Medical Forum – December 2017 – Public Edition by Medical Forum WA

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EDITORIAL

Goodbye 2017... It’s Been Fun 2017 has come down to these final three weeks. So what's happened to the past 320 odd days? Well, everything; too much and probably not enough.

deposited by a presidential convoy of black 4WDs. He also pulled a gem out of the vault – whatever DID happen to the Reid Report?

As trite as it sounds, the Season does give us the opportunity for some self-reflection and the more honest that is, the more useful it can be as the New Year comes a knockin’.

Bunbury GP Dr Clare Willix is recommitting her efforts to work for health equity for Aboriginal Western Australians. She can’t do that alone – the whole of society, regardless of politics and race, can do the same.

This year has been the usual cat and mouse with ‘spokespersons’, ‘disruptors’ and ‘forces of reason’ from here, there and Canberra… except the mice are as big as cats and don’t give a rat’s! It’s scary out there. Useful and important information is concealed and replaced with dazzling and breathtaking tripe – believe me, I’ve read tonnes of it. As money and politics have tightened, so have lips. You can’t buy an honest quote – delicious irony aside! As to answering an email or a call, pfffttt, that went out with yesterday’s Tweet. In our last issue of the year, we have asked wheels and spokes about their wish to make our community a healthier place. We were pleased and grateful in equal measure that the invitations were accepted heartily and the responses genuine. Health Minister Roger cook wants a meaningful discussion on the cult and culture of alcohol in our society. We will all be pickled in our graves when that one unravels but, as the philosophers say, it’s the journey that’s important. St John of God Health Care’s Dr Michael Stanford looks to simpler times when children walked to school rather than

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MEDICAL FORUM

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au

Kevin-Cass Ryall from Ramsay has a message for fellow executives – MOVE! Not chase-tails or look-over-shoulder type of corporate moves, but simply get off the chair and put one foot in front of the other – and make sure your staff does the same. It is a message that some health initiatives don’t come with a hefty price tag, just common sense and a positive work culture. Bayswater GP Dr Rohan Gay has the final word at least for 2017 on health care homes. Spoiler alert: “The only role for centralised bodies should be developing, publishing and overseeing chronic disease programs that are delivered at a local level.” Please, so whoever in high places (I’ll settle for a middle-ranking bureaucrat) reading this, listen and please answer our questions around capitation, the impact on independent General Practice, influences of special interests and whether this is yet another expensive dead duck? Next year will be full of many of the same dilemmas we faced this year. It will also be full of the reasons we all do what we do. A sense of purpose that our work has value. This cat is ready for her fifth decade of chasing mice.

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

DECEMBER 2017 | 1

CONTENTS DECEMber 2017

10 FEATURES 10 Deprescribing for the Elderly 12 Organ Donation: I Wonder If… 14 Christmas Without a Home 17 Communicating After Stroke NEWS & VIEWS 1 Editorial: Goodbye 2017 … It’s Been Fun

Jan Hallam Letters to the Editor Spreading Finite Resources Ms Learne Durrington Assisted Dying Mr Bill Marmion New Era of Screening Mr Gordon Harloe Rights are Lifelong Mr Andy McMillan 8 Have You Heard? 9 Beneath the Drapes 26 App Review: ACM Check (asbestos) 43 Type 1 Breakthrough

FIND US ON FACEBOOK & TWITTER! /medicalforumwa/

17 Lifestyle 44 Travel: Happy Canada Days

Dr Rob McEvoy My Local: P’tite Ardoise Recipe: Smoked Salmon Blinis Wine Winner: Dr Greg Hogan Wine Review: Zonte’s Footstep Dr Craig Drummond MW 48 Funny Side 49 Theatre: Rocky Horror 50 Competitions

46 46 46 47

2017

Christmas Feature Pages 27-35

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MEDICAL FORUM

clinicals

Herpes Simplex: Not Always Simple Dr Smathi Chong

Travel Advice? A Checklist Dr Peter Burke

What Vaccines Don’t Cover Dr Aidan Perse

Staying on Top of TB Dr Justin Waring

Glucocorticoid Replacement

Clin A/Prof David Henley

Foreskin Problems in Kids Dr Jill Orford

guest columns

Man Behind the Doctor Dr George Crisp

Chronic Pain and Medical Marijuana Dr Stephanie Davies & Dr Max Majedi

Public Interest and National Law Ms Morag Smith

Save the

Date 25

Land of the Sunbakers Dr Rohan Gay

Future Medicine

Playing the Change Game?

Thursday March 29, 2018 – 7.30am Royal Perth Yacht Club INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician) MEDICAL FORUM DECEMBER 2017 | 3

LETTERS To THE EDITOR Spreading finite resources Dear Editor, I would like to thank Dr Ralls for her feedback and invaluable insight into the challenges faced by GPs (Mental Health is Suffering, Dr Jane Ralls, November 2017). The WA Primary Health Alliance (WAPHA) recently commissioned mental health services to support Western Australians on low incomes to access better, more targeted primary mental health treatment. The services we have commissioned are provided by registered and clinical psychologists within a virtual clinic, and are delivered face-to-face, by telephone, or webbased: in all cases treatments are clinicianled. These evidence-based services are already making a significant difference to the lives of some of the most vulnerable people in WA, whose access to appropriate treatment was previously limited or non-existent, due to availability, affordability and/or location. WAPHA is accountable to the Commonwealth for commissioning psychological intervention services to treat mild to moderate mental illness within primary care across all of WA. As such, this represents the bulk of our investment. This is in addition to the Commonwealth’s Better Access program. Recognising concerns raised by some GPs, WAPHA has widened the referral criteria, allowing GPs to decide if a patient is financially disadvantaged, rather than the services only being available to Health Care Card holders. By applying a policy of treating more people earlier, we aim to prevent their illness progressing to the stage where it requires more intensive, prolonged treatment.

We also have a smaller funding allocation to help GPs with time-limited case management of patients with severe illness who have other complex needs. This does not extend to longterm treatment, which is a state responsibility.

Now it rests with doctors

Indeed, most severe and complex patients are managed in state-run mental health services. In some cases, this is in sharedcare arrangements with GPs, however, in metropolitan Perth, shared-care is the exception rather than the norm.

RE: Inside WA’s Medical Cannabis Story, November 2017, the previous Liberal National Government welcomed the introduction last year of Commonwealth legislation to make medicinal cannabis a controlled prescription drug.

However, we are aware of a small number of committed and resourceful GPs, such as Dr Ralls, who have developed a range of bespoke funding and other arrangements that allow them to provide long-term care for some severe and/or complex patients, essentially independent of the public system. The cessation of the Commonwealth operated ATAPS and Mental Health Nurse Incentive Program has impacted on the viability of such arrangements. We acknowledge the subsequent difficulties Dr Ralls and other GPs face in accessing treatment for their patients with severe, complex and persistent mental illness, including problems accessing state-based alternatives. We recognise this important population, albeit small, risks falling through the cracks created by gaps in service delivery. While Primary Health Networks, of which WAPHA operates all three in WA, have been charged by the Australian Government to reform primary mental health services, our mandate does not extend to long-term treatment, nor can we fund services that substitute for what should be provided for by state services. This includes long-term care of people with severe and persistent disorders. What we can do is continue to work closely with all parts of the health sector to promote integration, continue to liaise with other health agencies and continue to listen to GPs and advocate on your and your patients’ behalf to improve the system and, ultimately, the lives of even more people. Learne Durrington, CEO, WAPHA

People can't concentrate properly on blowing other people to pieces if their minds are poisoned by thoughts suitable to the twenty-fifth of December. Ogden Nash

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

4 | DECEMBER 2017

The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Dear Editor,

As a result of these changes, doctors in Western Australia wishing to prescribe medicinal cannabis can seek approval from the Therapeutic Goods Administration and an expert advisory committee. The previous government’s role was to put in place processes and protections to ensure the safety, efficacy and quality of the products being prescribed. The future of medicinal cannabis as a treatment option now rightly rests with the medical fraternity, which will undoubtedly be undertaking research and evaluation as to its effectiveness. Bill Marmion, WA Shadow Health Minister ED: For pain specialists Dr Stephanie Davies and Dr Max Majedi’s response to medicinal cannabis, see P19

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New era of screening Dear Editor, As many of you will be aware by now, the National Cervical Screening Program (NCSP) will change on December 1. Human Papilloma Virus (HPV) testing, with either reflex or co-test liquid-based cytology (LBC) will replace Pap smears as the Medicare rebatable screening test. The HPV vaccination program has had an enormously positive effect on public health outcomes. With HPV being responsible for virtually all cervical cancer, the national rollout of the HPV vaccine has seen, according to continued on Page 6

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MEDICAL FORUM

Major Sponsor: Clinipath Pathology

BACK TO CONTENTS

Herpes simplex – Not Always Simple

Dr Smathi Chong Clinical Microbiologist Clinipath Pathology

Herpes simplex virus (HSV) 1 and 2 are closely related to each other and more distantly related to Varicella Zoster virus (VZV), which causes Varicella (chicken pox) and Herpes Zoster (shingles).

HSV Serology has a more limited role. Many clinicians (and patients) expect Herpes serology to be able to do more than it can! Test results may not answer many clinical or patients’ questions.

Traditionally HSV1 causes most oral herpes and HSV2 causes most genital herpes. But this is no longer so and has changed, probably due to more frequent oral sex.

A positive serology simply indicates a patient has been infected with HSV at some time in the past. It is not able to time the initial infection unless seroconversion (HSV IgG changing from negative to positive) can be demonstrated. In Herpes reactivation, the IgG would already be positive.

Figures from Clinipath 2017: HSV Swab Origin

HSV1

HSV2

VZV

Oral sites

93%

Genital/perineal sites

45%

50%

HSV1 is frequently acquired in childhood and 75% of Australian adults would have had HSV1 by early adulthood. This would have been from oral contact with close friends and relatives who were shedding the virus, often asymptomatically. The classic “cold sores” are a blistering painful rash around the mouth. Like other viruses in the Herpes family, this ‘lifelong’ infection can lay dormant and reactivate. The risk of reactivation and severe reactivation is higher in immunosuppressed individuals but in most people there is no readily identifiable reason for their reactivation. Stress is often blamed.

Serology does not indicate the site of infection (e.g. oral or genital) although a strong positive HSV2 serology in the setting of painful genital lesions is likely to indicate genital herpes. Serology does not confirm whether symptoms are due to herpes. A positive PCR on a genital lesion would be more helpful. Positive serology is not able to tell if the person is infectious at the time of the test. HSV Serology or PCR would NOT be able to determine whether a person’s partner has been unfaithful! False positive (perhaps up to 5%) and false negative serology results can occur.

The highest risk is in symptomatic primary herpes infection of the birth canal/genital track. Herpes simplex serology may be more useful in the setting of pregnancy in patients with genital lesions suggestive of herpes to help risk stratify whether the episode is likely to be primary HSV. The highest risk would be PCR proven active genital lesions and negative serology. Treatment including anti-viral therapy and consideration of caesarean section may be discussed with the obstetrician. Management of the neonate with high risk of HSV should be handled by a neonatologist or paediatrician. Treatment These viruses may be treated with aciclovir, valaciclovir or famciclovir. Detailed therapeutic advice is beyond the scope of this article. Guidelines may be obtained from the Therapeutic Guidelines and from the King Edward Memorial Hospital (KEMH) website for management of HSV in pregnancy and in neonates Further Reading: Australian STI Management Guidelines Australian Therapeutic Guidelines King Edward Memorial Hospital Guidelines

Less common infections include: • HSV encephalitis (HSV1 in adults) and HSV meningitis (usually HSV2 in adults) • Conjunctivitis/keratitis – usually HSV1 or VZV (shingles affecting trigeminal nerve) • Herpetic whitlow – painful vesicles affecting the fingers and thumb caused by HSV1 or 2 Genital Herpes This causes most angst in patients as there is a social stigma. Approximately 1 in 7 of the general Australian adult population is seropositive to HSV2 but most are asymptomatic or subclinical. Laboratory testing HSV PCR is performed on a swab of a lesion to detect viral DNA. It is the test of choice for diagnosis of HSV infections. Clinical diagnosis may be confirmed by swabs of the lesions/ vesicles for HSV PCR. This can accurately distinguish between HSV1, HSV2 and VZV.

• HSV1 and HSV2 may be clinically indistinguishable

HSV IgM is no longer performed in most labs as they often throw up more confusion due to the non-specific nature of the test.

• HSV Serology is of more limited utility

HSV in Pregnancy HSV can cause severe neonatal infections including meningo-encephalitis, disseminated disease and even death.

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

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Serology is often negative in acute primary herpes infection as HSV IgG can take a few weeks to a few months to become positive. Serology positivity may also decline over time.

Patient Results: 9371 4340

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• Diagnosis of choice is PCR from a ‘dry swab’ or viral transport medium • HSV in pregnancy, especially primary genital infection, needs to be taken seriously • Antivirals are available for treatment or viral suppression

LETTERS To THE EDITOR continued from Page 4 the Cancer Council report, a 77% decrease in 18-to-24-year-old women with HPV (for the HPV subtypes covered by the vaccine) and a 34% reduction in precancerous abnormalities in 20-to-24-year-old women.

Rights are lifelong

The success of HPV vaccination and PAP screening program means Australia now has one of the lowest rates of cervical cancer in the world, something of which we should all be very proud.

With submissions to the state parliamentary inquiry into elder abuse deadline slated for November 17, the issue is very much in the forefront for Advocare, which advocates on behalf of vulnerable people. The complex world of advocating for others means treading a fine line (Protecting the Elderly from Greed, Deidre Timms, November 2017). There are often competing interests within families that require highly sensitive handling but one clear message is clear a person’s rights don’t cease to exist when they turn 65 yearsof-age.

The renewed NCSP provides exciting positive changes for cervical cancer screening and, as with all major change programs, brings new challenges. Cervical cancer screening is still required for vaccinated and unvaccinated women. Patients eligible for routine screening will need educating to adjust to the new five-yearly screening program, instead of biannual recalls. Patients will now be managed and tests ordered according to HPV risk, and there will be new Medicare criteria for followup tests. Specimen collection will now use liquid vials and not slides. This milestone in public health will reduce cervical cancer incidence even further, and see Australia become one of the leaders in cervical cancer screening. We look forward to helping you meet the challenges of this change. Dr Gordon Harloe, CEO and Anatomical Pathologist, Clinipath Pathology

Dear Editor,

One of the most important aspects of working in this field is our constant attempt to raise the profile of the services we provide here at Advocare. We’re hoping that increased awareness and positive changes will flow on from the state inquiry. There is heightened community awareness of domestic violence and child abuse but abuse of older people needs a lot more attention. We learn new things every day on the Elder Abuse Helpline, and some of them aren’t at all pleasant.

ED: See www.clinipathpathology.com.au for information on the NCSP.

It takes a lot of courage to dial a 1800 number and speak with someone you don’t know about a sensitive issue. Advocare is all about finding solutions and arriving at the best possible outcome and sometimes that means, after receiving permission to act on a person’s behalf, seeking legal advice. Advocare is also not just a service confined to the metropolitan area. We do a lot of community education in regional WA and speaking with country people makes you realise that they have issues regarding abuse of the elderly. It’s tougher for them and just one of the many challenges of living in remote areas. Hopefully, with upgraded technology, we’ll be able to improve our services to those people. A person’s rights don’t go out the window when they turn 65. They have them for life and it’s vitally important that they’re not trampled on. We often do presentations to medical professionals and the one thing we try to get across is if they see any signs that something isn’t quite right, then speak up. Ask the question and, if they feel it’s appropriate, call Advocare. Andy McMillan, Advocare ED: Elder Abuse Helpline 1300 724 679; 1800 655 566 (Country callers)

Pfft, I hate Christmas Day. It's for children and families. Not for people like me. Karl Lagerfeld

CURIOUS CONVERSATIONS

Sport, Music and Medicine French Horn player Dr Kate Stannage would love to hear the sound of trickling, lead-free water. I chose orthopaedics because… I love sport and medicine, so it’s a great way to combine the two. I’m also a pretty impatient person and the instant gratification of surgery is appealing. Ironically, I don’t do any sports surgery these days! My second career choice would have been… music. My French Horn is one of my most treasured possessions, despite the fact that the welds have sprung open and the keys stick. Watch out for me in the WA Doctors’ Orchestra in 2018!

If I could have a short chat with Health Minister Roger Cook I’d ask… when are the Thermostatic Mixing Valves going to be installed at PCH and will they solve the lead issue? And, last one, do you think it’s a good idea to have a feature wall in PCH’s orthopaedic waiting room painted RED? After all, red is the colour of… The book I’m reading now is… Home Fire by Kamila Shamsie. It’s a brilliant piece of writing exploring modern day Jihadism and its effect on family. Put it on your book club reading list!

My parents gave me a strong sense of… social responsibility and an enduring love of Swan Districts Football Club.

6 | DECEMBER 2017

MEDICAL FORUM

INCISIONS BACK TO CONTENTS

Man Behind the Doctor Dr George Crisp is concerned there’s a lot more to a healthy life than an artfully draped stethoscope. My medical practice looks pretty much as it did 20 years ago. It’s true that I do fewer consulting hours, but my day job in general practice is still primarily concerned with clinical interactions at the individual ‘doctor/patient’ level. But outside the consulting-room some things have changed, and quite significantly. I now spend much of my time reading, preparing and giving presentations, writing articles and submissions to government inquiries. I stood for parliament, joined Doctors for the Environment Australia and have been its WA Chair for nearly a decade. And, alongside my colleagues at Onslow Road Family Practice, we have worked to make our workplace more environmentally friendly and promote sustainable health in our community. Our surgery front garden is no longer picketfenced grass and roses. It’s a water-wise, food producing community space that also functions as an extension of our waiting room. Patients bring food scraps for composting and children often play there on their way to school. We've installed a prominent array of solar panels, a bike-rack and an outdoor notice board for health messages and community conversations.

So, what’s the point in striving every day to improve the health of our patients if it is to be undone by an increasingly unhealthy environment that we are creating? The nature of the existential threats of climate change and biodiversity loss may seem disempowering, but it does create opportunities. Just about everything we can do to reduce environmental damage has health benefits, from reducing pollution to eating more healthily, being more active and investing in the local economy. Doctors for change Doctors are natural advocates for their patients. We have the relevant knowledge, experience and, hopefully, the standing within our community to make positive changes. And, just as caring for our patients is important, so too is looking after a much wider community. And that’s one of the reasons I choose to wear yet another hat. I'm a keen hiker and once a

year I volunteer to lead a charity trek because it's a wonderful opportunity to test my medical skills and explore some highly interesting places such as Mt Kilimanjaro and the Sumatran rainforest. It enables me to actually get out there and experience a number of very different communities with the added bonus of improving my fitness level at the same time. And yes, I have another passion! I love playing in rock bands, which probably isn't an entirely healthy pastime because it involves quite a few long and late Saturday nights lugging my keyboards and amplifiers around various venues. For the past couple of years I've been playing with an ’80s cover band called ’80s Inc, which makes a lot of sense because that decade was definitely the best era for keyboard players. I also do the occasional gig with David Sofield's Paul Kelly covers band. It’s nice to know I’m not the only doctor in the house!

We are the environment Our medical practice changed, and I changed as well. There’s been a gradual awakening that our health and wellbeing is entirely dependent on the integrity of the biological systems that support us. And it’s an undeniable fact that they are being rapidly degraded in front of our eyes by our own actions.

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DECEMBER 2017 | 7

HAVE YOU HEARD?

The Health Care Home trial kicked off on December 1 in WA. The WA Primary Health Alliance has the task of overseeing it for the Commonwealth here. These practices in the Primary Health Network North have signed on for the trial: Bayswater Medical Centre, Beechboro Family Practice, Belridge Medical Group, Brookside Medical Centre, Claremont Medical Centre, Cottesloe Medical Centre, Craigie Medical & Dental Centre, DR7 Medical Centre, GP Superclinic@Midland Railway Workshops, Joondanna Medical Centre, Lindisfarne Medical Group, Maylands Medical Centre, Mobile GP and Homeless Healthcare, Rudloc Road Medical & Dental Centre Morley, Walter Road East General Practitioners and Yanchep Medical Centre. WAPHA told us that five more practices will be signing on for the December 1 deadline. There seems to be a lot of concern in GP land over the HCH concept. We have had a number of GPs contact us voicing fear over the potential risks to their businesses. Some thought HCNs were a slippery slope to capitation and fundholding that will increase administration without any proof of it leading to better chronic disease management.

Others believed HCHs could restrict incomes and signal the demise of some smaller GP-led practices and those practices that subspecialise. The trial will be watched with interest.

RACGP and assisted dying The RACGP’s official endorsement of voluntary euthanasia has caused a ripple in the membership with high-profile members threatening to quit because of it and the fact that the College consulted no one. The President Dr Bastian Seidel said if the Victorian Parliament passed the legislation (awaiting Upper House approval at the time of us going to Press) it should form a blueprint for other states. Australian Doctor surveyed GPs and GP registrars who appear to have disliked how the College went about the policy saying it was the few speaking for the many. It could also be said of the survey itself which was only 420 GPs and registrars from a membership of more than 26,000. Medical Forum’s own polls in 2008 and 2013 show a roughly even split of doctors for and against voluntary euthanasia with almost a quarter undecided. With WA’s own inquiry taking place currently, this certainly won’t be the last word on this significant topic.

Computer says yes It’s all about convenience via the internet. One of our editorial panel sent us a promo they had received from www.qoctor.com.au, which suggested that as a health consumer they “could get simple things like medical certificates, prescriptions and referral letters without queuing to see a doctor”. Moreover, medication could be express delivered to home or office, or a paper prescription sent to home or the local pharmacy, or on online medical certificate obtained with one of

a quality musical performance ,” she told Medical Forum.

WASO opens its doors The WA Symphony Orchestra’s CONNECT open rehearsals are giving adults with disabilities a chance to get to know their state orchestra in an intimate way and take home with them a sense of joy that only music can bring. Head of WASO’s Community Engagement Cassandra Lake said the orchestra had been offering programs for young people with disabilities and children in PMH for a number of years but the organisation was keen that this group of adults should have similar opportunities. “My goal for the program was to create a socially and emotionally positive environment for people and their carers and to experience

8 | DECEMBER 2017

BACK TO CONTENTS

Home trial jitters

There have been two CONNECT events this year and three are planned for 2018. Cassandra said the orchestra and its soloists, often from overseas, jumped at the chance open their rehearsals for this special audience of about 40. So far this year organisations such as Nulsen Disability Services, the Ability Centre, Activ and Rocky Bay among others have taken part in these free events. Cassandra said in 2018 people can experience pianists Piers Lane and Kathryn Stott, cellist Pablo Ferrandez and at Christmas a back stage look at Messiah. Above: Nathan, pictured here with his support worker Sibu Banya, meet WASO’s principal timpanist Alex Timcke. Nathan, who is supported by Nulsen Disability Services, attended the October event where he took the opportunity to discover the pleasure of sounds and develop his sensory skills.

their doctors. The operators of this national business have satisfied the RACGP’s need for knowing, is cherry picking OTC and prescriptions that don’t usually require a face-to-face consultation and referrals where the health consumer gets to choose a ‘regular GP’ and specialist for a group of predetermined conditions and the qoctor doctor does the rest! We’re not sure how rigorous they are about getting a ‘regular GP’ because handing over a GP's name is so the specialist can communicate with them! When we surveyed specialists way back, this was one strong comment – that patients who obtained referrals of convenience this way didn’t want to disclose their regular GP because they were embarrassed to do so. The cost of this episode is referred to “as little as $19.99” on the brochure. The website has a running total of what it says it has saved Medicare.

Two for one With a title like: Keeping patients safer: Australian-UK research collaboration shapes the future of regulation, only good can come of it, surely? AHPRA announced last month that it was collaborating with the UK’s Health and Care Professions Council (HCPC) to target the issue of patient safety in practitioner regulation “head on”. The regulators are mooting a research relationship to share data of over one million registered health practitioners across the two nations. AHPRA CEO Martin Fletcher said their research seminar in Melbourne last month would explore how both regulators could learn from data to improve regulatory effectiveness, patient safety and professional standards internationally. Martin said: “The research would look at complaint hotspots across health professions, preventing harm and using behavioural insights in the work that we do to protect the public.” They say two heads are better than one, or it could be heavier handedness. We’ll be watching.

PEDs and National Law Still with AHPRA, it has signed a Memorandum of Understanding with the Australian Sports Anti-Doping Authority (ASADA) to “align” the two agencies when performance enhancing drugs (PEDs) are provided by registered health practitioners without genuine therapeutic need. The pair will work closely on investigations and ‘align’ is probably better read as a crackdown on the inappropriate prescribing of PEDs. In not so many words, AHPRA CEO Martin Fletcher said the weight of his organisation would go a significant way in deterring the inappropriate MEDICAL FORUM

HAVE YOU HEARD? bACK TO CONTENTS

use of PEDs or practitioners would “held to account under our National Law.”

Mobile stroke unit trial

THIS ARTICLE WAS INTENTIONALLY DELETED

The Victorians are following the Europeans with the introduction of a mobile stroke unit complete with CT scanner to treat those people having a stroke in double-quick time. The Victorian Government has invested $1.5 million into the ambulance, which will work within a 20km radius of the Royal Melbourne Hospital in Parkville, which leaves those outside the perimeter to observe the basics – F.A.S.T. (Facial drooping, Arm weakness, Speech difficulties and Time to call emergency services) Only some people have strokes amenable to early intervention (about 40%). We are yet to find out if this stroke ambulance, which is fitted with CT scanner and a stroke nurse, radiographer and paramedics, will be funded long term. The Victorians are to be applauded for this early treatment in the field. They have the traffic jams and suburban sprawl to determine its efficacy. This four-year research trial will tell them if faster diagnosis and treatment can save lives and reduce disability (Victorians suffer over 14,000 strokes a year). The Mobile Stroke Unit has been delivered by Victoria Government in partnership with the Stroke Foundation, Royal Melbourne Hospital, Ambulance Victoria, the University of Melbourne, The Florey Institute of Neuroscience and Mental Health and the RMH Neuroscience Foundation.

Standards and fees Just a few weeks before former Kalamunda GP Dr Mike Civil jumped on a plane to take up a medical position on Christmas Island, he tabled the latest edition of the RACGP’s practice accreditation standards. The fifth edition will require GPs to warn patients about potential out-of-pocket costs associated with their referrals, without necessarily giving a detailed cost breakdown. The standards suggest that GPs could provide patients with a contact list so they can compare costs and select their own specialist – we wish them luck. It’s easier to pass a camel through the eye of a needle than to get a specialist’s receptionist to spill the beans on out-ofpocket expenses. The standards require GPs to always reveal their fee structure before providing treatment. Most GPs do this as a rule with posters on billing information posted in waiting areas. Other changes include the explicit requirement for practices to manage seriously abnormal and life-threatening test results after hours.

• Dr Lindy Swain will be the inaugural director the Kimberley University Rural Health Alliance, an initiative of the federal government and run through the University of Notre Dame Australia. • E/Prof Paul Worley, right, is the country’s first National Rural MEDICAL FORUM

Health Commissioner. The former GP was Dean of Medicine at Flinders University and held leadership roles in the Rural Doctors Association of South Australia and the Australian College of Rural and Remote Medicine. • ENT specialist Dr Tim Cooney has been appointed to the board of Telethon Speech & Hearing. Lawyer Jeremy Rigg was also appointed to the board.

• Mr Richard Alder has been appointed to the board of the Lions Eye Institute. • Prof Julian Rait, former MDA National boss has been voted onto the board of Avant. • Dr Jonathan Mortimer, Dr James Quirke, Dr Alan Leeb, Dr Peter Winterton, Dr Cory Lei and Dr Lewis MacKinnon have been appointed to the RACGP WA faculty board.

DECEMBER 2017 | 9

CLOSE-UP

It’s easier to prescribe an elderly person a pill, much harder to take it away and be sure you’re doing the right thing. Just ask A/Prof Christopher Etherton-Beer. A complex set of clinical and cultural factors govern the relationship between the prescriber of medication and those taking it. That relationship is complicated further when the patient is aged and cognitively frail. Geriatrician and clinical pharmacologist A/ Prof Christopher Etherton-Beer, of the WA Centre for Health and Ageing, who has spent much of his research time endeavouring to understand the effects of polypharmacy on the elderly, knows how passionate people can be about their medications. “Our first deprescribing pilot, that was over a decade ago now, was with volunteers in the community who had very strong beliefs about their medicine,” he said. “Our ideas have evolved over that time. We turned to aged care facilities and discovered we could have quite sophisticated discussions even with impaired older people and with their families around the risk-benefits of some of their medicines. For many older people, a lot of medicines were started years earlier when they were robust and now there is a greater risk of interactions and side effects.” Readers will remember the articles published on former Geraldton GP Kathleen Potter’s deprescribing study five years ago, which was part of her PhD. Chris was her supervisor and said the study used a well-defined algorithm but it was an open study of only about 100 people, which had its limitations.

This study and other studies will hopefully help GPs to navigate the complex area of medication use. Doctors need support “Doctors are the ones who must manage the risk factor of polypharmacy and GPs are really conscious of the problem. The feedback we get is that they’re looking for tools to help. They are bombarded with advice on how to start medicines but not much on how to stop prescribing and how to have those conversations with patients,” Chris said. “Looking back over the years we’ve been doing this research, we’ve had those same concerns. Satins are quite a good example of this dilemma. People said ‘isn’t it ridiculous this doctor prescribing a statin or a bisphosphanate to a 95-year-old in a nursing home’. So what do you say if that 95-year-old has a hip fracture or stroke that can impair their quality of life. It’s often not black and white.” “When we started work we were quite concerned that there needed to be more high quality data. Dr Doron Garfinkel published uncontrolled work in a palliative population, which showed that if you withdrew people’s medicine you could increase survival.” “We started with this data because it had a large magnitude of effect – 50% increase of survival in the course of the study but it was uncontrolled and we were sceptical about that. But going through the work we do

see positive results, anecdotally people feel better.” “Kathleen’s study had only about 100 people and was not powered for mortality, but there did not seem to be any harm indicated. We are starting to feel more positively that if you reduce the burden of people’s medicine, they might actually feel better and live longer. It’s a tantalising possibility.” Ageing in the home While this research is focused on aged care facilities, people are ageing in their own homes longer and more effectively. “The conversation with a lot of our patients is around risk and asking the question, what is the worst that can happen? We need to explore the person’s tolerance for that risk because we know that there are a lot of challenges in residential care too with the heavy burden of falls and infection.” “We are often saying to people, the difference is not always comparing living in a structure environment with living at home. It’s about support. We need to make the risk explicit and have clear conversations with the person and their family. We have a responsibility to exhaust all the options.” “We are so fortunate that we have extended lives to look forward to – we have to work to ensure they are not only longer but healthier lives.”

By Jan Hallam

Research is tricky “We thought it was important to do a larger, blinded study which we’re running currently called Optimed, but it’s a bit like pushing a boulder up a hill! It’s been hard to run and hard to recruit. We have about 200 in WA and less in NSW. It will be larger than our previous study but we’re not sure if we will get to our 500.” “However, we felt the blinded study was important because people bring a lot of bias when it comes to their medicine – both in terms of placebo and for those who believe their medicines are causing them problems. We know from the placebo controlled trials that people taking placebos get a lot of what they think a medicine should do. So it’s certainly not a straightforward story.” “We have tried to broaden the work. PhD student Amy Page has developed the Medication Appropriateness Tool for Comorbid Health conditions in Dementia (MATCH-D), which we will use to help determine to what extent improved medication management produces better health and functional outcomes for people living with dementia.” Chris and his team were awarded a $586,000 NHMRC grant in August for this work.

10 | DECEMBER 2017

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Deprescribing is no Easy Job

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DECEMBER 2017 | 11

FEATURE BACK TO CONTENTS

I Wonder If… In 2014, Bunbury orthopaedic surgeon Dr Neill Openshaw died suddenly. Last month his wife Anthea wrote to tell us about 13-year-old son Henry’s success in a writing competition for DonateLife. “As a family we made the decision to donate Neill’s organs. As a 10-year-old at the time, dealing with losing a beloved father and being included in the decision to donate his organs, have had a huge and lasting impact on Henry. I told him about writing for the magazine and thought he had forgotten about it until he told me he had finished the story and would I like to read it. I think it is a beautiful tribute to Neill, not as an orthopaedic surgeon but as a Dad who is so incredibly missed. Feel free to use it, both for Neill and to promote organ donation.”

Dr Neill Openshaw

Nearly four years ago, when I was just ten years old, my father died and we made the decision to donate his organs. Many say that when someone receives another’s organs they may take on characteristics that person used to have, so…

at their local beach. Do they now take their beloved dog down there with them and endlessly throw sticks and balls for them and talk to them as a best mate?

I wonder if…

My Dad’s kidneys have made them love the rush of driving faster and faster as the landscape outside their windscreen goes by in a blur. Are they now obsessed with cars and do they dream of one day building a Shelby Cobra with their son?

My Dad’s lungs made them live and breathe rugby and passionately support the Wallabies and the Force. Maybe they scoff and cough at the sight of the British Lions or the All Blacks, or they now constantly debate how much better rugby is than football. I wonder if… My Dad’s liver made them enjoy the sand on their feet and a cold beer in their hand as they watch the sun set over the ocean

I wonder if…

I wonder if they now love hamburgers, skiing, Cold Chisel, Doctor Who, Top Gear, Dunsborough, Kayaking, Coffee, Porridge, Travelling and Dallas. I wonder if… By Henry Openshaw

DonateLIFE November 19 was DonateLife Thank You Day to recognise organ and tissue donors and their families who have generously agreed to donate. Last year, Medical Forum polled WA doctors about opt-in/opt-out donor registration when renewing driver's licences and it was pretty evenly split – 45% opt-in 46% opt-out. There is a new registration process via the donatelife.gov.au website which makes it faster and easier to register. All those who register are urged to share the decision to donate with family and friends. • In 2016, a record 1713 Australians received transplants. • As at end September 2017, 1063 Australians had received a transplant

Henry Openshaw with his mother, Anthea, and sisters Emma and Charlotte at the winners’ presentation of the DonateLife writing competition.

12 | DECEMBER 2017

• Since January this year, more than 140,000 have joined the Australian Organ Donor Register taking the total to 1.063m people on the register.

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DECEMBER 2017 | 13

Feature

Living the Spirit of the Season Christmas can be an emotionally turbulent time, and even more so if life has dealt you more than your fair share of tough times. Medical Forum spoke with two people who help the homeless and the disadvantaged, Bev Lowe from Manna and James Shaw from Mission Australia. And, in both cases, their commitment to the vulnerable isn’t confined to December. John and Bev Lowe who run Manna helping to feed disadvantaged children and adults.

“I’ve been doing this for 60 years. I ran my first charity fete when I was 12 years-old and I’m still doing it,” said Bev Lowe who founded Manna with her husband, John. “It was more than 20 years ago when John and I were driving past a park in Newcastle Street in the city on a cold, wet night and we saw a group of people huddled under some trees sheltering from the rain. We went past five hours later they were still there so I said to John, ‘let’s go home and make them some soup’. We took it back, had a chat with them and realised there was no one looking after these people at all.”

“We call them ‘our boys’ and, for many of them, Christmas is sad and lonely. It’s not a great time to be homeless, and it’s the same on Father’s Day, too.” “We’re now doing nearly 400 Christmas hampers with everything from basic food items to a toilet pack. Many of these people spend time in hospital, so it’s nice for them to have toiletries they don’t feel ashamed of. We put a small gift in the pack, too.” “The women who find themselves in these situations seem to cope a bit better. They’re

“We do a lot of different things, ‘cradle to the grave’ I call it. But it didn’t start that way. All I wanted to do was make sure the soup was so thick that the spoon floated on top!” “We were getting reports from teachers that some children were coming to school hungry so we decided to do something about that as well. Before we knew it we were providing around 3000 breakfasts at 22 different schools. Even that’s morphed into morning teas and lunches! Our society isn’t a village anymore, people slip through the cracks and families are struggling.”

Manna helps anyone and everyone but, as Bev points out, there’s one particular group that needs it most of all. Isolated and lonely

14 | DECEMBER 2017

Manna offers a wide range of services, everything from programs such as Hot Healthy Meals, School Breakfasts, School Uniform Packs and Lunches for the Elderly.

Support for hungry kids

“So we started a once-a-week meal service and Manna has evolved from there. It’s really all about trying to make the world a better place.”

“Most of our clients are men and the vast majority have mental and physical health problems. They’re isolated and they feel the world has no place for them. What we do means a lot more than just handing out a meal because it makes them realise that someone actually cares about them.”

a lot more comfortable saying, ‘I’m in a mess and I need help.’ There are some we’ve seen right from the time they were babies in prams and they’re adults now. We’re their family, in so many different ways.”

“When times get tough we’re all too busy, sadly.” “It’s all too common to see a family slip from living in a comfortable home to sleeping in their car. An increasing number of seniors are finding it tough, too.” A typical Manna spread.

“These really are the forgotten people.”

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Manna is born

Feature

Mission Australia's annual Christmas Lunch in the Park brings some happiness when its needed most.

Mission Australia The annual Christmas Lunch in the Park is the longest running community event in Australia and it won’t be long before Jingle Bells will be ringing through the trees in Wellington Square.

with all sorts of family tensions rising to the surface and that’s not easy for people who are already highly vulnerable.” “We always place one volunteer as a ‘table host’ who sits with eight or nine guests and

Mission Australia covers a lot of bases with a strong focus on the mentally ill.

“Mission Australia has been doing this since 1975, that’s 42 years and more than 60,000 festive lunches handed out to those in need,” said James Shaw.

People doing it tough “It’s a pretty tough economy out there right now and that’s not helping when it comes to mental illness. We have services that are specifically designed to help with this problem, and with a particular focus on young people. We’ve got support in place in the Pilbara, towns such as Karratha and South Hedland, so we’re not just in the metropolitan area.”

“We’ve got a particular focus on those most in need and we’re working closely with our referral partners and community support agencies such as Ruah and Anglicare. It’s so important that people who use these services know about this annual event!” Feeding the thousands “We reckon we’ll have about 12-15,000 people this year supported by 250 volunteers and that makes it a pretty big logistical exercise. The whole thing is built from the ground up just for the day and it’s not just all about the food. We distribute more than 1500 care packs containing basic toiletries and there’s gift-wrapped presents for everyone, too.” “I worked as a volunteer at Lunch in the Park before I joined Mission Australia and the shared companionship is a wonderful thing. Christmas can be a notoriously tricky time MEDICAL FORUM

you hear some very human stories. And it’s important to remember that these are people who would probably be on their own on Christmas Day and, in some cases, not eating anything at all. That’s a pretty emotional thing in itself.”

“We also plan to make a significant effort in the area of social housing, which is an area of great need.” “Mission Australia is very appreciative of the wonderful work done by GPs. They’re on the ‘frontline’ of these social issues and it’s important they know we can provide services that support both them and their patients.”

By Peter McClelland It wouldn't be Christmas without him!

ED: www.manna.org.au and www.missionaustralia.com.au

DECEMBER 2017 | 15

The best of health for the festive season

The Executive, Management and Staff at Ramsay Health Care WA would like to thank our Specialists, referring Doctors and all of the medical community for their invaluable support throughout the year. We wish you all a safe and happy festive season and a prosperous 2018.

Attadale Rehabilitation Hospital

16 | DECEMBER 2017

Glengarry Private Hospital

Hollywood Private Hospital

Joondalup Health Campus

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FEATURE BACK TO CONTENTS

Communicating after Stroke Stroke can rob a person not only of their physical capabilities but also speech. Researchers are looking at ways to restore that important lifeline. When Medical Forum spoke to speech pathologist and clinical director of the Very Early aphasia Rehabilitation after StrokE (VERSE) trial, ECU’s A/Prof Erin Godecke, there were only 26 participants left in the three-year study. VERSE is seeking to establish if speech rehabilitation begun within 15 days of a stroke occurring, and continued over four weeks, improves communication outcomes for those diagnosed with moderate to severe aphasia. “We wanted to test if rehabilitation started this early makes use of the high levels of proteins which occur in the brain as part of its natural recovery after stroke. In rat models and human motor models we have seen benefit starting treatment within that timeframe but there is nothing in aphasia that mimics that.”

“In that early recovery stage, we are focusing on harnessing successful A/Prof Erin Godecke communications via a hierarchy of strategies without practising errors. There is a strong principle in neuroplasticity that if you want something done the right way on the right pathway, that pathway needs to be strengthened – and that’s true for motor, speech or action.”

• The cost-effectiveness of aphasia therapy in the long term. The research could lead to the development of the first prescribed therapy package for people with aphasia following stroke. “VERSE is exploring the relationship between aphasia and stroke brain recovery patterns by using a novel ‘brain mapping’ technique to help identify people who will respond well to early, intensive treatment,” Erin said. In the November issue we examined the role of telehealth in the delivery of stroke care in rural and remote areas where it is starting to bridge some gaps, not only in acute care but also rehabilitation. But there is still a lot of work to be done before there’s treatment equity in the regions. Erin said telehealth was extremely useful for some therapeutic interventions and didn’t require very hi-tech solutions. Tech beats distance “Rehab therapy can be delivered over Skype or Zoom using the person’s own device. It’s more approachable for the person in recovery and less expensive in terms of what it needs to drive it but satisfactory for outcomes.”

“Speech and language therapy lends itself beautifully to telehealth and is proving to be a boon for people who might otherwise struggle to access interventions.” Research in the UK was showing how virtual reality technology was helping to break down the isolation people with aphasia often felt. With impaired mobility, communication difficulties and in some cases geographical remoteness, a physical support group may not be easy to access. EVA Park is a virtual meeting space that gives participants a chance to meet each other and practise speaking with support staff input. “People-to-people contact is a vital element in rehabilitation and sometimes that’s overlooked by clinicians but often it’s what people who are in trouble want. Communication with partners, family and friends is frequently the No.1 priority of people whose speech has been affected by stroke,” she said. “Programs like this are really motivating for people with aphasia. It shows them that they can communicate successfully and use skills developed in recovery and rehab in their lives … that’s the stuff I’m really passionate about.”

By Jan Hallam

Difference detected “The data has not been analysed yet but our VERSE therapists and usual care therapists are anecdotally reporting a strong belief that early intervention works.” “The jury is still out on that but their response is that those people on VERSE trial are different. We just can’t work out how they are different yet. I hope we will start to see that difference manifested in people’s everyday communication.” The research is funded by the NHMRC and the Tavistock Trust for Aphasia in the UK and is a collaboration of clinicians from ECU, UTS, St Vincent’s Health Australia, Curtin University, La Trobe University, University of Arizona, the Florey Institute, UWA and Monash University at 16 acute care sites in Australia and New Zealand. The VERSE project aims to determine: • The optimal amount and type of aphasia intervention • The relationship between early aphasia therapy and depression • The effect of early, intensive aphasia therapy and quality of life at six months after recovery

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A scene from EVA-Park, the virtual meeting place for people with speech difficulties.

DECEMBER 2017 | 17

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Guest column BACK TO CONTENTS

Chronic Pain and Medicinal Marijuana Blue sky vs limited data, limited benefits, known harms and unknown pharmacokinetics – pain specialists Dr Stephanie Davies and Dr Max Majedi urge evidence before prescribing. Our concern over the rush and push for Medicinal Marijuana (MM) (Inside WA’s Cannabis Story, November) is that investors discuss the blue sky potential benefits without discussion of the negatives. As a profession we’ve seen the effects of other industries that ignored or released selective information on potential harms, the tobacco industry for one, Purdue Pharma another.

MM is outdated for treatment of chronic non-cancer pain…and has significant harms, such as inability to drive, to work, reduction of ability to function, and medium-to-long term potential harms to mental health disorders and addiction. in a total of ~6000 patients. These include eight clinical trials for nerve entrapment.

The aim of pain management is to improve pain and function – to give a patient the pain-reduced freedom to do what they want to do. The reduction in the use of opioids for chronic non-cancer pain is due to the lack of benefit over the short-to-medium term, and the significant harms. It is also because we have many more better pain options than we had 20 years ago. MM is outdated for treatment of chronic non-cancer pain (CNCP) and has significant harms, such as inability to drive, to work, reduction of ability to function, and mediumto-long term potential harms to mental health disorders and addiction. We now have a wide range of behavioural and low-risk medical options that are cheap, accessible, evidence-based and can be matched to the individual’s pain condition(s). Good physiotherapy, OT, psychology interventions, combined with interventional pain procedures are options for many people with spinal, regional, joint, or widespread pain(s). More options available Excitingly, two novel low-risk compounds are available, both of which are emerging as having additional CBD receptor actions without the harms of MM. They have minimal side-effects, are non-addictive, cheap, and available from compounding chemists today. We have used them in our clinical practice since 2015. Specifically, we are talking about palmitoylethanolamide (PEA) and low-dose naltrexone (LDN), which are glial modulators (important in neuropathic and plastic pain), and reduce inflammation (important in inflammatory pain). PEA is a naturally occurring anandamide in food, it is an endogenous lipid modulator in animals and humans, and has been evaluated since the 1970s as an anti-inflammatory and analgesic drug in more than 30 clinical trials,

MEDICAL FORUM

In one pivotal, double blind, placebo controlled trial in 636 sciatic pain patients, the number needed to treat (NNT) to reach 50% pain reduction compared to placebo was NNT=1.5 after three weeks of treatment. This

emerging evidence is of interest as no drug interactions or troublesome side effects have been described so far. LDN improves symptoms in fibromyalgia (NNT=5), Crohn's disease, multiple sclerosis,complex regional pain syndrome, and insomnia. LDN works as an antiinflammatory agent in the central nervous system, via action on microglial cells. These effects may be unique to low dosages of naltrexone and are independent from naltrexone's activity on opioid receptors. These both fit the bill of a cannabinoid-like option (not called cannabis because they aren't as the CEO of AusCann was hoping for). In addition, they do not interfere with driving (patients can't drive for about eight hours (no clear data) after having medical cannabis), don't increase mental health disorders, and don't require state or federal processes. continued on Page 21

Faculty of Pain Medicine Summary on MM (2015) With respect to the use of cannabinoids in patients with chronic non-cancer pain: 1. The Faculty of Pain Medicine (FPM) acknowledges the reality of the widespread, uncontrolled and unlawful use of cannabis preparations in the Australian and New Zealand communities. 2. Such use is primarily for recreational purposes. 3. * In Australia, there is no regulatory framework for medicinal cannabis or cannabinoid use. In New Zealand, there is a framework for the prescription of nabiximols (Sativex) in multiple sclerosis. Both cannabis possession and use are illegal in both countries. 4. FPM does not take a stance on the issue of decriminalisation of personal use of cannabis preparations. 5. FPM considers that calls for the liberalisation of the availability of cannabinoids as medicines are based more on anecdote than on sound clinical science and practice. 6. FPM is very concerned about the adverse event profile in cannabis users, especially in young people, including impaired respiratory function, psychotic symptoms and disorders, and cognitive impairment. 7. FPM adheres to the principle that substances intended for therapeutic purposes be fully characterised chemically, pharmacologically and toxicologically.

9. The sociopsychobiomedical conceptual framework that informs the assessment and management of people with chronic non-cancer pain requires active engagement of patients in multimodal management programs, and recognises the adverse effects on this that may be associated with polypharmacy in general and with cannabinoids in particular. 10. FPM does not recognise a need for greater availability of medicines in general and in particular does not endorse the use of cannabinoids in chronic non-cancer pain until such time as a clear therapeutic role for them is identified in the scientific literature. 11. With the possible exception of pain and spasticity in multiple sclerosis, there is little evidence for the effectiveness of cannabinoids in chronic non-cancer pain situations, whether or not the pain attracts the descriptor “neuropathic”. 12. FPM recognises the difficulties inherent in performing trials of any medication in patients with chronic non-cancer pain. Nonetheless FPM believes that trials of cannabinoids are necessary and should be conducted on a coordinated national basis, by highly credentialed persons and within strict parameters. ED: *Legislation has since been enacted which does regulate the manufacture and prescribing of medicinal cannabis (see November edition).

8. FPM does not support off-label or nonapproved prescription of cannabinoid products.

DECEMBER 2017 | 19

Guest column

continued from Page 19

Chronic Pain and Medicinal Marijuana Benefit:Risk inadequate We have both attended several Faculty of Pain Medicine (FPM) roundtable discussions and in WA with key stakeholders. The overwhelming medical view is that data of the risk-benefit ratio in the use of MM for CNCP is lacking. The gap is not that doctors ‘need to get with the program’; the issue is the cart is before the horse. A 2015 systematic review (Deshpande A) where five of six randomised controlled studies using smoked or vapourised cannabinoids (non-synthetic) as an adjunct to other agents including opioids for neuropathic pain (the sixth was for MS). The study duration was up to five days and all studies lacked adequate masking of the active treatment (possible reporting bias). The NNT to reach 30% pain reduction compared to placebo was NNT=4 after five days of treatment. All trials excluded individuals with a history of psychotic disorders and previous history of cannabis abuse or dependence. Each study found statistically significant pain reduction with cannabinoid use. However,

Long-term uncertainties

The overwhelming medical view is that data of the risk-benefit ratio in the use of MM for CNCP is lacking. The gap is not that doctors ‘need to get with the program’; the issue is the cart is before the horse. physical function did not improve or was not reported. Adverse events included psychosis, psychiatric issues, increased heart rate, impaired learning and memory. Concern exists about mental health, especially in youth or people with concurrent mental health conditions, which are more common in people attending pain clinics than mental health clinics. A greater proportion of individuals with persistent pain develop mental health clinical syndromes (generalised anxiety disorder, somatisation disorder, and major depressive disorder) and that the prevalence of these disorders was significantly higher (55%) than those in a matched control group (24%). Studies have also reported an increased prevalence of Borderline Personality Disorder in people with persistent pain (30%) compared to those admitted to psychiatric services (20%).

A recent meta-analysis raised concerns that long-term cannabis use may cause neurotoxicity especially in brain areas enriched with cannabinoid receptors such as the hippocampus. We agree with Zelda Therapeutics and Little Green Pharma that if MM is to be trialled by patients in Australia for pain, then this should be within targeted research projects. These would then provide data to determine if there is a subset of patients that may benefit after all the lower risk options have been trialled. These trials would need to reflect the proposed use, and not be limited to the short five-day trials that have been done on MM in the past. The Faculty of Pain Medicine (FPM) has a position statement on the use of cannabinoids in patients with chronic non-cancer pain. http://fpm.anzca.edu.au/ documents/pm10-april-2015.pdf . We strongly recommend it be read in full, including the references. ED: Full references available. A table summarising the FPM's position is on P19.

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MEDICAL FORUM

6/10/2017 2:14:46 PM

DECEMBER 2017 | 21

Fertility, Gynaecology and Endometriosis Treatment Clinic

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www.fertilitynorth.com.au

Fertility, Gynaecology and Endometriosis Treatment Clinic 22 | DECEMBER 2017

MEDICAL FORUM

Medicolegal BACK TO CONTENTS

Public Interest and the National Law The Medical Board under new powers, can take action if it deems it is in the ‘public interest’. Avant WA senior solicitor Morag Smith explores this development. Doctors may recall that in 2014 Mr Kim Snowball conducted an independent review of the Health Practitioner Regulation National Law. His final report made a range of recommendations, some of which were aimed at strengthening the management of health complaints to better protect the public. Health Ministers around the country accepted most of the recommendations and they will be introduced in two stages. Stage one amendments were passed by the Queensland parliament on September 6, 2016, and most jurisdictions have followed. The West Australian parliament is in the process of adopting the amendments. One of the key changes for doctors is an expansion of the immediate action powers. Previously the test was whether a practitioner posed ‘a serious risk’ to public health or safety. Now, in addition to this ground, the Medical Board can take immediate action where it is ‘in the public interest’ to do so. The notion of ‘public interest’ is not defined and the profession is justifiably concerned about how this will be interpreted. In NSW, which has a similar provision, the power is starting to be used as a matter of routine rather than in exceptional and urgent circumstances. One case that demonstrates how the power to protect the public interest can be used is Crickitt v Medical Council of NSW. Dr Crickitt was suspended on the grounds of ‘public interest’ after he was charged with the murder of his then wife. At the time of the suspension there was no evidence that Dr Crickitt posed a clinical risk to any person. When this decision was considered by the NSW Civil and Administrative Tribunal, members found that in addition to the need to protect the health and safety of the public generally, the concept of ‘public interest’ could extend to matters that affected the ‘honour and integrity of the profession generally’. The examples relied on included conviction of a serious crime and failing to lodge taxation returns over a long period of time. By way of further explanation, the Tribunal said that ‘public interest’ extended to the need for patients to have confidence in their doctors, also that patients expected medical practitioners to exhibit integrity, trustworthiness and high moral and ethical values.

Have you ever considered working in the Kimberley?

WA Country Health Service is seeking General Practitioners with current skills in Emergency Medicine, Obstetrics or Anaesthetics for long term employment opportunities in Kununurra, Derby, Fitzroy Crossing and Halls Creek. Suitable applicants for non-procedural positions will have extensive generalist experience, and be able to demonstrate significant emergency department and primary health care knowledge and skills. Applicants for procedural positions must hold a formal qualification in obstetrics or anaesthetics and able to practice without clinical supervision in the relevant specialist area. Suitable candidates must hold Fellowship of the Australian College of Rural and Remote Medicine (FACRRM) or the Royal Australian College of General Practice (FRACGP). Appointment to ‘District Medical Officer’ positions is based on skills and experience with a minimum requirement of 12 years experience in a general practice environment. The ability to practice independently is essential and previous experience working in rural hospital setting is desirable. Further information, contact people and remuneration packages for our current vacancies are available at: www.wacountry.health.wa.gov.au/index.php?id=552 or search ‘WACHS internet medical’

The National Law has always referred to the need to protect the public and to consider the public interest when taking regulatory action. In NSW where the concept of ‘public interest’ has been in use for some time, a legal practice note published in March 2017 may provide some comfort. This acknowledges that the ‘public interest’ is often met by imposing protective measures, for example conditions. If there is a concern that conditions will not meet the expectations of the public, those relevant public interest considerations should be identified and judged with due weight given to each consideration. Each case that comes before the Tribunal will involve different considerations of what is in the public interest and, over time, guidance will be given. Until then, the legal practice note from NSW is a good reference guide on how this power should be exercised. References on request

MEDICAL FORUM

The Kimberley. Put yourself in the picture.

DECEMBER 2017 | 23

··•·••·•··

Season’s Greetings We wish all our referring doctors a happy and safe festive season. Thank you for your support this year. We look forward to caring for your patients in 2018.

Leaders in Medical Imaging www.perthradclinic.com.au

guest column BACK TO CONTENTS

In the Land of the Sunbakers Dr Rohan Gay wonders where general practice dermatology fits into the scheme of things, and wants to do better. I love a sunburnt country, A land of sweeping plains, Of ragged mountain ranges, Of droughts and flooding rains. I love her far horizons, I love her jewel-sea, Her beauty and her terror The wide brown land for me! This poem by Dorothea Mackeller is emblematic of fair skinned people in the harsh environment of Australia – a cultural and biological experiment that has seen rates of skin cancer far exceed those in other countries. Australia and New Zealand have over double the rate of melanoma than the next country in order of incidence. The Curriculum for Australian General Practice 2016, says skin conditions in general “account for 15.9 out of every 100 patient encounters in general practice, and 11.3% of the total reasons for encounters” – common problem in Australian general practice. As a GP Supervisor I am constantly dismayed at the lack of dermatology skills in registrars who cite dermatology as the greatest deficiency of undergraduate, internship and

residency training (along with ophthalmology, non-operative orthopaedics and sports medicine). I have not done any formal training in dermatology but nor had I in other GP staples such as cardiology, respiratory, gastroenterology or urology, all soundly imparted in my undergraduate, internship and residency years. I received a good grounding in skin cancer during two resident terms in plastic surgery and spent a good deal of personal study filling in dermatology gaps in my knowledge. I certainly have not completed the 25 modules for the Certificate of Primary Care Dermatology costing $11,740. As a GP I am repeatedly frustrated by difficulty accessing dermatology services. Recently, a mother reported a seven-month wait for a paediatric dermatologist, and many patients complain of the unaffordability of dermatologist care for their chronic skin conditions. Public review is usually out of the question. The Australian College of Dermatology website reveals a single PTE training entry for WA in 2017 (compared with 11 adult cardiology and two paediatric cardiology places in WA).

The void in specialist skin cancer management has been filled by the proliferation of skin cancer clinics. Some of their treatment is good but some is not. The rub is that most care of my patients in such clinics is unknown to me. Skin cancer clinics exist in a parallel medical universe often with in-house pathology and proprietary diagnostic equipment. Skin clinic doctors do not require referral or to correspond with a patient’s true primary care physician. The only non-solicited correspondence from such clinics I have received in 12 years was a couple of instances in which permission was sought to refer patients of mine for specialist review. I refused, How can someone who has reviewed a patient’s skin reliably fulfil the primary physician’s role and integrate their dermatological condition into their overall medical management? Surely, we can do better. Surely, we should be leading the world in management of skin conditions in a manner integrated with our management of whole patients.

smithcoffey

MEDICAL FORUM

DECEMBER 2017 | 25

APP REVIEW

Asbestos Containing Material (ACM) Check Clinical Usefulness

Depends on Patient Type

Ease of Use Review by Dr Leanne Heredia It’s purpose Developed by Curtin University researchers, the app’s aim is to help identify asbestos containing materials in and around a household. (Research data is collected to estimate how many WA houses contain asbestos, in what form and condition.) The app could benefit users assessing their current living environment, renovating an older property or assessing the safety of a future property.

obtained as part of the questionnaire at either the start or the finish. • Descriptors aim to improve the accuracy of users’ assessments but could be more succinct. • The data collected and end report relies entirely on the user being able to accurately identify features in their home. The “overall condition” of any material bases itself on a subjective score of 1-10. Observer error may be a problem in reporting.

Details Free (no in-App purchases).15.9MB. For android or iPhone and other portable devices. No internet (wifi or inflight mode) connection required. Use Users are guided through a property inspection in 5-20 minutes using a simple multiple choice questionnaire. Visually ACM Check lacks lustre but the app is user friendly and gets the job done. Summary: Pluses: • Users can opt-out of sharing their data with Curtin University and are under no obligation to contribute to research. • Photos and visual aids make it easier for users to answer questions • When ranking the condition of a material and the likelihood of a material being disturbed, descriptors are provided to improve the accuracy of an assessment. • An instant report is provided showing the probability of asbestos exposure

– materials containing asbestos, their condition, the potential for disturbance¬ and urgency for action. • Report can be exported immediately as a pdf to an email, communication app (e.g. watsapp) contact, or the Notes section in your phone. • Provides a link to a list of unrestricted asbestos removal licence-holders in WA • Provides links to external resources on history of asbestos; medical implications; and support groups for those affected. • A opportunity for feedback to review and continuously improve the app.

• While this app says asbestos exposure poses health risks, it fails to capture the seriousness (lung disease and mesothelioma not mentioned) leaving users to use external links to access asbestos exposure health risks. • Although open for use in all states the app is only validated for assessing homes inside WA. Conclusion: The ACM Check App adequately screens houses for potentially risky asbestos material and serves its purpose of identifying any red flags. However, validity is limited to WA homes and its accuracy is user dependent. It would benefit from a visual makeover to ensure its user-friendliness. Someone with experience in this field, such as a builder, might find this app particularly useful. Further questions to matthew.govorko@curtin.edu.au.

Minuses: • The opt-out toggle for research should be made obvious and perhaps consent

Hepatitis E-Learning Resources for GPs Want to know more about the new hepatitis C treatments? Edith Cowan University (ECU) and the Department of Health, WA have developed FREE online hepatitis C and hepatitis B education programs for general practitioners, nurses and other health professionals. The programs have been approved by the RACGP QI & CPD program for 40 category 1 points. Explore the learning programs at hepatitis.ecu.edu.au or for further information email hepatitis@ecu.edu.au

I Systems & Intervention Research Centre for Health

2610864997_185x90_HEPATITIS_Press_V2.indd | DECEMBER 2017

11/9/17 5:37 PM MEDICAL FORUM

BACK TO CONTENTS

2017 Christmas Feature

Seasonâ&#x20AC;&#x2122;s greetings from WA Health Professionals Medical Forum wishes all our readers and supporters a Merry Christmas and a Happy New Year

MEDICAL FORUM

DECEMBER 2017 | 27

Christmas Greetings Feature

Professor John Yovich and the team at PIVET wish all our colleagues and friends a very happy festive season. We thank you sincerely for your continued support and look forward to working together again in 2018.

There's nothing sadder in this world than to awake Christmas morning and not be a child. 08 9422 5400 | www.pivet.com.au

Erma Bombeck

Merry Christmas & Best Wishes for a Happy, Healthy & Prosperous 2018. We thank you for your support this year and look forward to continue delivering high quality service to you and your patients in 2018.

28 | DECEMBER 2017

MEDICAL FORUM

Christmas Greetings Feature

My Christmas wish . . . It is no secret that Australians enjoy a glass of beer or wine from time to time, especially at this time of year. The vast majority of us enjoy alcohol in moderation and we do so safely. I wish you the happiest of festive seasons and encourage you to celebrate appropriately. However, I remain concerned about the public health risks associated with excessive consumption of alcohol, and I’d like to see debate about reducing alcohol-related harm in our community. In 2014, one person was hospitalised for an alcohol-attributable condition every 27 minutes, leading to the use of 113,500 hospital bed days. Earlier this year, I asked the Mental Health Commission and the Department of Health to do some work on the possibility of setting a minimum floor price for alcohol. Bottles of wine are being sold for less than $3, and you can get a standard drink for less than 40c. The time has come for us to take a look at the impact cheap alcohol is having on our community. A minimum price on alcohol has been long debated elsewhere – and regardless of outcome – I believe it’s a debate we need to have.

Roger Cook

Thanks for being part of the team in 2017. See you on the road next year.

MEDICAL FORUM

DECEMBER 2017 | 29

Christmas Greetings Feature

My Christmas wish . . . Wouldn’t it be great if allied health was empowered to truly manage chronic disease in the community? Then patients could truly have a ‘Health Care’ home. At the recent announcement of yet another regionally based chronic disease program – diabetes this time, but it could just as easily have been COPD, heart failure or asthma – I reflected on the numerous previous programs that have fallen over at the end of their funding cycle. How many physios, dietitians, exercise physiologists will my patients have to negotiate to avail themselves of a new service that doesn’t know them from a bar of soap? I’d restrict funding for the delivery of chronic disease allied health services to true, local community-based services. Local allied health providers have proven their sustainability in a largely non-subsidised environment and our patients develop close relationships with the entire local health team.

Thankyou for your continued support throughout 2017. We wish you all a very joyful festive season.

The only role for centralised bodies should be developing, publishing and overseeing chronic disease programs that are delivered at a local level.

Warmest wishes Dr Peter Hugo, Dr Aparna Baruah & staff

Dr Rohan Gay, GP, Bayswater

heartcarewa.com.au The Cardiologists and Staff would like to wish you and your family a safe, joyous festive season and a very happy new year.

We thank you for your continued support throughout the year and look forward to working with you and continuing to provide high quality care to your patients in 2018.

Dr Stefan Buchholz Dr Randall Hendriks Dr Mark Ireland Dr Ben King

30 | DECEMBER 2017

Dr Donald Latchem Dr Allison Morton Dr Mark Nidorf Dr Vince Paul

Dr Peter Purnell Dr Pradyot Saklani Dr Nigel Sinclair Dr Isabel Tan

Dr Angus Thompson Dr Peter Thompson Dr Alan Whelan Dr Xiao-Fang Xu

MEDICAL FORUM

Christmas Greetings Feature

My Christmas wish . . . In the words of Whitney Houston “I believe the children are our future, teach them well and let them lead the way”.

Wouldn’t it be fantastic if this year Santa Claus brought two things for WA children that would lead to their better health as children and adults? • “No drop off” zones around schools to ensure every able bodied child must walk at least 500m to and from the school gates every day • Compulsory food shopping and food preparation courses designed at teaching children to buy and prepare simple, healthy, flavourful and inexpensive food using basic ingredients Two great ways to help prevent obesity in later life.

Dr Mini Zachariah To all my referring doctors and colleagues, wishing you a Merry Christmas and a safe and Happy New Year. Thank you for your continued support and I look forward to working with you in 2018. Warmest wishes Mini

And, if I could get a third wish, I’d wish that the State Government went back to the excellent Reid Report and moved more funding for hospital care out of old, tired institutions in the city and out to bright new institutions in the suburbs, where the people live. The Government required bidders for the Midland Public Hospital contract to show how by 2020 (only two years from now!) they would grow public services on site from 307 beds to 460 beds so as to increase to 75% the proportion of patients in the catchment who could be treated locally. Come on Santa, bring us the final implementation of the Reid Report!

Dr Michael Stanford Group CEO, SJGHC

Seasons greetings and a warm thank you to all for your support throughout 2017, from Mark Hamlin, Joel Scaddan, Arun Abraham, Rachit Harjai, Victor Wang and associates.

MEDICAL FORUM

DECEMBER 2017 | 31

Christmas Greetings Feature

I stopped believing in Santa Claus when I was six. Mother took me to see him in a department store and he asked for my autograph. Clinic closed from from 24/12/2015 04/01/2016 Clinic willwill bebeclosed 23/12/2017– to 02/01/2018

Shirley Temple

On behalf of WA Country Health Service, I would like to extend my thanks to all country doctors and staff working in our facilities across the State. Together you are part of a highly skilled workforce committed to providing our communities with the best possible healthcare. It is the season to reflect on our success. With approximately 972,000 outpatient appointments and more than 139,000 acute hospital admissions this year, it’s been a particularly busy year for our country hospitals and health services. In 2016/17, there were 4692 births in country hospitals, which is almost 80 per cent as many as the State’s major maternity centre, King Edward Memorial Hospital. Overall, WACHS sees around 30 per cent of WA’s emergency presentations and on any given day, more than 1050 people are treated by our dedicated staff in major country emergency departments. None of this would have been possible without the dedication and commitment of our doctors and staff. Despite the challenges of vast distances, our staff excel in providing healthcare to the communities we live and work in. I’d like to take the opportunity to thank you for your contribution this year. May you and your families have a safe and happy Christmas. WACHS Chief Executive, Jeff Moffet

32 | DECEMBER 2017

MEDICAL FORUM

Christmas Greetings Feature

My Christmas wish . . . Iâ&#x20AC;&#x2122;d really hope to change the health inequity in our remote Aboriginal communities where chronic health conditions occur at levels equal to the most deprived Third World countries. Overcrowded housing and linked social issues cause skin and throat infections in children that predispose them to rheumatic fever and the potential development of rheumatic heart disease. Sufferers carry this disease burden into their adult lives, which jeopardises pregnancy and many other health issues. And it doesnâ&#x20AC;&#x2122;t stop there, either. Secondary prevention involves painful penicillin injections delivered every month by IMI injection. Vaccination against Group A Streptococcus and more acceptable secondary prevention options have been flagged, which is encouraging. But, at its core, prevention of a disease largely caused by overcrowding and poverty could be achieved by educating affected communities and by implementing innovative housing solutions.

Dr Clare Willix, GP, South West Aboriginal Medical Service Coordinator, Bunbury

A warm and sincere thank you to all our referring GP and Specialist colleagues. It has been a pleasure working with you this year. We look forward to continuing to work with you during 2018. Wishing you and your family a very Happy Christmas and safe and joyous New Year.

Prof Luc Delriviere & staff at The Liver Centre WA

Dr Phil Daborn A special thank you to all my referring colleagues for your continued support throughout 2017. Wishing you & your families a joyful festive season, and all the very best for 2018.

P (08) 6163 2800 F (08) 6163 2809 www.thelivercentrewa.com.au

MEDICAL FORUM

DECEMBER 2017 | 33

Christmas Greetings Feature

My Christmas wish . . . I would encourage people in the Western Australian community to ‘start moving more’ as regular exercise is essential to maintaining good physical and mental health. We know greater numbers of individuals are riding bikes to and from work or for enjoyment. Cycling is a great way of exercising while decreasing congestion on our roads and benefiting the environment. To encourage this growing community interest I’d further enhance Western Australia’s cycling infrastructure in metropolitan and regional areas, and encourage organisations to introduce end-of-trip facilities for their employees. We need to make it as easy and convenient as possible for people to make the switch from the car to the bike. I would also introduce school programs aimed at encouraging children to ride their bikes to school safely. In addition, I’d create incentives which motivate people to catch public transport. Walking from your house to the bus, train, or ferry, is an easy way to get some incidental exercise and is another initiative we should promote among children and adults.

Kevin Cass-Ryall, Operations Executive Manager – WA and SA Hospitals, Ramsay Health Care

Dr John Teasdale and the Team at WA Vascular Centre would like to wish you a very Merry Christmas and a Happy New Year. Santa offers free Arterial Blood Flow Doppler and Duplex Tests for diagnosis of Leg Pain & Ulcers (with doctor’s referral) for all Dec 2017 & Jan 2018 We all look forward to working with you in 2018. Perth (Bassendean), Fremantle, Joondalup, Mandurah & Northam. Appointments: Tel: 9279 4333 www.wavascularcentre.com.au

34 | DECEMBER 2017

MEDICAL FORUM

Christmas Greetings Feature

Perth Breast and Thyroid Multidisciplinary Care

Dr Corinne Jones Specialist Breast and Endocrine Surgeon Thank you to friends and colleagues for your support throughout the year. Wishing you all a Christmas of good food and good cheer, and a busy and prosperous 2018.

My family know not to get me any tech for Christmas. I can never get it to work, and it all becomes very tearful and pressurised. Dr Who (Peter Capaldi)

Dr Arun and his team wish you a very Happy Holiday season and a peaceful and prosperous New Year. Thank you to all our referring GPs and specialist colleagues for your continued support in 2017 and look forward to providing Gynaecological services to your patients in 2018. Waikiki Specialist Centre 221 Wilmott Drive, Waikiki 6169 T 9550 0300 F 9592 9830 E specialists@waikikiprivatehospital.com www.doctorarun.com.au

MEDICAL FORUM

DECEMBER 2017 | 35

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CLINICAL UPDATE BACK TO CONTENTS

Travel advice? Here’s your printout For a family going to Bali (Table 1) the list is not entirely right or wrong. The software advice, which tries to cover every location in an enormous archipelago, as well as the medicolegal aspects of advice from the adviser, is overly prescriptive. The GP still needs to make an assessment of risk in the particular travellers sitting before them. The Yellow Fever (YF) advice requires the GP to know where the YF risk countries are. Will that particular child now under your desk be the one to get nipped by a monkey in Ubud? Perhaps just vaccinate them all for Japanese Encephalitis (JE) and rabies, to be on the safe side? But that will be $2000. Chemist loves you. Dad does not. Hepatitis A vaccine deserves priority because it is such a common food and water borne virus, we do not have effective treatment for it, and it can be fatal, especially in older travellers. The vaccine is safe, effective, inexpensive, and lifelong if boosted. Typhoid by comparison is a hundred-fold less common, more treatable, and the vaccine is less effective for a shorter time. Country advisories do tend to be littered with the remnants of past global health scares. Half of the Indonesia advisory is about Zika, reflecting the inflated pre-Olympic concern regarding this arbovirus. Table 1: Family of 4 going to a Bali Resort for a week (December)

By Dr Peter Burke Travel Medicine Nedlands

Most general practice software includes printable advice for travellers – a ‘value-added’ gift from the GP to the traveller. How appropriate is the advice, really?

Travellers are cautioned about the incredibly unlikely association of Zika with Guillian Barre, and the need to avoid bird flu by not drinking poultry blood. Endemic rabies was eradicated from Japan decades ago (see Table 2). Ditto polio. Japanese Encephalitis (JE) could be thought of as a ‘successful Japanese export’; it may have started there but has been all but eradicated through farm management, vector control and vaccination, which the Japanese developed. And the snow? Does season matter? Altitude? It certainly matters to the mozzies. Country advisories cannot take into account all such variables. But the GP, equipped with the most complex risk calculator known to man, is expected to. A general principle in travel medicine is to focus on the things that commonly go wrong. Start with the old ‘three Fs’ of travel medicine. Food and water illness. Flying things (mozzies etc.) And Flirtation (Travellers may underestimate STI risk overseas.) Vaccination is still important, of course. The most common vaccine preventable conditions? Flu. Hep. A. Hep. B. Measles. All of these are viral infections that we are poor at treating. We want our travellers to be, as the old fridge magnet said, alert but not alarmed. Bilharzia in Bali? Leishmaniasis in the ski fields of Japan? Why, there would be more chance of a volcano!

My advice

Software Advisory Indonesia

Avoid Bali Belly. Care with food, water, clean hands before eating.

ADT ‘if required’

Avoid Dengue. Repellent DEET. Permethrin.

Polio ‘if no previous’

Standby treatment for Bali Belly. Must be safe for kids. Must be clear instructions.

HepA ‘all durations'

Childhood vax all current incl MMR x2. DTPa current for all.

HepB ‘all durations’

HepA

Typhoid

JE ‘medium and long stay, rural’

Don’t go to that monkey park

Yellow Fever, ‘if travelling from risk country’

Rabies ‘all durations if exposed’

Don’t pat anything with teeth

JE ‘medium and long stay, rural’

Urgent doctor if bite / post-travel fever

Rabies ‘all durations if exposed’

HFM outbreak. Avian Flu. Dengue. Filariasis. Leishmaniasis. Plague.

Eat. Play. Swim. Enjoy trip.

Beware Zika. Chikungunya. Avian flu. Dengue. Filariasis. Plague. Schistosomiasis.

MEDICAL FORUM

Table 2: Couple going to Ski Resort in Japan (January) My advice

Software Advisory, Japan

DTPa check current

ADT ‘if required’

Travel Insurance (with orthopaedic cover!)

Polio ‘if no previous’

Flu (but N/A in Jan)

Flu

Thermals. Stretches. Enjoy trip.

HepB ‘all durations’

Author competing interests: nil relevant disclosures. Questions? Contact the author at pburke@ulyssesmedical.com

DECEMBER 2017 | 37

CLINICAL UPDATE

What do these problems have in common? Dengue, Chikungunya, Zika, bilharzia, altitude sickness, Hepatitis C, HIV and crashing a motor bike whilst drunk without a license, helmet or experience? Answer – no needle prevents these things. A doctor’s advice before departure and encouraging travellers in a group to look out for each other can often make a big difference. Travellers believe that vaccines will keep them well but there’s more to staying healthy overseas. In a sentence, ‘be careful what you choose to eat and drink, keep the mozzies off, wash your hands and don’t pat of feed anything with fur and teeth.’ Be careful what you choose to eat and drink Traveller’s diarrhoea is the commonest ailment a traveller will experience in a developing country. With drinks, its best to avoid the tap water if you’re not certain it’s safe. Freezing won’t make it safe either, so avoid ice, but boiling will. Bottles and cans of drink should be safe if you break the seal (to ensure someone hasn’t refilled it for you). There are now water bottles with inbuilt filters that can safely be refilled from taps overseas. It’s not always true that eating on the street is dangerous, whilst the hotel is safe. Often local street food is fresh, prepared to order and cooked in front of you in a hot wok or ladled out of a bubbling pot. Buffets in hotels have often been prepared hours before, are often not hot enough, and serving spoons get mixed and moved. Generally speaking, cooked food that’s still hot will be safer than raw food that’s been

handled and it’s better to peel or rinse fruit yourself before eating. Keep the mozzies off Dengue is becoming increasingly common in the tropics, together with other mosquito borne diseases such as Chikungunya and Zika. Aedes, the mosquito that spreads these diseases, lives in urban areas and bites by day, unlike anopheles that spreads malaria and lives mainly in rural areas and bites at night.

No one will thank the doctor for messing up someone’s holiday by not warning about protective behaviours (assuming advice is heeded)!

DEET based repellents are readily available and effective – 30- 40% DEET will prevent bites for 6-8 hours, yet are also safe to put on an infant (whereas 80% DEET repellent is potentially more toxic and not a lot more effective). Loose clothing is also a good idea but colour doesn’t make any difference. Treating clothing with permethrin does. Wash your hands People who return from holidays often come down with a viral URTI and usually blame the plane trip. However modern planes have laminar flow (air comes from the overhead vent and out through the floor), and air passes through a HEPA filter every few minutes, so it’s quite safe and clean. Most respiratory viruses are in fact picked up through contact with surfaces – people in airports cough, touch a hand rail or door handle, and soon after someone else touches the same surface, and then their own face. Alcohol hand sanitizers are a quick and safe way to reduce this risk, especially in busy places (but don’t carry more than 100ml onto a plane in hand luggage, and put it in a snap lock bag as cabin pressure changes can make it leak).

Don’t pat or feed the animals The vaccine course for rabies covers three shots over a month and costs about $300. Most travellers on short trips are at a low risk. However, many travellers don’t even know rabies is a risk overseas, so the 1-2 people with animal bites or scratches we treat every week would not have been bitten or scratched whilst away if they were more careful. Rabies is a risk in most of the world, potentially from any mammal’s bite or scratch, it’s virtually 100% fatal if untreated, and treatment can be hard to find and will disrupt your holiday. Dogs are by far the biggest cause. The motorbike etc. Most travellers appreciate the risk from infectious diseases in developing countries; however, many come to grief through accidents and trauma. If you don’t know how to ride a motorbike at home, you won’t overseas, where the roads are in poor condition and road rules often non-existent. Travellers often make impulsive, rash decisions when on holidays, away from the stresses and safeguards of home life, exacerbated by alcohol and other drugs. Exposure to STIs is included in this as well.

Author competing interests: nil relevant. Questions? Contact the author on 9336 6630

38 | DECEMBER 2017

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What vaccines don’t cover

By Dr Aidan Perse Travel Health Plus Fremantle

CLINICAL UPDATE BACK TO CONTENTS

Staying on top of TB

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

By Dr Justin Waring Medical Director WA Tuberculosis Control Program TB grumbles on - there isn't much in the community but missing important clues can be embarrassing. Thank goodness for the Anita Clayton Centre.

CLINICAL UPDATE

In 2016 there were 144 cases of tuberculosis (TB) notified in WA at a rate of 5.6 per 100 000 population. In a global context this is a low rate, but the disease persists. The diagnosis of TB is often delayed because it is uncommon and usually subacute in presentation. This leads to excess morbidity and potential transmission. How to not miss TB The following are useful “red flags” for when to consider TB: • Country of birth: 90% of TB cases were born in a country where TB is common. Other risks include a history of contact with TB, being Aboriginal and health care work. • Recent arrival: More than 50% of cases migrated to Australian within the last 5 years. • Chronic, indolent cough: Most TB is pulmonary (~60%) and presents with a cough that has lasted for more than 3 weeks. Sputum production is often not prominent and haemoptysis is only a late symptom. The second commonest presentation is cervical lymphadenopathy. • Chest x-ray infiltrate: A normal plain chest x-ray virtually always rules out pulmonary TB. Note: CT chest is not indicated if TB is suspected. It rarely adds anything – collect sputum for AFB culture instead. New tests Molecular tests are increasingly useful for TB, particularly fully automated PCR (Xpert MTB/RIF assay). This can give the diagnosis rapidly, together with immediate information about drug resistance. However, the key to diagnosis is still collecting a suitable specimen e.g. sputum or a biopsy sample for culture. While a molecular test may be applied to this sample, the gold standard is TB culture and conventional susceptibility testing to detect drug resistance. This is especially important to remember when aspirating a lymph node or mass – don’t send for cytology only!

by Medical Director Prof John Yovich

ANZARD 2017 Report … detailing outcomes from all initiated cycles during 2015 The assisted reproduction database for all treatment cycles initiated in Australia and New Zealand (ANZARD) during 2015 is now published. It summarises that 39,006 women undertook a total 77,721 ART cycles and generated 14,655 liveborn infants. This meant that 22.8% of treatments resulted in pregnancy and 18.1% in births with at least one live infant. At the onset of a treatment cycle the average age for the woman was 35.8 years and 38.1 years for the men. For the first time frozen embryo transfer (FET) cycles numbered more than fresh ETs at 53%. This reflects improved culture methods in recent years with more embryos reaching the blastocyst stage and undergoing the superior vitrification technique. Because of this improvement, more IVF treatment cycles are being conducted using a GnRH Antagonist with rFSH stimulation protocols and Triggering the final stage of ovulation with a GnRH agonist rather than rhCG. A record 17.2% of these cycles had a Freeze-all policy to obviate the risk of ovarian hyper-stimulation syndrome (OHSS) which has now reduced to 0.6% overall. Because of the greater commitment to Cryopreservation, ANZARD now reports the livebirth rates for both fresh and thaw autologous cycles initiated (meaning 2828 donor egg and embryo cycles are excluded). Among the 83 Fertility Clinics performing >50 cycles (excludes 10 clinics), the live delivery rates ranged widely from 12.2% to 32.3%. The accrediting body RTAC will be seeking “please explain” information from the poorer performing Clinics for the first time with the intent to raise the standards. Pleasingly a 90% single embryo transfer policy has meant that the multiple pregnancy rate has reduced to 4.4%, well down from British at 15.9%, European at 21.6% and USA 20.1% rates reported in 2014.

Quantiferon: Quantiferon-TB Gold Plus is NOT a test for the diagnosis of active TB. It detects an immune response to TB, which is an indirect indictor of latent TB infection (LTBI). It is useful in contact tracing; screening people at risk of LTBI e.g. migrants, health care workers; or screening prior to immunosuppressive treatment. It should not be used as a diagnostic test in a patient with symptoms who is suspected to have active TB. Induced Sputum: Not all patients suspected of having pulmonary TB can readily produce a sputum sample. The Anita Clayton Centre (below) has a dedicated facility for collecting induced sputum samples in outpatients. This is a reliable method that is safer and less invasive than bronchoscopy. What if I suspect or diagnose TB? The Anita Clayton Centre is a purpose-built facility with dedicated nurses and doctors available for advice and support in the management of TB. All management (including tests, consultation and medications) is provided free-of-charge to the patient. The clinic commonly shares the care of patients providing a supportive role and contact tracing, while the primary physician continues to manage the patient. Contacts: Anita Clayton Centre, Suite 1 / 311 Wellington Street, Perth 6000, T: 9222 8500, E: accadmin@health.wa.gov.au, W: www.health.wa.gov.au/acc/ Author competing interests: nil relevant.

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NOW AT 2 LOCATIONS PERTH & BUNBURY

For ALL appts/queries: T 9422 5400 F 9382 4576 E info@pivet.com.au W www.pivet.com.au

DECEMBER 2017 | 39

YOUR TRAVEL ADVICE IS THE LAST THING ON HIS MIND

1–3

Up to 98% of travellers fail to adhere to safe eating and drinking advice whilst abroad

HELP PROTECT AT-RISK TRAVELLERS AGAINST DIARRHOEA CAUSED BY CHOLERA.4,5 85% protective efficacy against cholera demonstrated at 6 months after primary course.5

Oral, Inactivated Cholera vaccine

PBS Information: This product is not listed on the National Immunisation Program (NIP) or the PBS.

Before prescribing, please review Product Information at www.seqirus.com.au/PI MINIMUM PRODUCT INFORMATION. DUKORAL® Oral Inactivated Cholera Vaccine. INDICATIONS: Cholera caused by serogroup O1 Vibrio cholerae: Active immunisation of adults and children ≥ 2 years of age, who will be visiting areas epidemic or endemic for cholera and who are at high risk of infection. CONTRAINDICATIONS: None known. PRECAUTIONS: Postpone immunisation in cases of acute illness; Not protective against species other than O1 V. cholera; Does not necessarily prevent spread of cholera via a vaccinee exposed to V.cholerae bacteria; Not a sole measure in prevention of cholera outbreaks. Encourage clean hygiene practices; Subjects infected with HIV; Pregnancy Category B2. Use in Lactation: DUKORAL may be administered to lactating women. INTERACTIONS: Avoid food/drink 1 hour ± vaccination; Buffer may affect other oral vaccines. Administration of encapsulated oral typhoid vaccine should be separated by ≥ 8 hours. ADVERSE EFFECTS: Abdominal discomfort, loose stools, headache, rhinitis, cough or other respiratory symptoms (see full PI). DOSAGE & ADMINISTRATION: Dissolve effervescent granules in 150mL water (pour away 75mL for children 2–6 years), mix DUKORAL suspension with buffer solution and drink. Adults, children > 6 years: 2 doses; Children 2–6 years: 3 doses; administer doses at intervals ≥ 1 week. Re-start basic immunisation if > 6 weeks elapse between doses. Booster: Adults, children > 6 years: 2 years; Children 2–6 years: after 6 months. PRESENTATION: Whitish oral liquid suspension (vaccine) in a single dose glass vial with effervescent granules (buffer), in an accompanying sachet. STORAGE: Store at 2˚C to 8˚C. Refrigerate, do not freeze. Based on TGA approved PI dated 9 September 2003, last amended 6 August, 2015. REFERENCES: 1. Kozicki M et al. Int J Epidemiol. 1985; 14(1):169–172. 2. Mattila L et al. J Travel Med 1995: 1;2(2):77–84. 3. Steffan R et al. Trav Med Infect Dis. 2003; 1:80–88. 4. NHMRC. The Australian Immunisation Handbook 10th Edition. 2013. 5. DUKORAL® Approved Product Information, August, 2015. Product Information is available from Seqirus (Australia) Pty Ltd. 63 Poplar Road, Parkville, VIC 3052. ABN 66 120 398 067. Medical Information: 1800 642 865. ® DUKORAL is a registered trademark of Valneva Sweden AB. Seqirus™ is a trademark of Seqirus UK Limited or its affiliates. Date of preparation: October 2017. SEQ/DUKO/0517/0050f. 14533-MF.

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CLINICAL UPDATE BACK TO CONTENTS

Update: Glucocorticoid replacement Life-long glucocorticoid replacement is required for primary (Addison’s disease) and secondary adrenal insufficiency. Endogenous cortisol production is complex, with the classic circadian or diurnal rhythm (morning peak and nocturnal nadir) subserved by an ultradian rhythm whereby cortisol is secreted in discrete pulses of varying amplitude within the 24-hour daily period (Figure 1). Current cortisol replacement regimes fail to mimic either rhythm; however, recent changes around cortisol delivery methods have attempted to address these shortfalls.

Clin A/Prof David Henley Endocrinologist SCGH and West Leederville

an overall reduction in cortisol exposure to the patient (Figure 2) as post-absorptive peaks are eliminated. This translates into reduced body weight, reduced blood pressure and improved glucose metabolism. However (see Figure 2), it does not overcome the problem of waking in the morning with low cortisol levels, a time when endogenous cortisol levels are normally peaking. As a result, many hypoadrenal patients on optimal glucocorticoid replacement feel quite dreadful in the morning until about half an hour after taking their morning medication.

The rhythm and dose of cortisol ED replacement is important for those who regularly need it. And travel presents its own special considerations.

is not released until 4-hours later and blood levels peak around 6.00 am, consistent with the normal endogenous rhythm. A second lower dose is usually taken around 7.00 am to provide adequate cortisol exposure during the rest of the day. Modelled concentrationtime profiles have shown this regime to superimpose well on physiological cortisol rhythms (Figure 3). Ultradian rhythm mimics Pulsatile cortisol release is important for its receptor binding and downstream action; in theory, replacing cortisol in this way may reduce adverse effects. Oral regimes do not address this issue. Pilot studies have trialled pulsatile hydrocortisone delivered subcutaneously via a portable pump (similar to an insulin pump) with success in mimicking the ultradian cortisol rhythm. In reality, if developed further, this concept is likely to have a niche role for selected patients only.

Fig 1: 24-hour serum cortisol concentration profile in a healthy male

Modified release tablets – diurnal rhythm Plenadren®, a modified release tablet containing hydrocortisone, has relatively recently been approved for use in the European Union. The dual release action, achieved by combining an immediate release coating together with an extended release core, is designed for once daily cortisol replacement that mimics diurnal variation in plasma cortisol levels. When comparing a single dose dual-release tablet with a standard thrice daily immediate release hydrocortisone tablet regimen there is

Chronocort®, an alternative modified release hydrocortisone tablet, is currently undergoing phase 3 trials in the UK and holds the most promise in replicating the natural glucocorticoid circadian rhythm. The tablet has an insoluble barrier coat that protects all but the upper face of the tablet. The unprotected face exposes a delaying layer that slowly erodes in the small intestine to present the sustained release drugcontaining layer. Patients therefore administer their dose at 10.00 – 11.00 pm before bed; hydrocortisone

Trends in glucocorticoid replacement Hypoadrenal patients on glucocorticoid replacement have higher rates of cardiovascular morbidity/mortality. This is now thought to be due to cortisol overreplacement because past estimates of endogenous cortisol production rates were limited by the techniques available and we now know that daily cortisol production rates are much lower than initially estimated. There is therefore a current trend to reduce dosing regimens below those traditionally continued on Page 42

Fig 2: Single dose Plenadren® serum cortisol concentration curve compared with three daily doses of immediate release hydrocortisone. Taken from J Clin Endocrinol Metab, February 2012, 97(2):473–481

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Fig 3: Modified release hydrocortisone (ChronocortÒ) regimen serum profile compared with physiological cortisol rhythm (± 2 SD). Taken from J Clin Endocrinol Metab, May 2009

DECEMBER 2017 | 41

CLINICAL UPDATE

What’s normal? At birth and in early childhood the normal foreskin is fused to the glans preventing retraction. The foreskin gradually separates over a variable time frame, often between age 2 and 7 years, resulting in most being able to fully retract by 10 years. Less than 1% of boys require circumcision for persistent phimosis.

concern if urine flow is otherwise normal and there are no symptoms.

Phimosis

Acquired Phimosis. Lichen sclerosis, Balanitis Xerotica Obliterans (BXO), is a chronic inflammatory disease of unknown etiology with skin fibrosis and atrophy. This affects <0.5% of boys and presents with thickened pearly white plaques at the tip of foreskin, progressing to the inner prepuce, glans and

Here, the foreskin cannot be retracted to completely expose the glans. Physiological phimosis describes normal tightness seen in young boys. When attempting to retract the tip has a characteristic shape with the inner foreskin layer pouting through the preputal orifice (Image 1).

Congenital anatomical phimosis occurs as failure of loosening and separation of the foreskin during childhood. This is sometimes associated with buried penis, with or without megaprepuce (urine balloons around base of penis).

Knowing when to tell parents their baby boy needs some intervention is importnant. These notes will help.

eventually urethra (Image 2). Circumcision is treatment of choice and usually curative. Residual disease of urethral meatus is treated with topical steroid and/or meatotomy. Glanular adhesions that do not resolve prior to puberty may coexist with tight penile frenulum preventing retraction. Infections and discomfort may be experienced. Penile frenulotomy and division of adhesions are an option.

Ballooning during urination is commonly experienced as the inner layer separates and, in early childhood, it is not a cause for

Image 1: Physiological phimosis

Image 2: Balanitis Xerotica Obliterans

Image 3: Retained smegma

continued from Page 41

... Glucocorticoid replacement used, often now based on patient weight or body surface area, rather than a ‘one dose fits all’ approach. For example, we now commonly see hydrocortisone prescribed in a total daily dose of 15-20 mg (in divided doses) as compared with 30 mg previously. Many patients feel better on a thrice daily hydrocortisone regimen (rather than twice daily), although this depends on patient preference/compliance. Travel considerations Cortisol is a life-requiring hormone and as such, has some important travel considerations. • With current airport security it is worthwhile carrying a medical letter documenting medication requirements. This is also important should you require surgery or be injured overseas.

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• Patients might wish to separate cortisol replacement in case some luggage goes missing.

Key POINTs

• Revisit sick day ‘rules’: doubling or tripling doses in times of intercurrent illness; and where gastroenteritis interferes with absorption of tablets attend medical services for parenteral hydrocortisone.

2. Current replacement regimens fail to replicate endogenous cortisol patterns.

• Equip with IM/SC hydrocortisone (e.g. SoluCortef 100 mg) for emergency, especially if travelling in remote regions; have a travelling companion instructed in its administration. • When travelling in a foreign country, consider a ‘medic alert’ printed in that country’s language. References available upon request.

1. Cortisol secretion is complex with circadian and ultradian rhythms.

3. Plenadren®, available in the EU and Chronocort®, currently under development in the UK, aim to replicate endogenous cortisol patterns. 4. Cortisol replacement is life requiring and therefore careful planning for travel is essential.

Author competing interests: No relevant disclosures.

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Foreskin problems in kids

By Dr Jill Orford Paediatric Surgeon

CLINICAL UPDATE Foreskin inflammation There are multiple possible causes, such as inattention to hygiene, trauma (forcible retraction), infection (commonly staphylococcal, streptococcal or candida) or dermatitis (contact, allergy, drug reaction). Chronic inflammation may result in phimosis. Inflammation ranges from low grade with redness of distal foreskin (posthitis) to painful cellulitis with discharge (balanitis or balanoposthitis). Entrapped smegma. Foreskin “pearls” occasionally develop beneath the foreskin as a variant during separation process. Commonly situated laterally over proximal glans (Image 3) compared with dermoid cysts that are ventral midline. Treatment is conservative. Retained smegma can be a nidus for infection requiring treatment. Paraphimosis Failure, or inability to return retracted foreskin to cover the glans leads to oedema, venous congestion and can lead to ischaemic necrosis of glans. Narcotic analgesia or general anaesthesia may be necessary and dorsal slit is performed if manual reduction fails. This

is followed by circumcision, preferably performed several weeks later for optimum cosmesis, after oedema has settled. Reasons for Male Circumcision • Episode of significant balanitis, persistent or recurrent inflammation • Failure of topical steroid or recurrent phimosis after cessation of treatment. • Phimosis persisting in late childhood • Recurrent urinary tract infection with or without other urinary tract anomaly (10 x reduction in UTI). • Balanitis Xerotica Obliterans • Stenosis of preputal orifice restricting flow of urine • Hooded foreskin without hypospadias or chordee. (Not suitable for newborn procedure as distal urethra is often close to ventral skin and susceptible to injury.) • Disfiguring injury of foreskin • Cultural, religious or family preference with agreement of both parents • Public health in high HIV-prevalence settings References available on request.

Key POINTs • Hygiene advice: supervised daily retraction when the child is old enough to comply – retract while bathing, as far as comfortable, followed by return of skin to cover the glans. • Topical steroid can achieve retractable foreskin in over 80% of phimosis (not BXO) with optimum results if applied to clean foreskin for up to 4 weeks. • Foreskin inflammation treatments are: salt baths, topical antibacterial and/or antifungal, and hygiene advice. If cellulitis and pus, add analgesia and oral (IV if unwell) antibiotics. • Paraphimosis requires urgent reduction. • Circumcision is contraindicated when foreskin flaps are required to correct abnormalities such as hypospadias, chordee, buried penis and significant webbed penis.

Type 1 breakthrough Results from a four-year study into screening and treating young adolescents with Type 1 diabetes at risk of developing cardio-renal complications with blood pressure and cholesterol lowering By Prof Tim Jones medications have excited the team led by Prof Tim Jones, co-director of the Children’s Diabetes Centre at the Telethon Kids Institute. Prof Jones said the AdDIT (Adolescent Type 1 Diabetes cardio-renal Intervention ATrial) set out to examine the risks of complications during puberty and to find out if ACE inhibitors and statins could lessen the risk of kidney, eye and cardiovascular diseases in young people with Type 1 Diabetes. The study which involved screening 4407 young people at seven hospitals in Australia, the UK and Canada and recruiting 200 participants, including 40 in WA, has given strong indication that for those at risk, these drugs can work. But Tim cautions that more time is needed to follow these young people because experience would indicate that as children got older their diabetes got worse – for a range of reasons, not least of them because teenagers are not the most compliant of patients. “We have only had this group under our eye for three to four years and we do need to follow them for longer to determine the longterm effects,” Tim said. “The most exciting thing for us is being able to identify those at risk of complications early and to treat early.”

I Systems & Intervention Research Centre for Health

STI E-Learning Resource for GPs Any patient in your waiting room could have a Sexually Transmitted Infection (STI) and not know it. Edith Cowan University (ECU) and the Department of Health, WA have developed a free online education program for general practitioners, nurses and other health professionals, designed to improve both knowledge and skills in managing sexually transmitted infections. The program has been approved by the RACGP QI & CPD program for 40 category 1 points.

Explore the learning program at sti.ecu.edu.au or for further information email sirch@ecu.edu.au

10864997_185x90_STI_Press.indd MEDICAL FORUM

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TRAVEL

Happy Canada Days A seaplane takes off toward the glacier at Taku Lodge.

Before you decide to go to Canada, check a map. It’s a long way and it’s a good idea to tackle the trip in stages. Heading to Ottawa on the east coast of Canada? Then consider a jump to Sydney, then Hawaii and how can you bypass New York and Niagara Falls? This means one thing – get your visa sorted. We made landfall in Honolulu as it was the only Hawaiian city we could directly access from Sydney, though we found the return trip had more destinations on offer. While Honolulu served mostly as a resting post for us, a tour of Pearl Harbor was a must-see for its war-time significance. But unless you like 130 hotels lined up on the beachfront, try to avoid Waikiki. Next stop was New York and the city was gearing up for Independence Day. The best way to navigate the New York traffic is the hop-on, hop-off bus (with four different routes), which includes a ferry ride with commentary. The tickets allow two days’ travel. We were fascinated by the Thousand Islands (where the salad dressing name comes from) – an archipelago of 1864 islands dotted along an 80km stretch of the St Lawrence River, starting around Kingston, and divided between Ontario and New York state. We based ourselves in Kingston which has hotels on the water’s edge. Give yourself plenty of time to explore the town’s bars, sidewalk cafes, local supermarket and church. The ferry ride is a leisurely spot-the-luxury-house on these islands, which are mostly privately owned. Traveller’s Tip: pre-purchase your tickets to prevent queuing. The centre of Ottowa has a long central canal, along with a mix of old buildings and new. Churches, the governor’s residence, the canal with locks, the mint and parliament are prime examples of the former while the National Gallery, with its indigenous exhibits, illustrate the latter.

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The French-Quebec side of the city is fascinating. Again the hop on-off bus gives a good overview, including Chateau Laurier and new accommodation built in the old French style. Ottowa is clean but for those with allergic sensitivities, it can be ‘mould capital of the world’. Calgary is home to the famous Calgary Stampede, held each September. The spectacular backdrop of the Rocky Mountains included a drive to Banff (in Alberta). While not ski season, we could still visit the Sky Bistro via local bus, at sunset, on the top of the mountain, a trip to remember via cable car. A short trip takes in Lake Louise where theories abound as to how the deep lake gets its rich turquois colour. The scientific consensus is the silt-like rock flour, which is continually being carried into the lake by meltwater from the surrounding glaciers refract blue and green wavelengths of light. However it happens, it’s beautiful. On the lake nestles the Fairmont Chateau hotel, which is equally fascinating. It opened in the late 19th century as part of the expansion of the railroad. We were headed for Jasper to catch the Rocky Mountaineer train experience and on the way dropped into the Athabasca glacier, part of the Columbia icefield in the Canadian Rockies.

Rescued grizzlies in Sitka, Alaska

It’s a two-day train trip to Vancouver on the Rocky Mountaineer and there are two main routes through The Rockies – this one was spectacular. The service on the train is second to none, especially if you choose the Gold Leaf experience (and you should). The glazed tops to your carriages…well I now understand the term ‘rubber necks’ to describe tourists. Left, right or above – always something amazing to look at. The refreshments come thick and fast – let’s just say why drink water when you can drink wine, especially if you have to wait for the

Ottawa, Chateau Laurier is the backdrop to a war memorial

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TRAVEL

A seaplane was dwarfed by a cruise liner.

second sitting of breakfast or lunch in the dining car below. Kamloops is the half-way city, in British Columbia, where the north and south Thompson Rivers meet. We experienced the warm welcome of Canadian Indian chanting, champagne on arrival, bags waiting for us in our hotel room, and smiles all round. The next day, we left Kamloops for Vancouver and, as we followed the river, we could see the blackened evidence of the severe bushfires that swept through the region. The commentary on the train advised us on what wildlife to look out for and some information about the terrain we were passing through. We decided to stay in Old Vancouver, which has a rich history. Again, we opted for the hop on-hop off bus to familiarise ourselves with the specific sites, to which we returned to explore in more detail and soak up the ambience the next day. One of the great things about travel is stumbling upon the local ‘happenings’. For us there was a national soccer match that was absorbing people’s attention, an indigenous festival and the local markets. There always seemed to be something happening in this city of glass, where unlike Australia, the inhabitants seem hungry for sunshine. When cruising the Inside Passage via Queen Charlotte Sound, there are four or five ships cruising at any one time. Our ship stopped over at night to offload an elderly passenger with heart trouble – as a result, we arrived late to Sitka (Alaska) but the town stayed open late to accommodate us. This former Russian capital city boasts two centres that rescue and rehabilitate bears and raptors. This was the first town in which we saw the salmon jumping on the ocean shoreline as they waited to head upstream as part of the spawning cycle.

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A raptor eyes its handler's ear.

The ultimate prize was the Hubbard Glacier, the largest tidewater glacier on the North American continent. On the way back was the townsite of Juneau, where bush pilots in a classic De Havilland seaplane flew over five glaciers on the way to Taku Lodge. Here, we witnessed our first wild black bear, who was salmon tasting with a stick-wielding cook, and we got to savour and hear about King Salmon, log cabin building, and past trekkers to the lodge. At Ketchikan, a similar wilderness experience started from a seasonal fishing port where a rubber dingy took us to Silverking Lodge in Tongass National Park for a seafood meal then back in town, the largest collection of totem poles. Returning to Vancouver, we hardly touched the surface of things to see – but we tried. Stanley Park, Canada Place (the simulated flight experience of Fly Over Canada), and Granville Island markets, to name a few. Day trips abound, such as the one to Victoria Island where a Pacific Coach picks you up, drives onto the ferry, and disembarks at Victoria Island – the original capital of Canada with its mixture of old world charm and funky modern.

Gold Leaf service on the Rocky Mountaineer

The Butchart Gardens, all 22ha, were astounding. Something is in bloom at every turn. A trip to the Tree Top Adventure and Capilano Suspension Bridge over the Capilano River was notable not the least for the free transport to the venue! Heading home it was another half-way stop in Hawaii, but this time in Maui and we had a ball if for a fleeting 36 hours. Definitely on another itinerary some other time!

By Dr Rob McEvoy

DECEMBER 2017 | 45

FOOD & WINE

MY LOCAL

P’tite Ardoise 238 Beaufort St Perth Ph 9228 2008 www.ptiteardoise.com.au This is French bistro food at its finest. The menu is small but embraces all the classics from Soupe à l’Oignon Gratinée (French Onion Soup) to Canard à l'Orange (Wagin Duck Confit) and a superb Passionfruit Crème Brulee. The prices are reasonable: Entrees $16/Mains $32/Desserts $14 and a wonderful cheese coard with a beautiful Cantal, one of the oldest French cheeses made in the mountains of the Auvergne. P’tite Ardoise is licensed, prices by the glass and bottle ,and they have a no-corkage BYO on Wednesday and Thursday nights. It’s a slice of Parisian heaven right here in downtown Perth!

Smoked Salmon Blinis with Horseradish Cream Ingredients Smoked salmon Salted capers Fresh dill Red onion, thinly sliced in half rings Horseradish relish Dijon mustard Egg mayonnaise Light Sour Cream For Blinis (makes 30+) 2 cups SR flour 1 tsp baking soda 1 egg, beaten Pinch of salt ½ cup finely grated parmesan 1 tblspn finely grated parsley Milk as needed

METHOD To make horseradish cream: add 1 tblspn horseradish relish, 1 tspn Dijon mustard to 1 cup of egg mayo (homemade or quality shop-bought) and 2 tblspn of sour cream. Adjust quantities to your own taste. To make blinis: Sift flour and baking soda together. Add salt. Make a well and add egg. Mix to combine then add milk to create a thick batter. Add parmesan. Let stand until bubbles start appearing on the surface of the batter. Heat a frypan or griddle to about 170C, spray with cooking oil and add heaped teaspoons of batter leaving room for a little spread. When bubbles appear on the top of the blini, turn and cook other side. Continue until all the mixture is used (leftovers can freeze) To assemble: Spread horseradish cream on blini, add a portion of smoked salmon and top with a caper and a sprig of dill.

Wine

Winner

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This would have to be one of the best wine ‘moments’ we’ve ever heard at Medical Forum. Dr Greg Hogan fondly remembers sharing a bottle of Grange and fish and chips on the beach at Lancelin with his Dad. That’s pretty hard to beat! Greg’s also partial to a glass of champagne and a good pinot with friends and he’s just been told he’s won a case of Fermoy Estate, so there will be plenty to go round.

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WINE review

Z onte's – Big can be Beautiful Zonte's Footstep is a large-volume producer based in McLaren Vale, South Australia. It sources fruit from a number of South Australian regions including Langhorne Creek, Adelaide Hills, Barossa Valley, Fleurieu Peninsula among others. It is a partnership of a group of wine industry people with production in the hands of competent winemaker Ben Riggs. They produce more than a dozen wines, sourced from more than 200ha of vineyards, and the resultant 20,000 plus cases of wine are distributed across the wine drinking world. A variety of styles are made from the mainstream varieties and a number of Italian varieties that are gradually establishing themselves in the Australian wine scene, labelled with eclectic and imaginative names. I have found it interesting to review a volume producer as opposed to small-to-mid-sized producers usually reviewed in these tastings. And I have not tasted them in the large number of tastings I have been involved in (horizontal, vertical, regional, Australian Vs International etc) and I have missed them on the wine shop shelves. The five wines tasted are all-enjoy-now, easy drinking wines; simple, honest, made for short-to-medium term consumption, varietally expressive and economical. In fact all five wines tasted have a recommended retail price of ~$20. All are current vintage 2017 (or no declared vintage).

By Dr Craig Drummond Master of Wine

REVIEWER'S

PICK

2017 Zonte's Footstep Lady Marmalade Vermentino, Fleurieu Peninsula

This wine was my top of this tasting. A fascinating variety from the Southern Mediterranean (Sicily, Corsica, Sardinia), which is establishing itself in the Australian viticultural landscape. It is as it should be – crisp, clean, linear, showing lemon citrus and green apple. Firm acidity gives length with a clean refreshing finish. Easy to enjoy this summer.

1. Zonte's Footstep Bolle Felici Prosecco Bolle Felici translates as 'happy bubbles' and that is just what this wine is. Prosseco, aka Glera, is a Northern Italian variety. Its neutrality and firm acidity makes it ideal for sparkling wine production. They are charmat (tank secondary fermented) produced rather than the more complicated methode champenoise (bottle fermented). This wine typifies the style. Clean, fresh, linear, with green apple aromas and flavours and a nutty almond finish. Easy to enjoy as a late afternoon aperitif.

3. 2017 Zonte's Footstep Doctoressa Di Lago Pinot Grigio, Adelaide Hills Pinot Grigio (Italy) is as Pinot Gris (France). Italian 'styled' versions are less aromatic, more linear and acidic (in Australia often achieved by earlier grape picking). This wine shows the typical 'copper tinted' colour. The aromas are slightly pungent , a touch of typical grape phenolic, with spice and quince. The palate typically textural and unctuous with flavours of ripe pear and quince. Needs to be consumed with food.

2. 2017 Zonte's Footstep Sauvignon Blanc, Adelaide Hills Nose shows SB zestiness with pungent green fruit and nettle aromatics. The palate is dry with grapefruit and herbal flavours. Shows the characteristic raspy acidity of SB. Chilled it makes a great summertime drink.

4. 2017 Zonte's Footstep Scarlet Ladybird Rose, Fleurieu Peninsula Varietal content not declared but I think it is Grenache based. Beautiful pink/ magenta colour is very inviting. Aromas of rose petal and candy, with flavours of cherry kernel and strawberry. A dry-style, easy drinking wine. Great to consume while watching the late afternoon sun sink into the ocean.

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DECEMBER 2017 | 47

"Assassins!" - Arturo Toscanini (1867-1957) to his orchestr a

These quotes From

Disorder in the American Courts are apparently on the official record.

Witness: Having sex.

the bacteria in your ear 700 times.

•••

Women blink nearly twice as much as men.

Lawyer: She had three children, correct?

Men can read smaller print than women; women can hear better.

The Law is an ass

Witness: Yes.

Lawyer: What was the first thing your husband said to you that morning?

Lawyer: How many were boys?

Witness: He said, ‘Where am I, Cathy?’

Lawyer: Were there any girls?

Lawyer: And why did that upset you? Witness: My name is Susan!

Witness: Your Honour, I think a need a different lawyer.

•••

Lawyer: What gear were you in at the moment of the impact??

Lawyer: How was your first marriage terminated?

Astronauts cannot burp in space. There is no gravity to separate liquid from gas in their stomachs.

Witness: Gucci sweat and Reeboks.

Witness: By death.

As you age, your eye colour gets lighter.

Lawyer: Are you sexually active?

Lawyer: And by whose death was it terminated?

There are more living organisms on the skin of a single human being than there are human beings on the surface of the earth.

Witness: No, I just lie there. ••• Lawyer: What is your date of birth? Witness: July 18 Lawyer: What year? Witness: Every year. ••• Lawyer: How old is your son, the one living with you? Witness: 38 or 35, I can’t remember which. Lawyer: How long has he lived with you? Witness: 45 years. ••• Lawyer: Were you present when your picture was taken?

Every time you lick a stamp, you're consuming 1/10 of a calorie.

Witness: None.

••• Lawyer: Can you describe the individual? Witness: He was about medium height and had a beard.

Lorne Greene had one of his nipples bitten off by an alligator while he was host of Lorne Greene's Animal Kingdom.

Lawyer: Was this a male or a female?

A British gymnast survived a fall from a fourth storey window because he went into a somersault and came down on two feet.

Witness: Unless the circus was in town, I’m going with male.

We forget 80 percent of what we learn every day.

••• Lawyer: Is your appearance here this morning pursuant to a deposition notice which I sent to your lawyer? Witness: No, this is how I dress when I go to work. ••• Musician: "Did you hear my last recital?"

Lawyer: So the date of the conception (of the baby) was August 8?

Friend: "I hope so."

Lawyer: And what were you doing at the time?

Human thigh bones are stronger than concrete.

Witness: Take a guess.

Witness: Are you kidding me?

Witness: Yes.

The average person has over 1,460 dreams a year.

Did someone say facts? The liquid inside young coconuts can be used as a substitute for blood plasma. Wearing headphones for an hour increases

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48 | DECEMBER 2017

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THEATRE

Richard O’Brien with Craig McLachlan as Frank ‘n’ Furter in the Australian production of The Rocky Horror Show.

Naughty and Nice The year was 1973; the place was London; and Richard O’Brien was a young actor, writer and musician. Glam Rock, like all eras, was coming to the end of its eyeshadowed glittery life, to be replaced by equally theatrical Punk with its safety pins and torn jeans and everything in between. The one constant was that television was dreadful though it did serve to inspire creative spirits to get out there and put on a decent show outside the walls of the living room. If they put it on, surely, they would come? This was the world into which Richard O’Brien breathed life into one of most enduring cult theatre shows of the modern era – The Rocky Horror Show – and audiences have been packing houses to see the sweet transvestite from Transylvania for more than 40 years.

“Homosexuality was coming out of the closet. Gay men were emboldened to gather at pubs. They were being seen. Women were asserting their political and sexual freedom and Rocky was a mirror of all this – it didn’t come from nothing.” The show opened in a little theatre in London and news of its joyous, anarchic twists on all these cultural tropes spread like wildfire. Soon after its theatrical debut, a movie was proposed, which sealed the show’s destiny in the show biz firmament and made Tim Curry and Susan Sarandon stars. Richard played Riff Raff on stage and on screen and in Perth he’s decided to don the smoking jacket to walk the boards as The Narrator, an enormous coup for Perth audiences.

Now 75 and living between New Zealand and the UK, he is preparing to launch another national tour of the show in Australia. It will see him and the show open at Crown Theatre on February 17.

“The Narrator is fun to play. The idea of the character was to give some faux gravitas to the Juvenalian goings on, and I’m looking forward to joining this amazing Australian cast.”

Last month he reflected on the cultural ingredients that inspired such a gem when he spoke to Medical Forum.

The production sees Craig McLachlan reprise his role as Frank ‘n’ Furter, the undiminished, uncontrollable Bacchus overseeing a night of anarchic mischief. And is he a sight to see! This big strapping lad, who seems to be able to step out of a 1940s suit as Dr Blake and

“There was all this happening in music, but politically it was a revolution,” he said.

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into fishnets and corset with frightening ease, owns this character and, in the process, has given Frank some bushranger schtick. What is especially refreshing about McLachlan’s performance is that it is uniquely his own. He brings his own tool kit where for many who have played the role before him, may have looked a little too long at Tim Curry’s seminal characterisation. McLachlan certainly steps into the spotlight anew! It’s worth the ticket price alone. “Craig is a consummate performer and an outrageous show-off,” Richard said. “He succeeds in pushing the boundaries of both good and bad taste. He is a force to be reckoned with.” However, one senses that Richard is easily up to that task. He is, after all, Frank’s creator just as Frank is Rocky’s. For Richard, Rocky Horror has given him the ride of his life. “It has opened doors and given me professional freedom. Rocky and hosting The Crystal Maze quiz show on UK’s Channel 4, [which was watched by seven million people in its day], have been very satisfying.”

By Jan Hallam

DECEMBER 2017 | 49

Competitions

FEATURE

COMP

Entering Medical Forum's competitions is easy! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter. Movie: Call Me By Your Name It is the summer of 1983 and teenager Elio is on holiday at his parents' Italian villa where he spends his days reading, swimming and flirting with girls. When his professor father's new American assistant arrives, the atmosphere becomes charge with a different attraction. As the days pass, the two spend more time together sparking a growing attraction that will change their lives forever.

Movie: Paddington 2 It’s not so unexpected these days for characters in children’s book to burst into animated life on the big screen but few could be more welcomed than the sublimely bewildered Paddington, the Bear from Darkest Peru. If you thought making films from books deterred kids from reading, the fact that Michael Bond has sold more than 100 million books suggests otherwise. Bond died in June this year before the release of the sequel but not before seeing a new generation of youngsters falling in love with this bear with impeccable manners. The story continues in the London home of his adopted family, the Browns (Hugh Bonneville and Sally Hawkins) where he spreads joy and marmalade among his community. Paddington is searching for a special gift for his beloved Aunt Lucy’s 100th birthday and when he spots a unique pop-up book in Mr Gruber’s shop, he embarks on a series of odd jobs to buy it. But when the book is stolen, suspicion falls on Paddington but with his loyal family he works to reveal the real thief. Paddington 2, in cinemas December 21

In cinemas, December 26

Movie: Breathe Robin and Diana Cavendish are young, beautiful and in love with life and each other. They adventure to Africa where Robin contracts polio leaving him paralysed from the neck down. He fights dark depression and with the help of his wife and his friends finds a way to live a wild and full life. In cinemas, December 26

Movie: The Post This Spielberg film has been renamed The Post in honour of the Washington Post’s role in the publishing the revelations of the Pentagon Papers and the corruption of President Richard Nixon and his Attorney General John Mitchell. Starring Tom Hanks and Meryl Streep, it will be a winner. In cinemas, January 11

Movie: Jumanji: Welcome to the Jungle Four teenagers discover the bewitched Jumanji game, but this time it’s not the board game Robin Williams threw off the bridge 21 years ago but an old video game. Same crazy adventures but different platform and the aim of the game is to finish, or be forever lost in Jumanji.

Winners from October Movie – The Killing of the Sacred Deer: Dr Julia Charkey-Papp, Dr Carol McGrath, Dr Yulia Wilken, Dr Fred Faigenbaum, Dr Suzanne Gray Movie – Loving Vincent: Dr Ernest Tan, Dr John Masarei, Dr Annabelle Shannon, Dr Genevieve Robbins, Dr Michael Hart

ﬁt to ﬂy Health Shapes Up Musculoskeletal lowdown Wheels to Adventure

October 2017 Major Sponsor

Movie – Detroit: Dr Kylie Seow, Dr Rachel Price, Ms Cynthia Poh, Dr Gavin Leong, Ms Kellie Ashman, Dr May Ho, Dr Rob Hendry, Dr Kiran Mirle Ramegowda, Dr Alem Bajrovic, Dr Michael Armstrong Theatre – Let the Right One In: Dr Linda Haines Theatre – Masterclass: Dr William Chapman

50 | DECEMBER 2017

In cinemas, December 26

Staying in the Game

www.mforum.com.au

Musical Theatre: The Rocky Horror Show The Time Warp is on auto repeat but it never ceases to draw a whole new crowd in to join the growing league of devoted fans. Craig McLachlan reprises his role as Frank'n'furter and he does it so well, it might be a role for life. Crown Theatre, from February 17

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