Medical Forum June 2020 - Public Edition by Medical Forum WA

Into the Light MENTAL HEALTH OUT OF THE SHADOWS

Mental Health issue | Diabetes & Chronic Kidney Disease, Anxiety, Antidepressants

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June 2020 www.mforum.com.au

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EDITORIAL BACK TO CONTENTS

Jan Hallam | Managing Editor

Data, data, data

There’s nothing like a national health crisis to allow highly sensible decisions to rise to the surface in double quick time. Last month’s appointment of Victorian psychiatrist Professor Ruth Vine to a newly created role of deputy chief health officer for mental health alongside CMO Professor Brendan Murphy’s rock star deputies (two of whom are UWA Medical School alumni) has been a decision devoutly to be wished by all those working in the sector for eons. Having straight-talking clinical input at the national level can only enhance and strengthen decisions being made by the national Mental Health Commission.

Having straighttalking clinical input at the national level can only enhance and strengthen decisions being made by the national Mental Health Commission.

When we spoke to RANZCP president Assoc/Prof John Allan, he said it was essential that good, clean data be accessible in order for quality decisions to be made, especially around responses to suicide prevention. Making calculated guesses, with every good will in the world, he said, was like sticking your finger in the air to see which way the wind was blowing. He would like Australia to get busy and better at combining real-time data with administrative data so that clinicians have at their fingertips sound evidence on which to act. At the ministerial announcement, $7.3 million was pledged to enhance real-time data to help with the immediate monitoring and modelling of the mental health impact of COVID-19. A few ideas were thrown about: better and more finely tuned use of Medicare data, understanding not only how people present at hospitals but how they interact (or not) with friends prior to episodes, more use of social and economic data. The Australian Institute of Health and Welfare does a good job drawing this multifaceted information retrospectively. We need to find innovative ways of adding real-time collection to the mix and, from what we hear, there are researchers out there raring to go. There is much to consider in the new data-fuelled era for mental health. Privacy will be a big hurdle, just as it is for the tracing app, which we explore in this issue. But suicide prevention is of enormous importance; it always has been, but never more so now as the ripple effects of the pandemic response are being felt.

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MEDICAL FORUM | MENTAL HEALTH ISSUE

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CONTENTS | JUNE 2020 – MENTAL HEALTH ISSUE

Inside this issue 20 14 8

FEATURES

NEWS & VIEWS

LIFESTYLE

8 Close-up: Medicine kicks a

46 Antarctic adventure

goal – Dr Carmel Goodman

14 Into the Tele-future

Editorial: Data, Data, Data – Jan Hallam

13 Q&A Pyschiatrist

49 Wine Review: Happs

Dr Mathew Samuel

20 Testing the Waters

turns frosty – Dr Cathy Civil – Dr Louis Papaelias

24 COVIDSafe and Safety First

50 Books: Jon Doust Return Ticket

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MEDICAL FORUM | MENTAL 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 EDITORIAL TEAM

Familial hypercholesterolaemia A/Prof Damon Bell

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

Diabetic CKD management Dr Mark Thomas

Calcium score and CTCA Dr Lawrence Dembo

The Panic of Covid-19 Pandemic Dr Sergio Starkstein

Minimally Invasive Spinal Surgery Dr Paul Taylor & Greg Cunningham

Oral burning Dr Amanda Phoon Nguyen

Navigating diabetes medications Dr Andrew Klimaitis

Journalist James Knox (08 9203 5222) james@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

Antidepressants & sexual dysfunction Dr Angiolina Vellianitis

Support for families Michael Sheehan

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)

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 www.mforum.com.au

The COVID long haul Dr Sarah Newman

Testing boosts confidence Dr Michael Watson

Re-emergence Dr Joe Kosterich

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The COVID long haul As we all have a break from the intensity of pandemic disaster response, doctor health and wellbeing has never been more important, Dr Sarah Newman writes.

The COVID-19 outbreak remains a once in a 100-year phenomenon, the likes for which doctors and the community were unprepared. We have been living and working in pandemic conditions for some time now, and mostly have assimilated and accepted the necessary actions which have seen successful containment of the disease in Australia (so far). The psychological impact on health care workers has been profound. Initially, feelings of fear, anxiety and panic, a ‘pre-traumatic’ stress were experienced as we watched the uncontrolled viral spread ravage other countries. High levels of stress for doctors were created by a range of factors including lack of PPE, financial worries, profound changes to our work practice, and loss of social contact. Fortunately, the flood of cases we were anticipating did not eventuate. Now, with limited levels of community transmission and relaxation of restrictions, we are taking a breath and looking to the recovery and reconstruction phase of a pandemic. But what psychological implications can we expect in this next phase? Eventual recovery is likely to be prolonged, especially given real disease control with vaccination is realistically many months if not years away. We are simultaneously needing to look beyond COVID, while being primed to move back into disaster management at a moment’s notice. At the least we are now more logistically, materially and psychologically prepared with a

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We need to acknowledge as a profession the psychological impact this momentous time has had on us as frontline workers, and not simply dismiss it and return to ‘business as usual’. better equipped and primed health system to deal with any future waves of disease. We need to acknowledge as a profession the psychological impact this momentous time has had on us as frontline workers, and not simply dismiss it and return to ‘business as usual’. The psychological impact includes burnout, anxiety, depression and post-traumatic stress. These issues may develop long past the acute period as people are finally able to reflect on their experiences. Talking about our experiences, for some but not all, can be useful to deal with emotion, possible feelings of shame, guilt and moral injury experienced. What can we do to be psychologically ready for this period? This is very much a marathon – we, ourselves, need to prepare for the long-term by enacting realistic and sustainable strategies for maximising our resilience and burnout prevention.

We also need to support our family, friends and staff members who will also be psychologically vulnerable (even if they appear fine on the surface). At work we need to return to managing our patients’ chronic conditions. It is important that we stay abreast with reliable, timely information and avoid the toxic influence of social media. Our mindset is important; we are seen as community leaders; our outlook should encourage measured and informed action and instil hope in our patients. There are silver linings. Many of us will have learnt more about ourselves and our work colleagues, and come closer together as a team. Some work practice changes will have long-term benefits such as telemedicine on a grand scale, which will hopefully advance the way we deliver and service our patients. The future of COVID remains unknown, and we will only know the outcomes as they unfold. This can leave a feeling of powerlessness, but if we focus on what we can do, manage the situations as they arise, look after ourselves and our colleagues, seek help when needed and have hope for the future, then we are better placed to face new challenges. If you are experiencing any issues please contact: • Doctors Health Advisory Service 24/7 Advisory Line: 9321 3098 • Lifeline: 13 11 14 See www.dhaswa.com.au for the latest COVID-19 wellbeing resources

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OPINION

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Familial hypercholesterolaemia leads precision medicine The federal government has recently provided funding for improvements in the detection and management of familial hypercholesterolaemia (FH). It heralds an exciting time for the application of precision genomic medicine through collaboration between the laboratory, primary and secondary care. FH is a common inherited disorder of low-density lipoprotein cholesterol (LDL-c) catabolism, leading to increased lifetime LDL-c exposure and premature atherosclerotic cardiovascular disease (asCVD). FH occurs in 1:250 people, thus there are ~100,000 people with FH in Australia. However, currently less than 10% of these people are diagnosed, with ~90,000 people undiagnosed and under treated. People with untreated FH have a prevalence of asCVD of ~50% in men by age 50 years and ~30% in women by age 60 years. There is strong evidence that early treatment reduces the excess cardiovascular risk associated with this genetic condition.

variant for any given LDL-c, thus allowing personalised treatment. Furthermore, the relatives of a patient with a pathogenic variant are at risk of inheriting the variant. Genetic testing for FH makes cascade testing more accurate and has been demonstrated to be cost effective. Genetic testing for the initial member of a kindred identified at risk of FH (index case) is funded if requested by a specialist and family cascade testing for the variant in first (50% risk per person) and second (25% risk per person) degree family members will be rebated by Medicare when requested by primary and secondary care clinicians.

Medicare Criteria 73352 Characterisation of germline variants causing familial hypercholesterolaemia, requested by a specialist or consultant physician for a patient for whom no familial variant has been found; and who has any of the following: Dutch Lipid Network Criteria Score of at least 6, An LDL-cholesterol or 6.5 mmol/L or more in the absence of secondary causes, An LDL-cholesterol of between 5.0 and 6.5 mmol/L with signs of premature or accelerated atherogenesis.

We currently have very good methods to diagnose and treat people with FH â&#x20AC;&#x201C; but the largest challenge in FH management worldwide is to increase awareness and detection of people with FH. A healthy lifestyle including lowfat diet and regular exercise along with lipid lowering with statins and ezetimibe are the cornerstones of therapy. Lipid lowering therapy dramatically reduces the risk of asCVD, and is currently recommended from age of 10 for children with FH.

73353 Detection of a familial mutation for a patient who has a first or second degree relative with a documented pathogenic germline gene variant for familial hypercholesterolaemia.

Genetic testing is the gold standard for diagnosing patients with FH and is additionally important as patients with genetically confirmed FH have a significantly higher risk of asCVD than patients without a pathogenic

Before the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were released, the minority of patients with formally

A/Prof Damon Bell MB ChB, PhD, FRCPA, FFSc, FRACP

Chemical Pathologist and Endocrinologist

About the Author A/Prof Bell has expertise in the diagnosis and management of inherited and acquired lipid disorders. diagnosed FH were able to achieve the desired LDL-c targets (LDL-c <2.6 mmol/L without asCVD or <1.8 mmol/L with asCVD) with statin and ezetimibe therapy. However, PCSK9 inhibitors can reduce LDL-c by over 50% in addition to statins and ezetimibe, and are available on the PBS for people with FH who meet LDL-c and clinical criteria. The PBS criteria for Evolocumab (Repatha) were revised as of the May 1, 2020, lowering the LDL-c level to >2.6 mmol/L from 3.3 mmol/L for people with FH on maximally tolerated therapy and symptomatic asCVD. Criteria have also been introduced for non-FH patients with symptomatic asCVD and an LDL-c level of >2.6 mmol/L on maximally tolerated therapy, with a streamlined specialist application process and reapplications from all medical practitioners. Clinipath Pathology and Sonic Genetics have a comprehensive FH service to assist specialists and general practitioners with FH detection, including highlighting patients at risk of FH based on their LDL-c concentrations, offering FH genetic testing incorporating professional pre- and post-test genetic counselling and assistance identifying family members for cascade testing. References on request

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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IN THE NEWS

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Burning out Researchers from UNSW’s School of Psychiatry and Black Dog Institute, led by Prof Gordon Parker, have carried out studies into burnout – one has mapped personality styles which could predispose certain people to burning out and the other has developed a check-list of signs and symptoms by people experiencing it. While burnout is not currently recognised as a standalone clinical diagnosis, the World Health Organisation officially listed burnout as an occupational syndrome, which can have severe impacts on sufferers’ mental and physical health, while the financial impact of burnout is huge, with stress-related work absenteeism and presenteeism costing Australia $14.81 billion per year. In one of UNSW’s new studies, the responses from 1,019 people who completed a questionnaire indicated nine other factors commonly affecting people experiencing burnout. These included: anxiety/stress; depression and low mood; irritability and anger; sleep disturbances; lack of motivation or passion; lack of concentration, memory loss or brain fog; withdrawal from others; and physical

Opioids and Australia The social and economic costs of extra-medical opioid use to Australia in 2015-2016 was estimated to be 2203 deaths and $15.7 billion, according to a report published by the National Drug Research Institute (NDRI) at Curtin University. The researchers defined extramedical opioid use as the misuse of pharmaceutical opioids and illegal opioids such as heroin. In the March edition of Medical Forum, we explored extra-medical opioid use and found, much like the NDRI, that it is an issue that runs deep into the community. How deep? According to the NDRI, 645,260 Australians were misusing pharmaceutical and illegal opioids, while 104,000 were classified as dependent. Economically, the tangible costs of extra-medical opioid use were reported to be $5.63 billion with $1.08b in healthcare costs, $936m in drug-related crime, $481m in road traffic accidents, $2.48b in premature death, $459m in workplace costs and $194m in a non-defined category including prevention programs. The breakdown of the costs to the healthcare sector were $311m for 6 | JUNE 2020

symptoms such as aches, headaches, nausea and low libido; and emotional fragility. Participants included managers, students, teachers, home/child carers, nurses and midwives. While it was open to both males and females, 75% were female. “The other study also raises intriguing questions about whether more carefree and easy-going people might be less likely to develop burnout due to a ‘protective’ personality style. Perfectionistic and work-focused traits have also been discovered to be the biggest red flags for those developing burnout.

pharmaceutical treatments, $127m specialist drug treatments, $249m for inpatient hospital treatment, $235m for primary healthcare treatment, $41m in ambulance and emergency presentations, $31m for outpatient services and $85m in other costs. The authors say the intangible cost of extra-media use of opioids is $10.13b based on the reported deaths.

Flu vax monitored A pilot program led by UWA, Dr Alan Leeb’s SmartVax, MedAdvisor and the QUT will be monitoring the effects of flu vaccines administered by pharmacists this flu season. When the novel COVID-19 vaccine becomes available, the program could monitor its effects as well. Supported by a $40,000 grant from the JM O’Hara Research Fund of the Pharmaceutical Society of WA, the program aims to fill a void where no surveillance program exists to monitor the effects of immunisation from in-pharmacy vaccinations. Central to the project is active vaccine surveillance, which is particularly important for vaccines that change such as the flu vaccine,

and for new vaccines. For the first time worldwide, a four-strain flu vaccine specifically formulated for people 65 years and older is available, which will be monitored. Alan said the project was a gateway to being able to monitor adverse events for any new vaccine at the population level. Patients who receive immunisations at participating pharmacies will automatically be sent text messages to monitor adverse events following immunisation. Pharmacists will then be able to provide support when needed.

BCG and newborns Telethon Kids Institute researchers working with a global team have identified the mechanism behind one of science’s most enduring mysteries: what makes the 100-yearold tuberculosis (TB) vaccine, BCG, so effective at preventing newborn deaths from diseases other than TB. Telethon Kids researchers Professor Tobias Kollmann and Dr Nelly Amenyogbe identified a dramatic and rapid increase in neutrophils in mice and babies within three days of BCG vaccination. They first witnessed the phenomenon – known as emergency granulopoiesis (EG) –

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IN THE NEWS in mice, with their global team later validating it in blood samples from newborn babies in West Africa and Papua New Guinea. “It’s been known for a very long time that neutrophils play a very important role in managing sepsis, but until now nobody understood the role of BCG in initiating this critical process,” Dr Amenyogbe said. “It was actually thought to be biologically implausible, however, we’ve not only shown how BCG is involved, but that it kicks off this process almost instantly following vaccination – far more quickly than anticipated.”

Testing Dr Google With about 80% of Australians searching the internet for health advice and 34% of people attending emergency departments having looked up online their symptoms online, just how clinically effective is the internet? To answer this question Australian researchers have tested the effectiveness of online symptom checkers and their clinical abilities

to accurately diagnose and triage. For the purposes of the research, symptom checkers (SCs) are programs, apps and websites that provide probable diagnoses and triage advice. Researchers tested the diagnostic and triage abilities of 36 SCs on 48 simple non-co-morbid patient vignettes. Ten provided diagnostic and triage advice, while 17 provided purely diagnostic advice and nine were limited to triage advice. Healthdirect was the only Australianspecific SC. The findings suggest the limited abilities of SCs, with 36% of the patient vignettes correctly diagnosed. SCs were more accurate triaging, with 49% of the patient vignettes receiving appropriate advice, however, the researchers found this advice was particularly risk-averse, frequently suggesting urgent care when not appropriate.

Patient downturn Figures from the Medicare Benefits Schedule (MBS) reveal what has been suspected for weeks – there

was a 10% drop in GP visits for the management of chronic disease in March, equating to 96,000 less visits compared to the same time last year. Alongside the impact of COVID-19 on this decline, pathology data from NSW reveal a 28% drop in cholesterol tests being processed in March compared with February. Heart Foundation Chief Medical Adviser, cardiologist Professor Garry Jennings, said the data also showed an 18% drop in Aboriginal and Torres Strait Islander health checks in March compared to the same time last year. “A doubling of the number of calls to our Helpline compared to the same time last year tells us that many Australians living with heart disease are worried about their risk of COVID-19 complications, especially as restrictions ease,” he said. And while GPs claimed more than one million telehealth items in March, only a small proportion of GP visits for the management of chronic disease were delivered via Telehealth. The data also showed an increase in shorter GP visits of less than 20 minutes, compared to the same time last year, which is likely a reflection of increased flu vaccinations. Telehealth has helped slightly to bridge the gap for longer GP consults of more than 20 minutes, which saw a 9% drop from March last year.

Curtin grants Curtin University has been awarded $1.29 million in NHMRC grants to develop strategies to predict stillbirth and to investigate ways to eliminate tuberculosis in high-risk countries.

Shoulder tension Orthopaedic surgeon Dr Sven Goebel oversaw the first Australian joint replacement shoulder surgery using a computer-aided load balancing sensor recently at Bethesda Hospital. A reverse total shoulder arthroplasty was performed using technology that can intra-operatively quantify joint tension in the shoulder. Once the information is provided by the sensor, it is discarded and the sensor is not permanently implanted in the patient. Sven has been involved in a Perth-based laboratory study evaluating the sensor. He said that in the lab the sensor provided information that had never been available before. “It was helpful to receive active, dynamic feedback on the joint compressive load through the full range of motion.” MEDICAL FORUM | MENTAL HEALTH ISSUE

Dr Gizachew Tessema from Curtin’s School of Public Health will develop a strategy to predict the risk of stillbirth, preterm birth and low birth weight by analysing data from more than four million births in WA, NSW, South Australia and the Northern Territory. Dr Kefyalew Alene from Curtin’s School of Public Health and Telethon Kids Institute leads the second research project, which aims to design and implement an innovative approach for eliminating tuberculosis in high-burden countries such as Ethiopia and China.

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Medicine kicks a goal A love of sport and a curiosity for how the body worked led Dr Carmel Goodman into the fledgling area of sports medicine.

She tells Ara Jansen it’s a perfect 10 for challenge and satisfaction. Dr Carmel Goodman is happy to be the bad cop. She’s also happy to keep a secret. She regularly tells the athletes in her care that if they ever have a problem, come to her. “When an athlete is injured or has a medical problem that may prevent them from training, they are concerned that telling their coach may mean the coach perceives them as being weak or it may impact their team selection,” Carmel explains. “I tell them ‘don’t go to your coach, come to me and then you can tell them Carmel says you are not allowed to train’. I don’t mind being the bad cop.” Especially if it’s in the service of helping an athlete be their best. Challenging and stimulating is how Carmel describes her chosen field of sports medicine. It may not be the same kind of pressure as an accident and emergency room but there’s major pressure for athletes to 8 | JUNE 2020

consistently perform well and come back from injury as fast as possible. As the chief medical officer of the Western Australian Institute of Sport (WAIS), it also requires a calm and firm hand to navigate the, often, competing attitudes and priorities of coaches and parents, let alone the athletes. Like a United Nations ambassador, Carmel’s negotiation and diplomacy skills regularly get a good work out. WAIS works with between 200 and 250 elite and developing athletes in a daily training environment for a dozen different sports including cycling, swimming, wheelchair basketball, water polo, sailing, diving and athletics. It also works with individual athletes to support them in Olympic and Paralympic programs in other sports.

Trial by fire “I got my baptism of fire working with Ric Charlesworth and the

Australian hockey team in 1998 before the Sydney Olympics, where the Hockeyroos won gold,” she says. “As one of the most successful Australian coaches of all time and a medical doctor, Ric constantly challenged me and prepared me for contributing as part of an off-field team of coaches, psychologists, dieticians, exercise physiologists and physiotherapists in an elite sporting environment. “Over the years I’ve worked with some challenging coaches, especially ones who have a different philosophy around training, such as coaches from China and Russia who train in a vastly different way. “I’m happy to make the hard decisions and have those uncomfortable discussions. What I also find incredibly gratifying is that the athletes appreciate that. “The flip side is that whatever is

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CLOSE-UP

CLOSE-UP with elite athletes guided my research interests, which then translated into clinical practice in elite and recreational athletes. Particularly in the areas of iron deficiency and the impact of different phases of the menstrual cycle and oral contraceptive use on performance.

From left, Dr Carmel Goodman at work at WAIS; cycling the world; and as a young elite swimmer in South Africa.

Research support “Other research areas which translate to clinical practice involve overtraining and chronic fatigue in elite athletes and ergogenic aids such as caffeine and creatine.”

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Working with WAIS has also allowed Carmel to collect and study large amounts of training data from the elite athletes who train at the Mt Claremont facility. This has included everything from heart rate monitoring to muscle mass testing. going on – whether it’s an injury, illness or psychological problem – working as a sport and exercise physician with elite athletes, decisions are never black and white. Sports medicine can be an inexact science.” A careful balancing act is often required too. In the average person, six weeks of no training, rest or taking it easy for a hamstring injury is doable if an inconvenience. For an athlete in training, that’s an exceedingly difficult conversation to have. “We’re always pushing the boundaries of what would be strictly medicine by the book. We have to get inventive to find other forms of activity to try to get an athlete back training slightly sooner than the book but not getting them back too soon. That’s a real challenge.” Keeping the athletes’ confidences is a big part of Carmel’s work. She needs the dozens of athletes under her care to be honest with her and she constantly reminds them that all their conversations are 100% confidential.

Loyalty essential “I have never betrayed a confidence of an athlete. I’ve always been honest and negotiated with someone if there has been an issue that would impact their performance or the performance of the team. The athletes know my loyalty is to them and because of that they are comfortable confiding in me.”

Originally from Johannesburg, South Africa, Carmel migrated to Australia nearly 40 years ago. She still has enough of an accent to notice. Concerned about the political situation, Carmel and her husband, radiologist Jonathan Cartoon, moved to Perth in 1990. Carmel has always had a passion for sport and after qualifying as a doctor undertook a doctorate in exercise physiology and found herself specialising in sports medicine, which was still a very new discipline. From her early years, Carmel’s career has always been a mix of practice and academia. On arrival in Perth she took a position at UWA in exercise physiology. She continues to be involved in lecturing and postgraduate research supervision in sports medicine. She was named chief medical officer of WAIS in 1990 and has been a team doctor at Olympic and Commonwealth Games since 2000. In 2006, she was awarded the Sports Medicine Australia medal for outstanding contribution to a team in the field of sports medicine. In 1998, Carmel became the team doctor for the Australian hockey team. Hockey is one of the sports which has its national training base in WA. Throughout, she has kept a clinical practice, which eventually turned to working largely with elite athletes as well as recreational athletes. “Combining research and clinical practice is a lovely mix. Working

MEDICAL FORUM | MENTAL HEALTH ISSUE

“It’s all done under strict supervision, but we want to know when an athlete goes into a strengthening phase and might be doing weights in the gym, what helps them and what doesn’t.” At WAIS, doctors, physios and other related personnel constantly report to Carmel on athlete illness, injury and progress. This is particularly important when an athlete is coming back from an injury. In a central database linked to the Australian Institute of Sport in Canberra, all pieces of information are logged, which includes a minor sniffle through to something major. Carmel reviews all the charts, regularly checking in with staff if something concerns her or perhaps requires an alternative approach. She’s required to write policies and make sure that everyone is adhering to them, whether it’s around injections or mental health. “I meet regularly with the psychologists to discuss the mental health of the athletes. I also meet regularly with the coaches, nutritionists and exercise physiologists in each discipline to discuss what’s happening and how people are tracking. “I love the variety and it’s still a real challenge. I also enjoy the diversity and I’m learning all the time, because a lot of what we see is not in medical journals. I learn so much from the athletes because they really know their bodies. They can continued on Page 11

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Medicine kicks a goal cycle together on weekends and have done cycling trips all over the world including Spain, Italy and the UK.

continued from Page 9 be really intense about it and I find that I have to listen very carefully to what they say and am constantly using all my knowledge all the time.”

“Cycling is a great way to see an area. I also run in the places we visit. You see so much more than when you are driving.”

The postponing of this year’s Tokyo Olympic Games was obviously gutting for all the athletes and staff at WAIS. Carmel feels quite heartbroken for the athletes, especially the ones looking at Tokyo as being their last games shot. “While we can look somewhat objectively at it and say it’s not the end of the world not being able to compete, if you’ve worked with an athlete for years and they have given up everything just to do this, it is the end of their world. “It’s challenging to keep them motivated and keep their fitness up when the goal posts have moved. Collectively and individually you create a lot of energy working up to an event like the Olympics and then having to find six or more months of that energy and drive is difficult.”

Lived experience A national level swimmer, being awarded her Springbok colours at the age of 12, created an interest in how the body works and led Carmel into sports medicine. In those days, that didn’t mean anything more

scientific than taking extra vitamins in the hope they would help with strength and speed. Sports medicine was still in its infancy, but Carmel knew, somehow, she wanted to become a doctor, find out how the body really works and somehow inject her love of sport into it. Coming to Australia meant working hard to have hers and her husband’s qualifications converted and raising two daughters. Running worked better than swimming around her busy work and family schedule. Ever competitive, she started running with a group, has run a number of marathons and now hits the road a few times a week for fitness. Cycling is also Carmel’s other outdoor passion. She and Jonathan

Coming close to celebrating four decades of marriage, Carmel says cycling and taking long walks keep the pair connected as does a love of the arts. She says they still have plenty to talk about and are kept terribly busy with five grandchildren. Jonathan and Carmel met when she was in her final year of medicine and he was an intern. During all the years the pair have been together, the Goodman dinner table has never been short on a medical story or three. Carmel’s brother is a doctor and her younger daughter, Jodi, is a psychiatrist and married to a radiation oncology registrar. Elder daughter Lee-Ann is a lawyer, prompting the now-famed dinner table declaration that there would no longer be “discussions which go below the waist” in an effort to stop shop talk. Sometimes it’s ridiculously hard to make that happen.

WE HELP YOU GET ON TOP OF BUSINESS SO YOU CAN GET ON WITH CARING FOR THE COMMUNITY Talk to the ANZ Health Banking Specialist Team that understands your needs. Visit anz.com/health or contact your local State Health Director, Megan Carter, on 0411 140 781.

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Murdochâ&#x20AC;&#x2122;s latest acquisition expands healthcare footprint south of the river.

St John of God Murdoch Hospital has increased its private surgical capacity in the southern region by taking full ownership of the Murdoch Surgicentre day hospital. The Surgicentre provides a high quality and efficient environment for day surgery, in a standalone facility located on the main hospital campus. This provides a compelling alternative to major hospital lists, while still reaping the benefits of a leading healthcare provider. The Surgicentre has limited list availability for new doctors. Please contact Kelli Dawson, General Manager via kelli.dawson@sjog.org.au or 08 9438 9990 to discuss.

L-R: Ben Edwards, CEO St John of God Murdoch Hospital; Oliver Brennan, Deputy Director of Nursing; Kelli Dawson, General Manager St John of God Murdoch Surgicentre.

For more information please visit sjog.org.au/murdochsurgicentre 12 | JUNE 2020

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Q&A

Q&A with... Dr Mathew Samuel, Psychiatrist, Nedlands

MF: How and why did you take up psychiatry? What areas of the specialty took on greater meaning to you (and why)? MS: I took up psychiatry as I was keen to know how the human mind works. It was an enigma to find out where mind sits. All other specialties can feel and see the organs they are dealing with such as a cardiologist seeing the heart and ENT surgeons seeing ears, noses and throats. I have always been a person to talk and connect with people and I wanted to know how I could improve the stigma associated with mental illness as well. MF: You recognised, early on in the COVID-19 response, that health workers were particularly vulnerable to anxiety, burnout and depression and offered telehealth consultations. What was the uptake? MS: The uptake has been poor primarily because WA has been very lucky to avoid the brunt of COVID-19. I am not complaining as we are incredibly fortunate to keep it like that due to timely intervention by the state and federal governments. However, I have seen a few police officers and paramedics who have presented with increasing anxiety symptoms. MF: What are the greatest fears for frontline health workers? MS: It is amazing to see that most of the frontline health workers have not been worried about their mortality which shows that people who choose these jobs are incredibly brave and altruistic about their attitude towards humanity. The fear for them has been primarily about family members and loved ones. I am part of WA PTSD Research Foundation and we will be looking

to conduct a study to determine the extent of these fears. MF: Do you think there has been adequate acknowledgement of these fears and support for their wellbeing? MS: I am glad to let you know that there has been adequate acknowledgement in the media and workplace about these fears. I am not sure how much support has been offered for their wellbeing other than directing them to them to employee assistance services. MF: Is this a good time to evaluate the culture of medicine? MS: My argument is that we always need to evaluate the culture of medicine. I think this crisis will call for much more scrutiny on how we practise medicine in the coming years MF: What impact has social distancing and stay-at-home messages had on peopleâ&#x20AC;&#x2122;s mental health? MS: There have been significant ramifications. I have seen a spike in alcohol use, domestic violence along with anxiety symptoms. People have called our office with significant anxiety symptoms due to the economic fallout as well. MF: How have those people with existing mental health issues coped in this pandemic? MS: A lot of patients with stable mental illness have had relapses due to the pandemic. A lot of people are refusing to attend hospital and other clinics because of the fear of getting infected in a health facility. We have seen a worsening of mental health conditions due to an increase in alcohol use because of the lockdown and restrictions of human movement.

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MF: General practitioners report a decrease in the number of patients attending for general appointments? Is this also the case for psychiatry and psychology appointments? MS: No, it has been the opposite as we have seen an increase in outpatient appointments and my inpatient numbers have gone up as well. MF: Mental health support services have been forced to restrict their face-to-face services, while telephone helplines have experienced steep increases in demand. How can the mental health sector as a whole encourage people to attend to their mental health issues. MS: We need to tell people to continue to attend GPs, psychologists and psychiatrists and that these services are open for patient consultations. Telehealth in my opinion has opened a new world of opportunity for everyone, especially for our people in regional and rural areas. MF: The WA health system appears to have managed the crisis well within its capabilities. What do you think the messaging should be now to improve peopleâ&#x20AC;&#x2122;s mental health? MS: In my opinion, the public health message will be "Seek Help Now and You Will Not be Sorry Later On".

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Into the Tele-future Telehealth has stormed into GPs lives providing convenience and headaches.

James Knox reports.

Telehealth may have started slowly but the combination of a pandemic and the introduction of a comprehensive set of MBS item numbers is making it a go-to service for GPs in Australia. While the first wave of the pandemic seems to be in the past, telehealth could well be the future, or at least a more widely adopted service that provides both clinicians and consumers with a convenient and effective alternative to face-toface consultations. Ask a GP if in the course of their career they have taken a phone call from a patient and provided clinical care, and the vast majority would resoundingly have said ‘yes’. However, if you were to ask if that was a billed consultation, there would be an emphatic chorus of ‘no’. And that, in a nutshell, has been the problem with telehealth. Doctors have been providing the service, albeit informally, for a long time without the financial incentive to do more with it. However, this has changed with more than 290 telehealth or telephone item numbers being listed on the MBS since the start of the COVID-19 pandemic. 14 | JUNE 2020

Yet, will clinicians continue to use this service when physical distancing measures are rolled back? Will telehealth be an effective and secure alternative to face-to-face care delivery? And will general practice be economically viable if telehealth comprises a larger portion of billable hours?

Useful use case Before the pandemic, the primary use of telehealth consultations was to bridge the distances between clinicians and their patients located in rural and remote areas. They constituted a small portion of doctors’ consultations. However, the reality, now, is that telehealth can be as effective for a patient one kilometre away as it is for one who is 1000km away. And beyond the financial aspect, telehealth complicated the traditional faceto-face delivery and interrupted clinicians’ daily work flow, said Dr Nathan Pinskier, a Melbourne-based GP, director and co-owner of the Medi7 group of practices and former chair MEDICAL FORUM | MENTAL HEALTH ISSUE

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FEATURE of the RACGP National Standing Committee for eHealth. “If the model of care is based on people coming through the door every day and the waiting room being full, it is seen to be disruptive to slot a telehealth consultation inbetween face-to-face consults as there isn't a model to support it. “Unless you've actually created a whole model of care for telehealth, as has occurred in other parts of the world, it isn’t well suited to our system, which is predominately feefor-service and face to face.”

Acceptance by necessity The rapid integration of telehealth and transformation of the delivery of care was remarkable, according to Dr Pinskier, who spoke of the situation his group of practices went through. “We’ve gone from a model that is predominately fee-for-service and MBS with full waiting rooms to basically telling patients, ‘where appropriate, we'll give telehealth consultations, if the doctor is likely to be at risk of exposure to COVID’.

“The net consequence of that is 40% of our consultations are being done face-to-face and about 60% are by telehealth, of which 90% is over the telephone.”

Money matters Although the new MBS telehealth item numbers have the same values, or bulk-billed rebates, as face-to-face, without the ability to charge a gap, the financial viability of practices offering the service post-pandemic is in doubt. There are, of course, services which will always require face-to-face consults but there are others well suited to telehealth. Dr Pinskier said general practices had been reporting some reduced income, which could be attributed to telehealth, but there had also been a decline in face-to-face consults. “There are some scenarios where doctors are not going to drive the same income. Surgical procedures, for example, are items that obviously can't be recouped through telehealth and are potentially lost income. “It's relatively comparable for non-interventional procedures, but it's hard to know what's happening across the sector. We are getting reports of reduced average income of 10% to 25%.” With flu vaccinations being administered early and a milder flu season predicted, lower patient volume may continue, which may also cause GPs some financial woes.

Keeping it private Alongside financial concerns, Dr Pinskier added that privacy of telehealth communication was also problematic. “A lot of basic business rules and work we've been doing over the past decade have gone out the window, particularly around secure communications. “Once the crisis comes to an end, it's inevitable that some patients will grow concerned about possible breaches of privacy and questions

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Will it be a Tele-future? continued from Page 15 will be raised about why doctors didn't ‘lock it down?’, or the lack of a national protocol.” Part of the privacy problem is the effectiveness of the technology being currently used and the times where convenience was prioritised over security, he said. “If I don't want a patient coming to my waiting room but I want to get information to them, that probably means sending an email,” he said. “How is it that eight weeks ago the use of ordinary email was deemed to be totally inappropriate for health-care communications and a crisis comes along and today it is perfectly acceptable. “Now we’ve let the genie out of the bottle, shall we put it back in or do we just change our thinking, design different rules and different tools? I think that's the conversation we're going to be having going forward.”

Limits of control Loosening the controls over privacy may seem innocuous in the moment, but the consequences could be damaging to the patient and the clinician. Yet, the pervasion of the internet into our lives has primed us to choose convenience and be apathetic to the cost and commodification of our privacy. Simply reference the tome-like terms and conditions of almost any tool or service found on the internet for evidence as to how your data is used. One such tool that has been elevated as a result of COVID-19 has been Zoom, the convenient video conferencing service that offers free video chats to its users. However, privacy concerns were raised about its lack of end-toend encryption, providing user data to Facebook, and a tool that mined real-time data of attendees’ LinkedIn profiles, even if they chose to be anonymous, without disclosing this to users. Although Zoom is discussed in some detail, it is merely an example because of its rapid growth and 16 | JUNE 2020

popularity and its problematic use for clinical consults Prof Dali Kaafar, Executive Director and Chief Scientist at the Optus Macquarie University Cyber Security Hub, is a specialist in analysing and quantifying risks from an information perspective and has extensive experience researching privacy technologies. “The software and tools we use today are tangled in a very diverse ecosystem. For example, when we connect with Zoom's servers, there is information that will be extracted for so-called analytics functions for third-party trackers and servers. “This is nothing new … most of the websites and servers that we use today include these sorts of analytics and third-party tracking mechanisms that leak information about us.” He said in the case of Zoom, while the user information collected is primarily to improve and enhance the application’s performance, users are allowing personal information to be extracted as a trade-off for a free, convenient and effective service, which could be problematic for a clinician discussing confidential patient information.

Modelling the threat For clinicians and practices interested in maintaining privacy, Prof Kaafar suggests conducting threat modelling. “To understand the privacy risks, it is essential to assess whether something is a serious privacy issue or loss, or an impractical, unrealistic scenario,” he said. “In the case of a third-party accessing information, it depends on what is in the meta data and who has access to it. “The threat model there would be, ‘what is the information available to an entity about Patient A and Doctor B?’ ‘Do we really know any more information about these two entities other than their IP address?’ Prof Kaafar also urges clinicians not to underestimate the power of data mining and to be overcautious not to reveal information that could be aggregated, such as quasiidentifiers – age or postcode are

particularly problematic for privacy loss as they can be used for reidentification.

Managing the change With more clinicians and patients using telehealth, this could be the tipping point for wider acceptance of the services. However, this is contingent on the government maintaining the MBS item numbers beyond the pandemic. Dr Pinskier is confident it will. “It's inevitable that we will see an extension of telehealth item numbers in some shape or form,” he said. “It’s hard to envisage the government, consumers and providers allowing telehealth to be abolished. “The world has moved on and people who were reluctant or resistant to implementing telehealth, for whatever reason, have now come to accept it as just part of the fabric.” Dr Pinskier said from his conversations with the MBS, the government will look to amend the current item numbers based on how the system is being used. “They will probably implement some controls or restrictions because at the moment it's relatively unrestricted. My guess is post-September or maybe next year before we will see any significant changes. “There'll be some linkage back to principal practices. I'm not sure we want to see an open access world where anyone can set up a telehealth service in the absence of a physical practice. “We allowed virtual providers to set up and there's no continuity of care as they tend to cherry pick the low-hanging value services such as repeat prescriptions and minor conditions and have taken away these consultations from general practice but without the continuity of care. “So, there will need to be some rejigging of the item numbers, their relative value and how they're accessed with requirements that data be linked back to the regular general practice or the regular provider.”

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Dr Pinskier believes the MBS is constrained by its history. It was developed in the early 1970s as Medibank then in the 1980s as Medicare. As doctors are all too aware, the medical and financial landscape is totally different today from 40 years ago. “It was a model that was fit-forpurpose for its time but the world has changed and we have moved into an era of chronic complex diseases. The average person over 65 takes something like five medicines,” he said. “The MBS was designed as a transactional process. However, we are now looking at it from a longitudinal care process and we need to change it to fit the world in which we're operating. “So that's going to require a reform of payments for certain services. How we get there is going to be challenging as none of the models so far have really been effective or acceptable within general practice.”

Modern model of care If the MBS were more flexible, this could lead to a more appropriate

model of care for the patient, the practice and the clinical context, he said: “Take my 94-year-old mother, for example. Would she need to go every couple of weeks to see her GP if she could be managed appropriately over the phone? She could get her care over the phone rather than spend an hour getting to and from the surgery for a 10 or 15-minute consultation. “Once we remove those shackles around the MBS, and have funding that fits that model, we'll see a lot more of this. It could also allow practices to triage patients over the phone and if they don't need to come in, they don't come in and the practice gets paid for it. “At the moment, the only way you get paid for this type of care is when the patient actually walks into your consulting room.

The recent growth of telehealth in Australia is a prime example of a bottom-up intervention that provides appropriate outcomes for clinicians and patients who need it. Now it is up to those same clinicians to continue with it to ensure that broad use of telehealth is here to stay. “I have to give government a lot of credit. They listened and delivered. We now need to understand how to use it more efficiently and more appropriately so that we get the right benefits in terms of health care delivery outcomes,” Dr Pinksier said.

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“It’s almost impossible to believe that telephone, video and face-toface consultations are not going to continue in Australia as the world has moved on and we found we can do it another way and use our time much more productively.”

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The challenges of telehealth Dr Rosa Canalese, a GP and Senior Medical Advisor at Avant says the increasing use of telehealth has advantages but there are pitfalls. MF: How do you think doctors are managing the rapid roll out of telehealth due to COVID-19? RC: We’re receiving a lot of questions about telehealth because most doctors have had to adapt in a very short timeframe. It’s been a huge change to the way they practise. As a result, there has been little time to work through the problems or develop mitigation strategies. MF: What are the major challenges for doctors? RC: There are a number of challenges. Firstly, you can’t physically examine a patient so you have to devise strategies to get around that problem. Secondly, you need to manage the issuing and delivery of prescriptions, tests and referrals effectively. Finally, you have to ensure that your communication with patients isn’t compromised because, as we all know, communication is fundamental to effective consultations. MF: What are specific communication issues arising with telehealth? RC: In novel situations such as this, there is a risk that the quality of the conversation between the patient and doctor may be impacted. Both may have little experience of telehealth so the patient may not feel that they’re being communicated with effectively. They may not feel listened to or heard and, as a result, they may be more likely to be dissatisfied with the patient-doctor interaction and even complain. While the risk may be mitigated by the fact that patients may recognise that COVID-19 is a unique situation and, therefore they may be more understanding, there are still risks that practitioners need to be aware of. 18 | JUNE 2020

MF: So, what should doctors think about when communicating via telehealth? RC: It is important to discuss the limitations of telehealth compared with a traditional face-to-face consultation with the patient up front. We may need to think about how we are adapting our communication style for video conferencing or telephone. What do we need to do more of and what are we not able to do in these consultations? We need to consider how we compensate for the fact that we are not getting those non-verbal cues that we, as doctors, so often rely on. For example, if you’re on the phone, you may miss certain nuances in the tone of the conversation and you are not able to see patient’s facial expressions.

MF: So, not physically seeing a patient compounds the risks? How can communication help mitigate that risk? RC: When you think about the core function of a consultation, one of our key responsibilities is to gather sufficient ‘data’ to work out what is wrong with a patient so we can either formulate a diagnosis and/ or a problem list. Then, we need to think about what we’re going to do about that problem list. The quality of the data that you collect is important because it informs the quality of that decision making. So, if you don’t collect sufficient data or you collect inaccurate data, it will affect both the quality and accuracy of the diagnosis and management. For this reason, you need to think about the extra questions and other information you need to obtain and

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FEATURE how you need to obtain it because you can’t do a physical examination at that time. This may involve asking different questions, more exploratory questions or even ‘checking the understanding’ questions and the information patients are giving you.

legal risk of doctors making an incorrect or inaccurate diagnosis. There is also a risk of doctors providing incorrect management of the problem because they are working from an incorrect or inaccurate problem list.

MF: What strategies do you suggest doctors employ to communicate more effectively via telehealth?

In the end, it is about thinking about what are the medico-legal risks and what strategies we can put in place to help mitigate those risks. You can never mitigate the risks to zero but you can lower them.

RC: You need to ask the questions that we normally wouldn’t have to ask a patient because we’d be seeing it. For example, you may need to ask specific questions such as ‘Is your knee actually swollen?’, ‘Is you knee red?’ or ‘Is your knee hot?’. You may even want to ask the patient to send you a picture of their knee. When you do this, you need to ensure you are maintaining patient confidentiality and that you include a copy of the photo in the patient record. MF: Will employing these kinds of strategies help doctors reduce their medico-legal risk? RC: Yes. This is because if you don’t get the data you need and ask those questions there is a medico-

Most importantly, if you need to see the patient face-to-face to properly assess them, then, you need to set up a process to do this. This may involve asking them to come into your practice for a consultation, referring them to another practitioner or referring them to the hospital. MF: What other steps do you suggest doctors take to mitigate the risks of telehealth?

and even become chaotic in their thinking. We are also aware that, at the moment, the vast majority of telehealth consultations are occurring via telephone despite the Department of Health’s preference for doctors to use video. So, I’d suggest that both practices and doctors explore moving across to video conferencing. You should also avail yourself of the resources that are available such as the colleges, the PHNs, public health units who supply reliable and trustworthy information. There is a comprehensive Frequently Asked Questions and other resources on telehealth on the Avant website that focuses on the medico-legal risk.

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RC: The reality, at present, is that doctors are under a lot of stress. And we know that when people are under stress and distress they are less likely to make clear decisions

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Testing the waters Strategic testing, and plenty of it, maybe to be WA's best chance of managing future outbreaks of SARS CoV2.

Jan Hallam reports.

Whichever way you look at it, and especially if you’re looking at it from overseas, Australia has done an enviable job in containing what has proved to be a nasty, destructive viral pandemic. The unity of the early days of the Australian response has started to fragment as understandably each state deals with its own set of circumstances and conditions. However, one fundamental area that is far from consistent, and arguably should be, is testing. In this regard, WA is very much at the low end of the scale. While other states are in the hundreds of thousands, in Victoria more than 100,000 in the space of a week, WA recorded a total of just over 67,000 as of May 20. The genuine fears of PPE and testing kit shortages several months ago have long abated, so why is WA not doing more strategic asymptomatic testing? It is a question the AMA WA president Dr Andrew Miller has been asking for some weeks now. He is not advocating a free-for-all but he is particularly concerned that with the inevitable lifting of interstate borders, WA will see flare-ups that will need to be managed especially for vulnerable patients in hospitals and aged care facilities and key, frontline workers. “The testing is a puzzle to me. I still don't feel like I have a complete understanding of why the restrictions on testing were in place at the start, or on private pathology being involved, when they weren't held back in other states,” he said. 20 | JUNE 2020

“And I still don't understand why doctors can't just order COVID tests as they would for any other test – to eliminate as much as confirm. We must have very high testing rates targeted towards at-risk populations as we ease restrictions. Clearly schools are one area as are health care workers and pre-operative or pre-admission patients. “We know that people who have procedures when they're in the prodromal phase of COVID-19 have very bad outcomes. With seemingly low community spread, it's unlikely we're going to find a positive asymptomatic patient in the community but this targeted testing before patients go into a hospital would be worthwhile.”

Cost v Risk Dr Miller said that for the cost of a $100 test, it would be a small price for a hospital to pay if it avoided having to evacuate patients and shut down and deep clean wards, as was the case in north-west Tasmania. “A deep clean and shut down could cost millions of dollars. So, this pre-surgical, pre-admission testing would be a small insurance for facilities. And we shouldn’t leave it up to patients to decide if they need testing. Humans aren't always honest, even with themselves, particularly if it may mean them missing out on their procedure, or having to go into quarantine for 14 days. It would be naïve to think everyone will come forward if they've got symptoms.” Medical Forum asked the Health

Department of WA a series of questions around testing. Its full response is on our website (www.mforum.com.au). It is clear that COVID testing is very much a controlled activity with penalties for non-compliance. The spokesperson said the testing in WA reflected both population size and COVID activity in the population: “In the setting of very limited community transmission that WA has achieved thus far, it is not a priority in and of itself to try to match testing rates … from other jurisdictions that are experiencing outbreaks.” HoDWA said that it was abiding by the Australian Health Protection Principal Committee suggestion to test “people at risk of exposure who present with atypical symptoms, such as health care workers and residential aged care facility workers”. In terms of strategic and sustained workforce testing for health care workers (including aged care) and workers in essential industries such as education and mining, HoDWA offered: “We may consider shortterm wider testing in the future.” Regarding pre-surgical testing, HoDWA said: “Testing of asymptomatic patients prior to surgery is only approved for a limited number of patients undergoing specific aerodigestive procedures where prolonged aerosol exposure is expected.” The mining industry has taken the front step during the first phase

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of the pandemic response. Being declared an essential service by the Premier, Mark McGowan, it has continued to turn the wheels of the state’s economy and has created an important beach-head on the testing front.

Workplace focus On May 6, a few days after the government announced its DETECT Schools research testing project (with Telethon Kids to do the science), it announced that the mining sector would be involved in a similar testing program (through Curtin University and the Perkins Institute) called DETECT FIFO. Medical Forum spoke to Rob Carruthers, the director of policy and advocacy at the Chamber of Minerals and Energy WA, who has been involved in the DETECT FIFO negotiations between the mining companies and the DoH WA. Given the fly-in, fly-out nature of the workforce, mining companies were screening their workers themselves in various ways in the early stages of the COVID outbreak to “ensure that people were as healthy as they thought they were”, said Mr Carruthers. From pre-work questionnaires, health assessments and temperature screening, some of the mining companies moved early to PCR antigen testing and one prominent iron ore miner moved to point of care (POC) serology tests at the airport. “The DETECT FIFO project gives us the opportunity to wrap all of those screening measures into one and

ensure that there's a consolidated approach to both cohort testing and research which will underpin future strategy,” he said. “We've done a tremendous job in WA to see ourselves through the first few months of COVID-19, but our ability and effectiveness to continue to manage industry and businesses during this time is really going to turn on how important the DETECT program, more broadly, and the FIFO component particularly, is to keep our mines safely and effectively operating.” Mr Carruthers said the pandemic would fundamentally change the way the industry operated. “For an industry that operates in remote regional parts of the state and relies on being able to move workers from A to B and do it in a safe way, screening as part of this transit will be with us for the foreseeable future. Similarly face masks and other protective equipment may become a standard control for people on aircraft. That's yet to be determined, but both government and industry are looking into that.”

Relocating workers The closing of the interstate borders created challenges for the mining companies where the quarantining of eastern states and overseas workers for 14 days before every shift would be unviable as well as unacceptable. Mr Carruthers said that a number of companies decided to relocate entire families to WA – more than 2000 at last count.

funded by industry participants, and as Mr Carruthers describes it, they now have “skin in the game” to ensure it delivers on the expected outcomes. “And we're really pleased that it is a true partnership in that respect,” he said. “The cohort testing will be voluntary, but some companies will seek to supplement and go above and beyond that to require the broader workforce to be screened and be cleared to work before they return to site. “DETECT FIFO gives us the opportunity to look at the accuracy, reliability and sensitivity of different testing methods for early detection and diagnosis. A lot of the technologies that have been applied in COVID screening were not necessarily designed for that purpose. So, DETECT will give us, in the mid-term, a really strong level of competence and confidence that we're applying the right level of screening techniques. “I've been in the industry a long time, and I've never seen cooperation levels, the likes of which have come together in response to this crisis. And that's not just being between the companies, but also at the government level. There is, again, very strong alignment on the scope and intent of the industry and the government.”

DETECT FIFO has been fully

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Strategic testing boosts confidence Living with COVID-19 is more than likely, so how do we get back to patient care with renewed confidence? Dr Michael Watson shares his ideas. The overseas experience of the SARS CoV2 (COVID-19) pandemic is one of death and despair that is shared by patients and health care workers alike. AMA WA president Dr Andrew Miller provided sage advice on the attitude we should all adopt when he said: “We need to move away from the war-like analogy where the death of health care workers is seen to be inevitable.”

have some common sense and stay ahead of the curve,” he told me. Dr Kelly and his team moved quickly on gaining access to personal protective equipment for his clinical and clerical staff, they have risk managed based on individual staff needs, and implemented physical distancing, symptom screening and cohorting of at-risk patients from the start of the epidemic.

Dr Miller is an anaesthetist and is campaigning for nucleic acid amplification (NAT) testing of asymptomatic patients who will be undergoing intubation for semi-urgent (elective) surgery this winter. Intubation is an aerosol generating procedure that places health care workers at risk of respiratory infections including SARS CoV2.

Doctors talk to one another. That’s how we make sense of evidence and draw that into practice. Speaking to GP Dr Brendan Kelly, medical director at Reynolds Rd Medical in Applecross, his team reacted quickly to the pandemic. “After looking at the available evidence from across the world, we decided we should go hard and go early, we didn’t wait to be told what to do by the WHO or our governments, you just need to

While the public health emergency has been officially invoked, it’s important to remember that employers and employees are still subject to the Occupational Health and Safety Act 1984, which mandates that all practical steps be taken to prevent workplace injury and that includes work-related infections, of which SARS CoV2 is one. Providing a safe environment for patients and health care workers is paramount this winter and beyond. It’s important that we do this with Respect (empathy and compassion or understanding and kindness). Balancing the needs of patients, particularly patients at the end of their life, against the risks of infection is challenging, but still achievable. Keeping people physically safe but losing our respect for humanity is not acceptable. There is always a middle road and we need to find that path.

At the time of publication, it is still unlawful to offer NAT testing to asymptomatic patients based on directions from the Chief Health Officer under the Public Health Act 2016 (WA). Keeping our hospitals safe this winter is a high priority but so, too, is keeping general practices safe. It’s essential that we restore confidence so that patients attend for their acute and chronic diseases.

to devise our own protocols to protect our patients and staff.”

Given the pervasive global spread of this virus, it is likely that it is here to stay for many years. It’s important that we start to adapt now and set new standards for the safety of health care workers and patients. “Patients have expressed appreciation that we are taking things very seriously and this has been reflected in the confidence and morale of our staff and patients, and translated to continued high attendance rates at our practice” says Dr Kelly. “We have a small working COVID-19 team which meets regularly to review the most recent advice and data from around the world. We then use our training and real-world expertise based on local conditions

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We must have a ‘Target Zero’ approach and raise the standards of infection prevention. PPE use is very important but it can only take us so far. The sensible use of NAT testing of selected high-risk asymptomatic individuals should be allowed by government authorities to help us mitigate the ongoing risk posed by this potentially deadly virus.

JUNE 2020 | 23

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FEATURE

COVIDSafe and safety first The tracing app launched by the government is being met with mixed feelings by the tech and privacy experts.

James Knox reports. When the Australian Government launched the COVIDSafe app, it was compared to sunscreen's protective role against skin cancer, which is a big call in a sunny country like Australia. Are the prospects of the app really that bright? And will it be the panacea that it is marketed to be?

The app itself The government has touted the COVIDSafe as its own, which is partly true. It is based on the source code of the Singaporean Government’s TraceTogether app, while it was developed by Amazon Web Services (AWS) engineers. It is hosted, along with the data captured, in Amazon’s Sydney data centre, which has been certified by the Australian Signals Directorate with the highest classification level for domestic cloud services. The rationale for choosing AWS over an Australian-owned data centre, was due to its capacity to do-it-all, according to Foreign Affairs Minister Marise Payne: “The contract with AWS is a combination of hosting, development and operational services, which is more extensive than services provided by pure hosting providers,” she said at the time of the announcement. 24 | JUNE 2020

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FEATURE Essentially COVIDSafe turns a smartphone into a proximity monitor that communicates with other smartphones using the app by using Bluetooth Low Energy (BLE) technology to measure the distance between users, and the time they were in contact. Initially, user privacy, data security and government surveillance were highlighted as potentially problematic, but with the passing of the Privacy Amendment (Public Health Contact Information) Bill 2020, the majority of these concerns were eased. Yet, it seems, the privacy concerns are less of an issue than the app’s suitability and the effectiveness of its underlying technology, particularly BLE, and the way that it has been marketed to the Australian public.

All or nothing For COVIDSafe to be effective, more than 40% of the population will need to download it, according to the official messaging. Yet, downloads only tell part of the story, according to Associate Professor Adam Dunn from the University of Sydney. ‘If 40% of the population download the app and we optimistically assume that half of those people are using the app properly at all times, then the likelihood of registering a random contact or a contact in a random encounter is 4%. “Fewer than one in 20 potential contacts will actually be captured by the app and that is making some big assumptions about the technology it is based on.” A/Prof Dunn is the head of discipline for Biomedical Informatics and Digital Health at Sydney University with his primary expertise being in data driven methods of public health surveillance. In 2019, he and his team published an experiment analysing BLE signals to track proximity in indoor settings. They found BLE to be problematic to accurately measure proximity when indoors. “Even in relatively controlled conditions, it's very hard to work out which two signals are closest together, or which room people are in. We found that even the direction in which you hold your device makes a big difference to whether

or not the app thinks you're closer or further away.”

precautionary behaviours that have been so successful in Australia.

Ultimately, the inherent inaccuracy of BLE for proximity measurement could lead to false positives, where users are incorrectly identified as being in contact with a COVID-19 positive user, and false negatives where users are not notified, according to A/Prof Dunn.

“This is to make sure that the contact tracers have as much time as we can to be able to get on top of outbreaks.”

A/Prof Dunn questions the government claim that 40% or more of the population need to download COVIDSafe for it to be effective, saying it is a vast understatement. “The effectiveness of the app is likely to be very low, however, if 70% of Australians downloaded the app, and all of them were using it properly, and it worked reliably well, then it would capture up to half of the contacts.” However, no matter the actual effectiveness of COVIDSafe, A/Prof Dunn is keen to emphasise that any assistance that can be provided to human contact tracers is valuable. “If the app helps to contact trace better and it's more of a help than a hindrance, then there's nothing wrong with downloading it.” A major problem with COVIDSafe is how it operates on iPhones as Apple’s iOS limits apps in the background from using Bluetooth. “There are certainly some issues with making sure that the app is actually useful on iPhones,” he said. “To use it properly, people really need to have their phone unlocked and have the app in the foreground.”

Misleading messaging Although the underpinning technology maybe flawed, it is the messaging of the app that is problematic in his opinion. “The Government has been communicating this in terms of the ‘app will keep you safe and our aim and target is to get as many downloads as we possibly can’. One of the problems with measuring downloads means that everyone just has to download it and then they can leave it off,” he said. “We should not tie the downloading of the app to the relaxing of social distancing, or market the app as a form of sunscreen, because we need to remind people that they need to continue with the

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Privacy perspectives Concerns about user privacy and data use of the app have been partly addressed by the release of the source code of TraceTogether by the Singaporean Government. While the Digital Transformation Agency has put the COVIDSafe source code on GitHub for public scrutiny (https://github.com/AUCOVIDSafe), the COVIDSafe server code was not released, despite the Singaporean Government releasing its server code. This would have provided further transparency, particularly on how the captured data is encrypted. There are, however, aspects surrounding COVIDSafe and privacy that require clarification, according to Prof Dali Kaafar, Executive Director and Chief Scientist at the Optus Macquarie University Cyber Security Hub, New South Wales. Prof Kaafar is an expert in privacy enhancing technologies and risk analysis. Prof Kaafar told Medical Forum there were several misconceptions that needed to be de-mystified. “The first is location tracking: the app needs permission to access location because that’s how Google’s Android and Apple’s operating systems are designed. The app needs to ask permission to access location but the GPS coordinates are never accessed.” Another is the susceptibility of user information to be accessed between devices, which Prof Kaafar says is not possible as each device is given a random anonymised ID every two hours. “There is no way to continuously monitor on a regular basis a particular individual from another peer device,” he said. Prof Kaafar also address the potential for snoopers or hackers to compromise a device by accessing information collected by COVIDSafe, such as which users the device has been in contact with. He says this is not possible

continued on Page 26

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COVIDSafe and safety first continued from Page 25 because information is uniquely encrypted to each device and can only decrypted if permission is specially given and, even then, it is complicated to extract it.

Limitations Another privacy limitation is COVIDSafe’s centralised approach to data management, which essentially means that data captured from devices is not private to the central authority (the Federal Government) in charge of it. “When someone is diagnosed with COVID-19, the central authority will ask for consent from that individual to share information from their device … and will upload all the COVIDSafe app users they have been in contact with over the preceding 21 days, which are stored on the device,” he said. The hitch with this type of data is that it can also reveal who has been together at certain periods of time without their consent, which can lead to more information revealed than simply tracing COVID contacts. For example: a user has been diagnosed with COVID-19 (user A), the central authority requests their contact information, they analyse it, and find the user was at a café at a certain time with others (users B, C,

26 | JUNE 2020

D). The central authority can now co-locate through user A’s data that users B, C and D were together at a particular time and yet they don’t know the central authority is aware of this. Now imagine another user has been diagnosed with COVID-19 (user Z), the central authority analyses their data and finds that they were at a park at a certain time and in their contact data, users B and C are colocated together again. “The central authority can infer information about users B and C as the app immediately reveals their identities to the central authority without their knowledge or consent,” Prof Kaafar said. “This is a fundamental issue I have with this app – that implicit consent is given and a central authority knows a lot of information about people without their knowledge or consent.”

Why is this important? “It might not be important for many people. The fact that my wife and I were together in a coffee shop or a restaurant at some point in time, is really not a problem at all from my privacy point of view.” However, he said if it were a meeting that was sensitive, such as between a journalis and a contact or whistle-blower who wished to remain anonymous, the privacy

of that information is more critical and could have safety and security implications.

Privacy is personal Privacy is, by its nature, an individual consideration and perspective: A privacy risk for one, may be completely different for another. Ultimately, the success of an app such as COVIDSafe rests on trust in those responsible for running it to protect the privacy of users, their protocols in relation to data usage, and their transparency and competency to develop and deploy the technology. “Underlying its success is trust,” says Dr Kaafar. “When we are designing privacy preserving technologies, the point is to ensure there is a level of trust being maintained and that it is being created between the users of a service and whoever is running and deploying the app.” “This is incredibly important. If you build this trust, you will have more people adopting this technology and this app.”

Read this story on mforum.com.au

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FEATURE

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OPINION

Re-emergence Emerging from the COVID shutdown will bring challenges writes Clinical Editor Dr Joe Kosterich. The (attributed) Chinese saying about it being a curse to live in interesting times remains apt. As of May 18, WA, reduced intrastate borders from 13 to four and cafés reopened seating up to 20 people. More easing is likely this month. There have been other subtle signs of improvement including toilet paper being back on shelves. However, worryingly, the focus on COVID-19 has seen less focus on other health issues. What will be the health cost (including deaths) of the response? Mass unemployment and loss of livelihood will increase mental and physical health problems. A report presented to the federal health minister suggested an up to 50% increase – up to 1500 additional suicides a year for the

next five years. This will take more than mental health plans and medication. Rates of smoking, and alcohol misuse may also increase. Recessions are associated with increased chronic illness. Rates of heart disease, strokes and cancer may increase. Yet this will be slow and hidden. We won’t get a daily toll but these lives matter as well.

to flatten the curve so the health system could cope, not to have zero cases. As we emerge, we need to be clear of our intent. New cases are not a failure. Doctors and the public need to understand this.

GP practices are seeing 30-50% drops in patient volume. Many procedural specialists have even steeper drops. Pathology and radiology are not immune either. Cancer treatment facilities report up to 30% reductions in new referrals.

The COVID-19 response has created some positives. Flu season may be very mild this year due to social distancing. Telehealth will hopefully remain as an option across the board. A blend of working from home and office may see many people reduce their weekly commuting time. Parents have been able to spend more time with their children. Some patients report reduced levels of anxiety as there is less time pressure and demands on them.

The response has seen far less cases then predicted – a great achievement. However, the aim was

Many of us have ‘slowed down’. Let us aim to keep the positives as we re-emerge and resume our lives.

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GUEST COLUMN

Support for families at the ready As we see restrictions lifting, NGOs are seeing the “second wave” of anxiety and depression. Michael Sheehan urges GPs to be on the lookout. A significant number of clients contacting Relationships Australia WA have sought advice and support regarding anxiety exacerbated by the COVID-19 pandemic. Humans are social beings who thrive on meaningful connections, so the necessity to physically isolate from others can be extremely challenging and can intensify anxiety, especially for those who live by themselves and already experience an anxiety disorder. While anxiety is a natural emotion, problems can arise when the duration or severity of anxious feelings are out-of-proportion to the triggers or stressors that cause them. This can include recurring intrusive thoughts or concerns and physical symptoms, such as increased blood pressure and nausea. This can interfere with an individuals’ daily functioning when they can find it increasingly difficult to do things they are used to doing relatively easily. I encourage GPs to ask patients to make an anxiety checklist or self-reported inventory to measure levels of anxiety and severity of symptoms over time in response to treatment. These include the Depression Anxiety Stress Scales (DASS) 10, and the Kessler 10 questionnaire, which measures general distress. A standard way of treating anxiety is psychological counselling and Relationships Australia WA has been providing counselling services over the telephone, video conferencing or online to clients across the state during the COVID-19 response. The interruption of routines has had a negative impact on clients who suffer anxiety and depression where routine is an essential management strategy.

Without it they find it difficult to get motivated, which can lead to a cycle of frustration and feelings of uselessness. During lockdown we have helped clients to recreate regular structure and routine in their homes and with their children. This includes planning: • Something physical – such as a walk or exercise • Something creative – a crossword, jigsaw or some hobby they have enjoyed in the past • Something social – sending an email, calling a friend Other management options include: • Stress management techniques to limit potential triggers and to prepare for any upcoming pressures and deadlines, and to make overwhelming tasks more manageable. • Relaxation techniques to help calm the mental and physical signs of anxiety, including meditation, deep breathing exercises, long baths, resting in the dark. • Practise replacing negative thoughts with positive ones. Creating a mental image of successfully facing and conquering a specific fear can also provide benefits if anxiety symptoms relate to a specific cause. • Staying connected to a support network online, which includes family, friends and counselling and support services. • Physical exercise, which has been shown to improve self-image and release chemicals in the brain that trigger positive feelings.

dangerous. Research shows that FDV is more frequent and severe during periods of emergency, and increases whenever families spend more time together, such as Christmas. Unfortunately, some men are now are using COVID-19 as a tactic or reason for further control and abuse. Women have reported to us that their partners are: • Withholding necessary items such as medicine, hand sanitiser or disinfectants and threatening or preventing them and their children from seeking medical attention if they have symptoms. • Misinforming them about the pandemic to control or frighten them. • Further isolating them in the home by restricting their movements within the house, increasingly monitoring their mobile phone and email accounts, and restricting online access to supports and services. • Ex-partners using COVID-19 to threaten women about isolating the children and using Family Law contact orders to not return them after a contact visit. Relationships Australia staff can assist women to develop a safety plan, which is a personalised, practical plan with ways to remain safe while in a relationship, planning to leave, or after they leave. If you suspect someone is at risk of FDV, ask them about it, listen and communicate belief, validate the decision to disclose and offer to make a referral to a FDV specialist service like Relationships Australia WA.

Family Violence

ED: Michael Sheehan is an executive director of Relationships Australia WA.

Relationships Australia WA has similarly witnessed an increase in family violence calls at this time.

The national family and domestic violence helpline is 1800RESPECT.

Violence and abuse already present in homes have become more frequent, more severe and more

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CLINICAL UPDATE

Navigating diabetes medications By Dr Andrew Klimaitis, Physician, Duncraig Recommendations on the use of hypoglycaemic medications are getting clearer. Metformin is still first-line. Gliflozins (SGLT2s) and gliptins (GLP1s) improve survival though the latter require injections. DPP4s are safer than sulphonylureas. This is based on data showing mortality benefit with both SGLT2s and GLP1s, and increasing concern about hypoglycaemia, particularly in the elderly and patients with established vascular disease. Sulphonylureas are the ‘bad guys’ causing both hypoglycaemia and weight gain. DPP4s don’t prevent macrovascular complications, but don’t cause hypos or weight gain. Good diabetic control slows down microvascular complications so there is still a place for sulphonylureas and Acarbose, even without macrovascular benefits.

Key messages

Good diabetes control slows microvascular complications

Tailor medications to patient circumstances

Beware overtreatment in the frail. Most type 2s exhibit fasting hyperglycaemia. Toujeo (or Lantus) can be given once daily. Start with the same number of units as the average fasting sugar reading. Increase by two to four units weekly until the fasting sugars drop to single figures, eventually aiming for sixes and sevens. Ryzodeg can be used instead (once daily before biggest meal) if postprandial sugars are also elevated. This incorporates a short acting insulin into the regime. Twice or three times daily regimes

Start with Metformin. There is some mortality benefit and possibly slowing-of-ageing properties. With any suggestion of cardiac disease, especially heart failure, use an SGLT2. Studies show that gliflozins improve cardiac outcomes just as much in non-diabetics. Cardiologists prescribe them without PBS reimbursement. Gliflozins also preserve renal function in most forms of nephropathy. Their effectiveness with a GFR below 30 is less clear, but they seem to continue helping even without further glucose lowering. GLP1s sell themselves because of appetite suppression and weight loss. Not everyone tolerates them, but it is amazing how prepared patients are to self-inject if they might lose a few kilos. Gliptins reduce vascular complications, particularly strokes. This hasn’t yet been generalised to non-diabetics. Combining a GLP1 (PBS), SGLT2 (around $50 non-PBS), and Metformin maximises weight loss.

can be used later, but many type 2s are fine with once daily insulin. Dulaglutide (used weekly) is not PBS subsidised with insulin, though exenatide (used twice daily) is. GLP1s can mitigate insulin’s weight gain. Bariatric surgery should be discussed and can have dramatic benefit. Most patients know someone who’s had the operation. Their enthusiasm will generally reflect how things went for that person. Lastly, don’t overtreat the frail. A study of frail elderly living in the community, but requiring some form of home assistance, showed that maximal survival was at a HbA1c of 8.5%. Patients at 7.5% did worse, roughly equivalent to those at 9.5%. Tighter control presumably caused more hypos which then translated into falls, strokes, etc. Author competing interests – nil

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DPP4s are the best-tolerated agents, particularly in the elderly, but don’t use them (or GLP1s) in patients with a past history of pancreatic disease. If the glycated Hb remains above 8% then insulin should be considered. MEDICAL FORUM | MENTAL HEALTH ISSUE

JUNE 2020 | 31

Diabetic CKD management By Dr Mark Thomas, Nephrologist, RPH There has been a quiet revolution in the management of diabetic chronic kidney disease (DKD) in the past five years with the advent of Sodium Glucose Linked Transport 2 Inhibitors (SGLT2i’s) and glucagon-like peptide receptor agonists (GLP1Ra’s) finally providing agents with cardiac and renal outcome benefits. But powerful pills can have powerful side-effects, so patients and health-care professionals all need to know their use – and when to stop temporarily. Australia-wide surveys historically showed 50% of T2DM patients had either albuminuria or GFR under 60, especially with Aboriginality, diabetic duration over 10 years, Hba1c above 7%, BMI above 30, BP greater than 140/90 and/or

Key messages

Historically 50% with T2DM have impaired renal function

New diabetes medications provide renal and cardiac benefits

Careful monitoring is important.

smoking. However, no strategies other than ACE inhibitors or Angiotensin Receptor Blockers (ARB) had shown cardio-renal protection in randomised controlled trials. Between 2007-2013 there were neutral or negative outcomes from intensified diabetic control, combined ACEi/ARBs, endothelin antagonists, DPP4 inhibitors and other therapies. Positive RCT

evidence for either SGLT2i’s or GLP1Ra’s has emerged every year since then. SGLT2i’s prevent the renal proximal tubules recycling filtered urinary sodium and glucose back into the body. This allows overflow when blood sugar levels (BSLs) are raised, but avoids hypoglycaemia when BSLs fall, providing a steady loss of calories for the overweight, and additional sodium loss for the hypertensive. The resultant salt-rich tubular urine effectively reverses the pathological hyperfiltration seen with diabetes or obesity with a predictable average 3-7ml/min fall in eGFR within two weeks of starting. GFR stabilisation follows, with 20-30% less likelihood of death, acute or chronic kidney

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CLINICAL UPDATE

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CLINICAL UPDATE

disease or heart failure over the next five to seven years. Although the glycosuric effect falls when GFR under 45, the CV-renal benefit applies even as GFR falls, and is seen patients already on statins, ACEi or ARBs, and in all patient sub-categories. There is a predictable risk of glycosuric bacterial or fungal sepsis in the first two months after initiation, as already applies in diabetics with poor control, suboptimal hygiene or uncircumcised. This is best treated with scrupulous groin and

conventional DKA and managed by insulin-dextrose infusion until ketones resolved.

abdominal fold washing, drying and baby powder, and standing ready with pre-emptive cephalexin for dysuria plus clotrimazole for thrush.

A ‘sick day plan’ is needed for every diabetic CKD patient when unable to maintain adequate food and fluid intake: This includes self-monitored weight, BP and temperature; temporary reduction/omission of ACE, ARBs, diuretics, metformin, SGLT2i; check FBC, CRP, electrolytes, LFTs, VBGs, troponin & ketones, and hospitalisations for insulin/glucose infusion if not rapidly improving.

The major risk of euglycaemic diabetic ketoacidosis occurs in T1DM (or long-standing T2DM with reduced beta-cell reserve) if SGLT2i’s are continued during reduced fluid or food intake, needing to be ceased three days prior to elective surgery. If not avoided, then it can be identified by pH below 7.3, HCO3 under 15, blood ketones above 0.6 and BSL less than usual expected 25 in

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CLINICAL UPDATE

Calcium score and CTCA – which test when? By Dr Lawrence Dembo, Cardiologist, Murdoch The coronary calcium score is a powerful risk factor of a future cardiovascular event. Why? Because calcium is direct, visible evidence of coronary artery disease, while the standard risk factors are only risks of atherosclerosis. An elderly patient with a full house of risk factors and a calcium score of zero has a very low risk. A young patient with no risk factors and a very high calcium score has an extremely high risk of future coronary artery disease. Atheroma occurs with inflammatory changes in the wall of the coronary artery. Over time, some of the inflamed ‘soft’ plaques heal. A byproduct of this chronic inflammation is calcium deposition analogous to a ‘scar’. While the calcium is inert and not dangerous, the amount of calcium correlates with the total burden of coronary atheroma and the risk of future coronary events.

Key messages

Calcium score is a powerful risk prediction tool

Coronary CT (CTCA) is for diagnosis of equivocal symptoms

For symptoms, request CTCA not calcium score.

No IV contrast is required. Set-up takes less than five minutes and scan time is only a few seconds with minimal radiation exposure. The amount and density of calcium in the coronary artery walls is measured to derive a calcium score. Importantly, this test only quantifies coronary calcium and does not define any soft plaque or coronary artery narrowing. In the asymptomatic, a calcium score of zero implies a very low risk in the short-to-medium term and generally provides reassurance, which is additive to standard risk scores.

The risk profile of two thirds of patients will be reclassified from intermediate to low or high risk and may be used to guide the aggressiveness of risk factor management when compared to current risk scores. Up to 15% of intermediate risk patients have non-calcified atheroma despite a zero score which may provide false reassurance. In symptomatic individuals, a calcium score alone is not indicated. A CT coronary angiogram (CTCA) is recommended as it will visualise non-calcified soft plaque or coronary artery stenosis. Many practices include a calcium score with a CTCA. CTCA is a diagnostic test allowing visualisation of the coronary artery lumen to rule out stenosis and define the presence of vulnerable, soft (noncalcified) atheroma. The amount of plaque seen is also a strong risk predictor. The more plaque seen, the higher the risk. After sublingual GTN to dilate the coronary arteries, and IV contrast, ECG-guided CT images are acquired. The engineering of specifically designed cardiac imaging CT scanners is quite extraordinary. To minimise blur due to cardiac motion, scans need to be super-fast. Not all CT scanners are the same (a Toyota is not a Ferrari) with significant differences in spatial and temporal (blur) resolution. It’s important to do your homework before referring. For chest pain that is indeterminate (equivocal chest discomfort) in a patient who is intermediate risk, then the investigation of choice is a CTCA. A normal CTCA effectively rules out coronary artery disease as a cause of the symptoms (specificity ~ 99.9%) and in 8% of cases, defines another cause for the symptoms e.g. lung cancer, pulmonary embolus, hiatus hernia, pneumonia, etc. A Medicare rebate exists for some CTCAs referred by a specialist. There is no rebate yet for a calcium score. The author works at a practice that performs CTCA and calcium scores.

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CLINICAL UPDATE

The Panic of COVID-19 Pandemic By Prof Sergio Starkstein, Psychiatrist, Fremantle “It is fear what I fear most”, wrote Michel de Montaigne. Fear in the guise of anxiety or panic is recognised as the second major problem produced by the COVID-19 pandemic, after the infection itself. While fear has a dramatic impact not only among infected individuals but among the population at large, including healthcare workers, it is still unclear how best to deal with this problem. Suggestions to reduce anxiety include the consumption of media, keeping to healthy diet, exercise and sleep regimes, to practise mindfulness, and to reach out for support. However, this is putting the cart before the horse. For instance, who can advise on how much and which ‘media’ is safe to consume? Anxiety means to have fear about future events. To avoid future dangers and to appease this emotion most humans want as much information as possible. One of the non-ethical strategies of some media is to instil fear by producing material with dramatic overtones becoming a magnet of attention. This creates a vicious circle of fearmongering resulting

Key messages

Fear pervades those infected, the ‘at risk’ population, and healthcare providers Simple measures, whilst helpful, are not always easy to implement. in increased fear which stimulates more consumption of media. Secondly, healthy habits are easy to advise but difficult to implement in the context of high anxiety, especially during quarantine. A healthy diet and a refreshing sleep are the first victims of this toxic combination. There is poor motivation (and sometimes no physical space) to exercise; and a mindful silent meditation may even increase the monsters of fear when the quarantine results in increasing boredom, a decreasing financial state, loneliness and domestic violence. Finally, reaching out for company is complex while in quarantine, and lonely people may become lonelier, many times ending in despair and sadness.

workers? A recent article in JAMA suggests reducing fear by increasing safety measures, such as those recommended by the Centre for Disease Control. These include wearing PPE (gown, gloves, N95 respirator, a face shield, and, if possible, a powered air-purifying respirator). Add to this careful hand hygiene, and cleaning of workspaces and equipment. Nobody will argue against these recommendations, but extra measures may add to the exhaustion and frustration of healthcare workers. Conversely, knowing the relevance of PPE but lacking it may increase anxiety among healthcare workers in developing countries. The psychological morbidity produced by fear cannot be exaggerated yet rational ways of dealing with it in the context of heterogeneous personalities, major differences in the access to material and human resources, and disparate professional abilities remains a matter for deep debate. – References available on request Author competing interests – nil

What about fears among health

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CLINICAL UPDATE

Managing antidepressantassociated sexual dysfunction By Dr Angiolina Vellianitis, Psychiatrist, West Perth Sexual dysfunction (e.g. reduced libido, reduced arousal or erectile dysfunction, and delayed or absent orgasm) is a common side effect of antidepressants in males and females, affecting 30-40% of people taking antidepressants. Despite their frequency, sexual side effects are under-reported by patients, and often underemphasised by clinicians. It can impact quality of life, selfesteem, relationships, treatment adherence, and recovery from mental illness. Sexual dysfunction has been reported with virtually all antidepressants, including SSRIs SNRIs, tricyclic antidepressants, and monoamine oxidase inhibitors. The mechanism is generally thought to involve increased serotonergic transmission, which has additional downstream effects on nitric oxide production, and dopamine and noradrenaline transmission. It likely also comprises alpha-adrenergic and cholinergic receptor blockade. Step one in management is to assess thoroughly the symptoms and aetiology differentiating sexual side effects of antidepressants from

pre-existing sexual dysfunction due to other causes (e.g. diabetes mellitus, vascular disease or alcohol/drug use). Assessing for ongoing or residual symptoms of depression, which can also impact sexual function, is also important. Along with direct questioning, the Arizona Sexual Experiences Scale can be helpful in assessing severity. Often, it is a challenge to manage sexual side effects without risking the patient relapsing into depression. Presenting this dilemma to the patient can sometimes help make management decisions. Watchful waiting may be the first step. Up to 20% of sexual side effects diminish with time, usually over several months. Dose reduction can be another option with monitoring for symptoms of relapse. Depending on the half-life of the medication, it may take several weeks to notice any improvement. Adding or switching to an antidepressant with less propensity to cause sexual side effects, such as mirtazapine, agomelatine, or bupropion is an option. Beware the risk of seizures, and cost and availability issues, with bupropion.

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Sildenafil and tadalafil have been shown to improve erectile function in men with antidepressantassociated sexual dysfunction and may be a better alternative than changing medications or dosage. Delaying the dose of antidepressant medication until after sexual activity may also be a viable option. Drug holidays have been suggested in the literature, but for people with high risk of relapse, this may be inappropriate. Also, a brief drug holiday is unlikely to be effective for those on medications with long half-lives (especially fluoxetine). For cases where psychological or relationship issues are possible contributory factors, cognitive behavioural therapy or couples’ therapy can be helpful. Antidepressant-associated sexual dysfunction is common and is known to impact on medication adherence and recovery. Therefore, identifying and addressing this issue has the potential to significantly improve quality of life and mental health outcomes for patients. – References available on request Author competing interests – nil

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CLINICAL UPDATE

Minimally invasive spine surgery By Dr Paul Taylor & Dr Greg Cunningham, Spine Surgeons, Murdoch The principal goals of minimally invasive spine surgery (MISS) are to reduce surgical morbidity and recovery period of surgery. For most procedures, this comes down to two discrete elements. Firstly, to reduce the extent of the surgical dissection such as the traditional “stripping” of the spine for posterior fusion in which erector spinae musculature is dissected off the vertebrae to be fused (Fig 1a), and, secondly, to reduce blood loss therefore reducing the physiological insult of the surgery and the length of recovery. The reduced physiological insult of MISS has made surgical treatment suitable to some candidates not deemed fit for traditional open approaches. Early development saw sequential

Key messages

MISS aims to reduce tissue damage and blood loss, thereby shortening recovery It comprises a suite of techniques with technology dependent procedures and significant learning curves to address spinal pathology Not all pathologies or patients are suitable for MISS techniques.

muscle dilating probes used with tubular table-mounted retractors allowing access to many parts of typically the posterior spine throughout its length without substantial dissection. Using an operating microscope and typically custom-designed instrumentation to reduce visual obstruction,

lumbar and cervical discectomy, lumbar central canal stenosis decompression procedures were offered, typically through a 16mm or 18mm diameter tube retractor. Placing pedicle screw instrumentation into the spine was traditionally performed ‘open’. Techniques using cannulated equipment to deliver screws percutaneously (essentially using a Seldinger technique of wire placement into a pedicle and then placing a screw over that wire) began the treatment of some fractures and tumours with pure percutaneous rod and screw placement, and, along with the use of tubular retractors, began the development all MIS lumbar fusion techniques. Over the past decade, many techniques have developed,

Breast screening resumes

reastScreen WA (BSWA) - the state’s breast cancer screening program - has resumed mammogram screening services.

The metropolitan clinics were the first to re-open, with screening in rural areas restarting in early June 2020. Women who were invited to have a screening mammogram before the temporary suspension in April were prioritised and received the first available appointment. Other women are encouraged to book online or contact BSWA on 13 20 50 to schedule their appointment.

Women may book online www.breastscreen.health.wa.gov.au or phone 13 20 50 42 | JUNE 2020

Mar ‘18

BSWA’s Medical Director Dr Liz Wylie said she welcomed the reopening of BSWA’s screening services: “We will be booking clients based on clinical priority to ensure those who are most in need are screened first. The safety of our clients and staff remains of paramount importance and we will continue to ensure the highest levels of hygiene and care. We thank all our clients and GPs for their patience and understanding during this time.”

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CLINICAL UPDATE some good, some bad. A method of fusing L5/S1 by making a small incision close to the anus, dissecting the pre-sacral fascia and reaming the disc through the sacral promontory has largely been abandoned due to unfavourable outcomes. Techniques to instrument the anterior lumbar and thoracic spine, which are able to restore disc height and angle, maximise fusion potential, correct deformity and maximise load sharing across a large implant interface. These have proved very successful. The discipline is a world of acronyms, but the XLIF, ATP, and OLIF (to name a few!) approaches have proven worthwhile and remain widely used. Such techniques allow the treatment of conditions such as adult degenerative deformities in a wider range of patients. New areas of development currently led by South Korean and some US centres focus on the development of spinal endoscopy. Discectomy in the neck and low back, decompression surgeries and more are now routinely being performed. These procedures are

entirely dependent on custom endoscopes, irrigation delivery systems and shavers but may offer the promise of “ambulatory spine surgery” (local anaesthetic and sedation only and same-day discharge possible).

problems such as a dural tear through a tubular retractor becoming more difficult than in open surgery. Furthermore, surgeons having learned new skills must avoid the temptation to apply them to cases inappropriately.

There is a long learning curve requiring the surgeon to develop a completely new set of skills and so uptake is currently (rightly) limited.

In adult spinal deformity, for instance, the MISS techniques have limitations and often severe deformities require a traditional open surgical approach to perform necessary bony corrections.

The procedures are almost always highly technology dependent, so equipment costs are significant. Research on the “return on investment” of these procedures due to reduced morbidity and length of stay has shown benefit. However, some of the studies have been equipment company funded with sponsored surgeons. Hence bias potential must be acknowledged. In keeping with the published international results, local experience is demonstrating a patient benefit with accelerated recoveries, reduced hospital length of stay and reduced post-operative analgesic requirements. Complications on this learning curve, however, can be significant and dealing with relatively simple

With new medical technology being offered at an accelerating rate, we must not only fully assess the incremental improvement offered to patients, but also consider the limited health care budget. MISS is currently delivering both cost effective improvements in patient outcomes and expanding our treatment abilities. The future challenge will be continuing to implement available advances to optimise outcomes while delivering maximum economic value for those funding it. Author competing interests – nil

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CLINICAL UPDATE

Oral burning By Dr Amanda Phoon Nguyen, Oral Medicine Specialist, Perth There are numerous differential diagnoses for intraoral burning. Perhaps the most well familiar is a condition known as ‘burning mouth syndrome’ (BMS), famously afflicting singer Sheila Chandra. It is preferably called oral dyaesthesia due to the fact that patients with BMS may report oral mucosal pain, altered taste sensation, and a dry mouth in addition to, or sometimes instead of, a burning sensation. While not actually a syndrome, BMS is defined as “a chronic intraoral burning sensation that has no identifiable cause – either local or systemic condition or disease”. It is associated with normal clinical signs and laboratory findings. It is estimated to affect between 0.1% and 3.9% of the general population and is most typically seen in postmenopausal older women. Psychological factors such as somatisation, anxiety, depression and personality disorders are identified more frequently in BMS patients. The cause of BMS is poorly understood, but hypotheses include peripheral neuropathy or neuropathic pain, with central sensitisation. The most frequently affected area in people with BMS is the tongue. Symptoms are typically bilateral and symmetrical, and the pain tends to follow a temporal pattern, most commonly worsening during the day.

Key messages

Burning mouth syndrome (BMS) may present with symptoms aside from oral burning BMS is a diagnosis of exclusion Management may be difficult, and there should be consideration of any perpetuating psychosocial factors Many treatments have been trialled, including topical or systemic clonazepam, gabapentinoids, tricyclic antidepressants, and anti-spasmodics. Other management strategies including the use of Vitamin B12 or zinc supplementation, alpha lipoic acid, palmitoylethanolamide, lowlevel laser therapy and capsaicin mouthwashes. Patient education and anxiety management to improve the patients’ quality of life should also be considered. To date, few effective treatments are available and management of BMS can be difficult. BMS is a diagnosis of exclusion, and therefore other factors that may be associated with oral burning should be excluded before reaching a BMS diagnosis. Consider infective conditions such as oral candidiasis and traumatic cause such as damage to tongue papillae. This may be because

of mucosal disease, damage secondary to salivary gland hypofunction (such as radiotherapy, saliva problems, eating disorders, gastro oesophageal reflux and dehydration). Other differentials include salivary gland disorders or immunemediated conditions affecting the salivary glands such as Sjogren’s syndrome, oral mucosal diseases such as oral lichen planus, metabolic issues (e.g. diabetes, thyroid disorders), medicationrelated adverse effect (e.g. ACE inhibitors), allergies including reaction to dental materials or dentures, oral galvanism, deficiency states (e.g. vitamin B, iron or folate deficiency) and central nervous system disorders including multiple sclerosis or Parkinson’s disease. Author competing interests – nil

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Mental health and COVID A systematic review and meta-analysis of the psychiatric consequences of coronavirus infections has recently been published in The Lancet Psychiatry. Researchers identified 72 studies (65 peer review and seven pre-print) that featured data on the acute and post-illness psychiatric and neuropsychiatric features of coronavirus infections of 3,550 patients hospitalised with SARS, MERS, and COVID-19, aged between 12.2 and 68 years. The authors found acute cases of SARS or MERS included confusion 27·9%, depressed mood 32·6%, anxiety 35·7%, impaired memory 34·1%, insomnia 41·9%, steroid-induced mania and psychosis 0·7%. While post-illness cases were reported to have depressed mood 10·5%, insomnia 12·1%, anxiety 12·3%, irritability 12·8%, memory impairment 18·9%, fatigue 19·3% and in one study traumatic memories 30·4%.

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FEATURE

Antarctic adventure turns frosty A voyage of a lifetime turned a nightmare of pandemic size. Kalamunda GP Cathy Civil shares the highs and lows she and GP husband Mike went through to get home. We left Perth on February 23 to join a GP conference to the Antarctic at a time when COVID-19 was looking like a MERS and SARS – a foreign problem that would be contained long before it affected us. We had always wanted to see the Antarctic and with global warming escalating rapidly it seemed that the sooner we could go the better. So, when we saw an advertisement for a GP conference that ticked all of our boxes and more, it was our chance. Being both GPs, the conference was a way of making the trip more affordable and the line-up of speakers looked impressive. The trip was to start in Santiago where we gave ourselves a few extra days to look around before flying to Punta Arenas in the Magellan Straits to board the MS Roald Amundsen, a small, new Norwegian hybrid exploration ship. Having always been cruise cynics, this was our first cruise and certainly not your average one. This was very much a scientific exploration ship with a team of scientists, a science centre and an expedition team on board. We would have the opportunity to go hiking and kayaking and explore on the ice as well as an informative conference. We were blown away when we got on board. The ship was way beyond our expectations, full of 46 | JUNE 2020

sleek Nordic design and none of the superficial entertainment frills I associate with a normal cruise ship. The Norwegian officers were full of humour and common sense so that the ship appeared to run with effortless efficiency. And our cabin was beautiful with everything we could want, including a lovely bathroom and a balcony. The trip was REAL! It was HAPPENING! We sailed out of port and headed west to the Magellan Straits. We had never been so excited about a trip. And it fulfilled all of our expectations. The scenery was outstanding, and the clear blue skies produced wonderful air clarity, amazing colours and fabulous photos, but the amount of bare rock and waterfalls coming out of old glaciers did remind us that it had been the warmest Antarctic summer on record. It was great fun dressing up in our layers of new polar clothing, taking selfies, and waiting for our turn to head out in the zodiacs with our 12-person “Wandering Albatross” expedition group. We quickly made friends with the other team members who all shared our level of excitement. There was a code of conduct to keep the continent pristine and the animals happy. We needed to keep 5m from penguins (but it was OK if they came to us); 25m from seals and sealions, and we had to walk

in each other’s tracks to minimise damage to the delicate lichens and mosses. And we were absolutely not allowed to carry anything that could become litter. The sea ice was exciting to plough through, especially brushing through it in the zodiacs; the number and variety of whales, seals and penguins was unexpected; the opportunity to have two polar dips was fun and exhilarating; the birdlife was wonderful; we went kayaking amongst the icebergs … like WOW. Incredible. We even knocked back home brew vodka at the bar of the Vernadsky Ukrainian research base. We had experts in everything on board, from whale research and photography, to Antarctic survival skills and history and storytelling, and microplastics. We even had Henryk who had been on an expedition to re-enact Shackleton’s terrifying 1917 trip from the South Shetlands to South Georgia – a 1300km voyage in a lifeboat through treacherous seas, to get help for his stranded crew. We sailed as far south as Marguerite Bay, well below the Antarctic Circle which not many ships are equipped to do. We were on cloud nine the whole voyage. We sailed north again to the Falklands. Having lived in the UK in the 1980s, we knew a little about the Falklands war, but it

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FEATURE

became very real when we were there. There is understandably no love lost for the Argentinians who occupied the island for a few weeks and left behind 120,000 landmines as a parting gift. The voyage was at an end here and we had had our Captain’s Farewell with speeches, music and dancing the evening before our planned disembarkation. We knew that there might be some issues due to COVID-19 as we had been following the saga closely, but the chances appeared good for a normal departure. Suitcases had been put out ready for collection. But at the last minute the announcement was made that no one would be getting off that day.

The mood changed and uncertainty reigned. And, so it was to be for the following 10 days while the whole of the Hurtigruten organisation tried to find somewhere for us to disembark. We knew that no one was ill on the ship and we knew that the only town we had been to in 16 days was Port Stanley in the Falklands where there was no COVID-19, but that wasn’t good enough for the ports of Chile or Brazil.

We were going to arrive in Sydney several hours before the enforced hotel isolation rule came in, so we would be able to get our connecting flight back to Perth the next day as planned.

Finally, 14 days after leaving Port Stanley, and after a lot of high-level, delicate negotiations, the 330 of us were allowed to fly out from the Falklands military airport on two specially chartered planes to Santiago.

We were left kicking around on our 1.5m markers wearing masks and being marshalled by staff in full PPE for over five hours until we were summoned finally by some senior AFP officers to be told that those who lived within 20 minutes of the airport and had transport could go home to self-isolate.

In Santiago, the Australian and New Zealand GPs in the group were ushered quickly through a sanitised corridor for a connecting charter plane which flew us directly to Sydney. We breathed a huge sigh of relief and a round of applause went up when the plane took off!

Our relief was short-lived. On arrival at Sydney airport it became clear that no one knew what to do with us. The Ruby Princess had docked a few days previously and the minister didn’t want a repeat fiasco.

The rest of us could go to the airport hotel with a view to completing our onward journeys continued on Page 50

From the wonders of the Antarctic to the challenges of quarantine, it is a trip that Drs Cathy and Mike Civil wil never forget.

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Antarctic adventure turns frosty continued from Page 49 the next day. This was 3am and we had been travelling for more than 24 hours so we happily checked in and slept. Next day we were preparing to leave the hotel for our 10.30am flight home, but we were stopped and sent back to our rooms to await police who arrived an hour later to serve us with a public health order that stated that we were a COVID-19 threat and needed to be contained. We felt powerless and frustrated. We knew that we were safe. And it seemed that those who had left the hotel earlier than us had been free to take their onward flights or hire cars to go home. The next thing we knew we had armed police outside our door, and we were to be stuck in the room for 14 days ordering room service pizza and chips with no fresh air. Two days later, when it became clear that the airport hotel with rooms designed for stays of a few hours was not going to deal with full board for large numbers of people, we were moved to the Intercontinental in central Sydney. This involved an extraordinary number of AFP and defence forces personnel, and a convoy of buses and police escorts with flashing lights. It was a high security operation! So began our luxury hotel incarceration. We had a nice room

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it is true, but with tepid government rations in disposable packaging and plastic knives and forks, and a view of a building site. Fortunately, we had our lap-tops, our devices and free wi-fi, our holiday memories and each other. It was a win when we found a toilet brush and cleaning fluid outside the door, and we were given fresh linen one day. But we were treated as if we had the plague. When I heard our meal being deposited outside the door, and I retrieved it before it went from tepid to cool, I had an admonishing phone call telling me to wait until the telephone call to say that we were permitted to pick it up. That call could arrive 10 minutes after, or 45 minutes, or not at all. The rules kept changing. Around this time, our travel party were cited on the news by the NSW chief of police as being the “absconding doctors” who had run away from quarantine thinking they were above the law. You what? Those who had gone home had done so with permission of the police. The confusion and miscommunication were enormous and we couldn’t believe that we were being blamed! An internal message group had been set up among other detainees from our convention, and it was going off! We all tried to control the cabin fever and occupy the time usefully. I think we handled it as well as anyone else and better than many.

We were guinea pigs in the very confused system. Then Mark McGowan announced that the WA borders were to close, and WA residents were to get home quickly. Fortunately for us, this appeared to be a trigger for the police to review our public health order having realised that it really didn’t hold water. All the emails, phone calls, and pulling of strings from a lot of angry doctors was taking its toll on them, I’m sure. So, the PHO was revoked. It took another 24 hours for the wheels of power to release us from our rooms. We walked past a phalanx of police and security officers to the hotel exit. It felt like a guard of honour! And then, being cleaner than clean from infection, we felt very vulnerable heading into an infected world – at the airport and then squashed onto a jampacked plane back to Perth with no chance of social distancing. We narrowly escaped further hotel detention in Perth when a timely email from the NSW police came through to immigration which confirmed that we didn’t need any further quarantine. After an extra 10 days on the ship, and eight days in a hotel room, we were FREE … to do another 14 days home isolation. We have never been so happy to see our home. We broke open the champagne and danced and sang with a very surprised dog! Home isolation was going to be wonderful!

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FEATURE

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WINE REVIEW

Happs built to last

Review by Dr Louis Papaelias

School teachers Ros and Erl Happ first planted grapes in the Margaret River district as far back as the 1970s, putting them among the ranks of the first viticultural pioneers. To this day they still head the estate, which has grown to accommodate 30 different grape varieties. The fruit used comes from two vineyards, one in the northern warmer Dunsborough area and the other at the cooler Three Hills vineyard located at the southern extreme of the Margaret River district at Karridale just north of Augusta. All the fruit is dry grown, that is without supplemental irrigation, and that no herbicides whatsoever are used. The Happs attribute the health of the vines to the unique trellis system called “Up and Over Lyre”, which allows for improved sun exposure and airflow so that fruit flavours are maximised and disease and pests are minimised. As a result, the amount of sulphite used in vinification can be negligible. The final link in the chain winemaker Mark Warren, who is an experienced and talented craftsman able to coax and nurture the very best in the hand-picked grapes at his disposal. Like a good cook, he is able to show the fruit at its best without a heavy hand.

2016 Three Hills Eva Marie (13.1% alcohol, cellar door $30) Named after an early pioneer, this is a blend of Semillon (56%), Sauvignon Blanc (38%) and Muscadelle (6%). Four days skin contact and wild yeast fermentation as well as some barrel fermentation and lees stirring has resulted in a sophisticated and stylish SSB. Whiffs of honey, lemon and white flowers without overt fruitiness. Palate structure is clean with a pleasing and complex minerality. If you like the white Bordeaux Graves style of wine then this will surely please.

2016 Happs Two by Two Cabernet Petit Verdot

2019 Happs Fields of Gold Chardonnay

(14.3% alcohol, cellar door $30)

(13.6% alcohol, cellar door $30)

An unusual 50:50 blend of the two varietals. Dark berries, chocolate and pleasant “woodsy” aromas. Rich and long with firm earthy grip. Built to last.

Coming entirely from the Karridale site, there is white peach and grapefruit aromas and a whiff of struck match. Oak not noticeable. Clean, lively with generous fruit tightly reined in by crisp acidity. A more restrained style of Margaret River chardonnay reflecting its cooler site.

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'S EWER REVI

PICK

2016 Charles Andreas (14.3% alcohol, cellar door $45) Another nod to an early family pioneer. A classic Bordeaux blend from the best of the estate’s Cabernet Sauvignon, Merlot, Cabernet Franc, Petit Verdot and Malbec. Classic Cabernet cassis aromas along with spice, green leaf and violets. A supple mouthfeel with generous fruitiness balanced by soft tannins. A pleasure to drink now, yet will easily keep.

JUNE 2020 | 49

Closing the circle Author Jon Doust talks to Ara Jansen about his latest book, Return Ticket, which completes a trilogy and rounds out the life of his main character.

Jon Doust recently bailed up a bloke he knew in his local Bunnings, telling him he should read his latest book. “He said he only read manuals,” Jon said. “I told him fiction was a wonderful genre because it helped your imagination and juices your mind. I told him to read the bits about the men stuff or get his wife to read them to him!” While it might seem like an odd way to go about publicity, Jon is passionate about spreading the word around the themes of Return Ticket. While it’s the third book in the trilogy of Jack Muir’s life, the author says it’s a much bigger story about a man coming of age, coming to an understanding of himself and the interconnectedness between people which knows no racial or geographical boundaries. The trilogy started with 2009’s Boy on a Wire, which details Jack’s experience at a Perth boarding school, and continues with To the Highlands, continuing Jack’s life towards the end of the 1960s, working in a bank and going to Papua New Guinea. Jack’s adventures in Return Ticket start in 1972 when the hot-headed, 50 | JUNE 2020

impetuous young man disembarks a ship in Durban, South Africa, and never gets back on. He sails into misadventure, fleeing the stifling small Australian town of Genoralup by losing himself in the African nation at the height of apartheid and then ends up on an Israeli kibbutz. Caught between fleeing from and seeking what he needs, Jack tells the story both in real time and looking back as his older self. “Jack is my twin brother,” explains Jon, from his home in Albany. “He’s both better than me and worse than me. But he’s also the character which suits the requirements of the book. I wanted him to gain some maturity and wisdom and I wanted him to close his circles. I wanted him to reconcile and find peace and calm.” Given he’s drawn extensively on his own life across the trilogy, you could be forgiven for thinking the author had a few issues to figure out. As well as extensively mining his memory, Jon consulted personal diaries he has always kept and letters he wrote to his mum from boarding school. The book is dedicated to Jon’s mum, his wife

and the mother of his first Israeli girlfriend, a holocaust survivor, because they all made decisions which dramatically changed his life. These stories, in various guises have found their way into Return Ticket. “Writing this book was like giving birth to the last child knowing you are never going to do it again. You’re exhausted, your system is shot. It’s something like post-natal depression. You sit in a chair and wonder what to do next.” For Doust and many other writers, the cycle of publishing a book won’t quite come to a satisfactory conclusion. The cancellation of gatherings has meant he won’t be able to travel around talking about the book and listening to reader experiences. “I’m hoping that people might read more than normal and that those who love storytelling will find the book. What’s cathartic for me is to be able to talk to people about it. I’ll be doing it a different way this time.” Return Ticket is published by Fremantle Press.

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Medical Forum June 2020 - Public Edition

Articles inside

Books: Jon Doust Return Ticket

Wine Review: Happs – Dr Louis Papaelias

Antarctic adventure turns frosty – Dr Cathy Civil

Minimally Invasive Spinal Surgery

Testing the Waters

The COVID long haul

Testing boosts confidence

Into the Tele-future

Q&A Pyschiatrist Dr Mathew Samuel

Familial hypercholesterolaemia 5

Antidepressants & sexual dysfunction