Medical Forum March 2020 - Public Edition by Medical Forum WA

Problem with pills CHANGING THE CHRONIC PAIN PARADIGM

Pain Management issue | Opioids, Wearables, Neuroablation, Migraine, Advocacy

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Jan Hallam | Managing Editor

Pain & gain? “I think we need, somehow, to dial the stress down a little bit,” Dr Tonkin said. She added that the growth was for mostly low-level complaints, “not the important ones”.

The Australian Health Practitioner Regulation Agency (AHPRA) has started 2020 off in a state of great busy-ness. It has released a comprehensive survey of nearly 10,000 junior doctors to collect their views on the quality of their training and the culture in which they are undertaking it. It is an interesting document and like all surveys raises as many questions as it seeks answers for. Not surprisingly, the junior doctors on training programs are flat strap, but three quarters of them are happy with their program and would recommend it to those who come after them. We published some of the figures on page 15. Gratitude for the opportunity to get into highly competitive places can help you put up with a lot and that is completely natural. Working long hours never seems as long when you’re young and doing what you’ve always set your heart on doing. Service registrars and those awaiting trainee placements are another story with not such a happy ending. AHPRA also “welcomed two new policy directions from the COAG Health Council which reinforce that AHPRA and National Boards are to prioritise public protection in the work of the National Registration and Accreditation Scheme (the National Scheme)”. No quibble there. Medical Board chair Dr Anne Tonkin was quoted in The Medical Republic acknowledging that getting a notification from AHPRA was one of the most dreaded things that can happen to a doctor … but it shouldn’t be, apparently, because, as she says, the rate of complaints is growing so fast – by about 15% a year – that the experience is now commonplace. “I think we need, somehow, to dial the stress down a little bit,” Dr Tonkin said. She added that the growth was for mostly lowlevel complaints, “not the important ones”. Is that not a bit weird? Firstly, consumers are taking lucky pot shots, and then doctors expected to shrug them off. Doesn’t that send the wrong message for everyone concerned? This month’s Pain Management issue explores WA’s use of prescription opioids and it is perhaps a good example of the case in point: what consumers want, is not always what consumers should get. The dilemma for doctors is that these decisions are rarely black or white. There is, however, great work being done around nonopioid treatments for non-cancer chronic pain. Having alternatives to ill-informed consumer demand may be the best way to alleviate the pain of time-wasting vexatious complaints.

MEDICAL FORUM | PAIN MANAGEMENT ISSUE

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CONTENTS | MARCH 2020 – PAIN MANAGEMENT ISSUE

Inside this issue 18 30 22

FEATURES

NEWS & VIEWS

LIFESTYLE

16 Q&A Dr Sean Stevens

46 Travel: Hip Hop Peru

18 Close-Up Dr Alison Soerensen

Editorial: Pain and gain? – Jan Hallam

49 Wine Review: Fraser Gallop

6 Letters

22 The Problem with opioids

10 WA News

30 The wearables revolution

11 Local Brief

– Jan Hallam – Dr Louis Papaelias

50 Arts: Tim Finn’s Star Navigator

14 Global News

51 Out & About

15 Research Briefs

52 Social Pulse: Mount Hospital

28 Opioid: Clinicians’ views

Christmas

53 Social Pulse: Next Practice

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CONTENTS

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

Clinicals

ADVERTISING Marketing Manager (0403 282 510) mm@mforum.com.au EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au

Advanced pain management in the community Dr Ashish Chawla

Urine drug screening in pain management Dr Roger Cruickshank

Treating keratoconus Dr Ian Chan

Interventions for craniofacial pain Dr Philip Finch

Fibromyalgia syndrome Professor Eric J Visser

Developments in migraine treatment Dr Tapuwa Musuka

Complex Regional Pain Syndrome Dr Brian Lee

Oral ulceration Dr Amanda Phoon Nguyen

Neuroablation in chronic pain management Dr David Holthouse

Do we learn from history? Dr Joe Kosterich

Clinicians and biotech design Dr Matthew Oldakowski

Aged Care in 2020 Mr David McMullen

Journalist James Knox (08 9203 5599) james@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au GRAPHIC DESIGN Thinking Hats studio@thinkinghats.net.au INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Mark Hands (Cardiologist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon) CONTACT MEDICAL FORUM Phone: 08 9203 5222 Fax: 08 9203 5333 Email: info@mforum.com.au www.mforum.com.au

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OPINION

Do we learn from history? Each day in Australia over 50 people die from smoking-related diseases and in the US more than 180 people die from a drug overdose. Each year, worldwide, tens of thousands will die from either influenza or complications thereof.

Given there has never been a vaccine against any corona virus, we must be genuinely careful about rushing one without adequate testing.

Sometimes the most obvious gets forgotten. Medicine’s goal is to alleviate suffering. To quote Arturo Catiglioni “[Medicine was] born with the first expression of suffering and the first desire to alleviate this suffering”. So what gets everyone terrified? A novel new virus. Deadlines mean that much could change before this appears in print. However, I will make the bold prediction that this virus, like Avian Flu, and SARS will not decimate humanity. At time of writing the death toll was 425 and over 20,000 people had contracted the virus. Actual numbers may be greater as many people may have mild ‘cold like’ symptoms and not present to medical facilities. Most who have died had pre-existing medical complaints or were elderly. Pandemic sounds scary, even to doctors, but when one examines the official meaning it is surprisingly benign. There are six levels. Phase one is defined as "No viruses circulating among animals have been reported to cause infections in humans." How is this even a level? In phase five, there are reports of human-to-human transmission in two countries in a WHO region. Phase six is a global pandemic where there is a case in at least one other country in a different WHO region. With modern plane travel this is a fairly low bar compared to previous times. One person with the virus from China travels to the US. In 1918, 30% of the world’s population are believed to have contacted Spanish Flu. Deaths in the US were estimated at 500,000. Each successive global outbreak

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has seen far less deaths in either per capita or real terms. Yet our paranoia goes up in inverse proportion to the actual threat. Swine Flu in 2009 was less serious than regular 101 flu. CBS journalist Declan McCullagh noted in 2009: “Unfortunately, government officials – never willing to let a good crisis go to waste – seem more prone to extreme measures than the rest of us.” Do we learn from history? So far, the answer is maybe. The response to this particular corona virus (remember, the family is not a new one and most cause a simple coldlike illness) has been proportionate thus far. Is a vaccine needed? Given there has never been a vaccine against any corona virus, we must be genuinely careful about rushing one without adequate testing. In 1976 a rushed vaccine in the US caused more harm (Guillain Barre Syndrome) than the viral threat. We don’t need confidence in vaccination undermined. There is a happy space between ignoring a threat and going overboard. We are there at present and hopefully stay put. A bigger question is why does this get so much more attention than ongoing causes of death? This is because humans have always loved doomsday stories. From biblical tales, through to the Y2K virus or many others, we love to be scared. This is the latest version. ED: At the time of going to press, there were 62,000 known cases of coronavirus in Hubei Province and about 2,000 deaths. – References available on request

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Dr Joe Kosterich | Clinical Editor

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Advanced pain management in the community Western Radiology is a community focused radiology and intervention service with branches across the metro area. The experienced team of doctors at Western Radiology delivers a comprehensive service encompassing medical imaging, cardiac assessments, advanced interventional procedures and oncology services. Branches are set up and operated akin to a hospitalbased radiology practice in terms of the breadth and depth of items, speed and availability. Western Radiology provides uniformity across all locations, with the latest technology and standardisation of service items, making referring and interfacing both predictable and convenient.

Dr Ashish Chawla On Pain Management Image-guided injections are common procedures performed in symptomatic patients not only to decrease pain severity but also to confirm the pain generator, also to avoid or delay surgery. A critical factor in pain management is the correlation of clinical symptoms with imaging findings. Radiologists at Western Radiology with expertise in MR imaging and knowledge in pain management strategies, can distinguish active pain generators from incidental abnormalities. Moreover, their detailed knowledge of cross-sectional anatomy and patterns of contrast flow inform the planning and execution of safe and effective needle placement under image guidance.

Dr Daniel Wong Daniel on Rhizotomy: Radiofrequency procedures have been around since the 1950s and used for treating various chronic pain conditions. These minimally invasive non-pharmacological and non-surgical percutaneous treatments employ an alternating electrical current with oscillating radiofrequency wavelengths to eliminate or alter pain signals.

Quality, first, is the overarching principal at Western Radiology. Services are delivered with a focus on improving patient conditions around availability, efficiency and fast turnaround. This extends to meeting referring physicians’ needs along the same criteria, with additional emphasis on accessibility to radiologists and building strong working relationships.

Comprehensive pain management solutions: Uniquely, Western Radiology provides an extensive list of pain management interventions and cutting-edge therapies, several of which are normally only provided in a hospital setting. Pain Management Injections: Facet Joint Injections Lumbar Epidural Injections Selective Nerve Root Block (Cervical and Lumbar Nerve roots) Sacroiliac Joint Injections Greater Occipital Nerve Blocks Pars Defect Injections Sacrococcygeal Joint Injections Rhizotomy – Facet Joints, Morton Neuroma, etc Radio frequency Ablation of Morton’s Neuroma.

Service delivery standards: Availability – same/ next day appointments. Urgent bookings available daily on demand – Fracture, DVT, ectopic pregnancy etc. Urgent reports delivery – within half to one hour, including verbal feedback from radiologist. Normal reporting turnaround time – 4-24 hours. Electronic images & reports delivery – HealthLink (into desktop software), InteleViewer and

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Web-portal via PACS (includes availability at specialists and hospitals). Reporting – detailed, subspecialised reporting with fellowships including: Neuroradiology, Musculoskeletal, Advanced Body, Oncology, Breast & Thoracic and Intervention. Billing – all Medicare rebatable services including image-guided interventions are bulk billed. *excludes MRI

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reception@wradi.com.au

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Dear Editor... Between the devil and the deep blue sea

A separate analysis found that diagnostic issues account for nearly 50% of compensation claims against GPs, again with many (half) considered to have met the expected standard.

It can sometimes feel, particularly as a primary care practitioner, that you are damned if you do and damned if you don’t.

We know that one of the ways in which the complaints process can affect doctors is that it can lead to defensive medicine and it can be easy for doctors to feel the risks of being subject to a complaint if they fail to pick up something are too great – even if their care is subsequently found to have met the expected standard.

Between concerns about the cost of healthcare and dangers of overdiagnosis, patient complaints about missed or delayed diagnoses, and claims of doctors being unduly influenced by pharmaceutical companies, it can seem a constant challenge to test and treat just enough without falling into practising defensive medicine. Treatment follows diagnosis, as Dr Kosterich points out (Cracking open overdiagnosis, MF February 2020). The statistics he quotes on overdiagnosis are concerning. However, our experience is that doctors are much more likely to be criticised for having missed a diagnosis. Analysis of Avant’s claims data indicates that 20% of complaints and compensation claims against doctors of all specialities were primarily about diagnosis. Failure to diagnose or delayed diagnosis accounted for nearly 75% of these claims and a majority (67%) related to the early clinical assessment period. These were often about a lack of, or a delayed, referral or inadequate physical examination. Our analysis indicated that in more than half of compensation claims and complaints related to diagnosis, the doctor’s care was assessed as having met the expected standard of care.

Overdiagnosis, by comparison, may appear to be the lesser of two evils. I agree with Dr Kosterich on the importance of treating people as individuals, communicating effectively and involving patients in a process of shared decisionmaking about their treatment. Misunderstandings about the limitations of tests or treatments, unmet expectations about the likely results of treatment, failures of communication or breakdowns in the treating relationship, can all contribute to patients making a complaint or claim, even if the doctor’s care was clinically appropriate. I would be concerned, however, by any suggestion that doctors should reject ‘best practice’. It would be a brave clinician (especially a generalist) who declined to follow clinical practice guidelines. When a doctor’s care is called into question during the course of a complaint or claim, the care provided will be assessed against the standard of care as determined by reference to the widely accepted practice of their peers. There is considerable legal authority that where relevant guidelines or protocols exist, they will be

considered evidence of accepted professional practice and the appropriate standard of care. This is not to say that guidelines should be followed slavishly. There may be situations where it would not be appropriate to follow the guidelines in a particular patient’s case. But clinicians need to be very considered in their reasoning and document carefully the reasons why guidelines were not followed. Anyone departing from guidelines should be satisfied that their peers would accept that departure as competent professional practice. Dr Penny Browne, Chief Medical Officer, Avant – References on request

Spirit of cooperation As eloquently explained by Jeremy Nicholson (A Phenome Future, MF, February 2020), the Australian National Phenome Centre (ANPC) will play an increasingly important role in the health of West Australians. Medicine as we have known it is changing rapidly with the advent of big data, genomics and other ‘omics, artificial intelligence and precision health to mention a few. Many of these exciting developments come together in the ANPC. The ANPC is also a tangible example of what can happen when WA institutions cooperate to compete on the national and international stage. It is no coincidence that the formation of the ANPC parallels and is intertwined with the creation of the Western Australian Health Research Network (WAHTN) and its subsequent recognition in 2017 with NHMRC accreditation continued on Page 8

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

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LETTERS

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Urine drug screening in pain management Opiates ‘Opioids’ are a class of drugs that act at opioid receptors. The most notable are the µ-opioid receptor agonists, particularly morphine, extracted from opium poppy, and prized since antiquity for its remarkable efficacy as an analgesic. Opioids still remain among the most effective and useful analgesics, and have expanded to include a range of morphine derivatives such as codeine, heroin, oxycodone and buprenorphine, and synthetic opioids, such as methadone, tramadol and fentanyl. As central nervous system depressants, opioids can, at sufficient doses, cause fatal respiratory depression. The risk of overdose can be further exacerbated by concomitant use of other depressants such as benzodiazepines, alcohol, and cannabis. In addition, µ-opioid receptor agonists are strongly associated with tolerance and debilitating physical and psychological dependence. Thus, despite millennia of clinical effectiveness, opioid treatment must be balanced against the risks of toxicity and misuse (Trescot, et al., 2008) To mitigate these risks, several consensus clinical guidelines recommend urine drug screening (UDS) to assist in screening patients for suitability, prior to commencing opioid treatment. These guidelines also recommend ongoing random UDS, contingent on risk factors, such as history of drug misuse, family history of drug misuse, and mental illness (Jannetto, et al., 2018).

Urine Sample Urine tends to be a more suitable matrix for detecting substance use because most drugs have a more protracted window of detection in urine than in blood or oral fluid. Urine presents technical advantages such as sample volume and ease of collection and handling (Casolin, 2016). Hair testing is not recommended for detecting drug use due to technical limitations, and may present significant challenges in interpretation.

Nevertheless, while UDS may provide an objective indicator of substance use, urine testing has limited value in informing opioid dose adjustment for a variety of reasons. Firstly, the particular opioid drug that is being prescribed may not be targeted within the UDS panel offered by a given laboratory. In Australia, pathology laboratories typically conduct UDS within a regulatory framework that mandates a particular suite of target drug compounds. While the mandatory panel captures morphine and codeine, other opioid drugs are not compulsory, including fentanyl, oxycodone, tramadol, buprenorphine, and many others. There can be significant variability between pathology providers in the list of opioids included in the urine drug test panel offered. Even if the prescribed opioid is included in the UDS panel provided, the urine concentration may not necessarily correlate with either the dosage or the time since last dosing. Individual fluid intake, urine osmolality, and pharmacokinetics, for example, can significantly affect urine drug concentration.

Result interpretation Interpretation of UDS results can be further complicated by limitations of the analytical technology used. UDS usually takes the form of an immunoassay, either as a point-of-care ‘instant cup’ test, or by a laboratorybased immunoassay platform. Both immunoassay formats indicate the presence of broad drug classes, rather than identifying specific compounds within a class. For example, a typical immunoassay test may indicate the presence of an opiate class but would typically lack the specificity to differentiate between codeine, morphine, and the heroinspecific metabolite, 6-acetylmorphine. Importantly, immunoassay tests react to identify chemical compounds of similar structure. Therefore, an “opiate class” immunoassay test may identify morphine and its derivatives, but

Dr Christopher Cruickshank Toxicologist

Dr Aaron Simpson Head of Biochemistry

About the Author Dr Chris Cruickshank is a toxicologist with 20 years' pharmacology experience. He has been Scientist in Charge at the state's Pharmacology & Toxicology reference laboratory and also lectures at UWA. would not be expected to detect synthetic opioids with different structures, such as fentanyl, tramadol, or methadone. Immunoassays for these drugs may be available as optional add-ons, but may not be present in a given laboratory’s standard UDS panel. In addition, UDS immunoassays are typically qualitative and do not provide quantitative drug concentrations. Nevertheless, immunoassay urine drug tests may be supported by Medicare in appropriate clinical applications, and are most useful to readily screen for normal results that don’t require more complex testing. For an additional private fee, most pathology laboratories offer mass spectrometry confirmatory tests, which can provide greater specificity. For example, mass spectrometry can discriminate between codeine, morphine, and 6-acetylmorphine in urine. The scope of drug compounds targeted by mass spectrometry varies between pathology providers, and whether qualitative or quantitative concentrations are reported may also vary.

Conclusion Notwithstanding the technical limitations, urine drug testing is recommended at the commencement of opioid treatment for chronic pain. For higher-risk patients, the prospect of random urine drug testing may provide an additional deterrent to engaging in drug use, which may be particularly risky for a person receiving ongoing opioid treatment. – References on request

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continued from Page 6 and membership of the national Australian Health Research Alliance. It was that same growing spirit of cooperation and recognition that the past practice of competing within WA rather than together for WA that underlined the formation of the WAHTN and the ANPC. Cooperation of our universities, medical research institutes, Department of Health, hospitals, the Chief Scientist and the Department of Jobs, Tourism, Science and Innovation, among others, helped create both entities. That spirit of cooperation was rewarded early in the piece with interim funding flowing from Lotterywest to acquire initial core funding for WAHTN and equipment for the ANPC. Both Jeremy and I accompanied Health Minster Roger Cook on a trip to Israel last year where we got a glimpse of a health system that seamlessly integrates service delivery, research, innovation and commercialisation. While the trip highlighted some of the challenges we face in WA, it also reminded us of the many advantages we have. WA's climate is not too hot, not too cold, and our population is not too big, but not too small. We know success breeds success and it is no surprise that already the ANPC is attracting both additional staff and industry to WA. We also hope the collaborative spirit that created the ANPC will enable more world class initiatives to emerge from WA. Professor Gary Geelhoed, Executive Director, WATHN

RACGP smoking guidelines The Royal Australian College of General Practitioners (RACGP)’s new guidelines, Supporting smoking cessation: A guide for health professionals (2nd edition), recommends greater flexibility in prescribing for smoking cessation pharmacotherapy. 8 | MARCH 2020

Pharmacotherapy options available in Australia include nicotine replacement therapy (NRT, e.g. a transdermal patch or acute forms such as an oral spray, gum, inhaler or lozenge), varenicline and bupropion hydrochloride. Oral forms of NRT, gum and lozenges, are the sole PBSsubsidised therapy. This means that combination NRT (i.e. using two forms of NRT together such as a patch and gum) is not currently PBS-subsidised. Under PBS rules, a maximum 12 weeks of PBS-subsidised NRT is available per 12-month period. The Government should act to assist those who struggle to afford the medicines that are proven to help people quit smoking. Some people can quit, unassisted. However, those who take advantage of behavioural support and vital medicines including combination NRT, varenicline and bupropion will substantially increase their chances of quitting. A host of randomised clinical trials tell us that these medicines work. Varenicline or combination NRT almost triples the odds of quitting and bupropion and NRT alone almost double the odds of quitting versus a placebo at six months. The evidence is also clear that combination NRT is most effective. However, as things stand, we have fixed PBS rules that don’t reflect best-practice medical assistance. As a result, people trying to quit smoking miss out on PBS subsidies that could make a real difference. It’s vital to allow for PBS-subsidised combination NRT, which is proven to be the most effective form of NRT. We should also allow GPs to prescribe a second round of PBSsubsidised NRT within a 12-month period because it will help reduce relapse in people who have stopped smoking at the end of a standard course of NRT. This is a public health policy no-brainer, pure and simple. These medicines work, we just need to do more to help get them into the hands of people who need them most and removing restrictions on prescribing will do just that.

(ATHRA), the RACGP has not “endorsed” vaping nicotine. The relevant item in the guidelines reads: Recommendation 15 – Nicotinecontaining e-cigarettes are not first-line treatments for smoking cessation... The lack of approved nicotine-containing e-cigarettes products creates an uncertain environment for patients and clinicians, as the constituents of the vapour produced have not been tested and standardised. However, for people who have tried to achieve smoking cessation with approved pharmacotherapies but failed, but who are still motivated to quit smoking and have brought up e-cigarette usage with their healthcare practitioner, nicotine containing e-cigarettes may be a reasonable intervention to recommend. This needs to be preceded by an evidence-informed shared decisionmaking process, whereby the patient is aware of the following: • no tested and approved e-cigarette products are available • the long-term health effects of vaping are unknown • possession of nicotine-containing e-liquid without a prescription is illegal • in order to maximise possible benefit and minimise risk of harms, only short-term use should be recommended • dual use (ie with continued tobacco smoking) needs to be avoided. Conditional recommendation for intervention, low certainty

GPs and PrEP Researchers from UNSW Sydney are aiming to better understand the implementation and prescribing of HIV Pre-Exposure Prophylaxis (PrEP). We are conducting interviews with GPs across WA who have prescribed PrEP at least once. In the phone interview, which takes up to an hour, we discuss your clinical experiences of prescribing PrEP and your professional perspectives on HIV prevention. In recognition of time, participants are compensated with a $125 pre-paid gift card. Findings from this study will inform clinical education and policy. GPs can participate by emailing anthony.smith@unsw.edu.au. See www.prepinpractice.com for further information. Anthony K J Smith, Ph.D. Candidate, Centre for Social Research in Health

Dr Harry Nespolan, President, RACGP ED: Contrary to a blog on the Australian Tobacco Harm Reduction Association

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WA NEWS

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Local heroes saluted Professor John Newnham’s lifetime work to prevent preterm births has been recognised with the 2020 Senior Australian of the Year. The award will see John (pictured here with Prime Minister Scott Morrison) travel the country talking to groups about the work of the Women’s & Infant Research Foundation and the breakthroughs it has made to benefit women and their babies into the future. Also honoured was regional cardiologist Dr Tony Mylius with an AM in the general division for his “significant service to community health, and to cardiology”.

ED for Hollywood Planning approval for a private emergency department at Hollywood Private Hospital has been granted, with work expected to start this month. The new $67.1 million, 14-bed ED will have a resuscitation room, plaster/treatment room, consultation rooms and three 30-bed wards to accommodate emergency patient admissions. It is the second private emergency department for Perth, and the first north of the Swan River, though Ramsay Health Care’s 11th nationally. CEO Peter Mott said it was anticipated that the Hollywood ED would see cardiac patients, sports or surgical injury, and the elderly with medical conditions. The ED was the final stage of a $200 million five-year building project and was expected to open late in 2021.

Preserving ED capacity AIHW’s potentially preventable hospitalisations report, released last month, shows a significant number of ED presentations (1 in 15) could have been avoided if a GP had seen the patient first. State health ministers have been demanding the federal minister Greg Hunt increase funding for GP care to alleviate the ED crush. Apparently, the discussion between the ministers took place late last year when they were all gathered to discuss the five-year National Health Reform Agreement. While Mr Hunt was a no-show, health ministers laid the blame firmly at the feet of the Feds and poor Medicare funding. As Medical Forum reported a while back, research funded by the state government and conducted by UWA’s A/Prof Alistair Vickery and Dr David Whyatt demonstrated 10 | MARCH 2020

there were a significant number of potential ED diversions to GPs. Following on from that local research, the state has funded a GP urgent care pilot, which seeks to put something tangible in front of consumers. The pilot is still active and data will be coming through in the next couple of months or so.

Biobank focus With the state’s increasing involvement and development of precision medicine and the expanding field of ‘-omics’, the WA Health Translation Network (WAHTN) is forming a Biobank Steering Committee to help consolidate and coordinate the state’s numerous biobanks. As a result of a survey of its member groups, it is also looking to create a virtual biobank by using the Open Specimen software which has been successfully trialled at the Telethon Kids Institute’s Origins project. Firstly, though, it wants to create a register of the current biobanks.

ACROD parking review The WA Department of Communities will review the eligibility criteria for the ACROD parking program. The National Disability Services WA, which manages the program, welcomed the initiative which it said would ensure accessible parking bays were available for those who needed them most. Currently nearly 90,000 West Australians with a severe walking restriction have ACROD parking permits. The review will examine the potential to expand the program’s eligibility criteria to include people with guide dogs,

and investigate ways of working with private property owners, such as shopping centres, to limit the misuse of ACROD bays. NDS WA state manager Julie Waylen said while the demand for accessible bays often outstripped supply, there was a need for stronger monitoring and fines enforcement. She added NDS WA would continue to call for an increase in the number of bays as specified in the Building Code of Australia. ACROD permit holders and other people with disability are encouraged to participate in the review via access@dsc.wa.gov.au or phone 9440 2251..

Legislating safe zones The state government will legislate to establish 150m safe access zones around premises that provide abortion services in WA. The legislation would bring WA into line with all other Australian jurisdictions, apart from South Australia, whose parliament also has similar legislation currently before it. The proposed bill was preceded by a consultation process which received 4000 submissions from the public and from more than 40 public and private organisations. Seventy per cent of respondents supported the introduction of safe access zones. It is proposed the zones will operate around the clock, seven days-a-week. The legislation was expected to be introduced into parliament later this year and will set out behaviours prohibited in a safe access zone, such as harassment, intimidation and obstruction, as well as penalties for non-compliance.

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LOCAL BRIEF Early allergen exposure Recently updated infant feeding guidelines have had a clear impact on Australian parents, with a new study showing that 86.2% of 12-month-olds had been introduced to peanut-including foods and other potential allergens. The research, published in the MJA, was led by Dr Michael O’Sullivan, a consultant immunologist at Perth Children’s Hospital and UWA, Sandra Vale, National Allergy Strategy Manager and UWA PhD student, and Dr Alan Leeb, a Perth GP and developer of the SmartVax app, which helps to gauge food allergy. The guidelines, which came into effect in January 2019, recommend the introduction of the common food allergens (ie, peanut and egg) in the first year of life, regardless of their allergy risk factors. The researchers set out to estimate the proportion of infants who reacted, using the SmartStartAllergy SMS protocol and an online questionnaire. “At 12 months of age, 1673 of 1940 infants had eaten peanut-including foods (86.2%); 235 of 1831 parents (12.8%) reported food-related reactions,” the report said. “Questionnaire responses indicated that dairy was the food type most frequently reported to cause a food-related reaction (72 of 835 exposed infants, 8.6%); peanut-related reactions were

reported for 20 of 764 exposed children (2.6%). Ninety-seven of 250 parent-reported reactions to food (39%) did not include symptoms that suggested an IgE-mediated allergic reaction.”

Advance the plan More West Australians have been made aware of advance care planning as a result of an Australiafirst awareness campaign, “You Only Die Once”, developed and managed by Palliative Care WA. The campaign was delivered between August and October, during the passage of the Voluntary Assisted Dying legislation last year. The WA Parliament Joint Select Committee on End of Life Choices had identified that only 7% of the WA community had completed any form of Advance Care Plan to address their end of life wishes. A comparison of pre-and postcampaign survey results indicated a 60% increase in awareness of Advance Care Planning. In addition, more than 6000 people had visited the campaign website for more information over the period of the campaign. Palliative Care WA CEO Lana Glogowski said the response proved that not only was the concept effective but there was also an appetite for the topic.

Students go forth The first cohort of medical students from the newly-opened Curtin University Midland Campus have begun their placement at St John of God Midland Public and Private Hospitals (SJGMPPH). There are 18 fourth years students this year, with the number expected to grow in ensuing years. Acting Dean Professor Sally Sandover said many of the SJH staff have taught the students on campus over the first three years of their course. “Learning in the clinical setting is an exciting progression for the students and a wonderful opportunity to learn from dedicated staff,” Professor Sandover said. Midland CEO Michael Hogan said he hoped that once the medical students completed their studies, many would return to continue their career at the hospital.

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The WA Government is looking to create economic benefit as well as better health outcomes from its commitment to health research. It has created an industry reference group to help develop a Health and Medical Life Sciences Industry Growth Plan to help innovations lead to commercialisation, which will, in turn, help diversify the local economy. The group, chaired by Chief Scientist Professor Peter Klinken, includes sector experts, Dr Michael Winlo, from Emerald Clinics, Dr Katharine Giles, from OncoRes Medical, Ms Liddy McCall, from Yuuwa Capital, and Mr Abdul Ekram, from Austrade. According to AusBiotech, WA experienced Australia's biggest growth in the wider life sciences sector between 2017 and 2019 with a 50% increase in the number of organisations operating here. Dr Richelle Douglas is the new medical director at Derbarl Yerrigan. The new medical director of SHQ is Dr Cathy Brooker. The State Government has released Implementation Plan One 2020-2022 (IP1) of its WA End-of-Life and Palliative Care Strategy, which are both available to be viewed online. IP1 supports a shared responsibility between representatives to identify direction, plan and coordinate local initiatives, establish partnerships and work collaboratively. The WA Cancer and Palliative Care Network has two new clinical leads. Dr Simon Towler is Clinical Lead End-of-Life Care and A/Professor Alison Parr as Clinical Lead Palliative Care. Dr Towler has had many senior roles across WA Health. Most recently he was a member of the Sustainable Health Review Clinical Reference Group and a member of the Ministerial Expert Panel on Voluntary Assisted Dying. A/ Prof Parr is a palliative Medicine Specialist and Director of Medical Services at St John of God Murdoch Hospital (SJoGMH). The network paid tribute to former clinical lead Dr Keiron Bradley.

MARCH 2020 | 11

Clinicians and design Clinical input is vital in developing medical devices. Biomedical engineer and entrepreneur, Dr Matthew Oldakowski, has insight on the process. The Byers Centre for Biodesign at Stanford University developed the Biodesign method, a prescriptive framework designed to ensure that innovators focus on real, unmet clinical needs. Perth Biodesign follows this model and begins by identifying clinical problems during periods of clinical immersion, directly observing clinical practice and engaging with clinicians. Once we have identified a potential problem, we characterise the disease state, the existing solutions, the stakeholders and the market size and health economic burden. We then create a need statement to identify problems with existing mechanisms, the specific patient populations affected and then work to achieve tangible, realisable outcomes. At this stage in the development, while still being ‘solution agnostic’, we are able to confirm that an observed problem is, in fact, a real, unmet clinical need worth trying to solve. Then the brainstorming begins as teams develop multiple concepts and examine the risks involved with each in terms of technical feasibility, intellectual property, regulatory pathway, reimbursement and business model. When a concept is decided upon, we proceed with a detailed risk profile on the basis that the most exciting concept isn’t always the most realistic or the least risky. At this point we develop a commercialisation strategy to take our innovation to patients. At Perth Biodesign, this process is done over six months for our medical device course and three months for our digital health course. Applications will open early to mid-2020 for our Biodesign courses and clinicians are encouraged to apply or enquire about being a clinical mentor. We form multidisciplinary teams, involving at least an engineering, 12 | MARCH 2020

a clinician, a business person and a scientist. Often, we also have designers and other disciplines involved. Clinicians are an essential part of any Biodesign team bringing clinical perspective and with a strong focus on the patient as an individual. Beyond being involved in the team, clinical mentors are invaluable in providing nuanced and practical understanding of a particular disease state as well as the dynamics within the healthcare system. Clinical validation must be done with hundreds of clinicians and different medical stakeholders from around the world, rather than the handful from the local community. This is to ensure that innovators invent things that will meet the needs of clinicians and their patients. However, innovators must ensure that even if some clinicians respond negatively to their early concept, there is still a potential pathway to adoption in the future. That said, medical device development is very multifactorial and should not be driven solely

by a single clinician inventor. Innovators, clinicians or otherwise, must deeply understand the disease state and the clinicians’ thoughts and attitudes towards it, of course, but they must draw their own conclusions about clinical needs based on the evidence they gather, otherwise disruptive innovation would not be possible. Radically innovative companies will always have to overcome resistance to change by clinicians and the hospital system. Needs-based innovation through the Biodesign process is the antidote to this in that if a team is confident that they can address a real clinical problem to benefit patients and create value economically, then they can be confident that somehow, with enough time and resources they will be able to overcome reluctance to adopt new technologies or approaches. ED: Dr Oldakowski is a director of Perth Biodesign, a company which develops biomedical technology and runs courses to support aspiring biomedical entrepreneurs.

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Still with an ordinary health fund? Time to switch to the fund created for doctors Dr Nicola Ward Orthopaedic Surgeon Doctors’ Health Fund member since 2017

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*Terms and Conditions. To be eligible for the offer, the cover start date and join entry date must be between 12.01 AM (AEDST) 9 March 2020 and 11.59 PM (AEST) 30 April 2020. This offer is only available to those eligible to join Doctors’ Health Fund, who do not currently hold, or have held in the last 12 months, insurance with Doctors’ Health Fund. To receive an eGift Card, the new member must take out combined Hospital and Extras cover, and must be active and financial for 12 continuous weeks before the gift card will be issued. Only one Flexi eGift Card will be provided per policy as follows: a) $100 when purchasing a single Smart Starter Bronze Plus hospital cover and any extras cover policy; b) $200 when purchasing a couples Smart Starter Bronze Plus hospital cover and any extras cover policy; c) $150 when purchasing a single Prime Choice Gold hospital cover and any extras cover policy; d) $300 when purchasing a couples/family/single-parent Prime Choice Gold hospital cover and any extras cover policy; e) $250 when purchasing a single Top Cover Gold hospital cover policy and any extras cover policy; or f ) $500 when purchasing a couples/family/single-parent Top Cover Gold hospital cover and any extras cover policy. If the level of cover changes within the first 12 weeks, the value of the gift card will be determined by the lowest level of cover held in that period. If a member downgrades to extras only cover within the first 12 weeks the member will no longer be entitled to the offer. This offer is not available with other offers. You should look to the product issuer for all warranties, terms and conditions. The Flexi eGift Card is valid for redemption 3 years from issue. Flexi eGift Card terms and conditions apply, visit www.giftpay.com.au for full terms. For full terms and conditions of this offer visit https://www.doctorshealthfund.com.au/flexi-offer-RR20 Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy. DHF 282_3/20

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MARCH 2020 | 13

GLOBAL NEWS

Tau translation The folding of tau proteins from function forms to misfolded forms has been implicated in tauopathies, yet why this is the case is so far unknown.

Never too late to quit Damage caused by long-term tobacco smoking on lung cancer cells can be reversed within years of quitting, a study has found. The researchers recruited smokers, exsmokers and non-smokers into the study and took lung biopsies and then sequenced the genomes taken from bronchial epithelial cells. Due to the ethical concerns from taking lung biopsies, only 16 participants populated the study. Findings identified the mutational burden from tobacco smoking on lung cells, with between 1000 and 10,000 mutations per cell, for smokers. Ex-smokers were found to have the equivalent mutational burdens to non-smokers, whilst the smokers had four times more tobaccospecific mutational damage. The authors suggested that the damaged cells are replenished by cells that avoided mutagenesis.

Software pushed opioids US based practice management software (PMS) company Practice Fusion has agreed to pay $US145 million in a criminal resolution with federal prosecutors in Vermont for receiving payments from pharmaceutical companies to encourage physicians' prescribing practices. Practice Fusion offered 14 | MARCH 2020

two versions their PMS to practices, a paid version, or a free version, which featured paid advertising. The company solicited payments from pharmaceutical companies. In one instance Practice Fusion accepted a $1US million payment from an opioid manufacturer to modify the PMS’s clinical decision support alerts to influence and encourage clinician prescribing of their opioid products. In this edition we have covered the opioid situation in Australia.

favourable (40% for, 37% against). Most applications reported that randomisation made no difference to their application (69%), or the preparation time allocated (75%). Applicants who had been successful with their applications were more supportive of the lottery than those that were unsuccessful. Is this something Australia should look trial? Medical Forum seeks your comment.

Cancer blood test Randomised research funding Since 2013, the New Zealand Health Research Council (HRC) has experimented with randomised funding of health research grants, up to $NZ150,000. At the time of inception this was a first of this kind scheme which does away with the peer review process. Initially, applications need to satisfy the criteria for entry, then they are entered into a ballot with each application having an equal opportunity to be funded. How has this system gone you may ask? The HRC surveyed applicants from 2013 and 2019 and found the majority (63% for; 25% against) was in favour of this type of funding approach. When asked if other grants, such as drug trials, should be randomly funded, the response was less

A novel non-invasive blood analysis has been devised to screen for early-stage tumours, a study has found. Although analysis of blood has been established in oncology for monitoring cancer in diagnosed patients, due to insufficient sensitivity of the existing test, it is not effective in screening for early identification. A team of researchers have published a study suggesting blood analysis could be effective for cancer screening. The team developed an approach called targeted error correction sequencing which can evaluate sequence changes in circulating cell-free DNA thanks to an ultrasensitive direct evaluation. The researchers evaluated 200 patients with first or second stage cancer and analysed their blood samples detecting somatic mutations in

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Researchers from Columbia University’s Zuckerman Institute and the Mayo Clinic may have found a breakthrough. Tauopathies are a range of neurodegenerative diseases, such as Alzheimer’s, identified by a buildup of misfolded tau. The researchers said that the difficulty in analysing tau is in the filaments, or individual fibres which comprise it. They are 10,000 times thinner than the size of a human hair. However, using cryoelectron microscopy and mass spectrometry to analyse brain tissue has produced unprecedented detail. The researchers mapped the structure of tau on deceased human brain tissue from patients diagnosed from two tauopathies (Alzheimer’s and corticobasal degeneration). Then they reconstructed the structures of the filaments to observe how they are formed, grow and spread. They found post-translational modifications (PTMs) on the surface of the tau, which they suggest could be influencing its behaviour and be structurally important in tauopathies. Researchers hope this could lead to new advances in drugs that can target PTMs and slow the progression of tauopathies.

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RESEARCH BRIEFS the plasma of 71% of colorectal cancer patients, 59% breast cancer patients, 59% lung cancer patients and 68% ovarian cancer patients.

Antidepressant AI The efficacy of antidepressants for treating major depression when compared to placebos in clinical trials can be deceiving due to the diversity in diagnosis of depression and how the participants are being measured. This can lead to questionable treatment outcomes. Researchers sought a more accurate measurement of the effectiveness of antidepressant response for major depression by using a latent-space machine learning algorithm to analyse resting-state electroencephalography (EEG) for four depression treatment data sets. The algorithm was able to accurately predict symptom improvement with antidepressant sertraline whilst generalising across the data sets. The researchers suggest that using an EEGalgorithm could lead to a better neurobiological understanding of antidepressant treatment while providing a more accurate treatment of depression.

MRSA and poly-antibiotics A global research team, led by researchers at the University of Queensland has published worldfirst research examining the use of multiple antibiotics to treat Methicillin-resistant staphylococcus aureus (MRSA) Bacteremia. The clinical trial involved 352 patients in 27 hospitals located in Australia, Singapore, Israel and New Zealand and spanned the course of three years. The researchers found no

significant difference with polyantibiotic treatment of patients with MRSA in mortality, bacteria in the blood, infection relapse or treatment failure. Whilst patients that received more than one antibiotic had increased side-effects for kidney function.

Training survey mixed The much-anticipated Medical Training Survey (MTS) conducted by the Medical Board of Australia and AHPRA has been released with some fascinating insights into how young doctors are coping with this critical time of their careers. There were nearly 10,000 respondents, 10% of them were from WA. While the report is rich in information, it was striking to note the WA responses to work hours, which were among the highest in the country with 81% working more than 40 hours a week. Victoria and Queensland were the lowest with 74%. More alarming was 28% worked on average more than 50 hours a week with 6% working more than 70 hours. However, as the MBA chair will readily say, “In general, trainees rate their training very highly and there is a lot going well in medical training in Australia. Most trainees rated their clinical supervision and teaching highly. About 75% of trainees work more than 40 hours per week, but many value the training opportunities this provides. Most trainees would recommend their current training post and nearly all intend to continue with their training program.” The wellbeing and culture questions were not so great. With 33% of trainees experiencing or witnessing bullying and harassment, only a third of those experiencing reported it. When reported, the management response was patchy.

Meningococcal vax positive The efficacy of meningococcal group B vaccine, 4CMenB, has been demonstrated in findings from the B Part of It study – the largest meningococcal B herd immunity study – with almost 35,000 school students, aged 15 to 18 years. The B Part of It study was carried out in South Australia between 2017 and 2018 and authors have reported there has been no reported cases of meningococcal disease amongst the students since the study began. In the two years prior to the study, there was 12 reported cases. Although the study has demonstrated the effectiveness of the vaccination, there was no reduction in the percentage of students who were carrying the bacteria, including the B strain, which highlights the efficacy of 4CMenB for the vaccinated, but not the community, as the vaccine’s ability to reduce transmission is unlikely.

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Gut microbiota composition during infancy and subsequent behavioural outcomes Further evidence has been published supporting the relationship between gut microbiome and mental health. A strong association increased behavioural problems and decreased Prevotella, according to a longitudinal birth-cohort study by Deakin University, Barwon Health and the Murdoch Children’s Research Institute. The Researchers analysed faecal microbiota of 201 children at ages of one, six and 12 months, then followed up with the children at age two to measure behavioural outcomes. Adverse events associated with peanut oral immunotherapy in children An emerging treatment to desensitise individuals with peanut allergy is oral immunotherapy, where an allergic individual is gradually exposed to an increasing amount of the allergen. A systematic review and meta-analysis of 27 studies including 1,500 peanut allergic patients has examined the side-effects of peanut oral immunotherapy (POIT) has found: 6.6% of participants discontinued treatment due to adverse events; 7.6% of participants required treatment with epinephrine; rushed treatments with higher maintenance doses were found to have a higher risk and need for epinephrine; cotreatments in conjunction with POIT were at a decreased risk of sideeffects and discontinuation. Innate immune response to bacterial UIT sensitises high-threshold bladder afferents Further understanding of the mechanisms of bladder afferent function associated with urinary tract infections (UTI) has been published by an Australian team. The study isolated and sampled supernatants from female mice bladders, infected with Uropathogenic E. coli (UPEC) bacteria, then placed the samples into healthy donor mice to measure afferent function. It found UPEC-induced UTI mice had significantly enhanced bladder afferent firing; UPEC supernatant sensitised high-threshold bladder mechanoreceptors; recruitment of silent nociceptors amplifying bladder afferent responses to the UPEC supernatants.

MARCH 2020 | 15

Q&A with... Dr Sean Stevens, chair of the WA faculty of the RACGP

MF: Reflecting on the past 12 months, what have been the highlights for Dr Sean Stevens, both professionally and personally?

MF: The WA Faculty welcomed 250 new Fellows into the College last year. What do you think that says about the attraction of Fellowship?

SS: The past 12 months have been a period of stability in my personal life and major change in my professional life. I have really enjoyed seeing my teenage daughter and 11-year-old son grow up and ensure that I’m a big part of that. My wife of 23 years, the brains of the family, is in the penultimate year of her PhD. There is no one highlight, just lots of magical moments. I would highly recommend respiratory physician Professor Bruce Robinson’s The Fathering Project for all fathers parenting in the fast lane (i.e. most medical dads!). It really helps prioritise what’s important.

SS: I think it speaks to the high regard that the RACGP is held in. It remains the gold-standard qualification for our profession and is the endpoint of training for the vast majority of registrars.

Professionally in the past 12 months, the greatest highlight has been opening a new, innovative clinic in Victoria Park with my business partners Dr Mary Wyatt and Dr Sam Prince. It has been a breath of fresh air being able to adopt the latest technology, a re-imagined patient experience and being able to introduce new ideas quickly and effortlessly. Mary, Sam and I are so proud of what we’ve achieved. From the RACGP perspective, there have been two highlights. The first is the amazing performance of the WA faculty staff in delivering 71 educational events, double the number in 2018, with the same resources. The second I can’t call a highlight, but it was the amazing response by our GPs, staff and Victorian colleagues in responding to the sudden and tragic death of our Assessment Panel Chair, Dr Jack Christodulou in August. The November exams were an extremely emotional time for everyone, but the response was exemplary and made me very proud to be a member of the RACGP. 16 | MARCH 2020

their training, then it would break down many of the barriers between primary and secondary/tertiary care. There’s also evidence to show that a GP term early in your training has the effect of reducing your investigations for the rest of your career. In terms of how close to a unified, integrated health system we are, I think unfortunately we’re as far away as we’ve ever been.

MF: There is a decline in the number of medical students and junior doctors choosing to train in general practice, despite an increase in the number of locally training and trained doctors. Why do you think this is so? What can be done about it?

MF: There have been programs in the past that give students and post-graduates a general practice experience, particularly in rural areas. Do these need to be reinstated?

SS: I think the decline in the number of medical students and junior doctors choosing to train in general practice is due in large part to the slipping remuneration of general practice in real terms. Our junior colleagues can see the difference between GPs and non-GP specialists, particularly procedural specialists, and make their decisions based on this. The other factor, not to be under-estimated, is the jaundiced view some teaching hospital consultants and registrars have of general practice. A lot of junior doctors are surprised how challenging, rewarding and highquality general practice is when they actually do a term and this is often enough to alter their view of the discipline.

MF: The college and ACRRM are now responsible for training of general practitioners. Where do the challenges lay for the colleges in that pursuit?

MF: How much does the FederalState funding arrangements affect this? How close do you think we are to a unified, integrated health system? The Federal-State funding arrangements do play a role in so far as they prevent junior doctors doing rotations into general practice. If all doctors could do a term in general practice at some stage of

SS: Absolutely. Giving students and post-graduates a general practice experience, particularly a quality rural experience, has a major beneficial effect on their desire to choose GP as a career, their respect for GP as a discipline and their communication with GPs if they choose a specialty other than GP.

SS: This date has been delayed until 2022 and it will be a much smoother transition than most people realise. During the transitional period, it will be business as usual with the RACGP and ACRRM taking oversight of the the Regional Training Organisations (WAGPET in WA) from the health department. MF: Both levels of government seem to be encouraging a greater role for pharmacists in the care of primary care patients. How much is politics? How much of it is sustainable health policy? SS: It has been disappointing to see the use of pharmacists and other health care professionals in areas

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Q&A

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Q&A that are really beyond their scope of practice. Much of it is driven by political lobbying from the pharmacy guild, particularly where relaxation of standards in one jurisdiction is used to relax standards in other jurisdictions. The best and most sustainable health policy is where patients have their own medical home, where their care is provided by a GP who co-ordinates the rest of the team and their records are maintained in that home, preventing duplication of tests, hospital admissions and medication errors.

the backbone of procedural care in WA’s country towns for decades, yet now there seems to be a concerted push to remove them from this role. Finally, I would love to see a proper re-indexation of the Medicare rebates, a boost in funding for longer consults and funding of non face-to-face care (phone calls, videoconference and emails).

Read this story on mforum.com.au

MF: What would the college like to see from the Federal Government in the next 12 months regarding rebates and investment in general practice? SS: The college would like to see proper indexation of rebates at the level of health inflation, not the reduced rate currently applied. We’d also like to see the re-application of the indexing lost during the ‘Medicare Freeze’. The college would also like to see modernising of the MBS to support non face-to-face care, particularly for isolated patients or those with limited mobility. It would also be invaluable during the current Coronavirus outbreak. The college would also like to see support for longer consultations, the current schedule for attendance items encourages six-minute medicine (see graph), if there could be a reweighting in favour of longer consultations, which have shown to improve health outcomes, then everyone would be better off. MF: Are the Primary Health Networks working for general practitioners and their patients? SS: Yes, on the whole, I think they are. They perform an important role in co-ordinating populationbased programs, liaising between GPs and other sectors of the health system. MF: What is your health care wish list for the coming year? SS: Writing this in early February, the number one wish is for the Coronavirus emergency to be brought rapidly under control. I would wish for a reversal of the squeeze to push our procedural GPs out of regional, rural and outer metro hospitals. These GPs have been

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MARCH 2020 | 17

The Next Gen Advocacy is one of the toughest gigs in medicine – it’s essential but resilience is required. Mandurah GP Dr Alison Soerensen has had to learn quickly.

Jan Hallam reports

Just a few short weeks after the birth of her third baby last year, Mandurah GP Dr Alison Soerensen had her game-face on. Sitting at her desk at Murray Medical Centre, she had a young mother in front of her, fretting about how she, Alison, could be newly showered, neatly dressed, hair done and have coffee in hand, while she, patient, had struggled to get her baby ready and get out of her pyjamas in time for her appointment. “I’ll tell you what I told her – ‘you didn’t see me 30 minutes ago’. I can sit here calmly because I know my children are safe at home and they are not my sole responsibility at this moment. I only have clean clothes on because I stepped into them several minutes before I walked out the door,” she told Medical Forum. “I was glad my patient felt able to open up to me. I don't want you or her to think that I've got it all together because I don't. Nobody does. It's not good for anyone’s mental health to think like that. “This is why working in general practice is a privilege. I see people walk in the door at their most vulnerable but, in this safe space, they can be themselves, without fear of judgement. When they walk back out again, I hope they feel 18 | MARCH 2020

empowered and a somewhat better than when they arrived.” It also starts a conversation about her own insecurities as a busy GP and a young mother of two girls aged six and three and an eightmonth baby boy, and the need for her to have a GP and a safe space where she can be a patient. “I do have a GP but she is approaching retirement, so I am considering alternatives, but it is not as easy as it sounds. Some GPs feel uncomfortable being a doctor to another doctor. You want to be able to be a patient inside the consulting room, even if outside you are friends or colleagues,” she said. However, the importance of a doctor having a doctor of their own is without question. “We know that doctors often present with medical problems quite late because they have ignored their symptoms or have been too busy or frightened to seek medical attention. Other times they may come in quite early because they fear the horrible things their symptoms might indicate. “Then there’s the embarrassment of either of those scenarios playing out in front of a peer. There's a whole mental health side of things that’s important for us to be aware of as well – doctors being vulnerable but not necessarily wanting to admit that vulnerability. MEDICAL FORUM | PAIN MANAGEMENT ISSUE

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Picture courtesy of Katie Etherington

Imposter syndrome “It's something that's beaten out of us through hospital training, where it’s stiff upper lip, and press on. But there’s often a complex imposter syndrome afoot – thinking to yourself, people will think I’m completely stupid that I did OR didn’t see my GP; that I didn’t know the diagnosis. “And that feeling extends to your own kids getting sick. You find yourself caught between catastrophising about missing a serious illness, overreacting to a minor one and feeling stupid or silly for not ‘knowing’ what’s wrong. Social media groups such as Medical Mums and Mums to Be (although welcoming of all parents!) have sprung up to offer connection and support for the increasing number of doctors juggling parenthood and medicine.” Children have a habit of constantly challenging you to be your better self and in Alison’s case, also to be a better doctor. Indeed, Alison’s children are one of the driving reasons why she became active with the RACGP and the AMA, most recently contesting the AMA WA presidency in 2019. More pragmatically, it was the due date of the birth of her second daughter falling two weeks before her college fellowship exams several years ago that sent her on the road to medical politics. Not wanting to, nor thinking she should have to delay her exams, she

set about preparing the way for a breastfeeding infant to accompany her during the gruelling five-hour exam process. “I applied to the college for special consideration to be allowed to breastfeed my baby during rest stations, given that she would have only been two weeks old at the time. I got a phone call out of the blue when I was about 10 or 11 weeks pregnant from the exam department delivering the news that I wouldn’t be allowed to have a baby in the exam venue, nor could they accommodate breastfeeding breaks,” she said. “They would allow me to pull out up to a couple of days before the exam without financial penalty if I decided it was all too hard. I was flabbergasted. I said, ‘No, you actually have to accommodate me’.” As far as Alison was concerned, it wasn’t just a question about whether her individual application was accommodated or not, it spoke to far greater issues of equity and discrimination within the medical profession. Eventually a compromise was struck such that Alison was allowed to express milk between stations, whilst her husband cared for their daughter elsewhere.

Action to change The story has a coda. Alison sat (and passed) her exam and in the months that followed, spurred on by a mentor, she set about writing a draft policy for the college so that no

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other person in the same boat would have to go through the hoops and hurdles that she had experienced. “I shared my ideas with the Medical Mums group and used their feedback to refine the policy before submitting it to the college,” she said. The college did indeed release a policy, independently of Alison’s, though it seems it was inspired by much of the work she had put into hers. “There were some things that were absent, which I challenged the college on, but ultimately it was fantastic to have a policy where there hadn’t been one before.” During the process, her mentors were quizzed by the college hierarchy about this young Dr Soerensen from WA but were quickly reassured that Alison was not a troublemaker, simply someone on a mission. It began a passion for advocacy for just causes. When it comes to her involvement with the AMA WA, Alison said she had been a member since internship but felt that, as a young, female GP in outer metro with small children, the AMA didn’t represent doctors like her. However, a mentor encouraged her to engage with the organisation before disengaging. “I heeded that advice and applied to be a GP delegate at the national conference (in a non-election continued on Page 20

MARCH 2020 | 19

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The Next Gen continued from Page 19 year). I had many interesting conversations at the conference with well-connected WA female GPs. I got up at a few sessions to have a say, but I wasn’t quite prepared for the soapbox session at the end of the conference, which I was encouraged to participate in,” she said.

Picture courtesy of WAGPET

Soapbox start “I had no idea that putting in a topic (hers was “the AMA is an old boys club – does it really want to change and if so, how?) meant I was required to speak to it for three minutes in front of the entire delegation.” When she twigged, with a couple of hours before the start of the session, she jumped onto her social media sites and got feedback and ideas for what her arguments might be. “I asked the Medical Mums network, then around 7000 members, ‘help me understand why, if you are an AMA member, how you feel it represents you; if you're not a member, why not’ and I had about 200 responses in less than an hour,” Alison said. “The session began with the chair of the Federal Council and the AMA CEO, both of whom were women, in front and everyone else behind me. About 70% of the audience were middle-aged white men in suits. I remember feeling nervous; I could hear some muttering behind me as I was talking. I spoke about the strengths of the organisation but shared my concerns that its leaders weren't representative of the broader membership, let alone the changing face of medicine as a whole. I challenged the organisation to identify the barriers to a more equitable and diverse AMA and actively remove them. “There was a standing ovation of sorts, some remained seated, and that was OK. Afterwards it was clear by personal feedback, that other people in the organisation felt the same way. I was encouraged to become more actively involved. “A couple of months later, I was selected to be the DiT representative on the Council of 20 | MARCH 2020

General Practice. The invitation came at short notice and whilst it wasn’t easy with two small children and working in private practice, I dropped everything and flew to Canberra. It was the start of two great years on that Council, meeting and collaborating with passionate GPs from around the country. A few months after that, AMA WA reached out and ask if I was interested in being co-opted to the local State council. “It's been an interesting experience being involved and not having followed the usual pathway starting with student advocacy. It's a pathway that nobody speaks about, but it's 10 or 20 years long, and you become a leader in the AMA because you followed that path.” Her non-traditional rise within the organisation has been met by both encouragement and scepticism.

Outsider wariness “I remember being asked by a senior member what my intentions were. I admit I was a bit taken aback by that. I said I was here to ask questions and to learn. Perhaps I was naïve and didn’t know the history of the organisation, or how things were done. And maybe it's lucky that I didn't,” Alison said. “As we approached the AMA WA elections early last year, I was considering putting my hand up for the vice presidency. I hadn’t been tapped on the shoulder and as such I expected it would be a contested election. “I spoke to a couple of close colleagues about my intention to nominate for the vice president position and one of them flippantly said, I would've thought you'd put

your hand up for the presidency instead! “I laughed it off at first but then reflected on the suggestion. Of all the AMA branches, there appeared to be a specific pathway to leadership in WA. As in medicine, this hierarchical structure disadvantages those who are unable to get and stay on the path – parents having children, doctors from overseas, doctors in training who nowadays have to invest increasing amounts of time and energy into securing and maintaining fellowship positions etc. “This really bothered me because not only does it disadvantage individuals, but it also disadvantages the organisation because we end up with a fairly homogenous group of people sitting around the table. Whilst there have been moves towards increasing our diversity, at times it still feels that certain voices and opinions matter more than others. “These issues were the impetus that led me to run for president. I knew that Andrew [Miller] was running and I made it clear, my candidacy wasn't a personal judgement on his abilities to be president. Ultimately it was about giving the membership a choice whilst putting the organisation on notice.” “It was a really fascinating experience because there hadn’t been an election for a long time. Social media became a significant campaign arena. Members who’d never voted before were suddenly sharing their thoughts and feedback. “I published my piece about who I am and why I wanted to do this. I was humbled by the emails and

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CLOSE-UP phone calls of support. There were those who worried about how I’d cope if I lost, but my selfworth wasn’t tied to selection. As the saying goes, life is about the journey, not the destination.

Takes a village “I admit the timing wasn’t ideal for me. I was heavily pregnant with my third child and knew that if I did get up, I’d have to upskill rapidly. I'd probably have been at meetings breastfeeding a small human wondering, what on earth had I gotten myself into! Yet I knew I had something to bring to the table and that I wouldn’t be doing it alone – I had an experienced group of peers ready and willing to walk beside me.” Politics can be a tricky business and Alison also experienced what it was like to have detractors. Attending functions with an infant caused some to question her ability to do the job – and not necessarily just the presidency. Some thought she should be home raising her children. “I didn't run on a platform of being a mother but suddenly my kids were being drawn into this election. The double standards were laughable. I was fortunate to have role models who’d juggled medicine, motherhood and medico-political advocacy. Like it or not, this is the changing face of medicine.” she said. Despite losing the election, Alison believes that the current leadership

is committed to meaningful membership engagement. She was also pleased to see a number of female colleagues elected to State council but reiterates that the organisation must not limit itself to purely addressing gender diversity. It must also examine how to tackle intersectional disadvantage, internally and externally. “As a white, able-bodied, heterosexual, cisgendered, Australian trained doctor, I benefit from significant privilege,” she said. “I am free to work wherever I wish unlike many of my international medical graduate colleagues. I have family living locally that provide childcare and other support so I can get involved and make sure my voice is heard.

Challenging the system “I have medical colleagues who are married to fellow doctors, where once kids come along, there just isn't space for two careers to be full time let alone get involved in medical politics. Even when both parties want to work part time and share the domestic load, the system makes it incredibly challenging. “How can the AMA support them better to juggle parenthood and career? How can we hear their voices even if they can’t get to the table?”

record?” she laughed. “At the moment I think I’ve got enough on my plate between getting back into general practice, parenting three small humans and juggling my role on state council and a national college committee,” she said. “I must admit that I’m worried about the future of general practice in Australia. It is suffering the effects of chronic and deliberate underfunding and we are witnessing the erosion of the most cost-effective part of our health care system. “The flow on effect is that my fellow general practitioners are experiencing moral injury. With inadequate Medicare funding, they are prevented from providing timely, affordable, effective care to their most disadvantaged patients. Perhaps this will be my next focus. “I know from my experience with the breastfeeding advocacy, that although I will not sit my fellowship exams again (thank goodness), there are others who have and will benefit from that work. I hope the idea of planting trees whose shade I will never sit in, continues to be the theme of my future advocacy endeavours.”

Read this story on mforum.com.au

So, is there a next political step, for Alison Soerensen? “Are we talking on or off the

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The problem with opioids Opioids are the drugs that a perfect on minute, a problem the next. How do doctors face this dilemma?

James Knox reports From a distance, Australia has seemingly avoided the opioid crisis that has spread across North America, but upon closer inspection there are parallels between what is happening in our backyard and what is reported from the other side of the world. In the past 20 years, Australia has experienced an increase in opioid use disorders and the related harms and unintentional deaths that ensues, which coincides with an upsurge in the long-term prescribing of opioids for chronic non-cancer pain (CNCP). Opioids were not always seen as the go-to treatment for CNCP, rather they were reserved for terminal cancer patients and postsurgical acute care. This changed in 1996 when the American Pain Society suggested pain was the “fifth vital sign” alongside body temperature, blood pressure, heart rate and breathing. This led the medical community to look at pain as something to be treated. At the same time, pharmaceutical companies began marketing a 22 | MARCH 2020

range of opioid analgesics to clinicians in the US as ‘safer’ alternatives to drugs such as morphine, in the context of potential patient dependency. In the early 2000s, the same opioid analgesics were classified on the Pharmaceutical Benefits Scheme (PBS) for the treatment of CNCP. The data also tells a story. Opioid prescriptions in Australia have increased fourfold since the 1990s, along with significant increases in the prevalence of opioid use disorders and unintentional druginduced deaths. Between 2016-2017, 3.1 million opioid prescriptions were dispensed in Australia. In 2018, 3 people died per day on average, due to opioid overdose, with pharmaceutical opioids present in 70% of these cases. The appropriateness of opioids is now being questioned for functional restoration of patients with CNCP – opioids block the pain without treating the source – with research suggesting non-opioid MEDICAL FORUM | PAIN MANAGEMENT ISSUE

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interventions are more effective for the treatment of CNCP. In August last year, the Pennington Institute released its latest Australia’s Annual Overdose Report and with it came some uncomfortable reading: unintentional drug-induced deaths between 2001 to 2017 increased by 64.3%, while, in 2017, opioids accounted for 56.1% of all unintentional drug-induced deaths.

Statistical significance “We’ve had a massive increase in opioid prescribing to alleviate pain for patients, but I don't think it's been front and centre for clinicians in that process to manage people's risk of addiction or manage people's risk of misuse. We’ve got a growing illicit overdose problem, but also a very significant pharmaceutical overdose problem,” Mr John Ryan, CEO of the Pennington Institute, said. According to Mr Ryan, the prescribing of opioids is not necessarily the problem, it’s the controls around the use of them. “We live in a society where we expect pharmaceutical solutions to our problems. And that's perfectly reasonable. But the kind of risk management in relation to those pharmaceuticals has been proven to be inadequate considering the overdose [rates].” Education on the risks of opioids, along with awareness of potential for problematic behaviour, was needed. “I don't think the health sector, of which I'm a part, has adequately

focused on those broader issues, including addressing this growing relationship to addiction. It's a difficult area, there's no doubt about that, but it's so prevalent in the community, it's got to be faced,” he said. Although the report is not part of a policy initiative, Mr Ryan says the numbers should be persuasive enough to encourage change. “You have to acknowledge, after seeing the numbers, that we do need policy changes and an increased community awareness of the overdose problem. That's actually a big step forward if we can improve the level of understanding in the community.” “Better overdose response would be part of that because we need families of people who are on high-dose pharmaceutical opioids to know the signs of an overdose and how to respond. We also need more access to naloxone and to other drug treatments. Not enough medicos are prescribing opioid substitution treatment and there is not enough psychosocial support for people who are on opioid substitution treatment.” “[The solution] can be summed up by needing to improve our health approach to drug problems, whether they're pharmaceutical or illegal drugs. It's about ramping up a health approach.”

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Stigmatisation of drug abuse is a barrier that is holding Australia back from realising the magnitude of the situation at our doorstep, he said. “It's extraordinary that so many people are dying from overdose and yet we're not talking about it. The stigma that has come from illicit drug use is now impacting on people who are on prescribed pharmaceuticals as well.” “There's no evidence that stigma is protective but there is evidence to suggest that that it is hurting people, and it's hurting the families of people affected by drug use as well. People are actually dying for lack of knowledge, which, in 2020 Australia, should no longer be the case.”

Perilous pathway Ultimately, the narrative belongs to the Australian patients who have first-hand experience of opioid overuse. The journey of drug dependency can begin innocuously, without any forewarning of the perils that lie ahead. “Peer pressure, probably a splash of depression, and the availability of drugs,” is how Warren, a 36-yearold from the northern suburbs of Perth, describes his first encounter continued on Page 24

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The problem with opioids continued from Page 23 with illicit drugs. “Before I knew it, I was using on the weekends, then during the week.” Warren spoke of experimenting with cigarettes, cannabis and alcohol in his teens before using methamphetamine in his early 20s before progressing to heroin then codeine. “I was a habitual codeine user. We used to get it from a chemist. I was using cold water filtration to extract the codeine from the paracetamol. That was a relatively easy process,” he said. At this point, Warren’s story converges with that of many nonillicit drug abusers, as his drug dependency transitioned from illicit drugs to pharmaceutical medications, with long-term prescriptions for Tramadol being provided by his GP and Xanax and Klonopin from his psychiatrist. Warren, said it was easy to obtain these scripts concurrently, as long he stuck to his script. “As long as I went in, well presented and said, ‘everything's going fine, I’m working’ etcetera, I tick the box and I get the script. But underneath, I wasn't well at all.”

Normalising naloxone While the widespread opioid problem can be traced back to the United States years before it came to Australia, we have the opportunity to learn from responses implemented there, such as recognising the need for a practical intervention for the unintentional deaths due to opioids, for instance naloxone coprescribing. “In the US, following recommendations by the Centre for Disease Control and Prevention (CDC) and the American Medical Association, there has been a recognition of the importance of prescribing practices for pharmaceutical opioids and the co-prescribing of naloxone, said Professor Simon Lenton, Director, National Drug Research Institute, Curtin University. “Their recommendations apply to 24 | MARCH 2020

patients who have been prescribed large doses of opioids, greater than 50 milligrams (opiate oral morphine equivalent), or people who have other risk factors such as substance abuse disorder or concurrent benzodiazepine use. According to Prof Lenton, practitioners should be encouraged to discuss the risks of opioid use and, “raise the issue of naloxone as a potential medicine that could aid in the event of a family member, for example, witnessing someone going into respiratory decline and potentially at risk of overdose.” “Providing [naloxone] as part of the treatment is something that should definitely be happening in Australia. Prescribers should be thinking about the patients they are prescribing to and who might be at an increased risk of overdose and the role of naloxone. And now that an intra-nasal product is available in Australia, which can be easily administered, this is now viable as a part of routine practice.” However, Prof Lenton questions the appropriateness of the terms surrounding opioid use, such as ‘overdose’ and ‘abuse,’ for patients on prescribed opioids. “The language that's been used is more appropriate for people who inject drugs and really doesn't translate well to people who are on pain medication and who clearly don't have a history of drug injection,” He said. “Even the use of the term ‘overdose’, most people on chronic pain medication wouldn't think that applied to them. But there is an opportunity as part of a conversation about the potential side effects of this medication to raise the issue. “Explaining that, particularly when people inadvertently take too much, opioids can suppress breathing to the point where people can be at risk of dying. This conversation could provide a context to raise the issue that there

is medicine available [Naloxone] which can help reverse the effects on the rare occasions it happens.” “It's about using appropriate language and not alarming people, but being upfront with them about what the real risks of these very strong medicines are. This isn't to say that prescribing of opioids is inappropriate. Clearly, opioids have a very important role in pain management, but it's about recognising what the potential risks are and mitigating those risks.” Another aspect that's critically important, says Prof Lenton, is for patients who have an opioid dependency to be referred to an “appropriate evidence-based opioid substitution treatment, such as buprenorphine or methadone, which we know reduces the risk of overdose.” Although opioid overdoses and unintentional deaths are increasing at a community level, Prof Lenton says that interventions, such as naloxone, are not yet scaled-up to a level where they are likely to have an impact on reducing these statistics, which is why engagement of the general medical community on this issue is so important. Naloxone is free in WA under the Commonwealth Government’s Take Home Naloxone pilot scheme.

Risk mitigation Substance dependencies can present with a plethora of biological, psychological and social-environmental factors that influence aberrant behaviour, whilst opioid dependencies from longterm treatment of CNCP adds further complexity to treatment modalities. Often the foundations of opioid dependencies feature an array of predisposing, perpetuating, precipitating and protecting components requiring a long-term holistic treatment plan. Pharmacotherapy is just one aspect of the treatment, says Dr Richard O’Regan, Clinical Director, Next Step Drug and Alcohol Services. Dr O’Regan explained to Medical Forum how his clinic accessed and treated clients with opioid

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FEATURE use disorders: an assessment should be undertaken to first identify the features of substance use problems, then a recommendation of staged dispensing of prescriptions. Dr O’Regan said that although there might be patient push back, ultimately it could save their life. “It's the balance between doing what's in their best interests versus ‘I know this is a pain in your backside and I apologise for that, but in my hierarchy of needs, you being alive is much, much higher than you being a bit miffed’.” “Some doctors won’t do it or dislike the idea. A patient might say ‘you're treating me like a drug addict.’ Yeah, well, what I'm trying to do is to keep you alive, keep you safe.” Dr O’Regan suggests doctors not fall into the trap of a customer satisfaction type relationship with their patient by avoiding pointed questions when opioid prescriptions are broached, such as a basic history of past substance use, such as amphetamines, heroin, injected drugs, alcohol. “A lot of doctors struggle with patients on high-dose opioids over a long period of time. It's very, very hard, particularly if they’ve known you for a long time. And over many years, we've got to a stage where they’re on benzodiazepines, maybe one or two S8s. The doses creep up and up and up. It's quite challenging for the doctor then to stop and think, well, hang on, something’s going on here.”

“It's not a palatable answer from a patient's perspective. To have a conversation about the pros and cons of opioid prescribing and the non-medication therapies. It's a long conversation,” Dr O’Regan said. The difficulty is in battling the preconceived notions of five or 10 years of opioid treatments. Dr O'Regan urges clinicians to reflect on how they address opioids with their patients. “For a lot of practitioners, I think it's really hard. Do they have the time? Definitely not. Do they have the inclination? That's another question, of course, too. ‘Maybe I'd like to. But I've got this business to run here and I've got 10 patients in the waiting room…’”

Pharmacotherapy paradigms Conventional pharmacotherapy treatments for opioid use disorders tend to use opioid agonists that activate opioid receptors such as buprenorphine or methadone. While there are less conventional opioid antagonists (which will be explored later) that block the receptors, such as naltrexone. Next Step uses injectable buprenorphine (Suboxone) to treat opioid dependencies, which according to Dr O’Regan, “has been a real game changer for us and for our clients.” Dr O’Regan says that agonists, which stimulate opioid receptors, are a much better treatment because completely cutting off the opioid receptors, as with antagonists, leaves individuals vulnerable. “It’s never as simple as your opioid receptors; it’s you, it’s your partner, your children, your colleagues, it’s your mental health, it’s your other health factors as well,” he said.

“A lot of the folks that we see have had hard experiences and hard lives, without robust coping mechanisms. You've got to be gentle, but firm. Sometimes the caring nature of being a doctor takes precedence with doctors being too permissive. However, I have to do things that patients are not so keen on because I'm looking out for their health.”

“What we find with substance use disorders is a whole lot of chaos in a whole lot of areas. I think of the agonist therapy as ‘time out’. Clients don't have to go hunting and gathering and committing crime. They can actually take time out because they feel a lot better. [They are able] to study, to address legal issues, to address mental health issues, housing, education, relationships, etc.

Convincing patients on long-term opioid prescriptions to reduce their dosage and ultimately cease taking the drugs is no short conversation.

“If I remove a client’s capacity to deal with all the problems in their life, instantly, they are going to fall over, and their dependency is going

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to pop up some other place. We’re dealing with a complex system that's a long-term treatment.”

Another approach With two disparate pharmacotherapy approaches, Dr George O’Neil has championed the antagonist approach and has been administering naltrexone to patients with opioid use disorder at his not-for-profit, First Start clinic, in Subiaco since the 1990s. Dr O’Neil’s approach is unique as he uses Naltrexone implants for the treatment of opioid use disorder (OUD). Naltrexone implants are not listed on the Australian Register of Therapeutic Goods and not approved by the PBS for opioid dependency treatments, therefore each patient who comes to his clinic for implants must be approved by the Therapeutic Goods Administration’s Special Access Scheme. Oral naltrexone is scheduled on the PBS but only for alcohol dependency treatment purposes. Dr O’Neil estimates each naltrexone implant costs the clinic up-to $7000 but the majority of the clients that walk through the door pay a miniscule proportion or nothing at all. The status of his treatments is point of contention for Dr O’Neil, who believes Naltrexone implants, along with the holistic approach from First Step (housing, relationships, education and employment) is the most effective way of weening patients off opioids. He said First Step had seen up to 12,000 clients since it opened its doors and had successfully treated thousands for opioid dependencies with naltrexone implants. Dr O’Neil’s commercial venture, Go Medical, supplies the O’Neil Long Acting Naltrexone Implant (OLANI) to First Step patients. The OLANI – designed and manufactured by Go Medical - is a slow-realise biodegradable implant that delivers pharmaceuticals, such as naltrexone to patients with OUD. A criticism of naltrexone implants and the OLANI device is the continued on Page 26

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The problem with opioids continued from Page 25 limited evidence of the treatments’ efficacy, something Dr O’Neil says will soon be established with the National Institute of Drug Abuse (NIDA), in the US, providing a $US6m grant to Go Medical, Columbia University and the New York State Psychiatric Institute to establish the effectiveness of the OLANI for detoxification of patients with OUD and measure the relapse rate as compared with treatments such as opioid receptor agonists. However, Dr O’Neil is keen to stress there are studies demonstrating the efficacy of naltrexone implants compared to oral naltrexone with regards to post-treatment mortality rates due to overdoses. Dr O’Neil first heard of naltrexone being used for opioid use disorder in the mid-1990s when he was speaking at a conference on pain management in China. When he returned to Perth, Dr O’Neil encountered a patient for which methadone was not effective. He approached the TGA for permission to trial oral naltrexone on the patient and after the successful intervention, more patients followed. “I realised there wasn't another doctor in Australia helping people to use medicines to get off opiates. And from then on, I was, accidentally, the only doctor in the country doing so,” Dr O’Neil told Medical Forum. Dr O’Neil, believes the issues faced by patients are as a result of a broken system of pain management and suggests the prescribers are the part of the problem. “Doctors around the world are starting to wake up and realise, gosh, we’re using opioids for treating pain. Now we have patients addicted to opioids and we're treating them with more opioids. There’s still a total reliance on treating people with opioids. It’s not good medicine,” he said.

Parlance of pain What once was the ideal treatment of CNCP is now being recognised as anything but. However, for the 26 | MARCH 2020

general public the association of opioids and chronic pain is synonymous, according to Associate Professor Suzanne Nielsen, Deputy Director of the Monash Addiction Research Centre, in Melbourne. “Patients might expect to receive something strong for pain, expecting that [opioids are the best outcome], and perhaps not aware of some of the downsides, particularly of using these drugs in the long-term. “And similarly, for medical professionals. I trained as a pharmacist about 20 years ago and at that time we were told that if people had genuine pain, it was almost impossible for them to develop addictions to opioids. We now know that that's absolutely not true. Many health professionals were trained with that understanding.”

overdose is often used. And you see information around naloxone and reducing opioid-related harm using the term overdose. And that just isn't salient for our patients who are prescribed opioids for chronic pain. “Often, patients interpret overdoses as something that applies to people who take too many opioids intentionally or associate that with illicit drug use, and it isn't necessarily something that patients prescribed opioids for chronic pain feel like might happen to them. “Obviously, our mortality data says otherwise, but we do need to have language to try and bridge that gap and let patients know that there are risks with opioids even when they are used as prescribed interventions such as naloxone, which might be appropriate for a really broad range of people. “For patients with chronic pain, it’s important not to use the word overdose because it is such a value-laden term and it's often stigmatised.”

According to A/Prof Nielsen, a lot of the harms from pharmaceutical opioids were being experienced by people being prescribed opioids for pain.

A/Prof Nielsen suggests that explaining symptoms explicitly is more effective, not only for the patient but also encourage them to discuss these symptoms with their families.

“When we're trying to reduce opioid-related harm, we need to be thinking about the many different populations. We need different strategies for those who might get pushed off opioids through prescription monitoring versus those that might be on opioids for chronic pain and might have other risk factors,” she said.

“Alerting them to the fact that opioids can affect respiration and when it’s severe, it can cause people to stop breathing altogether. And, in that case, why that person should have naloxone in their home. We need to educate not only patients and their family members around these signs and symptoms and what to look out for.

“For example, being prescribed multiple central nervous system depressant medicines, or also having some of those comorbidities such as COPD, which increase the risk of mortality with opioid use. There's a broad spectrum of patients with a range of issues we need to consider.”

“Tragically we hear in coroners’ reports of people who died in their sleep when there was someone in the home who heard them with laboured breathing and just didn't identify that as a sign of respiratory depression, and therefore they didn’t respond.

The specific language used in doctor-patient conversations is particularly important, A/Prof Nielsen told Medical Forum. “When having conversations with patients about opioids, the term

“Education for family members who may see these signs and symptoms is vital so they can intervene by either administering naloxone on the spot or calling an ambulance and thereby reducing those preventable deaths.”

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Opioids: What clinicians have to say Medical Forum asked pain and addiction medicine specialists for their view on a range of issues around the use of opioids in WA.

Dr Wendy Lawrance, addiction medicine specialist, Next Step Drug and Alcohol Services, Fresh Start Recovery Programme MF: In your experience, does WA have an opioid ‘crisis’? WL: In 2018 there were 172 opioid-induced deaths in WA, being a rate of 6.63/100,000 population, which is higher than the rate of 5.61/100,000 at the peak of the ‘heroin crisis’ in 1999. Of the 2018 deaths, 91 were exclusively attributed to pharmaceutical opioids, 24 also had illicit opioids involved, leaving only 57 exclusively attributed to illicit opioids such as heroin, which is commonly thought of as the main culprit in opioid overdose deaths. More than two thirds (66) of the exclusive pharmaceutical opioidrelated deaths were accidental. All of these rates have been steadily increasing since 2007, and all but the illicit plus pharmaceutical rates are higher than the national rates. Interestingly, at a national level, there has been a noticeable increase in the accidental death rates exclusively due to pharmaceutical opioids since 2007 in the age brackets above 35 years-old.

health, reduce blood-borne virus transmission and criminal involvement. There is little evidence of marked efficacy or functional gains for opioids in chronic non-cancer pain beyond a few months. The Schedule 8 Medicines Prescribing Code (available at https://ww2.health. wa.gov.au/Articles/N_R/Opioidsbenzodiazepines-and-other-S8medicines along with lots of other useful information) explains the prescribing rules for WA. MF: What are your views on a prescription monitoring service?

MF: When is it appropriate to prescribe opioids? When is it not?

WL: Comprehensive S8 prescription monitoring already exists in WA, and very useful, though limited information is available to prescribers on patients they are consulting by calling the Schedule 8 Prescriber Information Service on (08) 9222 4424 in office hours. A National Real Time Prescription Monitoring System is under development and eagerly awaited by addiction doctors and others. It will identify people who would benefit from addiction and pain services and those from skilled GPs, and we may face workforce capacity challenges. Abrupt cessation of opioids can lead to increased overdose rates, and to changing to illicit opioids including strong synthetic opioids, which are a very worrying problem in North America. It won’t be a panacea as illicit, including internet, supply of pharmaceuticals will not be captured.

WL: Opioids are effective, evidence-based treatments for acute pain, and pain in a palliative care context. As opioid substitution therapy for opioid dependence, they reduce accidental overdose risk, improve physical and mental

MF: Much time and energy has been put into developing alternative pharmacological and multidisciplinary approaches to deal with chronic pain. In your experience, what is working? What is showing potential?

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WL: Effective and well-tapered treatment of acute pain, along with caution and universal precautions in opioid prescribing for chronic pain will go a long way to preventing medication related problems that I see in an addiction service. There is lots of useful information on the Department of Health website above. Naloxone, for opioid overdose reversal, is available both as a prefilled syringe for intra-muscular injection (Prenoxad®), and a single-use pump for intranasal administration (Nyxoid®). Both are available S3 and S4 (PBS). Under a Commonwealth program, many pharmacies, health, homeless and addiction services in WA are able to supply these efficacious treatments free to people who are at risk of experiencing or witnessing opioid overdose.

Dr Roger Goucke, pain specialist, Nedlands MF: In your experience, does WA have an opioid ‘crisis’? RG: I suppose it depends on with whom we are comparing. Although WA has some patients on high-dose opioids, it seems there maybe some diversion but I get the feeling this is less of an issue than it was several years ago. The Department of Health WA has clamped down on some high prescribers. It would be interesting to get an opinion from the Police. MF: Alternative pharmacological and multidisciplinary approaches? RG: I think it’s cultural both for

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FEATURE patients and practitioners. It’s easier to give a tablet and the patient wants a fix to the pain. The psychological techniques are well described on how to help manage pain that persists. Access to either one-on-one or (better) group-based therapies are limited through both state government and Medicare funding, although it’s improving. Engaging patients in therapy is also an issue and complex barriers exist. Preventing chronic pain in the first place now has good evidence for efficacy; aggressive treatment and follow-up of post-op pain, especially high-risk patients. Early intervention (in first 10 days) for workers comp pain cases.

Dr John Salmon, pain specialist, Cottesloe MF: Is there an opiate crisis in WA? JS: I don’t think there is an opiate crisis in WA, certainly not compared to the US where rampant, unscrupulous, income-driven opiate prescription has wreaked havoc. A concerted effort from the Health Department and pain specialists in WA has, fairly, successfully disendorsed the prescription of higher dose, strong opioids for non-cancer pain. The pendulum may even have swung too far the other way with the patients who were parked too frequently by the medical profession on high-dose opiates over the past 20 years, abruptly disconnected from their medication without appropriate alternative treatment options causing considerable, avoidable distress. MF: Opiate prescribing? JS: There is a consensus now that routine strong analgesic medication should be confined, as far as possible, to tapentatol (Palexia), slow and quick release, and buprenorphine (Norspan) patches and possibly sublingual (Temgesic). Tapentadol has a predominant noradrenergic mechanism with the opiate component less potent than codeine. Many years use in the US and Europe with monitoring has not identified any significant addiction or abuse behaviours. It also has low toxicity and no tendency to provoke

hyperalgesia and immune system dysfunction. Its risk-benefit profile should therefore be viewed quite differently from the other strong opiates and it’s unfortunate that it has been bracketed with them as a Schedule 8 based purely on its potency being equivalent to up to 80mg of oxycodone a day. It is apparent that many GPs view tapentatol the same as oxycodone, morphine or fentanyl on this basis which is not appropriate. The Health Department does not require a permit to prescribe tapentadol up to a dose of 500mg a day. Buprenorphine is also distinguished by much reduced dependency, abuse and toxicity issues and also does not provoke hyperalgesia and immune dysfunction. There is at least a tenfold genetic variation in individual patients’ response to medications including analgesics and therefore a requirement for dose flexibility. Some patients, particularly those previously on high-dose opiates, require a combination of tapentadol and buprenorphine to achieve reasonable analgesic effects. It is quite safe to combine these medications. Complex chronic pain patients with long-standing high-dose opiate dependency are frequently a management challenge. Transition to tapentadol needs to be done gradually with slow tapering of their usual opiate because tapentadol being mostly non-opiate does not counter withdrawal issues. Regarding when to prescribe strong analgesics the principle should always be to implement adequate evidence-based nonpharmacological pain management as far as possible before or at least in parallel to prescription of stronger analgesics. Always use the lowest dose that achieves reasonable symptom control and maintains function and quality of life without side-effects such as daytime sedation. Provision of nonpharmacological pain management treatment? If there is a crisis in pain management it is the ongoing failure of health (including medical) professionals in general to assimilate and implement the current knowledge regarding mechanisms of chronic pain disability. Undergraduate and postgraduate training remains woefully inadequate

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regarding pain medicine, which is a paradox considering that pain is the most frequent presenting symptom in medicine. While chronic pain disability, interactive with anxiety and depression, are the dominant causes of loss of quality of life and function and health-related economic cost in the Western World. The health system as a whole remains biomedically focused and there are huge commercial drivers rewarding physical interventions and surgical procedures, in turn fuelled by ever more detailed imaging of pathologies which are most frequently asymptomatic, degenerative change. The toxicity of rampant biomedicalbased management is exemplified by the appalling outcomes for work injured patients becoming permanently disabled chronic pain patients after relatively minor soft tissue injuries (about 4000 a year in WA). The adversarial environment inherent in the workers compensation and motor vehicle accident insurance schemes virtually ensures that psychologically vulnerable injured patients (about 25% of those injured) develop disabling chronic pain. Early identification of vulnerable patients and early proactive CBT pain management treatment, with adequate GP and allied health support, has been shown to largely prevent the evolution of chronic pain disability in recent controlled studies. The coming availability of highquality Internet pain management CBT should markedly improve provision in the wider community. Patients with intractable neuropathic or nociplastic pain mechanisms, the most prevalent mechanism in the more severely disabled and distressed patients, who have failed to respond to non-interventional management can be very successfully managed with implanted neuromodulation therapies, which now have a strong evidence level I base for efficacy and safety. Externally powered, smartphonecontrolled, minimally invasive implanted systems are becoming available, which should also be considerably cheaper than the fully implanted devices making the therapy more accessible.

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The Wearables revolution Wearables are fast moving out of the consumer realm and becoming an important clinical tool for health and wellbeing.

James Knox reports

Smart wearable health devices, colloquially known as wearables, have become intrinsic in many Australians’ daily lives with a reported 1.2m smart wrist devices sold in the first half of 2019 and are forecast to become the second most sold consumer electronics product in 2020 after smartphones. Wearables have come a long way from the humble beginnings of the iconic Casio Databank calculator watch from the early 1980s, to the latest Apple Watch, which is many times more powerful than the Cray2, the most powerful supercomputer of the Databank era. Although wearables are synonymous with smart watches, there is a burgeoning industry of clinical devices that go beyond purely wristbased devices, potentially offering improved provision of health care via artificial intelligence algorithms and predictive analytics based on real-time metrics of wellbeing and vital signs. From a connectivity standpoint, smart wearables will benefit from the proliferation of 5G wireless networks that should significantly reduce latency and exponentially faster download and upload speeds when compared with the current 4G network. However, the ‘smart’ or digital technology aspect of wearables may be new, especially in the context of clinical applications, but when viewed through a historical lens, wearable technology has 30 | MARCH 2020

been around for centuries. From the invention of eye glasses in the 13th century to the advent of digital hearing aids in the 1980s, we have been wearing innovative health solutions for a long time. Their success has been based on convenience to the user and a clinical solution to a health need. For nascent wearable devices to reach clinically efficacy, demand needs to be driven from clinicians, and engineers who are focused on the benefit to the end-user. Medical Forum spoke to people at the forefront of wearable health care design and application in Australia to explore what wearable technology is being developed here and what impact will it have in primary health care.

New world order Cuff-based systolic blood pressure measurement (BPM) has been one of the staples of medicine for almost a century, thanks to the sphygmomanometer, yet this method of capturing vital signs is rudimentary, uncomfortable and non-continuous. Continuous BPM requires an invasive arterial line inserted into an artery, but this is not practical nor common for noncritical cases. Finger-based blood pressure monitors can provide continuous BPM but the findings can be variable depending on the movements of the finger and the body, which is a similar limitation of the cuff-based sphygmomanometer.

A device that can produce reliable, non-invasive, continuous beatto-beat BPM, regardless of body movements, could soon be the new normal thanks to a team of engineers and clinicians in Melbourne that has developed a wireless device that measures real-time BP based on pulse arrival time, pre-ejection period and pulse transit time. The devices have undergone realworld testing in a clinical trial at Cabrini Hospital, Melbourne, with the published results demonstrating proof-of-concept. Medical Forum spoke with the study’s lead author, Associate Professor Mehmet Yuce (pictured), from Monash University. A/Prof Yuce has garnered a reputation for developing innovative wearable devices, designed for health care applications, over the past decade. He said clinicians would regularly approach him with ideas for devices that would help them in their dayto-day practice. A recurring theme in these conversations was the need for a non-invasive BPM that could provide real-time readings while not being subject to the variability of body movements. Based on this feedback, Mehmet and colleagues set to work five years ago on a cuff-less BPM. The resulting small wearable device, which is fixed to the sternum, features world-first technology, the first being a sensor that utilises continuous wave radar to transmit frequencies that penetrate through

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the chest to measure the blood flow timing from the heart. Another sensor uses bioimpedance, which sends a weak electric current through the chest to extract the pulse wave. The next sensors are placed at different locations on the body and use electrocardiography (ECG) to measure the duration it takes for blood to flow from the heart. An algorithm then processes the output from the sensors into accurate, real-time blood pressure readings. A unique aspect of these monitors is they can take measurements while a user is actively moving, even exercising for hours at a time, and still provide reliable readings. A/Prof Yuce envisages the two devices designed by his team will eventually go to market. He believes they could be particularly beneficial for patients in nursing homes or remote areas, so doctors can wirelessly access their patients’ vital signs from hundreds or thousands of kilometres away. Paramedics could use the device to measure a critical patient’s blood pressure from pick-up to drop-off, sending the measurements to the emergency department in real time. A/Prof Yuce predicts wearable devices will become commonplace in health care settings, especially with the possibilities of 5G, but not without collaboration between clinicians and engineers, who can co-design and develop practical solutions to real-world problems.

A/Prof Mehmet Yuce and his cuff-less BPM device (inset).

GPs and wearables The wearables on our wrists may not be ready for critical clinical data capture but they can provide clinicians and patients with useful information such as longitudinal heart rate data, which can be collected from a wrist-based wearable such as an Apple Watch then sent to an app, which a GP can view. For this type of technological integration to be adopted, the benefits need to be immediately obvious to patients and clinicians alike, from an efficiency and efficacy perspective. However, this type of disruptive technology requires patients, GPs and medical practices to change the architype of primary health care from a

face-to-face consultation to an interconnected, data sharing relationship. The positive outcomes from integrating disruptive technologies in general practice are something that Dr Simon Kos, CEO of Next Practice, is familiar with. Before his role with Next Practice, Dr Kos was the chief medical officer of Microsoft and has worked in digital health for almost two decades.

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According to Dr Kos, Next Practice is aiming to improve the patient journey in general practice through digital innovation to enhance, rather than reduce, the patient-centric focus of the medical clinics. “We've really thought about how the patient experience flows through the clinic experience and how aspects of the doctor-patient relationship can then flow back into tools that the patient can take away and use to self-manage aspects of their own care,” he said.

continued on Page 34

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The Wearables revolution continued from Page 33 By using a digitally innovative approach, Dr Kos believes that this will break the traditional paradigm of general practice. “We think a lot of general practices have historically been episodic and we’re trying to create more of a continuum of health information.” Alongside their general practice management system, Next Practice also has a patient application, all of which has been developed inhouse, which will capture aspects of patient data such as cardiovascular metrics from consumer grade wearable devices, such as the Apple Watch, and collate the information so that it can be discussed at the patient’s next GP consultation. As far as the efficacy of using consumer grade devices in a clinical context, Dr Kos said there had always been some contention, but their proliferation necessitated a change in how the clinician thinks about that data.” “While two different pedometers might not accurately report the same number of steps, if someone hasn't walked for the past three days and that person is elderly, that trend level information is absolutely clinically relevant, even if

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there's variance between different models.” “So that's what we're thinking about now. Not how we use consumer devices as a replacement for the data we would ordinarily capture from clinical devices, but more, how do you use consumer devices to establish trends of activity between consultations? That's really important.”

Person-centred design To ensure a wearable will be beneficial for the end-user, personcentred design is fundamental. As counterintuitive as this may seem, it is not always the case for the design of innovative technologies, according to Dr Leah Heiss, from the Royal Melbourne Institute of Technology and co-director of the RMIT Wearables and Sensing Network. “Many companies have a technology-first approach that is focused on fast turnaround pitches, investment, and getting products to market very quickly. This does not allow for meaningful engagement with the people who we hope will actually wear our technologies. If we are going to design devices that will change people’s lives, we need to make sure that the devices are integrated into those lives,” she said.

Dr Heiss emphasises that good design is paramount to the functionality and aesthetics, but more important is the cohort for which the device benefits. “So many resources are committed to the aesthetics of devices to count the steps of healthy people, yet so few are allocated to improving devices for people who are really unwell. The attitude seems to be that if you have a disability, you suddenly have no interest in aesthetics. This is crazy.” The Conversation as Therapy (CaT) pin is among one of Dr Heiss’s more prominent wearable design projects, which, at first glance, is a personalised brooch yet inside is a microphone, microprocessor and Bluetooth transceiver. The CaT pin detects loneliness by monitoring ambient sound to identify the presence or absence of speech by counting words over time. If a wearer of a Cat Pin has not spoken for a day, a text message can be sent to a contact to alert them. According to Dr Heiss, the CaT pin was designed with a fundamental understanding of the end-user and not only their need for the device but their emotional response to the device. To ensure use-case and end-user applicability, the CaT pin team, led

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“By working laterally across design, health and technology we can start to address the complex needs of people in the healthcare system. A technology-only approach is not sufficient, neither is a design-only approach.” The clinical application of a device such as the CaT pin may not, at first glance, seem as obvious as a cuff-less blood pressure monitor, yet upon closer inspection social isolation is a key risk factor for an older cohort. Dr Heiss believes the CaT pin can bring awareness of the health implications from loneliness to clinicians. Dr Leah Heiss bringing aesthetics to wearables.

by Dr Heiss, was a multidisciplinary collaboration of designers, engineers and Bolton Clarke, a notfor-profit aged care and health care provider. “I focus on creating wearable health technologies that resonate with us emotionally but also keep us healthy. I call these, ‘emotional’ technologies. Central to creating emotional technologies is engaging deeply with the people who are going to use the device – understanding what they would really like in their lives, and tailoring the technology around that. “While smart watches are fine, many wearable health technologies

such as cardiac Holter technology or falls monitors are created with efficiency and hygiene as paramount concerns, with little regard for how the wearer will feel using it, said Dr Heiss. “This leads to devices that have little resonance with the emotional experience of users. I am particularly focused on humanising wearable health technologies and this requires that I work in an interdisciplinary way across design, health and technology. At the core of my practice is collaboration and the challenge to create communication between disciplines who do not have a shared language.

“It also requires a mindset shift so that clinicians realise that the work of keeping people well is distributed, rather than isolated, with caregivers. This means that a network of family, friends, neighbours and support workers can help to keep people well, before a situation deteriorates that then needs support from clinicians.”

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Clinical Update Pain Management 36 TREATING KERATOCONUS Dr Ian Chan 38 CRANIOFACIAL PAIN Dr Philip Finch 40 FIBROMYALGIA

Professor Eric J Visser

41 MIGRAINE

42 CHRONIC REGIONAL PAIN SYNDROME

Dr Brian Lee

44 ORAL ULCERATION

Dr Amanda Phoon Nguyen

45 NEUROABLATION FOR CHRONIC PAIN

Dr David Holthouse

Dr Tapuwa Musuka

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Treating keratoconus By Dr Ian Chan, Ophthalmologist, Nedlands Keratoconus is a progressive, irreversible distortion of the cornea affecting around one in 400 young patients. Typically, the disease is diagnosed when the patient's vision is no longer fully correctable with glasses. The disease is caused by a combination of genetic predisposition, chronic allergies and physical eye rubbing. If left untreated, some patients will progress to have lifelong severe vision issues and possibly require corneal transplantation For the past 10 years, we have been able to effectively stop the progression of keratoconus with corneal collagen cross-linking (CXL). Corneal transplantation rate for keratoconus has steadily fallen around the world over the past decade due to earlier diagnosis and CXL treatments. CXL is a time-intensive minor procedure. The eye is exposed to ultraviolet light for a specific duration after the cornea is soaked in riboflavin 0.1% solution. The corneal epithelium is often debrided to allow the riboflavin solution to penetrate into the cornea. Similar to a corneal abrasion, there is pain and discomfort after the procedure but recovery is fast. Some 90-95% of patients stop progressing after treatment. CXL and keratoconus is still relatively unfamiliar to mainstream medicine. Owing to campaigning by some of our colleagues, Medicare finally provided an item number for this procedure in 2018. Previously, most of these procedures were provided in the private setting with no rebate from any health insurance. Since the introduction of the MBS item number, the majority of private health insurance policies cover hospital admission for collagen cross-linking. For the uninsured, there is a substantial Medicare rebate. CXL does not improve vision most of the time. The reason it is 36 | MARCH 2020

Key messages

Keratoconus is a progressive irreversible distortion of the cornea Its progress can be stopped by corneal collagen cross linking(CXL) Early recognition is the key to preserving vision.

done is to stop progression. Rigid contact lens can restore vision in most cases but these lenses can be uncomfortable and require special attention There are other minor procedures such as corneal ring segment implants and topographic guided laser corneal reshaping that can help to improve spectaclecorrected vision. Unfortunately, once the cornea is distorted by keratoconus, it is irreversible.

be able to diagnose keratoconus. However, young patients without a history of ophthalmic problems should be able to see 6/6 with recently prescribed glasses. If a patient chronically cannot see better than 6/9 with new glasses, then keratoconus should be considered. Allergies and eye rubbing are also risk factors. Our optometry colleagues are very good at early diagnosis and referral. However, disease and treatment awareness in the wider medical community is important in reinforcing effective treatment for these young patients Author competing interests- nil

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Early diagnosis and treatment are essential in keratoconus. General practitioners will not have the diagnostic imaging required to MEDICAL FORUM | PAIN MANAGEMENT ISSUE

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Way forward for non-destructive interventions for craniofacial pain By Dr Philip Finch, Pain Specialist, South Perth Chronic craniofacial pain can be hard to treat due to difficulties in understanding the pathology and pain pathways involved. Typical conditions include trigeminal neuralgia and post-traumatic trigeminal neuropathy, post herpetic neuralgia, occipital neuralgia and migraine headache. Many patients have tried and failed conventional treatment with drugs, and experience significant functional impairment eating, or talking in the case of trigeminal neuralgia, exquisite allodynia to touch in facial post herpetic neuralgia, and prolonged social and work â&#x20AC;&#x2DC;down timeâ&#x20AC;&#x2122; with occipital neuralgia and migraine. The mainstay of drug treatment for craniofacial neuralgias is anticonvulsants (e.g. carbamazepine lamotrigine)

gabapentin and pregabalin. Baclofen and onabotulinum toxin (Botox) are also used. Anticonvulsant use is often limited by adverse cognitive side effects, compounded by use of multiple agents or opioids. Less frequent severe adverse effects include skin rashes (Stevens-Johnson syndrome), drug-induced hepatitis and aplastic anaemia and agranulocytosis with carbamazepine. Despite experiencing partial control or remission of craniofacial pain with medication, patients often seek better symptom control through interventional techniques. Although effective, these can cause adverse neurological side effects. Even microvascular decompression of the trigeminal ganglion, offering

a high rate of long-term remission of trigeminal neuralgia, can cause cranial nerve deficits (e.g. unilateral deafness). Radiofrequency thermal ganglionotomy for trigeminal neuralgia invariably causes some facial numbness. Whilst not a significant problem if confined to the second and third divisions of the trigeminal nerve, it can lead to corneal keratitis if the first division is lesioned. Careful intraoperative electrical stimulation and lower thermal temperatures during lesioning reduces facial numbness but at a price of shorter remission periods. Gamma knife-focused beam radiation aimed at the trigeminal root entry zone can help patients with trigeminal neuralgia unsuitable for decompression or

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Key messages

Chronic craniofacial pain can be difficult to manage

Current treatments often have adverse effects

Non-destructive treatments offer analgesia and are simple to apply. radiofrequency treatment. Occipital neuralgia can respond to radiofrequency thermal lesions of the second cervical dorsal root

ganglion and third occipital nerve with quite prolonged periods of remission but, again, at the price of temporary post cervical area altered sensation and ‘burning’ dysaesthesias. Non-destructive electrical stimulation of cranial nerves or upper cervical nerve roots (neuromodulation) can provide very good analgesia with reduced downside risk as these electrodes are implanted subcutaneously through an introducing needle under ultrasound control.

The active electrode segments are placed adjacent to craniofacial sensory nerves including the supra and infraorbital nerves, the greater and lesser occipital nerves and even uncommon targets such as the auriculotemporal nerve and mandibular division nerves. An alternative placement in the cervical epidural space increases risk but can be effective for craniofacial pain states. Implanted systems can always be removed with little loss for the patient except perhaps financial expense, as these systems can be pricey. The introduction of sub-threshold stimulation waveforms in the past decade, especially 10 kHz high frequency stimulation and burst stimulation algorithms, have eliminated the often unpleasant paraesthesia sensations experienced in the face or occiput with earlier low (1-100 Hz) frequency systems. The newer waveforms have been shown to greatly improve the efficacy of stimulation compared with older ‘tonic’ waveform devices.

Sagital and Anteroposterior X-ray images of implanted supra and infraorbital electrodes for high frequency stimulation

Author competing interests – nil

FIVE MINUTE CLINICAL UPDATE Frozen Shoulder (Adhesive Capsulitis) Frozen shoulder is a common condition that causes a great deal of confusion, both from a diagnostic and treatment perspective. Primary or idiopathic frozen shoulder comes on spontaneously, although it often presents with a history of minor injury. There is a strong association with endocrine disorders, particularly diabetes. Women outnumber men. The typical patient is a middle-aged woman who was initially diagnosed with impingement and had some bursitis on her ultrasound. She has had lots of physiotherapy, two subacromial injections with no real response, and is now struggling with sleep and in severe pain. Pain levels are usually high. However, the diagnostic algorithm for frozen shoulder is simple. There are only

two criteria. Firstly, there is a global loss of active and passive range of motion, and x-rays are normal. What does this mean clinically? Understanding the difference between active and passive movement is key. In frozen shoulder, not only can the patient not move the joint fully in all directions (active), but neither can the examiner (passive). External rotation is the first movement usually involved. The only common differential diagnosis is arthritis, which will show up on an x-ray. All other conditions, such as impingement and rotator cuff tearing, will reduce active movement but the passive movement should be preserved. There are only three treatments for frozen shoulder with good clinical evidence to support them. The first, and the mainstay

By Dr David Colvin

of treatment, is glenohumeral cortisone injections. The injections have to be performed into the shoulder joint itself, not the bursa, and this is most commonly done with CT guidance. Within two weeks, there is often a substantial improvement in pain levels, but movement is slower to recover. It usually takes a course of 2-3 injections to see significant results. The other treatments are manipulation under anaesthetic or surgery to release the capsule. In my practice, surgery is almost exclusively reserved for diabetics who experience a more severe frozen shoulder. Frozen shoulder is a condition where symptoms evolve during the treatment phase. It almost always looks like impingement, initially. By the time the patient sees an orthopaedic surgeon, the condition has declared itself, and it’s easy to look like the clever specialist.

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Fibromyalgia syndrome – “A chronic case of the flu” By Professor Eric J Visser, UNDA, Pain Specialist, Joondalup In a typical case scenario, a 43-year-old female teacher has widespread body and neck pain, chronic fatigue, sleep disturbance and altered mood after a whiplash neck injury from a motor vehicle crash two years ago. She has flashbacks and dreams of the crash, has lost her job and is involved in legal action for compensation. She lives in a daze – ‘I’m too sore to move, and too tired to think.’ Fibromyalgia is a clinical syndrome with a spectrum of symptoms including chronic widespread pain and fatigue, sleep disturbance, altered mood and cognition; and, also, neurological, immune, autonomic and endocrine dysfunction. Fibromyalgia syndrome (FMS) is described by patients as ‘feeling like a never-ending dose of the flu’. It is a chronic stressor-sickness response triggered

40 | MARCH 2020

Key messages

FMS is a chronic stress-orsickness response to allostatic load in a predisposed person Psycho-neuro-immune, cortical, endocrine dysfunction and in some cases widespread smallfibre polyneuropathy are involved.

by a variety of physiological or psychological stressors. FMS affects up to 8% of the population, most commonly women between 30 and 60, with a higher incidence in patients with a history of developmental duress (childhood and adolescence), localised chronic pain, joint hypermobility, rheumatological disease, bipolar, anxiety (PTSD), depression, or a family history.

FMS is a prime example of a complex biomedical, psychosocial and environmental illness associated with whole-person physiological and psycho-cognitive effects. Organisms including humans have evolved systems to deal with stressors threatening physiological homeostasis, tissue viability and survival. The cumulative effect of stress on an organism is known as allostatic load. Organisms generate defensive stress responses to allostatic load to protect their tissues from damage. The acute stress response (‘fight or flight’) is a rapid defence system protecting us from imminent threat. However, if exposed to prolonged or overwhelming stress, a person will trigger a chronic stress continued on Page 41

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New developments in treatment of migraine By Dr Tapuwa Musuka, Neurologist, Murdoch Developments in understanding migraine pathogenesis and, in particular, the role of the neuropeptide, calcitonin generelated peptide (CGRP), have led to breakthroughs which will revolutionise treatment, especially chronic migraine (defined conventionally as over 15 headache days a month). Migraine is a common (affecting 2% of the population), disabling condition resulting in many medical consultations. It is the second commonest cause of years lived with disability. Despite this, triptans have been the sole migrainespecific therapy developed so far. Some of the prescribed medications for acute therapy of episodic migraine such as opiates are non-specific and are associated with a doubling in conversion to chronic migraine. Previously, migraine prophylaxis pharmacotherapy has consisted of drugs handed down from other conditions that have demonstrated some effectiveness with migraine. These include anti-epileptics (e.g. valproate, topiramate), antidepressants (e.g. amitriptyline), antihypertensives (e.g. candesartan, calcium channel blockers), nutraceuticals (e.g. magnesium, feverfew, butterbur) and, more recently, neurotoxin (Botox). Their mechanisms in migraine prevention is unknown. Neurologists frequently have to explain to

Key messages

Chronic migraine is a prevalent, burdensome condition, which is currently poorly treated CGRP targeting drugs are well tolerated and quite effective New acute treatments should be licensed shortly. patients why they are prescribing anti-epileptics or antihypertensives to treat their migraines. Lack of a migraine-specific mechanism also explains why they often have intolerable side effects and adherence is low, at only 25% after six months of treatment. CGRP’s role in migraine was first suspected in the 1980s when it was shown that during migraine, levels in the cerebral circulation (and not the peripheral circulation) increased. Other trials showed that a migraine could be induced by endogenous administration of CGRP. Efforts to target this neuropeptide have led to the development of at least three monoclonal antibodies: erenumab, fremanezumab and galcanezumab. They are humanised monoclonal antibodies that prevent nociceptive signalling via direct antagonism of CGRP receptor binding sites, likely at the trigeminal ganglion level. These are the first migraine-specific, disease-mechanism targeted

preventive therapies for patients with high-frequency episodic and chronic migraine. The Therapeutic Goods Authority (TGA) has approved them for treatment and prevention of chronic migraine. Clinical trials have shown convincing benefits in treatments targeting CGRP including reduced number of headache days. Of the responders, 40% experienced a 75% reduction in headache days after 12 months of treatment, and 25% were free of headaches. Presumably because of their mechanism specificity, they have very little unwanted crossmechanism effects and have shown little in terms of short-term adverse effects. They were so well tolerated in the clinical trials, that there was only single digit percentage drop-off rates (versus 30% in the topiramate trials). For pharmacologic reasons, these drugs are administered subcutaneously (with an easy to use self-injection device) and are dosed monthly or quarterly (long half-lives) which positively effects compliance. Currently they are not PBS subsidised so cost will be the main limiting factor ($300 to $750 per month). This will obviously impact their positioning in the chronic migraine treatment hierarchy. On the back of these new drugs, there are also disease-specific acute migraine therapies on the horizon. We have entered a new era in migraine treatment. Author competing interest – nil

continued from Page 40

Fibromyalgia syndrome – “A chronic case of the flu” response, aka the sickness response (widespread body pain, fatigue, sleep disturbance, brain-fog, poor motivation, anorexia), which is exactly what we experience when we are laid-low by the flu! Neuroimmune dysfunction (e.g. serotonin, norepinephrine, dopamine, cytokines, glia) is a key factor in this response. With repeated stress exposures, humans accumulate an

‘allostatic debt’ because homeostasis never fully returns to pre-stress levels. Less stress is required to trigger a subsequent sickness response, and FMS develops. Management involves a multimodal bio-medical psychosocial approach. Pain education (identify stressors, rehabilitation and demedicalising) is key. Analgesics and neuromodulators (e.g. tricyclics SNRIs) have

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a role. Avoid typical opioids (tramadol and tapentadol are OK) benzodiazepines and cannabinoids. CBT and mindfulness together with antidepressants assist with stress management. Sleep hygiene is important, as is regular activity and energy management. Physiotherapy and occupational therapy has a role. Author competing interests – nil

MARCH 2020 | 41

CLINICAL UPDATE

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Early ID of Complex Regional Pain Syndrome By Dr Brian Lee, Pain management specialist, Perth Complex regional pain syndrome is a bit of a mythical creature; often talked about, but not clearly understood. So let’s demystify. A patient comes to see you who is in considerable distress with their persistent pain. Perhaps the pain started after an appropriately treated wrist or ankle injury. Some months later, the patient describes ongoing pain out of proportion to the objective suggestions of adequate healing. What do you do? Despite what the name suggests, not all ‘complex’ pain in a region of the body is a Complex Regional Pain Syndrome (CRPS). While its pathophysiology is not well understood, its old term ‘Reflex Sympathetic Dystrophy’ alludes to its common findings associated with cutaneous sympathetic dysregulation.

CRPS generally occurs in body extremities (most commonly upper limb, such as hand/wrist) and follows an injury. This can include verifiable neural injury (such as in CRPS 2/causalgia), but do not in the majority of cases. Pain is almost certainly out of proportion to the original injury, and persists well after normal healing has occurred. A good tool to aid practitioners is the Budapest diagnostic criteria for CRPS, which summarises the common complaints and presentation associated with this condition including the four categories of symptoms/signs: 1. Sensory abnormalities: allodynia and/or hyperalgesia. While not specified in the criteria, patients often describe other neuropathic characteristics such as electric shock, burning, paraesthesia and

Key messages

CPRS pain is typically in an extremity

The pain sounds neuropathic and impairs movement

Temperature skin and hair changes plus extreme tenderness may be present. hypoalgesia. These generally do not follow a discernable dermatome distribution. 2. Vasomotor abnormalities: presumed vascular dysregulation often results in a noticeable colour asymmetry, which can be red ‘hot’ or blue ‘cold’. This is associated with temperature asymmetry, which can be assessed accurately with an infrared thermometer.

Marker Clips - info for GPs Patients returning from BreastScreen WA’s Assessment Clinic may ask their GP about marker clips. A marker clip is a small metal clip (a few mm long) that may be inserted into the breast by a radiologist to mark the site of a biopsy when the imaging detected lesion has been substantially removed during the core biopsy process. Marker clips may be required when multiple lesions are present to differentiate between lesions. This allows the biopsy site to be located if surgery is required, at which time the marker clip is removed. All marker clips have a small metallic component which is visible on X-ray. If the area of breast tissue containing the marker clip does not need to be surgically removed, the marker clip will indicate on

future mammogram studies that the patient has had a biopsy. Are marker clips safe? • The marker clips used at BreastScreen WA clinics are not harmful to the body, and have been approved for use in Australia by the Therapeutic Goods Administration. • It is safe for a marker clip to stay in the body if it does not have to be removed. • The marker clips do not rust or corrode. Women will be able to have an MRI examination if required. The clip will not set off a security metal detector. • International medical studies have not shown an increased risk or any long term complications associated with having a marker left in the breast.

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

Mar ‘18

What if your patient has any questions? If your patient has any queries about marker clips, she can call 9323 6710 to speak to a breast assessment nurse.

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CLINICAL UPDATE

NeuroSpine Institute

Device prices falling neurospineinstitute.com.au

The Medical Technology Association of Australia released figures last month indicating the extent of the price cuts to medical devices We welcome Dr Yee Hein to thethe team. In addition to since 2017 agreement with the general physician services, Dr Hein provides perioperative Federal Government.

Now Offering: Specialised Physiotherapy Treatment

Service for patients in need of treatment for back and neck pain, rehabilitation or recovery following injury or spinal surgery.

support to complement our surgical services.

The difficult negotiations were brought on by a private health insurance sector that was in near revolt with not only the cost being charged by device companies, but also the discrepancy that was revealed between the price Dr Andrew Miles hospitals Dr Michael Kernand that government paid Neurosurgeon Neurosurgeon charged in the private health sector.

Dr Yee Hein

Consultant Physician

3. Sudomotor changes present one symptom in three of the four categories, and examination reveals as changes to sweating at least one sign in two categories, (hyperhidrosis and anhidrosis). Multi-disciplinary while having continuing pain Significant oedema and swelling specialist practice offering disproportionate to any inciting are also seen frequently. Dr Paul Taylor event. Spinal Surgeon 4. Motor changes of reduced range advice and treatment across of motion (associated with pain) Suspicion of CRPS is one of the the full range of spine and few indications The MTAA said that the current price in affected areas, weakness, for an Acute urgent pain Dedicated Disc Service of a pacemaker is $35,132, which was tremor, and/or dystonia. A specialist review. Patients will be brain conditions. $12,343 2017. prioritised and common description of such Wereceive prioritiseexpedited patients with newly referred armcheaper or leg painthan with in proven nerve compression on CT or MRI. appointments, in both private and is the ‘claw hand’ presentation An insulin pump is currently $8574, public sectors. If in doubt contact of hand/wrist CRPS. Trophic $451 cheaper than last year; a hip a pain specialist colleague for changes of increased/reduced joint is now $8351, $853 cheaper 3 CONVENIENT LOCATIONS advice. hair growth, skin appearance than 2017; airflow valve system is Also offering outlying clinics in Mandurah, Vasse, Albany and Geraldton. APPOINTMENTS (often thin and shiny), and nail $5686, $614 cheaper than 2017; Perth Murdoch Wembley P 1800 NEUROSPINE | F (08) 8200 appearance. artificial bone is6147 $7066, $428 – nil Suite 7, Level 4 Author competing Suite 77, Level 4 Suite 10, Firstinterests Floor (1800 638 767) cheaper than 2017; and an artificial 140 Mounts Bay Road Wexford Medical Centre 178 Cambridge Street E info@neurospineinstitute.com.au A clinical diagnosis of CRPS can eye is $1741, $189 cheaper than 2017. Perth WA 6000 3 Barry Marshall Parade Wembley WA 6014 be made if a patient Murdoch WA 6150has at least

We get spines working. Workspine is dedicated specialist team committed to occupational spine rehabilitation. This multi-disciplinary service includes neurosurgeons and spine surgeons, interventional pain specialists as well as psychologists and specialist exercise rehabilitation staff. The Workspine team has extensive understanding and expertise in the workers compensation system, has a transparent and proactive approach to occupational spinal injury management. Workspine has three convenient locations listed below. Contact us now and let your patients be managed by our expert team. Dr. Andrew Miles FRACS

Dr. Michael Kern FRACS

Dr. David Holthouse FRACS

Dr Paul Taylor FRACS

NEUROSURGEON

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Guardian EXERCISE REHABILITATION

EXERCISE REHABILITATION

MURDOCH Suite 77, Level 4 Wexford Medical Centre 3 Barry Marshall Parade Murdoch WA 6150

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1800 975 776

WEMBLEY Suite 10, First Floor 178 Cambridge Street Wembley WA 6104

workspine.com.au

MARCH 2020 | 43

An Approach to oral ulceration By Dr Amanda Phoon Nguyen, Oral Medicine Specialist, Perth Oral ulcers can be a conundrum with a long list of differential diagnoses. Considering aetiology assists in understanding them. An ulcer is defined as the loss of full thickness surface epithelium, as distinct from an area of erosion, where there is partial, but not full thickness loss of surface epithelium. Oral ulcers may form as a result of trauma including iatrogenic means such as chemotherapy and/ or radiotherapy, from rupture of vesicles or bullae and other host-related factors. A most useful approach is to determine if an ulcer is persistent. This is typically anything lasting over two weeks. The differential diagnoses for a persistent localised ulcer include a chronic traumatic ulcer and its variant TUGSE (traumatic ulcerative granuloma with stromal eosinophilia), a major apthous ulcer, apthous-like ulcers, infective ulcers (e.g. deep fungal mycoses, tuberculosis or syphilis), or a neoplastic process. Consider biopsy for all persistent, localised ulcers to exclude early squamous cell carcinoma. Differential diagnoses for generalised persistent oral ulceration

Key messages

Oral ulceration has multiple differential diagnoses Categorising the ulcers into acute or persistent forms can be helpful

Consider biopsy in all persistent, localised ulcers to exclude early squamous cell carcinoma.

include the above, vesiculobullous disorders, immune-mediated conditions (e.g. oral lichen planus), drug reactions, and rarer entities (e.g. Wegnerâ&#x20AC;&#x2122;s granulomatosis, necrotising sialometaplasia, periarteritis nodosa). Common medications which may cause oral ulcers as an adverse side effect include antihypertensives, antidiabetics, NSAIDS, methotrexate and allopurinol. The list of possible implicated drugs is extensive. Common oral ulcers that resolve within two weeks can result from acute trauma, and apthous ulcers. Other differentials include viral (e.g. herpes simplex and the Group A coxsackieviruses), erythema multiforme and plasma cell gingivostomatitis. Causes of a traumatic acute ulcer are numerous, including mechanical, thermal, chemical and even electrical. Apthous ulcers may result from recurrent apthous stomatitis (RAS), haematinic deficiencies, celiac disease and Behcetâ&#x20AC;&#x2122;s syndrome. They may also present in conjunction with other syndromes such as periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA). RAS apthae are recurrent, painful and typically start in childhood. They tend to improve with age, and can occur in the minor, major and herpetiform forms. This condition is common, occurring in 25-60% of the population. The cause is not known, but a genetic predisposition is suggested. They are typically multiple, ovoid or round, and covered by fibrin and surrounded by a pronounced red halo. The hard palate and gingiva are rarely affected. Minor apthae are small, between 2-4mm, last seven to 10 days, and heal with no major scarring. Major apthae are less common, have a crateriform appearance, can exceed one centimetre in diameter, take months to heal and may heal with scarring. For management of these ulcers, predisposing and confounding factors should be corrected. Good oral hygiene is important. Chlorhexidine mouthwashes, topical and systemic corticosteroids and other steroid sparing agents may be considered. Author competing interests â&#x20AC;&#x201C; nil

44 | MARCH 2020

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CLINICAL UPDATE

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CLINICAL UPDATE

Neuroablative treatment for chronic pain management By Dr David Holthouse, Pain Specialist, Claremont Neuroablative treatment for the management of chronic pain conditions may be defined as the use of techniques in order to damage or temporarily impair neurological structures in order to facilitate the improvement of pain. Neuroablation has been employed commonly in chronic pain for the denervation of joints, especially spinal facet joints and neuralgias (e.g., occipital suprascapular). Trigeminal radiofrequency gangliotomy can treat trigeminal neuralgia and larger joints can also be targets of radiofrequency (e.g. hips, shoulders). Radiofrequencies can be achieved via heat (radio waves to cause local tissue heating), cold (carbon dioxide or other gases to achieve a refrigeration effect) or techniques involving electrical pulses such as pulsed radiofrequency rhizotomy. Side effects include post-operative pain flare-up, neural damage and general complications of the procedure, such as, bleeding and infection. A radiofrequency is typically performed in facetal pain (facet arthropathy). Ideally the diagnosis should be established with prior steroid injections to see if the patient experiences a temporary recovery. Injections without steroids are possible but improvement is typically less and the effects more difficult to recognise. Once diagnosis is established and there is recurrence of pain after the initial injections, the patient can either have repeated injections of steroid into the facets (if a long response), or be a candidate for a facet rhizotomy. Lumbar facets are the most commonly performed. The aim of the facet rhizotomy is to denervate the facet. The patient can have the procedure performed under a local anaesthetic although I believe, for humane reasons; it is best performed with sedation. Facet rhizotomies typically have a 70-80% success rate in eliminating

Given, that pulsed radiofrequency rhizotomies involve a smaller lesion and that the chances of getting a response at six months was significantly less (around 3040%), my feeling is that pulsed radiofrequency rhizotomies should only be performed if there is a significant chance that patients will have a flare-up with a thermal one based on previous observed pain behaviours.

Key messages

Neuroablation can be valuable in managing degenerative joint pain

It must be considered in the

overall context of patient management Steroid blocks may be helpful in working up these patients. facet related pain if the diagnosis is correct. The target of the lesion is a medial branch. A needle was placed on this branch and an image intensifier (or CT) used to confirm the position. It is essential to perform a lateral radiograph to ensure the needle has not transgressed forward and is near the spinal nerve. Once the needle has been accurately placed, a lesion can be performed. Lumbar thermal rhizotomies associate with an 80% improvement with the majority of cases lasting at least six months and many lasting over a year. In one series the average duration of improvements following thermal rhizotomies, was around 18 months. Pulsed radiofrequency rhizotomies are also effective in the lumbar spine but, typically, have a much shorter duration of onset. They are associated with a significantly less incidence of post-operative flare-up. When comparing patients treated with thermal versus pulsed radiofrequency, I found that the incidence of significant flare-up, causing patient distress, was around 5-10% (thermal) and fewer than 5% (pulsed).

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Cervical cryo-rhizotomies can also be effective. They have a lesser incidence of flare-up than thermal rhizotomies but also tend to work for slightly less time although most work beyond six months. The cervical spine has the additional potential complications of the spinal cord and a higher potential risk of vascular injuries causing impairment to cord blood supply. I will often adopt a pulsed radiofrequency rhizotomy in the first instance in preference to thermal, as they are certainly safer. As lesions are potentially smaller in the cervical spine, I believe there is a higher success rate. The chances of getting an improvement at six months for a cervical rhizotomy are around 70% versus around 30% for a lumbar rhizotomy. Neuroablative procedures are a safe option for treatment of pain. Typically, facet joints have been the major targets treated but there are also now very effective techniques whereby rhizotomies can be performed on the knee the hip and shoulder joint. In addition to these, other joints may also be targeted and neuroablative procedures can be applied also to various peripheral neural structures, such as the occipital nerve and the suprascapular nerve. If considering whether or not neuroablative procedures are appropriate, consult with a pain specialist. Author competing interests â&#x20AC;&#x201C; nil relevant disclosures. Questions? Contact the author

MARCH 2020 | 45

Lima is a city of hustle, bustle and breathtaking history.

Jan Hallam reports As a young cadet on a morning newspaper in the 1970s, one of my daily duties was to sort out the international cable stories that had piled up for the foreign editor overnight. There was a pile for Asia (big), a pile for the US (bigger), a pile for the UK and Europe (bigger again) and a humungous pile for bus crashes in the Colombian capital, Bogota. Throw in regular political coups, violent drug lords and planes falling out of the sky (as well as the aforementioned buses that still find the poor, mountainous roads difficult to navigate), and South America fell off a young single woman’s travel radar. Much better to visit as a greying 60 something with a dodgy hip – the universal definition of an untouchable. With a fluent Spanish-speaking daughter living in Lima, there was really no debate where I would head on my maiden South American adventure – Vamos, Peru!

Cathedral Basilica of Lima

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TRAVEL

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TRAVEL So, with an arm full of vaccines, most essentially a Yellow Fever certificate, and a hip full of SynVisc, the first leg of the 31-hour odyssey began. For West Coasters, you have to get yourself to either Sydney or Melbourne and, as Lima is not on a direct flight path from any Australian port, all flights go through the Chilean capital of Santiago. After more than a day on the ‘road’, arriving in Lima is a wonderful thing to achieve but be prepared (and patient) for another 50-60 minutes while your driver valiantly negotiates the insane Lima traffic. This will be the case for most of your time in this bustling city of 10 million people – and its slightly fewer cars, buses and trucks. Peru is divided into three geographical regions that all contribute to the greater good and a GDP that pushes it into one of the healthier South American economic zones. Colloquially, they are ‘The Coast’, with Lima at its heart, ‘The Jungle’, with the Amazon Basin thumping out the beats, and ‘The Mountains’, where the air is thin and the history is thick. The first part of the five-week adventure takes place at The Coast, broadly, and Lima, specifically. There has been continual habitation of Lima for thousands of years, but that still doesn’t prepare you for a 1500-year-old pyramid to appear miraculously at the end of a suburban street in Miraflores. The Huaca Pucllana is a preIncan step pyramid originally built by the resident Lima culture between 200AD and 700AD. It is a spit from the Pacific Ocean and commands views over the city,

The Huaca Pucllana

hence its political significance. It is part of a chain of pyramids and archaeological sites around the city – just a 10-minute car ride and you’ll be at the feet of another pyramid, the Huaca Huallamarca, in the upmarket suburb of San Isidro. Lima is like many modern cities that must co-exist with their pre-history – sometimes its valued and revered, sometimes it’s a bit of a nuisance. Like Athens, there is history with every shovel load in Lima. The best place to see what the shovels unearth are the museums. The Larco Museum has great raps on Trip Advisor and, interestingly, it is a private museum, something we don’t experience all that much in Australia. It is located in the wonderfully named Pueblo Libre, or Free Town, district of the city in an 18th century vice-royal building. Inside is 5000 years of Peruvian pre-Columbian history as told by thousands of pieces of pottery, metalwork, textiles and murals. The collection got serious in 1925 when Rafael Larco Herrera acquired his archaeologist brother-in-law

Alfredo Hoyle’s 600 odd ceramic discoveries. The collection has some notoriety for its extensive erotic pottery collection, but it is far from the drawcard. The artefacts of daily and royal life from millennia past capture the imagination in far more powerful ways than rather obvious drinking cups. To cap off a wonderful visit, the gardens are a thing to behold. In a city that sees little rainfall, these verdant, blooming grounds are a balm from the dusty city streets. The restaurant is crackerjack as well. For the bohemian (in us all), the Barranco district is full of artists, writers (Mario Vargas Llosa for one), photographers (Mario Testino, another), musicians and actors. Its stop-and-gawk colourful architecture, its parks full of interesting artworks and even more interesting characters, its quaint bridges make it a place to return to again and again, for a great coffee, a stroll to the sea, a drink at the chic bars. It’s a lot of fun. It’s probably pertinent here to discuss the Australian government’s warning: “Exercise a high degree of caution in Peru overall due to the high risk of violent crime.” I was in a privileged position of having family who knew who’s who in the zoo and location of the no-fly zones. However, common sense is the best companion a traveller can wish for.

The sunset over the Pacific Ocean of Miraflores

Lima has inhabitants who struggle economically. With the Venezuelan diaspora, Peru has had nearly 1,000,000 people cross its border to find work that is already difficult to find. The capital has more than its fair share of desperate people, so, yes, caution is urged. The rules that continued on Page 48

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MARCH 2020 | 47

Hip, Hop, Peru continued from Page 47 were impressed upon me, if ever I found myself alone in unfamiliar territory, were: • Never hail a taxi from the street • Once in an authorised cab or uber, keep the window up and the door locked • Use the municipal police force (they are highly visible and each district has a number of personnel on the streets) for help and guidance • Keep your diamonds and designer bags at home • Don’t flash the cash I never once felt unsafe and relished the lunchtime swarm in the Government district, known colloquially as Downtown. Here, street food vendors do battle with trinket sellers, who do battle with city workers, who in turn do battle with their political masters, in a race for the best seat in the hundreds of cheap and cheerful restaurants in the CBD. Everyone is equal at lunchtime. Limans love their food and lunch is the biggest meal of the day. No one wants to waste a minute. The L’eau Vive (Living Water) or its Spanish moniker, Las Madrecitas de Agua Viva, is a magical restaurant run by Carmelite nuns inside their charter house. During the lunch and dinner hours, the doors open to anyone who can afford its 20 soles ($AU8) three-course meals. When the doors close, they reopen to feed those who can’t. The food was tasty and wholesome and the welcome even warmer.

The gardens in the Museo Larco

I’m not a shopper, however, that said, with time up your sleeve, you can discover why the city is home to some of the best gold workers, tailors and shoemakers in the region. Good quality fabric, cotton, in particular, and skilled tailors make a bespoke suit or shirt in just a few days. Rings can be fashioned in a matter of two to three days.

Entrance to the L'eau Vive

midnight. Turkey is the hero and is often taken to the local bakery to be roasted because Limans either don’t have ovens or rarely use them.

Did I mention the churches? Just as I am a sucker for museums, I do love a good church, as most selfrespecting agnostics do. There are plenty to choose from, particularly in Downtown. Lima at Christmastide is when they are at their most smiley.

In the evening, families of all ages and sizes troop to mass, which can be as short as 45 minutes or can stretch on for quite some considerable time. But a bit like a football match, people seem to come and go at will. We left after a polite 90 minutes, just in time to see a few Baby Jesus dolls being blessed by the priest in time to return to the home manger for the stroke of midnight.

Lovers of religious art may not find anything particularly sensational but I did rather enjoy the depiction of the Last Supper with a roasted guinea pig on the menu. That gem could be found in the dining hall in the monastery of the Church of San Francisco of Lima on a tour of the church’s catacombs. There were a scattering of skulls and hundreds of femurs with hip balls attached – many looked in better condition than mine.

That auspicious hour is marked by some of the best unofficial firework displays bursting out across the skyline. From balcony and apartment block vantage points, people run books on which district puts on the best display. After the last cracker fizzes into the night sky, the ambulance sirens start wailing. It was all very reminiscent of Guy Fawkes night decades ago…and why backyard bonfires were eventually banned.

A city of many millions of Catholics at Christmas time is ripe for fiesta. On Christmas Eve, non-retail businesses close about 2pm and families head home to prepare the meal that will be devoured at

And a final note is on health care.

The shops may look grungy and a little dodgy but the outcomes are wonderful and the prices compelling.

Household potable water is bought in bulk, and for tourists, it’s in bottles available from supermarkets and bodegas across the city. Tap water is not to be drunk without boiling. There are also plenty of opportunities for food spoiling in this humid city. With seafood being the number one delicacy, it is also the number one super highway to the toilet bowl. Let common sense be your guide when choosing venue and dishes, then sit back and enjoy. The cuisine of Lima is delicious! The public health system is mightily overworked, the private system expensive, and as a result, pharmaceuticals of many hues are readily available over the counter, usually from the stern-looking pharmacist in the local shopping centre. Smiling is not advised, but medical knowledge is a significant advantage. Vamos, Lima. I miss you.

48 | MARCH 2020

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TRAVEL

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WINE REVIEW

Review by Dr Louis Papaelias

At a Fraser Gallop Nigel Gallop purchased 67ha of Wilyabrup undulating farmland in 1998. The property is located in Metricup Road amongst established ‘royalty’ vineyards such as Moss Wood, Cullens, Woodlands and Pierro. He planted 7ha of Cabernet Sauvignon and 7ha of Chardonnay on an elevated, north-facing slope, which form the heart of the estate and are its raison d’etre. No expense seems to have been spared in the pursuit of quality in both viticultural practices and in the making of the wine. Clive Otto heads the winemaking team. He joined in 2006 after an illustrious career at nearby Vasse Felix. In 2009 the first Cabernet that he produced (2007 vintage) won the Decanter Magazine World Wine Awards trophy for the best Cabernet Sauvignon in the world. This is a true boutique operation with all wines being expertly grown and vinified on the estate.

NOTE” Be sure to drink the reds at 18-20C. This may entail a small period in the fridge. At higher room temperatures the delicacy of the wine can be overpowered by the alcohol giving the impression of a wine out of balance. Recommendation. Clearly the Parterre wines are finer than the estate wines but the latter show very well indeed and serve a different purpose. Forced to pick a favourite, for me the Parterre chardonnay gets the nod.

Fraser Gallop 2019 Estate Chardonnay (12.3% alcohol $26)

Fraser Gallop 2018 Estate Cabernet Merlot (14% alcohol, $26)

Fraser Gallop 2017 Parterre Cabernet Sauvignon (13.5% alcohol, $50)

This spent only four months in stainless steel and old oak barrels after a wild yeast ferment. Deliberately fruity and crisp with just a lick of oak in the background, it makes for attractive immediate consumption. Its lively acidity and generous flavour will allow it to age for a couple of years if so desired.

A great vintage for Margaret River. Here there’s 62% Cabernet Sauvignon, 27% Merlot with Cabernet Franc, Petit Verdot and Malbec making up the rest. With nine months maturation in old oak, it has very attractive rich aromas of berry with olive, tobacco and hints of dark chocolate. Supple and balanced with fine tannins and persistent finish. Drink now and for up to 10 years.

Made unashamedly in the traditional Bordeaux classic style. 86.2% Cabernet Sauvignon with Petit Verdot 4.9%, Merlot 4.8%, Cabernet Franc 2.4%, Malbec 1.6%. It spent 18 months maturation in new and old French oak casks. Deeply coloured. Berries and cedar with a hint of violets. Full mouth filling with multiple layers, cassis, cedar and a hint of violets. Satisfying depth. Fruit acidity and tannins in a fine balance. A classy wine.

'S EWER REVI

PICK

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Fraser Gallop 2018 Parterre Chardonnay (13.5% alcohol, $43) Hand-picked, low yielding Mendoza clone chardonnay. Whole bunch pressed and fermented in French oak barrels with naturally occurring wild yeasts, with 10 months in total. Lifted nose of restrained white peach with a fleeting but attractive whiff of struck match. Lively and complex with generosity of fruit yet delicacy of flavour. Lingers long on the palate. To quote the famous Jancis Robinson, who after tasting the Parterre Chardonnay, remarked that it is “worth comparing to a Burgundy Grand Cru”.

MARCH 2020 | 49

Voyage written in the stars Tim Finn’s first opera will make its world debut in Perth. Ara Jansen reports. Spending six months in a leaky boat and countless days in a cramped band van gave Tim Finn all the right feelings to write his first opera. That and a visit to the HMB Endeavour replica in Sydney, reminding him what life was like in such confined quarters for Captain James Cook and those aboard. “I couldn’t believe how small the spaces were,” says Finn. “Cook’s room was this space which just seemed so theatrically alive because of that.” A career musician, Finn is perhaps best known for his band Split Enz and performing with his brother, Neil, in Crowded House alongside a successful solo career. He never set out to write an opera but one conversation led to some research and then led to some writing. Six years later, the opera Star Navigator is about to have its world premiere, commissioned by the West Australian Opera, New Zealand Opera and Victorian Opera. The production – which Finn describes as a number opera in style – is the story of Tupaia, a Tahitian star navigator who sailed with James Cook on the Endeavour after the master mariners met in 1770. Coming from two different worlds and cultures, the work is a journey to understanding through their differences and a shared love of the sea. “Imagine these two, on one ship! They are both geniuses and find themselves in each other’s worlds and they’re exploring new worlds,” Finn says. 50 | MARCH 2020

When Star Navigator makes its world premiere in Perth this month, it will be presented as a staged concert with international soloists James Clayton and Ta’u Pupu’a alongside the WA Symphony Orchestra, WASO chorus, Finn on piano and Tahitian instruments. With a career that dates back to his adolescent years, the singer, songwriter and multiinstrumentalist has worked in a variety of genres and styles, from pop and rock through to musicals and vaudeville. An opera is something he never thought he would do but once the idea of Cook and Tupaia started to come together, Finn realised it was the ideal way to explore their relationship. “It’s not that big a leap for me putting myself into characters’ heads and writing for them. In songs like I See Red, I was always playing characters in the songs I wrote and sang.” Now 67, Finn says he could never have done this work at 30 or 40.

He says those big life questions of ‘where are you going’ and ‘how are you getting there’ turn into different questions when you are not so distressed by what the world thinks, which is freeing. The opera is sung both in English and Tahitian and Finn says he was humbled by the kindness and generosity of people who were willing to help him with the form and language of the work. “I’m an artist, not an anthropologist. I create with emotions and with my heart and when I started talking to people about this project, I think they helped because they really felt that. I hope the audience will be able to engage with their hearts too.”

Win... Star Navigator is at Perth Concert Hall on March 28. For your chance to win a double ticket, go to mforum.com.au and click on the ‘Competitions’ tab.

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ARTS & ENTERTAINMENT

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ARTS & ENTERTAINMENT

Out & about Each month Medical Forum review what's on in Perth. If you want to win tickets to our features, simply visit mforum.com.au and click the 'Competitions' tab. Heart of the park Drawing on his love for the natural world, public artist Jason Hirst’s latest work has been unveiled in Bennett Springs at Dazzle Park in the Iluma Private Estate. The piece not only creates an immediate talking point but is designed to be the heart of the park and a place for community to meet, play, relax and enjoy.

Movie: The Secret Garden

Movie: Mulan

Based on the much-loved Frances Hodgson Burnett novel, this fourth film iteration stars Colin Firth, Julie Walters and Dame Maggie Smith with some impressive special effects. It’s the story of a lonely girl who discovers a secret walled garden and in doing so brings a family back to life. In cinemas, April 16

The eldest daughter of an honoured Chinese warrior, Hua Mulan, is spirited, determined and quick on her feet. When the Emperor issues a decree that one man per family must serve in the Imperial Army, she takes her ailing father’s place to become one of China’s greatest warriors. Luna cinemas, from March 26

The 6m tall sculpture features three breezy circular canopies injecting red, orange and yellow splashes into the green of the landscaped park. The nest-like atmosphere experienced by pausing under the artwork will change depending on the time of day, as shadows are thrown and recede. “I love that this piece can do double duty because it provides shade during the day, and at night is programmed with an impressive lighting display,” says Hirst. His other works, alongside his collaborators at Little Rhino Designs, can be viewed in the foyer of the Woodside building, Perth Children’s Hospital, Karratha Civic Centre, Harrisdale Senior High School and Skye One Seven Apartments.

Movie: Fantastic Fungi A consciousness-shifting film that takes an immersive journey through time and scale into the magical earth beneath our feet – a underground network that can heal and save our planet. Through the eyes of renowned scientists and mycologists such as Paul Stamets, best-selling authors Michael Pollan, Eugenia Bone, Andrew Weil and others, we become aware of the beauty, intelligence and solutions the fungi kingdom can offer in response to some of our most pressing medical, therapeutic and environmental challenges. In cinemas, March 19

Movie: Downhill Barely escaping an avalanche during a ski vacation in the Alps, a seemingly picture-perfect family is thrown into disarray, forced to re-evaluate life and how they truly feel about each other. Julia Louis-Dreyfus and Will Ferrell star in this biting comedy. In cinemas, March 5

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December Winners Doctors Dozen: Rosabrook Estate Dr Wei Hao Lee Fringe: Casting Off Dr Richard John Fringe: The Choir of Man Dr Riva Curtis Movie: Portrait of a Lady on Fire Dr Albert Quo, Dr Linda Lim, Dr Melanie Chen Movie: Bombshell Dr Elizabeth Elms, Dr Susan Downes, Dr Lin Chan Movie: A Beautiful Day in the Neighbourhood Dr Paul Laidman, Dr David Wright, Dr Ian Everitt Movie: Little Women Dr Loryn Geyer, Dr Belinda Lowe, Dr Sarah Harris

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Mount Hospital Christmas There were 75 doctors at the Mount’s Christmas celebration at Steve’s in Nedlands. In a year of corporate turbulence for Healthscope, Interim General Manager, Juanita Ielasi, and Director of Medical Services, Dr Greg McGrath, both attributed the hard work and dedication of clinical staff and management for the delivery of quality healthcare. 1 Juanita Ielasi, Gemma McGrath, Benita Prichard, Dr Michael Prichard. 2 Dr David Borshoff, Dr Caroline Crabb and Dr Tim Cooper. 3 Gemma and Dr Greg McGrath. 4 Dr Robert Larbalestier and Dr Kristine Wardle.

5 Dr Peter Baird and Kim Baird. 6 Dr Li On Lam, Flora Lam, Jaci Panicker, Dr Vijay Panicker. 7 Mel Rowe and Dr Ian Timms. 8 Dr Raj Kanna, Uma Kanna. 9 Priscilla McLellan and Dr Duncan McLellan. Pictures: Josh Wells Photography

52 | MARCH 2020

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SOCIAL PULSE

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SOCIAL PULSE Next Practice Open Day About 150 people, including Health Minister Roger Cook, came to the Next Practice open day in Victoria Park to see how the contemporary interior architecture and technology contributed to the patient experience. The waiting room has lounge furniture, herbal tea and relaxing music with iPads for juniors and a VR headset to reduce the trauma of immunisations and phlebotomy. The surgery also subscribes to the care4care program where every private consultation funds a health intervention in a developing country. 1 Retired GP Dr Colin Stevens handed over his longtime patient Valma Hicks when he retired to his son, Dr Sean Stevens, who is apart from chair of the RACGP also co-practice owner of Next Practice. Valma has been looked after by Stevens GPs for 23 years.

2 Bouncing Docs: Practice co-owners Sean Stevens and Mary Wyatt give the castle a workout. Sydneybased Dr Sam Prince is the third owner of the practice. 3 Mary and Sean with Health Minister Roger Cook. 4 Our patient living room, with touch screen, iPads for the kids, vaporiser with subtle essential oils, herbal tea, fresh fruit, relaxing music at 60 beats per minute (resting heart rate), green wall, patient advocate desk out into the living room and without harsh corners.

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MARCH 2020 | 53

Aged Care in 2020 Aged care will continue to be in the news as the sector absorbs the recommendations from the Royal Commission, writes Special Counsel David McMullen. The Byers Centre for Biodesign at Stanford University developed the Biodesign method, a prescriptive framework designed to ensure that innovators focus on real, unmet clinical needs. Aged care is a hot topic in Australia, fuelled by an ageing population and a climate of heightened media and public awareness about the sector. Here are some of the evolving issues to watch in 2020.

Royal Commission into Aged Care Quality and Safety Since October 2018, the Royal Commission has rarely left the minds of most aged care providers. Its interim report – ominously titled Neglect – foreshadows a fundamental overhaul of the design, objectives, regulation and funding of aged care in Australia. A final report is due by 12 November 2020.

2020 Aged Care Approvals Round (ACAR) The 2020 ACAR is open from March until May, allocating 10,000 residential aged care places; 750 short-term restorative care places; and up to $60 million in capital grants to successful approved providers, having regard to areas of unmet need, identified though Government consultation, Meanwhile, a Government-led impact analysis is currently underway to assess alternative arrangements to this current allocation model.

Quality and Safety The Aged Care Quality and Safety Commission began operations at the start of 2019, assuming the functions of the former Quality Agency and Complaints Commissioner. On 1 January 2020 it also took on the former regulatory functions of the Department of Health. The commission now has the full suite of regulatory functions in aged care. Amongst other things, it will continue to assess and monitor the eight (still relatively new) Aged Care Quality Standards 54 | MARCH 2020

which commenced 1 July 2019, with consumer dignity and choice as a central theme.

though realistically for many, widespread adoption could be some way off.

Use of restraints

In the shorter term though, real world impacts are already being felt where technology is used to increase care recipients’ connectedness. Already on the local market, for example, are systems designed to support older peoples’ independence by delivering a real-time view of their well-being (derived from smart sensors around the home) to other users (perhaps carers, friends and/or family) via a mobile app.

In response to a significant overreliance on chemical restraint in aged care, legislative controls were introduced in late 2019 making it clear that restraints must be used as a last resort only. A 12-month review of the regulation must be completed by 31 December 2020. The Pharmaceutical Benefits Scheme (PBS) listing for the drug risperidone has also been updated from 1 January 2020, such that prescribers now require additional approval if the medication is to be taken for longer than 12 weeks.

User pays? Aged care has a funding problem. The sector’s peak bodies describe an unsustainable situation, in ongoing decline. The Government responded to the Royal Commission’s interim report by announcing a $537 million funding injection. But general consensus is that this was not enough to fix even the discrete areas identified in the report as warranting immediate attention. It seems inevitable that whatever the Royal Commission’s final recommendations, government funding will be only a partial answer. Whilst at the lower end of the market, funds may be needed just to keep providers afloat, at the higher end, increased user contributions can mean more funds for the delivery of high-grade amenity. Maximum accommodation deposits paid at top residential facilities already frequently reach the mid-to-high $1 million, and generally correlate with facilities that have shifted away from hospital- or ward-style development towards modern design with better focus on resident privacy, comfort, and lifestyle.

Other existing technological aids to connectivity include the likes of a virtual ‘hub’ (which at least one prominent aged care provider offers) via use of a tablet device, to deliver entertainment, concierge services, social connection, monitoring and emergency assistance.

Consolidation of the market? This is difficult to predict with accuracy. Nevertheless, it may be that merger, divestment and acquisition opportunities will come about as smaller or struggling organisations find themselves overwhelmed by the Royal Commission’s final report, unable to properly respond to the inevitable regulatory changes, or perhaps unviable in what is a difficult financial environment. In other cases, organisations looking to the future may simply resolve that it is time to hand over their operations to another (possibly bigger or more sophisticated) organisation, to carry their legacy forward. Past events tend to suggest, however, that conditions on the ground can take time to translate to M&A activity. ED: David McMullen is Special Counsel at Panetta McGrath Lawyers.

Technology There are many exciting new technological advances on offer;

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Medical Forum March 2020 - Public Edition

Articles inside

Social Pulse Christmas: SGJ Midland Hospital, SJG Murdoch, SJG Subiaco, Ramsay, Bethesda Health Care; SJG Mt Lawley

Wine Review: Sittella Dr Martin Buck

Knee AO

US Prostate Testing

Breast Implant Update

Diabetes Testing

AI in Medicine

Women’s Care

Research Support

AI in Radiology

Stereotactic Body Radiotherapy

Real World Research

Clinician-led technology

Vaping

Superannuation – Rob Pyne

Australian National Phenome Centre

Silicosis

WA Digital Health Strategy

Genetic Testing in Cancer

WA News

Research Briefs

Global News

Opinion: Overdiagnosis – Dr Joe Kosterich

Local Brief

Q&A: Dr Andrew Miller