Power reset RECLAIMING LOST TIME
Musculoskeletal issue | COVID hangovers, sacroiliac & neuropathic pain, rehab & surgery
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October 2020 www.mforum.com.au
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Jan Hallam | Managing Editor
Them bones In essence, the cracks that were already there have widened and it will need more than bone cement to spackle them over.
It seems one of those wicked ironies that we’re signing off on the musculoskeletal edition on the eve of your correspondent heading into surgery for a hip arthroplasty. It is both confidence building to understand the depth of skill and learning of all of you who take part in this alchemy – taking a hip that is cactus and replacing it with a synthesis of earth, fire and water – and also terrifying to begin the journey as a bionic woman. It also gives cause for reflection. Had it not been for warm curdled school milk causing a lifelong aversion to full-cream dairy and appalling ball skills in the cruel world of a hockey field, I may not have found myself in this predicament – well at least not for another 10 years. It’s at this point in an opinion piece, a personal reflection should segue to a philosophical, political thesis using good healthy bones as a metaphor for the health system as a whole but that is too obvious. Instead, I commend to you an insightful Q&A with the new national president of the AMA, Perth orthopaedic surgeon (another serendipity) Dr Omar Khorshid. He lays out plainly the challenges and the necessity of getting the next few years right as the national and state health systems start evaluating how pandemics and health crises play out, and will continue to play out, in our technological world. This current health crisis has certainly laid bare for all to see, and not just those working in these systems, where its strengths and weaknesses lie. In essence, the cracks that were already there have widened and it will need more than bone cement to spackle them over. This newfound collective awareness is essential to develop an agile and future-fit health system, designed by and for those who work and use it. It needs sound minds and steady hands.
SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.
MEDICAL FORUM | MUSCULOSKELETAL ISSUE
OCTOBER 2020 | 1
CONTENTS | OCTOBER 2020 – MUSCULOSKELETAL ISSUE
Inside this issue 10 14 18 22 FEATURES
NEWS & VIEWS
LIFESTYLE
10 Close-Up: Professor Jon
1
Editorial: Them bones – Jan Hallam
46 Book: Small Steps –
Telestroke 24/7
47 Wine review: Calneggia
Watson, Executive Dean of the Faculty of Health and Medical Sciences, UWA
14 Q&A: Dr Omar Khorshid 18 Long-term effects of COVID-19
22 A return to sports, of sorts
6 8 26 31
a physio in Ethiopia and Rosabrook – Dr Louis Papaelias
In the news Survey of lockdown effects Perth syphilis outbreak – Dr Donna Mak
48 WA Opera returns
33 Muscles and movement – Dr Joe Kosterich
Doctors Dozen... Dr Edward Heydon has won the August selection of Sandalford wines in the Doctors Dozen draw. For your chance to win a dozen wines from the Calneggia gamily group of wines, including Rosabrook, see the review on Page 47 and go to the website to enter. www.mforum.com.au (click on the competitions tab)
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CONTENTS
PUBLISHERS Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au
Clinicals
ADVERTISING Advertising Manager Andrew Bowyer (0403 282 510) mm@mforum.com.au
5
Diagnostic pathways of MSK disorders A/Prof Louise Smyth
7
Advanced pain management Dr Ashish Chawla
34
Medicinal cannabis in managing MSK pain C/Prof Alistair Vickery
35
Sacroiliac pain, the great masquerade Dr Brian Lee
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Multidisciplinary approach for spines Dr Greg Cunningham
39
Rectal cancer: Optimising decision making Dr Nigel Barwood
40
Systemic sclerosis – a team approach Dr Janet Roddy
42
Hip & knee osteoarthritis Dr Brett Bairstow
44
Nipple Discharge Dr Jose Cid Fernandez
29
Picky eaters in young adulthood Ms Catherine Panossian
EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Journalist James Knox (08 9203 5222) james@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au GRAPHIC DESIGN Thinking Hats studio@thinkinghats.net.au INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Mark Hands (Cardiologist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon)
Guest Columns
CONTACT MEDICAL FORUM Suite 3/8 Howlett Street, North Perth WA 6006 Phone: 08 9203 5222 Fax: 08 6154 6488 Email: info@mforum.com.au www.mforum.com.au
4
Collaboration for impact Prof David Gilchrist
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Exercise & diet for arthritis – why bother? Dr Daniel Meyerkort
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OCTOBER 2020 | 3
Collaboration for impact UWA’s Professor David Gilchrist explores what true collaboration is and why we so desperately need it now.
Talking about collaboration is easy but practice is hard. This is especially the case in the context of public policy in a federation like Australia where a multiplicity of governments and policy makers seek to deliver on promises in areas such as health which are extremely complex to start with. However, barriers to real collaboration are hardwired into public sector modes of operation prioritising silos and making effective collaboration difficult in the extreme. My colleague Dr John Butler and I examined collaborations in the field in our new book, Collaboration for Impact – those that are working and those that are not – to distil the tenets of working collaborative practice. However, we first had to identify true collaborations and separate them from joint ventures and other structures employing multiple organisational inputs in the guise of collaboration. That collaboration is important, laudable and desirable is supported readily. Indeed, it is almost universally praised as both worthy of public policy objectives and of the greater democratic context in which universal health care is delivered. What we have identified is that true collaboration is counter-cultural rather than counter-intuitive so that finding examples of effective true collaboration is more difficult. The purpose of our book is to do two things: • to describe how properly conceived and executed collaboration can breakdown the interminable silos experienced in 4 | OCTOBER 2020
the public policy world; • and to describe what the components of a properly conceived and executed collaboration looks like.
collaboration also needs to have an authorising environment that is sponsored by a senior manager who champions the collaboration within the ‘home organisation’.
Fundamentally, though, true collaboration challenges the traditional working model of public sector and private not-for-profit and for-profit organisations.
The champion within the traditional structure must trust the leader of the collaboration notwithstanding that the normal reporting and governance processes might not apply in that environment. However, those leaders with a high CQ and leading collaborations, will always support the champion by reducing their sense of risk through timely reporting.
True collaboration is transgressive, it usually involves the violation of accepted conventions, rules, norms and boundaries. This is a reason why instances of true collaboration are hard to find and why it presents a challenge to managers in hierarchical organisational structures—true collaboration requires trust, flexibility and work environments that are separated from the traditional corporatised structure. To collaborate successfully, leaders need to have a special set of skills and the capacity to set aside their ego in return for truly inclusive decision making. Indeed, we have termed this leadership mindset required in order to achieve effective collaboration “Collaborative Intelligence” or “CQ”. A leader demonstrating CQ will accept relationships between personnel as central to collaboration—they will understand the people collaborate not the organisations. As such, interpersonal relationships are the building blocks of collaboration and so a person with high CQ will be generous in constructing and maintaining personal ties with, and between, collaboration personnel. Unfortunately, it is not solely up to those with high CQs and who are generous leaders. Any successful
Assurance to stakeholders within the ‘home organisation’ is a critical component in gaining and retaining trust. Of course, having a high CQ would include a strong capacity for communications, the ability to act with authenticity and to maintain support within the collaborative environment and within the partner organisations. These attributes engender trust and create legitimacy for collaborative leaders. The complexities of health in Australia and the programmatic nature of traditional responses, most recently emphasised as a result of the COVID-19 pandemic, suggest strongly that it is time to revisit the opportunity inherent in true collaboration, where experimentation and innovation can combine with the experience of public policy makers and practitioners to explore and report on new ways to respond effectively to the wicked problems we face. ED: Professor Gilchrist holds a chair at the UWA Business School and is Convenor of Not-for-profits UWA
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Diagnostic Pathways of Musculoskeletal Disorders Rheumatic symptoms may occur in a variety of autoimmune diseases as well as degenerative, infectious and metabolic disorders, and some have a heritable component. Clinical assessment should differentiate between arthritis and arthralgia. Joints, tendons, muscles and bursae may be involved in musculoskeletal disorders. Musculoskeletal symptoms may also be present in disorders involving other organs or systems such as thyroid or liver autoimmune disease. Pathology provides crucial diagnostic, prognostic and disease monitoring information. Diagnostic assessment includes screening tests as well as disease specific markers and inflammatory biomarkers that contribute both prognostic and disease monitoring information. Useful laboratory tests include those for ankylosing spondylitis, gout, rheumatoid arthritis and systemic ANA-associated rheumatic disorders (SAARDS). Ankylosing spondylitis (AS) is strongly associated with certain sub-specificities of HLA B27. Although disease penetration is low, this association is so strong that the lack of this marker virtually excludes the disease in Caucasians. Rheumatoid Factor (RF) and ANA are negative in AS, and ESR and CRP may be quiescent. Diagnostic guidelines mandate radiological follow-up. Spondyloarthritis may occur in other disorders. HLA B27 is less strongly associated with most of these but is nevertheless significant. Gout is due to the presence of uric acid crystals in synovial joints, usually reflected in hyperuricaemia, but it should be remembered that hyperuricaemia may occur without clinical gout.
By Associate Professor Louise Smyth MBBS GCUT FRCPA
About the Author: Speciality: Immunopathology Phone: 1300 367 674 Email: louise.smyth@clinicallabs.com.au Louise designed and implemented the Pathology program for the School of Medicine at the University of Notre Dame in Fremantle. She has a Graduate Certificate in University Teaching, qualifying her to supervise candidates for higher degrees as well as teaching undergraduate students. Louise is most interested in autoimmunity but has extensive experience including transplantation, immune deficiency and allergy.
Key messages
Pathology provides crucial diagnostic, prognostic and disease monitoring information Diagnostic assessment includes screening tests as well as disease specific markers and inflammatory biomarkers Useful laboratory tests include those for ankylosing spondylitis, gout, rheumatoid arthritis and systemic ANA-associated rheumatic disorders (SAARDS).
Testing pathways for rheumatoid arthritis are perhaps controversial. In recent decades, the importance of antibodies to citrullinated peptides (usually anti-CCP) has become clear. William Robinson (San Francisco, USA) has shown that these antibodies may be present in lower concentration, up to 10 years before the emergence of clinical disease.
between patients, according to antibody profile. CRP and neutrophil count are important biomarkers. SAARDS include lupus, scleroderma group of disorders, Sjogren syndrome and myositis/ dermatomyositis. Specific disease associated antigens are found in each of these disorders. A positive ANA is therefore followed by reflex testing. Investigation of lupus should include assessment of renal function (including microurine), FBP/ESR and screening for antiphospholipid antibodies. Serum complement is consumed in immune complexes that are associated with disease flares. Other autoimmune disorders, including Juvenile Idiopathic Arthritis, GI and thyroid disorders and vasculitis are outside the scope of this article.
While specificity is high, sensitivity is lower and similar to RF. Together sensitivity is >90%. Furthermore, it has been shown that there is a significant difference in outcomes
Building Better Partnerships
1300 367 674 | clinicallabs.com.au MEDICAL FORUM | MUSCULOSKELETAL ISSUE
OCTOBER 2020 | 5
24/7 telestroke … on its way The WA government has committed $9.7 million as part of the WA Recovery Plan to deliver a 24/7 statewide telestroke service. The extended service will see consultant stroke physicians available around the clock to enable clinicians in rural and outer metropolitan areas to seek expert assistance on quick diagnosis and appropriate treatment for their patients. An integrated communication and image viewing platform for acute stroke patient diagnosis and treatment will enable physicians to remotely transfer CT images, data, documentation and visual diagnosis of the patient. WA State Stroke Director Dr Andrew Wesseldine will oversee the project. He told Medical Forum that over the next few months, work will concentrate on designing and building the necessary ICT platform and planning the clinical workforce needs. “We're working toward a service so that a metro stroke clinician can virtually see a patient in a regional hospital and view CAT scans at the same time as potentially treating them. It will be a quite a challenge to build that system for 24/7 service but the driving force is the patient and what is best for them,” he said. In 2017, we spoke to Andrew about the existing telestroke service. He said then that the stroke field had seen extraordinary developments in acute treatment over the past decade, which made it challenging for people who were not experts to manage these situations. “Stroke is still an uncommon condition presenting to rural Eds,” he said then. “It’s not possible to have a SCGH or a FSH stroke unit in Geraldton or Albany, but we can bring the stroke doctor to the patient. The key has been communication that is contemporaneous, accurate, useful and delivered as often as possible by a stroke clinician to help the rural doctor or nurse with the care, decision-making and treatment strategies of their stroke patient. 6 | OCTOBER 2020
diagnosis, treatment and care in recent decades. “Australia has led the way in some of the most recent advancements, particularly improvements to emergency stroke treatments,’’ Prof Campbell said. Dr Andrew Wesseldine
That’s at the heart of the telestroke concept.” In July the, latest Australian Institute of Health and Welfare (AIHW) figures showed more Australians were now surviving stroke. There has been 30% fewer people dying of stroke since 1981 (from around 12,000 to 8,400 annually) despite the fact that the population has almost doubled in that time. Stroke Foundation Clinical Council Chair Professor Bruce Campbell said the new data was encouraging and reflected advances in stroke
“The introduction of dedicated stroke units, increased availability of clot dissolving drugs and implementation of endovascular thrombectomy, where a clot is removed from the brain all reduce disability after stroke. With the advent of telemedicine for stroke, more Australians, including those in regional and rural areas, are accessing stroke treatment quickly leading to improved outcomes.” Further to the decline in the death rate, the AIHW report revealed the rate of stroke events fell by 24% between 2001 and 2017, from 169 to 129 events per 100,000.
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IN THE NEWS
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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
(08) 9200 2777
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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
(08) 9200 2778
reception@wradi.com.au
www.wradi.com.au
OCTOBER 2020 | 7
IN THE NEWS
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Cancer care grows GenesisCare is at the centre two major private cancer centre developments – one south of the river, the second north. Last month the sod was turned on the building of a $17 million facility at St John of God Murdoch Hospital. The new facility is the result of a partnership between Centuria Healthcare, SJG Murdoch and GenesisCare. The building will be developed and owned by the Australasian real estate funds manager, Centuria Healthcare, expanding its existing healthcare presence in Western Australia. It is thought the facility will have capacity to treat up to 1,000 cancer patients a year and it will be fully integrated into the Murdoch hospital. The facility will also offer theranostics and nuclear medicine services molecular imaging equipment such as PET-CT and SPECT-CT. Over the Narrows Bridge at Hollywood Private Hospital, a partnership between Ramsay Health Care and GenesisCare will see, for the first time, patients at Hollywood having access to onsite radiation therapy with medical and radiation oncologists, haematologists, surgeons, radiologists, nurse specialists, clinical trial researchers, allied health and mental health professionals all on the one campus. The Hollywood centre will have a state-of-the-art linear accelerator, the Elekta Versa HD with the Brainlab ExacTrac Xray System, capable of delivering advanced stereotactic radiotherapy (SRT) and stereotactic radiosurgery (SRS). The centre will have a strong focus on prostate and breast cancer, aligned with
Short-stay or managed? Short-stay models of care for major orthopaedic surgery was canvased during a webinar and panel discussion organised by Australian Orthopaedic Association (AOA) and the Australian Ethical Health Alliance (AEHA). Participating in the discussion were private health insurers Medibank Private and Bupa. Possible business models and funding pathways were discussed. The webinar comes after it was announced that Medibank Private has acquired a 49% stake in the East Sydney Private Hospital. Reports indicate the insurer will initially invest $8.8 million to fund capital investment and operational costs required for the hospital to scale its short-stay model of care. AOA President Dr Andrew Ellis said his organisation remained “deeply suspicious of for-profit private health insurers who wish to enter the ownership of private surgical facilities or hospitals. They do this for business development reasons but under the guise of enhancing care in ‘doctor-led’ models. Out-of-pocket expenses are the smallest element in this move, as the majority of fees are
8 | OCTOBER 2020
Michael Salter (St John of God Murdoch), Cr Nicole Robins and Melville Mayor George Gear, Dr Shane Kelly (CEO, St John of God Health Care), Ms Eva Skira (Chair of Trustees SJGHC), Ben Edwards, CEO, SJG Murdoch), Dr Tee Lim (radiation oncologist and future head of Murdoch facility) and Louise Coffey (Acting GM GenesisCare). Top: The Hollywood centre
Ramsay’s nurse care coordinators and specialist breast nursing service, including partnering with the Breast Cancer Research Centre WA for additional dedicated breast care nursing support.
paid by the commonwealth through the MBS. The real reason is to disrupt established hospital groups, and encourage alternative methods of care by offering fee incentives to surgeons to participate in managed care in health insurer-owned vertical business structures. To gain surgeons’ and patients’ trust, the health funds must act in transparent ways in developing business models such as these and declare incentives they offer participating doctors and hospitals. They seem to genuinely wish to contribute to health reform, and in this setting, we welcome collaborative discussion and action."
Problem with iron A global study led by researchers at UWA has addressed the rising use of intravenous iron therapy in anaemic patients during major surgery and found there is little benefit. The RCT is the first to rigorously test a procedure, which has become routine practice. Up to half of patients undergoing major surgery have anaemia and over the past decade, hospitals around the world have given intravenous iron
to these patients in advance of their operation. Professor Toby Richards said results of the PREVENTT trial showed that although iron therapy did produce a response there was no benefit in the patient’s outcomes of blood transfusion, major complications or length of stay in hospital. However, one significant finding was that giving iron after surgery did improve anaemic patients’ recovery. Yet another UWA study with researchers and clinicians from Fiona Stanley Hospital have found that pre-screening patients before surgery to determine those with anaemia or low iron was vital in reducing surgery costs and improving patient outcomes. The research has been published in Anaesthesia. Adjunct Research Fellow Kevin Trentino said industry had been hesitant to use preclinics before surgery to identify low blood counts, because of a perception they were costly and required significant resources. “In this study we analysed the results of an anaemia screening clinic set up at Fiona Stanley Hospital in 2016 in which 441 patients having bowel cancer surgery received
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IN BRIEF blood screening before surgery,” he said. “We found, contrary to common belief, the benefits of pre-screening far outweighed the costs.” Fiona Stanley Hospital Consultant Anaesthetist Dr Hamish Mace said while some blood loss in surgery was inevitable, minimising the resultant transfusion and the associated risks were important for clinicians. “By increasing the patient’s haemoglobin before the operation, our patients were given a major boost going into surgery,” Dr Mace said. “Pre-operative treatment with iron also led to an increase in patients’ red cells after the operation, giving them a buffer to avoid transfusion."
DREAM comes true UWA’s DREAM trial, under the watchful eyes of Professor Anna Nowak, has published results that show a combination of chemotherapy and immunotherapy treatments can yield positive results for patients with advanced mesothelioma. They reported in The Lancet Oncology that the study was the first reported trial to test the combination of an immune checkpoint inhibitor with chemotherapy drugs. Trials were conducted in nine hospitals around Australia involving 54 patients who were considered unsuitable
for cancer surgery. Almost half the patients had a substantial shrinkage in their tumour, and patients lived longer than would be expected for chemotherapy alone. The antibody treatment continued for up to 12 months. However, once the antibody was stopped the majority of patients then had disease progression. Professor Anna Nowak said there was a strong unmet need to improve available therapies in mesothelioma and the results of this trial suggested chemoimmunotherapy could become a valuable treatment in this disease.
WA and opioid deaths The new edition of Penington Institute’s Australia’s Annual Overdose Report is sobering reading for WA with 227 West Australians dying of unintentional overdoses in 2018 – an all-time high for the state. The rate of unintentional overdose deaths in WA increased from 6.4 per 100,000 people in 2012 to 8.8 per 100,000 in 2018 – close to double the mortality rate for melanoma across all of Australia in the same year. WA also had more overdose deaths from different types of drugs including stimulants, prescription opioids, heroin, benzodiazepines, and anti-depressants. The report also reveals that, for the first time, WA had the highest rate of heroininduced overdose deaths per capita, overtaking Victoria. WA also saw the biggest increase in unintentional deaths involving benzodiazepines.
VR for spinal rehab Virtual reality (VR) is being put to the rehab test by people with spinal cord injuries as part of a project by researchers at Curtin University’s School of Occupational Therapy, Social Work, and Speech Pathology. Interactive, home-based VR simulation or ‘serious game’ is being used to improve upper limb function. The VR program uses cooking a virtual steak as a functional rehabilitation activity for people with cervical spinal cord injuries. Lead researcher A/ Professor Marina Ciccarelli said virtual tasks included seasoning, frying, flipping and transferring a steak from pan to plate, which when done repetitively over time helped improve the participant’s control and range of upper limb movements. Daily progress in the VR game could be remotely measured and reviewed by their therapist, and the level of challenge adjusted as needed. SpinalCure Australia, the Minderoo Foundation and Applecross Rotary supported the project by helping fund the purchase of the VR headsets.
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Armadale GP Dr Ramya Raman has been awarded the Business Events Perth / City of Fremantle Aspire Award to present her work on postnatal recovery at the World Organisation of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) Asia Pacific Region Conference. Autism researcher Dr Gail Alvares and digital health professional Ms Bec Nguyen are the recipients of the Telethon Kids Institute Aspire Award, which is coordinated by Business Events Perth. Speech pathologist and Curtin University researcher Dr Sharon Smart has won an Aspire Award. Sharon is one of the only speech pathologists in Australia actively researching tongue tie and the impact it has on feeding skills and speech production in infants and children. Business Events Perth / Perron Institute Aspire Award has been presented to Dr Alex Tang who is researching brain stimulation and imaging. Bioinformatics researcher Dr Saskia Freytag and diabetes researcher Dr Elizabeth Johnstone are joint winners of the Business Events Perth / Perkins Institute Aspire Award. Dr Freytag leads a research program on causes of severe epilepsy. Dr Johnstone was recognised for her work on the pre-clinical profiling of a potential kidney disease drug called DMX-200. Victorian GP Dr Karen Price has been elected President of the Royal Australian College of General Practitioners (RACGP), with her term set to take effect from the close of the RACGP’s Annual General Meeting on 30 November 2020.
OCTOBER 2020 | 9
CLOSE-UP
It’s always a gut feeling A passion for people, a thirst for knowledge and a love for music have been some of the drivers for UWA’s executive dean Professor Jon Watson’s career.
For Professor Jon Watson, faith can be found in the quiet contemplative pews of an Anglican church listening to a choir. Faith can also be found when the amps are turned up to 10 in the cover band he founded, Jonny and the Optics. A lover of modern and classic music, Jon reckons Bob Dylan’s recent Rough and Rowdy Ways album is his best since the 80s. Equally, faith can also be found in medicine. The recently arrived Executive Dean of the Faculty of Health and Medical Sciences at the University of Western Australia has faith in many things related to his profession, including a great belief in the power of people, their work and their stories. Born and raised in the UK, Jon gained his Master of Arts at Cambridge and then went to Oxford to study medicine. During those six years he met some of the “finest minds of my life” as five Nobel winners worked along one corridor. The collegiate system was also strong and exposed him to new friends, colleagues and contacts from all over the world and who have ended up working across the globe. He worked in Britain’s National Health System (NHS), including Queen’s Square and Hammersmith Hospital and his mission was to be a clinical academic. Early on, his interests included the study of hepatitis C, for which he gained his PhD. He also decided that gastroenterology was where his greatest interest lay. By the mid-1990s Jon – and many of his colleagues – had become disillusioned with the NHS and decided it was time to get out. He’d finished his registrar training and was working in a liver transplant unit. People told him he was mad when he agreed to take a job in Ballarat, Victoria, and move his family of three small children across the world. Call it a gut feeling, he signed on for two years and they stayed for seven. Culture shock was absent because everyone was so welcoming. Jon pursued his work as a gastroenterology specialist and says it was wonderful opportunity because he learnt so much but also had the opportunity to do some teaching. He then spent two years at John Hunter Hospital in Newcastle and then at 10 | OCTOBER 2020
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By Ara Jansen
CLOSE-UP came along. I kept up my clinical practice until arriving here. It has been a great privilege seeing patients. But I also don’t want to be the bloke in the office no one ever sees. I don’t want to be asking my colleagues to do things I wouldn’t do myself.” While administration and leadership are a critical part of his new role, he will also remain active in research thanks to several grants the university has received. “I’ve already learnt so much because everyday someone comes into my office and tells me what they are working on. I’m always interested and fascinated. I do one clinical day a month because I don’t feel like I am ready to give that away.
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“It’s a privilege to see patients and some of them I have been seeing for 25 years. I think I have seen something like 11,000 patients over 20 years.”
University Hospital Geelong before being appointed as Clinical School Director for Deakin University’s School of Medicine in 2011 and Dean and Professor of Medicine at Deakin in 2014. He has also served as a board director for the Postgraduate Medical Council of Victoria and as Board Chair of the National Centre for Farmer Health in Hamilton, Victoria. He’s a member of the
National Examining Panel of the Royal Australasian College of Physicians. Earlier this year Jon and his wife made the move west as he was appointed Executive Dean of the Faculty of Health and Medical Sciences at UWA. His children live and work in Melbourne. “I’m not sure I actually planned any of this out,” he says. “I feel like I took these opportunities as they
Jon’s mum was a nurse but there were no doctors in his family. Being blessed with a relentlessly enquiring mind, he didn’t know how he could put it to best use until he found medicine. “It can be frustrating, stressful and fascinating, but it’s never boring! I’m a very social person and I really like being with people. The reason I chose gastro was the mix of physician training. I liked the problem-solving part of being a physician, I like helping people and I like the procedural work. “In life you just keep reinventing yourself. Interesting things keep coming along. I trust my gut and I keep doing them, using the transferable skills I have to move forward.” More than ever before, Jon says having a medical degree, being a doctor or a specialist doesn’t mean that’s where you stay. He believes having that experience is transferrable into so many different, allied and related fields for a career. That can include working on boards or working in or helming an NGO. “The practice of medicine is of great interest to me since I qualified in 1989. There are so many places you can go and I think that’s worth considering when we look at how we train in medicine in the future. continued on Page 13
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It’s always a gut feeling continued from Page 11 It’s not so much about knowledge but it’s about giving students the skills for their next 30 years. Medicine remains popular as a career choice, but it’s also less popular probably because of the lifestyle. “Another area is that medics have much less autonomy. You could argue that doctors in the 1970s and 1980s had too much autonomy. There were more doctors who ran their own show. Now, many work for larger organisations. “The relationship between a doctor and the patient is sacrosanct and many professions have lost that. I hope we never lose it. You are here to be the advocate for the patient so sometimes you also have to work against the system. Doctors find it hard to work with economic imperatives and financial issues. This brings them into conflict and it’s a conflict that’s difficult to solve these days. “Despite all that, I don’t think I would have done things any differently. I still believe it’s an enormous privilege to help patients and teach students and doctors of our future.” Jon says at institutions such as UWA and Deakin, there are about 3000 to 4000 applications for 150 to 200 places in medicine each year. That’s proof enough that demand isn’t tapering off and that the profession is still attracting each generation’s brightest minds. Besides a great GP is “worth their weight in gold”.
Authorities have been co-operative and helpful in terms of fast-tracking applications for ethics approval and approval for clinical trials, he said. They are not involved in making vaccines.
Jon stepped into his new job in February, just as the pandemic hit. He’s seen it as an opportunity and wanted the university to be front and centre of investigations, trials and expert advice. UWA has played a key role in advising state and federal governments on COVID-19 strategy through the Group of Eight Universities’ panel of research experts and are actively involved in treatment trials through their COVID-19 Research Response Hub in collaboration with colleagues from major health services and other universities.
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Brought up as an Anglican who enjoyed singing in the church choir, Jon has managed to make his way to St George’s Cathedral to enjoy the choir and sit quietly for moments of reflection. “I think reflection is especially important. Most of us are not good at work life balance.” When Jon wanted to take a walk on the wild side he’d be singing with Jonny and the Optics, who were unashamedly lost in the ’70s. Known for performing in very loud suits – one featuring a test pattern and the other lime green with daisies – Jon will be looking for a new band to sing with here when his gut tells him the time is right.
Read this story on mforum.com.au
OCTOBER 2020 | 13
Q&A with... Dr Omar Khorshid, Orthopaedic Surgeon & National President of the Australian Medical Association
MF: With COVID-19 dominating the health agenda and government budgets, what will be the national AMA’s focus for the next 12 months? OK: We’re struggling to talk about anything other than COVID at the moment and it’s clear that it will remain a significant focus of the AMA for some time yet. Australia has done very well by world standards in tackling the spread of the virus, but we are not out of the woods. Governments will continue to need strong medical advice, particularly in the face of unrealistic and potentially dangerous calls to open up the economy before it is safe to do so. We need to get the balance right, recognising that without a strong health response to COVID-19, we will not be able to get our economy back on track at all. However, although COVID-19 is urgent, the AMA needs to be setting the agenda. The AMA is a trusted voice, and we will be using that trust to call for action on other pressing issues in our health system. We need a stronger, better health system that places disease prevention as its key focus, with the investment needed to make a real change. The AMA is advocating for 5% of the health budget to be allocated to preventive health. Integrated quality General Practice must be the gateway to the entire health system, further supported by digital health technology such as telehealth. The AMA has just released a detailed policy on this, and we will be prosecuting it. Our public hospitals need increased and certain funding so they not only cope, but flourish. We need to end the days of public hospital doctors working dangerously long hours due to being short staffed and underresourced. The AMA believes we need a detailed reform agenda for our private health system – and again, we have developed a series of detailed policy proposals for government that can be actioned now. Finally, for the most vulnerable people in our society, including those in the aged care sector, we will remain relentless in raising these issues with the Aged Care Royal Commission and beyond, so that we see lasting improvement.
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Q&A MF: In this context, what can the AMA offer its members by way of support and advocacy? OK: Members join the AMA for our policy advocacy. They want to work in a health system that supports them to provide quality care for their patients. Our job is to prosecute a policy agenda that supports this – and the above areas of focus are just the beginning. Doctor independence, whether in a government-run system, a privately insured and funded model, or in the context of a nationally regulated scheme, is critical. MF: The pandemic response has seen agile collaboration between the public and private health sectors. What is needed to continue that co-operation once the public health threat of COVID-19 subsides? OK: No part of the health sector will remain unscathed by the time the threat of COVID subsides. Waiting lists for surgery will be longer, the viability of many private sector practitioners and organisations will take years to recover, and the community will have suffered greatly. We also know that the Treasury coffers will have been exhausted and that health will be under the expenditure microscope. If we are to have a healthy economy in the future, we will need a healthy society. This will require investment and reform. We can’t afford to cut our way to a healthy future. In order for the type of collaboration we have seen during COVID-19, stakeholders will need to understand that life will not return to normal in the foreseeable future and that it is in everyone’s mutual interest to work together if we are to meet the needs of our patients. MF: What are we getting right and wrong in our national response to the pandemic? OK: So far, Governments have largely listened to the medical advice that they have been given, and National Cabinet has been an excellent vehicle to support a nationally coordinated response, although cracks are beginning to show. Australia also got onto the front foot in tackling the virus with a broad lockdown. You must get ahead of COVID, otherwise it will win every time. As we see a second
wave, there is a concern that Governments are being too slow to act, focusing too much on daily infection numbers. By the time these rise beyond an acceptable threshold, policy makers are already two weeks behind the eight ball. We are seeing some divergence in approach among jurisdictions. Some have eliminated the virus and have been forced to close their borders to those jurisdictions that are taking a different approach and continue to report new infections. Depending on what happens in Victoria and, to a lesser extent in NSW, governments need to revisit the elimination debate, otherwise communities may suffer a diabolical cycle of restriction easing followed by lockdowns. We also know that healthcare workers are at significant risk of COVID-19, making up a significant proportion of infections in the Victorian outbreak. This has exposed problems with access to PPE on many fronts. PPE guidelines have been too weak to properly protect healthcare workers and there have problems with the supply and, probably more critically, the distribution of PPE. Ultimately, the best protection from COVID-19 for healthcare workers and the community is the achievement of zero community transmission. This will require Government to continue to take tough decisions on restrictions and to be realistic about the extent to which we can open up again while the threat of the virus hangs over us. The community needs to play its part as well – we all have to change the way we live and how we interact with each other. We have not done enough to protect our vulnerable populations in aged care facilities, and they have suffered as a result. There has been too much of a blame game and not enough planning and support for this sector. While this hardly comes as a surprise, given the evidence before the Aged Care Royal Commission, this failure highlights just how far we have yet to go in addressing the systemic problems in our aged care system. We know what needs to be done, we need Governments and operators to heed the advice, and quickly.
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MF: The generalised economic pain of the pandemic is impacting on an already fragile private health insurance industry. How important are these funders to the national health system? OK: Even before the impact of the COVID-19 pandemic, private health insurance was in trouble. Membership has fallen continuously for the past 20 quarters and the government’s recent reforms have not reversed this decline. Younger people continue to drop their private hospital insurance, while people over 65 years are taking it up in increasing numbers, further jeopardising the stability of the system. Demographic shifts have created a trend which places upward pressure on premiums for those who maintain their insurance, leading the Australian Prudential Regulation Authority to state that private health insurance is in a ‘stable but serious condition, with that stability under threat’. The AMA is concerned that the likely financial impact resulting from the COVID-19 pandemic including unemployment, underemployment and a slowing economy, will result in even more young people giving up their insurance, increasing pressure on an already unstable system. The unique balance between the public and private sectors makes the Australian health system one of the best in the world. In 201718, 66% of elective surgeries (that is almost 1.5 million surgeries) occurred in private hospitals. Without our private system, our public hospitals will not cope with the increased demand. Just last year (September 2018 to September 2019) health funds subsidised more than 100 million services, paying $21.4 billion in benefits. MF: How can the AMA and the medical profession support that industry? Is that something the profession and the AMA should even have to worry about? OK: The AMA believes that all contributors want the Australian private health system to be effective, high quality, provide value, and to be inclusive. But we recognise the problem and its severity – the current policy continued on Page 16
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Q&A with Dr Omar Khorshid continued from Page 15 settings for PHI no longer work. However, we also recognise that the government is pivotal in the health insurance equation. It is behind so many of the policy levers that must be adjusted swiftly to reverse these trends and restore value and confidence into our private health insurance system. The AMA has outlined a few policy prescriptions for private health insurance. We support moves to restore the premium rebate, at least for younger Australians and low-income workers. Premiums need to be within reach of average Australians – otherwise we will have a two-tier system. The minimum amount returned to members for every dollar going in varies from anywhere between the high 70s to above 90%. This must be standardised, and it must be higher than the industry average right now. The Lifetime Health Cover loading must be reviewed, particularly the starting age. People are staying in university or TAFE longer, starting families later, and facing mortgage pressures more intensely. The starting age is supposed to be a signal to get into insurance, but it’s
now at a point of locking younger people out. It’s vital that people have transparency around their out-ofpocket costs. Gaps are the biggest bugbear for most people about their private health insurance. In fact, less than 3% of medical services are billed outside a no-gap or known gap arrangement, but that’s no comfort to those patients who find out that they’re not covered when they need it. That’s why the AMA has developed our Informed Financial Consent guide, to help doctors and patients work through all the issues before treatment starts. We’ve also called on the government private health website to do more. It must help patients understand that each fund pays a different benefit for the same MBS item, and what their health fund will pay.
MF: What are the issues that pose the greatest challenge for the national AMA organisation, which has undergone a volatile period of financial and membership duress? OK: The AMA is financially strong as its membership base. At a time when membership bodies are finding it difficult to maintain membership, the AMA’s membership penetration would be the envy of many. Like any other organisation, the AMA works hard to ensure that its budget is balanced each year. This year we have seen the re-organisation of some parts of the Federal office, with a strong emphasis on prioritising expenditure towards our key advocacy areas. MF: How can the AMA attract more members?
The AMA has been at the table on all the discussions about private health insurance. We have been at the table to consider alternative clinician-led models of care. We will stay at the table to achieve the best outcomes for the system and our patients.
OK: AMA members have told us that they value our advocacy work highest, and at the national level we will focus more than ever on strong advocacy that delivers tangible benefits to our patients and our profession.
It’s only by all the players in this equation working together, all of us giving some ground and pursuing reform, that we will succeed.
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Q&A that are resolved before most doctors realise they exist. The AMA needs to refocus its communication strategies with members and other doctors, so that all doctors are aware that they have a strong representative body in their corner that is actively listening to its members and committed to achieving the best possible outcomes in conjunction with other medical groups including Colleges. The AMA is the peak representative body for our profession – the challenge is to become an organisation that all doctors aspire to join. MF: Do you think there are too many disparate ‘medical voices’ trying to be heard in the political sphere? With medical advice based on evidence leading governments’ decision-making during the pandemic, will this change the advocacy style of doctor groups in the future? OK: The pandemic has in many ways strengthened the AMA’s position in the political sphere. The AMA has proven to be a calm and authoritative voice, both with governments and the community. We have been a strong voice for the community and the profession, and governments have listened to our advice. The reality is we are truly separate from government, and we are the only body that represents all the
profession and its specialties. The challenges ahead for the health system are ones that will affect all specialties, and all doctors – no matter what stage of their career. Although there are many other voices, the AMA is the strongest and most respected body representing doctors and will continue to advocate as the peak body in this rapidly changing environment. MF: What interested you about the AMA national leadership that made you want to stand for election? OK: I have watched many Federal Presidents of the AMA over the past 20 years and have seen the capacity of the AMA to deliver on a national stage. At the same time, I have observed the need for the medical profession to lead a reform agenda to deal with the current and future demographic and economic challenges that face our health system. If we want to enjoy access to a health system that is based around individual doctors and patients making decisions that are best for that patient, then we must be willing to fight for it. That means being willing to challenge some of the sacred cows and defining what we think are the critical aspects of a sustainable, high quality health system.
and if we do nothing, it is inevitable that the solutions others come up with will be unacceptable to the medical profession. MF: What did you learn from your time as president of the AMA WA that will keep you in good stead as national president? OK: As AMA WA President, it was very clear to me how important the AMA is to any conversations with the public about health care. There is an enormous amount of respect for doctors and for the AMA in the community and that respect can be used to advocate for changes that can improve the lives of thousands or millions of people, as opposed to the one-on-one interactions that we have as individual doctors. I also observed how little choice you get in terms of the advocacy issues of the day and how difficult it can be to set the health care agenda. The AMA must be strategic in terms of its advocacy agenda but also nimble in order to ensure that we remain relevant to members and effective in achieving change in a chaotic world.
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We cannot rely on the political class to deliver a health reform agenda
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FEATURE
The long-haul The devastation caused by the long-term symptoms of COVID-19 is redefining how we should view the virus.
It is not often one can say something has genuinely ‘changed the world’ without a modicum of hyperbole yet in the case of COVID-19, it has, with quarantines, social distancing and isolation measures enacted to mitigate the spread of the disease having become the new normal across the globe. For those who have contracted the virus, the disruption can be devastating both in the short- and long-term, particularly if they have been unfortunate enough to suffer from a constellation of debilitating symptoms over weeks and months. As COVID-19 spreads, so too does the collective knowledge of the long-term effects of the disease and the difficulties faced by ‘Long COVID’, the long-haulers. Approximately 10% of COVID-19 cases will go on to experience prolonged illness. The British Medical Journal defines post-acute COVID-19 (Long COVID) as a continuation of symptoms three weeks from the onset of first symptoms and chronic COVID-19 after 12 weeks of symptoms. In the early days of the pandemic, a worst-case scenario of a COVID-19 patient would be something like a patient in intensive care, on a ventilator, isolated from their family, gasping their last breath. 18 | OCTOBER 2020
Whilst the same exercise for a mild case of COVID-19 may conjure an image of someone with flu-like symptoms, soon to recover in a matter of weeks. For the long-haulers, they may start with a mild case and instead of the symptoms subsiding, they persist and can persist for months or indefinitely.
Long COVID According to UK’s Professor Paul Garner, for those unfortunate enough to suffer through Long COVID, they are stricken by a diverse constellation of symptoms, of which he can speak from personal experience. Prof Garner offers a unique perspective on Long COVID as not only is he suffering from it, he is the Director of the Centre for Evidence Synthesis in Global Health at the Liverpool School Tropical Medicine and the Co-ordinating Editor of the Cochrane Infectious Diseases Group, whilst earlier in his career he was an epidemiologist in Papua New Guinea and a doctor in the NHS.
Ironically, Prof Garner’s Long COVID journey began on a teleconference with Dr David Nabarro, one of six Special Envoys to the World Health Organization who are assisting the COVID-19 response. “During a teleconference with Nabarro he mentioned COVID-19 had a doubling time of three days and anybody who felt a little bit unusual needed to self-isolate. And I thought ‘I don't feel quite so well’. I didn’t feel dreadfully unwell, didn’t have a temperature, headache or a cough for the first few days and then the illness crept up on me,” Prof Garner said. “Within five days, a sort of emergent headache came and then on day six or seven of being symptomatic, I had absolute utter fatigue, my heart was racing, I thought I had myocarditis, I felt dizzy, sweaty, yet I did not have a temperature. “I felt I was passing out, I laid down and I actually started passing out on the bed. I thought I'd die, then came around two hours later after this sort of two-hour sleep. I then went through weeks of feeling a bit groggy but not feeling too bad, then suddenly coming out from nowhere, I had the feeling of a cricket bat hitting me around the head and flooring me completely
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for a day or two and then getting back up again. And this went on for 12 weeks. It just didn't stop. “Every time there was a new symptom, it would be deafness one day or pains in my legs and calves or occasionally a bit of a cough other days – I never really knew what I was going to get. “This was going on at a time when everybody was saying the illness only lasted two weeks and, of course, there was me with all this going on. “It was extremely frightening as it also messes with your mood. Everybody gets this wrong about mood saying, ‘oh, of course, you're going to be depressed because you're unwell, locked up and the world's going mad outside’. “I could be almost in tears in the morning with emotion that I didn't know where it came from, then completely happy and almost manic wanting to go out for a walk in the afternoon. It does mess with your head and people don't get that.” Eventually Prof Garner’s symptoms became less severe, though he was left with significant fatigue, which was exacerbated by both physical and mental exertion. “Early in the illness, around eight weeks, I felt so well. I thought I'd do some exercise and that led to
post-exertional malaise – where you push yourself a little bit and feel all right then, bang, within 24 to 48 hours you are flat as a pancake, can’t move, all the symptoms come back for two or three days," he said.
Anyone and everyone Co-morbidities, obesity and age are relatively accurate predictors of who may have an acute case of COVID-19, yet this is not the case for Long COVID, according to Professor Danny Altmann, an immunologist at Imperial College London. He told New Scientist: “There’s clearly something going on here. It is not their imagination or hypochondria. It doesn’t even seem to be linked to how severely they had the disease, as far as I can see.” Since mid-March, these symptoms have persisted for Prof Garner, who at the time was in his early 60s. He trained regularly and ran between 30-40km a week, with no co-morbidities prior to the onset of symptoms. “I spoke to doctors who didn't really know what to say or do, so I got in touch with chronic fatigue and myalgic encephalomyelitis people that I knew, and they were incredibly supportive. “I spent over three months trying to work out how to control the
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fatigue, such as how far I could walk, because I was so fit before, I was highly expectant that I could really hammer this disease out. I've had viral infections before and just jumped on the stationary bike and trained five minutes one day, ten minutes the next, 20 minutes the next and in a week I'm up and running again. “During Long COVID, I found out it wasn't just physical exercise, simply participating in Zoom calls used energy and if I used all this energy and went to bed drained, then I'd be floored sometimes for a couple of days afterwards. “My head was incredibly muggy because of the headaches and I couldn’t see or read very well.”
Outliers When the pandemic was emerging, COVID-19 tests in the UK were in limited supply, which meant Prof Garner had to choose between being driven 80km to the nearest testing centre or be admitted to hospital, yet due to the non-critical symptoms, he chose to self-isolate rather than use up a precious test kit that a front line medical worker could have used or the bed of a critical patient. continued on Page 20
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FEATURE
The COVID long-haul However, this meant, that in his case and others in his situation were not even considered COVID-19 statistics. It was only when he went to a hospital for a suspected pulmonary embolism that he was tested as negative, further complicating his treatment. He has since taken an antibody test which has come back positive. “The policy of the UK at the time was to stay home. The only people who got admitted to hospital or even seen were people basically dying, with SATs below 80 or respiratory distress. I probably was very seriously unwell, but didn't realise or acknowledge it,” he said. “We've got thousands of people already used to self-treating who are not in the system – I am not in any government statistics, so I'm not counted as a case. “It's taken me literally six months as a patient to access important information that can help me manage my condition and I've done it well as I've been banging on about it and people have sent me advice.” As one of the co-founders of the Cochrane Collaboration, Co-ordinating Editor of the Infectious Diseases Group and the co-ordinator at the Centre for Evidence Synthesis for Global Health, it would be apt to describe him as someone who has dedicated his career to evidence-based research, yet during the worst of his Long COVID experience, he relied on support groups for the most upto-date information. “People who had all these symptoms found solace in self-help groups, not their doctors. These self-help groups were usually about two to four weeks ahead of their GPs. “I had problems with my speech, particularly when I got tired, so I contacted a friend who's in charge of rehabilitation in a London hospital and she said, ‘get yourself down to casualty, you may be having a stroke, you need an MRI’. “And I posted these symptoms on a Facebook group, and all of these people said, ‘Oh, God, I've 20 | OCTOBER 2020
been having that for months’. Then I would check in with the chronic fatigue or myalgic encephalomyelitis communities and they would say this is quite common. “I'm not blaming the doctors, you know. What we need is not well known, but what we need is people to get the message out. These observations are important. Big studies in medical journals will be too late. By the time the medics have completed a longitudinal study, I'll be either recovered or dead. “I do think the medical systems for collecting information and disseminating it are not fit for purpose at the moment because things are moving so rapidly, because everything is so new.”
Getting the message out Prof Garner has unapologetically used his position to disseminate and legitimise Long COVID. While awareness of it is becoming more prevalent, he has heard too many stories of discrimination or outright dismissal by clinicians not to speak up.
the symptoms these people have is intermittent tachycardia, and if they do anything about it they are going to their GPs and casualty departments saying, ‘I've got a problem with my racing heart’ and these people are being diagnosed as having anxiety.
“I run the Cochrane Infectious Diseases Group and am known for my work on malaria and TB. I'm able to verbalise things in an accessible way. I have friends who say, ‘if I said what you're saying, people would just say I'm a 45-year-old non-medical woman and they wouldn't believe the kind of symptoms I come up with’.
“I know a psychiatrist who went to a casualty department with these symptoms and the casualty officer said, ‘oh, you're just anxious about being unwell and it lasting so long.’
“At my age and, you know, as an old bugger, a white male in infectious diseases, maybe this is what I can do to help, by using this position to give this condition some more credibility in these crazy times. “Things are in such disarray with advice and particularly for somebody like me on the fatigue spectrum and because doctors have denied chronic fatigue and myalgic encephalomyelitis, they think it's all in your head, so that's been an additional barrier. “Then there are people with Long COVID who have dysautonomia syndrome where their autonomic system is going haywire, they have incredibly high heart rates for no apparent reason. One of
Not so mild When the pandemic emerged the most acute cases were rightfully prioritised for hospitalisation and experimental treatments to reduce symptoms and hopefully bring patients back to recovery, whereas the so-called ‘mild’ cases were thought to recover without the need for intervention. As the number of hospitalised and non-hospitalised cases have exponentially increased, so too has the understanding that a portion will go on to experience adverse symptoms for months, while the majority of the cases will experience some form of continued symptoms. For younger people, catching COVID-19 is viewed as a mere inconvenience because the mortality rate is low. Yet the mortality rate does not highlight
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the actual risks, according to Mary-Louise McLaws, Professor of Epidemiology at the University of New South Wales and a member of the WHO Health Emergencies Program Experts Advisory Panel for Infection Prevention and Control Preparedness, Readiness and Response to COVID-19. “From an epidemiological and outbreak management perspective, the 20 to 39-yearolds have represented just more than 40% of all cases. And that's very disconcerting because while they may have non-hospitalised COVID, I wouldn’t label all of these cases as mild because that undermines their experiences and trivialises their potential for Long COVID,” she said According to Prof McLaws, people with less severe cases of COVID-19 who were in good health prior to the onset of symptoms may be more aware of the Long COVID symptoms compared with the acute cases where people had prior morbidities or risk factors. “They may well have not been able to identify the difference between the Long COVID, post-discharge, compared with the very young
and fit people recuperating. The non-hospitalised COVID patients recuperating talk about profound fatigue, headaches, diarrhea, palpitations, breathing difficulties and heart problems.
about COVID, that they'll just bounce back like they've got a mild flu. The authorities have used the rhetoric for not wearing a mask unless you've got symptoms, which is only 50% of the real story.
“One of the most important groups who must be protected from Long COVID are the 20 to 39-year-olds, because we wouldn't want them to go into their middle age having any of these symptoms.
“When the chief medical officer of every state and territory was using that rhetoric, it made me very concerned because we don't send health care workers onto a ward without a mask and they don't have symptoms.
“It has been estimated that symptoms can drag on for more than three weeks in 80% of people and the six-week recovery period is for a group who bounce back rapidly. However, for a lot of people, while they may no longer be infectious, they may not be well enough to consider that they're back to normal health.”
Mixed messages The focus on acute cases was exacerbated by the public health messaging, which at the time was focused on reducing the spread of the virus and balancing the demands on the health care system, yet inadvertently minimised the non-hospitalised cases, Prof McLaws said. “In Australia and overseas we have sent lots of incorrect messages to the community. We've used the term mild and that makes people think that they don't have to worry
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“Once you start using rhetoric as if it's a concrete truth, it's very hard for leaders to walk that rhetoric back. The rhetoric of a ‘mild’ COVID for the majority disrespects the insidious nature of this disease as a serious issue, particularly for the young who need to get back their quality of life and productivity. “It also sends a message to the medical fraternity that they may not appreciate the signs and symptoms of post-COVID and may think there's a different cause rather than it being directly associated with COVID, for instance fatigue, because extreme fatigue is sometimes thought of as a mental health issue rather than actually being a part of a post-recovery condition associated with this inflammatory disease.”
OCTOBER 2020 | 21
A return of sports, of sorts Olympic athletes have had a truncated preparation for the now 2021 Olympics in Tokyo but it’s their mental fitness that will see them through.
James Knox reports.
22 | OCTOBER 2020
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When the ubiquitous pandemic landed in Australia, the control measures incrementally encroached on almost all aspects of Australians’ day-to-day lives. However, the nation’s sports leagues stubbornly continued when most other nations decided to take their bats and head home. Although professional sports leagues are back, albeit with compressed seasons, limited crowds and isolation ‘bubbles’ and hubs, Australia’s Olympic team has not been so fortunate. In early 2020, as the world became acquainted with COVID-19, the organisers of the Tokyo Olympics were doggedly moving forward with the Games, declaring on March 2 that the event was continuing as planned. On March 11 the World Health Organisation labelled the outbreak a pandemic, leaving the organisers of the biggest sporting event with a difficult choice to make.
22 they would not be sending their athletes to the Games. On March 24, the organisers acquiesced to the pressure and delayed the Olympics until 2021. Yet, for the hundreds of future Olympians in Australia and the thousands around the globe, they were in the difficult situation of having to train for what could be the pinnacle of their careers while balancing the demands of each of their respective countries’ various control measures.
All in the mind It may seem overly simplistic to drill down to a single characteristic that defines an Olympian, or a professional athlete for that matter, but if one were to be identified, mental fortitude would certainly be core of what ultimately drives them to the pinnacle of their chosen sport.
containment measures, according to Dr Carmel Goodman, Medical Director of the Western Australian Institute of Sport (WAIS). Dr Goodman explained to Medical Forum that once governmentmandated restrictions were put in place, WAIS implemented remote training plans to maintain their athletes’ conditioning and continue their preparation for the Olympics. As WAIS runs a variety of programs, each of their athletes had different requirements for the remote training, such as for those who compete in team and contact sports such as water polo, and individual endurance sports such as cycling.
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And it is this strength of mind that has kept Australia’s Olympic hopefuls focused during the
It was the Canadian and Australian Olympic committees that essentially forced the hand of the organisers by declaring on March
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A return of sports, of sorts continued from Page 23 According to Dr Goodman, the remote training programs for each of their athletes varied from massively disrupted to relatively uninterrupted depending on the program, however, upon returning to WAIS, most of the athletes had surprisingly maintained their conditioning and skills and were able to quickly get back to their normal levels. “With this level of athlete, within a week or so, they can regain their skill level,” she said. “Motivation was not as big of an issue as I expected it to be. The athletes managed surprisingly well, from physical and mental points of view. We know they managed well from a physical point of view because of the fitness tests we conducted when they came back to their training environments.”
Managing the maintenance The athletes who had their regular training disrupted were provided with alternative training plans, yet this led to an unexpected increase in injuries, Dr Goodman said. “I was seeing a higher incidence of overall injuries. For instance, the swimmers and the water-based athletes who had started jogging or running experienced more lower limb injuries because they were not used to running or cycling.
have been delayed 12 months, their training regimes have not. “It is not like everything is geared towards the Olympics and then there is a significant tapering period. During the years between the Olympics, all the athletes are vying for selection and must be at their best almost all the time. “Then there is local, national competitions and overseas competitions. It's not like four years of training goes towards the Olympics, it is a continual cycle of performing and tapering.” “When I looked after the Australian women’s hockey team [Dr Goodman was the team doctor of the Hockeyroos] there was maybe a period of a few weeks at the end of each year that they would have off. “At any stage during those four years, they would be match-fit to play in an Olympic Games. The athletes are always training almost at a level that they could go
straight into major competitions because the Olympic selection is happening all the time.”
The mental game Although the mental fitness of an athlete can be their greatest strength, it can also be a weakness and something clinicians need to be mindful of, particularly during the current pandemic, Dr Goodman said. “We are now seeing considerable mental challenges for a lot of the interstate athletes who are really battling because they can't see their families due to the border restrictions in Melbourne and Sydney. “Throughout this situation, that is perhaps one of the biggest issues we are dealing with, from the athlete’s personal point of view.”
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“On the otherhand, the rowers, perfectly maintained their training because they could train at home on rowing machines.” In response to these injuries, WAIS’s exercise physiologists, coaches and Dr Goodman carefully assessed each of their athletes training programs and capacities to identify and recommend individual cardiovascular and strength loads for each athlete so they could maintain their strength and fitness.
Peak performance Although it may seem intuitive for Olympic athletes to increase their training to peak for the Games, Dr Goodman explained WAIS athletes are always close to their peak, which means that although the Olympics
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Effects of lockdown Not all the effects of COVID-19 are physical. How have the public health measures impacted on body and mind? Professor Jim Codde wants to find out. COVID-19’s acute health impacts are increasingly better understood for infected individuals but the secondary health impacts (e.g. mental health, health service demand, lifestyle factors, stress, and domestic violence) for the wider, uninfected community are less so. Similarly, while the economic impacts of the global shutdown will be acute for the next 12 months, the financial effects are likely to continue for several years, exacerbating the health and social consequences. While quarantine and isolation can reduce disease infection rates, there are also significant, associated psychological and mental health effects that impact on mental wellbeing. A recent systematic review found that time spent in infectious
disease quarantine resulted in negative psychological outcomes, including insomnia, depression, anxiety, post-traumatic stress, and emotional exhaustion. Additionally, where parents were quarantined with children, the mental health toll increased with one study reporting that no less than 28% of quarantined parents warranted a diagnosis of “trauma-related mental health disorder”. Psychological wellbeing and mental health have been shown to be associated with levels of physical activity, sedentary behaviours, diet, and quality of life. Therefore, any changes in either mental health or associated lifestyle behaviours may impact negatively on one another. The COVID-19 lockdown period provides an ideal environment in
which to study these impacts. The restrictions placed on movement outside the home and other physical distancing measures changed the way West Australians worked, socialised, shopped and exercised. While some restrictions are still in place, many have been lifted. It is essential to collect retrospective data now while the experience is still fresh in the minds of the community.
WA research survey To examine these questions, researchers at the University of Notre Australia are inviting West Australians over the age of 18 years to complete an online survey to provide insights on how the COVID-19 lockdown impacted on their “body and mind” and what issues may persist. The WHO released health promotion material about the importance of “staying physical at home”, “healthy eating” and “looking after our mental health” as part of their #HealtyAtHome program during the COVID-19 lockdown period. Other countries, including Australia, focused more on the importance of social distancing, personal hygiene and social isolation in their messaging while largely failing to provide strategies for maintaining optimal physical and mental health. The study’s outcomes will help inform development and delivery of health promotional activities at state and local government level should WA be impacted by a second wave of the virus or similar emergency. This state-government funded survey can be found at: https://notredame.syd1.qualtrics. com/jfe/form/SV_2i6cRGer71duajP and takes about 20 minutes to complete. – References on request
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Exercise & diet for knee arthritis – why bother? There are good reasons for a multifaceted approach to treating OA of the knee. Orthopaedic surgeon Dr Daniel Meyerkort explains. Australia, like much of the developed world is gripped in two pandemics, one being COVID-19, the other is linked to obesity, painful knee arthritis.
for pain relief and functional improvement. Patients should be encouraged to do sufficient frequency and intensity as better outcomes have been shown with higher participation rates.
Of knee replacements in Australia, 59% of patients have a BMI greater than 30 at the time of surgery. Obesity is linked to surgical complications, particularly infection. While the public’s imagination is easily captured by ‘robotic surgery’, despite a current paucity of evidence to show it clearly improves outcome, it is harder to convince patients that lifestyle modifications will be beneficial to their knee health.
Arthroscopy challenged It is now widely published that knee arthroscopy should not be first line treatment for knee arthritis, having a similar success rate to placebo surgery. This now includes patients with degenerative, horizontal-type meniscal tears. Knee replacement is a good option for moderate to severe disease, however, significantly higher dissatisfaction rates have been reported when surgery has been performed for early disease. A RCT comparing total knee replacement with multimodal physiotherapy (a 12-week muscular strengthening program + patient education + dietary advice + analgesics) demonstrated that this combination program provided patients with about 50% of the improvement compared with total knee replacement. The study population was patients booked for joint replacement (i.e. their disease was severe enough for surgery) and over the 12-month study period 74% of patients in the conservative group was able to postpone surgery. A muscular strengthening exercise program should be a core treatment of all patients
Weight Management
with knee arthritis. A randomised trial of muscular strengthening physiotherapy vs paracetamol demonstrated superiority of physiotherapy for symptoms related to knee osteoarthritis at 12 months follow-up. Smaller improvements were also seen in pain, activities of daily living and quality of life measurements. Recently the Good Life with OsteoArthritis in Denmark (GLA:D) program has been gaining popularity in Australia. GLA:D is an educational program with supervised muscular strengthening exercise delivered over eight weeks for patients with hip and knee osteoarthritis. Published results from this study of 9825 patients demonstrated significantly decreased pain intensity and improved quality of life scores at three months.
Maintaining progress Interestingly, these good results were maintained at the 12-month follow-up despite no further intervention past three months. Independent exercise outside of the structured clinical environment should also be encouraged in patients with knee arthritis. Importantly patients should be educated that exercise will not cause accelerated damage to the knee. Both land-based exercise (walking, cycling, strength training, yoga, Pilates, tai chi) and aquatic exercise have been shown to be beneficial
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Weight loss has been shown to improve knee pain and function with a direct correlation shown in patients with a BMI over 28. A minimum of 2.5% weight loss has demonstrated pain relief, with less physical disability with weight loss over 5%. Combination of dietary change and exercise has been shown to provide greater pain relief than dietary change alone. Interestingly in addition to the clinical benefits on knee function, weight loss has been shown to slow cartilage degradation on MRI imaging. In patients who have failed conservative weight loss measures and with a BMI > 40 (or >35 with additional co-morbities), bariatric surgery may have a role in management. A systematic review of 13 studies with 3837 patients demonstrated decreased pain, improved function and range of motion post bariatric surgery.
Accessible weight loss It can be hard to find time to talk to patients in detail about weight loss. It is my current practice to recommend patients obtain a copy of the CSIRO Low Carb Diet Series. Published data shows patients lose 4% of their body weight over six weeks and 6% over 12 weeks on this diet. It simply recommends healthy eating with higher vegetable/lean protein intake and the carbohydrate equivalent of around four slices of bread per day. Specific weight loss services targeted at patients with knee arthritis are also available, some of which are supported by health funds.
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Picky eaters in young adulthood Childhood eating habits can affect body and mind in young adulthood writes Catherine Panossian. Some of the core characteristics of Autism Spectrum Disorder (ASD) such as restrictive and repetitive behaviours can feed into mealtimes. It’s not surprising that feeding difficulties are five times more likely in children with ASD, compared to typically developing children.
quality of life for families and the child’s nutritional status. Interestingly, research shows feeding issues are not routinely screened in this population and may be overlooked because the growth and satiety of the child with ASD may not be affected. However, closer investigation may reveal they eat less than five food types, or the same thing for breakfast, lunch and dinner.
Types of issues than can occur include selective food intake and food neophobia (fear of trying new foods). In severe cases, reports of scurvy, rickets, faltering growth and malnutrition have been reported in children with ASD. We know that children with ASD may be at higher risk of poor nutrition. However, less is known of the dietary risks of children with more autistic-like traits. Some of the cognitive and behavioural issues – such as difficulties with communication, imagination and social skills – can also be observed among those in the general population. These are known as autistic-like traits. Some people have them to a higher degree but not enough for an ASD diagnosis. Understanding factors that are associated with autisticlike can provide further insight into clinical ASD. A recently published article in the Journal of Autism and Developmental Disabilities explored 811 subjects from the longitudinal Raine Study. This study explored the association between autisticlike traits in early adulthood (aged 20) and compared this to their food variety and diet quality in early childhood (ages one, two and three). Results showed that as autistic-like traits increased, food variety and diet quality decreased. Overall, subjects with higher autistic-like traits had lower total food variety, lower variety of foods from the five food groups (particularly citrus fruit), and lower variety of dairy foods (particularly yoghurt).
Aversion to dairy A notable result in this study was the lower intake of dairy. Diets low
in dairy products are commonly noted in children with ASD. This is thought to be influenced by a gluten-free casein-free diet that excludes dairy products. This is a popular diet among families who have a child with ASD, despite there being no conclusive evidence that ASD symptoms improve on this diet. Our study represented a clean sample with no potential bias from popular ASD diets. This provided important information that the nutrient calcium could be of concern in this population. Emerging studies have revealed that children with ASD are presenting with a lower bone mineral density, which can put them at higher risk of osteoporosis as they age. It is imperative they receive evidence-based nutrition advice to prevent further problems later in life. It is important to note that the results of this study didn’t show that low food variety caused autistic-like traits, but that those who have higher autistic-like traits may be nutritionally vulnerable. Picky eating is a part of normal childhood development. However, with children who have ASD and feeding difficulties, the issues go way beyond picky eating. Their difficulties are often more severe and longer term. It can impact the
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Severe restrictive eating habits in young children can affect their cognitive and behavioural development and in turn their ability to communicate. Nutrition is extremely important in children with ASD so they can grow, learn and develop.
Help at hand It is concerning that some parents find it difficult to locate health professionals to assist them with their child’s feeding difficulties. It is under-recognised and undertreated. Many families may seek alternative therapies which lack scientific evidence. Therefore, it is important to refer families to an accredited practising dietitian (preferably in paediatrics). In addition, a multi-disciplinary team may be required to help address the ‘food’ and the ‘behaviour’. Other health professionals such as occupational therapists, speech pathologists and clinical psychologists can be involved. Organisations such as the Autism Association of WA, Therapy Focus, Clinikids and Perth Children’s Hospital also offer services in Perth. ED: Ms Panossian is a practising dietitian and researcher at Edith Cowan University. She has recently published a paper, ‘Young Adults with High Autistic-Like Traits Displayed Lower Food Variety and Diet Quality in Childhood’ was published in the Journal of Autism and Developmental Disorders.
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Metropolitan Perth syphilis outbreak alert By Prof Donna Mak, Public Health Physician Over the past decade syphilis in the Perth metropolitan area has occurred primarily amongst men who have sex with men (MSM). However, there is increasing diversity in those affected, with a pronounced increase in cases among vulnerable groups, including Aboriginal people, women of childbearing age, people who inject drugs and homeless people. Between 2015 and 2019 there has been a threefold increase in infectious syphilis notifications in the metropolitan area. In the past 18 months there have been 26 notifications among homeless people, compared to six in the previous four years. There have been 57 notifications in Aboriginal people in the past 18 months, compared to 23 notifications in the previous four years. In the first half of 2020 there have been eight notifications in women who were pregnant at the time of diagnosis. Most alarmingly, there have been two cases of congenital syphilis in Perth
since 2018, including a stillborn, preterm child delivered in a hospital emergency department. In response to the changing epidemiology, the WA Department of Health’s Chief Health Officer has declared a syphilis outbreak in vulnerable groups in the Perth area, affecting: • People experiencing homelessness, including couch surfing • People experiencing acute mental illness • People who inject drugs • Young Aboriginal and nonAboriginal people • Culturally and linguistically diverse people Clinicians should offer screening for syphilis in all persons attending for diagnosis and treatment of any STI, or where screening for STIs is indicated. This is particularly important among pregnant women and women of child bearing age. Be aware that most pregnant women are sexually active and some change sex partners during pregnancy. Offer opportunistic syphilis blood testing to patients from the identified vulnerable populations whenever they present for healthcare, including, antenatal, drug treatment and primary health care services. Whilst engaging in conversations and risk assessment regarding sexuality and sexual behaviours can be complex and may take some clinicians and their patients outside of their comfort zones, it is important to be having these conversations to raise awareness of the increasing risk of syphilis.
Key changes in syphilis epidemiology in vulnerable populations, Perth metropolitan area, 2015 to 15 June 2020
When talking about risk of STIs, remember to: • Emphasise that the purpose of the conversation is to detect and treat STIs early to minimise the risk of transmission and longterm health issues caused by undiagnosed disease, including syphilis; • Use gender neutral pronouns for partners;
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• Reassure the patient about confidentiality; • Not to assume anything about the patient’s sexual behaviours or those of their sexual partner/s; • Ask about other risk factors for STIs and blood-borne viruses such as injecting drug use, including methamphetamine. Infectious syphilis should be treated with benzathine penicillin 2.4 million units IMI stat, given as a half dose into each buttock using pre-filled syringes. Benzathine penicillin is available free via the PBS doctor’s bag. It is important to take a blood test for syphilis on the day of treatment so the response to treatment can be monitored. Contacts of a confirmed syphilis case should receive the same treatment empirically, at the time of testing. All newly diagnosed cases of syphilis should be notified promptly to the Department of Health. Doctors may also contact Metropolitan Communicable Disease Control (MCDC) on 9222 8588, Mon-Fri 8am-5pm for assistance with contact tracing and advice on management. A suite of resources is available through dohquickmail.com.au. The WA Department of Health has also commissioned a professional development online learning platform that can be accessed free of charge at lms.ashm.org.au. Resources and guidelines are also available at https://ww2.health. wa.gov.au/Articles/U_Z/WASyphilis-outbreak-response. Further information regarding STI testing, management and contact tracing is available at http://ww2.health.wa.gov.au/Silverbook - WA Guidelines for Managing Sexually Transmitted Infections (Silver Book). ED: Prof Mak is a member of the WA Communicable Disease Control Directorate.
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Clinical Updates Musculoskeletal issue
Muscles and movement By Dr Joe Kosterich, Clinical Editor The second weekend in September saw the first blast of genuine spring weather. Like many others, certainty judging by the crowds at Bunnings, it was time to get into the garden and do the jobs around the house that had been too hard to contemplate on rainy weekends. But of course, to put new plants in the garden means digging out existing ones, moving soil and applying potting mix and mulch. By Sunday night I was certainly aware of muscles that I hadn’t thought about for a while. The musculoskeletal system is the biggest part of the body yet it can get less attention than other body systems. Problems from it tend to cause long-term symptoms rather than acute or lifethreatening illness. The Australian Institute of Health and Welfare (AIHW) published a report in May 2020 where it estimated that one in five Australians or 1.6 million over the age of 45 experienced chronic pain in 2016. It noted that pain encounters in general practice had risen 67% in a decade. Most of this comes from the musculoskeletal system. This month we have articles looking at aspects of this including the common problems of hip and knee arthritis and sacroiliac pain. Both remind us that accurate assessment is vital before launching into treatment. And there are a range of treatment options, so selection is important. Rehab and pre-operative planning are examined. We also know that treatment is not always as effective as we (and the patient) would like. Medicinal cannabis is a new, albeit ancient, treatment which has been legal in Australia for over three years now and its use is also covered. For the record I have a role as medical advisor to Little Green Pharma. Scleroderma is a less common cause of musculoskeletal, and another system, symptoms. A reminder about such conditions is also timely. This month we also have articles on assessment of nipple discharge and an update on management of bowel cancer. Once upon a time, humans didn’t need to exercise as most work was physical. Today most work is sedentary. However, we need to look after our musculoskeletal system too and regular exercise is the key. As doctors we are sometimes guilty of not practising what we preach. With warmer weather and sunshine upon us, it is the best time of year to get outside for a walk, run, bike ride or swim. Maybe get out into the garden too!
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Medicinal cannabis in managing musculoskeletal pain By C/Prof Alistair Vickery, GP, West Leederville The most common conditions associated with chronic musculoskeletal pain are back pain, osteoarthrosis joint pain, osteoporosis, rheumatic diseases, and cancer. The use of cannabis for musculoskeletal pain pre-dates recorded history. The Assyrians, Persians, Chinese and Indians used the cannabis plant as medicine for millennia. Irish physician and inventor Dr William O’Shaughnessy first introduced cannabis research into Western medicine in 1843, writing that cannabis “is extensively employed for a multitude of affections especially those in which spasm or neuralgic pain are prominent symptoms”. Prohibition of cannabis use and cultivation began in 1937 and medicinal cannabis was not available by medical prescription in Australia until November 2016. ‘Medicinal cannabis’ in Australia are pharmaceutical-grade (made to Good Manufacturing Practice standards), highly regulated products containing precise quantities and combinations of, 9 -tetrahydrocannabinol (THC) and cannabidiol (CBD) in oils, capsules, tablets and vaporisers. THC and CBD, the two most common cannabinoids in the cannabis plant, were first described in the 1960s and are partial agonists of the human endocannabinoid system (ECS).
length of treatment and stability. Each patient requires individual authority except from specialised authorised prescribers. Australia has a unique opportunity to examine the effectiveness and safety of medicinal cannabis for approved conditions. In many jurisdictions (e.g. Canada, Israel, and most states of the USA) access to the cannabis plant with unregulated concentrations, variable delivery and unknown combinations of hundreds of cannabinoids, terpenes, flavonoids etc, is legal for recreational use or dispensed for medicinal use. Care should be taken in interpreting the outcomes of many systematic reviews as they necessarily conflate studies of unregulated botanicals for medicinal purposes (i.e. recreational cannabis) with studies using pharmaceuticalgrade medicinal cannabis. However, such reviews have demonstrated sufficient evidence for the approval of cannabinoids in management of chronic musculoskeletal pain, particularly in neuropathic pain. Reviews of medicinal cannabis such
as Nabiximols (a registered 1:1 ratio of THC/CBD for pain from muscular spasm in multiple sclerosis) are more convincing, demonstrating that medicinal cannabis may have a role in managing chronic pain, particularly neuropathic-type pain, with a response rate of 67% and a 50% improvement in perceived pain scores. Interestingly, the presence of anxiety and stress were found to be important predictors of response to treatment. Further, surveillance studies have demonstrated that medicinal cannabis has low potential for harm, is well tolerated, and is helpful to patients. Additionally, cannabinoids have the potential for opioid sparing in those with pain. In Israel, 97% of pain physicians prescribe medicinal cannabis and 88% rated opiates more hazardous. Health Quality Ontario in 2018 issued quality standards for prescribing for chronic musculoskeletal pain, stating that opioid therapy should only be continued on Page 35
The ubiquity of the ECS in all homeostatic body systems has stimulated interest in the ECS’s importance and function and in the medicinal properties of the plant-based phytocannabinoids which mimic the neuromodulating endocannabinoids. However, studies until recently remained scarce as research grants and licensing were difficult for the past 80 years due to its illegality. Medicinal cannabis prescribing is subject to strict regulation by the TGA for appropriate clinical indications, dosing, formulation, 34 | OCTOBER 2020
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CLINICAL UPDATE
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CLINICAL UPDATE
Sacroiliac joint pain, the great masquerader By Dr Brian Lee, Pain Specialist, Nedlands Back pain affects up to 80% of Australians at some point in their lifetime. A commonly overlooked cause of this is sacroiliac joint pain, which some estimate to be involved in 15-30% of back pain presentation. The sacroiliac joint (SIJ) connects the sacrum to the pelvic girdle. It is a strong, ligamentous joint supported by musculature, and primarily functions to absorb shock between the upper body and the pelvis/legs and allows for very little motion. Issues may arise when the SIJ is too lax and allows too much movement, is fixed and moves little, or is inflamed (sacroiliitis) due to degeneration (compounded by joint laxity), infection or autoimmune conditions. Sacroiliac joint pain can be a great masquerader, often mimicking symptoms felt with other causes of back pain: • Dull, aching lumbar axial pain, typically radiating to the buttock, is similar to that of facetogenic axial pain. It can accompany lumbosacral stiffness and reduced range of motion, particularly flexion. • Sharp pain radiating to the buttocks/posterior thigh, and rarely extend beyond the knee down into ankle, is similar to radicular pain. This commonly
Key messages
SIJ pain may account for up to 30% of low back pain
Diagnosis can be challenging Treatment is multidisciplinary. occurs on weightbearing on affected side and worsens with climbing stairs or stepping on an uneven ground. While SIJ pain can be seen in patients of all ages and gender, there are risk factors. • Pregnancy and childbirth with progesterone-induced ligament laxity and hypermobility and associated weight gain. which may persist well after childbirth and cause ongoing pain • Gait instability (e.g. leg length discrepancy or scoliosis) causing uneven pressure on one side of the pelvis, accelerating degeneration • Previous spinal surgery, especially in the cases of lumbar fusion. In general, due to inherent immobility in fused sections of vertebrae, degeneration will be accelerated in neighboring facet joints or SIJ • Repetitive stress, including heavy lifting and laborious work.
challenging. Patients tend to report their pain as being ‘below the beltline’ and unilateral rather than central. A common description is a localised ache on one side of the sacrum that radiates to the ipsilateral buttock and posterior thigh. Examination may reveal a focal tenderness and reproducible pain on the PSIS, which directly overlies the SIJ. A positive response to a SIJ injection of local anaesthetic greatly increases diagnostic accuracy. Treatment for SIJ pain is multidisciplinary, involving extensive physiotherapy input to strengthen the supporting musculature, stretching and relieving associated muscle tension, and potential use of a pelvic brace. Judicious use of non-opioid analgesia will aid in rehabilitation. A pain specialist can aid with procedural relief, including both SIJ injections and radiofrequency ablation (rhizotomy) of lateral branches of sacral nerves that innervate the joint. Patients with severe laxity may find prolotherapy helpful in strengthening the ligamentous structure. A subset of patients may require a surgical fixation in treatment-resistant cases. Author competing interests – nil
Diagnosis of SIJ pain can be
Medicinal cannabis in managing musculoskeletal pain continued from Page 34 trialled after other therapies, such as cannabinoids, have been tried. The non-psychoactive cannabinoid, cannabidiol (CBD) alone has shown promise as an anti-inflammatory and anxiolytic. It is a safe non-intoxicant and in many jurisdictions is available over the counter. However, a UK review of over the counter CBD found that 40% contained no cannabinoids at all, 20% contained
THC which is illegal, and 20% contained inactive cannabinoids. Fortunately, in Australia, prescribed CBD products are only available by authority and are produced with certification of Good Manufacturing Practice. For musculoskeletal pain, CBD has been shown to have antiinflammatory effects in rheumatic pain in animal models. Medicinal cannabis is well-tolerated with fewer harms than with opiates
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and has demonstrated efficacy for pain reduction and opioid sparing. Dosing and ratios of THC and CBD need to be managed and monitored slowly and carefully to optimise outcomes and to reduce adverse effects in addition to managing patients with complex multi-morbidity. – References available on request Author competing interests – the author is medical director of Emerald Clinics
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Why Mount Hospital... Mount Hospital is a prominent provider of Orthopaedic Services. Our orthopaedic service attracts world class athletes and patients of all ages due to the reputation of our orthopaedic surgeons supported by our excellent staff and facilities. To find out more please visit: mounthospital.com.au/services/orthopaedics or phone 08 9327 1100.
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Mr Homan Zandi Shoulder, Elbow, Wrist & Hand
To view a complete list of our Orthopaedic Surgeons, please use the Specialist Search at healthscopeassist.com.au
Mount Hospital by Healthscope
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CLINICAL OPINION
Multidisciplinary approach improving spinal outcomes By Dr Greg Cunningham, Spinal Surgeon, Murdoch Advances in spinal surgical technology with changing population demographics has led to an increasing rate of spinal surgeries of approximately 5% every year. This acceleration necessitates advancement in preand post-operative care. Enhanced Recovery After Surgery (ERAS) protocols were first reported in the 1990s, pioneered post-operatively following colorectal surgery. Publications on care improvement now span surgical disciplines. The newest ERAS protocols for spine surgery incorporate pre- and post-operative treatment, acknowledging the journey can be enhanced long before theatre. Modern ERAS protocols in spinal surgery can include pre-operative: Prehab physiotherapy, patient/ carer education with home/ occupation assessment and the input of a pain specialist, physician or clinical psychologist depending on circumstances This multidisciplinary biopsychosocial approach reduces pain, disability, kinesiophobia and
Key messages
Enhanced Recovery After Surgery (ERAS) can expedite recovery after spinal surgery A perioperative biopsychosocial approach is used to improve outcomes A similar approach has been adapted for non-operative patient management.
anxiety/depression. Pre-surgery physiotherapy can decrease pain, risk of avoidance behaviour, and worsening of psychological wellbeing improving quality of life and physical activity. Anecdotally, in our practice, we see improvements with patients rapidly engaging with allied-health providers with whom they are already familiar, knowing exactly what to expect after surgery expediting their recovery. Post-operatively, the sooner spinal-surgery patients mobilise, the less oral analgesic/antiemetic medications is required and the shorter their hospital stay. Patients having simple decompressions to
complex multilevel fusions can be mobilised on the day of surgery, facilitated by their pre-operative training and education. Multidisciplinary care is vital for non-surgical spinal patients too. Input from pain specialists, rehabilitation physicians, physiotherapists and clinical psychologists improves patient outcome measures and functional/ occupation return. Treatment involves individual goal setting, addressing fear-avoidance behaviours and self-management strategies, promoting self-efficacy and sustainable long-term outcomes. The latest multidisciplinary approaches encompassing the biopsychosocial patient model demonstrates improved patient outcomes shorter hospitalisations and faster functional return. – References available on request ED The author acknowledges the input of Ceri Pritchard and Hayley French in the writing of this update.
Professor Richard Naunton Morgan — General Surgeon MBBS FRCS AMC FRACS
South Perth Hospital is pleased to advise Professor Richard Naunton Morgan, General Surgeon, has commenced a General Surgical service. Professor Naunton Morgan consults at 72 South Terrace, South Perth. Consultation bookings: 0466 342 100 Postal address: PO Box 214, Como WA 6952 Professor Naunton Morgan and his anaesthetist are no gap providers.
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OCTOBER 2020 | 37
38 | OCTOBER 2020
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CLINICAL OPINION
Rectal cancer: Optimising and individualising decision making By Dr Nigel Barwood, Colorectal Surgeon, Murdoch The five-year survival rate for colorectal cancer in Australia is currently over 70%, 10% higher than in the UK. WA has the world’s best CRCa survival rate. Screening and early diagnosis by colonoscopy are critical.
Key messages
Colorectal cancer survival is strongly stage dependent. Early investigation is critical.
Rectal cancers must be discussed at a dedicated colorectal MDT, and treated by subspecialists with high caseload and a dedicated specialist colorectal nurse.
Previously the patient was told how their cancer is best managed. We now incorporate the patient’s desires regarding their treatment, which often differs from our recommendations (e.g. an elderly patient wishing to trade lower morbidity for less cancer control). Local rectal cancer recurrence rates are now well under 5% (20-30% one generation ago) due to improved preoperative staging, selective adjuvant chemoradiotherapy and standardised total mesorectal excision (TME) surgery performed by colorectal subspecialists. Preoperative staging involves CT and or PET scan for metastases and pelvic MRI for T stage, Node status, EMVI (extramural venous invasion)
and MRF (Mesorectal fascia) status. Radiotherapy can often be given as short course (one week, lowdose) with surgery the following week. Patients may prefer this, and results are equivalent. Long course chemoradiotherapy is preferred for more advanced and lower third tumours. Adjuvant chemotherapy was six months, but three months is now adequate for many. Locally advanced tumours threatening the resection margin can be down-staged preoperatively
Extensive mesorectal nodal metastases and EMVI
Sacrum
Uterus
Mesorectal fascia
Primary mid rectal cancer
Tumour extension into Pouch of Douglas
us Cervix
a gi n Va
Pubic bone
Co ccy x
Bladder
Anal canal
Saggital MRI of 39yo lady with locally advanced rectal cancer. Managed by Total neoadjuvant therapy (chemo then ChemoRT) followed by anterior pelvic exenteration Saggital MRI of 39yo anterior lady withresection locally advanced rectal cancer. Salpingooophorectomy) Managed by Total neoadjuvant (Ultralow + Hysterectomy/Bilat
therapy (chemo then ChemoRT) followed by anterior pelvic exenteration (Ultralow anterior resection + Hysterectomy/Bilat Salpingooophorectomy) MEDICAL FORUM | MUSCULOSKELETAL ISSUE
with TNT (Total Neoadjuvant Chemoradiotherapy – long course chemoradiotherapy plus Folfox chemotherapy). T4 or recurrent rectal cancers are often referred to pelvic exenteration units for extended resections with clear margins the aim. Highly selected patients with a complete response to chemoradiotherapy may be offered ‘watch and wait’ (intensive follow up with resection only if tumour regrows). Metastases are resected where possible for cure. If not, palliative chemotherapy offers a median survival around three years and the primary usually isn’t resected. The acceptable distal margin is now up to 10mm. Resections can involve small parts of the upper sphincter complex in selected patients so very few need a permanent stoma. Early polyp cancers may be manageable by colonoscopic resection, or surgical wide transanal wide local excision. Minimally invasive rectal resection (Laparoscopic, robotic and Transanal TME) require a very high level of expertise and specific credentialing and should be used selectively only by experts. Most rectal resections in Australia are open. Hybrid resections e.g. colon mobilisation lap + pelvis open are a good alternative. No two patients or rectal cancers are the same. Different treatment options exist for each patient, making the decision-making process highly complex. Multidisciplinary team (MDT) discussion is mandatory. Multiple appointments with the colorectal surgeon and where needed radiotherapist, oncologist, stomal therapist. A specialist colorectal nurse is a key team member responsible for coordinating the MDT, educating and assisting the patient end to end along their cancer journey. Nurses often hear a different perspective to cancer specialists and can provide critical information for optimising rectal cancer treatment. Author competing interests – nil OCTOBER 2020 | 39
Systemic sclerosis – a team approach By Dr Janet Roddy, Rheumatologist, Shenton Park Systemic sclerosis, (scleroderma) is a multi-system, heterogeneous condition. The clinical manifestations are a result of vascular system and fibroblast pathology. Most existing therapies are vasoactive or immunomodulatory. There are recognised associations between anti-centromere antibodies (ACA) and limited disease, anti-Scl-70 (anti-topo 1) with diffuse disease plus interstitial lung disease, anti-RNA polymerase III (RNAPIII) with diffuse disease plus renal cell crisis. Anti-PM/ Scl is associated with myositis/ scleroderma overlap. Correlations, such as the increased cancer risk seen in anti-RNA PMIII positive patients may be helpful clinically. Raynaud’s disease present in up to 90% of scleroderma patients,
Key messages
Scleroderma is a heterogeneous disease.
Careful monitoring and early treatment may prevent organ damage resulting in reduced morbidity and mortality. Therapy is geared to the organ involved with early immunosuppression in rapidly progressive diffuse disease.
is often refractory to Nifedipine and may be complicated by digital ulcers. Therapy with PDE5 inhibitors (sildenafil or tadalafil) and intravenous iloprost is often required. Bosentan, an endothelial receptor antagonist (ERA), may prevent recurrence of severe digital ulcers.
Very few patients with isolated Raynaud’s develop scleroderma, but look for finger pulp pitting, abnormal nailfold capillaries or scleroderma antibodies. Skin thickening, the hallmark of systemic sclerosis, begins distally often with puffy fingers and progresses proximally. Skin thickening reaching above the elbows and knees defines diffuse disease. These patients are at risk of internal organ involvement especially during the first three to five years. Pulmonary arterial hypertension may occur at any time, often in patients with limited scleroderma. Home blood pressure monitoring may detect an early scleroderma renal crisis. Rapid introduction of ACE inhibitor therapy markedly improves outcome in this medical emergency.
Has your patient been injured at work or in a motor vehicle accident ? Guardian Exercise Rehabilitation has 20 years’ experience in rehabilitation interventions. Guardian Exercise Rehabilitation’s allied health clinicians provide treatment and prescription of therapeutic exercise-based programs for individuals afflicted with injury or illness, principally under a compensable-injury policy.
Experienced team of mobile Physiotherapists and Exercise Physiologists Industry leaders in clinical exercise interventions Outcomes focused with self-efficacy for clients Video consultations for remote patients throughout WA Our clinicians consult clients across a broad spectrum of injuries and illnesses, with significant experience in both musculoskeletal injuries and mental illnesses. We consult clients throughout their recovery journey, from early intervention through to chronicity management. We adopt a biopsychosocial approach with emphasis on collaboration, education and empowerment. Our programs optimise function and healthy re-engagement in work, as well as everyday and recreational activities. Referring to Guardian Exercise Rehabilitation will ensure your patient receives the most appropriate treatment required for the stage and complexity of their injury or condition. E-Refer now at guardianexercise.com.au
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40 | OCTOBER 2020
E. admin@guardianexercise.com.au
Mobile services: Physiotherapy | Exercise Physiology
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CLINICAL UPDATE
CURRENT APPROACH ASIG STANDARD SSc Patients TTE Primary Screening Tool
TTE & PFTs Repeat in 12 months
Screen Positive sPAP>40mmHg or DLCO<50%*
Right Heart Catheterisation
PAH
Screen Negative sPAP<40mmHg or DLCO>50%*
combination with other therapies has reduced mortality. Immunosuppressive agents (e.g. Methotrexate, mycophenolate, cyclophosphamide and rituximab) are used to treat early progressive disease depending on organ involvement, severity and progression.
Low Probability of PAH
No PAH
Figure 1- Australia Scleroderma Interest Group (ASIG) current approach for screening for Pulmonary arterial hypertension.
Pulmonary arterial hypertension (PAH) and interstitial lung disease accounts for most disease related mortality in scleroderma. The current approach for PAH screening is shown in figure 1. Treatment of PAH with ERAs alone or in
Three randomised controlled trials found improved survival in select patients receiving autologous stem cell transplant compared to cyclophosphamide. Transplantrelated mortality is significant, so patient selection and centre experience is crucial if considering this option.
Oesophageal reflux disease often requires high-dose proton pump inhibitor, in combination with H2 receptor antagonists. Small intestinal bacterial overgrowth (SIBO) may respond to an empirical course of rotating antibiotics. Rectal sphincter incontinence is common. Endoscopy or colonoscopy is often required, especially in patients not responding to therapy. Steroids may be necessary in some patients. However, be aware of the increased risk of renal cell crisis associated with prednisolone. References available on request Author competing interests – nil
The entire gastrointestinal tract may be involved in scleroderma.
“ When Annie lost her hearing, she began to lose her connection with Jack, too. I just had to do something.
Nezha Delorme, Amana Living Client Services Manager
“
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CLINICAL OPINION
“Annie had a stroke and lost her hearing. It became so hard for her to communicate with her friends and family, and it was especially hard on her husband, Jack, who loves her dearly and is her prime carer. During my training I’d learned how relationships can become strained as physical or communication difficulties arise. So, with the help of our IT team, we created a solution. We got an iPad for Annie and showed them how to use dictation software that converted Jack’s spoken words into text. It brought so much happiness back into their lives. And into mine.” Professionally trained. Naturally kind.
1300 26 26 26 | amanaliving.com.au
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OCTOBER 2020 | 41
Hip and knee osteoarthritis By Dr Brett Bairstow, Orthopaedic Surgeon, Mt Lawley & Carine Degenerative joint disease (osteoarthritis, OA) can have no clear aetiology (‘primary’ or ‘intrinsic’) or be ‘secondary’ to another pathology (e.g. trauma, sepsis, congenital). Primary and secondary factors can both be involved with the former modifying susceptibility and the latter affecting the onset age and location of disease. While symptoms include stiffness, loss of range, deformity, limp, weakness and functional limitation, pain is mainly why relief is sought. OA pain from the hip commonly presents in the groin or thigh, less commonly in the buttock or knee. OA pain from the knee is more commonly localised, but the hip and spine still need to be considered as potential sources.
The pain from hip and knee OA is usually gradual onset, mechanical (i.e. movement related) and associated with other complaints, as above, that can help with localisation. Patients with hip (not knee) arthritis often have issues with footcare and footwear. Illuminating questions focus on walking distance before stopping, use of supports (e.g. crutches or supermarket trolley) and difficulties with routine activities such as sitting in and rising from chairs. Examination starts in the waiting room. Evaluate walking, standing, sitting and any use of walking aids. Walking pattern can reveal stiffness (short swing), pain (short stance) and weakness (e.g. Trendelenburg). When supine, passive joint movement assesses symmetry, stiffness, range and stability.
Measures of joint range need not be absolute to help localise issues. Assessing leg length discrepancy, both apparent (to eye) and true (accounting for deformities) helps. Radiology is important and doesn’t need to be invasive (e.g. arthrograms) or expensive (e.g. MRI) if the diagnosis is suspected OA. For the hip an AP pelvis and AP/lateral hip (of the affected side) provides information regarding morphology and relative leg length. If surgical referral is likely, ask for films at 120% template magnification (allows for preoperative prosthesis sizing) and centred on pubis (shows more femur). Most hip surgeons still prefer hardcopy films. For the knee, AP weightbearing knees and lateral/skyline/notch views of the affected knee define the location and extent of degenerative
Cosmetic breast injections Bilateral cranio-caudal mammogram views of a woman with silicone injections
osmetic breast augmentation may involve the direct injection of C foreign substances into the breast, including silicone, Macrolane (a gel based on hyaluronic acid), polyacrylamide hydrogel (PAAG)
or fat. Often these foreign substances make the interpretation of screening mammograms difficult, as the substance and associated reactive calcification obscures normal breast tissue. The sensitivity of screening mammograms is severely reduced for women with cosmetic breast injections and the rate of false positives increased. When a woman attending BreastScreen WA indicates that she has had a foreign substance injected into her breasts, only one mammographic view is performed in the first instance. If this image confirms the presence of a foreign substance injected into the breast the screening procedure is stopped to prevent unnecessarily irradiating women when there is no prospect of obtaining an adequate study. An explanation to the woman is provided that screening mammography is not a suitable test for her to detect breast cancer. The woman and her GP will receive a letter explaining the reason for not completing the mammogram and that she will no longer receive invitations to attend for screening mammography. GPs may consider performing regular clinic examinations and breast ultrasound if the woman requests screening options.
www.breastscreen.health.wa.gov.au 42 | OCTOBER 2020
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CLINICAL UPDATE
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CLINICAL OPINION changes in stance in both knees and the extent throughout the more symptomatic knee. Specific magnifications are usually not critical in initial knee radiographs. Treatment is symptom based. Simple analgesics, appropriate use of anti-inflammatories, maintenance of low-impact mobility, minimising provoking activities, weight optimisation (where indicated) and possibly walking aids remain the mainstay of management. Don’t inject knees that aren’t going to respond to injections as this precludes implant surgery for three months. Majority consensus is that knee arthroscopic intervention does not have a role in the management of the articular surface disease itself but may have a role in non-endstage OA joints for symptomatic (in comparison to imaging-detected) meniscal pathology and relief of locking from loose bodies. Arthroplasty (joint replacement) is reserved for patients with conclusive OA with significant painful symptoms not ameliorated by a thorough trial of conservative measures. While joint
A
B
A. 120% AP views used to template prosthesis. B. Weightbearing AP views show narrowing (inset: operative pic). replacement surgery may assist with mobility, gait, subjective stiffness, deformity and function, it may not, and should be viewed as a measure to relieve pain resistant to reasonable lesser measures.
but they are significant endstage procedures primarily for the relief of otherwise intractable pain. – References available on request Author competing interest – nil
Hip and knee replacements do provide good long-term relief of symptoms in the majority of patients with OA who receive them,
Neuro Spinal Surgical Services, for privately insured and workers compensation patients. Neurospine Institute is a multi-disciplinary specialist practice offering advice and treatment across the full range of spine and brain conditions. Also offering: Spine Focused Physiotherapy Treatment Service for patients in need of treatment for back and neck pain, rehabilitation or recovery following injury or spinal surgery.
Dr. Paul Taylor Spine Surgeon
3 CONVENIENT LOCATIONS Murdoch | Perth | Wembley Plus regional clinics in Mandurah, Vasse, Albany and Geraldton.
Neurosurgery | Spine Surgery | Pain Specialist Medicine | Rehabilitation Medicine Perioperative & General Medicine | Spinal Physiotherapy | Workers Compensation
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Dr. Andrew Miles Neurosurgeon
Dr. Greg Cunningham Spine Surgeon
Dr. Michael Kern Neurosurgeon
GP EDUCATION
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1800 NEUROSPINE info@nsiwa.com.au (1800 638 767) � nsiwa.com.au (08) 6147 8200
OCTOBER 2020 | 43
Nipple Discharge By Dr Jose Cid Fernandez, Oncoplastic Breast Surgeon, Perth Most nipple discharge is benign in nature not requiring any surgical intervention. Up to 10% of cases harbour an underlying in situ or invasive malignancy. Assessment is aimed at differentiating these causes.
by abnormally high prolactin levels secondary to a pituitary tumour, or by hypothyroidism. Hyperprolactinemia (>1000 mIU/L) can be caused by some drugs (e.g. oral contraceptives, HRT, antidepressants, opiates, and some antihypertensives).
Nipple discharge elicited by squeezing of the nipple or from pressure on the breast (e.g. postmammogram) is physiological and not of concern, as is milk production during pregnancy and for several months after cessation of breast feeding.
Important features to ascertain from history are whether the discharge arises from one duct or many, is induced or spontaneous, is coloured or bloodstained, and if affecting one or both breasts. Note also the discharge frequency and consistency. Breast examination may indicate the presence or absence of a breast mass, or an abnormality affecting the skin of the nipple and areola.
Thick yellow/brown discharge from multiple ducts, unilateral or bilateral, can result from duct ectasia, a benign dilatation of the terminal milk ducts more prevalent in postmenopausal women.
Investigations Mammography is particularly useful in women over age 35. It specifically looks for microcalcifications suggestive of DCIS. Ultrasound can identify papillomas and cancers in ducts close to the nipple. Discharge fluid cytology has poor sensitivity to
Bloodstained single duct discharge is more likely to be associated with intraductal papillomas, epithelial hyperplasia, or less commonly DCIS or invasive carcinoma. Association with an underlying malignancy is more frequent in older patients.
Galactorrhoea is pale milky discharge arising from multiple ducts, spontaneous, bilateral, often copious, unrelated to pregnancy or occurring long after discontinuation of breast feeding. It can be caused
Nipple Discharge Breast Examination Abnormal Breast Lump
Normal
Eczematous Nipple Areola
Multiple Ducts
Single Duct
or Discolouration Full thickness punch biopsy
Not troublesome
Bothersome/
Not blood stained
Blood stained
Persistent Pagetâ&#x20AC;&#x2122;s disease
Benign Bilateral Milky White
TSH/Prolactine levels
Yellow/Brown
Investigate
Investigate
and treat
and treat
Follow Normal pathway
Reassure
Treat
Normal
Total Duct Excision
Cytology
Ultrasound
Ultrasound
Mammogram
Mammogram
CytolgoyUltrasound/Mammogram
and review medication
Abnormal
Cytology
Abnormal
Abnormal
Investigate and treat
Normal
Total Duct Excision
Normal
Not bothersome
Investigate
Mammogram
and treat
and Ultrasound
Bothersome
Microdochectomy
Abnormal
Investigate
Normal
Microdochectomy
and treat
in 1 year
44 | OCTOBER 2020
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CLINICAL UPDATE
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CLINICAL OPINION
Key messages
Bilateral milky discharge may be physiological or caused by pituitary tumours, hypothyroidism, and drugs Mammography, breast ultrasound, and discharge cytology can detect underlying ductal pathology Singe duct persistent or bloodstained discharge requires surgery to exclude malignancy.
detect malignancy. However, in the absence of clinical concerns or imaging abnormalities, a smear showing normal epithelial cells with no atypia can be reassuring. Hemoccult testing for presence of blood in the discharge fluid has poor sensitivity. Ductography and ductoscopy, where available, can be useful adjuncts to localise intraductal lesions before surgery. Check prolactin and TSH levels if discharge is bilateral, multi-duct and white. Colour and eczematous changes of the nipple and areola are investigated with full thickness biopsy under local anaesthesia to exclude Paget’s disease.
Management When discharge is associated with a significant abnormality, such as a breast lump on examination,
calcified DCIS on mammography, or Paget’s disease of the nipple on punch biopsy, comprehensive assessment of this usually requires further investigations tailored to the underlying condition before definitive surgical treatment. If no significant abnormality is found on clinical examination or imaging, the patient is managed according to whether the discharge is from multiple ducts or from a single duct, as follows: Multi-duct discharge without worrying features, and transient or not affecting quality of life, does not require treatment; reassurance is often enough. For discharge on breast expression, advise women to avoid squeezing their nipples and breasts. Persistent and/or bothersome discharge can be treated surgically by total duct excision carried out through a circumareolar skin incision, then
dividing the milk ducts from the underside of the nipple. Single duct discharge that is not bloodstained and is transient or intermittent can be reassessed with repeat mammogram and ultrasound at 12 months. Surgery is indicated if the discharge is either bloodstained or persistent (over twice per week) or associated with an underlying papilloma or with atypical cells on cytology. A single milk duct can be removed by microdochectomy. This requires identification and cannulation of the offending duct with a small probe prior to dissecting it from surrounding breast tissue. Total duct excision is less likely to miss an underlying malignancy, and thus a good alternative to microdochectomy for women not concerned with the ability to preserve breast feeding. Author competing interests – nil
Dr Manisha Doohan — Gynaecologist MBBS, MRCOG (UK), FRANZCOG
Dr Manisha Doohan, is a consultant in Obstetrics and Gynaecology (O & G). She has been a member of the Royal College of Obstetricians and Gynaecologists (MRCOG), London, since 2012. Having worked in this field since 2004, Dr Doohan completed her basic and advanced training, gaining Certificate of Completion of Training (CCT) from GMC, UK. She worked as a consultant in the UK and held various managerial positions. In 2018, Dr Doohan moved to Perth to join as a consultant in O & G at the King Edwards Memorial Hospital. She is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG). Dr Doohan has special interests in pelvic pain, contraception, sterilisation, colposcopy, endometriosis, fibroids, menstrual disorders, menopause, prolapse, endometrial ablation, advanced laparoscopic surgery including hysterectomy.
Consultations at: South Perth Hospital, Perth Women’s Health, 76 South Terrace, South Perth 6151 Email: md@perthwh.com
Enquiries: 0402 883 324 For referrals: healthlink—perthwom www.perthwomenshealth.com
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OCTOBER 2020 | 45
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OUTREACH
Moving in a new direction Physiotherapist Julie Sprigg went to Ethiopia to help that country’s battered health system and it changed her life.
Ara Jansen reports
When Julie Sprigg arrived in Ethiopia, she was armed with a belief that her physiotherapy skills could be put to work and a simple thought – she was there to do good. Her debut book, Small Steps: A Physio in Ethiopia, charts two adventurous years in the African nation where Sprigg volunteered at a convict clinic and then taught the country’s first physiotherapists to graduate from University of Gondar. “There’s one thing to feel prepared and to be prepared,” says Sprigg, who lives in Perth. “I’d backpacked through developing countries, worked in cross-cultural settings, including a hospital in England. I thought I was ready but I wasn’t prepared for how challenging it would be to work as a professional in a country where I didn’t speak the language and the living standards were incredibly low.
were invaluable and when working together with doctors can achieve exciting results for patients. In the book she talks about Sara, a young girl unable to walk due to a stroke. She also had TB in the chest, lymph nodes, spleen and liver, plus heart failure. She was in hospital for three months, where her father used to carry her on his back to the physio room. Sprigg says the combination of medical intervention and physical rehabilitation got Sara walking again. “She was able to walk home. We dropped her near her village and she walked home with her dad. I was standing on the side of the road with a lump in my throat trying not to cry.
“I also didn’t have any sense of how it would take a toll on my mental health.
“The ability for some of these kids to walk means to be able to go to school and be included in their community. For others it’s the difference between being able to work and begging in the streets.”
“Most of the expats I met went with an agency so they had support and knew other people. In retrospect it was a bit naive to have thought it would be fine to go without one.”
Sprigg says that physiotherapy was a new profession in Ethiopia and since then, more than 600 physiotherapists have been trained and work all over the country.
Her book, which was shortlisted for the 2018 City of Fremantle Hungerford Award, was written across nine years, aided by her meticulous journals (what else was there to do at night in a strange city) and gathered stories about local political turmoil.
“When I arrived at the University of Gondar, there were only seven other physios working across the country. Now there are physiotherapy departments in all the major hospitals in the major cities and towns and people practising in smaller and remote centres.
Collaboration
Life-changing
Sprigg’s work in Ethiopia proved to her that physiotherapy skills
After returning from Ethiopia, Sprigg switched to a career in
46 | OCTOBER 2020
foreign aid and development. She now works for the state government evaluating government programs to overcome social disadvantage and says her physio skills have proven invaluable in this context. Sprigg maintains contact with colleagues she met in Ethiopia as well as some of her students who are working there and overseas. She fell in love with the culture, found it a generally safe place to travel alone and people were helpful, respectful and thoughtful. On balance she says it was a positive experience and more importantly, a life-changing one. It’s also a sobering one when she compares a trip that she took back to Ethiopia in 2013 and saw children with disability in a school with no resources around the time she was due back home to have her kitchen remodelled. These juxtapositions remain difficult. “My time in Ethiopia changed me and continues to be such an influential experience. It has changed how I choose to live my life, accumulate material possessions and the things I prioritise.” ED: Small Steps is published by Fremantle Press.
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WINE REVIEW
Calneggiaâ&#x20AC;&#x2122;s value for money
Review by Dr Louis Papaelias
Mike Calneggia has been a prominent figure in the Western Australian wine industry for many years. His original estate, Selwyn Wines, was sold to Evans and Tate in 1999. Mike continued on with Evans and Tate for two further years following the acquisition. From there he was managing director of Australian Wine Holdings until taking up the reins at Calneggia Family Vineyards in 2007. Whilst at Evans and Tate, Mike met Brian Fletcher the winemaker who was to later become his chief winemaker at Calneggia. The two main vineyards in the company are located at Rosabrook, located 15km east of Margaret River townsite, and Clearview Estate, located at the northern aspect of the Margaret River appellation. Whilst not aiming for the super-premium end of the market, Calneggia has slotted into the niche of producing quality wines that offer value for money. I was offered to taste a sample of four wines from the extensive range. All wines were expertly made and showed very good balance of flavours.
Calneggia Asolo Prosecco, $30
2020 Calneggia Rose $25
This grape hails from northern Italy, produced in a large area spanning nine provinces in the Veneto and Friuli Venezia Giulia regions. The name is taken after the village of Prosecco. The main grape variety originally called Prosecco was renamed as Glera in 2009 within the European Union. Asolo is a town with its own special classification which signifies uniqueness and higher quality than standard Prosecco. Labelled as extra dry the 14g/l of residual sugar is hardly noticeable in this very crisp and fruity sparkling wine. An ideal aperitif, fresh and lively. Alcohol 11.2%
Made by Brian Fletcherâ&#x20AC;&#x2122;s successor, Severine Logan, who took over the reins in 2019. This is mainly shiraz with 3% tempranillo. Lovely pale salmon pink it has lively berry aromas. Attractive young fruit flavours continue through to the clean crisp aftertaste. Alcohol 13.3%
2018 Rosabrook Margaret River Chardonnay $26 Nothing to fault here. Clean pure varietal chardonnay. Ripe peach and melon and some oak seasoning for completeness. All flavours nicely balanced. Crisp clean finish leaving behind a lingering presence. Good value. Alcohol 13.5%.
MEDICAL FORUM | MUSCULOSKELETAL ISSUE
'S EWER I V E R
PICK
2018 Rosabrook Margaret River Cabernet Sauvignon $26
Classic varietal cabernet typical of Margaret River. Initially subdued, this wine opens up with breathing to reveal attractive cassis aromas with hints of olive, green leaf and chocolate wrapped up in nicely firm tannins. Again, like the other wines above, expertly made with no rough edges and a clean dry lingering finish. Good value. Alcohol 14%.
OCTOBER 2020 | 47
Winds of change The mainstage of His Majesty’s Theatre will be full of riotous colour and exuberance – just what we need after lockdown.
Jan Hallam reports. Music lovers in WA have been trickled fed live music since the state moved into phase four of the pandemic restrictions. From October 24, WA Opera flings open the doors of His Majesty’s Theatre for the first time in eight months onto Mozart’s glorious soundscape of Cosi Fan Tutte. It is just a few set-ups into the first act when hearts will be lost to perhaps the most perfect opera trio ever written, Soave sia il vento – May the wind be gentle. If people were told to go home after that number, they would leave satisfied. But luckily there’s a lot more where that came from. The winds have not be so unkind as to blow WA Opera’s 2020 season completely off course. The company has been incredibly creative in bringing opera and local talent to the community with such innovations as its digital opera, The Telephone, video casts with Ghost Light Opera, lunchtime concerts, Standing Room Only at Government House Ballroom, even singing classes for kids and adults. But it also had a stroke of luck having taken possession of the Cosi sets from the acclaimed Glyndebourne Opera production before the world shutdown. 48 | OCTOBER 2020
The original production was directed by UK theatre doyen Nicholas Hytner and had been revived by Bruno Ravella. While Bruno is confined to the UK, Margarete Helgeby Chaney will be his able assistant on the ground here at The Maj. Singers, too, needed to be shuffled but the singing talent pool is deep here in the West so the winds have been favourable there as well. Medical Forum spoke to soprano Prudence Sanders, a WAAPAtrained WA singer who is the only original cast member to make it through to Cosi 2.0 and she is one singer very keen to get herself on stage. She plays Fiordiligi, one the two lasses caught up in a trick to test their fidelity to their fiances. “When everything shut down, I had a lot of work cancelled but it meant I could focus solely on Cosi. It's such a big role that preparation is more akin to marathon training. “I once ran a marathon in Edinburgh during my 10 years studying and working in the UK. That training was months and months of pacing yourself.
Glyndebourne Productions Ltd. Photo: Mike Hoban
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OPERA
“Fiordiligi is a massive role physically and mentally and I had the luxury of going upstairs every day while my mum looked after my children for three hours. It was really fantastic. “But after months and months, I’m very excited to finally join my cast members and work on the next level. It's very much an ensemble piece.” Joining her are Ashlyn Tymms in the role of Dorabella, Paul O’Neill as Ferrando, Sam Roberts-Smith as Guglielmo, James Clayton as Don Alfonso, and Penny Shaw as Despina. The synopsis of the opera, devised by one of Mozart’s favourite librettists Lorenzo Da Ponte, is one to make the blood boil in much the same way as Shakespeare’s Much Ado About Nothing can – men playing games with women’s lives. But it is a comedy and it playfully stretches the bounds of credibility so far it is difficult to sit with fluffed up feathers for too long. And then there’s the music. It really is special. Welcome back WAO!
ED: Cosi fan Tutte will be staged at His Majesty’s Theatre from 24 to 31 October under current WA Government Phase Four restrictions.
MEDICAL FORUM | MUSCULOSKELETAL ISSUE
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