in a year or two. ($50)
Lovely berry fruit aromas give way to the fresh and pleasing taste of blackcurrants with hints of chocolate and olive. Nicely balanced and a clean finish. Eminently approachable now. Keep it a few years if you like. It is, like its sibling SSB, a real crowd pleaser. (13.5%, $28)
'S EWER REVI
PICK 2018 Parterre Cabernet Sauvignon Intense deep aromas of cassis, graphite and spice. Multilayered and concentrated. Integrated, complex and graceful. Lovely depth of flavour. Awarded a gold medal in the Decanter International Wine Awards A wonderful example of what has made Margaret River standout in the international wine scene. My pick of the bunch (14% alcohol, $50)
56 | OCTOBER 2021
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Margaret River Here we come! Opening soon, we are on the hunt for GPs, Nurses and Administrative
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