MAJOR PARTNERS September 2022 www.mforum.com.au Never forgotten Respiratory Health | COPD, allergy testing, lung nodules, real-time pathology
Privacy breaches and cyber incidents can happen despite your best efforts ^ # + Safeguard your practice Avant Practice Medical Indemnity Insurance^ # complimentary Cyber Insurance Supporting practices with Insurance | Finance | Technology | Risk Advice | Legal Services Protect your practice, your staff and your data today, with Avant Practice Medical Indemnity Insurance. avant.org.au/practices
In the current climate, there is good reason for people to worry about losing their GP. If anecdotes are to be believed, COVID is proving to be the final nail in the coffin for some doctors in their decision to call it quits – dubbed The Great Resignation.
EDITORIAL POLICY
I’ve banged on for years to anyone who will listen how outrageously inadequate the financial remunerations are via the MBS, proportion to the training (past and ongoing), and the ever-expanding responsibilities that rest with GPs. Money isn’t everything, but it’s not nothing either. 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.
And if surveys are to be trusted, at least one-fifth of current GPs are seriously considering pulling the pin in the next 12 months.
Seriously, I dread losing my doctor – not him leaving this mortal coil, but the R word – retiring. (Dr John you’re too young anyway).
Only the fact that the volatile financial market has bitten into superannuation savings might deter some from retiring right now. That’s not to say that general practice is not a rewarding career, although I use the word ‘rewarding’ with caution.
I have already told my GP he is not allowed to retire, but Dr John, if you’re reading this, that means you. (I have prepaid your AHPRA registration fees for the next 10 years, so there is no wriggling out of it.)
EDITORIAL Cathy O’Leary | Editor SYNDICATION AND REPRODUCTION
DISCLAIMER Medical Forum is published by Medforum Pty Ltd (Publisher) as an independent publication for health professionals in Western Australia. Neither the Publisher nor its personnel are medical practitioners, and do not give medical advice, treatment, cures or diagnoses. Nothing in Medical Forum is intended to be medical advice or a substitute for consulting a medical practitioner. You should seek immediate medical attention if you believe you may be suffering from a medical condition. The support of all advertisers, sponsors and contributors is welcome. To the maximum extent permitted by law, neither the Publisher nor any of its personnel 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 and do not represent the opinions, views or policies of Medical Forum or the Publisher. 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. 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 (Cth) as amended. All advertisements are accepted for publication on the condition that the advertiser indemnifies the Publisher and its personnel against all actions, suits, claims, loss or damages resulting from anything published on behalf of the advertiser. 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.
GPs –our treasuresnational
Advertisers
SEPTEMBER 20222 | 1MEDICAL FORUM | RESPIRATORY HEALTH
The relationship with a family doctor is like no other –even more important than the powerful bond with your hairdresser. At worst, you get a bad haircut with the latter – there is a lot more at stake with the former.
And if surveys are to be trusted, at least one-fifth of current GPs are seriously considering pulling the pin in the next 12 months.
CONTENTSTOBACK
2 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH IN THE NEWS 1 Editorial: GPs – a national treasure – Cathy O’Leary 4 News & Views 6 In brief 31 Milestone for Perth Children’s Hospital Foundation 32 AI joins the ED team 37 Reality can hit hard – Dr Joe Kosterich Cover image: Tony McDonough WINNING WINTER WARMERS Dr Alison Phillips from Midland Molescan can warm up with some spectacular reds from Evans & Tate as winner of our monthly doctors dozen competition. Check out Dr Craig Drummond’s review on the iconic Houghton Wines on Page 58. For your chance to win this month, go to www.mforum.com.au or use the QR code on this page. Inside this issue CONTENTS | SEPTEMBER 2022 RESPIRATORY HEALTH 12 14 2218 FEATURES 12 Close-up: Dr Talila Milroy 14 Respite care for homeless 18 RSL WA a health hub 22 New asthma management LIFESTYLE 56 Friends: the Musical 58 Wine review: Houghton Wines – Dr Craig Drummond ENTER OUR COMPETITIONSMONTHLYHERE CONNECT WITH US /medicalforumwa/MedicalForum_ /medical-forum-wa-magazineinfo@mforum.com.au www.mforum.com.au
SEPTEMBER 20222 | 3MEDICAL FORUM | RESPIRATORY HEALTH PUBLISHERS Fonda Grapsas – Director Tony Jones – Director tonyj@mforum.com.au EDITORIAL TEAM Editor Cathy O'Leary 0430 322 editor@mforum.com.au066 Production Editor Jan Hallam 08 9203 jan@mforum.com.au5222 Journalist Eric Martin 08 9203 eric@mforum.com.au5222 Clinical Editor Dr Joe Kosterich 0417 998 joe@mforum.com.au697 Marketing Quinn quinn@mforum.com.auHampton Graphic Design Ryan ryan@mforum.com.auMinchin AdvertisingADVERTISINGManager Andrew Bowyer 0424 883 andrew@mforum.com.au071 Clinical Services Directory Andrew Bowyer 08 9203 andrew@mforum.com.au5222 CONTACT MEDICAL FORUM Suite 3/8 Howlett Street, North Perth WA 6006 Phone: 08 9203 5222 Fax: 08 6154 6488 Email: info@mforum.com.au www.mforum.com.au CONTENTS Clinicals 7 Key role of PCR in flu & COVID times Dr Sudha Pottumarthy Boddu 47 Initial diagnosis and assessment of COPD Dr Scott Claxton 32 Bold action needed to curb silicosis Dr Renee Carey 34 Take a holiday and call me tomorrow Dr Jun Wen 52 Rare Care Centre: global needs, local leadership By Dr Gareth Baynam 54 Advanced AF rhythm management Clin/Prof Rukshen Weerasooriya 29 Hope for spinal injury becomes reality Duncan Wallace 10 The imperative of philosophy Dr Gary Ward 52 Vascular birthmarks: when to refer By Dr Rachael Foster 49 Modern allergy testing Dr KrummenacherMatthew 50 Real-time oncologypathologydigitalforsurgical Prof Camile S. Farah 39 Peripheral Lung Nodule Evaluation Dr Lokesh Yagnik 41 Acute withinfectionrespiratoryinchildrenneurodisability Dr Rachael Marpole Guest Columns This magazine has been printed using solar electricity, and the paper from plantation-based timber has been manufactured and printed with ISO 14001 accreditation, the highest environmental standard. PARTNERMAJORS
A $500,000 grant from mRNA Victoria has been awarded to Australian pharmaceutical startup RAGE Biotech, which will be directed towards development of an inhaled RNA therapeutic for chronic PerronDirectorinflammation.lungofWA’sInstitute Professor Steve Wilton is a scientific co-founder of RAGE Biotech and he developed the lead compounds for the potential novel molecular therapy for inflammatory lung disease with Professor Merlin Thomas (RAGE Biotech Founder/ Chief Scientific Officer and Monash University).
Dr Abed said this discovery would benefit all non-small cell lung cancer patients, regardless of whether they were genetically predisposed to adverse reactions to immunotherapy or not.
ECU’s Professor Cobie Rudd said the partnership with WACHS was a natural fit. The collaboration has an overarching goal of advancing and enhancing education and training that will lead to significant employment and innovation opportunities in the South West.
Bunbury Regional Hospital Director Jeff Calver said WACHS was keen to work with ECU to facilitate student placements and support educational opportunities
While immunotherapy has emerged as a major weapon in the battle against non-small cell lung cancer, which makes up 80-85% of all lung cancer diagnoses, it can also result in severe side effects for patients.
“If someone is found to not be at risk of side effects, doctors can ramp up the treatment and be more aggressive in fighting the disease,” she said. “If they are found to be at a higher risk, doctors can take it easier, monitor and intervene before patients develop serious Thetoxicity.”findings
However, principal midwifery officer at the Australian College of Midwives, Kellie Wilton, has hit back saying mothers should not be made to feel guilty about their pain relief choices and suggested hospitals could introduce nitrous oxide destruction systems to allow for its ongoing use. When these systems were introduced in Swedish hospitals, the carbon footprint from the gas was halved.
ECU & WACHS unite ECU and WA Country Health Service have signed a memorandum of understanding to develop interconnected regional clinical education, teaching, research and initiatives in the South West, including opportunities for internships, graduate employment and new course development.
NEWS & VIEWS continued on Page 6 Out of gas CONTENTSTOBACK
Gene aid in treatment
“The work is promising for chronic lung inflammation and a number of other respiratory disorders, and we look forward to further developments of antiinflammatories,” Professor Wilton said.
4 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
Nitrous oxide is used by more than 50% of Australian women to relieve pain in labour, followed by epidurals (nearly 40%) and opioids (12%), according to the AIHW. However, its carbon footprint (representing 6% of global gas emissions, with 1% due to health care) has led to a debate whether it should be replaced with other methods of pain relief.
Anaesthetist Professor Bernd Froessler and colleagues compared patient notes for all 243 women birthing at Lyell McEwin Hospital over a seven-week period in March/ April 2020, half of whom did not have access to N20. They found that although opioid use “significantly increased” when N20 was withheld, there was no increase in epidural use and no change in labour duration, caesarean section rates, birthing complications or newborn alertness.
Oncologist and ECU researcher Dr Afaf Abed and her team have been examining the human makeuplinkandlung179antigensleukocyte(HLAs)ofnon-smallcellcancerpatientsfoundastrongbetweenthegeneticoftheHLAsand whether the person was likely to develop side effects from immunotherapy.
were published in the European Journal of Cancer Inhale relief
As the health system scrambles to reduce emissions, attention has turned to nitrous oxide in the labour suite. A study out of Adelaide is saying that birthing women denied nitrous oxide to relieve labour pain during the COVID-19 pandemic have turned to opioids instead, without any adverse outcomes for mother or child.
At least 74% of those treated will experience immune-related adverse reactions and up to 21% of those will develop grade three or four toxicity, which can lead to lifelong complications affecting the skin, gut, liver or endocrine system.
SEPTEMBER 20222 | 5MEDICAL FORUM | RESPIRATORY HEALTH perthradclinic.com.au Meet Western Australia’s largest team of fellowship trained respiratory radiologists At Perth Radiological Clinic your chest imaging investigations are reported locally by WA’s largest team of fellowship trained accredited respiratory radiologists: • Teaching hospital consultant radiologist appointments. Involved in multidisciplinary team meetings at FSH, MIHC, Mount Hospital, SCGH and JHC. • RANZCR registered experts in occupational dust lung disease (RANZCR EODLD register) • Expertise in all types of chest disease including malignancy, ILD, occupational lung diseases, lung cancer screening, vascular diseases and trauma. Dr Stephen Melsom Dr Ramon Sheehan Dr Anuj Patel Dr Mark Teh Dr Roche Helberg Dr Jeanne Louw Dr Arjuna Somanathan Dr Bann Saffar Meet our doctors or for more information email sales@perthradclinic.com.au Silica Dust Have your patients been exposed? MAJOR PARTNER CONTENTSTOBACK
Murdoch Children’s project lead Professor Andrew Steer said the study would investigate how many children got sore throats, what was the most common cause and how they could change during different seasons of the year. The information collected will help inform how a vaccine could be used to prevent a wide range of illnesses caused by Strep A, including impetigo, septicaemia, rheumatic heart disease and kidney disease.
Former AMA national president Dr Omar Khorshid and WAPHA CEO Learne Durrington are the WA members on the Strengthening Medicare Taskforce.
Silverchain’s Dr Robyn Rayner, Professor Keryln Carville, Joanna Smith and Cate Maguire’s research article on a skin tear assessment tool has been recognised at the Coloplast Biatain Literary Awards.
More than 1000 children are being sought for a study to learn more about sore throats and how best to prevent them. The STAMPS study, led by Australian Strep A Vaccine Initiative (ASAVI) partners – Murdoch Children’s Research Institute (MCRI) and the Telethon Kids Institute – are recruiting 1050 healthy children, aged 3-14 years, in Melbourne and Perth.
Fighting MND Perron Institute and studentUniversityMurdochPhD Theunissen(Frankie)Frances is a finalist in the 2022 category.ScientistinSciencePremier’sAwardstheStudentoftheYearFrancesis a member of the Motor Neurone Disease Genetics and Therapeutics group at the Perron Institute, with lead Professor Anthony Akkari, and the Centre for Molecular Medicine and Innovative Therapeutics, Murdoch HerUniversity.workfocuses on identifying genetic markers for sporadic MND, where there is no prior family history. “Using these markers, we aim to group together patients who continued from
6 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH NEWS & VIEWS for students, which is anticipated to contribute to regional health Bunburyworkforces.Regional Hospital will be undergoing a $200 million redevelopment, while ECU Bunbury campus offers courses in nursing and midwifery, science, medical and health science, exercise science and paramedicine among others.
ASAVI co-director, Telethon Kids Institute Director Professor Jonathan Carapetis, said a Strep A vaccine was urgently needed.
IN BRIEF
Strep A infections disproportionately affect young children, the elderly, pregnant women and Indigenous Australians. Rates of rheumatic heart disease among Indigenous populations in northern Australia are some of the highest in the world. There is currently no vaccine available to prevent Strep A and infection can only be treated with antibiotics.
“A safe and effective Strep A vaccine is an important and practical solution for disease control, which will do so much to not only close the gap in Indigenous health in Australia but ease the burden of diseases caused by Strep A globally, particularly in developing countries,” he said.
Say arrgh for science
Over $600,00 of Healthway funding has gone to Curtin University health researchers, with Professor Jonine Jancey being awarded $379,374 to counter marketing of e-cigarettes and other electronic novel products and other amounts to Dr Zenobia Talati (sports stars marketing junk food), Professor Justine Leavy (alcohol advertising) and Dr Jonathan Hallett (young people and gambling marketing).
Page 4
The Lions Eye Institute has opened a new clinic at the Midland Specialist Centre under the leadership of Dr Hessom Razavi. He is joined by Dr Antony Clark, Dr Geoffrey Chan and Dr Jean-Louis de Sousa
Fremantle GP Dr Brett Montgomery has joined the Australian Asthma Handbook Guidelines Committee. Dr Montgomery is also a senior lecturer at the UWA.
continued on Page 8 CONTENTSTOBACK
SEPTEMBER 20222 | 7MEDICAL FORUM | RESPIRATORY HEALTH Scan the QR code or hoursforclinicallabs.com.au/locationvisitrespiratoryclinicopeningandlocationstoday!
The gradual relaxation of public health measures in WA since March 2022, along with the resumption of international travel, has been associated with increasing influenza detections since March 2022 (2 in March, versus 593 in June, Table 2).
assay which
emphasizes
By Dr Sudha Pottumarthy-Boddu MBBS FRCPA SARS-CoV-2 and co-circulating the need for multiplex respiratory nucleic detection includes both influenza and SARS-CoV-2 for multiplex PCR to diagnose and including SARS-CoV-2 allows the clinician to have a rapid and accurate diagnosis. enable the clinician to initiate targeted treatment early, avoiding inappropriate antibiotic therapy. ongoing evolution in the trends of respiratory infections in the current winter of 2022, emphasizes the testing for a broad range of respiratory pathogens in addition to SARS-CoV-2, if clinically indicated.
Dr Sudha Pottumarthy-Boddu has a distinguished career in microbiology with extensive experience in the US New Zealand and Australia. Sudha is a Diplomate of the American Board of Medical Microbiology, and a member of both the Antimicrobial Stewardship Committees and Infection Prevention and Control Committees at multiple St John of God hospitals in WA.
• A recent report from UK noted that viral co-infections were noted in 8.4% of the 6965 patients with SARS-CoV-2 infections (227 had influenza viruses, 220 had RSV and 136 had adenovirus detections).
Predictable seasonal patterns of influenza viruses worldwide is the backbone of worldwide influenza surveillance systems and vaccination programs over the past several decades. However, the public health measures implemented worldwide to contain the SARS-CoV-2 virus (between early 2020 and early 2022) resulted in a dramatic impact on the circulation of influenza and other respiratory viruses (Table 1). The total absence (0) of influenza detections between March to June 2021, is in stark contrast to 3296 detections in 2019 (Table 1).
influenza viruses are
D(ABMM) Key role of PCR amidst flu and ongoing COVID-19 Table 1. Comparison of Clinical Labs Respiratory PCR Panel diagnoses between March to June – 2019 versus 2021 and 2022 in Western Australia VIRUS TYPE NUMBER OF POSITIVE DETECTIONS MARCH TO JUNE 2019 MARCH TO JUNE 2021 MARCH TO JUNE 2022 Influenza A & B 3296 0 674 RSV (A & B) 371 81 63 Parainfluenza 1,2,3 & 4 240 271 71 MetapneumovirusHuman 92 214 137 Human Adenovirus 151 89 99 Human Rhinovirus 939 2832 1190 • Testing guidance from CDC when
• The weekly notifications of laboratory-confirmed influenza to NNDSS from mid-April 2022, has been reported to exceed the 5-year average.
A/B
respiratory viruses? The
influenza
• Australian National Notifiable Diseases Surveillance System (NNDSS) reported that influenzalike illness (ILI) activity has increased since March and peaked in May and June 2022.
• The CDC further highlights the need to remain vigilant for influenza infections even in summer and stresses the ongoing need to perform testing for influenza viruses and monitoring for novel influenza A virus infections.
• Summarising the United States influenza activity of 2021-2022, Centers for Disease Control and Prevention (CDC), reports that: o unlike the typical influenza season which begins in fall and peaks in February each year, in the 2021-22 season, influenza activity began to increase in November and remained elevated until mid-June; o it featured two distinct waves, with A(H3N2) viruses predominating for the entire season, with the second wave resulting in higher percentage of positive laboratory detections and higher number of hospitalisations than the first.
Building Better Partnerships 1300 367 674 | clinicallabs.com.au MAJOR PARTNER
viruses. Why test
• Influenza A notifications constituted 82.7 % of laboratoryconfirmed influenza reported to NNDSS, of which 94.4% were influenza A (unsubtyped).
This will
respiratory viral infections,
• Despite the acknowledgedlimitationsinthestudy, SARSCoV-2 co-infection with influenza viruses, was associated with receipt of invasive mechanical ventilation, compared to SARS-CoV-2 monoinfection.
The
• 16,707 influenza notifications were reported to NNDSS in the fortnight ending July 17th, 2022, with 204,911 total notifications to date in 2022.
acid
References on request
CONTENTSTOBACK
“This technique previously led the team to report on the pathology of ME/CFS and to examine specific ion channels in cells. Patients can experience different symptoms depending on which cells in the body are affected – from brain fog and muscle fatigue to possible organ failure,” she said.
Cutting red tape
Hi to HyCASA Hollywood cardiothoracic surgeon Pragnesh Joshi and cardiac electrophysiologist Rukshen Weerasooriya are leading a team which will make Perth a training hub for the specialist heart procedure Hybrid Catheter Ablation and Surgical Ablation (HyCASA).
You can read Prof Weerasooriya’s clinical column on Page 54.
8 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH NEWS & VIEWS continued from Page 6
Insight into Long- COVID Griffith University researchers are hoping to find a treatment for Long- COVID after proving the illness shares the same biological impairment as patients with Chronic Fatigue Syndrome –known internationally as Myalgic Encephalomyelitis (ME/CFS). Their study suggests COVID-19 could be a potential trigger for ME/ CFS and their 10 years of research on ME/CFS could help fast-track understanding and treatment of Long–University’sDirectorCOVIDofGriffithNational Centre for Neuroimmunology and Emerging Diseases, Professor Sonya Marshall-Gradisnik, said researchers had pioneered a specialised technique known as electrophysiology or ‘patch-clamp’ in immune cells.
It is considered the first in the Southern Hemisphere. They are expecting to train 12 teams in the next 18 months and have started with clinicians from Peninsula Private Hospital and Monash Medical Centre in HyCASAMelbourne.is a keyhole minimally invasive surgery performed on a beating heart. It is for patients with long-standing persistent atrial fibrillation (AF) and its aim is to interrupt the AF circuits and return the heart back to a normal rhythm. It combines endocardial radiofrequency ablation (which treats the inside of the heart) with epicardial ablation (which treats the outside of the heart). Most patients considered for HyCASA have persistent AF or previous procedures have not been Profeffective.Weerasooriya said a comprehensive HyCASA training program was important to provide AF patients with increased access to the procedure in Australia, New Zealand and the Asia Pacific.
Already, nearly 10 million cases of COVID have been reported in Australia and 5% are expected to be left with long-term illness. The findings will be published in Journal of Molecular Medicine
CONTENTSTOBACK
“The government is very reluctant to fund anything under Medicare in general practice that doesn’t involve the GP doing it,” said one of the petition authors, NSW GP Professor Charlotte Hespe. She hopes to change that. have similar underlying genetic mechanisms, allowing us to identify subgroups that may respond more favourably to certain therapies,” she said. “We hope this strategy will help us improve the outcomes of clinical trials for MND and inform the development of targeted treatments.”
The RACGP has called on the Federal Department of Health to allow GPs to approve access to subsidised glucose monitors for their patients. Not only is managing patients with type 1 diabetes within a specialist team well within the scope of GPs, it gave greater access for people with type 1 diabetes to essential monitoring and effective management of their condition, said college president Adj/Professor Karen Price. “On 1 July this year, the government announced that access to subsidised continuous glucose monitoring and Flash GM products for patients with Type 1 Diabetes would be expanded via the National Diabetes Services Scheme (NDSS). However, the NDSS outlines that health professionals authorised to certify continuous and flash glucose monitoring access forms are those for whom diabetes is the main scope of their practice.
“There is no logical explanation why other members of a health-care team are authorised, but GPs are excluded. Not only is it insulting to GPs, it creates an unnecessary barrier to patient access for something that could make a real difference in managing their health.”
In another RACGP push, a petition has been raised to allow practice nurses to give flu jabs under the supervision of a GP in general practices. The petition urges the government to create a new MBS item number for this purpose, based on existing item 10988 (an immunisation provided to a person by an Aboriginal and Torres Strait Islander health practitioner).
SEPTEMBER 20222 | 9MEDICAL FORUM | RESPIRATORY HEALTH Respiratory ForServicesmoreinformation To learn about the expertise and interests of our specialists, visit bit.ly/FaS-Subiaco subiaco.cpd@sjog.org.au (08) 6462 9689 sjog.org.au/subiacoGPs Our respiratory medicine service provides care for patients with lung diseases. We provide inpatient and outpatient services, including a full suite of Lung Function Testing, Functional Assessments, Outpatient and Inpatient care, for all respiratory diseases including biologics for asthma. Our specialists offer multidisciplinary, interventional and multi-specialist care in Lung Cancer, Pleural Disease, COPD, Bronchiectasis and Interstitial Lung Diseases. RESPIRATORY SPECIALISTS Dr Maree Azzopardi Professor Eli Gabbay Dr Veena Judge (Paediatrics) Dr KP Lim Dr Annie O’Donnell (Paediatrics) Dr Miranda Smith Dr Lokesh Yagnik CONTENTSTOBACK
We all
clinics
Locations: Cockburn, Como, Rockingham, Mandurah MURDOCH PSYCHIATRY is looking for multiple psychiatrists to join our, dynamic MDT team of psychiatrists, nurses, TMS clinicians, registrar psychologists, and occupational therapists.
• Rural
•
Our professional psychiatry services provide accessible and innovative evidence-based care at locations across southern Perth.
Why work for us Work in your area of interest, closer to home, great financial incentives for private practice starters in competitively priced rooms. Consortium arrangement for established practices.
10 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
The clinical governance model of all essential practice policies and procedures to help reduce private practice risks and complexities. In-house peer review, great referral base, cloud-based software, marketing campaigns and multiple other benefits. Neurologists, behavioural pediatricians and geriatricians are welcome to invite.
The imperative of philosophy GUEST COLUMN Ignoring philosophy and its relevance to medicine is like ignoring gravity, explains Perth GP Dr Gary Ward.
To express interest, or have a friendly chat please email tajsingh@murdochpsychiatry.org or call 0434 252 672 know gravity exists – we don't know exactly what it is, but we know we can't ignore it. We know philosophy exists, but mostly we ignore it – at our peril. Why is philosophy relevant to medicine? And what are the dangers of ignorance of its Philosophyinfluence? underpins how we think about the world, our relationship to the environment, and each other and shapes how we know what we know. Philosophical worldviews shape our perceptions of relationships, ethics, politics, aesthetics and the environment. At this point in human history, there seems to be a shift in the philosophical orientation we have to the world. A dominant world perspective until now might have been called dualism. This view has given rise to all the examples of ‘them’ and ‘us’ such as tribalism, war, colonialism, political parties and domestic violence. The dualistic perspective also separates the mind from body (the perspective that our consciousness and the stories and memories we carry are somehow housed in a separate domain called mind, separated from the rest of our Perhapsbody.)we are transitioning from a Newtonian, interactional, machinelike dualistic perspective of how the world works to one where there is a more complex flowing relationship between humans and the other aspects of the environments in which we are embedded. Evidence for this shift (on the macro-scale) includes the general acceptance of human-induced climate change and other forms of environmental degradation and (on the micro-scale) the recognition of the importance of the microbiome to our health. Historically, it has been an error or at least a blindness to the fact that humans are part of the milieu in which we exist and that we affect that milieu and are inescapably influenced by it. How is this relevant to medicine? Modern medical practices emerged
We
Treatment-resistant depression clinic: a. CBT and DBT treatment b. rTMS powered by Modalis c. Esketamine approved site. First responders’ clinics: DVA/ADF Drug and Alcohol Support Network: In liaison with Cockburn Wellbeing providing home detox and ongoing support. ADHD Clinic: Assessment and Pharmacotherapy, OnTrac ADHD Groups and 1:1 session Australian disability support services: One-stop-shop for psycho-social disabilities. are looking forward to extending our model of care for: Child and Adolescent clinics Memory Clinic • Complex, neurodiverse development clinics Civil Forensic Psychiatry and remote psychiatric
CONTENTSTOBACK
•
•
CONTENTSTOBACK
At the macro-level, might we shoulder a wider responsibility to offer not only biological solutions but a philosophical solution to the world’s most pressing problems?
Murdoch Hospital, Gate 3) Tel: (08) 9366 1500 | receptiononcologymurdoch@genesiscare.com genesiscare.com Where to find us
associated pain. Before proceeding with treatment, you should discuss the risks and benefits of the treatment with an appropriately qualified health practitioner. Individual treatment outcomes and experiences will vary. 100 Murdoch Drive, Murdoch WA 6150 (access via St John of
At GenesisCare, Murdoch your patients have access to high-quality, evidence-based care, tailored to their individual needs. Our campus location, collaboration with the SJOG Hospital network, and partnership with SKG Radiology, gives patients access to all their cancer treatment and care in one place. Patient care is managed by a multidisciplinary team of sub-specialised cancer experts, supporting seamless, personalised care with minimal wait times for specialist consultation and treatment. Radiation therapy inc. MR-Linac Imaging and diagnostics Inpatient oncology services Cardio-oncology Clinical trials Bringing the latest innovation in including skin irritation and God
•
The adages ‘you are what you eat’ and Hippocrates’s famous quote “Let food be thy medicine, and let medicine be thy food” are more credible with current science. There is also now acknowledgment of the contribution of fitness developed through exercise that helps build immunity, and that the use of the body’s natural systems through vaccines works to develop the capacity to live with pathogens and not have to eliminate them. A process-relational philosophy might underpin an orientation in medicine to work with patients to develop resilience, build or rebuild capacity, restore balance, to develop a surplus of health to forestall threats. Not a battle, but a Mightconstruction.weinvest more time and resources into this activity? What might it look like to offer this perspective to our patients?
•
• Theranostics •
Perhaps it is time for the medical profession (and the community) to develop the capacity to follow the adage “prevention is better than Whencure.” patients (or the government) pay us to provide health care, might we begin to offer a better return on their investment by delivering processes or new habits to build resilience and a surplus of health?
At a micro-level, do we take responsibility for our own health, or do we ignore the impact on patients when we display and demonstrate that we don’t care about our own health? If we are to advise patients on how they might reduce stress, might we practise what we preach?
ED: Dr Gary Ward is a Perth GP specialising in preventive medicine and health promotion.
SEPTEMBER 20222 | 11MEDICAL FORUM | RESPIRATORY HEALTH as a response to what is generally seen as external threats – infectious diseases such as cholera, plague, smallpox, etc and the trauma caused by conflict or accidents, or internal threats such as cancer, arthritis, or atheroma. The dualistic metaphor of war is used in this interactional orientation, which sees germs as the enemy, or cancer or inflammatory diseases as illnesses to be Perhapsfought.amore helpful orientation might come from a processrelational philosophy illustrated by the generally accepted perspective of evolution as a process of gradual change. That means we are in an inextricable relationship between what came before and what emerges to produce adaptations best fit for current circumstances.
•
GUEST COLUMN
GenesisCare, Murdoch - bringing the latest treatment technology to WA New integrated cancer centre
cancer care *Any medical procedure or treatment involving the use of radiation carries risks,
In addition, the development of all life forms, including us humans, has occurred in a dynamic relationship between and within the whole environment of the planet (and universe). Environmental science and ecology also illustrate the interconnectedness of humans and the Muchenvironment.ofmedical science and practice is now beginning to incorporate this perspective. For example, the recognition that we live in an intimate relationship with bacteria and other organisms that reside on us and in us, most of them beneficial, if not essential.
Setting course for change
“I thought about doing law, but it didn’t really interest me,” Talila says. “Plus, I was more engaged in science in high school. I also knew there was a huge discrepancy between the health of Aboriginal people and non-Aboriginal people. Medicine seemed like the place where I could make the biggest impact. I chose psychology as my major in my science degree which has worked in well.”
Talila was the only Indigenous medical graduate in her 2015 class at the University of Sydney. She spent her intern and resident years at the Royal Prince Alfred Hospital. With a Bachelor of Medicine and Surgery from the University of Sydney, Talila also has a Bachelor of Science, majoring in ShePsychology.spenther
undergraduate years working in the Faculty of Economics and Business at Sydney University, The Garvan Institute and Moreton Consulting. She gained further experience doing her rural general practice medical school placement in Roebourne and medical elective team at the Aboriginal Medical Service Redfern.
Dr Talila Milroy chose medicine because she’s passionate about Aboriginal social justice and hopes it will help her make a difference. By Ara Jansen
A mother of three, Talila had her first child in her first year of university, her second just before starting her medical degree and her third after finishing the degree. Her return to Perth in 2019 to start working as a GP was for numerous reasons including being closer to family, her children spending time with their cousins and the general cost of living.
CONTENTSTOBACK
Talila is a GP at Jupiter Health Clinic in Spearwood. One of drawcards of being a GP is not only the flexibility of work but there’s a lot of advocacy work, advising and helping people navigate the health system.
A Yindjibarndi and Palyku woman, Talila grew up in Perth, with family in the Pilbara. When she was 13, her mother got a job in Sydney, so she finished school there.
Earlier this year she was awarded her Fellowship with the Royal Australian College of General Practitioners. She lectures at UWA’s Centre for Aboriginal Medical and Dental Health and is considering a masters and PhD.
“Being able to use my position to help ofannon-AboriginalAboriginalcommunitymembersvulnerableofour–and–isimportantpartmyjob.”
12 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
CLOSE-UP
When she left high school, Dr Talila Milroy thought becoming a journalist was the way for her to advocate for Aboriginal social justice. She certainly never thought she would become a GP. Luckily for her patients, she didn’t enjoy the media and communications course and not long after, decided a switch to medicine, with a strong feeling it would better satisfy her goals around social justice, health care education and research.
CLOSE-UP
In May, Aboriginal health service South Coastal Babbingur Mia announced Talila’s appointment to their team. In a landmark appointment, she is the first Aboriginal GP to work there and possibly one of the first to work in the Rockingham and Kwinana “Babbingurdistrict.
“It also means a lot doesn’t need explaining so the patients don’t need to go through certain cultural and social factors as they are understood. We are providing a service with a deep understanding of where that person is coming from in a judgment-free way.”
“Being able to use my position to help vulnerable members of our community – Aboriginal and non-Aboriginal – is an important part of my job,” says Talila. “I enjoy providing comprehensive care and a needed service. Doing this work really aligns with my clinical goals and values. It’s challenging work.”
Talila says quality of care is a barrier for Aboriginal people seeking medical help. A long history of suboptimal care, judgment by authorities, health providers and hospital systems are just part of the complex puzzle. While she knows it takes time for the relationships to be rebuilt, there are many health professionals working to improve the “Havingsituation.Aboriginal health professionals and providers creating culturally safe health care spaces definitely is part of the solution – but all health professionals and services should be able to provide this. People should be able to access any health care and feel safe.”
For Aboriginal and Torres Strait Islander people born 2015-2017 in WA, life expectancy was estimated to be 66.9 years for males and 71.8 years for females, around 13.4 – 12.0 years less than the estimates for nonIndigenous males (80.3 years) and females (83.8 years).
In 2017, the leading causes of death among Aboriginal and Torres Strait Islander people were coronary heart disease, diabetes, intentional selfharm and lung and related cancers. In 2011, Aboriginal and Torres Strait Islander people living in WA compared with those living in NSW, Qld and the NT, experienced the second highest rate of total burden of disease (BOD) (498 per 1,000), highest non-fatal BOD (193 per 1,000) and second highest rate of fatal BOD (305 per 1,000). In 2011, Aboriginal and Torres Strait Islander people experienced total BOD at 2.8 times the rate of nonIndigenous people, for fatal BOD, 3.6 times higher and non-fatal BOD 2.0 times higher.
In 2016, around 14% of babies born to Aboriginal and Torres Strait Islander mothers were of low birthweight (LBW), compared with 6.5% of babies of non-Indigenous mothers.
In 2015-2017, after age-adjustment, the death rate for Aboriginal and Torres Strait Islander people in WA was 12 per 1,000. This was 2.1 times the rate for nonIndigenous people.
Now, working more regular and known hours, Talila says family time is the priority. She enjoys cooking –particularly Lebanese food and the odd novelty birthday cake – and reading, often choosing medical humanities titles.
“I’m married and if it wasn’t for my husband and his support, I would have not gotten through it. He held down the fort as a stay-at-home dad when I did long days and shift “Whenwork. I decided to do medicine, there were definitely discussions about how it would look and work, knowing it would be long term. My hat is always off to families who have two parents working fulltime. It’s not easy and the cost of childcare is not conducive.”
CONTENTSTOBACK
Mia is where I feel like I will be able to make a difference. As an Aboriginal woman, we are providing an opportunity for culturally safe care. Cultural safety is important in seeing our clients in a holistic way that meets patient goals and needs,” she says. “It ensures that we as health professionals nurture and celebrate culture, family, emotions and spirit as much as we care about physical and mental health. It means that we provide the best and most comprehensive care and ultimately achieve better outcomes for the individual and the community.
As part of encouraging more Aboriginal people to become involved in health care, Talila says she’s always happy to chat to people who show an interest. She speaks to more females but suggests that might just be selfselection in them seeking her out. Questions about being a mother are some of the most common, like how do you balance work and family in your reproductive years?
Talila is also particularly close to her grandmother and has been able to make up for the lost time of living in Sydney. She visits once a week and they chat, run errands or might draw together. Her grandmother has a particular love for op shops.
“We talk about all sorts of things. I really value our time together and value her knowledge. Just hearing about her life experiences, which are so different from mine. I can’t have learnt about what she shares with me in any other way.
According to the Australian Indigenous HealthInfoNet's Overview of Aboriginal and Torres Strait Islander health status in Western Australia, key facts for WA include:
SEPTEMBER 2022 | 13MEDICAL FORUM | RESPIRATORY HEALTH
Talila started with a fortnightly residency, which will expand as patient numbers grow. To date most of the women she has seen have come to her because in the past they have felt unheard or not been given the appropriate time.
She’s definitely a glass half full person and a high level of empathy can at times affect her deeply when dealing with patients, their health issues and life stories. It’s balanced with a sense of efficiency, being able to prioritise tasks and having strong communication skills.
“A lot of that is more reflective of a system which doesn’t necessarily value time with patients. I also have a good knowledge of the services and benefits available to patients, so am able to help with that and to navigate the system.”
Recuperating after a hospital stay can be tough for anyone, but for people without a home, finding a place to recover is even more challenging.
Cathy O’Leary reports
Some doctors wanted to test residents for drugs and alcohol, but he wasn’t keen on a monitoring or punitive approach or excluding people because of drug use or mental health
“That’s why they end up homeless in the first place. They don’t get treated by the mental health people because they’ve got a drug and alcohol problem, and the drug and alcohol people won’t treat them because they’ve got a mental health problem.”
Homeless Healthcare was the first service of its kind nationally, becoming the largest specialist homelessness primary care service in Australia, and since 2008 it has supported more than 5000 people experiencing homelessness through a range of clinics and out-reach services. Its medical respite centre, which opened its doors last October, provides 20 short-stay medical beds to care for homeless people after a hospital presentation or admission in the Perth metropolitan area.
“Oneproblems.ofthe things I’ve often said is that homelessness is about people falling through the gaps,” says Dr Davies, who has years of experience as CEO and medical director of Homeless Healthcare, which he set up in 2008.
14 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
When Dr Andrew Davies was fine-tuning the manual for WA’s first medical respite for rough sleepers, he faced early resistance from some GPs about how it should be run.
FEATURE
Medical respite –promise of a fresh start
CONTENTSTOBACK
With the State Government providing $4.4 million over two years, the centre was designed to offer post-acute care in a safe environment, while also linking people to services to help break the cycle of homelessness.
SEPTEMBER 20222 | 15MEDICAL FORUM | RESPIRATORY HEALTH FEATURE
Homeless people face a high rate of chronic health issues, often have complex co-morbidities and can often have conditions left undiagnosed and untreated for long periods of time. This results in an over-reliance on acute health
“Ourfacility.primary cohort are people who are rough sleeping, and we recognise that there are multiple degrees of homelessness,” she said.
24-hour care Residents aged 18 and over can stay for a period of up to 14 days in either service, and admission to the medical respite is by referral. GPs run morning clinics on site every day, while the facility is staffed by nurses overnight and has peer support workers onsite during the day.
Ms Thebaud said residents could take part in painting, cooking and other activities, and had access to computers and phones.
Residents are discharged from the medical beds when their health issues resolve, but if they have other ongoing issues such as trauma, they continued
The centre is operated by a consortium led by Homeless Healthcare with Ruah Community Services and Uniting WA, following a tender process. It is based at a former backpacker hostel once known as the Witch’s Hat, in
“As a GP who has been working in this area since 2014, it’s one thing having GP clinics, but it’s quite another thing seeing people discharged from hospital and then having to send them back because they’ve deteriorated,” Dr Davies “Havingsaid. the ability to bring someone into a recovery-focused environment has been a real gamechanger for stabilising people and getting them out of homelessness.” Dr Davies said the idea for the centre came from a Boston facility which had a very medical focus, with 112 curtained-off beds so it looked like a hospital – and the concept was tweaked from there.
“The thing I really wanted to add to it was the case management side of things, to get people socially stable because I think that’s the single biggest thing that’s impacting their Perth’shealth.”medical respite centre was endorsed by the State Government’s Sustainable Health Review, which highlighted the complexity of issues facing one of the most vulnerable groups in our society.
Theservices.medical respite centre provides a safe space for people to recoup, sleep, eat nutritionally and escape the daily ‘fight or flight’ way of living on the street. It also allows support workers to connect people to housing and accommodation and other community supports, and provides a window of opportunity to develop skills for independent living and help people transition out of homelessness.
It is hoped that the facility could significantly reduce rates of hospital admission and readmission in vulnerable rough sleepers.
supportwhoTheseStayWitch’sfunded‘stepCo-locatedNorthbridge.are10non-medicaldown’beds,whicharephilanthropicallyandcalledinanodtothepast.bedsaredesignedforpeoplenolongerrequiremedicalbutarenotreadytoleave.
“There were a lot of people who were falling through the gaps in terms of being in hospital and needing mental health support, but their referral to a mental health step-down was being denied because they had alcohol and drug “Orcomplications.serviceswere trying to get them straight into rehab, but the mental health component meant they were falling through the gaps.”
To reset their sleep cycles, they were encouraged not to stay in their rooms during the day and it was made clear that the facility was not a hotel so residents did their own washing, and while three meals were provided each day, they could use the kitchen to cook.
“It’s very empowering because people experiencing homelessness don’t have a lot of access to a kitchen to be able to cook something or eat healthily,” she“Wesaid.had a woman who loved ironing and would line up all the residents and offer to iron their clothes. We’ve had lots of wonderful characters come through, and they’ve made it what it is, and it’s been a real learning experience for us.”
“That facility doesn’t have a lot of input from case workers, yet they have shown very good reductions in this cycle in and out of hospital for people experiencing homelessness,” Dr Davies said.
on Page 17
AccessibilityZoeThebaud , who is director of residential services at the centre, said it was important not to peopleexcludebyusing rigid eligibility criteria. Drug and alcohol services, for example, are actively encouraged to refer people to the respite
CONTENTSTOBACK
16 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH Medical Stirling Cross Health Hub is expected to include a private hospital, medical centre, radiology and pathology facilities, servicing the growing healthcare needs of Perth’s northern and inner-city suburbs. Consulting Rooms Consulting rooms specifically designed to meet your requirements are available, providing excellent access and referral opportunities for specialists. Allied Health Opportunities are also available for allied health professionals, with a range of tenancy sizes available. Jamie FiniEnquiries to: Liam Brown stirlingcross.com.au +61 476 838 info@stirlingcross.com.au234 +61info@stirlingcross.com.au450959197 Designed by award award-winning architects Hassell, Stirling Cross Health Hub is an exciting opportunity to secure the future of your business in a vibrant, mixed-use wellness precinct. Sales and leasing opportunities now available. Visit stirlingcross.com.au for more information. A hub of collaboration HEALTH HUB
Dr Davies said homeless people had a reduced life expectancy, with 47 the average age of death. People coming out of hospital often had medical issues such as diabetes, post-surgery complications, infections or a combination of medical problems.
Dr Davies said it was made very clear to everyone that the facility was not a hospital, but it could help prevent hospital admissions and readmissions, or visits to emergency
While Dr Davies welcomes the involvement of more GPs, he said getting doctors on board had been ‘the easy bit’, with the main challenge being not only securing government funding but keeping it in the long-term.
Referrals desirable Ms Thebaud said that just as the facility was not a hospital, it was also not crisis accommodation.
The $30 daily fee for nonmedical beds was useful in motivating people to look for other “Iaccommodation.thinkpeoplevalue it more when there’s a monetary contribution, and we do offer financial counselling to help people work out budgets,” she said. “It’s about people having somewhere to recover when they’ve been discharged from hospital. Without this they’d be going somewhere that’s non-compatible with recovery.”
“Ifdepartments.wecanmanage to get people from the streets into hospital, through here and then out to some kind of more permanent accommodation, then it will have a real long-term impact. It’s not just about this admission or preventing the next one,” Dr Davies said.
Rooms at the front of the house are for those who are unwell and need closer monitoring, while rooms towards the back are for those who are more independent. Security is only used at night, but good safety measures have meant there has been very few incidents, which have been well-managed by staff. As details of the facility have spread among Perth doctors, nurses and other health workers, demand has been increasing.
“We can receive referrals from the community to avert someone from going to hospital in the first place –people who are sleeping rough and would more than likely end up in
It was difficult for people to recover from medical treatment if they were sleeping rough and couch surfing, and some people needed antibiotics that could be stolen from them on the streets.
“It’s about improving people’s life expectancy and making them more functional in society. And while I’m a total realist that many of my patients will never be employed, we have seen a number of people who have gone into employment, and that’s
“It’sphenomenal.notuntil you start saying that we will look at this altogether and work out where we start and how we do this in some sort of systematic way, that we can start to chip away and see things improve.”
“Thehospital.main goal is to support people out of that cycle of street sleeping or couch surfing, from becoming more unwell and back into hospital.”
“The initial idea started about 10 years ago but it took a long time to get any political traction,” he said. “Now, with the outcomes we’re getting, I think it will be hard for anyone to close the medical beds.”
SEPTEMBER 20222 | 17MEDICAL FORUM | RESPIRATORY HEALTH can stay on longer in a non-medical bed, where they pay $30 a day. They are not discharged onto the street if they are not ready.
Promise of a fresh start
“The building is beautiful, it’s so therapeutic, it’s next to parks, there is so much good about it. Of course, we’re learning what it might look like in the future if we have big personalities, people with lots of trauma, in spaces like this, so that with future funding, it could be purposebuilt or renovated to suit them.”
“There has to be a medical condition, so that’s a big part of us getting out talking to people so they understand what our service is about, so the referrals are appropriate,” she said.
CONTENTSTOBACK
ED: Doctors and other health professionals wanting more details about the centre can go to medical-respite-centre.www.homelesshealthcare.org.au/
“It’s been set up so that anyone across any metropolitan hospital can refer to us, not just doctors or EDs, and the more they refer to us appropriately, the more we get the word out,” Ms Thebaud said. House rules “We try not to have punitive measures. People can go off-site, but we do ask them to come home in the evening. And while we don’t like to use the word ‘curfew’, we encourage them to be back by 6pm for a hot meal, or back by 8pm. “We do this because beds are precious, and it’s disruptive to other residents if people are coming back during the night and they’re intoxicated.
Like with many services, its ongoing funding is uncertain, with the twoyear pilot funded until October next year and the results subject to an independent review.
continued from Page 15 FEATURE
Having said that, we give everyone a mobile so that if they’re held up, they can stay in touch.
FEATURE RSL WA’s Veteran Central is leading the way in cooperative models of care for the benefit of both veterans and serving ADF members. Eric Martin reports ‘Hub-and-spoke’careinaction Picture: Tony McDonough CONTENTSTOBACK
“We also used our brains in terms of the fit-out. People are not in a big waiting room looking at someone else's shoes or wondering what he or she is here for. Our triage service starts with the concierge people on the ground floor who know who is Veteranscoming.” are immediately sent to the appropriate level by a computerised continued on Page 21
using,modelconcept“Theexperience.hub-and-spokeistheexactwehavebeenalongwiththe veteran central model, and now we can help our clients virtually. We are also looking at hubs in the greater Perth metropolitan area and in regional centres,” Mr McCourt said.
“And if our clients, especially those who have mental health issues, find they can physically experience that it's welcoming and not intimidating, we're already ahead of the curve.
CONTENTSTOBACK
Anzac House Veteran Central, the reenvisioned service centre for the RSL WA, has produced agile adaptations to service delivery to broaden accessibility.
“They have been so successful that the former government instituted a series of veteran wellness centres (rebadged as ‘veteran hubs’ by Labor) nationally. They're using our model to try and replicate them throughout Australia.
“We have found out as we have rolled out this initiative, which started about five years ago, that it works because it's simple. You put the veteran and their family at the centre of the circle and rather than looking outwards for services, veteran service providers can reach inward – they are actively looking to give complementary services to a veteran.
SEPTEMBER 20222 | 19MEDICAL FORUM | RESPIRATORY HEALTH FEATURE
“The different service providers are private and pay a very reasonable rent at Anzac House on a contract that says that they give absolute priority to veterans. Their income is via the Medicare schedule or the DVA schedule or mixture of both.”
Medical Forum caught up with veteran and retiring CEO John McCourt to discuss the crucial insights gleaned from the Veteran Central
“What we've developed at Veterans Central in Perth is that the veteran can come in – and, indeed, serving members if they feel that they have a need to – and access services.
The hub-and-spoke co-operative model of care that has been enthusiastically adopted by WA Health recently, after the release of the Infant Child and Adolescent Taskforce report in March, has been humming along successfully for five years at Anzac House, providing holistic care for veterans.
There are doctors who will treat them as a GP, all the way through to dental assistance, medical hearing assistance, legal advice, financial advice, welfare support and advocacy advice, all under one roof.
Mr McCourt said that veterans and their families, even with minimal service, are issued with a White Card that entitles them to free mental health care. For injured veterans, the co-location of services enables the referral process to escalate organically from the GP to the specialist, who could attend as a consultant, to surgery at either a private or public hospital, with wait times closely monitored by the team who would advocate on their behalf.“Similarly, if a veteran comes in and says they have mental health issues, there are three tiers of mental health services at Anzac House Veterans Central,” he “Theresaid. is what they call the entry service, Open Arms, which is the Federal Government Mental Health Support Service, we have clinical psychologists, and we also have a Thepsychiatrist.”teamisnow moving beyond physical attendance to make their services available virtually, another key area highlighted for growth in wider healthcare planning, and Mr McCourt said that the value it represented for veterans was “Forundeniable.example, if someone's living in the Pilbara region and they need various supports – they may have mental health needs or physical health needs – they will benefit being triaged virtually,” he said. “And then if and when they must travel to Perth, they can get everything seen to at the same time, rather than up and back and up and Mrback.”McCourt said the team had learned two key factors since the start of the hub – the first of which was to make sure that the environment was as welcoming as “Andpossible.itsounds a bit trite but this building, for example, is open, it's got plenty of large windows and sky and it's not enclosed, it's not intimidating, it's relaxed. We thought carefully about what the customer’s square metre would be from the moment they enter,” he explained.
Silica Dust Have your patients been exposed? Past employment history could be important! Perth Radiological Clinic has the expertise to meet the new regulations for low dose chest CT scan for the surveillance of workers exposed to silica dust in the workplace, past or present. Scan for more information or email sales@perthradclinic.com.au perthradclinic.com.au 20 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
Royal Commission wants changes at the
‘Hub-and-spoke’
Mr McCourt said a lot of work had gone into a collaborative service approach, with service providers regarding themselves as one dealing with clients, a process that was kickstarted at Anzac House through a mix of organic growth and strategic “Weplanning.have developed some great printed and virtual communications so that people understand the process, understand what it is and how they can get involved,” he said.
“So that was word of mouth. It was talking to other people; it was a process of persistence and a process of developing a collaborative way of working to develop these services.” care in action
• The commission has heard numerous concerns about access to information held by Defence and DVA by serving and ex-serving members of the ADF and their families. These concerns are not limited to those seeking access to their own information, but also family members of the deceased. The report recommends embedding a trauma-informed approach and developing and implementing improvements to information-seeking processes, and consent to disclose processes. It seeks a co-design and revision of information by Defence and DVA to better support those seeking information from both departments.
top CONTENTSTOBACK SEPTEMBER 2022 | 21MEDICAL FORUM | RESPIRATORY HEALTH
•include:Legislative reform of the veteran compensation and rehabilitation system. The commissioners said that the present system was so complicated it adversely affected the mental health of some veterans and serving ADF members, which could be a contributing factor to suicidality. It recommends the Australian Government implement reforms “without delay”.
• Improved legal protections for people, especially serving members of the ADF, who want to engage with the Royal Commission.
• The Department of Veterans Affairs to take “urgent and immediate steps” to fix problems with the processing of claims for serving and ex-serving ADF members. Some claims have taken more than 300 days to process. The report cited 41,799 backlogged claims as of May 31 this year. It also recommended the removal of the staffing cap so DVA can recruit more staff.
• The commissioners believe that they are seriously constrained by the legal concepts of parliamentary privilege and public interest immunity claims to inquire into and receive the necessary evidence from prior inquiries conducted by parliament and to examine government decision-making. They are urging the Australian Government to immediately address the barriers for this Royal Commission. They added the government should also introduce an exemption for future Royal Commissions. They recommend reform of policies and practices related to public interest immunity to be limited to claims where there is a specific harm contemplated from disclosure.
“For example, the psychologists were saying, ‘we’re seeing a link between hearing loss and mental health issues’, and the researchers from the Ear Science Institute and Lion’s Hearing went on to research that there is a strong causal link between hearing loss and PTSD.
He explained that just by locating health-care professionals from different disciplines together, such as mental health, dental and hearing services on the second floor, the teams have not only been able to better coordinate appointment times, but also identify new crossdisciplinary topics for research.
elevator, where they can go straight to their appointment or, for a walk-in, a private “Sometimesinterview.youmay have to wait, but it's very, very rare and it's very rarely for long. All those sorts of things are really important,” he said. “If a person comes in off the street, they can actually at least get to see “We'resomeone.still learning, but we've got happy customers. It is such a breezy and inviting place and it doesn't look and smell like a museum.”
“We were lucky that when we were planning this four or five years ago, we had a psychiatrist who was very interested. And it just so happens that within Anzac House, a number of veterans themselves were saying what a good idea it was.
The Royal Commission into Defence and Veteran Suicide has just submitted its interim report to the Australian Parliament. It still has a more than year to run until its final report is delivered in 2024. However, it has issued a list of urgent and immediate recommendations, which the Royal Australian and New Zealand College of Psychiatrists have supported. They
“So just like that, they were talking to each other,” Mr McCourt said.
continued from Page 19 FEATURE
Even though emergency department presentations for asthma are falling – in 2017-2018 there were 38,792 asthma-related hospitalisations in Australia, a drop from 70,034 the previous year –there are still more than 400 people who die from asthma complications every year in Australia, according to Asthma Australia.
FEATURE
“We know there are many missed opportunities in terms of asthma care. People who have not been managing their asthma in ways that we would recommend are very much overrepresented amongst people who have serious asthma Peopleoutcomes.”living with asthma may get into the habit of reaching for their blue inhaler in the morning if symptoms are bearable enough, but Dr Montgomery thinks better asthma treatment is achievable
Missed chances
“Sadly, I think we would find similar statistics if we were to run a similar survey today,” Dr Montgomery said.
Being able to breathe well is something we can easily take for granted, but for the 2.7 million Australians living with asthma, the struggle for breath can be not only debilitating but also life threatening.
“Our prevalence of asthma is higher than many other countries,” says Dr Brett Montgomery, Perth GP and member of the National Asthma Council Australia Guidelines Committee.
Breathing easy: new ways to manage asthma
Navigating newer treatments and medications for asthma are key to helping the millions of Australians living with the sometimes-fatal condition breathe easier. Kathy Skantzos reports
CONTENTSTOBACK 22 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
“Asthma deaths are generally declining, but 421 Australians died of asthma in 2019. Even if that’s a smaller number than it used to be, that’s still 421 too many deaths. We would like it to be as close to zero as possible,” he told Medical Forum
While there is a long-term declining trend in asthma-related deaths, the 417 deaths due to asthma in 2020 isn’t a significant fall from the previous year.
A Medical Journal of Australia study published in 2015 showed that many Australians with asthma were missing out on effective treatments that could improve their asthma Itcontrol.found that only about half of people with asthma had good control and about a quarter had very poor control over their condition. In people with uncontrolled asthma, quite a large proportion were not using regular preventer medicines.
“Using this combination inhaler simply as needed may seem unusual at first because many of us would have been taught at medical school that steroids have to be taken regularly to work. I know I was sceptical initially. But there are now several big trials that looked at that strategy and found it is safe and about as effective as the traditional regular ICS plus as-needed SABA approach. That’s why they’re both seen as legitimate options now,” he said. Dr Montgomery likes to remind his patients about how ICS and SABA medicines differ.
Standard care Dr Montgomery said that most patients should be on a low dose of an inhaled corticosteroid medicine to improve lung function and to reduce the risk of and to prevent otherwise preventable exacerbations of asthma and Ifhospitalisations.thistreatment was not working effectively after several weeks – and assuming the patient was taking it correctly – then a longacting beta-agonist (LABA) lasting 12 or more hours could be incorporated into the treatment in combination with the low-dose
It has been standard practice for many years in Australia for doctors to prescribe regular daily maintenance of inhaled corticosteroid (ICS) at a low dose plus a SABA reliever as needed.
FEATURE
Dr Montgomery adds that patients should know that persistent symptoms of feeling wheezy or tight in the morning or overnight, frequent reliever use, or asthma interfering in their lives are all indications they are at higher risk of having a significant exacerbation of asthma which could be detrimental enough to land them in hospital or even cause death.
“If ICS medicines aren’t felt to work as quickly as they expect, some people give up on them and they just stick to what gives them instant relief. That’s a shame, because they’re missing out on significant protection. One thing I try to do with patients is to set them up with the right expectations for their new medicine, so they give it a good go for a few weeks rather than rushing to judgment.”
“The idea of that is you use it regularly, so you’re taking it twice a day, but on top of that you’re taking another puff from the same inhaler as you need it if you get symptoms,” Dr Montgomery explains. “This is a regime for people who haven’t got good asthma control on simpler preventers like a low-dose ICS Whatalone.”is much newer, though, is the use in mild asthma of budesonideformoterol in mild asthma simply as-needed, without a regular maintenance component. This was only approved by the PBS in 2020.
Thesaid.first way combinationsICS-LABAwereused was simply as regular maintenance inhalers, and this is still a valid way to use them, but some ICS-LABA preparations have other Formoteroluses.isalong-acting betaagonist (LABA) which, unlike some other LABAs, also works to relieve symptoms immediately, which means it can be used in other ways.
“I tell them that steroids reduce swelling and mucous production and other features of airway inflammation, doing more than the SABAs, which largely just relax airway smooth muscle. But a problem is that they act more slowly than SABAs, which means some patients reject them too quickly,” he
alsotonowbeencombinations“ICS-LABAsteroid.havearoundforyearsandarefamiliarGPs,buttherehavebeenalotofchanges with them, which can get confusing. There are new ICS-LABA combination inhalers, but there are also new ways of using them,” he
if people collaborativelywork with their “Patientsdoctors. might have symptoms that they find tolerable. Maybe it doesn’t bother them much if they’re waking up every morning a bit wheezy and they’ve got into the habit of reaching for that reliever puffer. For some people, that just becomes an accepted part of their life. But health professionals know that things could be better with different treatments,” he says.
“This isn’t how things should be if we were following the evidence,” Dr Montgomery said. “What we should be seeing is most people using lower doses of steroids, and most of those people using them frequently.
“Oftensaid. people need to be on inhaled corticosteroids for weeks to really see their optimal benefit. But patients are used to using their short-acting beta agonists, which work marvellously quickly.
“Infrequent use can be appropriate in mild asthma with otherwisebudesonide-formoterollow-dosebutisnotrecommended.
National Asthma Council Australia’s updated Asthma Handbook outlines optimal ways to manage the treatment of the condition at different stages, from mild to severe asthma, with the guidelines clearly stating that taking a simple shortacting beta-agonist (SABA) reliever medication alone is not enough. “There are very few people who have mild enough asthma that we’d be comfortable for them to use just the reliever puffers they can get over the counter,” Dr Montgomery said. “Almost all adults and adolescents with asthma should be on more than just a SABA.”
A study published in 2020, which looked at a sample of PBS data from 2014 to 2018, suggests that more than two-thirds of people being prescribed corticosteroids were being prescribed higher doses and most of those people were using them infrequently.
Page 25 CONTENTSTOBACK SEPTEMBER 2022 | 23MEDICAL FORUM | RESPIRATORY HEALTH
The pattern seen of high ICS doses and infrequent use is a concern, suggesting missed opportunities for achieving better asthma control and preventing exacerbations and hospitalisations.” Helpful info National Asthma Council’s new Selecting & Adjusting Asthma Medication for Adults & Adolescents visual medications reference, together with the Asthma & COPD Medications chart, illustrate the drug names according to the treatment steps. continued on
The first is as maintenance and reliever therapy (MART), which GPs will know has been used in Australia for about 15 years. Get in control
Laser Skin Care
“Our thateach.LaserDrJennytheWhiledoctorsofservicecomprehensive,aweclinic“FromdeliveredseenLaserto“Peopleacneissuespeoplearethe“BackDrtreattechniques,GPsclinicbybusy,practicedermatologywasfranticallyandwethoughtopeningaseparateandtraininginthelaserwecouldfarmorepeople,”Elliottsaid.then,thereweren'tplethoraofclinicstherenow,butthereweresomanywhoneededtreatmentforsuchasbirthmarkremoval,scarring,rosaceaandthelike.werewaitingsixmonthsgetasimpletreatment,butwithSkinCaretheycouldbesixdaysaweekfortreatmentbyamedicaldoctor.thestart,wewantedthetobedoctor-ledbecausebelievedthemodelprovidedmuchbetterandmoreprofessionalandsoweinvestedalottimeandenergytrainingtheourselves.”DrVinciullohassinceleftpractice,DrSarahPaton,DrTang,DrThuyNguyenandKamilaMytychhavebeenatSkinCareforover10yearsThiscontinuityhasmeantLaserSkinCarehasbeenable to grow and invest in innovative equipment and procedures.
Dr Ahmed Kazmi and Dr Jenny Tang
“We were also one of the first clinics in WA to offer laser hair removal, which is still one of the main treatments we perform, often for people with hormonal changes, ingrown hairs and even as a preventative treatment for conditions such as folliculitis and recurrent pilonidal sinus infections.
“In our clinic, the majority of patients are still looking to improve common skin conditions such as rosacea, acne, actinic damage, including solar keratoses and lentigines, benign appendageal growths and seborrhoeic keratoses.
“Our primary focus has always been in skin conditions and treatment options, and with our medical background, often as GPs, we apply a holistic approach including medical background review, improving lifestyle factors and having a genuine empathy for patient concerns.
24 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
Please contact us to register your interest and for other enquiries regarding our treatments
www. laserskincare.com.au
“At Laser Skin Care, we have access to multiple different lasers – CO2 ablative, erbium fractionated nonablative, Q-Switched Nd:YAG/ pulsed dye, IPL and diode. We have recently acquired the ability to inject and needle autologous conditioned serum, which is a similar process to platelet-rich plasma therapy where growth factors are extracted from the patient and injected into the skin. We are able to use it for hair growth, dyspigmentation and skin scarring,” Dr Kazmi said.
The medical grade equipment at the clinic determines very effective Oneresults.”ofthe more recent additions to the team is UK-trained GP and dermatologist Dr Ahmed Kazmi, who undertook a fellowship in hair disorders, including the many forms of alopecia, with Professor Rodney Sinclair in Melbourne last year.
“Initially it was almost exclusively laser treatments, but then other medical and aesthetic treatments evolved over the past 25 years,” Dr Elliott said, who continues to perform skin cancer surgery at his own “Especiallyclinic. with many new clinics opening, our huge point of difference is that referring doctors and their patients will be dealing with experienced doctors directly. Your patients are our priority and with the level of experience and dedication of our medical team, the service we provide is unrivalled,” Dr Tang said.
S outh Bank Central, 18/38
The team at Laser Skin Care are grateful for the support of our medical colleagues over the past 25 years. There will be a special event in November to be held at the practice.
When dermatologists Tim Elliott and Carl Vinciullo set up Laser Skin Care in South Perth 25 years ago, their doctor-led laser clinic was ground-breaking as much for the model of care as for the treatments using this relatively new technology.
–doctor-led, always patient focused
doctorenquiries@laserskincare.com.auon
“Being doctor-led we have a much greater repertoire of services on offer and can be very comprehensive in our approach, being able to consult, perform the therapies, prescribe appropriate medications and any follow up.
SPONSORED CONTENT
Contact Meadowvale Avenue, South Perth, WA 6151 Phone (08) 9368 6888 | Email lsc@laserskincare.com.au
Stimulating pathways to recovery Modalis specialises in MRI-guided Transcranial Magnetic Stimulation (TMS) which can improve the treatment options in pain management, psychiatry (depression, OCD, PTSD), neurology, rehabilitation and other areas of medicine, such as treatment of tinnitus. TMS therapy has advantages over other treatments non-invasive with a superior safety profile success rates pharmacological tolerance with few side-effects find out more about locations, pathways screening process. template for at Modalis be available Practice software
referral
including: •
therapy • good
“For many people, good asthma control is achievable,” he said. “For our patients who haven’t ended up in hospital yet, and whose experience of asthma may be persistent but apparently mild, it’s very easy for that to become
FEATURE
• drug-free • comparable
to
rTMS services
Breathing easy continued from Page 23 asthma drug demonstratingavailable,toboth health professionals and patients how to use their devices.
will
“It’snormalised.important to challenge that perception and explain to people why asthma control is important. It’s partly about making their day-to-day life less troubled with asthma symptoms but also about preventing those less frequent but more serious bad outcomes.”
on Best
from May 2022 08 6166 3733 tms@modalis.com.au 4245 Modalis Medicus half Page Ad.indd 1 19/5/21 12:31 pm CONTENTSTOBACK
This makes it easier for GPs to translate the recommendations into a prescription, while involving patients in the decision making.
our services,
“Ask the simple things like, is my patient actually remembering to take their puffer and are they taking it Highercorrectly?”doses of ICS are not found until step 4 of the guidelines.
The referral
Asthma Council has a series of how-to videos on every
and
SEPTEMBER 20222 | 25MEDICAL FORUM | RESPIRATORY HEALTH
Beyond this is the option of adding a long-acting muscarinic antagonist (LAMA) medication, in an ICSLAMA-LABA combination.
Dr Montgomery sees patient understanding as a core strategy in tackling the lingering public health challenge of asthma.
• quick, convenient sessions on an outpatient basis Visit modalis.com.au to
“It’s hard to keep up with all the latest devices but it’s a GP’s role – along with pharmacists and asthma educators – to help patients understand their medicines and how to use the devices they come in,” he Nationalsaid.
Over time, management may move up or down the steps in the chart depending on how well controlled a patient’s asthma is. Before stepping up from one level of the pyramid to the next and prescribing a more potent or complicated treatment, Dr Montgomery says it’s important to ask the patient some questions.
“LAMAs are familiar to GPs from COPD management, of course,” says Dr “ButMontgomery.theirusein asthma is quite new. They do have an evidence base in asthma, but the evidence –like the PBS criteria – is limited to people with severe asthma who are still getting exacerbations despite good use of solid doses of ICSLABA. They are heavily promoted at present but certainly aren’t a firstline Lookingoption.”atthe new medications chart, Dr Montgomery said it illustrated just how many different sorts of puffers there were.
28 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH SPECIALISING IN pre and early pregnancy carrier screening: 3-gene to > 1,000 gene NIPT – including high risk result discussion reproductive planning including IVF with pre-implantation genetic testing family history of cancer, cardiovascular or other genetic conditions other areas on request, please inquire. www.testingcounsellingconsultations,Genetic& privategeneticswa.com.au We are a comprehensive service with Clinical Geneticist and Genetic Counsellor consults available. EMAIL info@privategeneticswa.com.au PHONE 6460 5722 FAX 6313 0606 Heathlink EDI pvtgenwa Online, email or phone bookings; in person or video-call consultations. Urgent and priority appointments available.
Australia’s NeuroMoves exercise centres in three states, including the centre in Joondalup.
SpinalCure and its partners aim to change that through Project Spark – a major, globally significant research program based at Neuroscience Research Australia (NeuRA) in Sydney. This research builds on the eWalk trial, a world-first blinded randomised controlled trial under way at NeuRA, which is testing the ability of transcutaneous spinal stimulation to restore or improve walking in those with paraplegia.
Duncan Wallace at NeuRA
After a successful advocacy push by SpinalCure, the Federal Government has granted $10 million for spinal neurostimulation projects. This is the first time the Government has offered funding specifically for research that aims to bring us closer to a cure for SCI.
Four NFP organisations have come together to make the first of Project Spark’s community-based clinical trials possible. Directed by Professors Simon Gandevia and Jane Butler at NeuRA, the 75 volunteers will be treated by the therapists at Spinal Cord Injuries
continued on Page 31
Today, like every other day, someone in Australia will have an accident and join over 20,000 people in the country who live with the devastating consequences of a spinal cord injury (SCI). And lying paralysed in hospital, they will probably be told they will never walk again. This was true 38 years ago when a drunk driver left me at the side of the road, paralysed from the shoulders down. However, recent research breakthroughs have brought us to a time when those newly injured should not be given such dreadful and finite news. A spinal cord injury is a lot more than losing ability to walk. Severing communication between the brain and body affects every aspect of your physical and mental wellbeing. Loss of movement is just the tip of the iceberg – ongoing pain, digestive issues, pressure sores, spasms, loss of bladder and bowel control and impaired sexual function are just some of the effects that make everyday life so Indifficult.addition to this dreadful human cost, SCI is estimated to cost the Australian economy $3.7 billion a year with a lifetime cost burden (2020) of $75.4 billion, with $10.3b of this borne by WA. Apart from the support of loved ones and friends, and the innate capacity of people to handle adversity, there is another factor that feeds the ability to cope with all this – hope. For those of us who live with paralysis, that hope comes from scientific research and the progress towards a cure. An incredible milestone in SCI research was reached in 2018. Six volunteers recovered the ability to stand and walk with only the aid of a walking frame, years after they were injured. These exceptional results were achieved by an experimental treatment known as Mostneurostimulation.spinalcordinjuries in Australia are contusion injuries, where the spinal cord is crushed on one side but not completely severed.
Most of the headline results have been achieved by electrical stimulators implanted in the epidural space, but this requires an expensive operation, weeks of hospitalisation and is not without risks. The alternative is to place electrodes on the skin (termed transcutaneous neurostimulation), which is safe, inexpensive and can be made more widely available.
Hope for spinal injury becomes reality don't provide sufficient scientific evidence for the authorities to approve a stimulator for mainstream use.
While overseas results have been encouraging, the studies have involved just a few people and
SEPTEMBER 20222 | 29MEDICAL FORUM | RESPIRATORY HEALTH GUEST COLUMN
Clinical research into spinal neurostimulation that could give function back to quadriplegics is coming to WA, explains Duncan Wallace from SpinalCure Australia.
SpinalCure and our New Zealand counterparts, CatWalk, have committed to raise the funds required. Starting this year, this trial aims to improve or restore arm, hand and respiratory function for people living with quadriplegia, the first items on the wish list for this Igroup.willmost definitely be putting my hand up to be considered for this trial. Perhaps with the neurostimulation, I won’t have to do this metaphorically.
Neurostimulation involves applying tailored currents of electricity to the spinal cord to wake up nerve pathways in surviving tissue to attempt to re-establish some communication between the brain and Volunteersbody. overseas have not only seen improvements in muscle control but have relished recovery from those other things that make living with a spinal cord injury so relentless. For a person with quadriplegia like me, even seemingly slight improvements can mean an enormous amount.
CONTENTSTOBACK
30 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH If you have and you are over 40... Tell your doctor The earlier cancer is found, the greaterthe chance of successful treatment. For more information visit findcancerearly.com.auor call 13 11 20 03/2022 ... for more than 4 weeks? Problems peeing Runny Unexplainedpoo weight loss An unusual pain, lump or swellinganywhere in your body Becoming more short of breath A persistent cough A new or changed spot on your skin ... once or more? Blood in your poo Coughing up blood Blood in your pee Have you had any of these... Partner: Department ofHealth Find Cancer Early to close the cancer survival gap. Your postcode shouldn’t determine your cancer outcome, but unfortunately it does for regional Australians, who have lower rates of five-year survival for all cancers combined.
visit
The Find Cancer Early program aims to improve cancer outcomes for regional West Australians over the age of 40 by increasing cancer symptom awareness and encouraging people to visit their doctor, clinic nurse, or Aboriginal health worker earlier. recent campaign evaluation found that 70 per cent of 953 regional West Australians surveyed had seen the campaign, and as a result of seeing the campaign 108 people made an appointment with a General Practitioner (GP), while 245 people thought about making an appointment. In Australia, over 75 per cent of cancer cases first present in general practice as a result of symptoms. GPs play a vital role in the early detection of cancer, and regional GP’s especially have the potential to improve cancer survival rates for regional West Australians and close the gap. Our Find Cancer Early Guide for GPs assists GPs in the early diagnosis of prostate, lung, colorectal, breast and skin cancers. This guide employs evidence-based positive predictive value (PPV) tables that highlight the clinical features that best predict cancer. We recommend regional GPs download or print off our Find Cancer Early Guide for GPs at findcancerearly.com.au/gp/ and get into the habit of referring to it for guidance when patients report symptoms. For more information and other resources, the Find Cancer Early website findcancerearly.com.au. at findcancerearly.com.au/gp/
Find out more
or call 13 11 20 WE HAVE TOOLS TO HELP GPs FIND EARLIERCANCER Download our cancer risk assessment guides today. BasalCellCarcinoma(BCC) • Isthemostcommonandleast •dangerousformofskincancer.Appearsasawell-definedlumpor scalyareathatisredorpearlyin appearance. • Maybleedorbecomeulceratedearlyon,thenhealandbreak •downagain.Usuallygrowsrelativelyslowly.High-riskBCCsubtypes(e.g.micronodular,infiltratingormorphoeic)andBCCsinimmune-suppressed individualstendtohavehigherratesof recurrenceaftertreatment. SquamousCellCarcinoma(SCC) • Appearsasalumporscalyareathatis •eitherred,paleorpearlyincolour.Maybleedorformanulcerornon-healingsore. • Growsslowlyandisusuallyfoundon thehead,neckoruppertorso. SKINCANCER PPV=Positivepredictivevalue(%) orprobabilityofcancer (years)Age painBreast Nippledischarge Nippleretraction lumpBreast lump/Breastpain 40-49 0.17 1.2 4.8 4.9 50-59 0.80 2.1 2.6 8.5 5.7 60-69 1.2 2.3 3.4 25 6.5 >70 2.8 23 12 48 >5 BREAST CANCER Haematuria lossWeight Nocturia Hesitancy rectalBenignexam rectalMalignantexam Frequency/urgency PPV= Positive predictive value (%) or probability of cancer 1.0 0.75 2.2 3.0 2.8 12 2.2 PPV as a single clinical feature 1.6* 1.9 3.3 3.9 1.8 Haematuria 2.1* 12 9.4 1.8 Loss of weight 3.3* 2.8 3.9 15 3.2 Nocturia 2.0* 3.3 10 4.7 Hesitancy 3.1* Frequency/urgency 4.0 Benignexamrectal 13 Rectalmalignantexam PROSTATE CANCER Lung cancer clinical features Cough Fatigue Dyspnoea Chectpain Abdominalpain Abdominal tenderness Abnormal rectalexam Haemoglobin 10–13g/dL Haemoglobin <10g/dL PPV= Positive predictive value (%) or probability of cancer 0.40 0.43 0.66 0.82 1.1 1.1 1.5 0.97 2.3 PPV as a single clinical 0.58* 0.63 0.79 0.76 1.5 1.7 2.6 1.2 2.6 Constipation 1.5* 3.4 3.1 1.9 2.4 11 2.2 2.9 Diarrhoea 6.8* 4.7 3.1 4.5 8.5 3.6 3.2 Rectal bleeding 1.4* 3.4 6.4 7.4 1.3 4.7 Loss of weight 3.0* 1.4 3.3 2.2 6.9 Abdominal pain LUNG COLORECTALCANCER CANCERConstipation Diarrhoea Rectalbleeding Lossofweight Abdominalpain Abdominaltenderness Abnormalrectalexam Haemoglobin10–13g/dL Haemoglobin<10g/dL PPV= Positive predictivevalue (%)orprobability ofcancer0.42 0.94 2.4 1.2 1.1 1.1 1.5 0.97 2.3 PPV as a singleclinical feature 0.81* 1.1 2.4 3.0 1.5 1.7 2.6 1.2 2.6 Constipation 1.5* 3.4 3.1 1.9 2.4 11 2.2 2.9 Diarrhoea6.8* 4.7 3.1 4.5 8.5 3.6 3.2 Rectal bleeding1.4* 3.4 6.4 7.4 1.3 4.7 Loss of weight3.0* 1.4 3.3 2.2 6.9 Abdominal pain1.7* 5.8 2.7 >10 tendernessAbdominal
Our
Hope for spinal injury becomes reality
There have been many ‘firsts’ on both the national and international stage: The Stan Perron Centre of Excellence for Childhood Burns, led by world renowned burns specialist Professor Fiona Wood; the world’s first rare diseases centre focusing on the whole life journey; the Early Moves study – a world-first aiming to diagnose babies at risk of developmental delays via home videos recorded through a smart phone app; and Australian-first research paving the way for the nation’s first clinical exercise service for children living with chronic Wediseases.know that hospital can be a daunting and stressful experience and have invested in positive experiences for patients and their families including an artistin-residence program and music Wetherapy.areproud of funding the Kids’ Bridge connecting the hospital campus to Kings Park and the healing power of nature. There is strong evidence that being around nature boosts health and wellbeing, and aids recovery. This unique project helps patients, families and WA’sstaff.first children’s hospice is on track to open in 2024 and will offer a nurturing environment for children living with a life-limiting illness. This much-needed facility will focus on celebrating life and provide specialist care and treatment in the one place when the time comes. For families, it will offer respite care and support during an incredibly difficult Otherjourney.significant and exciting projects are in the pipeline and will be revealed in the coming months.
Over the years, donor contributions have funded innovative technology including a space infusion station, a panel of drug pumps making intraoperative MRIs safer and quicker for children undergoing brain tumour removal, and a carbon floating surgical table, an adjustable imaging table allowing patient movement in any direction whilst interventional radiology is under way.
continued from Page 29
PCH is now home to some of the world’s leading medical minds in childhood cancer, vaccinology and immunology, burn injuries and radiology, to name a few. Drawn to PCH by its reputation for excellence in research and clinical programs, these clinicians are at the forefront of health-care advances, developing cutting edge interventions and therapies that WA kids are benefiting from first.
A comprehensive cure for paralysis is likely to involve a combination of therapies, but this is no longer a matter of if, but when. Whilst neurostimulation is not that cure, its potential benefits are truly life-changing. In light of this and other research, the person injured today should not be told they will never walk again.
In the first year, we raised more than $2 million which provided the hospital with its first grant to purchase equipment for the Paediatric Intensive Care Unit.
GUEST COLUMN
CONTENTSTOBACK SEPTEMBER 2022 | 31MEDICAL FORUM | RESPIRATORY HEALTH
At Perth Children’s Hospital Foundation, we want children to receive the best health care possible. As the biggest funder of Perth Children’s Hospital after government, we fuel the fight on the frontline of children’s health, helping sick kids get well and stay well. This year, we’re celebrating $100 million in donations to Perth Children’s Hospital and Health Service since the foundation’s modern inception and are proud to have played an integral role in advancing children’s health care in OurWA.modern-day journey began in 1998, when the PMH Foundation was formally established as the official fundraiser for the hospital.
Fast forward 24 years and the state-of-the-art PCH has become a leading research and training hospital, offering world-class patient Throughcare.the remarkable support of our donor partners and the unwavering generosity of the WA community, the foundation is raising the bar.
As Perth Children’s Hospital Foundation celebrates $100 million in donations, its CEO Carrick Robinson reflects on the powerful impact of donor generosity.
Perth Children’s Hospital Foundation is ranked WA’s fourth largest philanthropic foundation in terms of funds distributed and is making a significant difference to the lives of sick children not just here at home but across the nation and around the world.
Milestone for hospital charity
ED: Duncan Wallace is executive director of SpinalCure, Australia’s leading not-for-profit group funding and promoting research towards a cure for spinal cord injury, www.spinalcure.org.au
Cardiac exercise stress testing offers a non-invasive approach for those with suspected coronary Australian Council of Trade Unions, we used a unique method which predicts how many Australian workers would develop lung cancer and silicosis in their lifetime as a result of their exposure to silica dust in one year. To do this, we started with an estimate of how many workers were exposed to silica dust in 2016, the most recent census data year available. We used past exposure surveys and reports from New South Wales and Victoria, as well as data from the census around the number of engineered stone workers in Australia. We estimated that 584,000 Australians are exposed to silica dust at work. We then modelled how many lung-cancer and silicosis cases would develop as a result of this exposure and looked at the impact of ways to reduce that exposure, including wet cutting, using good quality respirators, and banning engineered stone. artery disease. However, up to onethird of exercise stress test results are either inconclusive or nondiagnostic, resulting in significant resource wastage.
While silicosis has historically been rare in Australia, the increased UWA chair of Cardiology, Fiona Stanley Hospital-based Perkins researcher and scientific officer of medtech company Artrya Professor Girish Dwivedi has been exploring the potential of AI in a busy metropolitan emergency department.
Silica dust is an aggressive lungdamaging dust which can result in breathing difficulties, scarring of the lungs (silicosis) and lung cancer. We have estimated that as many as 10,000 Australian workers will develop lung cancer in their lifetime as a result of their exposure to silica dust, and 103,000 will be diagnosed with silicosis.
About 7% of Australian workers, or more than half a million people, are currently exposed to silica dust across various jobs, with exposure most common among miners and construction workers.
As a result, Safe Work Australia has recently released a regulatory impact statement for consultation. This statement looks at a number of options to reduce exposure to silica dust and the cost of these over the next 10 years.
The AI system, developed by the multidisciplinary research team using demographic and pre-test clinical information, can accurately predict exercise stress test results and could be used to identify patients who would have inconclusive or nondiagnostic results.
Bold action needed to curb silicosis AI joins the ED team
CONTENTSTOBACKCONTENTSTOBACK
Silica dust is found naturally in many building and construction products, including sand, stone, concrete and mortar. It is also used in the manufacture of building products such as bricks, tiles and glass. Engineered stone, used mainly for kitchen benchtops, is a particularly potent source of silica dust.
We have found that there’s scope to do much more than outlined, and that we could save many more lives than this.
GUEST COLUMN Curtin University’s
32 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
Safe Work Australia concluded that these options could save about five people every year from developing silicosis and prove cost effective.
The project aims to develop an AI-driven system that will give a personalised rating of the appropriateness of various advanced investigationscardiovascularforpatients who have presented to the ED with chest “Investigationspain. are an essential component of patient care and use of engineered stone is driving a re-emergence of this disease. This prompted the Australian Government to set up the National Dust Diseases Taskforce with the aim of improving the health and safety of those working with silica dust. Their final report, published in June 2021, recommended further analysis of the best ways to prevent exposure to silica dust.
In a report commissioned by the many patients who present to the ED with chest pain will undergo advanced cardiovascular imaging.
“The proposed system could be used as a personalised decision-support tool by clinicians for optimising the diagnostic test selection for heart disease patients, which would reduce
“There is growing recognition that there is significant variation in investigation practices, with associated patient harm, healthcare waste and economic cost.”
There are multiple investigation modalities available, each with their unique strengths and weaknesses. The decision on which investigation is most appropriate for the patient has become increasingly complex,” Prof Dwivedi said.
Dr Renee Carey says much more can be done to prevent a predicted rush of silicosis and lung cancer cases across Australia.
Our modelling predicted that more than 10,000 Australian workers will develop lung cancer and around 103,000 will be diagnosed with silicosis in their lifetime as a result of their exposure to silica dust at Wework.found that banning engineered stone could save almost 100 lung cancers and 1000 silicosis cases. This ban is not currently supported by government or considered by Safe Work Australia in their impact Otherstatement.methods of reducing exposure, such as mandatory wet cutting and on-tool dust extraction, could also reduce the health impacts of working with engineered stone as long as these methods are used alongside high-quality and well-fitted respiratory protection.
“Once validated in other studies, this has the potential to assess the utility as well as the risk with blood thinners in patients with AF, one of the most common arrhythmias seen in clinical practice,” he said.
“Ourscans.AI-based risk prediction system will identify patients at risk of heart attack and also those who would most benefit from treatment,” he said.
antithrombotic therapy for patients with atrial fibrillation (AF) requires assessment of stroke and bleeding risks.
For example, wet cutting of engineered stone could save 40 lung cancers and 300 silicosis cases, and on-tool dust extraction could save 50 lung cancers and 400 silicosis cases.
health care expenditure by reducing non-diagnostic or inconclusive tests,” he Appropriatesaid.
Banning silica dust in other industries such as mining and construction isn’t feasible. However, it is possible to reduce exposure and the resulting health effects.
Recently, Prof Dwivedi’s team at UWA received $896,606 through a Medical Research Future Fund Frontiers in Health grant to develop a tool to better predict the risk of coronary heart disease from heart CT
CONTENTSTOBACKCONTENTSTOBACK
SEPTEMBER 20222 | 33MEDICAL FORUM | RESPIRATORY HEALTH GUEST COLUMN
As part of the project, the investigators developed AI models that outperformed the existing clinical risk stratification scores for predicting the risk of major bleeding and death in AF patients.
If we use dust suppression on construction and mine sites, we could save up to 1400 lung cancers and 11,000 silicosis cases. Stopping workers from entering areas around mine site crushers could prevent 750 lung cancers and 7500 silicosis
Ifcases.itwas possible to reduce exposure among mining workers to a level experienced by the general population, we could prevent around 2300 lung cancers and 20,000 silicosis cases. These findings show that reducing exposure to silica dust will save lives. There are a number of practical steps that we can take now to save our workers from these debilitating but ultimately preventable lung diseases.
We, as a society, are mindful of not only physical health, but also psychological or mental health. Doctors are hearing more complaints from their patients on what are not detectable by laboratory procedures, including concerns such as chronic fatigue, back pain and headaches. Do these complaints really matter? We tend to pass these small inconveniences off as not getting enough sleep, pulling a muscle, or stress, but scientists at the Suboptimal Health Study Consortium (SHSC) are learning that these complaints may indicate more than a temporary Underinconvenience.theleadership of Professor Wei Wang (Centre for Precision Health, Edith Cowan University), researchers are studying suboptimal health status (SHS), a global health concern that is defined as a reversible physical state between health and disease.
a holiday and
A simple questionnaire has been developed to detect SHS, which has been validated among African Asian and Caucasian populations as a generic tool for health measure. People presenting with SHS tend to have varying health complaints accompanied by anxiety or depression and fatigue, and the sum of these conditions can have effects on mental health and the cardiovascular, digestive, and immune systems. Risk factors are broadly considered to be related to environmental and lifestyle factors and include smoking, work stress, air and noise pollution, lack of exercise, and poor dietary choices. Understanding SHS is important when one considers the proven links between SHS and chronic diseases such as cardiovascular disease and diabetes.
“Take call me Researchers are exploring how engaging in any form of tourism can improve suboptimal health status, writes Dr Jun Wen.
tomorrow” GUEST COLUMN
34 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH Perth’s comprehensive vascular and vein treatment destination Hollywood Consulting Centre T: 08 9386 6200 F: 08 9689 2222 HL: stponosh ponoshvascular.com.auMr Stefan Ponosh Vascular & Endovascular Surgeon
In these post-pandemic times, we have found ourselves increasingly concerned about one another’s health. Now that we have an appreciation for how it feels to live through the added stress of a pandemic, it seems that we have just a little more authenticity in our voices when we ask a friend or colleague, “How are you?”
CONTENTSTOBACK
Researchers have demonstrated that tourism can improve a person’s wellbeing, which is a complex state that, in a broad sense, describes a person’s quality of life. Tourism experiences promote positive psychology, optimism, relaxation, and personal growth. Physical activity and leisure experiences tend to happen simultaneously with tourism, and both exercise and leisure experiences are powerful tools to promote wellness.
The multidisciplinary team from the SHSC analysed questionnaire responses from 360 Chinese tourists and looked for correlations between SHS and tourism-related characteristics. Overall prevalence of SHS was 36.4%. Study participants who reported longer sleep at night and more physical activity had lower prevalence of PeopleSHS. with SHS who travelled frequently reported better mental health than those who did not travel often. The tourists who traveled more frequently also had a better immune status, not all that surprising given the known positive correlation between physical activity and the immune system.
GUEST COLUMN
CONTENTSTOBACK
genesiscare.com For more information, please contact our team and
When we consider the economic and emotional toll that poor health takes on society, it is exciting to imagine how the research happening at the SHSC will inspire others to expand the way they approach this and other topics of global significance.
Motivated by the widespread prevalence of SHS and the implications of not addressing it, Prof Wang recently enlisted the expertise of a multidisciplinary team to explore a unique way to address the SHS concern: tourism. This is in fact the first study to introduce SHS to the field of tourism, and tourism to the field of global health focusing on SHS.
Tattoo-free radiation therapy now available at GenesisCare, Wembley GenesisCare, Wembley offers the latest stereotactic treatments with the implementation of the Versa HD Linac and CRAD (surface-guided RT) technology. radiation therapy - eliminating the emotional impact of permanent marks on patients’ skin. a holistic approach to cancer care, GenesisCare, Wembley offers extensive support services: GenesisCare: 6014
You may wonder, is it really possible to prescribe a holiday when patients aren’t feeling well? Understanding more about the benefits of tourism may help to consider how those holiday experiences can be seen as a potent form of ‘medicine’ for individuals with SHS.
Tattoo-free
SEPTEMBER 20222 | 35MEDICAL FORUM | RESPIRATORY HEALTH
Tourism is available in various forms to almost everyone and this is what makes the results of this study so powerful. While SHS is a global concern, tourism as a treatment intervention can be used by people living with SHS everywhere.
24 Salvado Road, Wembley WA
With
ED: Dr. Jun Wen is a lecturer in Tourism and Service Marketing at the School of Business and Law, Edith Cowan University (ECU), Australia. His current research interests lie in global health, tourism marketing, and travel medicine.
Tel: (08) 6318 2868 receptiononcologywembley@genesiscare.comExerciseclinicAccommodationpackagesAlliedhealthOnsiteparking ••••
Tourism does not have to be extravagant with a high cost. Tourism can be as simple as a nature hike, a museum visit, or a camping trip. The benefits of the experience are just as valuable as an elaborate transcontinental trip. These benefits may carry over to the ageing population and to those with complex conditions such as dementia. The tourism industry rapidly developed virtual tourism experiences in response to the COVID-19 pandemic and this technology could enable individuals with complex conditions and physical limitations to enjoy the benefits of travel.
WBI is the first breast imaging practice in Australia to revolutionise the use of the Volpara breast density tool to better diagnose the early detection of cancer by considering the breast density of every patient when having a mammogram.
Core Vacuum-assistedbiopsy core biopsy
Why BreastWomen’srequest&Imaging?
Women’s & Breast Imaging (WBI) has been serving the WA community for more than four decades and is committed to providing quality screening and diagnostic imaging and related services specifically for women. We are a tertiary referral centre for resolving complex clinical and breast imaging problems. Our centre’s breast imaging history was pioneered in the early 1980s. WBI is an institution of women’s imaging specialising in breast disease. Our Cottesloe location is a one-stop private imaging centre offering a comprehensive service (including reporting), dedicated to breast imaging and intervention procedures and gynaecological ultrasound.
Breast implant assessment and surveillance
36 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH www.wbi.net.au 103 Forrest Street, Cottesloe Freecall 1800 632 766 E. info@wbi.net.au T. 9383 2799
To create a more comfortable experience for our patients, all our clinical and front office staff are female. The care of your patients is our primary concern. Our team delivers the respect and attention they deserve, in a professional manner, while maintaining a friendly and considerate atmosphere.
Dr Vanessa Atienza-Hipolito
WBI offers all imaging and image-guided biopsy modalities including upright tomosynthesisguided biopsy procedure (except MRI): Mammogram (3D-Breast Tomosynthesis) Breast ultrasound Fine needle aspiration (FNA) biopsy Ultrasound-guided abscess and cyst drainage
SEPTEMBER 20222 | 37MEDICAL FORUM | RESPIRATORY HEALTH
OPINION Dr Joe Kosterich | Clinical Editor
At time of writing, New Zealand is still where WA was at in April and the rest of Australia in February. You walk into a restaurant with mask on but take it off when you sit down. Case numbers in NZ are following the same trajectory as Australia as we followed the international pattern –just a bit later.
In 1970 Joni Mitchell sang “Don’t it always seem to go, that you don’t know what you got till it’s gone”. In 2022 this could apply to the state of general practice. The new federal minister has noticed that there is a crisis and direct billing is under threat. Absolute numbers can’t be obtained but the workforce is thought to have shrunk by 3-5% through COVID.
For many it feels like we have been hibernating for over two years. This column is written in New Zealand as we visit relatives not seen in three years. It was sad to see the state of the international terminal with shuttered retail outlets and, while small numbers enable faster processing, it is not good for those whose livelihoods rely on numbers.
Other specialties are not immune. It can take up to six months to see a private rheumatologist in Perth. Ophthalmology, psychiatry, paediatrics and dermatology have long wait times too. Many have closed their
CONTENTSTOBACK
We are not alone. In the UK the number of full-time GPs is the lowest in five years; in NZ it is estimated that half the GPs (average age 53, up from 49 in 2005) are set to retire in the next decade; and 39% of GPs and 46% in rural NZ are foreign-trained. Sound familiar?
In the UK the number of full-time GPs is the lowest in five years; in NZ it is estimated that half the GPs (average age 53, up from 49 in 2005) are set to retire in the next decade; and 39% of GPs and 46% in rural NZ are foreign-trained.
With the notable exception of those who suffer seasonal allergies, there is something about spring that makes people feel good. After the cold and wet of winter, rays of sunshine signal we can come out of hibernation. In nature, spring is time of renewal, birth and growth.
Reality can hit hard
Inbooks.typical style, the new government has appointed a committee to examine Medicare and funding. It will no doubt produce a tome with numerous recommendations in a year. It won’t address the fundamental problem – no government (especially with post-COVID debt) can provide every service everyone wants when they want it with no cost to the user. Remember, Medicare was originally designed to provide basic cover to all – not cover all costs for all services for all. Reality can hit with a massive thud. Reality is hitting the health system.
38 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH 8008-22 Web: www.orthopaedicswa.com.au Fax: 08 9332 1187 Email: reception@orthopaedicswa.com.au Tel: 08 9312 1135 Eligible patients have NO GAP for procedures with all major health funds MR BENJAMIN WITTE Knee Surgery ACL & Sports Injuries Knee & Hip Replacement Medico Legal MR SATYEN GOHIL Knee & Shoulder ACL & Sports Injuries Arthroplasty & Trauma MR THOMAS BUCHER Hip & Knee - Primary & Revision ACL and Trauma Gluteal Tendon Reconstruction MR ANDREW MATTIN Shoulder, Elbow & Wrist Hip & Knee Sports Arthroplastyinjuries& Trauma MR LI-ON LAM Knee, Shoulder & HipUni Compartmental KneeKnee and ACLArthroscopyShoulderandTrauma MR SIMON WALL Hip & Knee-Primary & ACLRevisionand Trauma Ilizarov Frames A/PROF CHRISTOPHER JONES Hip & Knee Replacement - Primary & Revision Computer assisted Surgery Hip TraumaResurfacing PROF PIERS YATES Hip, Knee & Trauma Primary & HipArthroplastyRevisionResurfacing A/PROF GARETH PROSSER Hip, Knee & Trauma Primary & Revision Young Adult Hip Hip MountCONSULTINGSJOGResurfacingMurdochHospitalROOMSHospital . Specialising in hip, knee, shoulder, trauma . Privately insured, DVA, Workers Compensation and MVA patients welcomed . Medico Legal assessments ORTHOPAEDICS WA
CLINICAL UPDATE
Peripheral lung nodule evaluation
detectingFDGmanagementdeterminesPETisindicatedfordistantmetastasis and not very useful in determining nodule malignancy risk.
CONTENTSTOBACK
continued on Page
Nodule management strategy depends on the risk, and this is currently being investigated in a prospective clinical trial. In general nodules are termed as low, intermediate, or high risk. Management Patient involvement in decision making is important for good outcomes. Management options include surveillance or diagnostic Forintervention.high-risk nodules greater than 1cm, presence of spiculation or thoracic lymphadenopathy, immediate specialist assessment is necessary. A FDG PET scan is useful for identifying occult extra-thoracic metastasis and thoracic nodal metastasis. There is a notinsignificant false negative rate for thoracic nodal disease on PET (PET occult thoracic lymph nodal metastasis) as well as a false PET positive thoracic lymph node (non-malignant PET positive lymph nodes from anthrasilicosis or granulomatous infections).
SEPTEMBER 20222 | 39MEDICAL FORUM | RESPIRATORY HEALTH
Key messages
Nodule assessment on non-lung CTs has limitations. Confirmation with a dedicated CT chest is Nodulefavourable.risk assessment for lung cancer depends on several factors. Clinical factors include age, family history of lung cancer and other cancers, asbestos exposure, and cigarette smoking. Absence of a smoking history does not exclude lung cancer.
Radiological characteristics such as size, shape, spiculation, effect on adjacent pulmonary architecture and background emphysema need to be interpreted. Peri-fissural nodules represent intrapulmonary lymph nodes and are usually benign although there are exceptions. Presence of mediastinal or hilar lymphadenopathy indicates urgent assessment irrespective of the nodule size.
Lung nodules are best evaluated on thin (</=1mm) slice CT reconstruction. There are limitations in comparing two scans with different slice thickness, a dedicated CT chest versus a nonlung CT and even CT chests done on different machines. Comparison with previous CT imaging is an important initial step during nodule assessment. Availability of prior imaging at the time of reporting adds value for the reporting radiologist and the clinician.
Nodule malignancy risk stratification
By Dr Lokesh Yagnik, Interventional Pulmonologist, Subiaco 41
A pulmonary nodule is a welldefined opacity surrounded by lung parenchyma measuring less than 3cm (greater than 3cm is a lung mass). Pulmonary nodules are classified as solid or subsolid. Subsolid nodules are subclassified into pure ground glass and part solid nodules.
Identifying the clinical context at the time of CT chest scan is paramount. If there are features of infection, then an inflammatory nodule is likely and may resolve at short term interval follow up CT. Alternatively, if detected on a screening CT chest, the malignancy risk is higher. There are several risk assessment scores used to determine the malignancy risk of a lung nodule.
Tissue confirmation of thoracic lymph node status with linear endobronchial ultrasound (EBUS)
Lung nodules are an opportunity to cure lung cancers
Peripheral lung nodules may represent early lung cancer hence are an opportunity for cure. Risk assessment: patient and the scan
Lung nodules are asymptomatic and often detected incidentally on CT chest and non-lung CT scans performed for other reasons.
60-year-old lady with previous breast carcinoma and metallic aortic valve had an incidental 10mm right upper lobe solid nodule (green arrow) with air bronchus sign (blue arrow). Deemed high risk for CTguided biopsy in view of fissure (yellow arrow) and surrounding blood vessels (red arrows). Primary right upper lobectomy not advised due to surgical risk, insufficient lung function and possibility of metastatic breast carcinoma. Lesion biopsied by radial EBUS to establish diagnosis and treated with a sub-lobar resection.
Visit skg.com.au for full details, some exceptions do apply. Now bulk billing. At SKG, we care about yourwelfarepatient’s
continued
SEPTEMBER 20222 | 41MEDICAL FORUM | RESPIRATORY HEALTH
A persistent nodule is concerning and an enlarging nodule highly suspicious for malignancy. If a nodule is persistent but stable in size and shape, radiological surveillance with CT scans for 24 months for solid nodules and up to five years for ground glass/ part solid nodules is a reasonable approach. Alternatively, evaluation with a FDG PET and proceeding to a biopsy is acceptable. For a nodule deemed low risk, surveillance is favoured. Managing patient anxiety around the detection of a lung nodule and consideration of their preferences during assessment is helpful in achieving good outcomes. Work up also includes lung function testing and assessing fitness for surgery since treatment options for earlystage lung cancer are lobar or sublobar surgical resection or for nonsurgical candidates, stereotactic body radiation therapy. This is often recommended following an MDT discussion.
Children with neurological disorders are more likely to need hospitalisation with pneumonia Prevention and treating modifiable risk factors are key New research seeks to identify ways to reduce symptoms and hospitalisations.
By Dr Rachael Marpole, Adv. Trainee, Respiratory & Sleep Medicine, PCH on Page 43
• Prevention by treating/managing modifiable risk factors is key.
We have identified three key risk factors for admission for acute respiratory infections in children with cerebral palsy (see Fig. 1). These include severe cerebral palsy (inability to control head posture against gravity), admission to hospital during the previous year, or two courses of oral antibiotics in the previous year. We have also worked on identifying potentially modifiable risk factors including oropharyngeal dysphagia (mealtime modifications like tube feeding, thickened fluids), frequent respiratory symptoms (coughing, choking on saliva, wheezing, or gurgling), current seizures, gastrooesophageal reflux, mealtime respiratory symptoms, nightly snoring and poor dental hygiene. What does it mean for GPs?
continued from Page 39
Pneumonia, a common cause for acute respiratory infection, is one of the most common causes of hospital admissions in children. We know that children with neurological disorders (e.g. cerebral palsy, epilepsy, and neuromuscular disorders) are more likely to be admitted to hospital with pneumonia than children with other conditions but, until recently, little was known why. We also know these children are older, have a longer length of stay and are more likely to be admitted to intensive care. When these children are tested, a respiratory pathogen is less likely to be found, because the cause of their pneumonia is from aspiration and not from infection.
• Maximise general health including ensuring current vaccination protection, dental hygiene, nutritional status, and physical activity is optimised.
For intermediate risk nodules, the options depend on the clinical circumstance, patient preference and risks of diagnostic biopsy.
Peripheral lung nodule evaluation
I am leading a research project to better understand respiratory risk factors for children with cerebral palsy with the ultimate aim of reducing symptom severity and the need for hospital admissions.
• Earlier treatment of wet sounding cough with antibiotics is indicated in these children,
Acute respiratory infections in children with neurodisability
Key messages
CLINICAL UPDATE
bronchoscopy is recommended for all lung nodules proven or suspicious for lung cancer when they are within the inner two thirds of the lung fields, associated with abnormal thoracic lymph nodes on CT chest or PET and when the lung nodule is not PET avid. Adenocarcinomas and intensely FDG avid lung cancers also carry a higher risk of occult nodal metastasis and tissue confirmation of nodal status is advantageous. Biopsy of the peripheral lung nodule can be performed at the same bronchoscopy by using a radial EBUS probe if the lymph nodes are non-malignant at onsite examination (Image A). EBUS bronchoscopy has an excellent safety profile. Alternatively, the nodule can be biopsied by CT guidance as a separate procedure.
When there is a history of infective symptoms at presentation when initial CT was done, then a shortterm interval CT scan can be done in six weeks to three months with antibiotic treatment assessing for temporal behaviour. Inflammatory nodules usually reduce in size or resolve on follow-up scan.
• Children with severe neurological disorders are at increased risk of respiratory infections.
CONTENTSTOBACK
52 | APRIL 2021 MEDICAL FORUM | CARDIOVASCULAR HEALTH Advert removed in compliance with Medicines Australia's Code of Conduct and the Therapeutic Goods Administration's Therapeutic Goods Act. https://medicinesaustralia.com.au/code-of-conduct/about-the-code/https://www.tga.gov.au/legislation-legislative-instruments
• Aspiration is often silent. There does not need to be an episode of choking or vomiting. Check that parents have had their child’s mealtime management assessed by a speech pathologist including management plans for when the child is well and unwell.
Current seizures
Ref: M19000347 Graphics by Freepik
• Gastroesophageal reflux is common in children with neurological disorders and managing this is important, particularly for treating silent aspiration. Referral to a paediatrician may be needed.
Blackmore AM, Bear N, Langdon K, Moshovis L, Gibson N, Wilson AC. Respiratory hospital admissions and emergency department visits in young people with cerebral palsy: 5-year follow-up. Archives of Disease in Childhood 2019. 45: 745-771. https://adc.bmj.com/content/early/2019/06/29/archdischild-2019-317714
The modifiable risk factors all have multiple treatment options. By treating these, it may be possible to prevent or reduce the severity of acute respiratory infections in this Ourgroup.research team is currently collecting evidence as to whether this can be achieved through the RESP-ACT study (Can RESPiratory hospital Admissions in Children with cerebral palsy be reduced? A feasibility randomised controlled trial pilot study). We are following 20 children with cerebral palsy over 12 months – 10 in the usual care group and 10 in the additional care Childrengroup. in the usual care group continue to be overseen by their current health care professionals. Children in the additional care group are seen by a respiratory doctor, a physiotherapist and a speech pathologist and offered a videofluoscopy swallow study and complex care coordination through a specialised nurse. A treatment plan depending on the child’s specific risk factors is developed and implemented. Each family is asked to complete a fortnightly survey on their child’s health, recording the medical treatments received and tracking the impact on their child’s health. Families and clinicians will be interviewed at the conclusion of the trial on whether the interventions were acceptable and achievable. We will also be considering wider application of the outcomes. Specifically, we will consider whether interventions found to be useful in children with cerebral palsy may also be effective in children with other neurological Thisconditions.research is in collaboration with Dr Noula Gibson PhD, Research CerebralbyMedicineHeadandRehabilitationDrBlackmore,Department,Physiotherapist,CoordinatorPhysiotherapyPCH,DrMarieTelethonKidsInstitute,KatherineLangdon,PaediatricConsultant,PCH,ClinicalA/ProfAndrewWilson,ofRespiratoryandSleepPCH.ItissupportedtheResearchFoundationofPalsyAlliance.
• Children with oropharyngeal dysphagia may not cough but present with gurgling/wheezing during and post feeding.
Author competing interests - the author leads the study
Mealtime symptomsrespiratorywhenwell (gurgly voice, wheezing, coughing, sneezing, choking) IRR = 3.8 (95% CI: 2.1 to 7.1)
Red Flags Risk factors for respiratory hospital admissions for young people (1-26 years) with cerebral palsy Ris k checklist: https:ww w telethonkids.org.au /cpchecklist Gastro-oesophageal reflux disease (now or previously) IRR* = 3.4 (95% CI: 1.8 to 6.3)
*
IRR* = 7.6 (95% CI: 4.2 to 13.8)
At least one respiratory hospital admission in the last year IRR* = 11.8 (95% CI: 5.6 to 24.7)
IRR* = 9.4 (95% CI: 3.5 to 25.8)
continued from Page 41
• If antibiotics are required for respiratory illness more than twice in 12 months, consider referral to a paediatrician.
Acute respiratory infections in children
CLINICAL UPDATE
SEPTEMBER 20222 | 43MEDICAL FORUM | RESPIRATORY HEALTH even if the rest of their examination is stable. Children with neurological disorders and wet cough may need a prolonged course of antibiotics as they may be unable to effectively cough.
Potentially Modifiable Risk FactorsSnoring every night IRR* = 2.8 (95% CI: 1.3 to 6.1) Z Z
IRR (Incidence Rate Ratio) indicates the expected magnitude of the respiratory hospital admission rate over a 5-year period when the risk factor is present versus when it is absent. E.g., Young people with CP classified as GMFCS V are expected to have a respiratory hospital admission rate about 23 times greater than those classified GMFCS I to IV over a 5-year period.
Frequent symptomsrespiratory (daily cough or weekly sounding sound chesty or phlegmy or wheezy)
CONTENTSTOBACK
Oropharyngeal dysphagia (requires foods or drinks with modified texture OR uses a tube OR coughs or chokes on saliva) IRR* = 12.7 (95% CI: 7.3 to 22.1)
Gross Motor Function Classification System (GMFCS) Level V IRR* = 23.25 (95% CI: 10.46 to 51.70) At least 2 courses of antibiotics for respiratory illness in the last year IRR* = 5.9 (95% CI: 3.0 to 11.6)
52 | APRIL 2021 MEDICAL FORUM | CARDIOVASCULAR HEALTH Advert removed in compliance with Medicines Australia's Code of Conduct and the Therapeutic Goods Administration's Therapeutic Goods Act. https://medicinesaustralia.com.au/code-of-conduct/about-the-code/https://www.tga.gov.au/legislation-legislative-instruments
52 | APRIL 2021 MEDICAL FORUM | CARDIOVASCULAR HEALTH Advert removed in compliance with Medicines Australia's Code of Conduct and the Therapeutic Goods Administration's Therapeutic Goods Act. https://medicinesaustralia.com.au/code-of-conduct/about-the-code/https://www.tga.gov.au/legislation-legislative-instruments
52 | APRIL 2021 MEDICAL FORUM | CARDIOVASCULAR HEALTH Advert removed in compliance with Medicines Australia's Code of Conduct and the Therapeutic Goods Administration's Therapeutic Goods Act. https://medicinesaustralia.com.au/code-of-conduct/about-the-code/https://www.tga.gov.au/legislation-legislative-instruments
SEPTEMBER 20222 | 47MEDICAL FORUM | RESPIRATORY HEALTH
The demonstration of irreversible airflow limitation on spirometry (post bronchodilator FEV1/FVC ratio <0.7) in the presence of a history of cigarette smoking (more than 10 pack years) or other contributors such as air pollution makes a diagnosis of COPD likely. The degree of airflow limitation, however, is not a reliable predictor of symptom severity in COPD.
As with the assessment of any respiratory disease, smoking cessation is imperative as it is the only intervention with clear positive impact on disease progression.
Mostly bronchodilator therapy does not lead to a sudden increase in lung function or reduction in symptoms but many of the benefits (quality of life) are over longer term.
Initial COPD management includes a combination of pharmacological and nonpharmacological strategies. Patient education of COPD is vital, so people understand what they have and what treatment is for. Up-to-date vaccinations for flu, pneumococcus and COVID can help reduce exacerbation frequency and severity. Exercise helps maintain fitness and weight control. This can be incorporated into a pulmonary rehabilitation program although there are several administrative barriers to this (referral usually needs to be from a specialist or Pharmacologicalhospital).therapy can improve symptoms, quality of life, and reduce exacerbation risk but there’s no reliable evidence of a positive impact on disease progression or overall mortality. Therapy needs to be targeted to the symptoms to be treated. Generally, all patients will complain of breathlessness so generally all patients will benefit from bronchodilator therapy. Local guidelines (copdx.org.au) detail the initiation of bronchodilator therapy but generally for someone who is symptomatic most of the time either a regular long-acting beta agonist (LABA) or longacting muscarinic antagonist (LAMA) is indicated. If symptoms persist, adding the alternative bronchodilators so they’re on dual therapy (LABA/LAMA) is indicated.
CLINICAL UPDATE
Initial diagnosis and assessment of COPD
Author competing interest – nil
COPD is a common lung disease responsible for significant disability. It is a common cause of hospitalisation and death. In Australia it is under diagnosed and often over or even undertreated. Primarily a lung disease, it has extrapulmonary manifestations and is frequently associated with respiratory and non-respiratory comorbidities all of which can influence symptoms and outcomes. Spirometry is the essential test in diagnosing COPD. There is no other way of demonstrating airflow limitation and so confirming COPD. Barriers to performing spirometry are rarely insurmountable, even with the current COVID pandemic.
By Dr Scott Claxton, Respiratory Physician, JoondalupCONTENTSTOBACK
In initial managementpharmacologicalofCOPD,there is little role for inhaled corticosteroids (ICS). They have a role to play in the patient with frequent exacerbations despite dual bronchodilator therapy but at a lower dose than usually used for asthma. Long-term ICS use still has the risk of long-term steroid side effects (e.g. cataracts, bone density, infection). Given the significant co-morbidities for COPD patients, the risk and benefits of ICS therapy needs to be assessed. Diagnosing COPD with the appropriate smoking history can be straightforward but a proportion of patients will have asthma-COPD overlap and this may require more specialist investigation to confirm the diagnosis and ensure appropriate therapy. This may be considered if there is prior history of asthma and a history of significant smoking or if there are asthma features at presentation (variable symptoms, bronchodilator response on spirometry).
Further assessment for defining the severity of COPD depends on measuring the severity of symptoms. This includes exercise tolerance (modified Medical Research Council [mMRC] scale), general COPD symptoms (COPD Assessment Test score [www. catestonline.org]) and exacerbation frequency (≥ two exacerbations or ≥ 1 Thissevere).allows a consideration of potential symptoms of exertional dyspnoea, cough, general fatigue, exacerbation risk with a view to directing therapy. Appropriate choice of pharmacological therapy lowers likelihood of overtreatment or unnecessary treatment. Chest radiology is helpful insofar as identifying comorbid respiratory conditions (e.g. emphysema, fibrosis, lung nodules or bronchiectasis). It is not sufficient to make the diagnosis alone. Other investigations can be helpful in assessing extra pulmonary disease (e.g. cardiovascular disease, osteoporosis, type two diabetes, hypertension). These can be done depending on the clinical picture and likelihood of the presence of other diseases.
Tailored therapy can provide optimal outcomes while avoiding undertreatment and poor disease control or overtreatment with potentially significant side effects.
not reliably correlate
stronger positive sIgE
By Krummenacher
Screening patients with low pre-test probability for allergy is generally not useful, as positive results are more likely to be clinical ‘false positives’.
standardlattercases,facilitatestilladvice.Immunopathologistslimitationsbeselectionappropriately,clinicalSerumallergytestingofforaeroallergenssIgEpatch(whichdelayedforsyndromes,forAlthoughreactivitysituationsusedrequiredspecialists.maystandardtestingComponent-resolvedtherapy.diagnosticismoreexpensivethansIgEtesting,solaboratoriesonlyacceptrequestsbyNevertheless,itisrarelyupfront,beingmostoftenasanadd-ontesttoresolvewithsuspectedcross-ortofurtherriskstratify.sIgEtestinghasutilityinvestigationofvariousallergyitisnotappropriateallformsofhypersensitivity.Inhypersensitivityreactionsarenon-IgE-mediated),skin/testingistypicallyrequired.testingisavailableformanyandfoods,butonlyalimitednumberofdrugs,manywhichhavepoorsensitivity.Skinisrequiredformostdrugcases.sIgEtestingisapowerfultoolwhenutilisedalthoughtestandinterpretationcanchallenging,particularlyifassayarenotappreciated.canprovideNevertheless,someallergiesrequirespecialistassessmenttoskintestingand,insomeanobservedchallenge,theofwhichremainsthegoldforallergydiagnosis. Author competing interests – nil CLINICAL UPDATE Modern allergy testing
SEPTEMBER 20222 | 49MEDICAL FORUM | RESPIRATORY HEALTH
Dr Matthew
allergy severity Serum sIgE testing is not appropriate for all forms of allergy/hypersensitivity; specialist assessment with skin testing may still be required, particularly for drug allergies. CONTENTSTOBACK
increases the likelihood
Although a stronger positive sIgE result increases the likelihood of the patient having a clinically significant allergy, it does not reliably correlate with severity of the allergy; assessment of severity, and thus indication for carriage of adrenaline autoinjectors, is based on the clinical Whenhistory.a patient tests positive to an allergen via standard sIgE testing, it is not possible to know which of the many antigens contained within the ‘cap’ the patient has IgE antibodies directed towards. It is helpful to appreciate this concept, as not all antigens have equal clinical significance. In fact, patients with significant allergies to certain exposures may be reliably sensitised to only a few specific antigens of interest. Furthermore, some antigens show substantial cross-reactivity with other allergens, a common cause of ‘false positive’ results. For example, grass pollens contain proteins also common to many plant-based foods, causing some pollen allergic patients to also show positive sIgE results to certain foods. Many of these cross-reactive proteins are labile, meaning they do not survive cooking or digestion, thus not precipitating systemic allergic reactions when ingested. Therefore, although the food sIgE result is positive, the patient is not clinically Recognitionallergic. of this phenomenon has led to development of ‘component resolved diagnostics’, where sIgE testing is directed towards individual allergen components. For example, most patients with peanut anaphylaxis will be sensitised to the peanut protein Ara h 2. Thus, testing for sIgE towards Ara h 2 specifically can aid in determining whether a patient with positive peanut sIgE is more or less likely to tolerate a peanut challenge or be at ongoing risk of Investigationanaphylaxis.ofvenom allergy is another example where component resolved diagnostics can assist management. Bee and wasp venoms contain several cross-reactive components, most notably crossreactive carbohydrate determinants (CCDs). Therefore, some patients have positive sIgE tests towards both bee and wasp venom despite being clinically allergic to only one species. In this situation, sIgE testing towards species specific proteins – e.g. Api m 1 for bee venom – can determine the primary allergy and thus ensure prescription of appropriate desensitisation
Accurate diagnosis of allergy requires careful clinical assessment and demonstration of allergen sensitisation, defined as presence of IgE antibodies targeting allergen components (antigens). The main methods used to establish sensitisation are skin prick testing (SPT) and serological testing. SPT is generally only performed by specialist allergists/ immunologists, but serological testing can be requested by all clinicians.
Historically, the radioallergoabsorbent test (RAST) was the predominant serological method. This has now been superseded by a similar method known as serum specific IgE (sIgE) testing.
Ininterchangeably.sIgEtesting,patient serum is incubated in a small ‘cap’ containing antigens representative of the allergen in question, typically derived from whole allergen extracts. IgE antibodies targeting any of these antigens will be bound. The amount of IgE binding is then determined and reported quantitatively. Sensitisation can occur in the absence of a clinical syndrome of allergy, so sIgE results must be interpreted in the clinical context.
clinically significant allergy but
, Clinical Immunologist & Immunopathologist, Osborne Park Key messages Positive serum specific IgE (sIgE) results can occur in the absence of clinical allergy. Interpret results in light of the clinical presentation
A result of a does with
Nevertheless, the terms ‘RAST’ and ‘sIgE’ are still often used
By Prof Camile S. Farah, Oral Physician & Pathologist, Nedlands
The need to re-appraise current surgical oncological practice is upon us, driven in part by the digital Key messages Real-time intraoperative digital pathology can be used to determine tissue histoarchitecture and surgical clearance of tumours
Handheld CLE devices enable in vivo digital visualisation of tissue histoarchitecture with absolute recapitulation of standard histomicroscopy allowing real-time assessment of pathological tissues and clearance of resection margins, with on-the-fly communication between surgeon and pathologist.
Accurate decision-making during surgical resection of various human cancers is reliant on good communication between surgeon and pathologist. The frozen section is essentially unchanged since described by pathologist Dr Louis B. Wilson in 1905 at the request of surgeon Dr William Mayo, one of the founders of the Mayo Clinic.
Real-time intraoperative digital pathology for surgical oncology
Figure 2 Figure 1
Despite the historic value of the frozen section, many surgeons and pathologists alike question its utility, arguing that assessing the ex vivo resection or the surgical bed is of greater clinical benefit. Various studies support these varying approaches in distinct cancer types including head and neck, breast and brain.
In the recently published study, neurosurgeons used CLE to treat six patients with gliomas, three with other primary brain tumours, one with metastasis, and one with reactive brain tissue. Video-flow images were generated of the operative field during surgery, while pathologists viewed the images simultaneously outside the operating theatre at distant sites. One was in another state, four were at home, and six were elsewhere in the hospital. All video and still CLE images were correlated to corresponding frozen section and standard H&E histology sections. Video-flow CLE allowed correct tissue histoarchitecture interpretation in 96% of digital biopsies. This was possible in a fraction of the time taken to undertaken frozen section assessment. The duration of application of the CLE system was one minute per case and 0.25 seconds per digital biopsy, with the first image that demonstrated identifiable histopathological features being acquired within six seconds. Frozen sections were processed within 23 minutes, which was statistically significantly longer than CLE Intraoperativeimaging.digital pathology with CLE allowed real-time assessment of tissue histoarchitecture without taking tissue biopsies, facilitated communication between surgeon and pathologist, and permitted accurate decision-making during oncological surgery. Overall, it resulted in immediate informed decisions with significant advantages over frozen section Anassessment.example of this approach in the context of head and neck pathology is provided here, where a moderately dysplastic oral epithelial lesion is imaged before resection (Fig. 1), after which the peripheral mucosal (Fig. 2) and deep surgical (Figs. 3-5) margins were imaged. The peripheral mucosal margin demonstrates normal squamous epithelial transitioninghistoarchitecturetothesurgical bed, while the deep margin demonstrates fine elastin fibres and collagen bundles (Fig. 3), muscle (Fig. 4) and underlying adipose tissue (Fig. 5), all imaged from different parts of the surgical Removalbed.ofall premalignant epithelium was established before wound closure and confirmed on standard H&E sections.
CLINICAL
CONTENTSTOBACK
Intraoperativeassessment video-flow digital pathology coupled with telepathology achieves near perfect concordance with permanent hematoxylin and eosin stain (H&E) tissue sections but in real-time.
Handheld fluorescencebased miniaturised confocal endomicroscopy with telepathology is at least 23 times faster than frozen section
50 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH are now a reality and easily applicable in theatre. A recently published US study examined the utility of real-time intraoperative surgery using confocal laser endomicroscopy (CLE) and telepathology for navigating a series of 11 patients with brain masses.
The benefits of intraoperative digital pathology during oncological surgery extend beyond good communication between surgeon and pathologist. They include reduced operating time, greater accuracy of pathological diagnosis, better surgical clearance with normal tissue margins, efficiency in
UPDATE
Women may book online www.breastscreen.health.wa.gov.au or phone
1 08/08/2022 3:37:16
digital workflows allow the integration of artificial intelligence with image-guided surgery and computer-assisted diagnostics, whereby each surgical case is utilised as another opportunity for continuous training and refinement of both surgical approaches and pathological Thisdiagnoses.further improves diagnostic and prognostic accuracy for patients while simultaneously building a repository of knowledge for surgeons and pathologists to refine their surgical procedures and diagnostic interpretations. Although many of these parameters require validation in different oncological settings, the imperatives of contemporary patient care necessitate adoption of procedures, processes and technologies that enable a digitally driven sustainable healthcare system. Dr William Mayo would have been the first to recognise the central role that digital pathology would play in shaping future medical practice.
13 20 50
SEPTEMBER 20222 | 51MEDICAL FORUM | RESPIRATORY HEALTH
– References available on request Author competing interests – the author is CEO & Managing Director of Optiscan Imaging Ltd, an ASXlisted Australian company which has developed, manufactured, and commercialised handheld fluorescence confocal laser endomicroscopes for real-time intraoperative digital pathology applications.
CONTENTSTOBACK
If women have any breast symptoms of concern whilst breastfeeding, they are advised to see their GP without delay for a consultation, clinical examination, and appropriate diagnostic breast imaging.
operating theatre utility, reduced pathologist travel time, ability to interrogate the complete surgical bed, limited impact by blood in the surgical field, reduced need for repeat surgery, reduced need for adjuvant therapies, better patient outcomes, and better health Importantly,economics.
CLINICAL UPDATE Figure 4 Figure 5Figure 3
BreastScreen WA_breastfeeding and screening_2022.indd PM
As the average age of mothers in Australia increases, more women who are over 40 years and breastfeeding are contacting BreastScreen WA for a screening mammogram. Screening mammograms are significantly less effective in detecting breast cancers during breastfeeding due to increased breast density. Women who are breastfeeding are advised to postpone their screening mammogram until 3 months after cessation of lactation. This allows the breast tissue to return to pre-breastfeeding density.
Breastfeeding women and screening mammograms
UPDATE
Maximal growth of IHs occurs in the first eight weeks of life. A small IH in the first two weeks can grow quickly, so early referral is essential.
Alongside implementing its statewide clinical service for late 2022, the RCC has commenced streams of activity covering education and workforce capacity building; digital technologies; partnership and advocacy; and connection to global
It is important that patients expertise, research, and clinical Increasingtrials.
Once IHs are in the involutional phase (often heralded by reduced volume, subtle surface wrinkling, colour change from bright red to purple to whitish) beta blockers have a less clear role, although they may hasten involution.
Broadly speaking, a birthmark is present from birth, and vascular birthmarks are either red, blue, or occasionally skin coloured, depending on the type of vessels involved and their location in the skin. The ISSVA classification system for vascular anomalies divides into tumours and malformations.
primary care provider capacity and confidence in rare disease care is a key focus for the RCC.This includes GP training and Aboriginal Health Worker positions, GP training resources and workshops as well as co-creating online communities of practice linking primary and specialist care. Collectively, RCC activities will also
The serendipitous discovery that oral propranolol blocked the growth of IHs has led to propranolol (now also atenolol) being used as first-line treatment for IHs that are ulcerated, segmental or large, cosmetically significant or affect function (e.g. block vision).
the diagnosis of IHs and delays diagnosis and treatment. IHs may be superficial (cherry red), deep (bluish – these can be difficult to distinguish from venous malformations) or mixed with a superficial and deep component. Many IHs will proliferate and then involute leaving an excellent cosmetic result. Large protuberant IHs can leave architectural distortion with some fibrofatty residual and lax skin. IHs that ulcerate will leave scarring.
52 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
Infantile haemangiomas (IH) are the most common benign tumour of infancy with a classic history of a period of growth after birth, followed by a period of involution. characterisedHistologicallybyglut-1positivity on immunohistochemistry, a biopsy is rarely required for diagnosis.
CONTENTSTOBACKCONTENTSTOBACK
Vascular birthmarks: when to refer
Topical timolol is helpful only for small superficial IHs where parents do not want to use an oral beta blocker. There is absorption of timolol through the skin and the dose absorbed is less controlled.
to respond to the need to connect and provide a range of crosssector rare disease care services to address challenges for children and families living with rare and undiagnosed diseases.
Significant hemangiomas are often not controlled by topical timolol and the opportunity to stop their growth is lost.
Rare Care Centre: global needs, local leadership
There may be a mark on the skin at birth, but the growth after birth is a key part of the history. Photos of the baby at birth and at review can be very helpful to confirm the diagnosis. If the hemangioma is fully formed at birth and does not grow after birth, it should be referred for review and other diagnoses Ultrasoundconsidered.isoftenunhelpful in
Significant strides have been made in the care for West Australian children with a rare or undiagnosed disease with the launch of the Rare Care Centre (RCC) at Perth Children’s Hospital. It is taking a leading role in international efforts to help establish rare diseases as a global policy priority while aiming to deliver integrated and networked care locally. It is the first centre in the Southern Hemisphere created Key messages
Without a history of growth after birth a diagnosis of infantile hemangioma should not be made Oral beta blockers are gold standard for IHs that are cosmetically concerning, ulcerated, segmental and or affecting function Children with hemangiomasmultipleshould be screened for liver and brain involvement.
CLINICAL
By Dr Rachael Foster, Dermatologist, Nedlands By Dr Gareth Baynam, Medical Director, Rare Care Centre, PCH
Pulse dye laser is an adjunct treatment for ulcerated and very superficial IHs and can be used to clear residual telangiectasia once the IH has completely involuted. Excision or plastic surgery may be required for IHs that leave an unacceptable scar or fibrofatty Ifresidual.achild is born with more than five infantile hemangiomas, liver and brain ultrasound is recommended. Oral beta blockers may be indicated if there are visceral hemangiomas, and thyroid function may need to be tested. Large or segmental IHs can be associated with PHACE or LUMBAR syndrome and need referral and multidisciplinary assessment.
understand beta blockers do not cause the hemangioma to shrink away immediately, rather the aim is to stop the IH from growing any bigger. Beta blockers are continued until the time the IH would have naturally stopped growing, and then the IH can continue to naturally involute. This process can take two to seven years and occasionally longer.
An international panel of more than 220 medical experts and experts with lived experience, representing over 100 countries, have been active since 2020 in co-designing the model and operational framework for the GNRD. The pilot will connect multi-disciplined centres of expertise to collaborate globally, providing the bedrock of a structured, inclusive approach for all regions and all rare diseases, to help ensure no one is left behind.
Segmental port wine stains (PWS) of the face involving the forehead or upper eyelids can be associated with Sturge Weber syndrome requiring MRI, ophthalmology review and close monitoring for any signs of seizure activity or developmental delay, with paediatric neurology. Multiple PWS on the body should be referred for review. Reticular port wine stains can be difficult to distinguish from cutis marmorata telangiectatica congenita (CMTC) which can be associated with ipsilateral limb hypotrophy. In these cases, longitudinal monitoring is Therequired.infantile hemangioma with minimal or arrested growth (IHMAG) can mimic a reticulate PWS. The clue in the latter condition is tiny dark blebs that appear over time.
The complexity of rare diseases and their infrequency have forced an evolution in the model of care from a multi-disciplinary approach towards ‘networked care’, to enable access to expertise from across an international network of experts to inform local care. The establishment of the GNRD will connect rare disease centres of expertise with progressively expanding geographical and disease coverage and be transformative to help dissolve the existing barriers for a large and vulnerable population.
A simple venous or lymphatic malformation usually presents as a bluish or skin coloured swelling. Venous malformations tend to be compressible. Treatment may be sought if cosmetically bothersome and or causing pain. A combination of physical therapy (compression), surgery, sclerotherapy, and emerging medical therapies (oral sirolimus and anticoagulation) can be trialled to improve cosmesis, pain and function. Those with multiple blue swellings should be referred for assessment.
Now is the time to translate political willingness into action by supporting the creation of networks of experts and multidisciplinary and cross-sector specialised centres for rare disease. This will lay the foundation for the development of a Global Network for RD (GNRD).
Salmon patches Salmon patches (simplex nevus) also known as stork marks or angel kisses, are common, superficial capillary vascular malformations that can affect the upper lip, nose, glabella, eyelids, forehead, scalp, occiput, and lower back. The eyelid and faint glabella salmon patches (SPs) will routinely fade, but paranasal, lip, prominent V shaped on the forehead, scalp, occiput, and lower back SPs tend to persist. Those persistent at 12 months are unlikely to fade. Pulse dye laser is offered for SPs unlikely to self-resolve as soon as possible; laser is better tolerated in younger children, and often less treatments are required. Very prominent SPs can be associated with underlying genetic diseases (e.g. Beckwith-Wiedemann Extracranialsyndrome). malformationsarteriovenouscanmimicSPs or faint port wine stains clinically and may not show growth and high flow on ultrasound until around puberty. Port wine stains These darker capillary vascular malformations are present at birth and respond to pulse dye laser especially on the face. I perform pulse dye laser monthly for the first 12-18 months to try and get maximal fading without needing general anaesthetic.
– References available on request Author competing interests – nil
Internationally, rare diseases are the single biggest health cost with care for people of all ages estimated to cost more than cancer, obesity, heart attack, stroke, and Alzheimer’s combined. Rare diseases paediatric inpatient costs in the US mount to 1.5 times the cost of all common diseases, and on parity in adults.
SEPTEMBER 20222 | 53MEDICAL FORUM | RESPIRATORY HEALTH inform and help lay pathways for adult care.
Venous and malformationslymphatic
CLINICAL UPDATE continued on Page 54 CONTENTSTOBACKCONTENTSTOBACK
The RCC is a partnership between Child and Adolescent Health Service and multiple philanthropic foundations including the Angela Wright Bennett Foundation, McCusker Charitable Foundation (via Telethon Channel 7 Trust), Stan Perron Charitable Foundation and Perth Children’s Hospital Foundation with its major Rare Care Centre partner, Mineral Resources Limited. Rare disease statistics are staggering. They are the biggest killer of children globally. Collectively they affect around 400 million people, with the majority of cases occurring in childhood.
Topical sirolimus ointment between laser sessions can be helpful.
The first hybrid surgical and catheter AF ablation program (HyCASA = Hybrid catheter and surgical ablation) of its kind in the Southern Hemisphere has been established in Perth and is now a global education centre for this procedure. Since catheter ablation of AF was first described in 1998, the use of this intervention has increased exponentially, and its annual growth rate exceeds other cardiac interventions. This increased use of catheter ablation in AF management is supported by randomised controlled trials and clinical guidelines and has also been driven by major technological advances.
Atrial fibrillation (AF) is the most common sustained rhythm disorder, and its treatment has been revolutionised during the past 20 years. This includes improved detection (Apple watch etc), better anticoagulation (DOAC), left atrial appendage management and catheter ablation.
An endocardial catheter-only approach to posterior LA wall ablation is challenging due to risk of thermal injury to the oesophagus, which potentially leads to the extremely rare but devastating complication of atrial-oesophageal fistula (estimated 80% mortality).
Advanced AF rhythm management
By C/Prof Rukshen Weerasooriya, Cardiologist, Heart Rhythm Clinic WA
Rare Care Centre
Furthermore, endocardial-only posterior wall ablation frequently fails because of complex muscle fibre
CONTENTSTOBACK
HyCASA ablation strategy This comprises epicardial surgical and endocardial ablation components. The ablation target is the posterior left atrial wall between the four pulmonary veins. This area is targeted in patients with non-pulmonary vein mediated AF because a high percentage of non-PV sources originate from this anatomical region which shares the same embryologic origin (and therefore electrophysiology) as the pulmonary veins.
CLINICAL UPDATE
Technological advances have greatly improved our accuracy of energy titration during catheter ablation. This avoids excessive energy delivery reducing the risk of tamponade, phrenic nerve palsy and oesophageal injury and also avoids inadequate Epicardial thoracoscopic posterior wall ablation
The health inequities faced by people living with a rare disease are further amplified in regional and remote regions and indigenous populations. Now is the time to build on the metropolitan (PCH) hub partnerships of the Rare Care Centre to advance rare care for regional and remote regions. We have an opportunity to partner to build on our world-leading initiatives supported by the Roy Hill Community Foundation and partners in the Pilbara, such as Pilbara Faces (3D facial analysis), Pilbara Voices (Aboriginal translations of medical terms) and Pilbara DNA (access to clinical whole genome sequencing), to deliver improved care for many thousands of remote region and Indigenous children living with a rare disease. continued from Page 53
There has been increasing incidence of AF in all industrialised populations with an increase of 1.2% per annum seen in Western Australia between 1995 and 2010. Catheter ablation alone is highly effective in patients with a small left atrium and paroxysmal AF, though challenges remain for those patients with a large left atrium and persistent AF.
54 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH energy delivery thereby reducing risk of repeat procedures. Many recent advances have occurred because practical application of high-performance computing in the catheterisation laboratory allows rapid computation of location, cardiac signals, and catheter contact ‘on the fly’. The challenge is to achieve better results in persistent AF, particularly in patients failing endocardial catheter ablation and, so far, most randomised controlled trials of additional catheter ablation strategies have been Thedisappointing.Converge study is one of the few positive RCT in patients with persistent AF demonstrating superior outcomes by additional ablation, in this case comparing HyCASA (pulmonary vein isolation plus surgical thoracoscopic posterior LA ablation) with catheter ablation (pulmonary vein isolation plus linear ablation across the LA roof) in persistent AF patients.
In addition, my team has chosen to add Atriclip left atrial appendage occlusion in all cases because this removes additional potential AF sources from the appendage and obviates the need for long-term
SEPTEMBER 20222 | 55MEDICAL FORUM | RESPIRATORY HEALTH
The first hybrid surgical and catheter AF ablation programme (HyCASA) of its kind in the Southern Hemisphere was established in Perth and is now a global education centre for this
Subxyphoid port access anticoagulation in the majority of Potentialpatients. complications of surgical HyCASA include cardiac perforation or injury (<1%), pericarditis (almost universal usually settles before discharge), stroke (< 1 in 500) and incisional hernia (< 1%) Endocardial catheter ablation remains the mainstay of invasive AF treatment. The HyCASA approach is reserved for the most difficult and recalcitrant AF cases. Our approach is to offer a patient HyCASA if they have failed two previous catheter ablation attempts and if the patient remains highly symptomatic.
HyCASAprocedureablation strategy comprises both epicardial surgical and endocardial ablation
The HyCASA approach depends upon a team-based approach with close collaboration between a cardiothoracic surgeon and cardiac electrophysiologist. The surgical component is beating heart and entirely thoracoscopic by access via one sub-xyphoid and three axillary
Considering the highly selected patient population (difficult recalcitrant AF cases), the success rate has been: 82% of the 75 treated patients achieving successful AF suppression. These patients would otherwise have failed AF ablation and been only considered for pace and ablate or rate control only.
Author competing interests – Heart Rhythm Clinic of WA is the only practice currently offering this treatment in Australia.
-SERVICESFullbody hair restoration services (Including eyebrow, eyelash & beard -transplants)Solutionsfor victims of hair loss due to scar or burn - Male & female hairline lowering - Transgender hair alignments - Hair revision surgeries - Non-surgical hair loss treatments & products NEW HAIR CLINIC PERMANENT HAIR RESTORATION BEFOREBEFORE AFTERAFTER Consulting Rooms: Image 21, Suite 4/21 Stirling Hwy, Nedlands WA 6009 For all Appointments T 08 9389 6000 E www.newhairclinic.com.aureception@newhairclinic.com.auWe o er world-leading surgical, non-surgical and natural treatment solutions for hair loss. GOLD standard hair transplant clinic with over 25+ years experience. CONTENTSTOBACK
Theports.surgical and catheter components are separated by six months (surgical ablation first then catheter ablation). The delay is designed to ensure complete resolution of post ablation inflammation and oedema before commencing consolidation ablation by endocardial mapping and ablation.
Considercomponentsreferral for HyCASA when patients have failed catheter ablation and remain symptomatic as an alternative to the pace and ablate or other rate control strategies.
CLINICAL UPDATE
Key messages
orientation on the posterior LA wall and complexity of endo-epicardial connections. Epicardial posterior left atrium ablation avoids oesophageal injury because energy is directed away from the oesophagus by clever engineering and catheter design.
Friends are there for you They are six of the world’s best-known friends and they’re back on stage at the Regal Theatre this month for Friends! The Musical Parody. By Ara Jansen MUSICAL THEATRE CONTENTSTOBACK 56 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
Friends! The Musical Parody is at the Regal Theatre from September 9-11. Bookings from www.ticketek.com.au or 1300 795 012.
MUSICAL THEATRE
Friends! The Musical Parody celebrates the misadventures of the iconic 20-something pals as they navigate the pitfalls of work, life and love in 1990s Manhattan. It’s a typical day at the Central Perk until an unexpected runaway bride arrives and kicks the whole gang out of second gear. This theatre show plucks the best moments from Friends’ decadelong run and recreates the moments through an uncensored, fast-paced and music-filled romp.
to have a fun and entertaining night out. Many people are also wearing their favourite Friends merchandise to the shows.
The much-loved original television sitcom starred Jennifer Aniston, Courtney Cox, Lisa Kudrow, Matt LeBlanc, Matthew Perry and David Schwimmer and ran for 10 seasons. It also featured the opening theme I’ll Be There for You which went No. 1 in numerous countries after it was turned into a proper song by The Rembrandts.
Produced by Sam Klingner, Friends! The Musical Parody is drawing people of all ages as it tours Australia. Surprisingly, Klingner says it’s not just Friends’ fans but people of all ages who want
SEPTEMBER 20222 | 57MEDICAL FORUM | RESPIRATORY HEALTH
CONTENTSTOBACK
“I love that people can spend a few hours in a theatre and forget everything else,” he says. “They can laugh and smile and be thoroughly entertained. “One of things which made the original Friends so popular was how relatable the show was – it’s about life. That speaks to everyone.”
All the music in the show is original and fashioned around iconic moments from the TV show. Friends’ boffins will find plenty to delight them, and musical theatre lovers will also recognise cleverly placed references from other Broadway
Thismusicals.Australian production features WAAPA graduate Maverick Newman as Chandler alongside a cast who were not only required to be able to sing, dance and act, they also needed to have comedy chops.
Cameron Mitchell is the in-house “Friendspert” when there was any question about the TV show and plenty of the cast and crew are also longtime fans of the sitcom.
“It’s a fast-paced show with no time to stop and think. For the cast, there isn’t a moment when they’re not doing something. When we were looking for the characters, we were looking for people who could parody the mannerisms of the characters, to make people laugh. We spent a lot of time on that because it’s 100% dialling it up from the TV show. We auditioned more than 500 people across the country to find just the right Choreographercast.”
When you put together the names Rachel, Monica, Phoebe, Joey, Chandler and Ross, it can only mean one thing – Friends ! Join those favourite friends at the Central Perk for a night of unstoppable laughs in a musical that lovingly lampoons the beloved NBC sitcom.
Whilst not aspiring to the level of the great Jack Mann or Gladstones high premium releases, they are honest, good value, well-crafted wines that reflect their variety and/or origin.
More recently Houghton Wines has been purchased by multinational company Accolade and, in 2019, underwent restructuring with the sale of its Swan Valley Estate. Now it is concentrated in the Great Southern and South West with all wine making through its winery in Nannup. Vineyards include Moondah Brook (145ha), Pemberton (92ha), Mount Barker (74ha) and Frankland River (89ha), with fruit also sourced from Margaret River, Harvey and Ferguson Valley. Cellar sales are combined with Brookland Valley Wines in Margaret River. Wines tasted for this review are all from the new ‘Premium Release’ range, and all at the same mid-market price point.
Houghton Premium Release 2021 Margaret River Chardonnay (rrp $30)
Houghton Premium Release
CONTENTSTOBACK
Review by Dr Craig Drummond Master of Wine
Houghton Premium Release 2020 Frankland River Shiraz (rrp $30)
58 | SEPTEMBER 2022 MEDICAL FORUM | RESPIRATORY HEALTH
Of particular note was the contribution of legendary winemaker the late Jack Mann, who did a staggering 51 vintages at Houghton Wines. In 1937, he created the Houghton White Burgundy, a Chenin Blanc-based wine, which has been one of the biggest selling wines in Australia and still enjoys good sales (since 2005 as Houghton Classic White to comply with EU labelling laws).
My pick of the tasting. This wine has vibrant lifted aromatics showing stone fruit, tropical pineapple characters, and cashew nuts. What I like about this wine is the fruit intensity on the palate, and the balance of fruit, acid and oak. Shows nectarine flavours, mealy characters from lees contact and nutty oak nuances. A very enjoyable value-for-money wine, drinking nicely now, but with qualities which will give it a further five years’ life.
From a good vintage in Frankland. An elegant style with underlying fruit power. The nose is intense, with violets, blackberry and vanillin oak. Flavours of redcurrant, mulberry and some dark chocolate. Very fine grained tannins, drying at this youthful stage. Firm acidity, great structure. Oak is dominant but will integrate. A nice Cabernet with a 10-12-year future.
Attractive in the glass, limpid with a green-gold hue. The nose resplendent, typifying this Margaret River blend, with overt fresh cut grass, dried herbs and green pea. The palate clean and crisp with zingy acid giving structural integrity and a long refreshing finish. Flavours of lime, grapefruit and green capsicum. A lean style with lowish alcohol of 12.5% suggests early picked fruit. Best consumed now but will drink well for a couple of years more.
Houghton 2019 Frankland River Cabernet Sauvignon (rrp $30)
A solid, full bodied, mouth-filling wine. As I have said in my past articles, Shiraz from the Lower Great Southern subregion of Frankland River seldom disappoints, this wine being no exception. Deep red colour with a purple meniscus indicative of this wine’s youthfulness. Aromas of black olive, ripe cherry, with a touch of white pepper. Palate shows satsuma plum, ripe mulberry, plus that varietal spice and pepper. Mellow and integrated. Supple finish. A young wine that will reward over the next 8-10 years.
WINE REVIEW
2021 Margaret River Sauvignon Blanc Semillon (rrp $30)
A WA icon undergoes modern change
Every West Australian wine consumer will be familiar with the iconic winery, Houghton. Established in the Swan Valley in 1836, it became a part of WA history and put the Swan Valley on the Australian wine map.
caretoBuilt Looking to sell your practice? Dr Br ison 0418 921 073 Brenda.Murrison@breckenhealth.com.au Damian Green 0423 844 268 Damian.Green@breckenhealth.com.au
