Medical Forum July 2020 - Public Edition by Medical Forum WA

Being there ADVOCATING FOR MEN’S HEALTH

Men’s Health issue | Testosterone & fracture, alcohol & COVID, prostate complexities

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July 2020 www.mforum.com.au

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EDITORIAL BACK TO CONTENTS

Jan Hallam | Managing Editor

Enough with the talk Now what’s left is a thirst for a new decision-making paradigm, one that demands action; that weighs up risk versus benefit.

These are nothing if not fascinating times. Nervous, no doubt, but defining and potentially exciting. Whatever your sightline of society, government or healthcare, nothing feels the same. Yes, elective lists are starting to fill, general practice is adapting to the transformative upheaval of telehealth but, still, there’s a disconsolate mood. A wariness that the old models of care and businesses are no longer fit for the new purposes demanded of them. COVID-19 showed the Australian people just how fast and decisive their governments could be. Some will, inevitably, argue the virtues or otherwise of these actions, because some things such as the difficulty of keeping all of the people happy all of the time never change. The heavy public health measures that slammed the economy have been somewhat offset by some heavy government spending. The ‘we’re all in this together’ rhetoric has been matched by action which has earnt governments an impressive swag of trust. Now what’s left is a thirst for a new decision-making paradigm, one that demands action; that weighs up risk versus benefit. Having demonstrated they have the capacity to act quickly, governments have let a significant genie out of the bottle. Mental health advocates are throwing down the gauntlet to government – stop spending money on bureaucracy, and paying lip service to suicide prevention and start funding real services in places where real people are in real need. Meaningful research is informing useful modelling which in turn is being spun out to help people in high-risk environments. There are no secrets here, just a previous lack of focus that can change – in the blink of a virus’s eye. Men’s health is another area that demands clarity. There are groups with agency who have a plan of action; who actually want to see those policy documents, which roll out of government departments like Jaffas during a dull movie, become useful blueprints to create a healthier community. We owe it to ourselves and each other to make something tangible from the scorched earth – and take advantage of governments required to govern.

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 health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

MEDICAL FORUM | MEN 'S HEALTH ISSUE

JULY 2020 | 1

CONTENTS | JULY 2020 – MEN'S HEALTH ISSUE

Inside this issue 16 12 10

FEATURES

NEWS & VIEWS

LIFESTYLE

10 Q&A with Tim Hammond

46 CINI: making a difference

12 Close-Up: Dr Richard O’Regan

16 Suicide: Predicting the

– Dr Sayanta Jana

49 Wine Review: Vasse Felix – Dr Craig Drummond

25 Opinion: A different gender gap? – Dr Joe Kosterich

unpredictable

20 Mental health looms large

Editorial: Meaningful action, now, please? – Jan Hallam

28 Never waste a good crisis

Doctors Dozen... For your chance to win a dozen bottles of premium Vasse Felix wines, go to the website www.mforum.com.au and click on the competitions tab

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MEDICAL FORUM | MEN 'S HEALTH ISSUE

CONTENTS

PUBLISHERS Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au

Clinicals

ADVERTISING Advertising Manager Gary Sullivan (0403 282 510) mm@mforum.com.au

7 EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au

Guidelines for PCOS diagnosis Dr Kalani Kahapola Arachchige

Testosterone and fracture risk in older men Professor Bu Yeap

Erectile dysfunction & Peyronie’s disease Dr Shane La Bianca

Journalist James Knox (08 9203 5222) james@mforum.com.au

Alcohol ranks 6th in risk factors for burden of disease in Australia

Alcohol contributes 6% of disease burden for men compared with 2.8% for women

Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au

Alcohol-attributable hospitalisations and deaths did not decline between 2004-2015

Men have markedly higher rates of alcoholattributable hospitalisation (1.6-fold) and alcoholattributable death (2-fold) compared with women 3

Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

Men, COVID-19 and alcohol Dr Michael Christmass

PSA & localised prostate controversies >50% of harm attributable to alcohol in Australia is from harm to others Dr Matt Brown

Men’s mental health Dr Davinder Hans

Looking for hope Dr Adam Brett

GRAPHIC DESIGN Thinking Hats studio@thinkinghats.net.au INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Mark Hands (Cardiologist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon)

People, not robots Dr Tom Shannon

the 44 Managing dizzy patient

QoL postprostate cancer Create an infographic at venngage.com treatment Dr David Sofield

Maddison Brennan

Guest Columns

CONTACT MEDICAL FORUM Suite3/8 Howlett Street, North Perth WA 6006 Phone: 08 9203 5222 Fax: 08 6154 6488 Email: info@mforum.com.au

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Men really are a thing! Jack Beros

The risk of not taking risks Dr Michael Watson

Always make it ‘patient first’ Ms Penelope Strauss

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JULY 2020 | 3

Men really are a thing! Specific health programs for men are desperately needed writes Jack Beros, from Men's Health and Wellbeing WA.

Support for female-specific programs of health education and treatment have been maturing for years and rendered genuine and timely, positive results. It’s taking longer for it to dawn that males, too, are a thing – a huge cohort with their own specific needs and subsets. What will it look like as we strive for men taking more responsibility for their own health, and health and wellbeing approaches that meet men and boys where they are at? The first National Women’s Health Policy was launched in 1989. There were many years of evidence building, lobbying, and valuable independent progress before that. The first National Male Health Policy didn’t arrive until 2010. A Western Australian Men’s Health and Wellbeing Policy was launched by the state government in June 2019. There are good reasons why it all happened in that order. Past research and government policy often ignored gender differences. Older research sometimes didn’t even include females in test populations. So some table banging by women (and male supporters) has brought much-needed change. Meanwhile, across Australia, the health and wellbeing statistics for males are poor and getting more alarming. Shockingly, the leading cause of death in 15 to 44-year-old Australian males is now suicide. Compared to females, males have shorter life expectancy, higher burden of disease, and the majority of injuries, workplace fatalities, road trauma, homelessness, jail population, children’s behaviour problems, and learning difficulties at schools happen to men and boys.

4 | JULY 2020

So new policies and a focus on ‘men as a thing’ can only be welcomed, but, so far, the development of strategic and funding frameworks that could deliver substantial change is sorely limited. Some essential funding has flowed to longitudinal studies and other research, as well as some significant practical programs. However, it is all far from being proportional to the real need, and the genuine human and economic costs of not addressing these issues. The reasons for this are complex. Part of it might be that governments, funding bodies, powers-that-be, and indeed many men themselves see males through the lens of the three Ps – the perpetrators, the patriarchy, the problem. Some readers will have their hackles up at that and that will not necessarily be along gendered lines. While that land-mine is in the field, it is a serious obstacle to change. So too is the perennial reluctance of governments to find funds for emerging matters, even when a cost/benefit analysis is clearly going to render up a no-brainer. Another obstacle is the reality that many good programs on offer are underutilised by men and boys. That is probably rooted in stoicism, and the ‘I must not appear weak’ legacies of the past. Importantly, these may now be being reinforced by negative messages young men and boys appear to be taking on from the media. Men’s Health and Wellbeing WA (MHWWA) has been in existence (albeit under a few names) for 20 years, with varying foci. Today we sit poised as the peak body for

the men’s and boy’s health and wellbeing sector in WA. We are looking to: • Broadcast a positive message – men and boys are good things who contribute significantly to the fabric of our society. Sometimes we struggle. Perhaps we weren’t taught that we can say, “I could use some help here”. And sometimes we seriously screw up and that needs to stop. • Promulgate awareness that we are social animals, and that being appropriately vulnerable sometimes requires the greatest courage. • Promote the services of, and provide support and information to, our member organisations. • Create and foster opportunities where ‘conversations-that needto-be-had’ can be conducted safely with deep listening, empathy, and generative approaches to some of society’s entrenched issues. That will allow us to uncover centrist positions that can enable legitimate advocacy. MHWWA currently receives no government funding and relies on its member base and donations to deliver on this promise. An effective peak in this sector is vital to a reasonable rate of progress on these vital issues and we would welcome doctor support. Doctors can access our newly launched online services directory for men and boys. From suicide support to overcoming addictions, financial, accommodation, violence, lifestyle, fathering, relationships. www.menshealthwa.org.au/ directory/

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Working together…even when apart. We’ve still got you covered.

Perth Urology Clinic remained open during COVID to support you and your patients. For urgent referrals or queries please utilise our GP Hotline via our usual number below or please contact our individual consultants on their mobile numbers.

Working together to provide comprehensive urological care Dr. Jeﬀ Thavaseelan Dr. Shane La Bianca Dr. Andrew Tan Dr. Akhlil Hamid Dr. Trenton Barrett Dr. Matt Brown Dr. Anna-Lena Brink Dr. Manmeet Saluja

Hollywood Clinic

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refer@perthurologyclinic.com.au 1800 4 UROLOGY (1800 487 656)

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Phone (08) 9322 2435 / Fax (08) 9322 5358

Healthlink: jthavase

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The risk of not taking risks There is nothing new about risk but as the SARS CoV2 has shown, decision-making becomes more complex in a crisis, writes Dr Michael Watson. So why is it that two experts can give different opinions about the same situation when using an identical statistics-based risk assessment? The simple answer is that risk assessment is an objective mathematical process but riskbased decision making is more complex and requires subjective assessments of benefit vs risk. The mistake leaders often make is considering the risks of a situation without first considering the benefits. Let’s take patients attending their GP during the COVID-19 crisis as an example. The single focus on the risks of catching the SARS CoV2 virus resulted in patients being too frightened to attend their GP. People with chronic diseases didn’t keep up their usual GP checkins and missed opportunities to prevent minor illnesses from becoming major ones. Were patients undervaluing the benefits their GP’s oversight? I don’t think so, I think people were simply giving in to fear and failing to put the risks into perspective. Government messaging may be partly to blame. The failure of government to adequately monitor the COVID-19 situation and to communicate the true risks to the public played a role. The VirusWAtch surveillance system, which was established in 2007, has been partially defunded and rendered less able to respond to the SARS CoV2 pandemic. If this surveillance system was rebooted and rolled out now to all general practices, the state would have a highly effective early warning system which would renew the confidence of GPs and patients. The cost would be miniscule compared to the benefits of an accurate real-time assessment of the risk this virus actually poses. I am often asked whether WA should now re-open its borders. While it is essential to the economy 6 | JULY 2020

There is a smorgasbord of opportunities to improve our society (and at the same time mitigate the risk of SARS CoV2) that have emerged through this pandemic.

and the future of the state, my answer is still no because I don’t think we have a sufficiently robust and ethical risk-based decisionmaking process in our businesses, organisations and government bodies. This means we are destined to repeat the mistakes of other countries, even though we have successfully bought (at great cost to our community) precious time to prepare ourselves. There is a smorgasbord of opportunities to improve our society (and at the same time mitigate the risk of SARS CoV2) that have emerged through this pandemic. The biggest risk is us not capitalising on the benefits and going back to the bad old ways of doing things. We have uncovered fantastic new ways to improve the environment through reduction in energy consumption and greenhouse gas emissions. We have increased outdoor activities, seen the benefits (for many) of working from home and recognised the importance of local supply chains. Judicious use of telephone consultations and widespread use of video conferencing to avoid unnecessary travel are all examples that will bring long-term benefits which should go a long way to solving many of the problems of the 21st century.

against the potential risks, we can restructure the way we do things to maximise benefit and minimise risk. There is little in life worth doing that does not involve risk. Trying to avoid all risk brings the far greater risk of lost opportunity. We need to get back to football, interstate and overseas travel and the full delivery of health care services, but this will require the government to facilitate a process of sensible risk-based decision making. The architects of that model must be the people. Government officials can’t possibly understand the intricacies of every individual business and organisation in the state. We need our community leaders to be given the freedom to work with their members to promote the benefits of what we do and to develop codes of practice (in conjunction with organisations such as WorkSafe) to help mitigate the risks of SARS CoV2. This is impossible to achieve if we are forbidden from introducing measures to mitigate risk such as NAT testing of asymptomatic individuals. We also need enhanced surveillance systems, funded and coordinated by government (such as VirusWAtch), that will help us monitor and respond to the risks of SARS CoV2 as they evolve.

We need a risk-based decisionmaking framework built on Respect (empathy and compassion i.e. understanding and kindness). By fully understanding the benefits we bring to each other, weighing these MEDICAL FORUM | MEN 'S HEALTH ISSUE

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Latest guidelines for PCOS diagnosis What is Polycystic ovarian syndrome (PCOS)? An endocrine condition primarily associated with alterations in testosterone and insulin hormones with known heterogeneous presentations involving a woman’s appearance, fertility, cardio-metabolic risk and mental health. In 2018, the first international guidelines for PCOS were published.

Diagnosis of PCOS Diagnosis has been challenging for a number of reasons. The widely accepted Rotterdam criteria holds true for diagnosis. The most important tool in diagnosis involves a detailed clinical history and examination. Biochemical and imaging tests provide supportive evidence for diagnosis. Rotterdam Criteria: 1. Oligo-ovulation or anovulation 2. Clinical or biochemical signs of hyperandrogenism 3. Polycystic appearing ovaries on ultrasound (PCOM) Any two of the above three criteria are required for diagnosis after conditions that mimic these symptoms have been excluded. Exclusion of other cause include testing for TSH, prolactin, FSH and based on clinical picture test for Cushing’s, congenital adrenal hyperplasia or neoplasia. 1. Oligo-ovulation and anovulation is defined: First year post menarche, it is common to have irregular menstrual cycles • >1 yr post menarche > 90 days for any cycle • >1- <3 yrs post menarche cycles of <21 to >45 days • > 3 yrs post menarche, <21 or >35 days or <8 cycles a year • Primary amenorrhoea by age 15 or >3 yrs post thelarche 2. Clinical or biochemical signs of hyperandrogenism Clinical hyperandrogenism: • Can be objectively quantified

using a modified Ferriman Gallway score for the presence of terminal hair (not vellus). Scores of ≥ 4-6 changed from the previous score of 8. Consider racial and ethnic variations. • Acne on its own is not a feature of hyperandrogenism, especially in the adolescent age group. However, severe cystic acne or acne persisting well beyond adolescence with the presence of biochemical evidence of hyperandrogenism can be considered as a criterion. Biochemical Hyperandrogenism: • Assessed by testing for testosterone and SHBG to calculate free androgen index (FAI) and/or calculated free testosterone in follicular phase. • Androstenedione and DHEAS testing can be done if testosterone levels are normal, and 17 OH progesterone testing if congenital adrenal hyperplasia is suspected. Other causes of hyperandrogenism include idiopathic hirsutism, classical and non-classical congenital adrenal hyperplasia and obesity related hyperandrogenism. Androgen secreting neoplasia should be suspected in the setting of new and rapidly developing hyperandrogenic symptoms. 3. Ultrasound – Polycystic ovarian morphology (PCOM) • Up to 70% of adolescents meet USG criteria for PCOM as multicystic ovaries are common in this age group. Hence USG should not be performed before eight years following menarche. • In adult populations, a transvaginal approach is preferred. More than 20 follicles in either ovary and/ or >10ml ovarian volume is required for the diagnosis. Caveats to consider: • When the clinical picture is unclear (specially in adolescents), it’s advisable to defer the diagnosis and reevaluate the patient in a few years. Labelling such a patient as

Dr Kalani Kahapola Arachchige Chemical Pathologist and Endocrinologist

About the Author Kalani has special interests in female reproductive endocrinology. Kalani maintains an endocrinology practice at the Keogh Institute and at the WA Specialist Clinic.

•

“at risk of PCOS” and deferring the definitive diagnosis for up to eight years post menarche is considered reasonable. Women with PCOS, as they reach their fourth decade, can develop regular menstrual cycles and notice an improvement in the androgen levels. Similarly, persistence of hyperandrogenic features into menopause is also possible. Obesity is not part of the diagnostic criteria. It is important to understand that all obese women do not have PCOS and vice versa. Obesity is considered a different entity to PCOS and can lower SHBG and lead to increase FAI contributing menstrual irregularity. Lean women with PCOS tend to have more hyperandrogenic features whilst obese and overweight individuals are more likely to show signs of insulin resistance. Even though insulin resistance and raised LH: FSH ratio reflects the underlying pathophysiology in PCOS, these markers are not used as diagnostic criteria due to their non-specificity.

Further reading: https://www. monash.edu/_ _data/assets/pdf_ file/0004/1412644/PCOS_EvidenceBased-Guidelines_20181009.pdf

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200 Patient Results: 9371 4340 For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au

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JULY 2020 | 7

Consumer sentiments The Consumers Health Forum conducted a survey which reveals some stark numbers about how patients felt about accessing their doctor during the pandemic, and perhaps some of those behaviours might be here to stay. The results should certainly influence how health services may adapt to the changing moods. See the infograph here. Consumers were also surveyed by the Australian Digital Health Agency about what they wanted from their My Health Record and the top five on the wish list were test scans and results, notes from their GP, information on medicines they have been prescribed, Medicare information and their immunisation status – all very useful things to have at your fingertips.

CONTINUITY OF CARE COLLABORATION CONSUMER SURVEY: ACCESS TO HEALTHCARE DURING COVID-19

MOST COMMON SERVICES MISSED

21%

32%

General Practitioner

MHR Statistics (April 2020) • 22.75 million My Health Records • 15.6 million records with data in them • 1.95 billion documents uploaded • 65 million clinical documents uploaded – by hospitals, pathologists and radiologists • 128 million medicine documents uploaded – by GPs and pharmacies.

Suppliers scrutinised In the wake of the procurement scandal that rocked the NMHS, the WA government is establishing a debarment regime aimed to improve business practices and provide the Government with the power to suspend or debar suppliers from the procurement process. In the worst cases of wrongdoing, such as a supplier being convicted of fraud, bribery or corruption, the new regime would prevent these suppliers from doing business with government. Public feedback of the regime is sought by July 27.

Vax for at-risk The meningococcal B vaccine will be funded under the National Immunisation Program for the first time this month, available now for people at highest risk from infection. From July 1, MenB-MC, sold as Bexsero, will be funded for Aboriginal and Torres Strait Islander children under two, and for people of any age with any of

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of respondents said they had delayed or avoided a medical appointment in the last 3 months

BARRIERS TO KEEPING UP WITH REGULAR HEALTH CHECKS

36%

Allied Health Practitioner

22%

Pathology Test

The ADHA responded by fast-tracking the uploading of information from the Australian Immunisation Register for those records which had not been updated. At the end of April, of the 22.75 million My Health Records nearly 70% had information in them; including nearly 10 million with immunisation information.

52%

During the COVID-19 pandemic, there was a significant drop in engagement with healthcare services for non-COVID health issues in Australia. In May 2020, the Continuity of Care Collaboration (CCC) conducted a survey of 729 people about access to healthcare.

THE MOST COMMON FEELINGS ABOUT USING HEALTH SERVICES WERE:

59%

worried they would be around people with COVID-19 if attending health appointments

55%

felt it was safe to delay regular appointments if nothing has changed and they are feeling OK

36%

were worried health services were too busy

31%

did not feel safe visiting healthcare services in person

51%

said they would only seek medical help face to face in an emergency

43%

said they prefer to have their usual appointments over the phone or online at the moment

were worried about taking public transport to health appointments

30% 28%

said that health services they usually use are closed

found telehealth could be difficult to use due to technology or poor access to internet / phone

23%

were worried they could be breaking lockdown rules

47% of women preferred telehealth options compared to 34% of men

three immunological risk conditions: defects or deficiency in complement components; treatment with the monoclonal antibody eculizumab; or asplenia. People with those risk conditions are also eligible for the combination ACWY meningococcal vaccine under the NIP, as well as pneumococcal and Haemophilus influenzae type B vaccines.

to be completed by 2023. The regional city’s mental health step up/step down service, which will have 10 beds, is also one step closer with a $5.6 million injection from the WA government. Similar services are under way in Kalgoorlie and Karratha.

A dying wish... Geraldton spend Work is set to start on the $73.3 million redevelopment of Geraldton Health Campus. Ground works are expected to commence soon and be completed in the first quarter of 2021. The health campus will remain fully operational throughout the redevelopment, which will include an expanded emergency department and a new intensive care unit colocated with a redeveloped eightbed high dependency unit. A new integrated mental health service, with a 12-bed acute psychiatric unit and a mental health short stay unit, will also be built as part of the improvements. Building is expected

Professor Samar Aoun from the Perron Institute and La Trobe University will conduct a review of patient perspectives of palliative care models. Previous research indicates that end-of-life experiences for many Australians does not reflect their values or choices. Many, for example, say that in the final stages of their life they want to be at home, surrounded by family and friends, but despite that preference and advances in palliative care services, fewer than 10% experience this. The independent review will look at patient experiences and preferences on receiving palliative care and the perspectives of their families and carers. It will also explore the needs

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IN THE NEWS

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COVID-19 NEWS of those who were unable to access palliative care. The findings will be put to service provider forums to develop ‘enhancements’ to palliative care models in WA.

WA leads the way BreastScreen WA has become the first breast screening service in Australia to connect to My Health Record, giving women their mammogram results as soon as their test is assessed. The service has been providing results to women electronically since last year and they can also choose to receive either an SMS or a letter, and their GP is also kept informed electronically if the patient consents.

No heroics, please The TGA has reminded advertisers that therapeutic goods advertising must not undermine public health campaigns. The warning is aimed at advertisements for cold and flu medicines that may urge the old ‘soldier on’ concept. In the time of COVID, anyone with cold and flu symptoms (even if temporarily controlled) are urged to stay at home.

Mental health, southside Bethesda Health Care is spreading its wings southwards with an approved plan to build a private mental health service in Cockburn. It was announced back in February when the world was turning on its head with coronavirus. The service on 10,000sqm of land in Cockburn Central West will include 40 overnight beds (for voluntary adult admission only), a mental health and wellbeing centre and consulting suites with construction due to begin at the end of 2020 and the doors are expected to open in 2022/23.

eScripts are coming It looks like the practice management software companies are all ready and raring to push send on eScripts with all the major companies applying for national approval. In WA, the state government has approved the use of Bp Premier Jade SP3 Build 1.10.3.894 for prescribing and Minfos software for dispensing. This was the state of play as we were going to press and that other software providers are pending.

A drug developed by UWA’s ‘spinout’ company Dimerix will be used in a global trial to treat patients who have Acute Respiratory Distress Syndrome (ARDS) as a result of COVID-19. DMX-200 is a potential renal therapy to reduce damage from inflammatory cells limiting onset of fibrosis.

The Department of Health and Western Australian Health Translation Network grants program is sinking $1.1 million into projects that will increase understanding of the short- and long-term health impacts of COVID-19 as well as provide a data collection system.

Respiratory physician Dr Anna Tai at SCGH will lead a team exploring the use of convalescent plasma in early treatment of COVID-19 patients. The research will allow scientists to study the technique which has been used to treat other viruses such as Ebola and SARS.

A/Professor Roslyn Francis and her team from UWA will examine whether inflammation associated with COVID-19 persists in the lungs and blood vessels after a person has recovered from the virus.

UWA Professor Jon Watson and team will develop an integrated data and biobanking platform to record and collate clinical information on patients infected with the COVID-19 virus.

SJGHC opens RMO applications St John of God Health Care has opened applications for RMO positions across the organisation’s Midland, Mt Lawley, Subiaco and Murdoch hospitals.

Results of UK trials (still to be peer reviewed) of a cheap and widely used steroid, dexamethasone, shows reduced death rates of about a third of critically ill COVID-19 patients. Excitement is being tempered by The Lancet‘s recent retraction of COVID studies but it hasn’t deterred Britain's Health Ministry from approving the drug’s use in the NHS.

CEO Dr Shane Kelly said that the response to COVID-19 demonstrated how essential it was that the health system was integrated. Clinical experiences included general medicine, oncology, respiratory, cardiology, emergency medicine, orthopaedics and obstetrics and all things in between. MEDICAL FORUM | MEN 'S HEALTH ISSUE

JULY 2020 | 9

Q&A with... Mr Tim Hammond, Barrister, The Fathering Project board member

MF: What drew you to the Fathering Project? TH: I had known of Professor Bruce Robinson’s work – both with the Fathering Project and also as a leading medical scientist in Western Australia – for many years and had long admired his wisdom, candour and insight in both medicine and fathering. So, after politics, the time seemed right to make a contribution to an organisation and a cause that I strongly believed in and was passionate about. MF: What was your experience with your father growing up? TH: My Dad probably fitted the mould of an ‘old fashioned’ father figure. He was a fairly reserved bloke and didn’t talk much about things like feelings. He passed away when he was relatively young at the age of 54, when I was in my mid-20s. I often reflect on that with some sadness because we really missed out on a lot of shared experience along the way. MF: How important is a father figure in the lives of children growing up? TH: A father figure is of crucial importance in the lives of children growing up. The reality is always going to be that the father-child relationship is fundamentally reciprocal. Fathers or men who can provide guidance and love also gain a sense of confidence. So, as a two-way street goes, it is a pretty important one. MF: What were your personal dreams before marriage and children? Has that changed, if so how? TH: My personal dreams before marriage and children mainly revolved around professional aspirations. They were to play a role in federal politics, but also to 10 | JULY 2020

try and continue to work in areas in the law with strong connections to social justice. Finding myself legally representing people who were sick and injured, mainly from asbestos-related conditions, was very fulfilling. Marriage and fatherhood reshaped my personal dreams more than I could have possibly imagined – and in a really good way. Everything fundamentally shifted. As much as it may sound like a glib cliché, the reality is I had no idea just what a profound impact being a father and a husband could have until children came along. We are now blessed to have three of them. It is very much the case that my dreams are now focused around adventure, fun, kindness and all of those shared experiences with my wife and my children. Hopefully chasing down those dreams will instil the same ambition in my kids. MF: Can you successfully have both career and family? TH: Yes, I think you can. It does require, however, a lot of work at both. In my view it needs a constant level of checking-in to make sure that obligations and tunnel vision in a career don’t compromise the integrity of the family unit. It is very important to ensure honest and open communication. Having a successful mix of both is achievable, it just takes work. MF: Law and politics, like medicine, are brutally demanding of time and energy, how important is it to draw a line in the sand? TH: It is fundamentally important to draw that line in the sand; to carve out time consciously. To be available for your family. That can be tricky when cases need to be conducted time-intensively or there are particular difficulties with a case. Post politics, I have returned

to the Bar and a lot of my work is representing victims of asbestos disease who have limited life expectancies and their cases need to be run quickly. I also represent survivors of historical institutional sexual abuse, which also requires a fairly high degree of emotional investment to ensure the job is not only done professionally, but also in a manner that is sensitive to the complex trauma that is usually associated with such claims. However, I strive to be present when I am with my family and ensure that work is left at work or in my study (I won’t pretend that I always succeed though!). MF: Is our society enabling for fathers to take greater roles in their children’s lives? TH: Slowly, but surely, I think this is becoming the case. It is an incremental shift, but it is an important one and the more we take the conversation away from this false notion of role demarcation in the family unit (i.e. breadwinner out of the house and a care provider being based at home), the further we take the prospect of enabling dads to have significantly greater roles in their children’s lives. MF: When you stood back from politics in 2018, what was the range of reactions to your decision? TH: I was bracing for an onslaught of criticism because I thought there would be a lot of people who would be scornful of me deciding to effectively ‘give up’ life as an MP. However, I was incredibly humbled and pleasantly surprised to find that this was most certainly not the case. I was overwhelmed with the amount of positive feedback I received from all sectors of the community. I think in many ways that feedback was driven by

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Q&A

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Q&A the fact that I approached the conversation about my decision to resign honestly. MF: Who did you listen to most? TH: The people I listen to the most are those who I trust; who time and time again provide wisdom, advice and guidance, who are able to see a world outside politics. I listen to my oldest friends, some of whom I have known since high school. Also my wife and my kids. We have a very open conversation at home about important family matters – stepping away from politics was obviously a significant one. MF: Do you think the imposed pause on our lives as a result of the pandemic responses has made any difference to the way we think about parenting in general and fathering in particular? TH: As confronting and challenging as it is, I reckon the pandemic response has also created opportunities for disruption - in a really good way. So many dads I

speak to were ‘forced’ to recalibrate the way they worked and as they spent more time at home, they found they really liked it! I think it also has created a catalyst for this important understanding that as fathers and father figures, the most valuable thing we can be doing is not spending 40 hours a week bringing home a pay packet - and adding to that the time away from home with a commute. Instead, our most valuable contribution is just to be present. The confinement brought about as a result of the pandemic has meant that a lot of dads have realised that a lot more quickly than they otherwise might have. That has to be a good thing. MF: Has it changed the way we think about work? TH: Working from home has changed the way we think about work. I must say I find the labelling of ‘work/life balance’ to be unhelpful. I just don’t think in this day and age, given the immediacy

of electronic communication, we can expect an arbitrary level of demarcation of work on one side of the ledger and life on the other. The inference is that we have to trade off one thing for the other and therefore achieve some mythical unicorn called ‘balance’. It seems to me that getting this right now and into the future is probably more about work/life integration. If we can integrate work in our life in a way that creates and enhances meaning in our family time, then that seems to me to be the direction we need to head. The experiences of the past several months has hastened that march to work/life integration. Our time on this planet is so short. If we are lucky (and I consider myself very privileged) to do paid work we find truly fulfilling, we should chase it down and do it. But we should always be aiming to do it in a way that places as little compromise to the integrity of the family unit as possible.

The Hammond family – Tim, wife Lindsay, and children Tully, O'Hara and Sidney

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They’re not who you think Addiction specialist Dr Richard O’Regan talks to Ara Jansen about addiction medicine and how the people who seek out his help aren’t always who we expect.

Ten people are waiting in your reception area. Which of them has an addiction problem? You immediately pick the rough-looking guy on the end and the teen with too much black eyeliner. Actually, it’s the guy with the fresh haircut and recently dry-cleaned suit. Dr Richard O’Regan might chide you gently for making the stereotypical choice and jumping to conclusions, but the truth is 98% of people accessing Next Step Drug and Alcohol Services are most likely to be just like that clean-cut guy. In most cases, a set of life circumstances have caused them to find relief in alcohol or drugs, which has subsequently hurtled out of control. “A lot of people think that addiction medicine is dealing with stereotypical rough types who talk badly and do drugs like meth,” says Richard, Next Step’s Director of Clinical Services. “It’s not true and it’s something a lot of people miss. There are a lot of smart people with substance abuse problems who are at the other end of the scale. 12 | JULY 2020

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CLOSE-UP “To me it’s something of a privilege to be the person who can be nice to them and give them hope. It’s about showing them even a glimmer of hope and not judging them, or rather judging them positively so they feel that life is not quite as difficult. I want to make them feel a sense of moving towards their goals in life. “How do you talk about these things if you don’t know how, or have a lot of shame and stigma around it? The stigma of addiction or violence through addiction is a big deal for people with these issues. It’s good to raise that awareness. It’s to that end that I want to continue to raise the profile of Next Step and the profile of addiction medicine as a specialty amongst other clinicians and to make it more normalised for the public.”

Taking the Next Step Formerly the Alcohol and Drug Authority, Next Step provides a range of treatment services and family support for people experiencing drug and alcohol problems. This includes services in nine metro clinics, outpatient and medical support for young people and The Community Pharmacotherapy Program (CPP) which provides support, information, advice, training and resources for clients, pharmacists

and medical practitioners involved in methadone and buprenorphine treatment for opioid dependence. A GP by training for nigh on three decades, Richard has worked in the area of addiction off and on for most of it. While training for his college fellowship, he worked at the Alcohol and Drug Authority and had his first exposure to the field. He says moving into it as a specialty wasn’t a conscious decision, in fact, when he began it was still largely unrecognised as a specialist field. What a difference a few decades can make. “While I was training in a hospital, I realised that being a GP was the place to go for me. I really didn’t have an interest in pursuing a specialty like surgery,” he says. “I thought about being a psychiatrist but really being a GP interested me because you could be a bit of a jack of all trades. I liked the idea of being versatile and being in control and doing what you felt was required. “As I worked in the field, I became more and more interested in addiction medicine. It really piqued my interest. Addiction medicine wasn’t a specialty in the late-90s and the Chapter of Addiction Medicine (AChAM) was formed in 2001 as a subdivision of the Royal Australasian College of Physicians.

Richard and wife Dr Glynis Jones

“There wasn’t a moment that made me decide to specialise, it was an accumulation of experiences and opportunities. It was a relatively new frontier and there wasn’t as much background knowledge and research as there is now. People were learning things and developments were being made, which was exciting.” Trained in Perth, Richard left the state in 2008, spending time in Queensland and Tasmania, working both as a GP and in addiction. When he returned in 2011, his work in addiction medicine became his full-time focus. “I don’t think addiction medicine was taken particularly seriously in the early days. Now it is,” he said.

Pain & addiction For the last two years Richard also worked with the team in the Department of Chronic Pain at Sir Charles Gairdner Hospital. He says connecting addiction medicine and the treatment of chronic pain was long overdue and has now become much more highly valued. With the COVID-19 restrictions loosening, Richard found it telling that the images that flooded social media and the news media were of people toasting being able to have a beer at the pub. That having a pint was a predominant marker of society getting back to normal. If this is how we mark it, then Richard suggests that perhaps we need to ask some deeper cultural questions. He’s not a teetotaller himself and far from a wowser about alcohol. His patients have often asked him that question. His answer is that he understands that there’s a time to have a drink. “I think we’re approaching a time when we will have to acknowledge there may not be a completely safe level of alcohol consumption, as we have been saying in regards to smoking tobacco for years. It’s becoming more apparent that it’s toxic for the body. “The thing about risk is that chance plays a part – you could drink two glasses of beer regularly and never have a problem or you could have a single big night out drinking, get into a fight and end up with a brain injury, or worse.”

continued on Page 15

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They’re not who you think continued from Page 13 It’s perhaps his extensive work in counselling and working with people addicted to drugs and alcohol which makes Richard affable and easy to chat to.

A helping hand “The approach that I have is that I want to help this person. I’m aware that most of what needs to be done, needs to be done by the person. My job is to help and guide them to the opportunities available to help make a difference. “I understand that people have difficulties with their relationships or their job so it’s about providing them with help, support and guidance. I can’t stop someone from using if they are in a share house with other people who do drugs. I can’t compete with that. But helping them create more positive opportunities requires patience, while knowing they have to make the change.

Captain and Casey on the debrief couch with Richard

“Equally, I can also be the sort of person that they want to continue having a conversation with.”

was the limit of what you can do. You also have to choose not to be consumed by it.

enormous change. Nightly debriefs on both sides with Glynis have been a huge help.

Those conversations can be on all manner of topics and don’t always focus directly on addiction. They can range from politics to favourite books. Richard is a sci-fi buff and loves anything Marvel, citing them as a great escape. It’s a passion he doesn’t mind talking about with his patients as it can uncover common ground.

Coping & debriefing

“We spend half an hour talking about what’s going on at work for us both and without a doubt it has made a difference. Like medical colleagues might do, this is a collegial debrief. Sometimes there’s a bit of black humour involved, but that’s pretty normal in medicine generally.”

“The most important part is being able to engage with the person you’re working with. In addiction a lot of the time it’s about sticking to the plan and to keep coming back. There’s no magical treatment. Like large parts of medicine, it comes back to lifestyle and a person has to do that themselves.” To keep his own balance, especially after hearing some of the more harrowing and distressing stories, he must make his own good choices. At the end of each working day, these choices are walking the dog, chatting to his wife and enjoying a book. “You peel yourself away from the day and know that what you did

“I think there’s something about my personality – and the personalities of people who do this – which means we cope with it, perhaps better than others.” Being married for 28 years has also acted as an anchor for Richard. His wife Glynis Jones is the Associate University Librarian in Library Engagement and Experience at the University of Western Australia. His Westie terrier Casey and cat, Captain, also have a huge soothing influence. Richard and Glynis love movies and during the cinema closures they used their Saturday nights to work through the Wes Anderson catalogue, which includes such classics as The Royal Tenenbaums, The Life Aquatic with Steve Zissou, Isle of Dogs and The Grand Budapest Hotel.

A hobby woodworker at one time, Richard likes getting crafty and nutting out problems. At one point during his career he had six months off and decided to prove that cats can be trained. He triumphantly taught Captain to fetch and shake hands.

Read this story on mforum.com.au

In the past few years, Richard has moved from a largely clinical practice to management at Next Step as director. He’s found it an

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FEATURE

Predicting the unpredictable Suicide prevention is the hardest in the hard basket, but data and strategic thinking are making the impossible seem possible.

Mental health is difficult: It’s difficult to diagnose, to treat, to predict and to understand. Suicide is beyond difficult as there are so many individual factors that lead to someone intentionally taking their life, which makes it a uniquely problematic phenomenon to research. This is reflected in the national suicide rate, which has gradually risen in the past 10 years. According to the Australian Bureau of Statistics (ABS), in 2008 suicide was the leading cause of death among people aged 15-44 in Australia. The ABS also reported that men were three times more likely to intentionally take their own lives. The median age for suicides was 44.3 years of age for males and 44.7 for females. In writing this piece, the topic of prevention strategies for at risk cohorts was broached with Professor Andrew Page. In his response, he reframed suicidal ideations as something to be considered as a variable risk factor that’s not just applicable to certain at-risk cohorts, rather, just one: everyone. “What we need to be looking at is what would increase that risk within us, because thoughts of killing yourself are wide spread. We've looked within university cohorts and over the past year, close to half of them have thought about killing themselves at some point in time, so 16 | JULY 2020

we know that this is not an isolated problem.” Prof Andrew Page is the Pro Vice-Chancellor of Research, School of Psychological Sciences at the University of Western Australia and part of the research leadership team at the Young Lives Matter Foundation (YLM).

Prevention by prediction

Suicidal ideations are like most other aspects of mental health – variable – and experienced by many people at one or many points in their lives, usually innocuous enough not to raise alarms. Anxiety, depression, obsessive thoughts, rigid thinking. Sound familiar? In small enough cases they can be useful in navigating through life, or triggers to address the causality, yet in prolonged and chronic cases, they can be debilitating. This way of looking at whole population suicidal variability is not just an interesting idea to reframe suicide, it’s a practical tool that can measure risk, save lives and also reduce stigma. Part of Prof Page’s work, in collaboration with Perth Clinic, and with YLM is the development of a world first tool, the Dynamic

Developmental Vulnerability Index (DDVI), which utilises artifical intelligence and machine learning to predict suicidal or self-harm behaviours. The phases of suicidal ideations begin with fleeting thoughts of suicide, progressing to planning or attempting suicide, to the ultimate tragedy of the action itself. It’s the subtlety and significance of these phases that the DDVI has been designed to identify for intervention. The Young Lives Matter Foundation (YLM) was formed with the singular purpose of developing new interventions that would reduce the suicide rate, such as the DDVI. The YLM team is comprised of a multidisciplinary group of mathematicians, statisticians, psychologists, and psychiatrists. “Young Lives Matter is about looking at creative and innovative ways that we can more effectively predict self-harm and suicide, especially with youth, so that we can more effectively target preventative efforts,” Prof Page told Medical Forum. The impetus for YLM to specifically look at predication was based on what hasn’t been done, rather than focusing on what has already been done. “When we looked at what was happening across the nation, there was a lot of work on prevention but there was less work in terms of prediction. And if you have finite

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James Knox reports.

FEATURE that person can act out their ideations. “Suicide risk fluctuates. If you're trying to predict something that fluctuates with something that's static, all you're going to do is be able to predict the average, you won't be able to predict those fluctuations. And that's what we need to do.” According to Prof Page, by reframing the research to focus on when someone is at risk rather than who is at risk opens the possibilities of measuring variability.

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“Once you've changed the question you no longer ask, ‘who are the individuals?’ but you ask of individuals, 'what should I be measuring and at what time period' to be able to work out when risk is increasing and when it is decreasing.’”

resources the question becomes, how do you allocate those finite resources in the most effective way that you can predict? “The problem has been that the prediction of suicide has been notoriously poor. In fact, it's been so poor that some people have suggested we should just give up trying to predict at all. As a group, our response to that was: If it's a problem that everybody thinks is too hard, it's one that we should be trying to solve. And clearly, we need to solve it in new and different ways and not just keep on doing the same things that we have been doing expecting them to be able to solve the problem.” The team at YLM decided to shift the research paradigm of suicide prevention, Prof Page explained. “Up until now, most researchers have tended to think about suicide risk by trying to identify who is at risk and so they generally find older men, people with mental health problems, substance use etc. And what we've said is, well, if you think about suicide risk, if you talk to anybody who's felt a risk of suicide, what they'll say is, ‘yes, I was thinking about killing myself yesterday, but I wasn't the day before. I'm not today, but I might tomorrow.’” By measuring the variability or fluctuations of suicidal ideations, instead of at-risk cohorts, the team at YLM can identify when someone is most at risk and intervene before

The current iteration of the DDVI is being trialled at Perth Clinic as a self-report questionnaire administered on iPads. When patients initially present to the hospital, they are asked to complete the questionnaire and continue to report, using it daily. The patient reports are then processed by machine-learning algorithms based on dynamic risk factors for self-harm and suicidal behaviours to predict individual risk. If a patient reports consecutive days of increasing self-harm or suicidal ideations, staff are alerted and resources can be allocated prior to a suicidal action. If the same patient reports reduced ideations, their risk is lower and the hospital's resources can be redirected. Beyond the hospital, Prof Page envisages self-administered questionnaires or possibly a wearable device for individuals to monitor their own risk and if there is a flag, such as reduced sleep or elevated vital signs, they make the data available to a health care professional, such as their GP. In its clinical use the DDVI has provided encouraging results, however, Prof Page does not see it as a one size fits all, rather the dynamic risk factors can be adapted for different people in different situations such as for Aboriginal People in their communities, or school students. Suicide affects everyone it touches but there is no avoiding the overwhelming majority of suicides

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in Australia are male. Yet, what are the factors that make men so much more susceptible to taking their own lives? For one thing, it is a lack of communication, according to Emeritus Professor John Macdonald: “If only men would talk, then that would be a sure path to prevent suicide.” Prof Macdonald is the former Director of the Men’s Health Information & Resource Centre and Foundation Chair in Primary Health Care at Western Sydney University and patron of the Australian Men’s Shed Association. Prof MacDonald has over 30 years’ experience in primary health care and education with a particular focus on the socialdeterminants of health. “In addition to talking, there must be an effort to acknowledge that behind the suicide ideation could be unemployment, family issues, such as separations from children. We tend to quickly label anybody who approaches us in this context as being mentally ill and label them as depressed and understandably, we medicate them. “If we look at the rate of medication over the last 15 years for depression, it's increased phenomenally. We've equated suicidal ideation with depression and I think we should have the courage to question that and go behind what is causing the depression.” “This is not to say those of us who say ‘let’s look at the social determinants’ have the easy answers, however, it's much easier and understandable to prescribe something, something that the literature is saying is useful for these cases than to actually deal with the issues behind it.” If we see someone as being emotionally distressed or mentally ill, it will, of course, influence the way we deal with them, prescribe for them, or seek to help them. We should focus on the issue of emotional distress rather than just quickly label someone as being mentally ill. As part of a study investigating the social determinants of suicide Prof Macdonald interviewed families of men who had taken their own lives and men who made serious attempts to end their lives. continued on Page 18

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Predicting the unpredictable continued from Page 17 “The general conclusion was many of the cases were a result of an accumulation of terrible life events, which led people to a situation where they could no longer cope. And those things could be unemployment, could be separation from a spouse, loss of home. “If someone had been sexually abused or abused as a child, that didn't set them up well to deal with the [stresses of life] that we all have to deal with. If sad life events accumulated that was often what led people to say, ‘well, that's enough.’” Prof Macdonald said social support is an essential component of the social determinants of male health, citing his involvement in the Australian Men’s Shed Association, which he sees as essential for men to be in contact with others that are in the same or similar situations, particularly for older men, in reducing or preventing emotional distress.

Modelling the care Emergency rooms can be chaotic places with endless streams of variable presentations, each requiring a multidisciplinary team of clinicians to provide care, which leads to a formidable balancing act of resource scaling to meet these demands, especially for patients experiencing emotional distress and who are at risk of self-harm or suicide. With this in mind, it was unusual to learn that Airbnb’s newly renovated headquarters in San Francisco was an inspiration for UWA's Professor Sean Hood to research service design for emotional distress and mental health presentations to a Perth ED. Professor Sean Hood is the head of psychiatry in the UWA Medical School, Associate Dean of Community and Engagement in the Health and Medical Sciences Faculty and a Director of UWA Young Lives Matter Foundation (YLM). According to Prof Hood, Airbnb hired a team of designers to follow their staff for around three months to monitor how they worked and 18 | JULY 2020

moved through the office before reporting back with design suggestions of an office redesign.

track that mathematically, we can flag that person as more at risk and provide more resources at the point in which they need them,” Prof Hood said.

Based on this approach, Prof Hood, formed a small team of psychiatrists and mathematicians to go into the emergency department at Sir Charles Gardner Hospital and track patients who presented with self-harm or suicide risk. The team then noted the steps of each patient’s flow through the hospital, from the initial presentation to when they were discharged, and then the mathematicians coded these steps into a network model which they could manipulate to identify the impact on the patient of each clinician who saw them and then tested what would happen if they removed a particular clinician from the patient flow. Such a role was the psychiatric liaison nurse, whom the team found was vital as they were the key team member in the patient flow that would capture patient data specific to self-harm and suicide. “At the time, the hospital was reviewing this service and we could show them what would be lost if the service was removed; what vital information would not be captured anywhere else in the system,” Prof Hood said.

Data driven service delivery Now imagine combining data captured from the Dynamic Developmental Vulnerability Index with emergency department patient flow data, and having an algorithm to predict risk of self-harm or suicide during a patient’s journey through the hospital. Targeting resources could be a whole lot easier. “One of the key issues with mental health is we can look back and say ‘I see significant risk factors in that patient with poor outcomes but the same factors were present in almost everyone else we saw.’ But if we can better predict a person has a cluster of symptoms, which we might not clinically consider, and

“Ultimately, we are hoping this has an impact on suicide but in the short-term we can better utilise the resources that we have. “Currently, most of the decisions are made by clinical wisdom with a clinician saying, ‘I just feel this is risky, I don't feel happy about sending them home’ without external diagnostic guidance.”

Traditional approach Although taking the non-cohort approach to suicide risk modelling has its merits, there are groups in Australia that have far greater risk than others, such as Aboriginal and Torres Strait Islander people. Another project that Prof Hood and YLM is a is focused on is the use of mathematical techniques to map the utility of traditional Aboriginal healers in treating mental health. “This is an area that's not well understood and obviously very culturally sensitive. An aim is to know, as a psychiatrist, when it would be most useful for me to refer a person to a traditional healer. And ultimately can we get Medicare rebates or funding to support this service, which for many patients is going to be better than the alternatives, such as uprooting them from their Country and taking them to a hospital.”

Community based care Similar to the role of men’s sheds for older men, community-controlled services in Indigenous communities can provide pivotal peer support because of the shared trauma these people have experienced, Associate Professor John Allan explained to Medical Forum. “Throughout Aboriginal culture, the issues of dispossession and displacement from country and intergenerational trauma have brought considerable loss that is still really prominent today. This is part of the alienation many people feel.” A/Prof Allan is the President of the Royal Australian and New Zealand

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FEATURE College of Psychiatrists (RANZCP), the Executive Director of Mental Health Alcohol and other Drugs Branch in Queensland Health, and was the Chief Psychiatrist in both Queensland and New South Wales. A/Prof Allan has extensive experience in the mental health and wellbeing of Aboriginal and Torres Strait Islander people, particularly in North Queensland where he spent 20 years working with communities and developing mental health services. “Often, the care and treatment services provided, however good they are, might not be the thing that person needs. They might need Indigenous healing or peer support.” “The Indigenous communities I have worked with that have been able to alter [the care] through community control services have fostered a sense of purpose and pride in what people are doing,” he said. “Community development and peer support is often being controlled by councils or elders which gives communities some control over the situation rather than feel they are at the mercy of the police or health workers. That’s where there has been success in altering outcomes. “Remembering that not all Aboriginal people are the same or have the same social circumstances, it’s important not to label but to look at the strengths of each person and community.”

Real-time data collection It would be remis not to discuss with him the grim forecasts of the University of Sydney’s Brain and Mind Centre for the potential increased risk of suicide due to the economic fallout from the COVID-19 pandemic. This is why, he said, the RANZCP has called for real-time data collection and monitoring of people at risk of suicide. “The stresses of the pandemic have highlighted the many gaps we have. So, the big concern is the changing economic conditions. We know that unemployment is a trigger for suicide,” A/Prof Allan said. “We need to understand the patterns of change, yet we don't have real-time data collection or monitoring of what's actually happening. We need to be able to identify hotspots, trends and groups of people most at risk.” He doesn’t want real time data limited to suicides and suicide attempts but for suicidal feelings and behaviours to inform a model that can predict these patterns of behaviour. If this sounds ambitious, it is, in light of what is currently available. A/Prof Allan said that the current predictive modelling of suicide was not robust when compared with, for example, the COVID modelling, which comes down to the difficulty in identifying and extrapolating the factors associated with suicide risk.

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“Suicide is actually a rare event. It's a terrible event but it's a rare event in terms of the numbers. So, it's actually quite hard on an individual level to predict who might do what.”

Mental health first aid Attitudinally, there is a dissonance in how individuals feel they can help with mental health compared to physical health, A/Prof Allan said. “If someone falls over and breaks their arm, most people know enough first aid to help, to immobilise the arm and call and ambulance. But if a person was feeling low, expressing suicidal thoughts, not everyone feels confident to talk to that person and offer assistance. “Having a general knowledge of mental health is especially important now with hundreds of thousands of people unemployed and millions in insecure employment. “People can be trained in mental health first aid, in just the same way they are trained to deal with a broken arm, and have confidence to get a person help and what the pathways to care are.” Reducing the national suicide rate is beyond difficult but with an understanding of risk variability, real-time data monitoring, predictive algorithms, communitybased interventions, and the simple act of having a conversation, there is hope.

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Mental health looms large If the same decisive action is taken to protect our mental health post-pandemic as has been taken for our physical health during the crisis it could be a very different world.

James Knox reports.

The collective effort in Australia to flatten the curve has been admirable yet there are concerns the response to the looming mental health fallout does not have the same impetus. While the Morrison government has released the Mental Health and Wellbeing Pandemic Response Plan along with $48.1 million in funding for mental health, how and when it will be implemented, and how effective it will be, are uncertain.

The known knowns The most troubling aspects of the COVID-19 pandemic were, and still are in many ways, the unknowns surrounding the disease, such as the basic reproduction number, the case fatality rate and, most importantly, effective treatment strategies. There is more certainty in what is known from a mental health perspective because, although COVID-19 may be nascent, recessions are not and previous economic downturns can inform what is to come, such as increased suicide rates associated with increased in unemployment. Australia may have withstood the 2007-08 global financial crisis, but 20 | JULY 2020

we are almost certainly entering a recession, with hundreds of thousands of Australians already unemployed due to COVID-19 and millions more in insecure or government-subsidised employment. According to Professor Ian Hickie, Co-Director of Health and Policy at The University of Sydney’s Brain and Mind Centre, this could lead to a situation where the mental health care system will be overwhelmed, in much the same way it was feared the acute sector might buckle with COVID-19. “We've been very lucky in Australia to have avoided the larger health effects of the virus, but the economic and social impact will be as profound in Australia as anywhere,” he said. The Brain and Mind Centre released scenario modelling based on factors such as unemployment projections, community connectedness and specialised mental health services in the North Coast of NSW – a region that has higher pre-existing rates of suicide, youth unemployment and lower educational achievement compared with the rest of Australia. The modelling suggested a 25MEDICAL FORUM | MEN 'S HEALTH ISSUE

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50% increase in suicides due to the economic fallout from COVID-19 pandemic if no action was taken. As far as the Mental Health and Wellbeing Pandemic Response Plan is concerned, Prof Hickie, who was the inaugural commissioner of the national Mental Health Commission, is far from impressed, telling Medical Forum the plan lacks the specificity and urgency required to adequately address the post-pandemic mental health fallout. Instead, it emphasises the imperative of the states, territories and federal government to sign-up to a unified approach, which he said was important, but nothing new. “We've had 25 years of national mental health strategies focusing on getting everyone to sign up with very little specificity about the necessary action. That was bad enough when things were business as usual, yet the forecast employment statistics will result in a 25% increase in suicide rates, which will be most marked in areas that are already most at risk.” Prof Hickie spoke of the dissonance in the pandemic response and the post-virus consequences: “The lack of urgency around mental health and suicide prevention

compared to the virus response is obvious. We saw immediate responses to protect physical health, and as [Chief Medical Officer] Professor Murphy correctly points out, tens of thousands of lives were saved. “In mental health, there's even some reluctance to discuss suicide rate [projections], even though we had a national campaign called You Can Talk (#youcantalk) last year. People are now saying, ‘we're not sure that we should talk too much about this in case we encourage the situation, or, become hopeless about the situation’. “It is inaction that will lead to hopelessness, it's the lack of purposeful activity that leads to hopelessness. In the words of the Health Minister, Greg Hunt, ‘plan for the worst, deliver the best.’ I think that's exactly the situation with regard to the mental health of suicide prevention,” Prof Hickie said. Minister Hunt also spoke of the deep anxiety about people's economic future, which Prof Hickie said was at the heart of the matter. Over the next 12 to 18 months this anxiety would manifest in a significant increase in mental health issues, along with alcohol and drug

MEDICAL FORUM | MEN 'S HEALTH ISSUE

use and suicidal behaviour. “It'll be the straw that breaks the camel's back for many people. Those who have previously been vulnerable, those who have already had financial and personal difficulties, are more likely to have significant mental health problems and suicidal behaviour, often mixed with drug and alcohol behaviour, because of this crisis,” Prof Hickie explained.

One size does not fit all As for the Mental Health and Wellbeing Pandemic Response Plan, Prof Hickie said it offered nothing new nor what was needed, being as it was encumbered by unified national agreements, rather, than the required rapid response tailored to regional demands. “Thinking we'll do something in two years, is missing the opportunity to save as many lives as possible. The effect of [recessions] can last for five to 10 years because of ruined life trajectories, career, employment, education and experience. “There’s not a great deal of emphasis on effective health continued on Page 23

JULY 2020 | 21

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Mental health looms large continued from Page 21 system action. We don't need more awareness campaigns, more help lines telling people to seek help. People will be seeking help in their thousands. We need more effective help when and where they present, whether that is at the GP, an ED or online.” While the plan may discuss coordination of care, the most important details such as how and when these things will happen are not specified. And Prof Hickie has seen this all before. Even more frustrating for him is that modelling exists. The Brain and Mind Centre's modelling of North Coast Primary Health Network (NCPHN) data, an area with some of the highest rates of suicide in the country, has been extrapolated to include the wider Australian population based on unemployment modelling. The North Coast NSW region has a suicide rate 40% above the national average, underpinned by adult and youth unemployment, social and health issues, socioeconomic disadvantage and limited health services. However, with regionally focused interventions, the worst could be avoided. Prof Hickie cites the work his team and the NCPHN have been doing on developing regionally specific mental health solutions, tailoring primary health services to areas within the region that are particularly disadvantaged. The NCPHN has been working with The Brain and Mind Centre on developing regionally specific mental health solutions, essentially tailoring primary health services to areas within the region that are particularly disadvantaged.

Problem with private Mental health care, beyond primary health, tends to be the domain of private practice, which is a barrier of entry for those without the means. And if the modelling is correct, the public health system is set to be overwhelmed with mental health presentations. However, there is a template for avoiding this, says Prof Hickie.

Professor Ian Hickie

“The Government showed us how to get there in physical health. They immediately took action to make the resources of the private sector available, should they be needed, by immediately commissioning the private sector,” he said. “There is $700 million of activity, infrastructure and workforce in the private mental health sector in Australia that’s not available to the general public.” The situation would be dramatically improved with access to specialist care, much of which is locked up in the private sector. “Any GP in the country will tell you that they have done all they can, the front door job, and there is nowhere for their patient to go. There is nowhere to keep their patient safe. “Issues such as patients being placed in a private hospital after a suicide attempt is the same as the Government purchasing private beds for patients who

MEDICAL FORUM | MEN 'S HEALTH ISSUE

have pneumonia in order not to overwhelm the public sector. “The most obvious thing is to do that: public purchasing of private infrastructure and capacity. We can’t leave half of our national capability outside the scope of practice, which is what we do in mental health all the time.”

Face the reality As Prof Hickie sees it, the difference in response to the physical and mental health demands of COVID-19 reflects a fundamental unwillingness to engage with the realities of mental health. “We talk endlessly about reducing the stigma. You reduce stigma by action. A lack of action is just perpetuation of discrimination. In mental health and the challenges facing indigenous Australia, you can say what you like but it’s action that speaks so much louder than words.”

JULY 2020 | 23

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MENT0246

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GUEST COLUMN

A different gender gap Men and their health is complex and needs understanding from clinicians, writes Dr Joe Kosterich, Clinical Editor. By all measures, men do worse when it comes to health. Life expectancy is lower, rates of smoking and alcohol-related problems are higher. Suicides are significantly higher. Even deaths from COVID-19 have been higher in males. Of course, there has been improvement over the years. The current generation drinks less than the previous one. Cancer and heart disease survival has improved, and life expectancy has increased albeit the gender gap remains. The question that has always intrigued me is whether men ‘ignore’ their health as is often claimed or do they have it lower on the priority list. For example, I know too much alcohol is not good for me, but I want to enjoy it anyway. I am aware

of that niggling pain, but it does not bother me enough to get it seen to. And the big one, I feel sad, or down, but I will ‘soldier on’. None of this is a criticism of anybody. On the flip side, does our health system cater as well for men as it does for women? Despite being less paternalistic than in the past, entry into the health system still requires people to cede a degree of autonomy. This may not come that easily to many men. In mental health, counselling is valuable but talking about feelings comes more naturally (in general and yes, we are all different) to females.

‘blokes’ to get together and talk whilst also engaging in activities. It enables discussion between peers and the sharing of experiences. Is it a ‘treatment’? Of course not. But not everything that humans experience has a medical cause nor needs a medical approach. It is certainly the case that men (and women too) can be the authors of their own misfortune. There is a clear limit to what any other person or any system can do when the individual is not interested. What we can do is understand the drivers in men’s health and do as best we can to improve it, one bloke at a time.

An initiative which has been successful is the Men’s Shed. This is a non-medical model which allows

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GUEST COLUMN

Always make it ‘patient first’ Vulnerable teens weighed down by gender issues need care and support, says researcher Penelope Strauss. Trans and gender diverse young people are individuals whose gender does not align with the sex that was assigned to them at birth (i.e. what was marked on their original birth certificate). Current research estimates that 2.3% of high-school aged young people in Australia are TGD. And that here and globally, these young people experience significantly higher rates of mental health concerns including depression, anxiety and PTSD compared to the general population. Trans and gender diverse (TGD) young people also report alarmingly high rates of suicidal ideation and attempts, with one in two in Australia attempting to end their life by suicide (at a rate similar to that reported in the UK). They also experience barriers in accessing health services, and are often faced with clinicians who are unaware of gender diversity, or who are unsupportive. As there is an increasing number of gender diverse young people seeking clinical services, clinicians, especially GPs, are in a unique position to support TGD young people as they are often the first point of contact with the health care system. TGD young people may see GPs for a range of reasons including those unrelated to gender (e.g. for a vaccine) as well as genderspecific needs. These could include help with referrals for specialised gender services (some states have paediatric gender clinics with multidisciplinary teams), to mental health support, affirming legal gender, and seeking general information and support Regardless of the reason, it is vital that the GP and the setting is welcoming to people of all gender expressions and identities. Indeed, we know from prior research that TGD people who have a negative experience in a health care setting are likely to avoid health care later on in their life, resulting in poor health outcomes.

The colours of the Transgender Pride flag

GPs can make their practice more welcoming to people of diverse genders in a number of ways, but some key steps include: • Ensuring that forms are inclusive of all genders. This is best done by including an open text box for the patient to write in their gender in their own words and including a space for patients to share their pronouns and preferred name. This is especially important for all TGD patients, as some people may not have legally changed their name and gender marker. • Providing training for all staff as gender diversity is not routinely included in a GP’s education, it is understandable that this is a new area for many. Many TGD community groups provide introductory training, and there is freely available training on primary care online at https:// nwmphn.org.au/health-systemscapacity-building/trans-gpmodule/. • There are various global and Australian standards of care for treating TGD patients that GPs can refer to in order to upskill themselves.

MEDICAL FORUM | MEN 'S HEALTH ISSUE

• Showing you are an ally. Physically displaying items that show the practice is inclusive such as pride flags, resources specific to gender diversity, and having non-gendered toilets. • Not assuming medical pathways. Not all TGD individuals want to pursue gender-affirming medical intervention such as hormones and/or surgery/ies. It is imperative not to assume the medical pathway the young person desires. Young people deserve to be able to be their true selves in health care settings. There is no one-size-fitsall approach as every individual’s experience of gender is different, so it is important to listen to the TGD young person with an open mind and be guided by what they want. Key to the care of TGD young people, as with all medical care, is putting the patient’s needs first. ED: Penelope Strauss is a research fellow in youth suicide prevention at Telethon Kids Institute.

JULY 2020 | 27

Never waste a good crisis These famous words from Winston Churchill should echo for doctors recovering from the financial hit of COVID-19. Jan Hallam reports. The reassuring bubble of medicine being recession proof has been well and truly popped by the experiences of the past three months. However, in this instance, it wasn’t a recession that stopped medical practices in their tracks, it was a public health state of emergency that went fast and heavy, effectively turning the tap off for some with the ban on elective surgery, and drip-feeding others with the introduction of bulk-billed telehealth. The long-term impacts are still to be revealed. Medical Forum spoke to Stephen Jones a principal in the financial services firm, Smith Coffey. In Mr Jones's time, he’s steered clients through recession and the global financial crisis but admits nothing quite matched the shutdown

experienced in March.

in walk-in consultations, left GP practice owners feeling the pinch.

It seems counterintuitive that doctors’ incomes would be damaged during a health crisis but that’s exactly what happened to the cash flow of private specialist medical businesses, finding themselves in the same boat as so many businesses across many sectors during the shutdown.

Mr Jones said medical businesses operated with very little surplus cash, so when patients stopped walking through the door, so did the cash flow. The initial concern for many of his clients was meeting outgoing commitments such as loan repayments and tax instalments – and it didn’t help that shutdown coincided with an approaching BAS payment.

For GPs, the pain was softened by government policy changes around telehealth which enabled them first to see COVID-19 related consults and then to use telehealth more broadly. The rub was that telehealth could not be privately billed which, when combined with a 25-30% decline

“This was before the government stepped in with JobKeeper and tax breaks while putting pressure on banks to defer interest and loan repayments,” he said. “So, yes, it caught people off guard in the sense that they had never contemplated this ever eventuating. And to be fair, it never has. The

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FINANCE cash flows in the medical sector have never been interrupted, unlike say in mining and construction industries where markets are dynamic. “It was a shock to us and to them and perhaps took a little bit longer for the cogs to turn. It also took the banks time to work out the problem. People were still getting sick. The penny hadn’t dropped that a significant amount of a doctor’s income was from private billing and it was not certain when that income would return.” So, how can doctors use these experiences to build financial resilience? “It takes some serious thinking and decision making because protection costs money and it's essentially inefficient because it ties up cash or increases your loan for no growth,” he said. “And, you know, it's like any salient event, you remember it for a year. Everyone will put in some buffers continued on Page 31

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CLINICAL UPDATE

Testosterone and fracture risk in older men By Professor Bu Yeap, Endocrinologist, UWA & Fiona Stanley Hospital The Western Australian Health In Men Study (HIMS) recently looked at how sex hormones might influence bone fracture risk, particularly hip fractures, in men. In 3,307 community-dwelling men aged 70 years and older, men with plasma testosterone levels in the middle two quartiles experienced the lowest risk of any fracture, and of hip fracture. Men with lower and higher plasma testosterone levels had greater fracture risk. The study allowed for other variables (e.g. age, existing medical conditions, frailty) indicating that testosterone was independently associated with fracture risk. This was 30-40% lower (40-50% for hip fracture) in men with mid-range plasma testosterone, compared to men with plasma testosterone in the lowest 25%. Men with plasma testosterone in the highest 25% had similar risk of any fracture, and hip fracture, as with men in the lowest 25%. Plasma oestradiol levels were not related to fracture occurrence. Most previous studies have linked plasma oestradiol levels to fracture risk in men. HIMS, with a 10-year follow-up and 330 fracture events, including 144 hip fractures, is the largest study of its kind. The findings indicate plasma testosterone levels, rather than oestradiol levels, are a robust hormonal indicator of fracture risk

Key messages

A U-shaped association of plasma testosterone levels with fracture incidence is seen in older men Men with mid-normal range testosterone levels had lower risk of any fracture, including hip fracture Testosterone treatment is indicated for men with pituitary or testicular disease (causing androgen deficiency) to restore levels to the physiological range.

in older men. Due to the nature of HIMS, it is not possible to assess the rate at which testosterone was converted to oestradiol in tissues such as bone. A major Australia-wide randomised controlled trial (T4DM) of testosterone treatment in men aged 50-74 years with waist circumference 95cm or greater and either impaired glucose tolerance or newly diagnosed Type 2 diabetes, completed in 2019, is about to be reported. T4DM will discover whether testosterone treatment in men who do not have pituitary or testicular disease prevents or reverts Type 2 diabetes and whether testosterone treatment improves bone mineral density,

and bone micro-architecture. If so, a larger interventional trial would be needed to clarify the role of testosterone treatment to reduce fracture risk in men. The T4DM results and its bone sub-study, T4Bone, will be very informative. Testosterone treatment is currently indicated in men with pituitary or testicular disease resulting in symptoms and signs of androgen deficiency, with commensurately low testosterone levels. Careful clinical assessment should precede, and ongoing clinical and biochemical monitoring accompany, testosterone therapy, aiming to achieve physiological levels. The HIMS findings regarding fracture risk, reinforce this concept, highlighting that very high plasma testosterone levels may not be beneficial. Certainly, misuse and abuse of testosterone, (e.g. for performance or image enhancing) should be strongly discouraged. – References available on request Author competing interests – the author has received speaker honoraria, conference and/or research support from Bayer, Lilly, Lawley Pharmaceuticals, Besins Healthcare and Ferring

Never waste a good crisis continued from Page 29 but how long do you leave them in place for, because they are inefficiencies.” Mr Jones believes business would be better placed to consider what improvements have been made to their business over the past three months. “It is probably safe to say that the good old days pre-COVID are not

coming back, so from a financial sense we have to look at each process and make it as efficient as possible,” he said. “Is telehealth going to be an improvement to keep? What other technology can be used? How can technology be used to prevent inefficiencies but enhance cash flow. “Consider the value both professionally and financially of the work you do and match the best approach to each. Is face-to-face

MEDICAL FORUM | MEN 'S HEALTH ISSUE

required for everything or could technology be used? “Is it important to have cash reserves, working capital provisions, flexible work force? “The shutdown also gave doctors a real-time look at what it's like to have no income, which is what happens at retirement. It gave people an opportunity to assess if they were financially and mentally ready for that.”

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32 | JULY 2020

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CLINICAL UPDATE

Managing erectile dysfunction and Peyronie’s disease By Dr Shane La Bianca, Urologist, Murdoch Erectile dysfunction (ED) is common as males age. Unusual below age 30 (estimated <10%). it may affect more than 75% of men over the age of 70. Peyronie’s disease (PD) prevalence varies (210%) greatly between populations studied, most likely reflecting variations between social views on self-reporting and clinical detection methodology. Only 10-20% of PD cases resolve spontaneously.

Treatments

ED and PD have similar aetiologies. Both are associated with cardiovascular co-morbidities: diabetes, obesity, hypertension, dyslipidaemia, smoking, low testosterone and pelvic/prostate surgery. Penile trauma is reported in around 10% of cases.

Additional oral agents such as curcumin and colchicine may be of use in early PD (painful inflammatory phase) but dosing is complex. Acetyl L-Carnitine and Pentoxifylline (another PDEi) may also improve curvature, decrease plaque formation and improve erectile function. All these oral therapies are supported by level two evidence at best.

The underlying pathophysiologic mechanism for PD plaque is poorly understood. Plaque formation may relate to trauma or repetitive microvascular injury to the (semi-) erect penis. The pathophysiology of PD is likely multifactorial – genetic predisposition, trauma, tissue inflammation and aberrant wound healing all contributing.

Phosphodiesterase-5 inhibitors (PDE5i) are a safe option for all men with ED or PD, except those with symptomatic angina. A trial of daily 5-7.5mg Tadalafil should be considered in both conditions as initial therapy to improve baseline erectile function. L-Arginine is a useful adjunct to PDE5i, acting via nitric oxide dependant pathways.

Patient evaluation requires a comprehensive clinical history focused on disease status (acute or chronic), ED nature (e.g. lack of response to stimulation, loss during penetration, penile curvature, change over time, prior treatments) and other medical co-morbidities that might affect treatment options and outcomes. Physical examination includes the genitals, circumcision status, PD plaque size and location, assessment of the degree of penile deformity based on digital photography (dorsal and lateral views) and assessment of peripheral pulses.

Penile traction therapy may have some benefits in PD (level three evidence) in terms of correcting penile pain, curvature and improving corporal elasticity and erectile response. It should be used in combination with oral therapies and for at least six months. Low intensity Shock Wave Therapy (LiSWT) is not supported by recently published trials. Intralesional therapy with collagenase is effective (level two evidence), but not available here. Despite no large-volume or highlevel evidence-based data to suggest the best treatment option in PD, surgery offers the most rapid and reliable outcome addressing advanced aspects of PD, such as extensive plaque, severe ED and complex penile deformities. Author competing interests- nil

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Modifying risk factors is critical to addressing ED. Both conditions can compromise sexual function and quality of life. Distress over symptoms, penile appearance, and erectile function must be considered.

MEDICAL FORUM | MEN 'S HEALTH ISSUE

JULY 2020 | 33

Men, COVID and alcohol – time to review the guidelines By Dr Michael Christmass, Addiction Medicine, East Perth A poll commissioned by the Foundation for Alcohol Research and Education conducted in April 2020 provided a sobering update on Australian alcohol use during the COVID-19 pandemic. Twenty percent of households reported purchasing more alcohol than usual and, of these households, 70% reported using more alcohol than usual. In these households, 34% admitted daily alcohol use and 32% were concerned about alcohol use in the home. Another consequence of COVID-19 may be more patients presenting to medical practitioners with alcohol-related problems. Many will be male. Let’s take a brief look at draft guidelines regarding alcohol consumption.

ALCOHOL DAILY

CONSUMPTION

ABOVE SINGLE OCCASION RISK

ABOVE LIFETIME RISK

5.9% DAILY

7.6%

77% consumed alcohol daily in past 12 months

4.2%

24%

9.5%

45%

27%

Table 1

use disorder, we reduce harm to another individual.

It is clear that problematic alcohol consumption is more common amongst males than females (Table 1). Men experience more overall harm from alcohol than women despite the well-established outcome that, at higher levels of consumption, risk of harm increases faster for women than men (Table 2). Importantly, more than 50% of harm attributable to alcohol in Australia is from harm to others. When we help a man with alcohol

Latest advice Data on lifetime and single occasion risk (Table 1) correspond to outdated NHMRC guidelines (2009). In December 2019, based on updated evidence, the NHMRC released Draft Australian Guidelines to Reduce Health Risks from Drinking Alcohol.

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CLINICAL UPDATE

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CLINICAL UPDATE

Key messages

Alcohol purchase and consumption has increased during the pandemic Problematic drinking is more common in males New guidelines are being released this year.

The lifetime risk guideline has been reduced from 14 to 10 standard drinks a week. Single occasion risk remains at four standard drinks. Based on mathematical modelling and systematic evidence reviews, risk of death from alcohol-related disease or injury is less than one in 100 where alcohol is consumed within this guideline. Modelling indicates risk of death caused by alcohol increases with total amount consumed (e.g. per week) but also in consuming over fewer days (i.e. higher consumption/episode). It is important to recognise uncertainty assigning level of risk to any specific amount of alcohol consumption. This is in part due to doubt over the existence and

Alcohol ranks 6th in risk factors for burden of disease in Australia

Alcohol contributes 6% of disease burden for men compared with 2.8% for women

Alcohol-attributable hospitalisations and deaths did not decline between 2004-2015

Men have markedly higher rates of alcoholattributable hospitalisation (1.6-fold) and alcoholattributable death (2-fold) compared with women 3

Table 2

>50% of harm attributable to alcohol in Australia is from harm to others 4

magnitude of any cardioprotective effect of alcohol. Further, alcohol is known to cause cancer in humans (Group 1 carcinogen). Evidence from systematic reviews suggest alcohol consumption as low as one standard drink per day is associated with increased risk of breast and gastrointestinal cancers. Finally, the 2009 guidelines are old and updated guidelines should

be released in 2020. It hoped that a brief summary of the new information available for screening, assessing and treating men with alcohol use issues will be ready soon. â&#x20AC;&#x201C; References available on request Author competing interests â&#x20AC;&#x201C; nil relevant disclosures.

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Tackling PSA screening and localised prostate controversies By Dr Matt Brown, Urologist & Robotic Surgeon, Murdoch Few areas of medicine have attracted more controversy than PSA screening and early intervention in prostate cancer. Much of this followed two landmark trials (PLCO and ERSPC) that did not show a significant mortality benefit for PSA screening. Not only was PSA screening ineffective, but in that era, many patients underwent radical treatment for non-aggressive cancers. With a combination of poor efficacy and overtreatment, it was unsurprising that a ‘backlash’ against PSA screening ensued. The RACGP Red Book incorporates these issues – effectively counselling against PSA screening. However, prostate cancer is the most common cancer in Australian men and the second most common cause of cancer death. Despite high prevalence and significant lethality, prostate cancer trajectory is usually measured in decades. Hence followup of the original PSA screening trials (median nine years) was actually too short to properly assess for an impact on mortality. With follow-up to 13 years and, most recently (in the Rotterdam subset) 19 years, a significant impact of PSA screening on death rates can be seen. Based on a CISNET

Key messages

PSA screening is now supported by national guidelines An MRI should always be done before a biopsy. analysis, PSA screening reduces prostate cancer mortality by 25-35%, comparable to colorectal and breast cancer screening.

Concerns Morbidity of Biopsy. Traditional prostate cancer diagnosis revolved around a transrectal biopsy for an elevated PSA. However, following the PROMIS and PRECISION trials, elevated PSAs are a trigger for an MRI – not a biopsy. Moreover, when a biopsy is performed, it may be targeted (reducing the number of needles) and many practitioners have shifted to a transperineal approach (with a much lower risk of infection). Overtreatment. The possibility of overtreatment is a concern, but largely historical. In the modern era of accurate stratification, improved diagnostics and MDT-led management, men do not undergo treatment for indolent disease. One US study indicates a tripling in conservative management between

2005 and 2015. Our experience would be similar. Morbidity of Treatment. Prostate cancer treatment has a bad reputation due to concerns about inaccuracy/side effects (radiation) or incontinence/impotence (surgery). Modern radical prostatectomy has undergone significant evolution. Excellent results for continence and (to a lesser extent) potency are typical. Surgical expertise is paramount, but what happens outside the operating theatre is equally critical. High-volume surgeons will therefore work with a team of prostate cancer specialist nurses, physiotherapists, sexual medicine practitioners, and senior urology nurses. National guidelines on PSA screening have been published by the Prostate Cancer Foundation of Australia and endorsed by the RACGP. A PSA test may be done every two years from ages 50 to 69. Referral should be considered if the PSA is above 95th percentile, or more than 3.0ng/mL (2.0ng/mL in high risk groups). To reduce false positives and assist with Medicare criteria, a patient should have an MSU and two PSAs with free total ratio (minimum a month apart) before referral. – References available upon request. Author competing interests – nil

Men’s mental health – the silent epidemic By Dr Davinder Hans, Psychiatrist, Nedlands One in eight men will experience depression and one in five men will experience anxiety during their lives. Men comprise approximately 75% of suicides in Australia. The number of men who die of suicide in Australia is nearly double the national road toll. Deaths due to alcohol abuse-related causes are almost double that of females. Australian men have lower rates of mental health literacy and face numerous barriers accessing help for these issues.

A tragic confluence of low rates of diagnosed depression, high rates of suicide, and poor engagement with mental health services lead to a complex interplay of factors that need to be considered to help men overcome the burden of mental illness. Firstly, identification of mental illnesses in men is difficult due to how males express emotional discord. Particularly in the early stages, depression in men often manifests as irritability, anger, aggressiveness and risk-taking behaviour. These features

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can mask more typical symptoms of depression (tearfulness, sustained low mood, changes in appetite, reduction of interest in leisure). Secondly is a misconception of socially prescribed rules about masculinity and ‘what it means to be a man’. Some men place their sense of self-worth into external indicators of success (e.g. career, financial continued on Page 41

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CLINICAL UPDATE

People, not robots, the next advance in prostate cancer By Dr Tom Shannon, Urologist, Nedlands The aim of prostate cancer treatment is to achieve cure whilst maintaining physical, urinary and sexual function. Technology with better MRI, more precise resection and radiation has helped, but problems persist. Prostate cancer patients tend to present late and have co-morbidities with obesity, diabetes and cardiovascular disease that directly affect outcomes. By holistically addressing all these issues, we can generate better cancer outcomes, but possibly more importantly, improve overall risk of disease through lasting lifestyle change. Over the past 10 years, we have moved from the typical surgeonand-patient interaction to a teambased approached that takes the patient on a journey through cancer diagnosis, rehabilitation, recovery of function and survivorship. To engage the patients in their own care, the initial focus is on education and support, with a prostate cancer specialist nurse who has undertaken advanced training, is independent and remains a patient advocate during the journey. Cancer is framed as a challenge that can be faced

Key messages

Prostate cancer management is changing Reframe prostate cancer as a challenge to be defeated rather than feared Holistic care can improve outcomes.

and defeated, rather than a feared imposter. After an explanation of diagnosis and reading literature, nurses answer questions over an unhurried long review. Patient emerge from their review more relaxed, with clarity and purpose. The next step is often a weight loss and exercise program targeting the central obesity common in male cancer patients. Average weight loss at three weeks has been 7.3kg, (with mainly visceral fat loss), a fall in SBP of 15mmHg, much improved diabetes control and improved mood (in press). Weight loss more than 15kg is common with longer programs, with satisfying compliance of more than 90%. Nomograms predict significant

reductions in CV morbidity and mortality. Incontinence can be minimised by good surgery. Weight loss and pelvic floor training with a physiotherapist can reduce long-term continence issues and physiotherapists can help in considering when therapy can work, or when corrective surgery is needed, to prevent long periods of inconvenience. Sexual function is a major concern of patients and has become a focus of pre- and post-operative care. It is now an expectation that sexual function can be resumed soon after surgery, initially with help and later, spontaneously. This eases much of the anxiety around treatment for many men. Vascular health is reinforced as critical to erectile recovery. Survivorship has become more important with the longer life expectancies, especially with more advanced disease. Exercise becomes critical and patients are commonly involved in exercise programs or trials. Author competing interests - nil

Men’s mental health – the silent epidemic continued from Page 37 achievements), leading to an unhealthy level of competitiveness and sacrifice their own mental health needs, whilst chasing an illusion of success. This leads to an ever-shifting ideal which is impossible to achieve, thereby creating a sense of failure further compounding the inability to express underlying feelings of anxiety or distress. Seeking help is the third issue. Men tend to be more reluctant to accept help especially for mental health concerns. Fear of social stigma related to mental health issues is the most prominent factor leading

many men avoiding mental health services or even researching their options for support. One approach to these issues is to promote change in the ways that men think about mental illness itself. Efforts to break down stigma by organisations such as Beyond Blue has improved mental health literacy amongst Australian men. A second approach involves changing traditional concepts about how helpseeking is perceived. Rather than a sign of weakness, and therefore something to avoid, we ought to flip things around positioning helpseeking as a show of strength, involving taking back control of one’s situation and improving one’s life by getting things back on track.

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These conversations and mindsets can normalise the connections and engagements we know encourage positive mental health outcomes in men. We are changing the language used in discussions about mental health. Terms like ‘mental fitness’ instead of ‘mental illness’, and ‘struggling with or battling against pressures’, instead of ‘feeling sad or depressed’, can reduce some of the difficulties which traditionally exist in these discussions. This can lead to more open discussions about mental health difficulties and improve men’s access to mental health supports. Author competing interests -nil

JULY 2020 | 41

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CLINICAL UPDATE

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Quality of life post-prostate cancer treatment By Dr David Sofield, Reconstructive Urologist, Palmyra One in seven Australian men will be diagnosed with prostate cancer. Early diagnosis is associated with prolonged survival. With treatment 95% will live at least five years, often 10-20 years. Curative treatment with surgery (radical prostatectomy (RP) and radiotherapy (RT) is effective but side effects are common and can have a major impact on quality of life.

UI and ED are common following prostate cancer treatment and significantly impact quality of life. These issues need not be accepted and can be managed effectively. Awareness of treatment options is lacking and is key to men accessing care.

Urinary incontinence Any amount of uncontrolled leakage is significant and should be taken seriously. RP results in stress incontinence-leakage occurs in response to ‘stress’ on the bladder (e.g. lifting, coughing, laughing etc, known as SUI). This is due to weakness of the voluntary External Urinary Sphincter (EUS) which

resides at the apex of the prostate and suffers direct injury and denervation, particularly in cases of locally advanced cancer where wide resection is necessary. Radiotherapy can also result in UI but typically this is due to contraction of the bladder with loss of storage capacity in addition to EUS injury and usually develops over a period of years, post-treatment, and can be challenging to manage. Management options include preoperative weight loss, physiotherapy (pelvic floor muscle strengthening), and anticholinergic medication (not effective in SUI). Surgery is an option where physiotherapy fails. A urethral sling is effective for mild SUI (three pads or under 300ml loss per 24 hours). continued on Page 44

Australian first for BreastScreen WA

My Health Record

reastScreen WA is the first breast screening service in Australia to connect with My Health Record. WA women, who have have consented, will have their mammogram results uploaded to My Health Record from the 31st March 2020.The fast-tracking of results will further support women and their health care providers as more care is delivered digitally. Having the results kept in one convenient and secure place means they can be accessed at any time to help inform decisions about patient care. BreastScreen WA provides free screening mammograms to asymptomatic women and specifically targets women aged 50 to 74 years, however, all women 40 years or over are eligible and welcome to attend.

www.breastscreen.health.wa.gov.au or phone 13 20 50 MEDICAL FORUM | MEN 'S HEALTH ISSUE

Mar ‘18

Urinary incontinence (UI) occurs in 5-40%, erectile dysfunction (ED) in up to 80%. Fortunately, effective treatments are available for UI and ED post-treatment. Neither needs to be accepted as inevitable consequences of cancer treatment and quality of life can be restored effectively in most cases. Access to such treatments are hindered by a lack of awareness amongst patients and their GPs.

Key messages

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Managing the dizzy patient By Maddison Brennan, Balance Audiologist, Subiaco Dizziness is a nondescript symptom meaning something different to each individual. The term is commonly used by patients to characterise sensations including vertigo, imbalance, presyncope, and light-headedness. Over one third of Australians over the age of 50 experience some dizziness or vertigo. The differential diagnosis of dizziness is complex. One third of patients are still symptomatic after a five-year period and only one in four ever receive treatment for their dizziness. Even for benign paroxysmal positional vertigo, studies show the average time from symptom onset to diagnosis can be 19 to 70 months. Undiagnosed and untreated dizziness can significantly impact quality of life. The psychological impacts include increased social isolation, anxiety, and depression. Dizziness can lead to lost work time and reduced productivity. In the elderly, it is associated with reduced physical activity and an increased falls risk. For the majority of patients, a thorough history will make the diagnosis and inform treatment. This history would include temporal features, associated auditory or wider symptoms, and any specific triggers.

Key messages

Dizziness is common Accurate assessment is needed to inform treatment

Vestibular rehabilitation can improve symptoms. A formal assessment of the vestibular system with an audiologist can offer supplementary information to facilitate diagnosis and management. Test results include objective, side-specific, and receptor-specific information.

a vestibular lesion, doing so through assessing the vestibuloocular reflex. Caloric testing’s pitfall is that it only measures the horizontal semicircular canals. Video head impulse testing (vHIT) complements caloric testing and can assess function of all six canals, helping to better localise peripheral lesions.

Vestibular Rehabilitation

Videonystagmography (VNG) utilises an infrared video system attached to goggles to monitor and record eye movements. The VNG battery includes a series of subtests evaluating different components of the peripheral and central vestibular system, including preliminary tests for central lesions. Electrophysiological testing is performed to assess auditory evoked potentials, including vestibular evoked myogenic potentials (VEMP). VEMP testing assesses the function of the otolith organs and is a valuable diagnostic tool in the diagnosis of semicircular canal dehiscence.

Vestibular rehabilitation therapy (VRT) is the foundation of treating many causes of dizziness. The vestibular pathway demonstrates a high degree of neural plasticity and the aim of VRT is to facilitate central compensation. Successful VRT results in improved gaze stability, reduced dizziness, improved postural stability and gait, and helps patients restore normal function and activity. VRT has been demonstrated to show both subjective and objective improvements in a patient’s symptoms. – The author wishes to acknowledge the input of Ellen Putland in the writing of this update. Author competing interests - nil relevant disclosures.

Caloric irrigation remains the gold standard for diagnosing peripheral

Quality of life post-prostate cancer treatment continued from Page 43 An artificial urinary sphincter, which is patient-operated, is 90% effective in severe incontinence. The complication rate (parts failure, infection erosion) is higher than with a sling.

Erectile dysfunction (ED) This is commonly pre-existing in the those being treated for prostate cancer with 50% at age 50 having 44 | JULY 2020

some ED, increasing 10% per decade post-surgery most will have severe ED which may improve over 1236 months. Erectile nerve sparing correlates with recovery but is not always possible with locally advanced or high-grade cancers ED management can be nonsurgical. This includes penile rehabilitation early post-op with PDE5 inhibitors, vacuum device and intracavernosal injections to maintain penile tissue health whilst

awaiting nerve function recovery. Penile prostheses may be inflatable (effective with high patient and partner satisfaction). Complications include infection and parts failure. Malleable implants are simpler with less complications but also less effective. Author competing interests – nil

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CLINICAL UPDATE

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GUEST COLUMN

Looking for hope Perth psychiatrist Dr Adam Brett found Johann Hari’s book, Lost Connections, powerful and insightful. He tells us why.

Our solution-focused court works because we help people reconnect.

I would urge all colleagues to read Johann Hari’s new book Lost Connections: Why You’re Depressed and How to Find Hope. While this and his earlier book, Chasing the scream: the search for the truth about addiction, may not tell you anything new, they may change how you practice. Initially, I thought it was quite anti-psychiatry but that view was not just. We are evidenced-based clinicians and this book shares the evidence from the social sciences. It is critical of the biological narrative we have assigned mental disorder and it asks us to remember the psycho-social issues. I know no one has forgotten them but by putting them at the forefront, they may help us reconfigure our service design. I am lucky in that I work in a therapeutic, solution-focused mental health court in Perth. It is the only one of its kind in Australia. We believe that we make a massive change in some of our clients and yet we have never discovered why. We are in the process of studying this and have commenced a project with the University of WA. I have always thought that the secret to our success has been the client-focused, multidisciplinary, inter-agency approach. This book helps explain why this might be. I believe we need to radically rethink how we are doing business in order to best help our communities. While there is a significant place for psychiatry and medication, addressing people’s mental health issues require a holistic approach where practical assistance and reconnection are critical. In the same way that his first book gave compelling evidence why the war on drugs has not worked, Lost Connections explores why prescribing medication, with little extra input, is likely to fail. The push to discharge clients rapidly back to their GPs without addressing their key issues does us and them a disservice.

Our solution-focused court works because we help people reconnect. Examples include helping a client obtain dentures – result, a boost to his self-esteem because it helped him re-engage with the community and gain meaningful employment. This intervention was much more critical to his recovery than his prescription of an antidepressant. However, the two need to go hand in hand, in a coordinated manner. For a number of years now, I have proposed a ‘one stop shop’ where people can get all of their needs met. This includes expert psychiatric care, psychological therapies, accommodation support, vocational assistance and an opportunity to meaningfully re-engage with the community. Sometimes, this may just mean a cup of tea, a piece of fruit and a chat. The key ingredient would be that the person would feel listened to and would hopefully get a sense of empowerment. This book claims to offer a radical new way of thinking about the worldwide epidemic of anxiety and depression. He reviews the evidence for the causes and then offers some solutions. Hari has a great skill of weaving biographical stories into the science that he writes about. He started this book by describing his personal experience of antidepressants and the biological story about neurotransmitters and depression. He goes on to explain why this rhetoric has been unhelpful.

gives a historical explanation of the serotonin theory, going back to the TB wards and iproniazid and its serendipitous use for depression. He then goes on a critique about the DSM criteria for depression using the grief exception as an example. He discusses the impact of life events and social class on the development of mental health issues; and endogenous versus reactive depression. The nine causes of depression and anxiety and the evidence for these, he believes can relate to being ‘disconnected’. Disconnection from meaningful work, from other people, from meaningful values, from childhood trauma, from status and respect, from the natural world and from a hopeful or secure future. Psychiatry’s focus on the biological approach to treatment draws in discussions on Big Pharma and Hari urges a more humane, social approach to the understanding of depression. I also believe that mental health services have become more biological and there seems to be a split between what they provide and what the nongovernment organisations provide. These services need to be much closer aligned to help individuals. As for solutions, it’s about reconnection on a human level – social interventions within communities that turn around people’s lives. Doctors can help with that reconnection with social prescribing. Hari concludes with the plea that we have been tribeless and disconnected for too long and that it is time for us all to come home.

He starts the exploration by discussing the powerful placebo effect. He goes on to explain the ‘chemical imbalance’ evidence. He

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COMMUNITY

Making a difference Having a shared vision to make tangible differences to disadvantaged lives keeps WA Indian Docs inspired. The Director of Medical Services at St John of God Midland Public and Private Hospitals, Dr Sayanta Jana, returned to Perth from a trip to India in early January with renewed purpose for the fundraising work being done here for Children in Need in India – Australia (CINI). Sayanta is the current president of WA Indian Docs, a charitable organisation that was established in 2016 and CINI is one of its major beneficiaries. “We initially started as a group of just 30 doctors and now the membership stands at more than 350. From the very outset, our key strategy was to unite as many doctors as possible with a common vision to make a real difference to society, from our own homes and practices in WA,” he said.

dedication and commitment she has provided to CINI Australia over the years,” Sayanta said. “In fact, when I first started off in my health management career, it was actually somewhat embarrassing to see the amount of work Jennie and the team were doing for CINI, while we were busy with our lives and professions. But we did have the desire to make a difference and several doctors and our friends started to make their nominal donations and contributions.

Like minds

Medical Forum spoke to Dr Jennie Connaughton, the founder of CINI in Australia, in the May edition and reported on the work being done at the local level in India. Sayanta and WA Indian Docs knew of her work long before.

“As the leadership group of a small organisation, one of the first and foremost things we agreed upon was to start working for a smallto-medium sized charity where we could see a difference after every fundraising initiative and higher benefit to donation ratio.

“I had known Jennie for several years and we continue to be astonished by the leadership,

“This is why we unanimously chose CINI Australia as our chosen charity and we are still going strong

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after four years of support and fundraising.” The WA Indian Doctors Foundation’s hard work fundraising was recognised in 2018 by the Australian Charities and Not-for-Profit Commission (ACNC) and the group was registered as Australian Charity with Deductible Gift Recipient (DGR) status with the ATO. “The recognition from ACNC has given a real thrust to all our charity initiatives including for CINI Australia. We are now raising funds and investing a lot in several public health initiatives, partnering with BreastScreen WA, Cervical Screening WA, general healthrelated counselling, public health awareness as well as the specific work we undertake to support CINI Australia,” he said. “We have a key focus on maternal and child health in Australia, particularly in communities including the Indian community where breast-screen uptake rates continue to be among the lowest among all migrating and ethnic populations. “Last year, we partnered with the Indian Society of WA as a key

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COMMUNITY

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hour away from the nearest main road, let alone the nearest primary health care facility.

Outreach “You would definitely feel helpless in such remote locations, where basic counselling for pregnant mums and newborn babies, along with family and social support for basic nutrition and sustenance is so critical. “The desire to embrace health education, and raising public health awareness blew me away. The CINI health care worker had responsibility for people in several villages and arrived by foot or riding a bicycle.

partner for community fundraising. To be a new, relatively small notfor-profit organisation and having raised more than $350,000 in a space of less than three years is no mean feat.” Sayanta took the opportunity to visit India and see firsthand the work being done with the help of CINI Australia. “After 10 years of working with CINI I finally managed to visit several of their centres in Kolkata and

surrounds, and in West Bengal. It was a truly humbling experience to see where the funding was reaching and the difference it was making to people’s lives. It was even more touching to be part of the setup that was giving so much back to the community. “I went on a road trip of about 100km from Kolkata to visit some very remote villages and accompanied CINI staff on counselling home visits. Some of these villages were more than an

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“When I checked with her, she had more than 100 ‘cases’ on her books – mums and babies that she cared for every day. This makes our concept of workload, safe hours, work-life balance and activity pressures in a western health system a little diminished. “It was good to see that our funds raised in WA through our foundation was reaching such remote locations and providing much-needed support to families with good coordination with the local primary health networks. “I also visited the boys’ shelter in Tangra, Kolkata, where CINI has continued on Page 44

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COMMUNITY

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Making a difference continued from Page 43 its headquarters. Again, a very humbling experience. CINI is working so hard to save destitute children including orphans from living on the streets. “I met kids who have been lost and found at the Howrah railway station and who can tell you their name but not their address, and children who have been left behind by parents. Every story is so heart-wrenching. “It was fantastic to see CINI staff working behind the scenes to give these children a better quality of life, and keeping them healthy while maintaining efforts to retrace their families.” Back in Perth, Sayanta has a renewed sense of purpose for fundraising, which he admits can be hard and challenging. “It's unimaginable how in the past few months the lives of these children and young mothers have been so heavily impacted by the COVID-19 pandemic and also the Amphan super-cyclone that ravaged these very villages I visited during my trip. Keeping the interest of corporate sponsors even for such noble causes can be quite challenging and particularly where the focus

can get distracted by thinking more about return on investment than the social and material difference such donations can make, he said.

Real benefits “To see the difference even $1000 raised can make to people’s lives for the next three months is inspiring. “We try to be smart in what we do to make a difference, but we

would not have raised any funds if we hadn’t tried. We don’t have any staff on payroll, instead we have volunteers including doctors (GPs, specialists, junior doctors), dentists, medical students and admin staff and even family members who give their spare time to our fundraising initiatives without any hesitation. “I often get asked, why do I keep doing this? Where do I find the time? Yes, there are sacrifices involved, including giving away precious family and personal time over the past few years since we put into practice our fundraising vision. “I’m not alone, we have a committee, who are in turn supported by their families committed to this worthy cause. Helping others in need only works if you expect nothing in return.” ED: Dr Sayanta Jana is current President of WA Indian Docs and the Principal Director of the WA Indian Doctors Public Ancillary Fund – WA Indian Doctors Foundation. You can find more information, www.indiandoctorswa.org.au Email: foundation@indiandoctorswa.org.au

Read this story on mforum.com.au

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WINE REVIEW

Vasse Felix’s soaring heritage The Margaret River region is considered by many to be the finest in Australia and now enjoys a world-class reputation. This has all emanated from the planting of vines in 1967 by Perth cardiologist Dr Tom Cullity at his Vasse Felix property in Cowaramup. David Gregg was employed by Tom to make their first wines. I did the 1987 vintage with David and identified his skill and prowess. He eventually became owner and created the wines which have made Vasse Felix famous. David continued as winemaker after the Holmes a Court family bought the property in 1987, later bowing out to other great winemakers – of particular note are Clive Otto and current winemaker Virginia Willcock. As David related to me the story of Vasse Felix’s falcon logo, Tom Cullity imported a falcon to overcome the significant problem of small birds damaging the grapes. When a bird of prey circles vineyards, small birds vanish. Much training on a restraining line went into this falcon. Then came the great day to release it to do its wonderful work. The falcon flew towards the horizon and was never seen again!

Review by Dr Craig Drummond Master of Wine

Vasse Felix 2018 Sauvignon Blanc Semillon (RRP $26)

Vasse Felix 2018 Shiraz (RRP $37)

Vasse Felix 2017 Cabernet Sauvignon (RRP $47)

A Margaret River classic. I tasted this same wine for this column last year and selected it as my favourite in that tasting. It has retained its vibrancy and wonderful primary fruit flavours, but now has an added level of richness and complexity with guava and quince flavours creeping in. A great wine to match with seafood. The dominance of 82% Sauvignon Blanc is still evident in the firm acid backbone and clean finish.

Shiraz is the Aussie workhorse as it grows in many areas and climates. I have always preferred cooler climate Shiraz but have to admit this is yet another very good wine from this great producer. Youthful with structural definition to age 10 years. Aromas initially brooding until the lifted spices, blackberry and smoky oak show through. Plush fruit across the palate. Ripe satsuma plum, a touch of white pepper and gripping tannins. Needs time in the glass. A good Shiraz.

From the premium range, this is a richer, deeper, more concentrated wine than the Filius. Shows a deep purple youthful colour. Nose is complex, oaky with cassis to the fore. Supple on the palate. Juicy blackcurrant flavours, dried herbs and sandalwood spice. Will integrate further and result in great drinking over 12 to 15 years.

Vasse Felix 2019 Filius Chardonnay (RRP $28) The Filius (meaning ‘son of’) wines are ‘entry level’ wines as this one is really very good. In fact, in the June 2020 edition of Decanter (UK’s top consumer wine magazine), it was selected in the top 20 Australian Chardonnays to ‘snap up’, identifying it as excellent value for money. A flavoursome wine, it is varietally expressive and easy drinking with citrus and white peach. Clean, linear but with enough oak influence to give texture and structure. I drank it with homecooked fish and chips and it was great.

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'S EWER REVI

PICK

Vasse Felix 2018 Filius Cabernet Sauvignon (RRP $28) A youthful medium- to full-bodied wine. Lifted aromas of blackberry and black olive. Flavours of dark plum and blackcurrant. Good length and with a dry finish from those grippy fine Cabernet tannins. Good current drinking and will reward cellaring for a few years.

Vasse Felix 2018 Chardonnay (RRP $39)

It’s easy to see why Vasse Felix is famous for its Chardonnays when looking at this wine from the premium range. Shows limpid mid-gold colour, enticing rich and complex aromas, wonderful flavours of nectarine and peach and interwoven fruit, acid and oak. It glides across the palate. It has balance, richness and power, structure and texture. This is real Margaret River.

JULY 2020 | 49

You don’t buy a practice every week, but we do

It’s a big decision, Huge. For most, it’s a once in a lifetime proposition. We take this very seriously too. So much so, that over the last 25 years we’ve developed a process for medical professionals looking to go out on their own. But we don’t just look at you, we look at the business as a whole. We act as your partners in ensuring that it is a viable and proﬁtable opportunity. We assess everything - location, competition, client-base and growth potential. Then, and only then, we tailor a loan to meet your needs. Forgive the pun, but we have a lot of practice when it comes to buying a practice. Visit us at boqspecialist.com.au or speak to your local ﬁnance specialist on 1300 131 141.

Medical Forum July 2020 - Public Edition

Articles inside

Looking for hope

CINI: making a difference – Dr Sayanta Jana

QoL post43 People, not robots 41

Erectile dysfunction & Peyronie’s disease

The risk of not taking risks

Always make it ‘patient first

Q&A with Tim Hammond

Suicide: Predicting the unpredictable

Testosterone and fracture risk in older men

Men really are a thing

Opinion: A different gender gap? – Dr Joe Kosterich

Close-Up: Dr Richard O’Regan