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Cardiovascular Health issue | Atrial Fibrillation, Arrhythmia, Man v ECG Machine, Chemo Toxicity
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EDITORIAL BACK TO CONTENTS
Jan Hallam | Managing Editor
Isolation and connection There will be much to unpick once this pandemic has receded: how governments... handled the big decisions; how communities and individuals reacted to their fears; the role of media, old and new.
So, this editorial is coming to you from self-isolation, having succumbed to a virus but highly unlikely to be THE virus, or so my GP and I both decided (well mostly me) after a bulk-billed phone consultation. It does give one a slightly different perspective on the extraordinary events we are seeing and the uncertain times in which we live. Speaking strictly from a journalist’s perspective, news learnt today will be either irrelevant or superseded by tomorrow, so that has contributed to confusion and mixed messages. You have to be wired to a 24/7 news cycle to keep up and, to be perfectly honest, that is not good for anyone’s mental health. In the middle of March, I managed to talk to the director of WA Communicable Diseases Control, Dr Paul Armstrong. What he said then (the imperative for public health measures to flatten the curve to preserve hospital critical care function; to buy some time for the scientists to come up with antiviral medications if not vaccines; the need for more personal protective equipment; and unique mitigating strategies for remote communities) are all relevant today. Those messages haven’t changed. What is changing, and expected to change, is the more rapid spinning of the numbers counter, the lockdowns and shutdowns and a feeling that the world may have been fundamentally altered. There will be much to unpick once this pandemic has receded: how governments – democracies and authoritarian alike – handled the big decisions; how communities and individuals reacted to their fears; the role of media, old and new. From a health service perspective, the ‘frontline’ has been exposed to an extraordinary degree. I haven’t been around long enough to use the word unprecedented, but it feels appropriate – that frontline is stretched. It goes all the way through the system – hospital; general practice; clinical staff and administration staff; policy makers. No one is getting much sleep. There is so much to learn here, and I am sure that as these pivotal members of our community work their way through the masses of sick and worried patients, they are jotting things down ‘for next time’. We have been hearing techies bang on about disruption for years now. It took a naturally occurring virus to push governments and systems to attempt to think quick, think smart, think collaboratively and think remotely. Let’s hope it continues.
MEDICAL FORUM | CARDIOVASCUL AR HEALTH ISSUE
APRIL 2020 | 1
CONTENTS | APRIL 2020 – CARDIOVASCULAR HEALTH ISSUE
Inside this issue 20 18 14
26
FEATURES
NEWS & VIEWS
LIFESTYLE
14 Close-up:
1
Editorial: Isolation and connection – Jan Hallam
44 Travel: Climbing Krabi
4
Times change, people don’t – Dr Joe Kosterich
48 Social Pulse:
6
Letters to the Editor: A GP’s birds’ eye view – Dr Joanne Samer
49 Wine review:
Interventional Cardiologist Dr Michelle Ammerer
18 Q&A: Cardiologist Dr Tony Mylius
20 Into the Ether: My Health Record
26 Real-time Prescribing
8
– James Knox
46 Wild Butterfly: The lessons Perth Urology masterclass Bellarmine Wines – Dr Craig Drummond
Protecting doctors – Dr Joe Kosterich
50 Something About Mary
The science and COVID-19
52 Otto heads back home
10 Urgent care clinics
53 Out & About
worry GPs
40 Intraoperative radiotherapy
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CONTENTS
PUBLISHERS Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au
Clinicals
ADVERTISING Advertising Manager Gary Sullivan (0403 282 510) mm@mforum.com.au EDITORIAL TEAM
31
Post-Thrombotic Syndrome Dr Patrik Tosenovsky
32
Man vs ECG Machine Dr Michael Davis
35
AF & CAD Dr Andre Kozlowski
36
Post Chemo heart failure Dr Kalil Anvardeen
38
Heart skips and bumps Dr Tim Gattorna
39
Monomorphic VEB Dr Justin Ng
41
CVD and renal disease Dr George Chin
12
On being a doctor Dr Anna Stavdal
28
Public health for the 21st century Dr George Crisp
42
Silicosis Update E/Prof Odwyn Jones & Prof Bill Musk
Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Journalist James Knox (08 9203 5222) james@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au GRAPHIC DESIGN Thinking Hats studio@thinkinghats.net.au INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Mark Hands (Cardiologist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon) CONTACT MEDICAL FORUM Phone: Fax: Email:
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APRIL 2020 | 3
OPINION
Times change – people don’t Writing anything about Covid19 with a deadline further out than five minutes is fraught – but here goes.
Perspective is the first casualty when panic takes over.
Beneath the veneer of civilisation, human nature has changed little over the millennia. We scare easy. There is a new twist on the old joke about a man going up to the bar. The current version has him coughing twice and the bar closes for two weeks. Shooting the messenger is popular with those who don’t want the public to be aware of what is happening. However, much coverage of COVID-19 has been fear mongering. Newspapers and TV news have been breathless in their descriptions of the latest “victims”. Most, like Richard Wilkins, Tom Hanks and Peter Dutton feel fine. They have no symptoms and can hardly be described as “victims”. We don’t get these updates in winter with flu “victims”. An NSW school was the first closed when one student tested positive. He was not unwell. There are increasing calls to close all schools. Yet children get the mildest of cases. And who will care for them? Elderly grandparents or should parents stop working? Maybe they can hang out at the shops. Perspective is the first casualty when panic takes over. There are and will be fatalities. This happens every winter with seasonal flu. Worldwide deaths are 7000 at time of writing – 20% of the US influenza deaths this season. Over 80% are in three countries. Mortality rates are inflated by the fact that they are based on confirmed cases. For each one confirmed there may be hundreds more. In early March, a Victorian GP with very mild viral symptoms went to work. He ultimately tested positive
4 | APRIL 2020
prompting the Victorian health minister to opine: “I have to say I am flabbergasted that a doctor that has flu-like symptoms has presented to work”. Is there a doctor with mild viral symptoms who hasn’t worked? There have been days when I was the most unwell person I saw. This demonstrates how out of touch health ministers are with the realities of medical practice. Doctors have never previously stayed home with minor viral symptoms. The virus will not be contained – it is going “viral”. It will spread to all countries with tens of millions of cases. Aside certain risk groups (those over 80 or with other medical problems – same as flu) “victims” will have a minor illness and make a full recovery. The damage to the economy will be far greater than that done by COVID-19. Those who cry no overreaction is too great totally ignore that these consequences will be severe and long lasting. On the plus side, full credit to Scott Morrison on his national address re hoarding. Two quotes come to mind. One by Friedrich Hayek ‘Emergencies' have always been the pretext on which the safeguards of individual liberty have been eroded. And the other by Rudyard Kipling about keeping your head when all about you are losing theirs. As doctors, we need to keep our heads! https://www.theaustralian.com. au/nation/coronavirus-100000people-now-infected-panic-buyingspreads-to-us-britain/news-story/ a9e4bb0187d385f206acc99a59395156
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Dr Joe Kosterich | Clinical Editor
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Is there a link between oral health and cardiovascular health? There has long been conflicting data on the association between oral health (namely periodontal disease/ periodontitis) and cardiovascular disease (CVD). A number of chronic infectious, inflammatory and immune diseases are associated, with significantly higher risk of adverse CVD events including periodontitis. Periodontitis is a non-communicable disease with high prevalence of about 50% affecting the gingival and periodontal supporting oral tissues that anchor teeth into the jaw. It is the sixth most common human disease. Traditional risk factors for CVD (inclusive of atherosclerotic diseases, coronary heart disease, cerebrovascular disease and peripheral vascular disease) remain lifestyle factors, principally tobacco smoking, dyslipidaemia, hypertension and altered glucose metabolism. However, there is a significant body of evidence to support an independent association between periodontitis and CVD, as well as diabetes, COPD and chronic kidney disease. Patients with periodontitis have a higher prevalence of CVD, a higher prevalence of coronary artery disease and risk of myocardial infarction, higher prevalence of cerebrovascular disease and risk of stroke, higher prevalence and incidence of peripheral artery disease, and higher risk of heart failure and atrial fibrillation. There is limited evidence that CVD is a risk factor for the onset or progression of periodontitis.
Benefits of oral hygeine There have been no randomised controlled trials on the effect of periodontal intervention on primary prevention of CVD, but there is some evidence from observational studies of oral health interventions such as tooth brushing, dental prophylaxis, increased dental visits and periodontal treatment which have produced a reduction in the incidence of these events. There is, however, insufficient evidence to support or refute the potential benefit of the treatment of periodontitis in preventing or delaying a cardiovascular event. There is some
By Professor Camile S. Farah BDSc MDSc (OralMed OralPath) PhD GCEd GCExLead FRACDS (OralMed) MAICD AFCHSM FOMAA FIAOO FICD FPFA FAIM Lab: Subiaco WA
About the Author: Speciality: Oral Pathology Areas Of Interest: Oral mucosal and salivary gland, head and neck and bone pathology. Phone: (08) 9213 2173 Email: camile.farah@clinicallabs.com.au Professor Farah is a Consultant Oral Pathologist at Australian Clinical Labs. In addition to practising at Perth Oral Medicine & Dental Sleep Centre, Camile holds a hospital appointment as Consultant in Oral Medicine & Pathology at Fiona Stanley Hospital, and is a member of its Head and Neck Cancer Multidisciplinary Team. In 2019 he was named the Australian Research Field Leader in Oral & Maxillofacial Surgery for his research on oral cancer and premalignant pathology. limited evidence that systemic statin intake may have a positive impact on periodontal health, but insufficient evidence that statin intake may enhance the outcomes of periodontal therapy. Non-surgical treatment of periodontitis involving supra- and sub-gingival debridement of the affected teeth is often delivered in several short sessions, or in one full-mouth treatment. Delivering periodontal debridement in one full-mouth session triggers an acute systemic inflammatory response associated with transient impairment of endothelial function. There is no evidence for specific effects of periodontal treatment on increasing ischemic cardiovascular risk. Similarly, periodontal treatment is safe with regard to cardiovascular risk in patients with established CVD. There is no evidence to support discontinuation of antiplatelet therapy, vitamin K antagonists, or novel oral anticoagulant (NOAC) therapy before periodontal debridement procedures. Delayed post-operative bleeding may occur but local haemostatic agents are effective in controlling this.
Patient education Patients with CVD should be advised that periodontitis may have a negative impact on their CVD and may also
increase the risk of a CVD event and that effective periodontal therapy may have a positive impact on cardiovascular health. All patients with newly diagnosed CVD should be referred to their dental professional for a periodontal examination and cleaning. Patients should be advised of the need to clean teeth and gums carefully at home and to have personalised advice and care from a dental professional to minimise the potential negative effects of periodontitis on CVD. Oral hygiene procedures should include twice daily tooth brushing with either a manual or electric toothbrush (for a minimum of two minutes each time), cleaning between the teeth and around the gums with floss or an interdental brush, use of specific antibacterial toothpastes to control plaque accumulation, and having regular dental check-ups. Long-term mouth rinsing with most commercial products has not been shown to be effective in managing periodontal disease and is not encouraged as part of a regular oral hygiene regime. References See Sanz et al. J Clin Periodontal 2020;47:268-288 and “Contemporary Oral Medicine� at https://www.springer. com/gp/book/9783319723013
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APRIL 2020 | 5
Dear Editor... A GP’s birdseye view ED: Northern suburbs GP Dr Joanne Samer has started a Facebook page to communicate with her patients, particularly around the coronavirus. This is an edited extract of two posts that she shared with Medical Forum. Good evening all. I have been mulling this post over in my head all weekend and have decided now is the time to write it. I am a local GP and member of the community. I know many of you and you know me. I am writing this to urge you all to start taking this COVID-19 virus very seriously. The statistics show us that the young are not likely to get very sick, but they can still transmit the virus. So "Teach Your Children Well" and teach them how to wash their hands. They, AND YOU, should wash as often as possible with soap and warm water for 20 seconds – so as soon as we come into the house, before we prepare food and eat, after we go to the toilet, at play time, lunch time, before bed... It is those of us over the age of 55 who are most at risk, especially if we have high blood pressure, lung disease of any kind, diabetes, are immunocompromised. The reason for social isolation is to reduce the risk to this part of our community and there are MANY who fit this category. Now is not the time to put ourselves first. Now is the time to prepare sensibly. Now is the time to think about the greater good. Now is the time to put our parents and grandparents first. Now is the time to put those that look after us first – our shopkeepers, our bus and train drivers, our uber drivers, our local hairdresser or beautician or health professional. Now is the time to get serious Doctors are going to do their best as will everyone else on
the frontline. WE NEED YOUR COOPERATION if we are going to come out of this…with low numbers and less infections. It is up to all of us to start now. I urge everyone in our precious community to look out for each other, show as much love, care and consideration as we can possibly muster for each other. Wash your hands, do not cough in public, self-isolate if you are at all unwell, and most importantly, protect our community. What will you do when you win the lock down lotto?
So, get creative and plan. Share your creative and fun ideas here so we can all benefit. Then share this post with your friends and family and sit back and see which of us is lucky enough to win the Lock Down Lotto! Remember, lock down is GOOD, not bad as it stops the spread and protects those who are at risk. And I REPEAT… lock down is GOOD, not bad as it stops the spread and protects those who are at risk. Dr Joanne Samer, MBBS, Post Grad Dip Health Sciences, GAICD
Let’s assume this nasty virus leads you to be stuck at home for let’s say two weeks.
Protecting doctors
What are you going to do for those two weeks? How will you occupy your time? How will you cope physically, emotionally and spiritually?
Thank you to Dr Penny Browne (Between the devil and the deep blue sea, March 2020) for her thoughtful reply to my column on overdiagnosis.
What if you cannot go to the gym or the local pool or the hairdresser or the dog groomer? What if you have four children under the age of 10 literally stuck at home and not allowed out for two weeks? What if your mother lives alone, is fiercely independent and usually refuses any help you offer her? What if you can work from home? What if you cannot work from home and your income is going to be less or worse still, be cut off? What if you have a disabled child living in shared accommodation? My solution? Prepare now and plan to make this experience as fantastic as you can! See it as an opportunity and not a disaster. See it as time to you will want to look back on, and to value because of the way you coped and turned an anaphylactic reaction into a mosquito bite underneath your little toe. An itch and nothing more.
I agree fully that doctors are obligated to follow guidelines which really have become directives. The problem is that, arguably, they may be better at protecting doctors than benefiting patients. This is what needs to be raised and discussed so that less harm occurs. Dr Joe Kosterich, Clinical Editor, GP
Correction In the contents page of the March edition, we incorrectly named toxicologist Dr Christopher Cruickshank, Roger Cruickshank. We apologise for the error.
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LETTERS
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Treatment of angina – tips and tricks Recent data are reshaping how angina is approached, which may be relevant to primary care. Firstly, a large RCT (the ISCHEMIA study) re-iterated that we need not automatically proceed to revascularisation for stable angina, given no clear mortality benefit in doing so (after excluding left main stem or high-grade 3 vessel disease, and of course unstable angina). Secondly, a sham-controlled RCT (ORBITA) suggested that good antianginal treatment could obviate any additional symptomatic gains from a stent, at least in the short term.
About the Author Dr Adil Rajwani leads the CTCA, CT Calcium Score and CMR service at Western Radiology, and the echo service at Royal Perth Hospital. He has a particular interest in CMR, and is one of the few cardiologists in WA to hold Level III accreditation of training by the Society for Cardiovascular Magnetic Resonance (SCMR).
Historically, angina was frequently treated by percutaneous intervention. Now, after excluding high-grade disease by CT Coronary Angiography (CTCA), chest pain clinics are more likely to recommend medical therapy in the first instance. Consequently, patients are more likely to need GP input in managing anti-anginals.
First-line anti-anginal therapy All major guidelines recommend either beta-blockers (e.g. atenolol) or calcium-channel blockers (e.g. amlodipine). Many doctors assume beta-blockers are “cardio-protective”, but this is only the case if there is also reduced ejection fraction or recent heart attack. In fact, amlodipine may be a marginally more effective antianginal. One way of choosing is to look at the heart-rate (atenolol first if fast) and blood pressure (amlodipine first if high). Combining both is the optimal treatment if one drug isn’t sufficient; up-titrate to the maximally tolerated dose and review response after 2-4 weeks. As needed sub-lingual GTN should also be prescribed. Beta-blockers are well-tolerated, but side effects can include erectile dysfunction, claudication, hyperglycaemia, worsening psoriasis, and bronchospasm. Concern in COPD is generally unwarranted, however. Amlodipine can cause ankle-swelling, especially at higher doses.
Second-line agents Many turn, next, to long-acting oral nitrates, but other options are nondihydropyridine CCBs (verapamil and diltiazem), nicorandil, and ivabradine. Bradycardia may preclude many of these, but nitrates and nicorandil are OK. Hypotension can also be tricky – ivabradine is an option but there is some concern about potential increased risk of MI and AF. Many doctors are unaware that allopurinol is an effective anti-anginal – a great option if both bradycardia and hypotension are present. Ranolazine is also widely used in Europe in this setting; not currently authorised in Australia but a TGA application is apparently imminent. Avoid adding verapamil to betablockers (risk of heart-block), and
warn about constipation. Nicorandil has little additional benefit if already receiving long-acting nitrates, and watch for rectal/oral ulceration. GTN patches are useful if GI malabsorption, and pre-medicating with sublingual GTN prior to exercise is surprisingly effective.
Timing of specialist advice Unstable/crescendo symptoms will often prompt invasive management, and ongoing angina despite two drugs at a good dose warrants further assessment. In parallel, it is worth checking for anaemia, hypoxia, fast AF and thyrotoxicosis as unrecognised precipitants. Finally, don't forget statins, aspirin, diet and lifestyle (and not anti-anginals) remain your patient’s main defence against MI.
Western Radiology is the largest community-based provider of CTCA in Perth, with branches across the metropolitan area. Our reporting cardiologists understand how important it is to provide clinical context to the report, ensuring you are best supported in managing your patient amidst an ever-shifting landscape of evidence-base and technology.
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APRIL 2020 | 7
RESEARCH NEWS
What science is discovering about COVID-19
Undocumented cases
Evidence of early approach
A significant number of undocumented cases not being detected or diagnosed due to mild, limited or no symptoms for COVID-19 has been estimated, according to a study published in the journal Science.
Singapore’s response to COVID-19 has been, so far, effective, considering they were the third country to report cases and had the most reported cases in midFebruary, outside of China.
The researchers developed a simulated model based on datasets of infections and population movements from 375 Chinese cities before the lockdown in Wuhan on January 23, estimating 86% of all COVID-19 infections in China were undetected prior to the lockdown, while 65% of the cases were detected after the lockdown. Individuals’ contagiousness has also been estimated with the basic reproductive number (R0) to be 2.38 (95% CI: 2.04–2.77) per COVID-19 infection. Whilst the infection source for 79% of the documented cases was estimated to come from undocumented infections. Title: Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2) infectious diseases are critical.
A study published in The Lancet analysed the Singaporean response to three clusters of local transmission cases, found enhanced pneumonia surveillance, testing of patients in intensive care units and clinicians’ testing, based on clinical or epidemiological suspicion, assisted in early identification of cases. Whilst reactive contact tracing and quarantine of close contacts, ensured no further transmission of the virus. The researchers emphasised the importance of intensive testing and case-finding among close contacts of diagnosed individuals as crucial to preventing clusters from spreading. Title: Investigation of three clusters of COVID-19 in Singapore: implications for surveillance and response measures DOI: https://doi.org/10.1016/S01406736(20)30528-6
DOI: https://doi.org10.1126/science.abb3221
COVID-19 research resource A useful tool to track the latest, verified COVID-19 statistics have been developed by Johns Hopkins University. Link: https://coronavirus.jhu.edu/map.html
8 | APRIL 2020
Suppression vs Mitigation Modelling of non-pharmaceutical interventions has provided an insight into the potential mortality rates and demands on health care services. A paper published by the Imperial College COVID-19 Response Team analysed two public health strategies:
Suppression – reduce the R0 to below 1 to eliminate transmission. Mitigation – reduce the R0 but not below 1, to slow the spread of transmission (AKA flatten the curve). Both strategies were tested with five non-pharmaceutical interventions: case isolation in the home; voluntary home quarantine; social distancing of those over 70 years of age; social distancing of entire population; closure of schools and universities. Modelling of the most unlikely scenario, no control measures, based on an R0 of 2.4%, predicted 81% of the populations in Great Britain and the United States would be infected, with peak mortality occurring in about three months with 510,000 deaths in Britain and 2.2m in the US. Both countries are predicted in this scenario to reach critical care bed capacity in the second week of April with 30 times the demand greater than resources. The researchers modelled the ideal mitigation policies (combining home isolation of suspect cases, home quarantine of those living in the same household as suspect cases, and social distancing of the elderly and others at most risk of severe disease) predicting a possible reduction in peak healthcare demand by two thirds and deaths by half. While modelling of the ideal suppression strategies (combining social distancing of the entire population, home isolation of cases and household quarantine of their family members, and possibly supplemented by school
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In this monthly review of what is new in the world of medical and scientific research, the Medical Forum editorial team has focused on contemporaneous research on COVID-19.
RESEARCH NEWS Health security
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An analysis of 182 countries’ health security has found half were operationally capable, according to a study published in The Lancet.
and university closures) would need to be maintained until a vaccine is developed to eliminate transmission. Title: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand DOI: https://doi.org/10.25561/77482
Open Research Datasets Looking for peer-reviewed coronavirus information updated in real-time? Head over to the COVID-19 Open Research Dataset (CORD-19). This free, openresource database, exclusively focused on coronavirus research, with more than 29,000 scholarly articles, has been launched on the Semantic Scholar platform. The database is the most extensive collection of scientific literature related to the ongoing pandemic and features natural-language processing algorithms to assist in searching for specific papers. https://pages.semanticscholar.org/ coronavirus-research
Vaccine research The first phase 1 clinical trial of a potential COVID-19 vaccine is underway in Seattle, Washington, with the first of the 45 participants having already received their first of two doses, which will be given 28 days apart. The participants will be followed up over the next 12 months to assess the drug’s safety and efficacy.
The interventional vaccine, mRNA1273, was developed with genetic code copied from COVID-19 onto the genetic platform mRNA (messenger RNA) by researchers at the National Institute of Allergy and Infectious Diseases and biotechnology company Moderna Inc. If phase 1 is successful, the drug will need to go through phases 2 and 3 prior to approval, which is estimated to take up to 18 months. Study: Safety and Immunogenicity Study of 2019-nCoV Vaccine (mRNA-1273) to Prevent SARS-CoV-2 Infection The potential vaccine is URL: https://clinicaltrials.gov/ct2/show/ NCT04283461
Immune response World-first research about the immune response to non-severe COVID-19 is being conducted by researchers from the Peter Doherty Institute for Infection and Immunity in Melbourne. They analysed blood samples taken from one of the first patients diagnosed with COVID-19 in Australia.
The study used International Health Regulations (IHR) annual report data and developed a five-level scale to rate the countries: Level 1: Very little functional capacity is in place to prevent and control the risk or event. Level 2: Little functional capacity available on an ad-hoc basis with the support of external resources. Level 3: The country is functionally capable at the national level; however, effectiveness is low at the subnational levels. Level 4: The country is functionally capable of dealing with various events at the national and subnational levels. Level 5: The country's functional capacity is well advanced and sustainable at all levels of health systems. The authors found 52 (28%) countries had preventative capacities and 60 (33%) had response capacities at levels 1 or 2, while 81 (45%) countries had prevent capacities and 78 (43%) had response capacities at levels 4 or 5, suggesting these countries were operationally ready. Most countries, 138 (76%), scored highly in detection capabilities. Whereas 44 (24%) countries did not have an effective enabling function for public health risks and events. Over half of the countries, 102 (56%), had level 4 or level 5 enabling function capacities in place; 32 (18%) had low readiness and 104 (57%) countries were operationally ready for an outbreak of a novel infectious disease. Title: Health security capacities in the context of COVID-19 outbreak: an analysis of International Health Regulations annual report data from 182 countries
The researchers found the immune system responds to non-severe COVID-19 by recruiting the same immune cell populations as it does with influenza, according to a paper published in Nature.
DOI: https://doi.org/10.1016/S01406736(20)30553-5
Title: Breadth of concomitant immune responses prior to patient recovery: a case report of non-severe COVID-19
Read this story on mforum.com.au
DOI: https://doi.org/10.1038/s41591-0200819-2
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APRIL 2020 | 9
Urgent care clinics worry GPs GPs have weathered an MBS freeze, crippling bureaucracy and now federally funded urgent care clinics that threaten their viability.
Jan Hallam reports.
WA general practitioners concerned about the establishment of four new St John Ambulance (SJA) urgent care centres (UCC), being built with $28 million of federal government money, were asked to participate in a survey organised jointly by the RACGP and AMA (WA). The AMA (WA) and the college have raised their concerns with SJA, with little joy, so it is hoped when a larger number of GPs are made aware of the ambulance operator’s plans in the primary health care space, there may be some traction with politicians. They said their concerns included the lack of consultation with affected general practices, the lack of transparency around the SJA business and clinical models and the unfair competitive advantage the new UCCs would have, given the operational funding they are receiving from the federal government. “Unlike the WA Governmentfunded WA Urgent Care Network Pilot (developed and supported by WAPHA, AMA (WA) and RACGP) which utilises existing general practices, the St John Ambulance UCCs will provide Australian Government subsidised urgent care 10 | APRIL 2020
services, in direct competition with existing general practices,” the joint statement said. “Of particular concern…are the funding mechanisms behind the SJA UCCs. The Commonwealth grant of $28 million provides both infrastructure and operational funding, which will create an uneven playing field, resulting in higher overall operational funding than Medicare rebates alone would provide for SJA UCCs. “We have been clear at the research governance meetings, which were not consultative in nature, that the proposed locations of the SJA UCCs do not correspond with unmet need. Our requests that local general practices be consulted have so far been ignored, and there is a concerning lack of transparency around the details of the funding and clinical/business models of the new SJA practices.” The survey said: How will this impact you? SJA will be competing with local general practices with the unfair advantage of Commonwealth government funding subsidising their operational costs. Nothing will prevent SJA establishing general practices
to operate alongside the Commonwealth subsidised SJA UCCs, as they have at their existing centres. This could lead the SJA UCCs being used as a referral source and patients being directed to SJA operated general practices. No research or evaluation has been planned or conducted to measure how the SJA Urgent Care Centres affect surrounding general practice services. Without immediate action, the viability of general practices in areas where SJA Urgent Care Centres operate are at risk. There appears to have been no attempt to integrate the SJA UCCs with existing medical services, including the WA Government and WA Primary Health Alliance operated Urgent Care Network, which utilises local general practices and is actively supported by the AMA (WA) and RACGP. Both organisations are advocating directly with Department of Health seeking the immediate introduction of governance mechanisms that will eliminate unfair competitive advantages and ensure SJA UCCs only address unmet need, do not compete with local general practices, and offer sustainability and value for money.
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FEATURE
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FEATURE By way of history, annual SJA reports from at least several years ago indicate a growing interest in participating in the primary care space, made reality when it bought three Apollo Health Centres – in Joondalup, Cockburn and Armadale. In that purchase, they acquired not only equipped urgent care centres but general practice and dental facilities as well. Anecdotally, general practices in the vicinity of the centres voiced their disquiet about the impact it would have on their viability. Little was, or could be done, as the notfor-profit SJA had acquired the Apollo Health centres with its own consolidated revenue. When Medical Forum interviewed SJA’s Urgent Care Director, Dr John O’Toole, published in December 2018, Dr O’Toole stressed the urgent care centres were not a replacement for a person’s own GP. “We want to facilitate a patient’s relationship with their GP, not interfere with it. If a patient is appropriate for urgent care, send them and we will attempt to fix the problem, but we’ll them send back to you,” he said. “If a patient presents with a routine problem that would be better managed in an appointment with their regular GP, we will advise them as such. Urgent care does not perform health assessments, management plans, preventative medicine, referrals to specialists (other than acute specialties such as plastics and orthopaedics). This is the remit of the GP and we are careful to reinforce this.”
Political play Then in February 2019, just three months before the May election, the MHR for Moore, Ian Goodenough, told parliament that he supported SJA’s request for funding for a fouryear trial for 10 urgent care centres to provide patients alternatives to presenting at EDs for non-lifethreatening conditions.
It is unknown if there are any other elements of primary care being “trialled” or what MBS item numbers will be used, or if new item numbers will be created, or if SJA has partners, commercial or otherwise, in the venture.
SJA and Mr Goodenough sought $185 million for the initial infrastructure start-up costs, including four years’ operating costs.
It is believed by some GPs that SJA have signed leases for premises in Midland and Cannington with flyers distributed to GPs in these catchments. By the time of going to press, nothing was known of the progress of the Mandurah and Osborne Park centres.
“This financial support will ensure that patients can continue to be bulkbilled,” he said. “Assuming that the trial is successful and becomes normalised, the financial support reduces to $15 million per annum operating assistance to support all 10 centres from there on.”
Chair of the WA faculty of the RACGP Dr Sean Stevens said that the college was appalled with any initiative that fragmented patient care and created an uneven playing field for general practice which was already overworked and under resourced.
Hansard records Mr Goodenough citing that SJA UCCs had seen about 57,800 patients the previous year (2018), “a third of whom would have otherwise attended an emergency department”.
“There was no consultation with general practice or the state government about the decision to fund these centres, which also cuts across the WA general practice urgent care pilot that predates the Budget announcement by a year,” Dr Stevens said.
He did not speculate where the other two thirds would have sought treatment. There is little transparency as to the nature of the government-funded trial from either the government or SJA, which has declined to comment to Medical Forum, or provide satisfactory responses to AMA (WA) or RACGP presidents.
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He said the college was already particularly concerned about the impact on private general practices of the existing co-located GP clinics at SJA’s UCCs, four new centres would be an added blow.
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APRIL 2020 | 11
Practice in the modern world While modern medicine is relentlessly changing, Norwegian clinician Dr Anna Stavdal, President Elect of WONCA, says the doctor-patient relationship must stand firm. We live in a world changing at breakneck speed, where health services are tending to be commodified, digitalised, commercialised, specialised, fragmented and monopolised. But our human needs, minds, bodies and basic fears have stayed pretty much unchanged throughout history. Humans need humans, especially when we find ourselves in troubled waters – regardless if "Dr Google" is only a click away. So, based on experience and science, society is best served in supplying health services to its citizens by supporting and empowering the family doctor in a primary care team as the cornerstone of the system. Basic competencies in the toolbox, apart from state-of-the-art professional knowledge and skills, must include a thorough understanding of the prevailing context – socioculturally, geographically, demographically and epidemiologically.
This happens whilst facing and standing up against the moneydriven forces of a market promising good health and longevity from their vast array of services, tests and medicines, which are not always adequately scrutinised by proper science, but which seduce patients and health personnel alike. The growing and worrisome epidemic of over-diagnosing and overtreatment resulting from this activity may be good for business but not necessarily for the health and wellbeing of our patients. So, guidance, navigation and, not least, protection of our worried, anxious even demanding patients are important competencies crucial for the primary care team. Listening, understanding and gaining trust is crucial. Trust must be earned, and pass the test of time, through continuity of care – the very hallmark of the family doctor.
It goes without saying that a family doctor in a remote rural district must be specially prepared and trained to enable the handing of some occurrences that, in an urban setting, would find its way directly to the ED department in the nearby hospital. No matter the circumstances, however, in general, 95% of the needs presented, should be handled and contained in primary care.
Family medicine is based on the core values of personal, comprehensive and continuous care. And it works! The late Barbara Starfield, professor and researcher of public health at Johns Hopkins University, showed that a good long-term personal relationship with a freely chosen primary care doctor not only increases the individual’s health, but also that of the population as a whole.
A familiar and often difficult dilemma for the family doctor is whether (and when) to refer or not to refer. Under crossfire from all kinds of directions, we must weigh benefits against potential harms, costs against effectiveness and prioritising applied costs against opportunity cost.
A paper, published in the British Medical Journal in April 2019, confirmed Starfield’s findings. By comparing a number of highquality scientific articles on what we call "continuity of care", close to 82% confirmed that the quality of ongoing doctor-patient relationships affects mortality
12 | APRIL 2020
rates. The better the individuals` relationship with their long-term doctor, the lower their mortality rate from all causes of death. Comprehensive, medical care is more than adding up “the sum of fragments of organ-specific medical knowledge”. In order to understand and treat prevalent conditions in our time such as chronic fatigue, medically unexplained physical symptoms, fibromyalgia and irritable colon, no biographical or other information disclosed by the patient is irrelevant. The family doctor is best positioned and suited to handle these patients within their practice. The convincing scientific evidence of the effect of personal, comprehensive and continuous care, should guide us in how we develop and prepare our profession for the future. We should put energy back into building relationships and mutual long-term understanding between patients and family doctors. That way we can really make ourselves useful when our patient is in need of her doc – listen, comprehend, diagnose, treat, guide, protect, contain, coordinate, refer if need be, only then.
WONCA Sydney 2022 Mandurah GP and former RACGP president, Dr Frank Jones, is the convenor of the WONCA 22 world conference in Sydney, having led the college bid at the conference in Kyoto, Japan, last year, staving off a challenge from UK’s RCGP. The Sydney event will mark the 50th anniversary of WONCA, which began in Australia. www.racgp.org.au/wonca-2022/home
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APRIL 2020 | 13
A Nancy Drew in cardiology A love of problem solving has drawn cardiologist Michelle Ammerer to a field of medicine that has captivated her for 20 years.
Ara Jansen reports. Ask a doctor why they became one and chances are they’ll tell you it’s to help people. That was never the first answer for consultant cardiologist Dr Michelle Ammerer. While, of course, she certainly wants to help heal or save a life, she’s always been fascinated by science and problem solving. It’s this intense curiosity and love for sleuthing which has made her one of the State’s most respected cardiologists. “I decided to be a doctor in Year 10 after I had done work experience in a law office,” recalls Michelle. “It reminded me I loved science. I’m kind of amazed because I didn’t really have a role model and had never been in a hospital. I liked problem solving and working things out. “I had a background in dance and rhythmic gym at school so my other plan was to be a back-up dancer for Kylie Minogue!” Michelle was determined at university to study a discipline which ended in a job, rather than an amorphic and hopeful occupation. “I wanted direction. I wanted to know exactly where I was going.” While recently stepping down from 16 years as director of coronary care at Sir Charles Gairdner Hospital, Michelle continues to 14 | APRIL 2020
operate there as well as at St John of God Subiaco and alongside her partners at Western Cardiology. She spent 15 years on the board of the Heart Foundation and continues her pro bono work as a trainer with the Royal Australian College of Physicians.
Boston calling In 2004, Michelle was one of a select handful chosen from hundreds of applicants to complete a career-highlight fellowship in Interventional Cardiology through Brigham and Women’s Hospital, part of Harvard Medical School in Boston. Whilst at Harvard, she was noted as one of the 40 Under 40 in 2008 and then named their First Amongst Equals, she went on to be a judge of subsequent lists. She considers giving back one of the best things she can do for the next generation of doctors and cardiologists. “I’ve mentored and supervised trainees and, I think, in cardiology you learn so much by observation. I can see myself in these students and if they have the right traits you must help them grow. “Some people have just got it and some people haven’t. You can help students improve on things but I’m not sure you can always help them learn if they don’t have that thing which can make them a good or great doctor. I think a great one requires attention to detail, being thorough, staying up-to-date, among other things.” MEDICAL FORUM | CARDIOVASCUL AR HEALTH ISSUE
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SCGH was where Michelle did her intern, resident, registrar and basic physician training. Like others, she tried several different rotations, but cardiology won her heart fast. One of the reasons she has loved and continues to love cardiology is the camaraderie and support from her teachers, many of whom eventually became her peers and partners. “Our patients are sick and need help. It’s an adrenaline rush like a rollercoaster. I love it and I have my mentors and teachers to thank in many ways for what I have learned. “The people I’ve worked with have been great to be around and have taught me so much. They were the reason I wanted to do cardio at Charlies and later Western Cardiology.
Inspiring colleagues “I wanted to work with people who were excellent in a great environment, and people who I bonded with. As it turned out, I was the first female they trained in cardiology at Charlies, the first female cardiologist at the hospital and the first woman in WA to train in stenting. I never set out to do that, I just paid attention to being good.” A sense of humour is very much at the heart of a cardiologist Michelle says. Much like other professions dealing in life and death, knowing when it’s time to loosen a valve with something light-hearted is vital to mental wellbeing. And yup, she’s heard all those finger-on-thepulse jokes. Michelle considers herself careful, particular, fastidious and pays
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attention to detail. She dislikes laziness and suggests many of her closest colleagues feel the same way. No, they aren’t complete sticks in the mud. Yes, they still know how to have fun. She’s firm, driven and knows her own mind. Speaking with her reveals an unquestioned confidence. “My parents were really fastidious in terms of making sure you studied. My mum was a schoolteacher and a model before that. Presentation was important. At medical school, my girlfriends and I would look at older female doctors and decided we could be doctors and still be interested in fashion. I still like fashion and keeping up-to-date.” continued on Page 17
APRIL 2020 | 15
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A Nancy Drew in cardiology 6am – without fail, rain or shine. A fact she tries not to bring up when talking to patients who tell her they can’t find time for exercise. Yes, she practises what she preaches when it comes to a healthy lifestyle.
continued from Page 15 Compared to other specialties, part of the attraction for Michelle is the innovation. While the art of medicine is always there, she also relishes the evidence behind it.
Fluffy white Samoyed dogs are known for their determined, lively and playful temperaments. Mozart and Michelle also share a birthday month.
One of the character traits she didn’t know she had until she started working as a doctor was the ability to be intensely calm “when the sky’s falling down”.
While the demands on life as a specialist and at home keep her constantly in motion, if she’s ever curled up on the couch with a book, Michelle’s choice of reading material is usually books about the history of medicine or fictional medical mysteries. There’s that sleuth again.
“When patients are unstable or something is happening, you have to be calm and work methodically to save them. Calm under pressure, that was never assessed at medical school. Some people just can’t do it but I have to say I enjoy it.”
On the home front At home, if there’s ever a problem, her action meter is measured by “if everyone is breathing and has a pulse, it’s ok.” No need to get into a flap about small things. Outside her family, skiing is one of her passions and echoes her Austrian family name, Ammerer. She first got on skis at the age of three. Michelle’s Austrian relatives taught her to ski well when she was younger and these days it’s her sport of choice. Sometimes she briefly flirts with
wondering what it would have been like to be a ski instructor after meeting a woman around her age who lived on a mountain and seemed to have her own idea about life. But this doctor’s love for medicine and investigation still means being a cardiologist wins out over being a snowologist. Recently celebrating her 20th wedding anniversary, the mother of two almost-teens also has a Samoyed dog named Mozart. You’ll find the pair out walking companionably every morning at
“Medicine has been a fabulous career because I have met a lot of great people. Everyone is very collegial. “Equally, I love dealing with emergencies and treating acutely unwell patients. If a patient comes in having a heart attack and we do a primary angioplasty which saves their life, I love rising to that challenge. I really do love it.”
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APRIL 2020 | 17
Q&A with... Dr Tony Mylius, Cardiologist and Consultant Physician, Northam
MF: Medicine has taken you on an amazing journey. What has guided these decisions? TM: I moved to Perth from Adelaide in 2003 when Sue and I married and I decided it was better for me to move here than drag her all the way over there and dislocate her from her family. Joining Western Cardiology at the time gave me the opportunity to establish practices in Applecross as well as St John of God Subiaco, and Sue and I established clinics in Mandurah, Rockingham and Northam – where Brian Lloyd had previously provided services for many years before his retirement. I grew up in Papua New Guinea until I was 16, and then our family moved to Adelaide where I trained at Flinders University and Flinders Medical Centre, before working in New Zealand for four years in the early 1990s. I returned to Adelaide and set up practice in the Fleurieu Peninsula south of Adelaide. So, I have always had a focus on regional practice and have enjoyed the (semi-) rural lifestyle. Getting to know patients, and to be part of the community adds to the rewards of medical practice. Working with my wife, Sue, also adds to our enjoyment of life in the country! MF: What have you learnt about the art of medicine along the way? TM: I think the benefits and rewards of the personal interaction to maximise patient health outcomes, personal ‘health status’ and wellbeing are often under-valued in these days of focus on ‘digital health’, procedural medicine and ‘fast medicine’. While we need to continue to develop ways of effectively distributing care, we should not lose sight of the value and benefits of inter-personal connections in the therapeutic relationship with our patients in achieving improved health outcomes. 18 | APRIL 2020
My experience in medical practice has led me to a passion to improve health system performance and health service delivery. Often it is not that we (as a health system) don’t know what to do, but that we ‘don’t do it’. My role as Clinical Co-Lead of the Cardiovascular Health Network and as a senator in the Clinical Senate, allows me to work across the system with a view to addressing these issues. MF: What drew you, as a young doctor, to cardiology? TM: Opportunity was the main determinant in completing cardiology advanced training in combination with general medicine at a time when ‘dual training’ was more usual. The synergies of combining my passion for clinical medicine and rural/regional practice influenced my decisions not to continue with procedural cardiology, which freed me from the constraints of being tied to a procedural facility, and made it possible for me to focus on enhancing regional service provision and clinical cardiology service provision. Regional medicine often requires clinicians to take a broader, more comprehensive view on patient care. While patients need access to sub-specialist interventional and procedural services, they first need access to appropriate clinical care, diagnosis, investigation and facilitated access to appropriate procedural or sub-specialist management but with ongoing ‘holistic’ care. MF: In the 30 years of heart work, what have been the defining moments for you? TM: It sounds obvious now, but establishment and reinforcement of evidence-based secondary prevention in ischaemic heart disease after the travails of debate around
statins in the 1970s has been a major milestone in cardiological practice. Continuing research reinforcing the role of clinical cardiological management to reduce recurrent events and mortality has been critical. With our frequent focus on interventional care, we need to maintain our efforts to improve health service performance around non-procedural management. Percutaneous coronary interventions, improved technology and procedures, minimally invasive surgical coronary and valvular interventions, as well as electrophysiological diagnostic and therapeutic procedures have revolutionised cardiology outcomes – and patient wellbeing. But, again, often the problem is not that we don’t have effective treatments, it’s that patients don’t get access to those procedures. MF: What drew you from the city? TM: In 2010, after Sue and I had provided visiting services to Northam from 2003, an opportunity came to take on the Regional Medical Director role in WACHS Wheatbelt. which prompted us to make the move to Northam full-time. Working in part-time private practice until I finished in the Medical Director role in 2013, I moved into full-time clinical practice in Northam in 2010. Clinical consulting, non-invasive testing service provision and visiting specialist services have developed in our rooms in Northam. Providing clinical consulting services and visiting specialist services to Northam Hospital, I had thought I would need to work between Northam and Perth, but we became busier and servicing around 50,000 people in the Wheatbelt meant that I have been occupied full-time in Northam.
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Q&A Providing Aboriginal Cardiology services to Northam, Merredin, Narrogin and Moora has also been a rewarding challenge. The burden of disease is significant and the need for enhanced access to consultant specialist clinical and treatment services provides challenges and opportunities. MF: What impact has increased regional investment had on local communities? TM: The major investment of Royalties for Regions dollars into the Wheatbelt (as part of the broader SIHI program) has resulted in significant changes in infrastructure with a range of new buildings, renovations and facilities developed. These investments have provided continuing opportunity to enhance clinical service provision. In order to achieve this, it is vital that we continue to recognise that one agency alone cannot address all the health needs in the region and that collaborative efforts are essential to maximise health service provision. As a community-based specialist providing rooms-based consulting as well as visiting services to Northam Hospital, and remote advice to other hospitals and practitioners when asked, it is critical we don’t lose sight of the need to address the challenges of engaging practitioners and service providers across siloes. Emergency services were identified as being a major concern for communities and the development of enhanced emergency care
through infrastructure investment, the Emergency Telehealth Service and increased medical staffing have had significant benefits in addressing these needs. MF: Attracting doctors – GPs and specialists – to rural practice remains a challenge. What are your views on training pathways? TM: Rural and regional practice offers great professional and personal opportunities for challenge, reward and satisfaction. It is important that we recognise the need for families to be supported in access to schools, lifestyle, personal, child and family supports in the regions. Innovative thinking around how we can enhance these personal and professional support networks exists and continue to be developed. We do need to think outside the square and allow some flexibility so that rural practice doesn’t become an either/or decision. Perhaps instead of incentive payments for doctors to move, funds could be used to support spousal and family travel between the city and the country; rethink full and parttime roles. We need to keep focused on enhancing and maintaining the rural community’s access to medical services, how we do that shouldn’t be set in stone. A range of organisations are actively engaged in these arenas – and crosssystem collaboration is critical to the success of the opportunities. MF: How has your rural experience changed the way you practice medicine?
TM: Rural practice and life rewards both my wife, Sue, and me. Our work together enhances the service we provide professionally and personally. Enjoying life and achieving personal and professional satisfaction are rewards which are not available to everyone – and are greatly valued by us. In receiving the honour of Member of the Order of Australia this year, I have been humbled and gratified with the regard, which this conveys, of patients as well as colleagues and the broader regional community. It has been especially gratifying to receive the award because my mother received an MBE for her work in Community Development in PNG in the 1970s and my grandfather received an MBE for his work as a general practitioner and in medical professional contributions in Melbourne in the 50s. In addition, my father was a doctor and health administrator in PNG, initially in clinical practice, then in the medical faculty of the University of PNG and the Health Department before moving to Adelaide and being involved in the early days of Divisions of General Practice and GP training programs in the late 1970s and 1980s. So, obviously my life decisions and directions have been influenced by my experiences and vice versa. My suggestion for anyone contemplating spending time in rural and regional areas is, have a go and enjoy the ride!
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APRIL 2020 | 19
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FEATURE
Into the ether Can the nationalised electronic health record be saved from itself?
James Knox reports.
20 | APRIL 2020
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FEATURE The slow crawl towards a nationalised shared electronic health record (EHR) culminated in My Health Record yet there is still much to be done to ensure the system is adopted and used by clinicians and health care consumers alike.
Australia’s eHealth odyssey The journey of the Australian nationalised shared electronic health record (EHR) began at the end of the last millennium with the establishment of the National Health Information Management Advisory Council (NHIMAC). The remit of the council was to to address barriers to e-health, consequently identifying the need for a nationalised EHR system. NHIMAC then formed the National Electronic Health Records Taskforce which subsequently released the Health Information Network for Australia report in 2000, which proposed the HealthConnect project. The first stage of HealthConnect began in 2001 with the development of the Better Medication Management System (BMMS); a nationalised electronic medical record that linked prescriptions, prescribers and pharmacies, later rebranded as MediConnect. In 2005 the National E-Health Transition Authority (NEHTA) was formed to lead Australia into the future of e-health by developing standards, specifications and infrastructure required for a digital health sector. The Northern Territory Department of Health launched the EhealthNT Shared Electronic Health Record in 2005, now called the My eHealth Record (NT). NEHTA commissioned the Boston Consulting Group to report on the agencies’ progress in 2007. The report recommended, among other actions, further stakeholder engagement and an organisational restructure with a clinical unit. In 2008, the Australian Health Ministers Advisory Council commissioned a nationalised eHealth strategy based on of NEHTA’s progress. Deloitte delivered a national strategy in the same year, recommending a nationalised electronic health record system to be formalised. The Personally Controlled Electronic Health Record (PCEHR) was announced as part of the 2010/11 federal budget by the then Labor Government. By 2012, the PCEHR was launched and seven months later NEHTA claimed 56,000 individuals, 1171 health care organisations and 1325 clinicians had registered. In 2013, the Practice Incentives Program eHealth Incentive (ePIP) was established to encourage general practices to upload patient shared health summaries. It was reported that almost A$1 billion was spent on the PCEHR by 2015. In 2016, NEHTA was renamed the Australian Digital Health Agency (ADHA) and the PCEHR renamed to My Health Record (MyHR). MEDICAL FORUM | CARDIOVASCUL AR HEALTH ISSUE
Another national digital health strategy was developed by ADHA in 2017, which recommended the delivery of MyHR to every Australian by 2018 – unless they opted-out. In January 2019, MyHR was delivered to all Australians who chose not to opt-out. In the same year, the PCEHR/MyHR systems were reported to have cost almost A$1.97 billion. Between March and December 2019, there was a total of 22.68 million records, more than 90% of Australians. However, half of the records were empty. ADHA reported GPs were uploading between 2 million and 3 million documents each month by the end of 2019, while also reporting more people had opted-out than the number who had checked their MyHR.
Issues with interoperability The benefits of EHRs, when effectively implemented, can be enormous: reducing medication errors and patient misidentification, breaking through interoperability barriers, simplifying and unifying administration burdens. Yet, like so many aspects of information and communications technology in health care, the conceptualisation may be evidence-based with clear use-cases. However, implementation can be glacial and poorly governed with the delivered 'solution' not being fit-for-purpose, with ever-expanding financial burdens, as evidenced by MyHR. Project delivery delays and cost blow outs can be forgiven if the use-case of the specific technology is demonstrable and the opportunities of engagement are overt. MyHR satisfies the former, the latter is questionable. The benefits of using MyHR have been obfuscated by the difficulty of using it with the added complexity for clinicians and supporting staff around data entry, extending already stretched workflows. Interoperability is something of a given for most individuals and industries in the age of artificial intelligence, 5G and the Internet of Things, yet it does not come easy to the health care industry where information silos dominate. This goes a long way in explaining why MyHR has struggled with wide-scale adoption by clinicians. Dr Nathan Pinskier has a unique perspective on MyHR as he was a clinical lead in NEHTA from 2008 and is currently a strategic clinical advisor at ADHA. He was the former chair of the RACGP Expert Committee Practice Technology and Management. Although there may be a broader understanding of electronic health records in 2020, back in 2008 they were practically unheard of, Dr Pinskier says. “I don't think there was a strong view or understanding, certainly in the general practice community, of what a national electronic health record might look like. We were still grappling continued on Page 23
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Into the ether continued from Page 21 with the basics of having local electronic health records. “Most clinicians understood that you could record some clinical information, generate a referral, receive some correspondence and write prescriptions. That's what we understood electronic health to be. “We didn't really understand the concept of silos in health care and the requirement or the potential to aggregate data, interconnectivity or interoperability. Those terms just did not really exist on the national landscape at a clinician level.” For clinicians and consumers to fully embrace MyHR, the interoperability barrier will need to be addressed, to reflect other services consumers currently use online. “The consumer now expects to access everything online, whether it's financial transactions or social interactions,” says Dr Pinskier. “People, reasonably, have started to expect the same type of transactions and capabilities to exist in health care, but, unfortunately, health care was never really designed to deliver that sort of capability.” Interoperability may be a substantial barrier but so, too, are the norms surrounding the use of records in health care. “If you ask the average clinician about patient records, they would say, ‘my notes are for my personal use to provide care to my patients and not something that I share with them’, and they certainly wouldn’t share records with other health care providers other than through a direct communication,” he said. According to Dr Pinskier, the proposition of a nationalised shared health record is not the problem, rather the benefits have not been tangibly demonstrated for the end users. “The implementation of My Health
Record has been done in a way which has not readily engaged clinicians around usability.” Ease of use is fundamental to engagement, especially in a voluntary system. Users will trial it but if it is too difficult to use, they’ll avoid it, which is the current challenge the MyHR faces. “If it's not easy to use and doesn't fit into your workflow or it's a burden or an extra mouse click, clinicians won’t embrace it, won’t use it, and won’t see the value in it,” he said. “The shared health summary creates an impost because it’s an additional document that’s not part of the normal workflow and the consultation. The other dilemma is clinicians are generally not sending electronic messages out anyway.” Dr Pinskier is keen to highlight the importance of feedback from clinicians who have used MyHR, as this is fundamental to understanding its limitations and benefits. “The real stories come when we go into people's practices and see what and how things are being done on the ground. Unfortunately, we don't hear those stories often enough. “If there are things that you want to work better, call it out. If you think it's worthwhile and you want to make it work, and there's a problem, call it out. Speak to someone. Whether it's the ADHA, RACGP or the AMA, call it out, make sure it gets taken up as an issue and gets resolved.” To encourage general practices to use MyHR, the Federal Government rolled out the Practice Incentives Program eHealth Incentive (ePIP) program which offers up to $50,000 a year, (maximum, $12,500 per quarter) for uploading 0.5% of their patients’ shared health summaries. Although the ePIP resulted in a plethora of records being uploaded, the program incentivised quantity rather than quality. “The problem with ePIP was the government decided to implement a volume process, a mandate for a certain quantity for each practice to upload,” Dr Pinskier said. “The RACGP didn't think this was a very sensible thing to do; practices just uploaded anything, rather than uploading the right information for the right patient.” While the quality of the shared
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health summaries in MyHR is a problem, so is the policy and design limitations of the system, and the methodology used. “There's no technical constraint for anybody uploading a shared health summary, and that's a problem in itself. There's also no model that suggests it’s a good thing to upload on a regular basis, rather than the practice participating as it receives funding from it.” MyHR certainly has its failings and frustrations, yet for someone who has been involved for over a decade with NEHTA and ADHA, Dr Pinskier still believes in the concept of a nationalised EHR system. “Was the original idea a good one? Does still stand up today? The answer is yes. Was the technology that we used at the time, the right technology? Maybe, maybe not. Do we have better technology today? Yes. “In 10 years, is it likely that the health care technology will be compatible? The answer is no. We need to think about what we are prepared to reinvest in redesigning My Health Record with new technology.” Eventually, says Dr Pinskier, the decision to move towards a more usable system will come from the people it was designed for. “We have to decide, as a community, if this is something we think is important, or are we just going to keep living in a sort of a hybrid world of partial paper and disaggregated data? “That may work for a while but, in the long term, it does affect health care delivery, it does affect outcomes, and we can do better. Are we prepared to accept mediocre or do we want to aim for excellence?”
Upside-down development While a nationalised EHR is a worthy project to pursue, the redundant standard which underpins MyHR, the Clinical Document Architecture (CDA), raises the issue of its longterm viability. The CDA standard is the format used for health care documents uploaded to MyHR for interoperability between clinical systems. When the PCEHR was developed, the CDA standard was considered viable, however, the documents are static. continued on Page 24
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Into the ether continued from Page 23 A superior and more dynamic alternative to the CDA standard, the Fast Healthcare Interoperability Resources (FHIR), which offers far greater interconnectivity and interoperability than the CDA standard, could unlock the potential of MyHR. The FHIR standard has been adopted by the 'Big Five' tech giants in Apple, Google, Mircosoft, Amazon and Facebook for their health care applications and solutions. The creator of the FHIR standard, Mr Grahame Grieve, is fully aware of the inherent limitations of the CDA standard and MyHR, as he was one of the architects of the PCEHR systems specifications at NEHTA. Mr Grieve is currently consulting with ADHA on various projects including MyHR. He said from the technology perspective, it was clear early on that the PCEHR, now MyHR, would not be viable. “About half way into the PCEHR development, I realised the program was not going to achieve its stated goals, and 10 years later it has still hasn’t achieved its goals,” he said. “Clinical leads would tell me what they wanted, and I realised I couldn’t achieve that level of sophistication in the specifications that I was writing. Those specifications were beyond the expertise of the average developer and inadequate for the clinical leads.” When he realised the CDA standard was not fit for purpose, Mr Grieve created the FHIR standard, which could have provided the clinical leads with what they required from the PCEHR. However, the money had been spent and the deadlines had been set, and the FHIR standard was not amalgamated into MyHR. Yet, the failures of MyHR go beyond the interoperability limitations of the CDA standard. “Fundamentally, it is a ‘people problem’,” Mr Grieve said. “To 24 | APRIL 2020
get people to agree with each other around the exchange of data. It’s a slow process. To make behaviour changes that align with the infrastructure development is difficult.” “It's not just about changing the standard, it's about sitting back and saying, ‘what do we want to do and how would we achieve what we want to do with a new standard’. The standard enables the discussion, but it doesn't solve the problem.” Technical and budgetary constraints are significant barriers to transitioning to FHIR but so is the myriad agreements between states, the Federal Government and health care providers. “The current arrangements with MyHR were limited by the kind of agreements we could negotiate based on the standards we had,” Mr Grieve said. “If we simply replace the standards, but don't revisit the agreement with the participants in the program, we won't achieve anything. “We really need to revisit who does what, where, and their expectations of MyHR. Unless we can agree on what we're trying to achieve rather than merely change the technology, we'll just spend money without any actual observable outcome. “My advice to government is, before it spends any money on revisiting the standards, it needs to have made it clear to investors what constitutes a workable agreement among the clinical community.” To illustrate just how difficult it is to deliver a functional EHR system, observe how different states and territories deal with data. “During the first implementation, for instance, we were told that we had agreements with the states for the content models, but when we went to implement them, the states said ‘we don't do things that way’ and that's why the program has been conservative around changing the technology,” he said. “First, we need to have an environment where we can decide how we make it worthwhile.”
Rebuild or retire? With out-of-date standards, lack of clear benefits, a $2 billion bill, and 12 years of development, is it time to ask the question: should the plug be pulled on the MyHR?
According to Mr Grieve, it depends on what is done with the system to improve it. “I hope, as a political brand, MyHR will continue. But in its current technical incarnation, its architectural approach is doomed. I hope the government will find the money to rebuild MyHR to be more technically capable and deliver clinical outcomes so the brand can flourish and prosper. “I fear, if the brand collapses, the government's interest in infrastructure development projects in health care could collapse and decide that it's too hard to do.” Mr Grieve believes in its current iteration, the MyHR cannot claim benefits that are not real. “It has to deliver those benefits and currently there isn’t a coherent story to tell. They’ve certainly tried to tell the story, but in the end, it’s what makes a difference to people. “Whether they're doctors or patients or nurses or health care administrators, what makes a difference to them is services, not data. If the system we have is a data aggregation arrangement that doesn't allow useful services, then all we will ever be doing is marketing something that's just not working. “If it met people's goals, then the government wouldn't have to push it so hard. It would have significant uptake by itself. The combination of the goals it has and the services it delivers are just not compelling for consumers or clinicians.” Although Mr Grieve knows the failings of MyHR all too well, he believes it still has potential. “MyHR is a solution sitting on great infrastructure. Had it been opened to support the country's general platform infrastructure rather than containing it to only support a particular solution, it would be in a much better position,” he said. “It was a great investment; the problem was that the government was told this was a solution that they could build rather than an investment stream that they would have to maintain to leverage the benefits of that investment. “We have some really good infrastructure, we just need the imagination, determination and funding support to actually use the infrastructure we built.”
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Real-time prescription monitoring It may seem a long time coming, but WA is edging towards a mandatory real-time monitoring service.
James Knox reports. The WA Department of Health is slowly progressing towards a realtime prescription management system which will connect with other states and territories with the objective of reducing problematic prescription usage and prescribing practices of schedule eight (S8) pharmaceuticals.
who use it can see how and when S4 and S8 opioids and other controlled S8 pharmaceuticals are being prescribed.
WA currently utilises the Prescription Monitoring Program (PMP) for S8 prescriptions, which is a monthly reporting system that provides prescribers retrospective notice of problematic prescribing for a drug dependent and oversupplied person, long after the pharmaceuticals have been dispensed.
National action
As the PMP system produces monthly reports, there is inherent latency in providing clinicians with information they need to make informed, in-the-moment prescribing choices, as notices could be sent long after a prescription has been dispensed. With increasing overdoses and accidental deaths from controlled pharmaceuticals over the past 20 years in Australia, particularly S8 opioids, real-time prescription monitoring is considered a viable harm reduction strategy. Tasmania was the first state to implement RTPM with the Drugs and Poisons Information System Online Remote Access system (DORA) in use since 2012. The Australian Capital Territory began using the DORA system in 2019. Whilst using the DORA system is voluntary in both states, prescribers 26 | APRIL 2020
Victoria implemented its own RTPM system, SafeScript, in 2019 which differs from the DORA systems as it is mandatory for all prescribers and dispensers.
In 2018, the COAG Health Council agreed to a federated RTPM model, releasing a communique at the time saying: “The minsters agreed to… a federated model with jurisdictions committed to progressing development and adaptation of systems to connect to and interface with Commonwealth systems to achieve a national solution.”
It is expected that in 2020, WA will be joined by South Australia, Queensland and New South Wales in planning and implementing RTPM systems.
WA’s RTPM system will connect to the NDE, yet nationalised data sharing of prescription information comes with a multitude of state and territory agreements, along with legislative and policy changes in WA.
Each of these systems will connect to the national data exchange (NDE), a federally funded, Australia-wide system providing state and territory interconnectivity and interoperability for prescribers and pharmacists with real-time prescribing information.
How close is WA to having a functional RTPM system? How will it be implemented? And what will this mean for prescribers and dispensers? Medical Forum spoke with the WA Department of Health and WA’s Chief Pharmacist Neil Keen for the answers.
The NDE, rolled out in December 2018, is the primary architectural component for the Electronic Recording and Reporting of Controlled Drugs (ERRCD) system, the national RTPM system, based on the Tasmanian DORA model.
Towards real-time
The ERRCD system has been made available to each state and territory by the Commonwealth since 2013 yet the ACT is the only state to take up the offer so far.
The Prescription Monitoring Program (PMP) in WA is far from perfect with notices being sent to prescribers up to three months after a script has been dispensed to potentially drug dependent and oversupplied persons, highlighting the need for RTPM in the state. The program only monitors S8s, whereas other systems scrutinise S4 opioids, such as Tramadol, as well.
Both Dora and SafeScript were developed independently to the ERRCD and national data exchange, funded by the individual states, with the Victorian system costing a reported $30m.
The WA Department of Health (WADoH) has decided to connect to the NDE rather than having a purely state and territory-based system as in Tasmania, Victoria and the ACT. This means data sharing
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FEATURE agreements need to be formed with each state and territory based on the Medicines and Poisons Act 2014 (WA), prior to the system being rolled out. WA currently has no formal data sharing agreements with other jurisdictions, but it is hoping these will be completed in 2020. WADoH does, however, occasionally receive or make requests with health departments in other states and territories regarding individual patients and these are dealt with on a case-by-case basis. The WA RTPM system will be based on SafeScript currently in use in Victoria, and will be mandatory for prescribers and dispensers and will be designed integrate into an envisioned national system. “The new RPTM system is expected to improve the current process in that the information will always be up to date, will be accessible to practitioners 24/7 and available via secure electronic channels on the clinician’s own computer,” Neil Keen told Medical Forum.
The current system Although the WADoH hopes to roll out RTPM in 2020, the current system is what prescribers and dispensers rely on and depending when the data sharing agreements and legislative changes happen, it could be in place for some time yet.
dose is more than 90mg morphine equivalents per day*; immediate release opioids where the dose is more than 45mg morphine equivalents per day*; all injectable preparations*; methadone*; alprazolam or flunitrazepam; S8 medicines not registered with the TGA. * Specialists can prescribe these for up to 30 days without prior authorisation from the department. While prior approval is required for patients under 18 years, recorded as oversupplied or drug dependent or with a history of substance abuse within the previous five years. For a patient to be classified as drug dependent, a medical practitioner diagnoses them, then reports the case to the WADoH. The patient can choose to accept the diagnosis or dispute the report with the department, which will then review the case. Whereas an oversupplied person can be identified via a health professional’s report, prescription monitoring conducted by the department, or from police reports. Excessive S8 prescriptions from multiple doctors over three- and six-month periods is the type of behaviour identified as oversupplied.
For clinicians with patients on longterm S8 prescriptions below the approved thresholds, the WADoH says it “undertakes both routine and ad hoc monitoring of Schedule 8 dispensing records… [and] uses a risk-based approach to monitoring”. If a prescription is considered problematic by the WADoH, it may request the patient to be referred for specialist appraisal if there is no specialist support for the prescribing regimen. It says: “The advice to the general practitioner is that the patient be referred to an appropriate specialist relevant to the diagnosed condition. “In certain circumstances the department may request a non-pain specialist such as a rheumatologist to also refer the patient to a pain specialist for a second opinion.” As for the support structure for patients identified as drug dependent and/or oversupplied, WADoH advised they could be referred on to Next Step Drug and Alcohol Services.
“PMP is considered generally effective, within the limitations of the technology in use,” Mr Keen said. “Each year the Health Department responds to tens of thousands of calls and provides patient dosing histories to medical practitioners across WA. The records are continuously monitored, and people believed to be oversupplied or doctor shopping are identified, and their cases managed.” The PMP has two clear functions: Ensuring compliance with the Medicines and Poisons Regulations (2016) and the Schedule 8 Medicines Prescribing Code, and identifying patients that have been flagged as drug dependent or oversupplied. These are the medicine types and dose thresholds that require prior authorisation: opioids in any combination, where the total
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APRIL 2020 | 27
A new era for public health Addressing disease at the population level must be the focus of the health system and its practitioners in the new era, says GP Dr George Crisp. The past 150 years has seen the most remarkable and continuous progress in improving human health outcomes, with a dramatic fall in infant and childhood mortality and near doubling of longevity (and “health span”). The emergence of modern medical science and means to apply it through parallel advances in engineering and technology have been key to this. But while our high-tech individualised medical interventions and treatments have become the focus of healthcare, the majority of gains have resulted from preventive measures and applied at the population level. For example, the single biggest health advance has been attributed to the introduction of water chlorination to eradicate water-borne disease in growing industrialising cities. Other important developments include sanitation, food safety, tobacco control, air quality, occupational and motor vehicle safety, maternal and infant health and vaccinations. We are now facing new and
emerging challenges arising from continuing growth and consequential interference of ecological and environmental systems.
conditions that support and protect our health, which jeopardises the functioning of our modern health services.
Globally, there are rising rates of non-communicable diseases, novel pathogens, consequences of increasing climatic extremes and air pollution. In the developing world, malnutrition and diarrhoea, mediated through food and water insecurity, have never resolved and now face a renewed threat via these new environmental pressures.
In parallel and for similar reasons, we are also losing biodiversity at an escalating rate, undermining ecosystems which are essential for production of food, medicines and many other health services.
The effective way to deal with these problems is through looking upstream to their origins, then understanding and addressing the determinants of them. Dr John Snow addressed the cholera outbreak in central London, not by developing more effective rehydration agents, but by removing the Broad St pump handle and interrupting the source of contaminated water. Climate change, identified as the greatest challenge to our health this century more than a decade ago, affects our health both directly, and by adversely affecting underlying
Solving these problems requires preventive action at a population level, that is public health*, and we can all play a role in promoting a health future both inside and beyond our consulting rooms. For more information, the Planetary Health Alliance is an international consortium of over 200 universities, non-governmental organisations, research institutes, and government entities committed to understanding and addressing global environmental change and its health impacts https://www.thelancet.com/journals/ lanplh/home *Public health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO).
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Clinical Update Cardiovascular Health 31 POST THROMBOTIC SYNDROME
38 SKIPS, THUMPS AND BUMPS…SHOULD I WORRY?
Dr Patrik Tosenovsky
32 MAN V MACHINE Dr Michael Davis
35 AF & CAD: AN UNEASY MARRIAGE Dr Andre Kozlowski
Dr Tim Gattorna
39 MONOMORPHIC VENTRICULAR ECTOPIC BEATS Dr Justin Ng
41 JUGGLING RENAL AND CVD MANAGEMENT
36 SUBCLINICAL HEART FAILURE POST CANCER CHEMOTHERAPY
Dr George Chin
Dr Kalil Anvardeen
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Post thrombotic syndrome and non-thrombotic vein obstruction By Dr Patrik Tosenovsky, Vascular Surgeon, Joondalup Post-thrombotic syndrome (PTS) is a combination of signs and symptoms that include any of the following: swelling, pain, skin colour changes or leg ulcer. It is a complication of lower limb DVT. Similar signs and symptoms can be observed on a leg of patients who have never had DVT, and this is sometimes called venous stasis syndrome (VSS). In both situations, reflux or obstruction (often both) play a crucial pathophysiological role. This will lead to a venous hypertension. Primary obstruction causing haemodynamic changes is usually seen in the deep axial veins (IVC, iliac, femoral or popliteal veins). The incidence of PTS is cited as between 10% and 50%, and its severity varies from mild ankle swelling or chronic ache with no other signs or symptoms of chronic
Key messages PTS and VSS have similar signs and symptoms Both need venography rather than simply advising stockings Treatment is mini-invasive venous disease to recurrent cellulitis, skin hyperpigmentation and a tissue loss. VSS patients present with similar complaints. It is not difficult to make a clinical diagnosis in PTS cases since there is usually a symptomatic DVT in the history, but it is harder in VSS cases. Imaging is critical and a venous ultrasound is a good non-invasive start. Evaluate the lower limb venous system including abdominal and pelvic veins. Sensitivity of duplex ultrasound in detection of
venous obstruction is unfortunately poor, therefore recent European and North American guidelines suggest more invasive imaging for all symptomatic patients. Treatment is mini-invasive, and it can be offered as a one session day-case surgery. Even during the initial venography, where an obstruction is verified by using Intra Vascular Ultrasound (IVUS), outflow obstructions can be successfully treated with venoplasty and stent. During the same setting, the incompetent superficial axial veins can be closed using either laser catheter or a cyanoacrylate glue. The results of vein stenting are encouraging and it is recommended to all symptomatic patients because the associated morbidity and complication rates are low. – References available on request
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Man v Machine: Beware the computer-generated ECG report By Dr Michael Davis, Cardiologist, Perth Cardiologists are regularly referred patients based on incorrect ECG machine reports, with misdiagnosis of the heart rhythm or overdiagnosis of prior myocardial infarction being the most common. The referring doctor may not have tried to interpret the ECG or be concerned about the medical or medicolegal consequences of disagreeing with the machine. Often, faxing or emailing a highquality copy of the trace to a cardiologist will resolve the issue immediately (a photo sent from a phone can suffice but is not as good), though not every cardiologist is a super whiz on ECG interpretation! Machine accuracy is improving, but algorithms vary between machines. No studies compare devices, primarily because manufacturers are reluctant to expose their patented algorithms.
Arrhythmias, pacemaker rhythms
left bundle branch block.
ECG machines have about a 95% positive predictive accuracy for identifying sinus rhythm, falling to 53.5% for non-sinus rhythm. The problem in both situations relates to difficulties recognising small amplitude P waves, or P waves hidden by noise, QRS complexes or T or U waves.
When an ECG is done in the setting of chest pain, wide variations exist in both over-call of ST elevation and under-diagnosis. ST elevation due to early repolarisation can be either a relatively benign normal variant or in rare cases a marker for risk of sudden death.
Over-interpretation of atrial fibrillation is common, most usually due to frequent atrial ectopics (see figure). Overdiagnosis can result in administration of potentially harmful treatment.
Key messages
Pacemaker rhythms are very poorly recognised, being interpreted as myocardial infarction, left ventricular hypertrophy or conduction disturbances mostly
IHD, LVH and prolonged QT
Pericarditis causes ST changes associated with chest pain.
Don’t blindly trust the ECG machine, make your own interpretation Clinical ECG Interpretation by Dr Araz Rawshani is a good online tool Get cardiologist input if unsure.
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wave progression is commonly interpreted as “possible anteroseptal myocardial infarction” but is usually an overdiagnosis. If the clinical context suggests prior MI as a possibility, then echocardiography is the best way of ruling this in or out. Diagnosis of left ventricular hypertrophy is poor both by man and machine. Echocardiography is a much better tool. Accurate measurement of the QTc interval is difficult even for experts and the clinical context is everything. ECG machine diagnosis of atrial fibrillation when the rhythm is clearly regular and P waves evident before each QRS complex. The machine has also over-called inferior wall myocardial infarction.
Very early in the course of myocardial infarction, the ECG can look completely normal, and acute changes can be masked by conduction abnormalities, particularly left bundle branch block. History and the clinical context are more reliable when managing a patient presenting with chest pain. Act with caution, and do not delay treatment by measuring the troponin level before referring the patient to ED.
Old inferior wall myocardial infarction is a common ECG machine misdiagnosis, usually based on Q waves detected in leads III and aVF. This often results from a more horizontal heart position because of body habitus, with the Qs disappearing with the ECG recorded during held deep inspiration, changing the position of the heart relative to the leads. If there is no significant Q in II, prior inferior wall infarction is unlikely. Poor anterior lead R
If your machine measures the QT interval as prolonged, first check electrolytes and for any medications (e.g. psychotropic drugs, erythromycin or ketoconazole) which may be contributing. Remember that medication might be unmasking a genetic abnormality. If the patient has syncope, or a family history of syncope or sudden death, refer significant QT prolongation to a cardiac electrophysiologist. – References available on request Author competing interests – nil
When it comes to cancer, your patients will be cared for, completely. As a GP, we know that you are seeing a growing number of patients whose health, lives and families are impacted by cancer. You play a hugely important role in helping them to find the best care and know that when it comes to cancer, time is of the essence. So why choose St John of God Subiaco Hospital for your patients’ cancer care?
All the services your patients need, for all cancer types, in 1 convenient location
Onsite chemotherapy manufacture for agile tailoring of treatment
WA’s only private on-site molecular laboratory (Australian Clinical Labs) for fast diagnostic results enabling targeted therapies
Our renowned Bendat Family Comprehensive Cancer Centre has undergone significant refurbishment to enhance capacity and comfort
45 active oncology clinical trials, providing early access to leading-edge treatments
Experienced caregivers and allied health support patients and families throughout their journey
We believe that all care should be delivered completely. For more information and to meet our specialists, visit sjog.org.au/subiacocancercare
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APRIL 2020 | 33
34 | APRIL 2020
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CLINICAL UPDATE
AF & CAD: an uneasy marriage By Dr Andre Kozlowski, Cardiologist, Subiaco The role of anticoagulants (AC) in atrial fibrillation (AF) and antiplatelet agents (AP) in ischaemic heart disease (IHD) as separate treatment are undisputed with clear benefit. The combination of both has become more frequent, though making safe and effective treatment more complex.
Accessing Home Care can be confusing To help we’ve created this simple guide Step 1. ACAT referral. You, the GP, refer them for an ACAT assessment via www.myagedcare.gov.au/health-professionals
This combination requires an individual approach to achieve balance between benefit and risk. In AF and chronic IHD, an effective AC in AF is also sufficient to protect from coronary thrombosis and no additional AP treatment is required except for patients with increased ischaemic risk due to extensive disease and recurrent coronary event. In AF and coronary angioplasty with stenting (PCI), coronate intervention causes plaque disruption and increased platelet activation. The process of healing is delayed by the antimitotic properties of the drug eluting stents (DES) in the early period. A post-procedural period of four weeks requires triple therapy (TT) including AC and two least potent AP agents, usually aspirin and clopidogrel. After four weeks, treatment is simplified to dual therapy, usually AC and aspirin. More potent clopidogrel or ticagrelor may be considered in patients with higher risk of recurrent ischaemia at the cost of increased bleeding.
OR Ask your
to call us and we will conference call MyAgedCare with them to arrange the referral.
Step 2. Your will be contacted by the ACAT to arrange to visit them and work out the amount of help they may need.
Step 3. with Department of Human Services (DHS) The
Step 4. 1. ACAT 2. DHS
approving their care level. with their income assessment. - this may 3. Home Care Package Assignment take 6 to 12 months.
Usually, 12 months of dual therapy is recommended. The new generation of stents with lower risk of stent thrombosis allow earlier discontinuation of this. However, the decision should be made by the cardiologist. In PCI and high risk of bleeding, triple therapy should be maintained. if possible, for four weeks following PCI. In patients with high risk (e.g. older age, poor renal function, active bleeding, peptic ulcer), the treatment may require simplifying to AC plus an AP agent. Recent trials (Re-dual PCI) indicated an effectiveness and safety of triple antithrombotic protection with dabigatran, aspirin and clopidogrel instead of dual therapy. Continuing complex treatment in high-risk groups beyond the “vulnerable” first few months requires individual risk assessment and patient awareness. The risk of stent thrombosis progressively declines in the first months after PCI. Any elective procedure should be delayed for three to six months. The decision to interrupt or discontinue treatment – though usually safe after six months – should be made in consultation with the cardiologist. Patient compliance can be an issue. Reluctance to continue complex treatment is not uncommon and is often a consequence of bruising, prolonged bleeding. Reassurance, social support and regular surveillance for such patients is crucial.
can call us on 1300 26 26 26
and we can mail the form to them.
Step 5. They have 56 days to organise their services.
Step 6. Compare service providers With their in hand – they call their preferred providers to compare services and costs, and hopefully we’re one of them.
Step 7. Select a service provider and sign up Their services can start immediately. yourself stuck, call the team at If you or your Amana Living. Leonie and Andrea have helped hundreds of people get their Call us during
hours.
1300 26 26 26 amanaliving.com.au Providing quality care in WA for over 50 years.
Author competing interests – nil MEDICAL FORUM | CARDIOVASCUL AR HEALTH ISSUE
APRIL 2020 | 35
Subclinical heart failure post cancer chemotherapy By Dr Kalil Anvardeen, Cardiologist, Midland In the 1980s, the cancer survival rate was less than 50%. Today, almost seven in 10 Australians will survive for at least five years after a cancer diagnosis, and in some cancers the survival is as high as 90%. This is due to treatments with chemotherapy, radiotherapy, surgery, immunotherapy, hormone therapy and targeted therapy. Unfortunately, some therapies required to cure or control the cancer are cardiotoxic. This can lead to subclinical and clinical heart failure (HF) in patients with or without underlying cardiac risk factors. Cancer therapeutics related cardiac dysfunction (CTRCD) might lead to interruption or alteration of cancer therapy. Some patients can present weeks and years after treatment. Cardiotoxicity as a result of cancer treatment has various manifestations, including myocardial dysfunction and heart failure, coronary artery disease, valvular dysfunction, arrhythmias including QT prolongation, arterial hypertension, thromboembolic disease, peripheral vascular disease, pulmonary hypertension, and pericardial disease.
36 | APRIL 2020
Diagnosis of cardiotoxicity Transthoracic echocardiogram (TTE) is the most commonly used modality due to its availability and reproducibility. Global longitudinal strain (GLS) assessed via 2D speckle tracking echocardiography has been widely studied and is the tool for early detection of subclinical LV dysfunction.
Cardiac MRI or MUGA (Multigated Acquisition scan) can be used if TTE is not technically feasible or available. Cardiac troponins are the gold standard biomarkers for the diagnosis of myocardial injury. Elevations in BNP are more reflective of abnormal filling pressures and may be less consistent in the detection of subclinical LV dysfunction.
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CLINICAL UPDATE
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CLINICAL UPDATE Table 1.
Key messages Cancer survival has increased significantly Chemotherapy agents can be cardiotoxic Morbidity can be minimised by early recognition and management.
Management strategies Oncology therapy
Cardiology therapy
New BNP or trop I rise but with normal cardiac imaging
Continue
Cardio-oncology review. Consider closer monitoring, or start low dose ACEI or BB.
Early functional cardiotoxicity
New reduction in GLS or grade III-IV diastolic dysfunction and normal biomarkers
Continue
Cardio-oncology review. Consider closer monitoring, or start low dose ACEI or BB.
3
Early mixed cardiotoxicity
Normal LVEF with abnormal biomarkers and GLS/diastolic dysfunction.
Continue
Cardio-oncology review. Start low dose ACEI or BB.
4
Symptomatic HFpEF
Symptomatic HFpEF
Interrupt and review risk/ benefit
Cardio-oncology review. Diuretic for fluid congestion, ACEI or BB if continuing cancer therapy.
5
Asymptomatic LVSD
New LVEF reduction to <50% or a reduction in LVEF >10% to a LVEF <55%.
Review and balance risk/ benefit
Cardio-oncology review. Start ACEI and/or BB and uptitrate to 50-100% target dose for HF as tolerated.
6
Symptomatic LVSD
Symptomatic reduction in LVEF <50%, or a reduction in LVEF >10% to a LVEF <55%.
Interrupt and review risk/ benefit
Cardio-oncology review. Start ACEI and/or BB and up-titrate to 100% target dose for HF as tolerated.
Group
Classification
Definition
1
Early biochemical cardiotoxicity
2
Classification and management Based on TTE and biomarkers, Pareek et al suggested a six-step classification of myocardial toxicity from their cardio-oncology service and management strategies seen below in table 1 (adapted from European Journal of Heart Failure). Continuing cardiotoxic cancer therapy may be suitable in selected cases depending on the risk/benefit ratio, severity of left ventricular impairment, symptoms, cancer stage and response. If LVEF falls below 50%, then incorporate either biomarker elevation or GLS reduction (< 18% if normal at baseline, or <15% relative reduction of GLS if reduced at baseline). If ACE Inhibitors or beta blockers are not tolerated, or the patient is already taking these agents when cardiotoxicity is diagnosed, consider adding aldosterone antagonist. If LVEF is below 35% follow the European Society of Cardiology HF guidelines regarding eligibility for cardiac resynchronisation therapy,
sacubitril/valsartan and ivabradine. Morbidity and mortality related to cardiotoxicity can be reduced by early risk factor modification, timely identification of cardiotoxicity, initiation of cardioprotective medical
therapy, referral to appropriate specialists and development of a multidisciplinary approach. Author competing interests – nil
Specialist care, closer to home St John of God Carine Specialist Centre offers a convenient location in Perth’s northern suburbs for specialist care and consultation. More than 30 specialists from St John of God Subiaco and Mt Lawley Hospitals consult at the centre, providing your patients access to two of Perth’s leading private healthcare facilities. P: (08) 6258 3800
www.sjog.org.au/carine
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APRIL 2020 | 37
Skips, thumps and bumpsâ&#x20AC;Ś should I worry? By Dr Tim Gattorna, Cardiologist, Subiaco, Midland, Northam & Kalgoorlie Palpitations are a common, subjective symptom resulting in frequent presentations in the primary health care setting. Although generally benign, they can occasionally be a manifestation of a potentially life-threatening arrhythmia. Appropriate evaluation is therefore required. Cardiac or arrhythmic causes are the most common aetiology. Other causes include medical conditions (e.g. endocrine and metabolic abnormalities), psychiatric disorders, medication effects, and drug or other substances. It is important not to label a patientâ&#x20AC;&#x2122;s palpitations as secondary to panic/anxiety without
Key messages Palpitations are frequent in the community History, examination and basic investigations can determine cause in many patients Case finding and management of AF is critical as is awareness of red flags. a proper evaluation, as around 50% of this group will be diagnosed with an arrhythmic cause. A targeted and thorough history is required given the majority of patients present in sinus rhythm,
Table: Risk stratification
Skipped beats Thumping beats Short fluttering Slow pounding AND Normal ECG AND No Family History AND No Structural Heart Disease Low Risk Manage in Primary Care
History suggests recurrent tachyarrhythmia Palpitations with associated AND/OR symptoms Abnormal ECG AND/OR Structural Heart Disease Refer to cardiology
Palpitations during exercise Palpitations with syncope/ near syncope High risk of structural heart disease Family history of inheritable heart disease/SADS High degree AVblock Refer to cardiology with urgency
Table published with permission of Primary Care Cardiovascular Journal
38 | APRIL 2020
between episodes of palpitation. The description of skips, jumps and thumps may represent ectopic beats (atrial or ventricular); rapid onset/onset of racing heart may be consistent with a supraventricular tachycardia. Ask about onset and offset (sudden or gradual), duration (momentary or sustained), frequency of episodes, triggers, any associated symptoms (e.g. syncope, breathlessness or chest pain), pre-existing cardiac issues and any family history of sudden cardiac death or cardiac conditions.
Which investigations? This depends on the history, frequency and duration of episodes. A 12-lead ECG (if symptomatic at the time) is the gold standard. Ambulatory (Holter) monitoring is useful if frequent symptoms, whilst an event monitor is useful in less frequent symptoms. Loop recording (for recurrent syncope), echocardiography to evaluate heart structure and stress testing (if exercise induced or suspected IHD) can be helpful. Smart phone monitoring/apps may be the future. continued on Page 39
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CLINICAL UPDATE
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CLINICAL UPDATE
Managing frequent monomorphic ventricular ectopic beats By Dr Justin Ng, Cardiologist, Nedlands Ventricular ectopic beats (VEBs) are common. Frequent (>60/hr or 1/min) in healthy subjects has an estimated prevalence of one to four percent in the general population. Over 10 percent on a Holter monitor is considered a high VEB burden. Monomorphic VEBs represent a focal arrhythmia arising from a single site. Generally, individuals with frequent monomorphic premature ventricular contractions (PVCs) have a benign clinical course. A portion have bothersome symptoms cardiomyopathy can develop in a minority of cases. The clinical presentation of patients with frequent VEBs is variable. A large proportion are asymptomatic and are discovered on a routine ECG or during monitoring for an unrelated procedure. Other patients are mistaken to be bradycardic by palpation of the pulse and are referred for investigation based on this. Individuals can be highly symptomatic complaining of palpitations, ‘missed beats’, ‘heavy beats’ and fluttering in the chest. Tiredness, dyspnoea, lightheadedness and mental clouding are other common complaints. Heart failure symptoms may be the initial presentation.
Indications for treatment The majority of individuals with frequent VEBs have a benign
Key messages
Echocardiography assesses structure and function.
Frequent monomorphic VEBs are common. The vast majority have a benign c course
A 24-hour Holter can quantify the burden and to see whether there is more than one morphology.
In high symptomatic burden or with evidence of VEB induced cardiomyopathy there are safe, effective therapies Ongoing clinical surveillance is important in conservatively managed asymptomatic individuals.
Cardiac MRI may be warranted if there is any evidence of a wall motion abnormality, an abnormal ECG or multiple morphologies of PVCs making structural heart disease more likely.
clinical course. A small proportion of individuals with a high burden of ventricular ectopy can develop left ventricular dysfunction and an even smaller proportion, VEB induced polymorphic ventricular tachycardia. As such the indications for treatment include high symptom burden, VEB induced cardiomyopathy and rarely PVC induced polymorphic VT. It is important to identify the those with structural abnormalities. A 12 lead ECG is helpful to confirm the morphology and location of the VEB as well as to look for other evidence of structural heart disease such as Q waves, T wave inversion and epsilon waves anteriorly, suggestive of arrhythmogenic right ventricular dysplasia(ARVD).
Given the small incidence of PVC induced cardiomyopathy clinical surveillance is appropriate even for asymptomatic patients. In individuals with a high burden of symptomatic VEBs or individuals with evidence of VEB induced cardiomyopathy, treatment is recommended. Beta blockers or calcium channel blockers remain first line options. Flecainide (once ischemia and abnormal LV function had been excluded) or sotalol are second line. Catheter ablation with the aid of 3D mapping has a high success rate. It is generally reserved for patients who either cannot tolerate medical therapy or have failed medical therapy. The procedural risk is relatively low, and the curative rates are high. Author competing interests – nil
continued from Page 38
Skips, thumps and bumps…should I worry? Correlation of the rhythm at the time of symptoms is the key to the diagnosis (arrhythmic or not). Thyroid function and full blood count as a baseline are recommended with further tests dependent on the history/findings. Blood pressure and palpation of the pulse at each consultation is highly recommended as an irregularly, irregular pulse may be indicative of Atrial Fibrillation (AF). This needs
confirmation with a 12-lead ECG. The diagnosis is important as AF is associated with a high morbidity and mortality, can be asymptomatic, and effective treatment including oral anticoagulation is available. The management of palpitations depends on the cause and associated prognosis. Simple reassurance in many cases is appropriate, although medical therapy and referral to cardiac
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electrophysiologist may be required in some cases. Red flags include frequent, persistent and sustained episodes and significant associated symptoms (e.g. syncope, chest pain), abnormalities on resting ECG such as T-wave abnormalities, long or short QT interval and evidence of prior AMI (Q waves) or short PR interval (possible Wolff-Parkinson White syndrome). – References available on request
APRIL 2020 | 39
IORT arrives St John of God Subiaco Hospital has become the first private hospital in Australia to introduce Intraoperative Radiation Therapy (IORT) for breast cancer. Breast surgeons Prof Christobel Saunders and Dr Lee Jackson, along with GenesisCare Radiation Oncologists Dr Yvonne Zissiadis and Dr Margaret Latham, are undertaking the IORT procedures and training of other breast surgeons is underway. The procedure is only suitable for certain women whose breast tumours are low-risk. Christobel told Medical Forum that she had worked on IORT trials at University College London in the 1990s. There will be follow-up studies done on those patients, which will give a deeper picture of the efficacy of the therapy. The surgical team operates to remove the tumour, add shielding
From left: SJG Subiaco CEO Prof Shirley Bowen, Dr Lee Jackson, Prof Christobel Saunders, SJG Foundation CEO Bianca Pietralla, donors Robert and Maria Carcione, Dr Yvonne Zissiadis and Dr Margaret Latham
to protect surrounding tissue, and then the radiation oncologists direct a calculated dose of radiation into the incision at the tumour site. “Studies have shown that if radiotherapy is given at the same time as surgery for certain selected, low-risk breast tumours, there is equal local control. So, in other words, no higher local recurrence rates,” Christobel said. “IORT can help women avoid six or seven weeks of post-op therapy. That is great for every woman but especially those who live in the country, who we know have a 50% chance of choosing mastectomy because they don’t feel they can stay away from their homes and lives for that long.
“But it’s important to reiterate it’s not for every patient, and it needs tumour pathology.” Christobel said IORT was available at SCGH but because of scheduling and difficulty it was not often used. “The IORT means an extra 45 minutes in the operating theatre, but that avoids anywhere between three and seven weeks of daily radiotherapy afterwards,” she said. The IORT equipment was funded by philanthropic support of a group of St John of God Foundation donors, including the Carcione Foundation.
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NEWS
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Juggling renal and CVD management By Dr George Chin, Nephrologist, Palmyra It has been repeatedly demonstrated that patients with chronic kidney disease (CKD) have higher prevalence of cardiovascular disease (CVD) than the general population. They also experience more severe CVD. The risks escalate as stages of CKD advance. As any medical student knows, traditional CV risk factors include hypertension, diabetes, smoking status, dyslipidaemia and family history of CVD. The CKD population has additional so-called non-tradition renal-associated risk factors. Albuminuria, a common manifestation of CKD, is an independent risk factor of CVD. In population studies, the degree of proteinuria is correlated with CV mortality. Albuminuria has also been associated with both severity of coronary artery stenosis and the number of vessels with significant lesions. As a predictor of future CV events, the presence of albuminuria is as significant as a previous history of coronary artery disease. Inflammation (CKD is proinflammatory) is associated with altered lipid metabolism. Increased
Key messages Patients with CKD have increased risks of CV adverse events, compared to the general population Renal function and proteinuria should form part of routine CVD assessment Optimising CVD management in CKD population remains the nephrology world’s holy grail. oxidised low-density lipoprotein and poorly functioning high-density lipoprotein have been associated with CV risk in patients with CKD. Dysregulated calcium and phosphate metabolism, and secondary hyperparathyroidism, known complications in CKD, contribute to accelerated vascular calcification. In addition to enhanced calcification of atherosclerotic plaque, calcification of the medial layers of vasculatures is commonly seen in our patients, particularly in the dialysis population. Histologically, this is very similar or even identical to the Mönckerberg’s sclerosis, first described in 1903.
The degree of medial calcinosis has been correlated with serum phosphate levels and calciumphosphate product. Other renal-related CV risk factors include myocardial fibrosis, anaemia, uraemic toxins, endothelial dysfunction, oxidative stress and volume overload. Intestinal dysbiosis has been shown in patients with CKD, and byproducts of this phenomenon has recently been linked to vascular calcification and adverse cardiac outcomes. To complicate matters, obesity, hypercholesterolaemia and hypertension appear to have protective roles that are associated with greater survival in the dialysis population – an observation known as reverse epidemiology! Given the excessive CV risks in CKD population, isn’t it intuitive to address these risk factors aggressively, as one would do in the general population? Maybe! Studies tell us there are no benefits to statins use in primary and secondary CV prevention in the dialysis population. Statin use might even increase the incidence of haemorrhagic stroke. In the non-dialysis population, combined use of simvastatin and ezetimibe has been shown to reduce major adverse cardiovascular events but have no effect in mortality outcome. Similarly, use of antiplatelet agents have only been demonstrated to reduce incidence of myocardial infarction but not total mortality, cardiovascular mortality or stroke, based on Cochrane Systemic Review in 2013. Author competing interests – nil
Figure: Prevalent Dialysis Mortality – Australian Patients vs General Population (Adopted from ANZDATA 42nd report 2019)
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APRIL 2020 | 41
Silicosis Update By Emeritus Professor Odwyn Jones AO and Clinical Professor Bill Musk AM Introduction 1. Crystalline silica is present in many products including sand, rocks, concrete and more particularly synthetic composite or artificial/engineered stone used for kitchen and bathroom surfaces. The is a snapshot of the silica content of engineered stone compared with natural stone: • Marble typically < 5%, but can be more ; Granite 2540%; Sandstone 65-70%; Engineered Stone > 90%. • Exposure to silica dust can cause various diseases (Safe Work Australia, Crystalline silica and silicosis, 2020): Silicosis, chronic bronchitis, emphysema, lung cancer, kidney damage, and scleroderma. 2. The WA Department of Mines, safety alert 11-2018 emphasises: • Effective respiratory protective equipment must be provided in workplaces where there is risk from respirable crystalline silica (RCS). • Workers must be given information, training and instruction with regard to such risks. • Employers must provide workers with health surveillance if there is risk to a worker’s health as a result of exposure to RCS. 3. Work Health and Safety (WHS) Regulation 50 requires that air monitoring by an occupational hygienist be carried out if there is a risk that the exposure limit be exceeded. 4. WHS Regulations also require that health monitoring/ surveillance be an essential part of the control measures. Such surveillance includes a lung function test which, if performed repeatedly, can be a useful measure of progressive lung damage. 5. A well-planned health surveillance system consisting of chest CT scans and lung function tests should be carried out on workers before commencing
42 | APRIL 2020
employment and at least every three years thereafter (annually for high-risk jobs) (Cancer Council, 2019).
Workplace standards 1. There’s been considerable discussion recently regarding the adoption of an appropriate TWA standard for crystalline silica: • The mandatory limit for silica dust in Australia has long been a TWA of 0.1 mg/m3 for an eight-hour working day and five-day week. Safe Work Australia (SWA) has introduced a 0.05 mg/m3 standard, but this will not be fully introduced for three years. • Since this announcement, SWA has recommended a further reduction to 0.02mg/m3.
National Taskforce Interim advice was submitted to the Health Minister Greg Hunt in December 2019. The final report is due December 2020. Following are some relevant extracts: • More than 300 diagnosed silicosis cases in Australia since September 2018, due mainly to poor silica dust control in the engineered stone fabrication industry. • WHS regulators must play an active role in enforcing the legal duty of employers to minimise the risks to worker health due to inhaling silica dust: this is a priority.
• All workers at risk of developing silicosis need to be identified as early intervention is critical to minimising harm and maximising good health outcomes. Consequently, a National Dust Disease Registry should be implemented to capture disease notification data. • There is growing support for considering limiting the importation of engineered stone products containing the highest levels of silica. • WHS policy and regulatory practice could be enhanced by integrating epidemiology, occupational hygiene, occupational physician expertise and worker representation. • More communication needed to increase the awareness, knowledge and understanding of all the issues relating to accelerated silicosis amongst workers, SMEs, PCBUs and, in particular small family businesses. • Greater support is needed for those diagnosed with accelerated silicosis, including legal and financial support. • Future support is needed for respiratory and occupational physicians, occupational health nurses and GPs to understand better the increasing incidence of accelerated silicosis. • All jurisdictions need to have consistent and comprehensive health surveillance programs with screening available to all exposed workers.
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GUEST COLUMN
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GUEST COLUMN Accelerated silicosis • This has become an emerging epidemic, primarily restricted to workers and stonemasons using manufactured artificial or engineered stone products. The illness is caused by the inhalation of large quantities of respirable crystalline silica (RCS), with particles in the size range < 4 microns. These very fine particles penetrate deep into the “alveolar gas exchange region” of the lungs where they can trigger nodular fibrosis (scarring) in the lung tissues. This reaction hardens and stiffens the alveolar lining thereby reducing its capacity to transfer oxygen into the bloodstream. • Unlike chronic silicosis, which manifests 10 -20 years after initial exposure (and possibly longer) accelerated silicosis develops within 5-10 years after initial exposure. However, the minimum total lung burden of RCS required to trigger either disease is unknown. The rate of change of lung function for those suffering accelerated silicosis is much worse, and even if there’s no more exposure, silicotic nodules may continue to develop, giving rise to “progressive massive fibrosis”, which is incurable without lung transplantation. • The Australasian Faculty of Occupational and Environmental Medicine (AFOEM) and the Thoracic Society of Australia and New Zealand (TSANZ) have both recommended the establishment of a national respiratory health surveillance program and a national occupationally acquired respiratory disease registry for notification of cases. • As recommended by both AFOEM and TSANZ, artificial stone workers should undergo spirometry lung function testing, diffusing capacity of the lungs for carbon monoxide (DLCO) testing
(considered to be a sensitive biomarker of early disease), and an ILO chest X-ray or preferably a CT scan for early detection.
Australian Engineered Stone Advisory Group The Australian Engineered Stone Advisory Group (AESAG) was established in 2018 by Australia’s major suppliers of engineered quartz surfaces to respond to the occupational risk of silicosis for stonemasons fabricating their products without optimum safety measures in place. Its members currently supply about 77% of engineered stone products in Australia and its concern for the health and wellbeing of those workers is laudable. AESAG is currently seeking authorisation by the ACCC, on behalf of itself, future members and other suppliers of engineered stone to: • Adopt industry accreditation standards for fabricators and stonemasons working with engineered stone. • Seek to require such fabricators to comply with work health and safety practices and laws prevailing in all relevant jurisdictions. • Consider refusing to supply engineered stone to fabricators if such practices and laws are not adhered to. Whilst these requirements are wellmeaning, there are a number of conflicting challenges: • This application will allow the AESAG to make a collective decision about compliance, rather than undertaking individual assessments. • It is common practice for such proposals to be discussed and approved by impacted stakeholders (i.e. fabricators and stonemasons) and/or their representative bodies. There is no evidence that such discussions have taken place. • Apparently, Victoria is considering introducing a scheme for licencing organisations that work with engineered stone. If this eventuates, it would be inappropriate for the AESAG to operate a separate scheme for accreditation. • It is possible, under the AESAG proposals, for a primary customer to be accredited without recognising the customer’s right to outsource its fabrication work
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to other fabricators without the knowledge of the supplier. Regardless of these concerns, AESAG’s presence and commitment to improved industry safety practices and standards, is a major step forward. Due credit must also be given to the attempts of individual suppliers to inform their customers of the health hazards associated with fabricating engineered stone and the need to adopt well-known health and safety practices. Finally, it would be highly beneficial to have a more transparent system, whereby regulators could inform AESAG suppliers of fabricators who do not comply with required health and safety standards. Surely, it is to everyone’s advantage to work cooperatively in improving the health and safety standards of those working in the industry.
Applied research needed • There is a need to better understand the disease pathway from the time of exposure, the type of stone dust causing harm, through to accurate diagnosis and treatment. • The taskforce report called for a strategic approach to research to better understand accelerated silicosis. More specifically: 1. The pathogenesis of accelerated silicosis, the exposure patterns to artificial stone, and the influence of particle size. 2. Identify factors such as biomarkers related to the disease severity and risk of progression. 3. Best practice to minimise exposure and minimise or eliminate risks. 4. The efficacy and sensitivity of radiological methods (especially CTs) to diagnose early evidence of the disease.
Conclusion In a developed country such as Australia, with well-organised public health and regulatory systems and world-class research facilities, it should be possible to bring an end to the scourge of accelerated silicosis quickly. However, it can only be done through a national, integrated approach, involving the full cooperation of all concerned including product suppliers, fabricators, state and territory regulatory bodies, public health authorities and research organisations. APRIL 2020 | 43
TRAVEL
James Knox scales the heights and discovers some mysteries about sport climbing … and himself.
The journey to Rai Leh is as breezy as the warm winds coming off of the Andaman sea: fly into Krabi international; take a short minibus trip to Au Nang (a prominent beachfront resort town); hop on a long-boat to Rai Leh, then let the relaxed rhythm of life flow over you. Once the long-boat putters into the warm turquoise waters and settles into its mildly unsettling rhythm, Rai Leh’s grandiose limestone cliffs soon come into view, towering over sundrenched beaches and lush tropical jungles. The tiny town of Rai Leh is a tranquil place with enough amenities to ensure you don’t need to visit the relatively chaotic Au Nang. Rai Leh is positioned in a landlocked peninsular with thick jungle and cliffs standing between you and the mainland. But relaxing in the tepid waters and baking under the smiling sun isn’t what brought me here, it’s the soaring limestone cliffs. 44 | APRIL 2020
Reh Leh is literally a climbing paradise for novices to learn the fundamentals in a safe and controlled environment. There is a plethora of climbing schools with experienced and patient guides. Before being immersed into the world of sport climbing, 6a, 6a+, 6b, 6b+ were meaningless numbers to me, yet for two weeks in December, they became an obsession. Climbing is a sport of numbers, or more specifically ‘grades’, with different grading systems used to describe the difficulty of the climb, depending on the type of climbing and the region. Grades are assigned by the climber who sets the route, which entails bolting anchors into the wall at key locations. In Thailand, the French grading system has been adopted for sport climbing routes with beginner grades ranging between 1-4, intermediate 6-7, advanced 7-8, and 9 achievable only by the most elite climbers. MEDICAL FORUM | CARDIOVASCUL AR HEALTH ISSUE
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Aiming high in Krabi
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TRAVEL
Depending on the amount of climbing one has done, their level can be distilled down to a grade, for me this was 6a, as I swiftly found out attempting to climb anything beyond this. Climbing in Rai Leh is also a great way to encounter the local fauna. As climbers sweat their way up walls, inquisitive macaques will effortlessly climb by, whilst on the ground, monitor lizards lackadaisically navigate their way between climbers and their gear, with little interest or fear of the people around them. Back to the numbers, once I found my level of ‘6a’, I was determined to redpoint (complete a route without falling) a 6b+ before leaving, which was slightly too ambitious for me. However, once I found my limit, climbing became something of a brutal pleasure: the more I fell, the more I wanted to push on with torn up fingers and aching limbs pleading for a book and cocktails on the beach. The procedure for climbing beyond my limit goes something like this: plan ascent, chalk fingers, climb, become stuck on a difficult problem, eventually fall, climb back up and repeat until completion, reassessment of plan or an existential crisis. All the while listening to my inner monologue featuring mercurial classics such as: ‘you’re way too high, this isn’t a great idea’, ‘oh sh*t, you’re about to fall, yep, you’re falling off’, ‘you’re not coming off of this wall until the route is completed’, ‘this is a really bad idea’, ‘see, not that hard.’ Although I didn’t redpoint a 6b+, I did what I initially set out to do, which was to challenge myself in the comfort of paradise and satisfy my desire for a slightly pampered adventure.
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APRIL 2020 | 45
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DOCUMENTARY
Telling Claire’s Story The Murray family’s determination to have their daughter’s story understood by a community that failed her a decade ago has resulted in a remarkable documentary. Jan Hallam reports. Ten years ago, Claire Murray, a 24-year-old young mother of two, died in a Singapore hospital from complications of a live liver transplant after a decade of battling the effects of childhood trauma from sexual abuse and bullying that led to homelessness and drug use. The tragedy is that Claire’s story was not widely known at the time she became headline bait for local media, simply because no one asked the most fundamental of questions, why. Why did a happy young girl’s school life alter so terribly? Why did the health system fail her on multiple occasions from the time her parents started seeking help for her depression when she was just 12 years old? Why did a television station ask viewers of its nightly news bulletin in a phone poll if Claire, whose liver transplant had failed because of blood clots, should receive further treatment or be left to die? The documentary, Wild Butterfly, aims to address some of these questions while tackling head on the issues of community responses to childhood trauma, bullying and stigmatisation of drug users. Claire’s parents, Michael and Val Murray, promised their daughter 46 | APRIL 2020
that her full story would be told to encourage change in the way our society handles these issues and alter their destructive consequences. The documentary has been almost a decade in the making by filmmaker and psychotherapist Shireen Narayanan. It began when the former director, now a lead researcher, at Curtin University’s National Drug Research Institute, Professor Steve Allsop, put her in touch with the Murrays. “When I first met the Murrays, it was less than a year since Claire had passed away and the family were very vulnerable, grieving and traumatised, not only by Claire's death, but what had played out so brutally in mainstream and social media,” Shireen said. The film was, as Shireen describes, “an eight-year marathon production” for her team. “This process involved a lot of investigative journalism and the more pieces of the puzzle we put together, the more we realised how Claire's story is integral to a much bigger story,” she said. “We were compelled to not only tell the story, but it needed to be part of a project that would make a difference. That has led
to the development of a social impact campaign. So, we began developing campaign objectives and, in that process, gathering a group of multi-disciplinary experts across the sectors – from child and adolescent mental health, alcohol and other drugs, media, medicine, social work, psychology and education.” Finance for films is always difficult, however, this campaign, with ambassadors such as adolescent mental health expert Professor Patrick McGorry and Blue Knot Foundation president Dr Cathy Kezelman (an Australian Centre for Excellence in complex trauma), drew a different pool of potential funders. The union movement was supportive of the project and became its major backer. “The unions were not in any way deterred by the fact that while the film deals with what I call the trifecta of stigmas – sexual abuse, mental health and drug use – and the film's themes of fairness and social justice speak to the heart of the union movement,” Shireen said. “They not only wanted justice for Claire, they wanted to raise awareness of discrimination and violence, about standing up for humanity and equality, and they
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DOCUMENTARY also wanted to see the perpetrator of Claire’s sexual abuse brought to justice.”
about and what caused her medical problems. And often people don't look beyond the drug use.
For Steve Allsop, Claire’s story became personal when he discovered that he knew her father, Michael. Before the men had talked at length, Steve’s knowledge of Claire’s story was only what the media was reporting, and he was already appalled.
“It's not true to say that everyone who uses drugs has got some trauma in their lives, but those who have the greatest need, those who end up in our drug treatment services, do have a multitude of problems. By just saying to them, ‘stop doing it’, not only fails to understand the problem, it can make things worse.
The full story horrified him. “I was initially cautious about Michael’s proposal because I had seen how badly Claire and her whole family were treated, and I thought that they could be persecuted and devastated again. It's still a hell of a risk for this family,” he said. “But they were determined, so I put them in touch with Shireen, who I know and trust.” Steve’s working life has given him a deep understanding of the stigma and discrimination of drug use and users. “The lack of understanding of them as human beings, is the single biggest issue we have to address. And because of the stigma and discrimination, vulnerable people refuse to see themselves as being at risk and that gets in the way of effective prevention and treatment,” he said. “Governments are also less inclined to put money into those sorts of issues. Historically, that's been the case, notwithstanding significant improvements in federal and state funding over the years. “Then, of course, when people do reach out for help, they don’t always get the help they deserve. “A physician I worked alongside on an advisory group about pharmacotherapy came out with something that has really stuck with me. When we were looking at what seemed to be a roadblock for outcomes, he piped up: ‘It's not rocket science. It's not that hard. Doctors do all sorts of complex things. It's just that they don't like doing them very much’.
“Drug use in this case is intimately caught up with sexual abuse, so what does that knowledge do to your judgment now? That's what the film draws our attention to – not to judge until you know the full story and neither let your judgment get in the way of good clinical diagnosis.
health services; primary health care and drug and alcohol services; and vice versa, as well as significant improvements in access to services. In terms of the media coverage of the small proportion of Claire’s story, Steve says: “I think that if we repeat that sort of media coverage about drug use, we're going to prevent people putting their hand up for help. It actually prevents us doing good prevention and it prevents us doing good treatment. “And the other issue is, would you like your daughter, your son, your friends to be treated this way? “I think it's changing. Senior people in the media are beginning to realise they need to be talking about these issues differently.”
“And neither should we allow the media to sensationalise people’s stories.”
Steve’s hope the film will raise the community’s consciousness around stigmatisation and discrimination.
Steve said improved communication in the health sector was vital.
“We denigrate people who are affected by drugs as lesser human beings. And that's not to say we shouldn’t hold people accountable for bad and unacceptable behaviour, but we must try to understand what their drug use is about.
“There are some excellent drug treatment services and excellent patient care and management. And there are some fantastic doctors liaising with drug treatment services, and housing services. But the treatment services can be difficult to navigate.” “In Claire’s story there were a lot of failures along the way, like a lack of follow-up between services. Even a communication between professionals ‘Did you get that message? Everything okay?’ That may take time but it takes less time that having to keep re-admitting patients.” He said there was now a better connection between medical and
“Half my time is trying to persuade people to give a damn and not jump to conclusions. I guess it shows in this documentary that people, not just medical practitioners, but the community generally, jumped to conclusions about what Claire’s drug use was MEDICAL FORUM | CARDIOVASCUL AR HEALTH ISSUE
“That should lead to better integrated treatment services. Governments are putting more in but it is just the start of the journey. Shireen’s vision for change looks at increased public awareness. “We're not about pointing fingers. We're want this film to strengthen the conversation and understanding of trauma and how that fits into informed practice,” she said. At the time of Claire’s death, she had, not without controversy, won support from the then Health Minister Dr Kim Hames, who approved an interest free loan to the Murrays for her Singapore treatment. He writes in the film’s prospectus:
Claire Murray
“My political involvement in supporting the Murray family was born of the deep concerns of people who develop dependence on alcohol and other drugs as the result of having experienced the trauma of sexual abuse. I hope that this documentary can contribute to a change in the way our community reacts to these complex and devastating issues.” APRIL 2020 | 47
SOCIAL PULSE
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Urology Masterclass Perth Urology’s third annual masterclass at the Westin Hotel in February attracted 146 delegates, who had the chance to quiz specialists in all aspects of urology care. 1
Dr Shane LaBianca and Dr Anna-Lena Brink speak on haematuria
2 Dr Matt Brown answers a question on PSA 3 Dr Jeffrey Thavaseelan and geriatrician Dr Larry Liew discuss urology issues in the elderly 4 The conference room 5 Dr Trenton Barrett discussing aspects of female urology 6 Dr Akhil Hamid presents on renal problems
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7 The panel discusses “Prostate myths or truths”
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WINE REVIEW
Bellarmine leads the way in Pemberton Back in 2009, in my review of this then fledgling, but impressive wine producer, I predicted that it would rise to great heights under the management and direction of winemaker Diane Miller. She was appointed winemaker in 2008 and came with a wealth of experience including viticulture and other facets of production and marketing. Under her guidance, Bellarmine has become a leading producer in Pemberton. In fact, distinguished wine writer James Halliday gives the wines top rating in his five-star system – the only Pemberton producer to achieve this. Bellarmine is owned by German pathologist Willi Schumacher, who chose this site, after a worldwide search, for its pristine and picturesque location, its gravel over limestone soils and the cool climate and its elevation of 220m. Established in 2000, the 20ha are planted to Riesling, Sauvignon Blanc, Chardonnay, Pinot Noir, Merlot, Shiraz and Petit Verdot. Their specialty is Riesling, produced in three styles of varying sugar levels – no surprise for a German venture – and Di does this so well. All wines are single vineyard wines, with no outsourcing of grapes.
Review by Dr Craig Drummond
Bellarmine 2019 Pinot Noir (RRP $26)
Bellarmine 2017 Riesling (RRP $26)
Bellarmine 2016 Shiraz (RRP $28)
Another great wine! In fact, it challenged the Select Riesling for my pick. I am difficult to please with WA pinots, but this wine has the required qualities. A medium-to-full-bodied style of Pinot. Colour is a vibrant ‘Burgundy red’, the nose shows beautiful red fruits – elevated red cherry and blueberry. Palate supple and smooth, very complete. Ripe, rich flavours of cherry and black plum. Oak is integrated, tannins supple and smooth. A structured and complex young Pinot. I will be looking at this wine as it evolves.
This is in the typical Aussie dry style, and gives just what we expect. Citrus aromas, floral, with a touch of flower blossom. Leads to a palate showing lime flavours, background minerality with a character I describe as ‘river pebble’ or ‘talcum’, which I enjoy in Riesling. A very good wine which will develop wonderfully over years. Why is Riesling so underrated in Australia?
Deep brick red with a browning edge. Nose shows developed savoury notes and spicy black fruits. The palate is mellow, supple. Flavours of mocha, all spice and blackcurrant. Integrated oak and mellow tannins with a firm acid backbone. Alcohol of 14.5% giving warmth. This wine needs decanting and breathing for it to show its true colours. At four years of age, I feel it is optimal.
Bellarmine 2019 Chardonnay (RRP $26) A young, clean, linear and balanced wine. It’s initially restrained on the nose, then opens up. Characters of stone fruit and melon. Oak is integrating. A slightly ‘tighter’ Chablis style. Easy to drink now, will evolve over three years. Nice wine.
'S EWER REVI
PICK
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Bellarmine 2016 Select Riesling (RRP $26)
This wine is sublime. The style is Germanic, made in the mould of the great wines of the Mosel district of Germany. Fermentation is muted before the wine ferments through to dryness, resulting in a residual sugar level of 65g/litre and an alcohol level of only 7.5% (most dry wines we consume are less than 5g/litre) Aromas are fresh, vibrant and lively, with lifted floral and lime characters. The palate displays clean, linear purity. A poised wine with razor-edge balance of fruit and acid, the sweetness disguised somewhat by the acidity. Flavours of lime and green apple with a binding minerality. Will age wonderfully. Why don’t we see more of this style in Australia? A wine so easy to drink, so refreshing, with length, clean finish, and oozing personality.
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ARTS & ENTERTAINMENT
Effie the (no longer) Virgin Effie turns 30 this year and has discovered sex and desire. Her creator Mary Coustas talks to Ara Jansen about how Effie has changed her life. MF: To celebrate Effie's 30th, you've created a new show called Love Me Tinder. Effie's married, lost her virginity, she must have a lot to say about that. MC: Love Me Tinder is the third part of the trilogy. In the first show, A Date with Effie, she was looking for love. In Effie the Virgin Bride, she got married to Shane Bradley Cooper, her first kiss from primary school. Love Me Tinder takes place seven months after the wedding. This one deals with the reality on the other side of the fantasy. What happens when [life is] mundane, every day and routine? What happens when one of the most attractive, coveted, lustedafter-virgins of modern history finally yields to the pressures of marriage and intimacy? It occurred in Effie’s Southern Hemisphere, “a beast, a ravenous beast, was released from within” and, in one night, Effie went from frigid to feral. As far as she’s concerned, the genie is well and truly out of the bottle and this dangerous curiosity has taken hold. Effie loves Shane and she doesn’t want to lose the love of her life because of this. MF: Celebrating Effie’s 30th anniversary, how do you think of her? Is she a sister, a character who sits in the cupboard until you get on stage, or like having another personality? MC: I see Effie as the child in me.
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Effie is the love letter to the first decade of my life growing up in the working class Melbourne suburb of Collingwood. I liken Effie to putting on my favourite pair of ugg boots. It’s an utter joy and the only time in my life where I am totally fearless and free. MF: What’s the secret to Effie’s longevity? MC: Effie speaks the truth in a way that is totally acceptable and refreshing. In a time of such political correctness and overmonitoring of freedom of speech, this is a necessity and something comforting for the audience, as much as it is for me. Effie’s intentions are never negative. It’s theatrical and fun and we cannot get enough of that, especially in times like now where there is so much fear and judgement. MF: Did you have to think hard about how the character would age in attitude and tastes, or was it natural and effortless? MC: I have always found Effie effortless. It’s like another skin for me. I revel in her openness and her ability to touch and connect with anyone and everyone. Half of the show, every single night, is improvised. It’s that part of the show that is the high wire act. People go crazy for it because you never know what’s going to happen. And magic always happens.
MF: The world isn’t the same as it was 30 years ago, so how did Effie navigate that? How did you keep her funny, keep her soul but still move with the times and make sure she didn’t become a relic of a bygone era? MC: I have put the character in so many different situations. Whether it’s with prime ministers, sporting stars, the general public or very difficult things like Make a Wish for children whose final wish was to spend the day with Effie, or the litany of TV shows that I have appeared on over the past three decades. Situations that challenge us force us to extend ourselves and that’s when we are at our most present and often where we rise. MF: Do people laugh with or at Effie – or both? Is there power in that? MC: I think people do laugh with and at Effie. They laugh at how she looks at the world as well as how she reacts to it. We love larrikins who are relaxed, loveable and down to earth. That Aussie spirit is so much of our country’s character. It insists we don’t take life, or ourselves, too seriously. Regarding the power of that, if we look at what the media and society often tells us, that is in order to be a success you need to be educated, Anglo and acceptable in so many ways that Effie isn’t. This is where a great character can make a category all of its own. It’s like
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could remember. The loudness, the generosity of spirit, the life-loving nature of them, and I wanted to expose that to the world. The first stage show, Wogs Out of Work, became an instant and humongous hit around the country, followed by the TV show, Acropolis Now. Thankfully these shows were able to break down many of the barriers that were between us. A stereotype is something that we instantly recognise and in order to understand something it needs to have some form of familiarity. It’s that initial connection that is the gateway to seeing what else is behind that familiar facade.
I felt like I had been turned inside out; that all my feelings were no longer shielded by composure. That thicker skin that had always protected me had been ripped away. I felt totally exposed. But the benefit of immense loss is that your humanity is far more accessible. I felt more empathetic; quicker to tears and quicker to laughter. Those emotions made me a better actor, person, wife, friend, daughter and eventually mother to my daughter, Jamie, who was born in 2013. I had more to say, more to give. The last three stage shows since that time have been the best work I’ve done, because of Stevie.
MF: How has Effie changed you? What has she given you?
parliamentary privilege. I feel like the mask of Effie is the get out of jail free card that I need to speak about the taboos that need to be addressed. She makes everything acceptable, memorable and quotable. MF: Is Effie more like you now than she was 30 years ago? Are there moments when you think, “oh my goodness, that’s me” not the character? MC: Totally. Initially Effie was like a lot of young people, concerned only about her own needs. There’s a spunkiness to that but over the years there’s a greater opportunity for me to comment on so much that is happening. So much that we’re all trying to get our heads around. The everyday challenges that we all need help and insight into. Occasionally I’m surprised by it, but mostly I’m conscious of the power that it has to get to the core of something that we all need to address. I like to think of it as joyful medicine.
MC: Effie has been such a gift for me. I can take life pretty seriously. There’s an intensity that I have that Effie perforates. She’s kept me young, curious and employed. It’s a co-dependency that works for both of us. And thankfully for the public as well. I know the power that she wields. And I know the healing that she brings. I’m forever grateful of that. And at a point in my life where I have been overwhelmed with grief, she is the Sherpa that helps lift me. MF: Why do you think you’ve been doing your best work in the last five years? MC: After the loss of my stillborn daughter, Stevie, in 2011,
MF: Is it fair to say Effie helped introduced wider Australia to our multicultural and migrant community all those years ago? MC: We are all looking for new things to fall in love with. I knew there was a rich world that I came from that was lovable. Rich in character, contradiction and theatricality. I’d been captivated by the Greeks from as far back as I MEDICAL FORUM | CARDIOVASCUL AR HEALTH ISSUE
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CULTURE
Otto heads back home After almost two decades, Western Australia’s iconic and much-loved blue whale is back. Ara Jansen reports. The 24m blue whale skeleton – which has been named Otto – was recently unveiled in its new home in the WA Museum, which opens later this year. The skeleton has been spectacularly suspended in a dynamic ‘lunge-feeding’ pose in the heritage-listed Hackett Hall building. The pose of the whale is based on the latest research around feeding behaviour which reveals that blue whales roll and lunge as they feed on krill. This is the first time in the world a blue whale skeleton has been displayed in such a dynamic pose, showcasing the latest research into the feeding habits of this marine mammal. The endangered blue whale is the largest animal to have lived on earth and the Museum display allows visitors to walk under the skeleton and meet the blue whale at eye level. Suspending the skeleton required experts to create the frame which would hold Otto. Canadian marine skeleton specialists Cetacea worked with local company CADDS Group to create a precision-engineered, bespoke metal frame to suspend him, which in another world first, used technology usually reserved 52 | APRIL 2020
for mining and engineering projects. The skull alone weighs more than 800kg and would have weighed double that covered in flesh. “When we were discussing the content of the New Museum, there was probably only one object that had a free pass in,” explains CEO Alec Coles. “There was no question that the blue whale had to come back.” After a call for public submissions, the 123-year-old blue whale was named Otto, in honour of the Western Australian Museum’s taxidermist, Otto Lipfert, who had the incredible foresight in 1897 to collect and preserve the skeleton for future generations. The adolescent blue whale washed ashore at the mouth of the Vasse River near Busselton in August 1897 and it took three years for Mr Lipfert to prepare the bones for transport to the museum in Perth. He then moved the skeleton up the beach by horse and cart to the Busselton Train Station and packed it onto a train bound for Perth. In a three-sided shed behind the museum, on the corner of Francis and Beaufort Streets, Mr Lipfert
reassembled the whale for public display, using more than a tonne of iron rods. When a new museum building was constructed in the 1970s, the skeleton had to be lifted into the fifth floor with a crane before the roof was put on. When that building was closed, he was taken off display. Over the years, the blue whale has become one of the State’s most loved treasures and a significant memory for many children who saw it during visits to the museum. With Otto in his new home, it’s a chance for a whole new generation of children to be fascinated. “There’s huge affection for the blue whale,” says Mr Coles. “There’s also huge sadness from the people whose kids have grown up and not seen the whale, but hopefully, they will see him now.”
See Otto... See Otto at the WA Museum when it opens in November. Entry will be free for the first 18 months.
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ARTS & ENTERTAINMENT
Out & about Each month Medical Forum review what's on in Perth. If you want to win tickets to our features, simply visit mforum.com.au and click the 'Competitions' tab. Virtual art
City of Girls
Netflix fun
Forget what you know about Elizabeth Gilbert and her book Eat, Pray, Love. It tends to colour people’s view of the American writer. When it comes to her most recent novel, City of Girls, she’s produced yet another wonderful, engaging and life-spanning story. City of Girls has all the fizz and excitement of New York in the 1940s while telling the story of a woman who makes unusual choices. Filled with colour and stories of life in the theatre (which is how our heroine comes to NY), it’s also a romp through the life of a woman who lived by her own rules and reclaimed her own sexual agency despite society’s grim and often loud disapproval.
Stuck at home? We’ve picked a couple of crime series from Eastern Europe on Netflix which are interesting and just a little left of centre. Ultraviolet from Poland is a quirky and colourful show about a rideshare driver who co-opts a group of amateur detectives to solve crime in her town, largely using the power of social media. The Sniffer is a Ukrainian detective show with a difference as the lead character has an incredible sense of smell, which allows him to distinguish all sorts of details about a crime scene. They are in source language with subtitles.
Movie: Hearts & Bones A war photographer returns home for his latest exhibition when a South Sudanese refugee appears at his door with a request – that he not exhibit any photographs of the massacre in his village taken 15 years earlier. What emerges is an unlikely friendship between the two and a mystery solved.
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Don’t miss out on art, culture and education – instead enjoy some of the world’s greatest museums and galleries through virtual tours. You’ll be spoilt for choice with the British Museum in London, New York’s Guggenheim Museum, the National Gallery of Art in Washington DC, Musee d’Orsay in Paris, Seoul’s National Museum of Modern and Contemporary Art, Pergamon Museum in Berlin, Van Gogh Museum (Amsterdam), Uffizi Gallery in Florence, MASP in Sao Paulo and the National Museum of Anthropology in Mexico City. And of course, there are plenty of artworks, information and videos on their sites too. You’ll be fascinated by what you find.
Dance like no one’s watching No Lights No Lycra Perth is the place you can get your boogie on and dance in the dark for the pure joy of it. Shake off your stress. Sessions are held all over the world and the Perth group recently streamed their first online session. Check out @nolightsnolycraperth on Facebook on how to join in the fun from your own home. No special clothes or shoes required!
February Winners War Horse: Dr Charles Armstrong Doctors Dozen: Sitella Wines: Dr Catherine Civil Movie: I Still Believe: Dr James Flynn, Dr Joanne Keaney, Dr Colin Smyth, Dr Rosie Stroud Movie: Bloodshot: Dr Stuart Paterson, Dr Kevin Kwan, Dr Craig Schwab, Dr Paul Kwei Movie: Peter Rabbit 2: Dr Moira Westmore, Dr Michel Hung, Dr Russell Date, Dr Farah Tan Alliance Francaise French Film Festival: Dr Mariet Job, Dr Gabe Hammond, Dr Lin Arias, Dr Barry Vieira
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You don’t buy a practice every week, but we do
It’s a big decision, Huge. For most, it’s a once in a lifetime proposition. We take this very seriously too. So much so, that over the last 25 years we’ve developed a process for medical professionals looking to go out on their own. But we don’t just look at you, we look at the business as a whole. We act as your partners in ensuring that it is a viable and profitable opportunity. We assess everything - location, competition, client-base and growth potential. Then, and only then, we tailor a loan to meet your needs. Forgive the pun, but we have a lot of practice when it comes to buying a practice. Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.
Car loans | Commercial property | Credit cards | Equipment finance | Fit-out finance | Foreign exchange | Home loans | Personal loans | Practice purchase | Practice set-up | Savings accounts | SMSF | Transaction accounts | Term deposits | Vehicle finance The issuer of these products and services is BOQ Specialist – a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”).
