Medical Forum WA 0519 Public Edn by Medical Forum WA

Into the Wild Womenâ&#x20AC;&#x2122;s Health Workplace Culture Pregnancy & Fertility

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May 2019

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EDITORIAL Jan Hallam, Managing Editor

What’s That Buzz? What a month! The world has seen a picture of a real black hole somewhere out there in space. We have an election campaign in progress which will probably uncover many other types of black holes and a whole lot of talk about the need for action to stop our health system from falling into a black hole. The buzz word is sustainable.

all before and, if we’re not cynical, we’re at least wary given that the words ‘will’ and ‘do’ are totally dependent on the election cycle, and that the devil is in the detail. The report delves into eight broad areas – public health, mental health, early childhood, access to care, administration “driving safety, quality and value through transparency, funding and planning”, digital health, workforce and research and innovation. And if there is to be any advancement in any of these areas, which seem so very bogged down currently, a new buzz word needs to spread – collaboration. To prove just how difficult that will be, even at this launch, a disgruntled GP expressed his disappointment that primary care and GPs particularly “as those who drive most health demand”, did not figure strongly enough for his liking.

At the April launch of the final report of the Sustainable Health Review, Health Minister Roger Cook told a CEDA gathering that the entire Cabinet approved the endorsement of the 30 recommendations. He went on to spruik what the government was going to do about them. It filters down to $26.4 million to get the ball rolling on initial projects which include $3.3 million to start the planning for the “co-location” of KEMH to the QE II campus, and four other projects for increased community care, child health and mental health services, with a 20bed medical respite centre for homeless people.

Yep, that old fragmentation chestnut. There is no question that the process wasn’t valuable – it was, but so was the Reid Report and who knows how many other reports. It’s those darn black holes again.

The prevention budget will grow from 1.6% of the health budget to 5% by 2025 – from $140 million a year to $440 million and the focus will be the harms of alcohol and obesity.

Just as the health of the planet has a combustion point, so too has the health system and cranky overweight Baby Boomers are already putting on the pressure. At no point in our history has it been so critical that the ‘will’ and the ‘do’ quickly becomes ‘are’ and ‘doing’.

It was a rousing meeting, full of goodwill and exuberant expectations – but everyone in the system has heard it

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Marketing Manager Felicity Lockyer (0403 282 510) mm@mforum.com.au

MEDICAL FORUM

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

Administration Jasmine Heyden (0425 124 576) jasmine@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

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

MAY 2019 | 1

CONTENTS MAY 2019

INSIDE 10 Close-Up: Prof Con Michael 14 Doctors Drum: Workplace Culture – the Good, the Bad & the Ugly

18 Rural Health Conference:

Healthy Country, Healthy Lives

46 Battling Antarctic Winds to Save Lives

NEWS & VIEWS 1 Editorial: What's That Buzz? - Jan Hallam 4 Letters to the Editor:

Script Monitoring Saves Lives - Christine Campbell A Case In Point - Stephen Milgate Social Prescribing: Zamia Group - Dr Rash Patel 6 Have You Heard? 7 Beneath the Drapes 12 Spotlight: Dr Donna Mak on Culture and Saying Goodbye 20 Medicolegal: Family Violence - Enore Panetta 37 App Review: A Better Visit - Ruth Frazer

LIFESTYLE 48 Funny Side 49 Wine Review: Houghton Heritage - Dr Martin Buck 50 Film 2040 and the Planet’s Future 50 Wine Winner - Dr Sarah Henderson 51 Competitions

14 MAJOR PARTNER 2 | MAY 2019

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CONTENTS MAY 2019 CLINICALS

23 The battle Against S. aureus infections Dr Paul Armstrong

31 Managing Endometriosis in 2019 Dr Rae Watson-Jones

37 Social Egg Freezing Dr Joo Teoh

39 Binge Eating Disorder Dr Vash Singh

32 Functional Hypothalamic Amenorrhea Dr Tamara Hunter

41 How to Triage Chest Pain Dr Michael Muhlmann

33 Recurrent Miscarriage Dr Philip Rowlands

35 Choosing the Right Contraception Dr Alison Creagh

43 Nausea and Vomiting in Pregnancy Dr Chris Gunnell

45 Breathlessness, Cardiac or Respiratory? Ms Cia Connell

GUEST COLUMNS

The Doctors Health Advisory service of WA provides Medical Practitioners with a confidential health service around the clock. How to contact: For doctors in crisis or for those wanting to speak with a DHASWA doctor:

8 Bullying â&#x20AC;&#x201C; Changing Medical Culture Dr Sarah Newman

26 Lifting Flu Jabs in Under-5s Dr Paul Effler

(08) 9321 3098 24 hours/day, 7 days/week

Drs For Drs list is now live at

www.dhaswa.com.au

27 Knowing the Costs of Cancer Ms Melanie Marsh

29 WA: The State of STIs Dr Sally Murray

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), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Mark Hands (Cardiologist), Stephan Millett (Ethicist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon),

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MAY 2019 | 3

Script monitoring saves lives

A case in point

Dear Editor,

Dear Editor

I am among many thousands of parents who have laid to rest their child, knowing the government could’ve helped to prevent it.

I refer to your recent article Retiring Doctors, a Case in Point (April edition, p13), and the experience of Dr David Young an anaesthetist who is no longer working in procedural medicine.

My son, Benjamin James, passed away at the young age of 28 due to an accidental fentanyl overdose in 2015. I tried everything I could to stop Benjamin being prescribed addictive medications. I gave Medicare copies of multiple doctor’s prescriptions and chemist receipts that he’d received in just one day. Nothing was done. Growing up, Benjamin was always an active and passionate sportsman, he had school mates who remained strong friends to the day he passed away. But he found high school very unsettling and was eventually prescribed Valium by a doctor when he was 15. It was the beginning of a long dependence on prescription medications. After Benjamin died, I joined ScriptWise, a national organisation dedicated to preventing prescription medication harms, I saw Kim Ledger in an interview talking about prescription monitoring. All I want to see is change to the system which failed my son. We need national real-time prescription monitoring, more education and awareness for the general public and more treatment options, and we need them now. Ms Christine Campbell, ScriptWise Board

I believe his case is yet another example of the need to reform the AHPRA regulations to allow our senior doctors to continue to contribute and maintain standards of public safety. The stated public position of all major political parties is for senior Australians to maintain their contribution to the Australian economy and the Australian community. It’s time for a registration system that supports that goal, not one that works against it.

...................................................................... SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors.

4 | MAY 2019

Dear Editor, Following on from my Guest Column about Social Prescribing (April edition, P 15), I thought readers would like to know the origins of the Zamia Group. The group can be traced back to August 2018 when, at the end of the Social Impact Summit at UWA, some current members stood in the rain in the uni carpark for over an hour talking passionately about Social Prescribing and the benefits it could bring to patients, the community, health professionals and the ailing health system. Our first meeting took place soon after.

Under current regulations Dr Young cannot be a ‘retired doctor,’ and act as a team doctor for a sporting organisation or the bush fire brigade. The current system is an ‘all or nothing,’ ‘us and them,’ ‘in or out,’ approach, that does not meet the reality of senior doctors gradually stepping down in responsibilities.

Our enthusiasm for Social Prescribing (SP) has not diminished. On the contrary, we have been exploring the practice in the UK and Canada, learning about different strategies and models. The benefits of SP in those experiencing complex and interdependent chronic conditions including mental illness, isolation and other social issues are remarkable on many levels. The WA health system simply cannot afford to miss out on such a potentially effective opportunity.

The current system in my view encourages senior doctors to ‘hang on,’ because there is nowhere really to go other than to leave their profession completely and cease to exist as a medical practitioner.

Our long-term objective is to have SP an integral part of the primary health care system in WA. Our short-term objective is to conduct a pilot project to demonstrate its multiple benefits.

Hopefully more work will be done to allow these doctors to maintain a role whilst at the same time maintaining high standards of public safety. Our proposal for a senior active doctor’s registration category would meet these criteria.

Well-designed SP would potentially reduce GP work-related stress, including frustration linked to the lack of alternatives to prescription medications, thereby improving the health and wellbeing of our GPs.

Australia has the opportunity to develop without any further cost an end of medical career registration system that is worthy of the enormous contribution our doctors make to our wellbeing and welfare.

Benjamin Campbell

Social prescribing: Zamia Group

Mr Stephen Milgate AM, CEO Australian Doctors Federation ......................................................................

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

As a group we are concerned not only about the needs of our patients but also deeply troubled by the growing evidence of deteriorating physical and mental health in doctors, both of whom would benefit from social interventions. The first International Social Prescribing Day was on the March 14, 2019, to highlight the importance and significance of SP within healthcare. To introduce SP successfully in WA we need to have the support and engagement of GPs. For the success of our pilot project, we require input and advice from our local GPs, since they are the ones who will write the social prescriptions! We would like to hear from you, We welcome any feedback. If you would like to be directly involved, please join the Zamia Group. Email us at zamiaconnect@gmail.com Dr Rash Patel, Zamia Group ......................................................................

This publication protects and maintains its editorial independence from all sponsors or advertisers.

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LETTERS TO THE EDITOR

Major Partner: Clinipath Pathology

By Dr Aaron Simpson, Head of Biochemistry

Biochemical Investigation of Infertility Infertility is defined as a failure to conceive after one year of regular unprotected intercourse in women <35 years, and in women aged >35 years, after six months of unprotected intercourse. With the average age of first pregnancies now being 30 years, infertility and its investigation is becoming more common. It should be initiated sooner in women with irregular menstrual cycles or known risk factors for infertility including endometriosis, pelvic inflammatory disease, or reproductive tract malformations. Female infertility, male infertility or a combination of both has notably increased with an estimated 10-18% couples having trouble getting pregnant or having a successful delivery. Causes There are various causes of infertility which may relate to female, male, or both factors. Female causes are usually related to the woman's age, issues with ovulation or pelvic anatomy, such as endometriosis or polycystic ovarian syndrome (PCOS). Male causes include sperm defects or dysfunction. A thorough history and examination usually focuses further diagnostic evaluations. History should focus on infertility duration, menstrual, medical, surgical and gynaecological history. Physical examination includes BMI assessment, thyroid and breast examination, signs of hyperandrogensism, vaginal or cervical abnormality, pelvic/ abdominal tenderness and adnexal masses. Diagnostic tests NICE guidelines propose that an initial infertility evaluation of all couples consists of: Semen analysis: Results should be

KEY MESSAGES Infertility assessment involves both female and male partners. Evaluation includes a comprehensive history and physical exam. Semen analysis, ovulatory status by history or lab testing and checking tubal patency are the ‘basics’. Ovarian reserve is assessed with AMH, day 3 FSH and E2 levels.

interpreted in reference to WHO values which assess; semen volume, pH, sperm concentration, total motility, vitality and morphology. If the first semen analysis is abnormal, repeat testing should be performed because of inherent variability. Assessment of ovulatory function: Women with regular 28-day cycles with molinimar (luteal phase) symptoms are likely to be ovulatory. In those with irregular cycles ovulation assessment should be performed. A progesterone performed 7 days prior to the onset of menses is the most easily documented. An alternative is an over-the-counter ovulation prediction kit that measures urinary lutenising hormone (LH), which provides indirect evidence of ovulation by demonstrating a mid-cycle LH surge. Such kits have a 5-10 percent false positive/ negative rate and confirmation by serum LH measurement may be required. Non biochemical methods include endometrial biopsy, which was once considered ‘gold standard’ but is no longer recommended for ovulation assessment unless endometrial pathology is suspected. Determination of ovarian reserve: This describes reproductive potential as a function of the number and quality of oocytes. A number of screening tests are used, however no single test is highly reliable in predicting pregnancy potential thus a combination of tests is often used. A day 3 Follicular Stimulating Hormone (FSH), with high values (>20IU/L) suggests pregnancy is unlikely with treatment using the womans’ own oocytes. In women with adequate ovarian reserve sufficient production of ovarian hormones occurs from small follicles early in the menstrual cycle, to maintain FSH at a low level. A paired day 3 oestradiol (E2) is often utilised with higher values indicating advanced premature follicle recruitment that occurs in women with poor ovarian reserve. Given that high E2 levels can inhibit FSH production, measurement of both helps negate false negative results. An Antral follicle count (AFC) performed in follicular phase by ultrasound is also a good nonbiomedical marker of ovarian reserve. Anti-müllerian hormone (AMH) produced by small preantral and early antral follicles, reflects the primordial follicle pool and

About the Author Aaron has dual fellowships in Chemical pathology and Endocrinology and has been widely published in both disciplines. His particular interests are endocrine hypertension, adrenal, pituitary and calcium metabolism disorders, diabetes and gestational diabetes. Aaron is Head of Biochemistry at Clinipath Pathology, and also sees patient for endocrinology consultations at the WA Specialist Clinic in Osborne Park.

parallels fertility; rising during puberty, peaking in the early 20s, and falling from 30 years on, to undetectable levels post menopause. AMH can be measured anytime during the menstrual cycle, although a mild decrease can occur in the luteal phase and some clinicians prefer early follicular phase testing. The oral contraceptive pill can lower AMH results so that testing may be unreliable. In general, AMH can be measured anytime during the menstrual cycle and appears to be a direct, reliable and early indicator of declining ovarian function. AMH is useful in identifying reduced ovarian follicle pool in particular patient subgroups, including cancer patients and those with previous significant ovarian injury from radiation or surgery. Given that AMH level correlates with the number of oocytes retrieved after stimulation, it is the best biomarker for predicting poor and excessive ovarian response in patients planning IVF, though its accuracy in predicting live birth is poor and should not be used to exclude couples from IVF/ICSI. Assessment of fallopian tube patency: Whilst not a biochemical test, either a hysterosalpingography (HSG) or a hysterosalpingo-contrast sonography (HyCoSy) are standard of care when evaluating tubal patency, with HSG also appearing to have therapeutic effects. Diagnostic laparoscopy is reserved for suspected endometriosis or pelvic adhesions. Further Reading American Society of Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertility and Sterility; 103(6), 2015:e44-50. NICE guideline. Fertility problems: assessment and treatment: Clinical guideline Published: 20 February 2013, Updated 2017. https://www.nice.org.uk/guidance/cg156

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

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

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HAVE YOU HEARD?

Urgent care, desperate election Can’t you smell an election in the air! The role of general practice in urgent (as opposed to emergency) care has been gently warming over the past couple of years. St John Ambulance’s buy-out of the Apollo Health Centres in Joondalup, Cockburn and Armadale started the ball rolling. But add a federal government under electoral pressure and rocket fuel has just been added to the fire. Federal Health Minister Greg Hunt announced $28m for the establishment and trial of four new urgent centres at Cannington (in the seat of Swan held by Liberal Steve Irons), Midland (Hasluck, held by Aged Care Minister Ken Wyatt), Mandurah (Canning, held by Liberal Andrew Hastie) and Osborne Park (Curtin, with new Liberal candidate Celia Hammond). St John has been promised the funds to run the four-year trial. That’s a boost for St John but some GPs aren’t so happy about it. The chair of the WA faculty of the RACGP

SJGHC a primary trainer Health Minister Roger Cook announced that first year interns will now do their entire training at SJG hospitals after the private health care group was accredited to run its own medical intern program. SJG Midland public hospital has been appointed a Primary Employing Health Service, which means interns have employment access to both public and private settings. SJGHC will be able to directly employ interns from next year. The first intern program will see 12 medical graduates in the first year with plans to grow over subsequent years. Interns will have access to a range of specialty areas such as general surgery, emergency medicine, paediatrics, intensive care and neurology/stroke. Initially the intensive care option will be undertaken at St John of God Subiaco Hospital and the rest undertaken at Midland. It will then expand to other St John of God Health Care hospitals.

GPs can help ED congestion Following on from the urgent care issue, a UWA study investigating hospital emergency department presentations in WA found that between 20-40% of all patients could have been managed by GPs, and if diverted into primary care, it could reduce ED presentations between 200,000 and 400,000 a year. The study, published in Emergency Medicine Australasia, involved GPs assessing patients presenting to hospital EDs to determine if they could

6 | MAY 2019

Dr Sean Stevens said the trial risked fragmenting care and would lead to poorer health outcomes. He said research showed that patients who maintained strong relationships with their usual GP and practice experienced far better health outcomes. “In WA last year, GPs and their healthcare teams provided over 14 million patient services, at significantly less cost than services provided in hospitals or other forms of specialist care.” he said, adding that primary care provided outside this model resulted in duplicated or unnecessary services. The other head scratching fact is that the Federal Government asked its primary health networks – in WA that is WAPHA – to explore how GPs can provide more urgent care in their own surgeries. Readers may remember WAPHA’s Chris Kane writing in the March edition urging GPs to register their interest. So somewhere between then and now, a nervous election got in the way.

have been managed in general practice. Study lead author A/Prof Alistair Vickery, from UWA Medical School’s Division of General Practice, said the burden of ED presentations was increasing and contributing to overcrowding, long delays in care and inefficiencies in WA hospitals. This study was the first to involve GPs clinically assessing patients presenting to ED to determine whether, in their opinion, the patient could have been managed in general practice. “We found that previous criteria, used within Australia and internationally, such as triage category, diagnoses or method of arrival to ED did not correspond to the clinical assessment of GPs,” he said.

Funds focus on women After the inquiries, comes the sunshine. Well that’s the theory but it doesn’t always work out that way – unless the nation is staring down the tunnel of an election. The National Women’s Health Strategy 20202030 has promised more than $50 million in funding to improve women’s health in areas such as ovarian cancer ($20 million) and endometriosis ($10 million). In this issue Dr Rae Watson-Jones explores endometriosis management (P 31) and funds will pour into research as well as public awareness campaigns. Stillbirth, which we recently reported was maintaining its stubborn levels, will be a focus with $1.3 million being invested in support services for families. More than $4 million will go to reproductive and family planning organisations and $1.5

million for promotion grants for women’s health groups.

Colleges call the shots The paper has been signed and it’s now official. The RACGP and ACCRM have entered into an agreement with the Federal Government to select candidates for and oversee the delivery of the Australian General Practice Training (AGPT) program. Applications for 2020 places are open and maybe some promotional work needs to be done. Applications for entry into the AGPT program last year fell by 11.5% with a total of 1460 candidates accepting training places, 1351 with RACGP and 109 with ACRRM. The RACGP president Dr Harry Nespolon said that having the profession select trainees ensured only the most skilled candidates were granted entry to the program.

Albany and RPH filip The WA government is opening its wallet for radiotherapy services for cancer patients at the Albany Health Campus. Pending the outcome of a feasibility study and business case, the next steps include construction of a specialised bunker, equipment procurement. and the establishment of associated patient, clinical and administrative spaces. Currently more than 350 Great Southern residents travel annually to Bunbury or Perth to access outpatient radiotherapy treatment. It is also investing $22.7 million to expand and renovate RPH’s

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intensive care unit to make traumatic stays for patients and their families a little more bearable. Part of the works will allow more natural light into the area and improve the waiting area for relatives and friends of ICU patients. The 24-bed ICU has the largest trauma workload in WA. During 2017, nearly 1500 people were admitted to the ICU, staying on average for 13 days.

Abortion and safety zones News from the US last month put women’s issues front and centre. In Texas, politicians were asked to consider a bill that would criminalised abortions, meaning both women and their doctors could face the death penalty for participating in an abortion. House Bill 896 was even too extreme for pro-life Republicans and it was voted down. In Ohio, a bill known as the “heartbeat bill”, which prohibits abortions after six weeks has now become law. It replaces legislation which allowed abortion up to 22-24 weeks or until viability. The new Act will criminalise abortions with doctors facing felony charges and possible prison time if they perform an abortion after a heartbeat is detected. Doctors will also be liable for disciplinary action by the Ohio State Medical Board. However, in WA, the state government is working to introduce safe access zones around women’s health clinics where abortions are undertaken to prevent protesters abusing consumers and staff. A discussion paper has been released which explores a legislative framework for such a move. The paper is open for public consultation but the Health Minister Roger Cook flagged that its purpose was not to review or debate abortion legislation in WA. Feedback is open until May 31 at www.healthywa.wa.gov.au/safeaccesszones

All talk … In related local political news, State MP Nick Goiran has been successful in delaying a vote on new surrogacy laws, which he opposes, by filibustering Parliament with a near 24-hour speech. The surrogacy laws are intended to provide single men and same-sex couples access to surrogacy, which they currently do not have. The proposed laws would align WA with the federal anti-discrimination laws. The laws will now be scrutinised by a parliamentary committee. A review of the Western Australian Human Reproductive Technology Act 1991 and the Surrogacy Act 2008 was undertaken by independent reviewer, A/ Prof Sonia Allan. It’s key recommendations include establishing a government advisory body on research and issues relevant to the regulation and practice of the technology and surrogacy; a donor conception register to enable all donor-conceived people to access identifying information about their donor; amendments to discriminatory provisions within the Acts that prevent access to the technology and surrogacy; and, changes to allow patients who face impending loss of fertility or ability to bear a child, be allowed to access in vitro fertilisation procedures.

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Breast implants registry Monash University’s Australian Breast Device Registry has enlisted 90% of eligible surgeons, including a number from WA, to help track the long-term safety of implantable breast devices in patients. However, researchers would like to see more to give full national representation. Project Lead Dr Ingrid Hopper said the health and wellbeing of Australians was at the centre of the registry with every year an estimated 20,000 women having breast devices implanted for a variety of reasons. The registry produces de-indentified public reports on complications and revision rates for all devices, such as breast implants, breast tissue expanders and acellular dermal matrices/mesh. It will also be the primary point of contact for reporting ALCL, a rare and largely treatable form of cancer of the immune system linked to breast implants.

Syphilis action plan In this edition, sexual health physician Dr Sally Murray explores the state of STIs in WA, in particular syphilis (P 29). News has come in that the federal government in partnership with the National Aboriginal Community Controlled Health Organisation has started to roll out Phase 3 of its enhanced response to the syphilis outbreak. The new phase begins with training and provision of kits at Mala’la Health Service in Maningrida, Western Arnhem Land, in the NT, followed by Eyre, far north and Adelaide regions of South Australia, and the Pilbara and Western Kimberley in WA. More than 7500 people have been tested for syphilis under Phases 1 and 2, and 186 local health professionals have been trained to use the test kits and in sexual health education in general.

Mental Health Commissioner Tim Marney will step down on June 14 after five years in the position. Last year’s Eureka prizewinners Prof Wendy Erber and A/Prof Kathryn Fuller have been awarded a $140,000 Foundation for Australia-Japan Studies (FAJS) grant awarded under the Rio Tinto Australia-Japan Collaborative Program. Their research, ImmunoflowFISH, helps identify blood cancers. Medicinal cannabis company AusCann has announced that former Teva pharmaceutical executive, Mr Ido Kanyon, is its new CEO replacing Ms Elaine Darby. A 12-bed comprehensive stroke unit has opened at the Joondalup Health Campus. Prof Peter Klinken has been reappointed as WA Chief Scientist to June 2022. WA's Helen Storer has been appointed to the board of the Australian Practice Nurses Association. Rosemarie Windsor took home the President's Award.

More elderly to transition The feds and the state have collaborated on providing 60 permanent Transition Care Program (TCP) places and 120 temporary TCP places over the next four years. The WA Government will provide up to $23.45 million to co-fund the initiative, which it is hoped will free up hospital beds and offer better care to elderly patients. The package includes nursing and allied health support in the home or residential care for 12 weeks after leaving hospital.

Helping mums breastfeed UWA researchers have created a platform to help women breastfeed their infants for longer. LactaMap addresses the four key areas which concern breastfeeding women – pain, maternal milk synthesis, baby’s ability to remove milk and medical conditions which may inhibit breastfeeding. Lead researcher Melinda Boss, a senior research fellow in the pharmacy division of UWA’s School of Allied Health, said that once the GP has the information base, they can then work through the platform to develop a personal care plan for the patient. The platform contains 112 clinical practice guidelines as well as the LactaPedia glossary and 21 information sheets which can passed on to patients. According to the AIHW, less than 16% of Australian babies are exclusively breastfed to five months of age, which is sobering given the World Bank Group considers exclusive breastfeeding to six months has been identified as the single biggest potential impact on child mortality of any preventative intervention.

MAY 2019 | 7

Bullying – Changing Medical Culture Dr Sarah Newman, Assistant Director of the Doctors’ Health Advisory Service of WA, provides her take on this problem within the profession. Bullying is recurrent abuse of power which can take many forms. According to popular media, it is wide spread and endemic in the medical workplace. It is not an uncommon experience; up to 50% of doctors, doctors in training and international medical graduates report having been bullied or harassed. Bullying can be a damaging influence on the wellbeing of staff, the wellbeing of workplaces and on patient care. Victims are often the most vulnerable in the workplace; juniors, females, medical students and international graduates, with the most common perpetrators those in positions of power. Bullying is entrenched in our medical teaching and so engrained in medical culture that in some units it is regarded as normal behaviour by senior staff. Some units in prestigious hospitals have had training accreditation withdrawn, upon external review, because of perceived endemic bullying.

Although bullying (and harassment) are an acknowledged problem, unfortunately the response to resolve it has been less than comprehensive. Many victims experience difficulty in raising issues, as traditional conflict resolution requires them to approach the bully first with their concerns. This is often unpleasant, with victims worrying about implications for their training, ongoing working relationships, and stigmatisation from often senior doctors and colleagues.

They may also feel overly sensitive or as not “tough enough”.

Second, a systematic approach is needed. This includes coordinated actions between hospitals, colleges and organisations where bullying claims are taken seriously, investigated appropriately and the complainant feels heard and respected in the investigation process. Protocols that are fair, visible and sensitive are necessary. A review of our medical training ensures good habits are learnt and reinforced from the first year of medical training. Ongoing cultural change will take a new generation of doctors and numerous organisational changes. A future medical workforce without the spectre of bullying and harassment is worth the effort for the safety of our doctors, workplaces and patients.

Further, many experience a suboptimal response from senior managers (with limited training in conflict resolution), or non-action from organisations such as hospitals and colleagues. So, what do we do? First, acknowledge our personal responsibility in tackling bullying and no longer tolerate bad behaviour. This

Photo courtesy Tourism Western Australia

means speaking out for ourselves and for others where bullying is seen, especially those vulnerable.

ED. The Australasian Doctors Health Conference is in Fremantle on November 22 and 23 and national and international speakers will present. All doctors and medical students are invited.

2019

ADHC

AUSTRALASIAN DOCTORS’ H E A LT H C O N F E R E N C E 22-23 NOVEMBER 2019 PE RTH AU STR A LIA

#drshealthp er

DO YOU HAVE A PASSION FOR DOCTORS’ HEALTH?

19 th

Join your colleagues to be engaged by speakers, clinical and practical learning sessions, and social events.

#drshealthperth19

Creating a healthy workplace 8 | MAY 2019

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INCISIONS

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*The NovaSure® procedure is performed by a gynaecologist. Precisely measured radiofrequency energy is delivered for an average of 90 seconds, and the entire procedure typically takes less than 5 minutes to complete. 3 References: 1. National Women’s Health Resource Center (United States). Survey of women who experience heavy menstrual bleeding. Data on file, 2005. Based on women aged 30–50 years. 2. Australian Commission on Safety and Quality in Health Care, Clinical Care Standards, Heavy Menstrual Bleeding, October 2017. 3. NovaSure® Instructions for Use. Marlborough, MA: Hologic, Inc. 4. Cooper J, et al. A randomized multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia. J Am Gynecol Laparosc. 2002;9:418-428. 5. Gallinat A. An Impedance-Controlled System for Endometrial Ablation: Five-Year Follow-up of 107 Patients. J Reprod Med. 2007;52(6):467–472. ADS-01814-AUS-EN REV.002. © 2018 Hologic, Inc. All rights reserved. Hologic, NovaSure and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States and/or other countries. This information is not intended as a product solicitation or promotion where such activities are prohibited. Because Hologic materials are distributed through websites, eBroadcasts and tradeshows, it is not always possible to control where such materials appear. Hologic (Australia) Pty Ltd, Suite 302, Level 3, 2 Lyon Park Road, Macquarie Park NSW 2113. Tel. +61 2 9888 8000. ABN 95 079 821 275.

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Balancing the Board “The public now have a pathway whereas before it was confusing for the public” Emeritus Professor Constantine ‘Con’ Michael has been instrumental in the creation and implementation of key medical governance structures in WA and in Australia.

rof Con Michael was appointed to the Australian Health Practitioner Regulation Agency (AHPRA) Management Committee in March 2009 as a member with expertise in health, education and training. Before the inception of AHPRA, complaints about, and regulation of, medical practitioners were addressed by the relevant state medical boards. In 2016, he was appointed a practitioner member of the Medical Board of Australia while holding the position of Chair of the WA Board of the Medical Board of Australia. “Minimum regulatory force” “AHPRA’s mandate and that of the Medical Board is to protect the public while ensuring that it is safe for medical practitioners to practise medicine,” Con told Medical Forum. “I don’t have to tell you that the meetings we have with practitioners who are dealing with complaints about their clinical performance, struggling with health impairments, or who are dealing with workplace or training issues, puts them under an incredible amount of stress. All of those things can and do impact further on a practitioner’s clinical practice.”

10 | MAY 2019

“So with all of what we see it’s important for the Medical Boards to be supportive. For a practitioner, however, it is sometimes hard for them to understand why it may seem to them that the Medical Board is being unduly harsh, for example by placing conditions on their registration.” “We don’t like interfering with their practice, nor with the generation of their livelihood but, where it is necessary, we do so to make the public safe and equally safe for the practitioner to practise medicine.”

“There is concern for the practitioner and there can be compassion without risking public safety. It is important to remember the primary job of the Medical Board and of AHPRA is to ensure public safety. But that is done by balancing the interests of a practitioner against that of the public.” “The Board attempts to complete its investigation efficiently and applies a minimum of regulatory force if the decision warrants such an outcome. If a practitioner needs to be sanctioned, where appropriate the minimum regulatory force is exercised.” A stellar career and balance

“One of the important things the boards and AHPRA do is to rehabilitate and reeducate practitioners, particularly if there is a performance or health impairment issue. We try with supervision and education to get them back into clinical practice with conditions.”

Con’s concern for just and speedy outcomes for notifications, together with a nuanced understanding of the administration and regulation of medicine, comes from a career that spans clinical practice, education and engagement with key decision-making and policy bodies.

“By rehabilitating a practitioner, by placing conditions on their registration in order to return them to safe practice and, in turn, protecting the public is an educative process and not a punitive one. If we succeed in doing that then I think we have done our job. The process is not, contrary to popular belief, a heavy handed, poorly thought out process. It is a considered decision made after a thorough investigation and any decision is not made lightly. About 85% of notifications (complaints) result in no further action.”

He was the principal adviser of medical workforce at the WA Health Department, consultant medical adviser for St John of God Health Care, and current Chair of the WA Board of the Medical Board of Australia. He was previously a director of the Australian Medical Council, past Chair of the St John of God National Ethics Committee and past Chair of the Reproductive Technology Council of WA and the recent Chair of the Embryo Research Licensing Committee of the NHMRC. He was a Director and Governor of the University of Notre Dame Australia

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CLOSEUP and is current Chair of its medical school advisory board. Con is also a Fellow and past president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and Fellow of the Royal College of Obstetricians and Gynaecologists, London (a previous Sims Black Professor). In 2001, Con was made an Officer of the Order of Australia for service to medicine in the field of obstetrics and gynaecology, and medical education. AHPRA is in many ways a high point for Con because it brings a consistency to procedures dealing with notifications and registration, issues that needed to be addressed across the range of portfolios he has been involved with. “To bring 14 and now 15 boards together, because paramedicine has joined the scheme, was no mean feat. The system has reached maturity and I think with maturity came a system that was workable, fair, equitable and consistent across the country,” he said. “Now there is consistency in registration and mobility of registration, and consistency in the notification management and protection of the public but the Boards don’t lose sight of the fact that at the other end of the notification is a practitioner, so we are cognisant of the serious emotional impact a notification can have on the practitioner.” “My biggest concern in today’s environment is how investigations or allegations affect junior practitioners. There have been suicides. Not so much from allegations but from a combination of things, of which a notification is only one. That’s why investigations cannot continue for a long time.”

“When you’re sued for alleged negligence in medical practice, the experience is said to be akin to the emotional toll of personal tragedy or even bankruptcy. That’s why it is important to settle matters quickly. I think the current system has very few aged notifications, so each month most States mostly close notifications quickly. That’s very important. It is a good signal for the doctors.” “It is a terrible thing to have someone complain about you to the Medical Board. How we manage it is terribly important, and manage it quickly and consistently. If there is no action to be taken, then the practitioner can go straight back to practise without any great hiatus.” “The recently developed national triage scheme allows for an early outcome and for consistency in investigation. It allows for efficiency. I know it is a big organisation and there may be some delays, but it looks after so many boards. I like to think that AHPRA after 10 years, has reached maturity and having learnt from its early years is now an organisation that works well and provides an efficient infrastructure for the boards to function.” Changing face of medicine According to Con, some specialities within the medical profession are more likely to attract complaints than others. In a world where the practice of medicine is rapidly changing and patient expectations are changing, medical practitioners need to be aware of what they are doing and how they interact with their patients. Whether it be using social media or face-to-face consultations. Implied contracts of informed consent are rapidly changing.

obstetrics and gynaecology, has had issues, particularly in permission to undertake vaginal examination. When I was being taught, if a person went to see a gynaecologist it was expected that a vaginal examination was likely; not any more. Today chaperones. or more precisely a practice professional assisting, together with informed consent are best practice.” “These processes are not just for the benefit of a patient but also for the protection of the practitioner.” “Someone recently said to me, maybe we will have to ask for informed consent for students and doctors-in-training to examine their patients. It will be sad day if that happens because it will discourage clinical examination, which I believe to be an integral part of a consultation. I think we need to watch our conduct as the most respected members of the community, and not lose our integrity and self respect.” The halcyon days Con was born in North Perth and went to Perth Modern School. He graduated in medicine from the University of Western Australia and lived through what he unashamedly says was the halcyon days of medicine in WA. “That’s where I come from and that’s where I am. I am coming to the end of my time. I don’t plan to be here forever, although some people think that that is my plan, but where I still have something to offer and I can continue to give back to my profession, I will do so.”

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Grandma and Mahler How different cultures deal with death and beyond is brought into sharp relief by Dr Donna Mak, who pays tribute to her 104-year-old grandmother.

Dr Donna Mak and her children at her grandmother’s memorial.

Rise again, yes, rise again, Will you My dust, After a brief rest! Mahler’s Resurrection symphony

his was not the kind of ‘rising again’ Grandma had in mind when she told us ‘I saw a corpse stand up while he was being cremated.’ Grandma’s cognitive functions had been deteriorating before her death three months after her 105th birthday. Or 104th birthday according to Western tradition in which people are born aged zero, as opposed to Chinese tradition which rounds up the nine months spent in utero to one year.

they ‘distributed’ themselves and their nine children between Hong Kong and southern Guangdong province to minimise the chance of everyone dying together. After the war she arranged two co-wives for her husband – an ingenious way of keeping the family’s human and economic resources under one roof and her household management in a society where most men supported several wives, each with her own household. One of the stories grandma told repeatedly was how her father insisted on being carried from Hong Kong to his ancestral village in China to die and be buried. Everyone thought he would die on the journey but he stayed alive until just after entering the front door of his family home, and was buried nearby, thus fulfilling his final wish.

But during one of her lucid moments she made it quite clear that she wanted her body to be buried, not cremated. This came as no surprise given that it is Chinese tradition to return to one’s ancestral village to die and be buried, and Grandma was a very traditional woman.

However, burying a body is easier said than done in 21st century Hong Kong. Such is the demand for burial plots, and failing that, a space in a columbarium where the living can visit and remember the dead, that a monthly lottery is held to decide who will have the privilege of paying the princely sum required to secure these items of real estate, if only for a few years.

Born in 1914 in Guangdong province, she entered an arranged marriage with my grandfather at the age of 16, moved to Hong Kong and established a small business selling bed boards (equivalent of a mattress). During the Japanese occupation

So Grandma was embalmed and taken to a ‘coffin home’ (a building where embalmed bodies are stored in coffins awaiting burial or cremation) after her funeral while waiting for the next lottery. She didn’t win first time around.

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There was family disagreement about whether to respect her wishes and continue entering her into the lottery. In the true spirit of Chinese pragmatism a compromise was reached. Two months after Grandma died, she was buried with her husband in his newly renovated burial plot overlooking the ocean at Chai Wan Cemetery. His bones were removed from his coffin, cleaned and put into Grandma’s coffin, so now they will always be buried together (or at least for as long as the five yearly grave renewal fees continue to be paid). It seems a particularly fitting resting place for Grandma because she recognised her husband, whom she had outlived by 50 years, in every photo we showed her despite not being able to recognise herself or any of her children. Purely by coincidence, before boarding the midnight flight from Perth to Hong Kong to attend Grandma’s funeral, I performed Mahler’s second symphony with Perth Symphonic Chorus and the WA Youth Orchestra conducted by Maestro Tze Law Chan, a Singaporean Chinese guest conductor. The combination of Mahler’s music and Maestro Law’s gentle and understated yet deeply expressive conducting style prepared me for Grandma’s funeral and helped me to grieve for her in a way that I can’t express in words.

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Around 71% of hospitals reported discrimination, bullying or sexual harassment at their campuses in the past five years, with bullying the most frequently reported issue, according to the Australian Senate Committee on the medical complaints process, citing RACS’ Expert Advisory Group.

“Good culture is a good thing, it attracts talent, drives happiness, and it comes from good performance, it drives that quadruple aim we talk about in business, good outcomes, happy staff, good budget outcomes. Culture does that. But it is not amenable to legislation and regulation, it needs to be in the DNA.”

“Our ED has put in numerous strategies for wellness for our junior doctors and senior doctors have meetings to talk about wellness, they have artwork on the wall every month; someone can bring in their artwork or photos. So what you have is a very stressful place that is very well supported and drives fantastic culture.”

“Despite the consensus that bullying and harassment are unacceptable, there is concern that the actual prevalence of such behaviour is unknown or underreported,” the Senate Committee concluded.

Good culture, the panellist continued, should be found in all departments, including emergency.

A woman’s place

The first Doctor’s Drum for 2019 captured many of the Senate’s themes, the bad versus the good in medical workplace culture. Good communication seemed to be key to solving problems, along with oldfashioned caring for each other Positives of good culture But what is culture? One of the panellists stated that he came from a good workplace culture.

“Anybody who has been an ED doctor will know that ED is a chaotic, stressful and disorganised place to work and I did get approval to use the word disorganised. I don’t mean that in a way that says that the place is not well run. The workflow is very disorganised and anything can happen at any time so, of course, it could be a place where there is stress, where there is bad culture, bullying and harassment.”

When workplace culture goes bad it can mean various things, as the next panellist’s personal experience revealed: Keen on paediatrics from the start, the panellist started in a ‘good workplace culture’, did full-time clinical work until 2005 and then became a head of department. “I had a full-time clinical load as head of department because the roster had already been written for the next few months. I ended up doing the emerging leaders’

“I think that we all know what culture means or is, but I had to look at what it is historically and ‘cultura’ is the origin of the word. In fact it is a word about worship, to believe in somebody else’s ideas and to pay reverence to them. Which is what we should think about when we think about workplace culture, how we actually interact and pay homage to the spirit of the organisation,” the panellist said. “It is something that can be managed or can be made, it is not necessarily an innate concept. In fact it is the development of the mind’s faculties or manners, and manners is an important part of good culture. Because most of bad culture is bad manners or bad behaviour that can be refined by education and training.”

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program which added completely to my stress levels and workload and I actually engaged my own management coach at my own expense to try to help me through the chaos. I had an increasing feeling of the service being out of control over the first 12 months.” She reflected on her department. “There had been a trebling in the occasions of service over the five years with no increase of FTE in any area. There was increased patient acuity and complexity in paediatric oncology; lots of increasing family expectations and a general anger about any child who was diagnosed with cancer.” The panellist wrote a comprehensive document providing short, medium and long-term solutions to the problems. While interest was shown, little action ensued. She attended a Harvard program on negotiating, at her own expense. On her return, her report did not get her accolades, but rejection from her colleagues. “I managed to achieve pariah status in a hospital that I had worked for around 10 years, where I knew everybody and I thought they knew who I was; because I had become the ‘princess in Oncology who was looking for money and making out that we were in a terrible state’.” “It was an incredibly isolating experience. And I found it personally very stressful and I do get it that it is part of my personality, but that’s what it was for me.” Her efforts to increase funding worked, but getting the FTE to her area was not so easy. It took another two years of hard work to fill the second FTE position. The panellist went on to describe instances

with a patients’ family where she felt unsupported, which she said led to a deterioration in her physical and mental health. After confrontations she would develop chest pain, palpitations and shortness of breath as well as tremors leading eventually to exhaustion and emotional lability where she could not get out of bed in the mornings. “I continued to work because that’s what you do. I turned up to work every day. I had meetings with the executive to inform them of my health issues. They were very difficult meetings and at the end of one, I think the quote of the episode, ‘You don’t look like a woman on the edge, in fact you look absolutely fabulous’.” The panellist resigned from her position soon after being asked to see a psychiatrist.

“Clearly I, along with my clinical psychologist, GP, and rehabilitation psychologist were just not capable of creating my own return-to-work plan,” the panellist said. She eventually did return to work, but eventually resigned from the position and became a general paediatrician and teacher. Sparking discussion The reactions to these first two presentations brought up issues for some and brought out proposed ways to avoid or minimise bad culture. One said if doctors were footballers they would be better looked after. “A footballer would get a sports psychologist, an organiser, a dietician, people telling us not to drink alcohol, get drunk, and not sleep

continued on Page 17

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Thank you. Thank you for making us the biggest private hospital in WA 2019 marks the 25th year Hollywood Private Hospital has been part of Ramsay Health Care. Since that day, we have more than doubled our licensed bed numbers, opened 16 additional operating theatres, built and expanded our standalone mental health facility, The Hollywood Clinic, and made major investments in research and technology. Today, Hollywood is considered the biggest private Hospital in WA and is a leader in a broad range of medical specialities, including urology, cardiology, psychiatry, oncology, neurosurgery and orthopaedics, with over 650 accredited specialists. And we continue to go from strength to strength, with exciting plans for growth in the near future. Thank you to our doctors, staff, volunteers and an incredibly supportive community, who have made this possible.

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continued from Page 15 the night before exams. Why can’t doctors be looked after in this way? And waiting for us to be ill is part of the problem. Only seeing people when you have a problem is the problem?” “How can we introduce some kind of system that looks after us when we are well? When can we stop funding people at the end of the line with their blocked arteries and when can we start funding exercise and mindfulness and good health exercises,” one asked. One audience reaction was, simply, to walk away. “I spent 10 years working in a practice and left two years ago and realised how unsafe it was for me. I was a student educated to ‘speak truth to bullshit.’ In my experience most people walk when they come across a workplace culture they don’t like.” The panel identified a number of specific systemic solutions.

The Notre Dame medical school has an eight-week program called Essence Plus, which starts in first year, and is underpinned by mindfulness, and remains part of the MD program for its duration. SJG Midland Hospital’s staff engagement was cited as a successful example of a workplace culture. Regular meetings are held between staff, including junior doctors, and management and the director of mission actively leads the culture of the organisation. The panel agreed that there were good and bad cultures across the state and within the same organisation, and that work representatives, played a key role in mediating complex disputes. Can you buy love? While organisational structures were seen as important, the panel did not see any substitute for simple acts such as knowing staff member’s names. Money was not necessarily key to solving workplace abuse. Simple acts of decency were seen as significant. “A lot of it does not cost a lot of money. Just treating someone with respect, knowing their name. I know specialists in the tertiary sector who do not know the name of their junior doctor, but in their private work they are best buddies with their junior doctor,” said one doctor. Another responded: “I would be horrified if I didn’t know the name of my junior doctor. We are lucky at my workplace because we are not strictly a private hospital, we also deal with public patients. It is not the patients that are different, but the organisation and how it works.” The problem manager The panel was asked, early on, whether they would employ the brilliant, but rude,

expert, putting skills above respect. One asked about what could be done about problematic management who get anointed and appointed but about whom staff are too frightened to complain? How can change be driven from the bottom up? Some thought that difficult managers would fade but ultimately a good culture would keep them out in the first place. Panel conclusions The panel was asked to summarise the key points necessary for a good workplace culture. • “Be a positive example, that’s what we can do for our colleagues and that will bring good culture”. • “Be a clinical leader and create a forum for your junior staff to talk about the issues with you as their clinical leader.” • “Have a coffee with your juniors and spend a few minutes to go through both non-clinical and clinical issues so the whole team can get to know each other.” • “Be respectful to the staff, no matter what their seniority, and treat them how you would like to be treated yourself.” • “Show empathic clinical leadership.”

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Rural Docs on Climate Change to Waste The National Rural Health Commissioner, Emeritus Professor Paul Worley, opened the conference by sharing his views on the National Rural Generalist Pathways and promoting a supported, sustainable and cost effective rural health system.

rofessor Worley was also an active Twitter broadcaster of sessions, tweeting a slide from Dr Christine Jeffries-Stokes and Annette Stokes who discussed the link between contaminated drinking water and chronic disease in remote Australia. Keynote presenters did not disappoint a packed audience, with Craig Challen eliciting gasps from the audience when he recounted the risks to all in the rescue of trapped Thai boys, which involved administering anaesthesia in a confined environment and transporting sedated patients underwater with extremely limited visibility. Craig Reucassel of ABC’s War on Waste, gave an overview of the issues surrounding medical waste and the challenges involved, including the profession’s role in reducing waste.

Clockwise from top left; Emeritus Professor Paul Worley, CPR in action, Craig Reucassel, Dr Nadine Perlen, Dr Christine Jeffries-Stokes and Annette Stokes

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FEATURE

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FEATURE

The invisible effects of climate change on ED WACHS' Dr Mark Monaghan goes behind the statistics to explore how climate change will affect medical practice.

ur temperature trajectory is clear. We have already increased in average temperature over 1 degree Celsius over the past century, and we are breaking records at a consistent and disturbing rate. What we know of heatwaves is that they kill in a way that we may not initially recognise. In 2009, when 180 people died from the black Saturday fires, in Melbourne alone 372 people died from the associated heatwave. While some health consequences, such as the thunderstorm asthma that resulted in 8500 additional people presenting to Victorian EDs around November 21, 2016 are obvious, the deaths from heat waves and air quality tend to be invisible. They are not recognised as direct heat illness. They occur to our most vulnerable people, the elderly and very young, the socially isolated, those with mental health, cognitive and other chronic health burdens that for many reasons are at increased risk. And we can expect this excess mortality to increase as our climate warms. There are things we can and are doing to mitigate this, for example heatwave warnings, public education, local community health surveillance of vulnerable people and designing urban landscapes to reduce heat island effects. We need clear and effective long-term federal policy on mitigating temperature rise and a coordinated national strategy and investment in our health emergency sector to manage this inevitable health burden.

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Family Violence in Health Care By Enore Panetta, Panetta McGrath Lawyers, Perth With family and domestic violence (FDV) the leading contributor of preventable death in Western Australia, what of a medical practitioner’s responsibility to screen for, respond to and report FDV? Please note that the majority of cases involve men as perpetrators and women as victims of FDV, so this article mainly focuses on women’s experience of FDV. When should I screen for FDV? Given that one in five women who experience FDV will make their first disclosure to their GP, medical practitioners have a significant opportunity and responsibility to identify and respond to FDV. A number of policymakers have suggested routine screening to help medical practitioners identify patients experiencing FDV, but many practitioners are perhaps reluctant to use screening tools. The reasons vary: they may feel overwhelmed by the emotional responsibility of disclosure; they

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may feel inadequately trained in how to respond; or they may have experienced FDV themselves, which in turn influences their response.

If your patient talks to you about FDV A patient may disclose in the course of treatment that they have been or are the subject of FDV.

A 2015 Cochrane study found that screening increased identification of women experiencing FDV, but, in all healthcare settings, there was not enough women helped by routine screening.

In these circumstances, your skills and sensitivity are essential and the following is suggested: • Listen, communicate belief and validate the patient’s decision to disclose; • Conduct an assessment of patient and child safety. If either is in immediate danger, call the Police or the Department of Communities - Child Protection and Family Support, in collaboration with the patient; • Document physical injuries (including type, extent, age and location) and specific descriptions of violence (using quotation marks) - be careful not to include any interpretation or subjective opinion about your observations as your notes may be required as evidence if charges are laid against the perpetrator; • Provide information on options and services available, including contact details and referrals as required; and

At what times in a woman’s life is she at greater risk of FDV? More than half of women living with abusive partners experience violence during pregnancy – the frequency and intensity of violence often increases. Pregnancy can also be a trigger for commencement of violence – a quarter of Australian women were abused for the first-time during pregnancy. In recognition of the additional risk of miscarriage, premature labour, low birth weight and a higher incidence of infant death, the World Health Organisation recommends routine screening for FDV during pregnancy.

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Protection and Family Support. However, it is permissible under the Children and Community Services Act 2004 to give information in good faith to the Department of Communities – Child Protection and Family Support about any aspect of a child’s wellbeing. If the patient or a child is in immediate danger, disclosure of FDV to the Police or the Department of Communities is justified and appropriate, although it is preferable any disclosure is made with the knowledge and consent of the patient. Disclosure may also be permitted to a colleague or other health care professional who has a legitimate therapeutic interest in the care of the patient. In these circumstances, consent to disclosure of confidential information will generally be implied.

• Provide ongoing support and follow up as appropriate. Confidentiality and information sharing Medical practitioners are under a duty of confidence in relation to all information that comes to them in the course of their health care relationship with patients. Accordingly, practitioners should be very

careful about divulging information about a patient’s disclosure of FDV without the patient’s consent. In Western Australia, there is no specific statutory requirement for reporting FDV, although medical practitioners do have a legal responsibility to report all reasonable beliefs of child sexual abuse to the Department of Communities – Child

In due course you may also be required by subpoena to produce documents to a court and/or attend court to give oral evidence. Where confidential patient information is divulged pursuant to a valid subpoena, there will be no breach of confidence. However, it is recommended that you seek advice from your professional indemnity insurer or legal adviser before responding to a subpoena.

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CLINICAL UPDATE

The battle against S aureus infections By Dr Paul Armstrong, Director, Communicable Diseases Control Directorate, DoH We know MRSA can close hospital wards but community-acquired MRSA is on the rise and nobody knows why.

Staphylococcus aureus, a commensal carried in the nose, throat or on skin of many people (colonisation), is transmissible by direct contact or via fomites and a common cause of skin infections, such as impetigo and boils. Less commonly, it can also cause deeper soft tissue infections (pyomyositis and cellulitis) and invasive, life-threatening infections, including meningitis, bone and joint infections, pneumonia, and septicaemia. One feature of S. aureus is its propensity to cause recurrent infections, due to prolonged carriage of a pathogenic strain. Strains of S. aureus resistant to penicillin emerged in the 1950s. Methicillin, a penicillin relative, was developed to overcome this, but within a decade, methicillin-resistant Staphylococcus aureus (MRSA) strains arose, becoming endemic in hospitals from the 1970s. MRSA is a notifiable condition in WA. The incidence of hospital-acquired-MRSA infections in Australian healthcare facilities is largely controlled, in contrast to the rise in cases in the community of CA-MRSA. The rise and rise of CA-MRSA in WA In the early 1990s, the worldâ&#x20AC;&#x2122;s first CAMRSA strains emerged in the Kimberley. Infections due to CA-MRSA have since risen steadily, across the state but more so in remote areas (particularly the Kimberley region, where the rates are 25-fold higher than in metropolitan Perth (see Figure 1)). The drivers for this rapid expansion are not well understood but we do know that most infections are from limited strains with

anywhere in the world. In fact, skin infections are so common they are normalised, even in healthcare settings, which results in underreporting and under-treatment.

Impetigo example: Is it Staph or Strep? If it's Staph, is it resistant to the usual antibiotics? particular virulence genes, imported and proliferated widely. In fact, infections due to MRSA strains are increasing more than methicillin-sensitive strains, highlighting the need for appropriate microbiological diagnosis and antibiotic treatment. Community-onset S. aureus bacteraemia increasing in WA A recent analysis of community-acquired S. aureus blood stream infections (CA-SABSI) in WA and Victoria showed that it is on the rise in both states.1 Independent risk factors were advancing age and being male, with men over 60 years particularly at risk. With mortality around 20% in adults, CA-SABSI is a particular public health concern and further work is planned to investigate host and organism characteristics. Skin infections in Aboriginal people Skin infections due to S. aureus and Streptococcus pyogenes are associated with social disadvantage, and Aboriginal people have considerably higher rates of infection. Unfortunately, almost half of all Aboriginal children from remote areas have impetigo (caused by staphylococcal and/or streptococcal bacteria), the highest rate of

Fig 1: Rates of community-associated MRSA in WA, 2009-2018, by region.

Superficial skin infections are more than just a minor annoyance. As well as the risk of the more serious deep infections mentioned above, indirect effects of streptococcal skin infections include acute post-streptococcal glomerulo-nephritis and acute rheumatic fever, contributing to renal failure and rheumatic heart disease, in the long term. MRSA in aged care facilities There is growing evidence that MRSA is a problem in aged care facilities. One recent Australian study found colonisation with MRSA of 16%. Risk factors include advanced dementia, prolonged antibiotic use, presence of chronic wounds, previous hospitalisation and the need for indwelling devices e.g. urinary catheters or intravenous devices. We lack evidence on how to reduce the prevalence of MRSA in staff and residents of aged care facilities, so increased surveillance along with strict hand hygiene and infection prevention and control practices remains the mainstay of control. How to control CA S. aureus infections? Early diagnosis and appropriate antibiotics are key to treating bacterial skin infections and preventing more serious sequelae. Sensitive strains of S. aureus should be treated with flucloxacillin or dicloxacillin, or cephalosporins for those allergic to penicillin. MRSA strains are resistant to all beta-lactam antibiotics, including cephalosporins - anti-MRSA antibiotics will also be effective against streptococcal organisms, a frequent co-infection. For patients with recurrent skin infections, antibiotic treatment and decolonisation of skin using antiseptic washes and antistaphylococcal nasal ointment over several days should be considered. Guidance on antibiotic treatment of MRSA infections and decolonisation can be found at https://ww2.health.wa.gov.au/Articles/J_M/ Management-of-CA-MRSA An excellent resource for treating skin infections in Aboriginal people is the recently-developed National Healthy Skin Guideline www.telethonkids.org.au/ skin-guidelines References available on request.

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Bid to Lift Flu Jabs in Under-5s Department of Health’s Dr Paul Effler urges GPs to help lift influenza vaccination rates among younger children. As we prepare for the upcoming winter influenza season, a big focus for WA’s Department of Health will be on lifting the vaccination uptake in the under-fives. Despite a slight increase in influenza vaccination among our under-fives – 15% in 2017 to 19% in 2018 – WA lags behind the rest of the nation in this vulnerable cohort. Nationally the uptake was 26%, with a dramatic increase seen in states which introduced preschool programs in 2018 such as Queensland, New South Wales and Victoria.

WA’s coverage is also well shy of our 2008-2009 rate of 42%. Vaccination for young children took a nosedive after 2010 when hundreds of children experienced adverse events following vaccination with a single brand of vaccine, Fluvax®.

Though Fluvax was subsequently deregistered for use in children, and rigorous measures were put in place to ensure the early detection and reporting of potential adverse reactions, ongoing wariness of the influenza vaccine among WA parents and providers has left our vaccination rates in young children languishing. Despite regaining some ground since dropping to an all-time low of just 7% in 2010-2014, there is still a way to go. Young children experience high rates of influenza infection and hospitalisation and are also a major source of transmission to others. During last year’s season, 11% of all influenza infections reported in WA were among children under five, and 27% of those cases were hospitalised. Recent research has revealed that some WA parents continue to be more concerned about the safety of the influenza vaccine than influenza infection itself. This is despite influenza’s potential to cause serious respiratory disease resulting in

hospitalisation and, in some cases, death. Another concerning finding of recent research was that GPs were less likely to recommend influenza vaccination to parents who were seeking advice. We need this to change because we know that children are three times more likely to receive the influenza vaccine if it comes recommended by their health care provider. The vaccine has been shown to be very protective in young children, with a study from WA reporting influenza immunisation was 85% effective at preventing laboratoryconfirmed influenza illness among children younger than two years of age. While influenza vaccination is recommended for everybody, the under-fives and other vulnerable groups including pregnant women, the over 65s, Aboriginal people, and those from six months of age who have a medical condition such as heart disease, kidney disease, chronic respiratory conditions and other chronic diseases are urged to vaccinate.

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Knowing the Costs of Cancer A diagnosis of cancer brings with it physical and mental anguish but Cancer Council WA’s Melanie Marsh argues that financial hardship shouldn’t be part of the mix. Money should be the last thing on your mind when dealing with cancer but for too many patients it’s a major source of stress.

or their homes, remortgage assets, or increase a credit card limit to meet treatment costs or everyday living expenses.

A range of costs add up during diagnosis, treatment and recovery and they vary depending on cancer type, stage and treatment options. For example, a person diagnosed with early-stage cancer may only have surgery, while a person diagnosed with a blood cancer may have long-term treatments. It is difficult for patients to know what to expect.

The sobering reality is that Australia’s poorest socio-economic groups are 37% more likely to die of cancer than those in the highest.

About 27% of cancer patients currently pay $10,000 or more, and almost everyone pays for costs such as diagnostic tests. But out-of-pocket costs are just one part of the broader problem of financial toxicity.

In the last financial year alone, Cancer Council WA provided more than $245,000 in financial assistance to West Australian families affected by cancer. This is just a snapshot of the issue as not everyone feels comfortable reaching out for help, or knows it’s an option.

Too often we hear of patients making decisions based on what they can and can’t afford, rather than what’s best for their medical condition. People affected by cancer borrow money, access superannuation early, sell investments

Your chances of surviving cancer shouldn’t be determined by your bank balance or postcode.

What we can do is try to fix the processes that compound the problem. Cancer Council Australia has joined forces

with Breast Cancer Network Australia, CanTeen and Prostate Cancer Foundation of Australia to propose a standard for informed financial consent as a key component of delivering quality care. Improving transparency about treatment options, charges and expected out-ofpocket costs across the entire journey can enable patients to be more engaged in conversations with their doctors. Thankfully, Australia has some of the highest cancer survival rates in the world, but we need to make sure we’re doing all we can to ensure surviving cancer doesn’t leave patients with debilitating debt. If you or your patient has questions about treatment, our financial assistance program, or any of our supportive care services, phone our qualified cancer nurses on 13 11 20. You can find a draft of the Standard for Informed Financial Consent here: https://www.cancer.org.au/content/IFC_ standard_public.pdf

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1 Insurance policies available through MIGA are underwritten by Medical Insurance Australia Pty Ltd (AFSL 255906). Membership services are provided by Medical Defence Association of South Australia Ltd. Before you make any decisions about any of our policies, please read our Product Disclosure Statement and Policy Wording and consider if it is appropriate for you. Call MIGA for a copy or visit our website at www.miga.com.au 2 A business must be a Qantas Business Rewards Member and an individual must be a Qantas Frequent Flyer Member to earn Qantas Points with MIGA. Qantas Points are offered under the MIGA Terms and Conditions www.miga.com.au/qantas-tc. Qantas Business Rewards Members and Qantas Frequent Flyer Members will earn 1 Qantas Point for every eligible $1 spent (GST exclusive) on payments to MIGA for Eligible Products. Eligible Products are Insurance for Doctors: Medical Indemnity Insurance Policy, Eligible Midwives in Private Practice: Professional Indemnity Insurance Policy, Healthcare Companies: Professional Indemnity Insurance Policy. Eligible spend with MIGA is calculated on the total of the base premium and membership fee (where applicable) and after any government rebate, subsidies and risk management discount, excluding charges such as GST, Stamp Duty and ROCS. Qantas Points will be credited to the relevant Qantas account after receipt of payment for an Eligible Product and in any event within 30 days of payment by You. Any claims in relation to Qantas Points under this offer must be made directly to MIGA by calling National Free Call 1800 777 156 or emailing clientservices@miga.com.au. ÂŠ MIGA November 2017

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WA: The State of STIs STIs and syphilis, in particular, are posing serious challenges to public health and doctors need to ask questions, says physician Dr Sally Murray. World-wide, more than 1 million STIs are acquired every day; West Australians are part of that problem. In the past year, infectious syphilis rates doubled, with nearly 400 cases (that’s more than one new diagnosis every day). Rising rates are the result of a significant syphilis epidemic across northern Australia, and because of PREP (pre-exposure prophylaxis) for HIV. Gay and bisexual men in Perth have increased their use of PREP with the PREP-IT trial and, more recently, PBS listing. On the plus side this has halved HIV rates but it has resulted in increased rates of condom-free sex, and subsequently syphilis and gonorrhoea diagnoses. However, syphilis has gone beyond ulcers and rashes; congenital syphilis cases have been diagnosed in both Perth and regional WA. The answer is easy; test and test again. Every pregnant woman should be tested for syphilis and if they are in a high-

risk group be re-tested in later pregnancy. And with high rates of syphilis, ‘atypical’ presentations are common. Only 50% of people will have a classic painless chancre; multiple painful ulcers need a genital ulcer multiplex swab (GUMP) PCR to exclude syphilis. Young men with sudden onset deafness or visual loss also need testing for syphilis. It then must be treated with long-acting IM benzathine penicillin. Pharmacies will source it, otherwise call your local public health unit or STI clinic (South Terrace Clinic – 9431 2149, Royal Perth Hospital – 9224 2178) and ask for help. Men who have sex with men and bisexual men (especially those on PREP) also need regular testing for other STIs including extragenital (throat/rectal) sites. Cases of gonorrhoea increased by 45% in MSM by the end of 2018. Chlamydia and gonorrhoea PCR testing is accurate for both sites and treatment of asymptomatic infection stops STI ping pong.

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MSM also need regular renal testing as PREP can damage renal tubules.

When testing for STIs, be aware that treatment guidelines are changing.

Syndromic management of urethritis and cervicitis now recommends doxycycline 100mg bd for one week instead of stat doses of azithromycin (plus ceftriaxone 500mg IM if gonorrhoea is suspected). This updated management helps tackle rising rates of Mycoplasma genitalium resistance. Routine testing for M.Gen is recommended in all patients with cervicitis or PID and patients with persistent urethritis. In WA we have M.Gen macrolideresistance testing which shows whether a patient needs azithromycin or moxifloxacin

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Managing endometriosis in 2019 By Dr Rae Watson-Jones, Obstetrician and Gynaecologist, Mount Lawley Endometriosis, a chronic condition estimated to affect 700,000 Australian women and girls, occurs when cells similar endometrial cells grow on pelvic tissues and organs (and rarely outside the pelvis). These cells respond to oestrogen and progesterone in a manner similar to the endometrium resulting in bleeding, inflammation and pelvic scarring manifesting as severe dysmenorrhoea, chronic pelvic pain and subfertility. Step one in management is considering the diagnosis. Women with endometriosis frequently report years of dismissal of symptoms by doctors. Many are told period pain is normal and to learn to deal with it, that they should have a baby and their symptoms will get better, or worse – that the symptoms are a manifestation of anxiety or depression. The Australian government announced a National Endometriosis Action Plan in July 2018 to increase awareness, streamline

This is an under-recognised condition causing missed days off work and school, decreased participation in social activities and depression.

KEY MESSAGES Endometriosis is common, affecting 10% of Australian women and girls. Refer women with severe endometriosis. The psychosocial impact of endometriosis is significant. services, promote earlier intervention and decrease the social disruption experienced by so many women. Suspect endometriosis in any woman reporting severe period pain, especially if leading to regular absence from school or work. Chronic pelvic pain, deep dyspareunia and infertility are also common symptoms Routine pelvic ultrasound can diagnose endometriomas. More advanced techniques can assess for other features including site-specific tenderness and ovarian mobility, assessment of the pouch of Douglas and the presence and depth of

deep infiltrating lesions. The presence of these features may prompt early referral to a specialty endometriosis service. Early involvement of such a service may avoid repeat surgeries. A normal ultrasound does not exclude endometriosis. Laparoscopy is the mainstay of diagnosis. Where possible, a biopsy should be taken for histological confirmation. Management at the time of laparoscopy depends on the extent of the disease and the skill of the surgeon. If a woman has severe endometriosis (bilateral endometriomas, deep infiltrating disease involving bladder or bowel and / or obliteration of the pouch of Douglas), she should ideally be referred to a tertiary centre for multidisciplinary involvement. This team may include a

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Functional Hypothalamic Amenorrhea By Dr Tamara Hunter, Subspecialist in Reproductive Endocrinology and Infertility Next to pregnancy, PCOS and Functional Hypothalamic Amenorrhea (FHA) are the most common causes of secondary amenorrhea.

attitudes along with anxiety and stress intolerance.

FHA is a chronic form of anovulation and is a diagnosis of exclusion. It is part of the WHO group 1 ovulation disorders and is commonly seen in women who experience significant weight loss, excessive exercise or a high degree of physical or psychosocial stress.

1. Correct the energy imbalance

There are five principles to the management of women with FHA.

FHA occurs as a result of the interaction of the metabolic, nervous and hormonal systems leading to a suppression of hypothalamic-pituitary-ovarian (HPO) axis. Patients with FHA will have a typical laboratory picture of low LH and normal FSH, along with undetectable levels of estradiol and progesterone. Androgen level (testosterone and DHEAS) will also be low. They will also often have prolactin, TSH and T4 levels that are low or low-normal. Due to the activation of the nervous and metabolic systems these patients will often have hypercortisolemia.

Women with FHA also have a higher prevalence of disordered eating and food

32 | MAY 2019

It is important to assess the dietary energy intake versus the exercise energy expenditure. Engaging the services of a dietitian skilled in this area is of value and the action taken depends on the deficit. For example, weight gain through refeeding in patients with anorexia nervosa or exercise modification and increased dietary energy for athletes. Few studies have examined the precise weight gain needed for resumption of the HPO axis. One study has suggested a weight gain of at least 2kg above the weight at which the cycle ceased and at least 6-12 months of weight stabilisation is required before resumption of menses.

2. Correct the psychosocial issues with CBT

Women with FHA will have altered bone metabolism with a reduced BMD and an increased incidence of osteoporosis and fracture risk. This is due to a combination of being hypoestrogenic and having nutritional deficiencies - which speaks to the complex nature of this presentation. Hypercortisolism can further supress bone metabolism. As a result of the dysfunctional or absent signally from FSH and LH, women will have poor ovarian follicle development and oocyte maturation which results in poor estradiol secretion from the follicles and ultimately a poor luteal phase which effects embryo implantation. This leads to infertility, an increased risk of fetal loss and small for gestational age babies.

This condition suppresses the hypothalamic-pituitary-ovarian axis. Dysregulation of hormones result.

Women with FHA have greater difficult in coping with daily stressors and greater prevalence of psychiatric and mood disorders. Significant ovulatory recovery through cognitive behavioural therapy (CBT) has been seen in a small RCT of FHA women without other significant history. In this study there was also improvement in metabolic factors such as cortisol, leptin and TSH with CBT.

3. Prescription of HRT over COCP

In FHA it is not recommended that the combined oral contraceptive pill (COCP) be used for the sole purpose of regaining menses or for bone protection. It is beneficial to counsel patients that the COCP may indeed mask recovery of the HPO axis.

It is suggested that clinicians consider short term combined hormone replacement therapy (HRT) and ideally

after only 6-12 months of corrective interventions, as the long term bone health parameters may be compromised if left longer. 4. Bone health

Multiple studies have confirmed that the COCP has limited to no benefit on BMD. Transdermal 17B-estradiol along with a cyclical oral progestin (e.g. medroxyprogesterone acetate 2.5mg BD) has been demonstrated to have a positive effect on BMD and the best bioavailability. Bisphosphonates and denosumab are not recommended in this population.

5. Fertility management

Ovulation induction is recommended after correction of energy imbalance and psychological factors. Patients benefit from a complete fertility workup â&#x20AC;&#x201C; including the partner. Firstline management is pulsatile recombinant GnRH via a pump, however this is not available in Australia. Combined recombinant FSH and LH is standard treatment, given in slowly increasing rFSH doses with the intention of monoovulation. This is best performed in a fertility centre setting with monitoring. Treatment often takes weeks, even months, and the treatment burden is difficult for patients. Treating patients with a BMI <18.5 kg/m2 is not recommended due to the increased risk of fetal loss, intrauterine growth retardation and pre term birth.

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Recurrent miscarriage By Dr Philip K. Rowlands, Obstetrician and Gynaecologist, Duncraig Miscarriage is defined as the loss of a pregnancy before 24 weeks. Recurrent miscarriage (RM) is the loss of two or more pregnancies in Australia and effects 5% of couples. In certain European countries, RM is defined as three or more consecutive pregnancy losses. Despite exhaustive investigations, over 50% of cases reveal no aetiology or pathological reason for RM with disappointment and frustration for patients and clinician. The main risk factors are maternal age (risk of aneuploidy in oocytes for women less than 35 is 10%, whereas 40-44yrs is 50%) and prior miscarriages. After two miscarriages the chance of livebirth is 70% within two years. After three miscarriages the incidence of further miscarriage increases exponentially. Investigations are pelvic ultrasound scan, blood tests (Antiphospholipid antibodies, FSH, LH, estrogen, progesterone, AMH,

KEY MESSAGES Following a diagnosis of RM live births can occur in around 70% of women Increasing maternal age and more than three miscarriages worsens prognosis. A cause is identified in under 50% of women.

FBC, TSH, fasting insulin/glucose, thrombophilia screen, parental karyotype) and cytogenetics on products of conception.

Some couples may have invested many years, multiple cycles of IVF and thousands of dollars in trying to have a child of their own.

Causes and treatment Antiphospholipid syndrome is found in 15-20% of women with RM and is the most treatable cause. Treat with Aspirin 150mg and Clexane 40mg daily during pregnancy, then Clexane alone for six weeks postpartum. Inherited thrombophilia (Factor V Leiden mutation, protein C or S deficiency) account for 15% of causes of RM. Treatment options include Clexane or Aspirin daily although Cochrane review of nine studies showed minimal benefits. Genetic factors cause of 2-5% of RM. Referral to a Clinical geneticist is recommended. A balanced reciprocal or Robertsonian translocation is the most common karyotype anomaly in the parents (85%). Maternal diabetes (if poorly controlled) increases risk of RM together with congenital malformations. In hypothyroidism utilise thyroxine if TSH above 2.5. If progesterone is low in first trimester advise progesterone support tailored to individual patients’ specific clinical requirements. In uterine malformations (5-10%) such as subseptate, septate and bicornuate uteri, trans cervical hysteroscopic resection techniques (septoplasty) are recommended (generally day procedures).

Fibroids (especially submucous) decrease conceptions by 50% and double miscarriage rates. Removal is recommended. Virtually all pathologies (e.g. polyps adhesions) are treated with either hysteroscopy or laparoscopy. Cervical incompetence generally preceded by spontaneous rupture of membranes or painless dilation of cervix usually 2nd or early 3rd trimester. Risk factors include prior cone biopsy, LLETZ or cervical length under 25 mm before 24 weeks of pregnancy. Treatment traditionally involved a MacDonald vaginal cervical cerclage, however if it is not possible to place vaginally (secondary to short/deformed cervix) or prior failed vaginal cerclage, then a laparoscopic supra cervical cerclage can be placed. This is a relatively simple day case procedure allowing placement of the suture ‘higher’ at the cervico-isthmic junction. The suture is left in situ indefinitely and all deliveries require Caesarean section. Author competing interests: nil relevant disclosures. Question? Contact the editor.

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Managing endometriosis in 2019

WA: The State of STIs

gynaecologist with skills in advanced laparoscopy, a colorectal surgeon, fertility specialist, pain specialist and a gynaecology specialist nurse. Inappropriate management of endometriomas can damage the ovary significantly impacting future fertility. Hormonal manipulation can manage endometriosis pain. The pill can be taken either cyclically or continuously. An intrauterine levonorgestrel device can be very effective for chronic pain. Intramuscular long acting progesterone is effective but often disliked due to the side effect of irregular bleeding.

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Gosarelin implants are PBS listed for a once off, six month course for histologically proven endometriosis. The disadvantages are menopausal-type side effects. The psycho-social impacts of this condition are important. Information and support groups are available. Author competing interests: nil relevant disclosures. Questions? Contact the editor.

after their initial week of doxycycline. This is critical as at least 50% of patients will be resistant to azithromycin. Worryingly, up to 15% will also be resistant to moxifloxacin. If symptoms persist patients may need referral to a specialist STI clinic. The Australia STI Guidelines (http://www. sti.guidelines.org.au) are an excellent ‘go-to’ for up-to-date information. The WA Silverbook (https://ww2.health.wa.gov.au/ Silver-book) is useful for clinicians working in remote and regional WA. STIs continue to flourish in WA – be curious, ask more, test more and make no assumptions.

MAY 2019 | 33

34 | MAY 2019

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Choosing the right contraception By Dr Alison Creagh, Medical Educator, Perth How can we help patients choose a contraceptive method, given their very different priorities and needs? Early on in a contraceptive consultation, it’s helpful to assess for contraindications to any of the possible methods, and to check for medication interactions. Specific questions need to be asked about such issues as migraine with aura (absolute contraindication to combined methods), or uterine fibroids (possible contraindication to IUD), and over the counter preparations such as St Johns wort, as these are not necessarily identified by patients. Some factors involved in making a choice of contraceptive method include: • Effectiveness • Possible side effects – or myths about side effects • Other benefits, such as assisting with acne, premenstrual problems or heavy menstrual bleeding • Cost & accessibility To help patients to make a choice, it is worth exploring these issues. For example, for Susanne a pregnancy would be a disaster, and she wants something highly effective but reversible. Implants or IUDs might become her preferred options. Marianne wants good contraception, but has awful heavy periods, so a hormonal IUD, combined pill or ring, or even a depot injection, could meet both of her needs. Part of this discussion can

address any commonly held myths, of which there are plenty! Common myths include that hormonal contraception causes weight gain (there is no evidence for this – apart from depot injections!), or that IUDs are unsafe for those who are nulliparous (safety is equivalent for nulliparous and multiparous people). Contraceptive cards, such as the recently updated Family Planning Association (FPAA) card, can be used to demonstrate the available options, ranked in order of efficacy. It is available at: https:// shq.org.au/download/contraceptivecard/?wpdmdl=2085 It may be helpful to provide “potted summaries” of the methods of interest to a patient e.g. “the copper IUD is very effective, lasts for 5-10 years, and has no hormones in it. However, sometimes periods can be heavier or more painful, and the insertion can be painful.” Using the card helps us to show patients the Long Acting Reversible Contraceptive methods, or LARCs, as the first-line options, due to their approximately twenty times greater effectiveness compared to the shorter acting options.(1) If people decide to use a shorter acting method, it’s helpful to discuss how to maximise effectiveness e.g. “What’s going to be the best way for you to remember to take your pills on time?” Strategies may include

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Choosing one contraceptive method that is right for a woman requires some clinical cunning and knowledge of the paitent. reminders in phones, or putting pills next to the bed or the toothpaste. Once the choices have been narrowed down, additional information can be provided, such as how to use the method to obtain maximum efficacy, how to obtain the method (or the insertion process), and other important benefits and risks. Be aware the short acting methods are most likely to be discontinued. It is helpful to suggest a return visit if any difficulties are encountered, and options for asking extra questions, such as the Sexual Health Helpline, can be offered (sexhelp@shq.org.au) Further Reading: 1. Washington University. The Contraceptive Choice Project. Available from: http://www.choiceproject.wustl.edu/

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BreastScreen WA – Supporting West Australian women’s health and wellbeing for over 30 years! 2019 marks the 30th anniversary of WA’s only accredited breast cancer screening service, BreastScreen WA. From a single clinic in Cannington opened in 1989, with one X-ray machine, BreastScreen WA has grown into a state-wide, contemporary screening service that uses the latest technology to access and image the women of WA. BreastScreen WA now has 11 permanent clinics, including one in Bunbury and four mobile units travel around WA. In 1989 BreastScreen WA performed 4,685 mammograms and in 2018 screened nearly 125,000 women. BreastScreen WA has performed well over 2 million mammograms during the past 30 years. Dr Liz Wylie, Medical Director, BreastScreen WA, observed that BreastScreen WA has seen many technological improvements in its thirty years and continues to provide a ﬁrst class service with highly trained staff at all of its clinics.

All WA women aged 40 and above, with no breast symptoms, are eligible for a free mammogram and may book their appointment online at www.breastscreen.health.wa.gov.au or by calling 13 20 50.

1989

2001

Launch of website

2002 BreastScreen WA Consumer Reference Group is formed Opened ﬁrst BreastScreen WA Clinic in Cannington

2008

2015

Padbury clinic opens

Wanneroo Clinic opens

2010-11 The digital revolution begins

2003

New breast assessment centre at Fiona Stanley Hospital

Digital technology in all clinics and in the radiology rooms

1990

2016 Mandurah clinic opens

BreastScreen WA forms an Aboriginal Women’s Reference Group and creates Aboriginal resources BreastScreen WA is mobile! By 1995 there are 4 mobile units travelling around WA

2005

New towns added to the mobile schedule vistiting about 100 WA towns in a two year cycle

1994

1995

BreastScreen WA can make opportunistic bookings at events!

BreastScreen WA wins multicultural award!

BreastScreen WA expands north… Welcome Mirrabooka

City clinic opens, BreastScreen WA becomes ﬁrst state service to go state-wide

David Jones Rose Clinic opens in the Perth City store

2013

1993

Service continues to expand Welcome Midland

2012 New mobile screening units

Rockingham clinic opens

2006

Cannington clinic relocates

Bunbury breast screening and assessment centre opens

BreastScreen WA develops electronic GP notiﬁcations

2017 BreastScreen WA performs its 2 millionth screen!

2014 Online bookings, new website and social media launched. BreastScreen WA receives WA Health Excellence Award for the Online Booking project.

1999 Assessment comes under the BreastScreen WA umbrella – Sir Charles Gairdner and Royal Perth Hospitals GP Advisory Committee is convened

2000 BreastScreen WA achieves full accreditation with BreastScreen Australia

Mobile in the Suburbs initiative proves a success utilising SMS invitations BreastScreen WA hosts it’s ﬁrst annual Picnic in the Park for Aboriginal women in Kings Park

2007 One million screens!

2019 Cockburn Clinic opens

A new secure client result portal is in the development stage and personal client results will be available online later in 2019.

Visit: breastscreen.health.wa.gov.au or call: 13 20 50 36 | MAY 2019

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CLINICAL UPDATE

Social egg freezing – fertility on ice By Dr Joo Teoh, Infertility Specialist and Obstetrician & Gynaecologist, Wembley Modern lifestyle has a detrimental effect on the world’s fertility rate. In many developed countries, childless women aged 40-44 years have doubled from 1976 to 2006, now over 20% of these women. Fertility rates are below replacement levels (two children per woman) for over 80 nations, projected to increase to over 130 countries by 2050. Then, 66% of the world’s population will be below replacement level. Many women choose to have fewer children, and delay the time of their first child. For many women, each child has a significant impact on their financial and personal lives. Parenthood can be put onhold for many years, while women wait for a good relationship with the right partner and a stable career path.

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Egg freezing is becoming “hot and trending” in the news and social media. Silicon Valley companies (e.g. Apple, Facebook) are sponsoring their female employees to freeze their eggs. The reasons for egg freezing for fertility preservation can be broadly categorised into medical and social.

There is a risk this procedure is glamorised and the success rate over-estimated.

KEY MESSAGES Women should be offered egg freezing if it is their best option. Comprehensive counselling includes cost and expectations. Best results occur if eggs are frozen before a woman is 36.

For medical egg freezing, oncology patients freeze their eggs prior to receiving gonadotoxic agents. Less commonly, other medical conditions like mosaic Turners and SLE can also cause premature ovarian insufficiency. In social egg freezing, healthy women choose to freeze their eggs to extend their fertility window. With improved egg-freezing techniques by vitrification, the survival rate of frozen eggs is good (85%). Data suggests that the pregnancy rates using frozen eggs is generally similar to IVF (23-27%). Women should be advised that while success rates are good, there is no guarantee of having a child. For a reasonable success rate, women should have their eggs frozen

before age of 36. For those older than 36, some suggest we should aim to freeze about 30 eggs; not all women can produce that number of eggs, even from multiple cycles of ovarian stimulation. Comprehensive counselling of women make them aware of the high cost and they have realistic expectations about success. Delaying conception can increase the chance of complications during pregnancy which may affect the health of the mother and child. Women must be made aware of the regulations and future costs in relation to the frozen eggs. In many countries, the duration is limited to 10 years with possible extension (e.g. UK and Australia). It is also possible that eggs will have to be donated or discarded when not used in the future. Author competing interests: nil relevant. Questions or references? Contact the editor.

APP REVIEW

A Better Visit

APP NAME : A BETTER VISIT CLINICAL USEFULNESS

By Ruth Frazer

Bona fides and purpose A Better Visit is a free, iPad app by Dementia Australia (helped by Lifeview Residential Care and Swinburne University) to help families and friends to connect and communicate with a loved one living with dementia. It aims to prevent withdrawal and make it more likely for this person to participate in everyday activities - “this social isolation can have a profound impact on the person with dementia and the primary carers”. A recent report found that 60% of people weren’t sure how to talk to someone with dementia. Those dementia sufferers who are also hard of hearing but hate to be left out can be a real challenge. For those able to try new things but cannot entertain themselves (e.g. reading or watching TV)

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EASE OF USE

this app provides a trip to familiar places that makes the carer’s visit easier and allows ‘together time’ that is non-stressful. Specifics There are eight games. “Some of these games, particularly Traces and Co-colouring and Washing windows, require no problem solving. Reveal and Tictac Tango would also be possible, but perhaps confusing for moderately severe dementia, and Gone Fishing, Marble Maze and Bowls require some dexterity and those without such dexterity might be anxious, especially those who hate not being able to do things.” It’s very much horses for courses: “We bought a music box that played the classical music he loved. All you had to do was lift the lid and the music played and

close the lid and it stopped. But he could not handle that and asked that we take it away.” On this app, you can easily change the music settings. The app is designed to be interactive, stimulating and fun. “Playing noughts and crosses with some classic songs key to your moves or using the window washing game to reveal images of iconic Australian locations can’t help but prompt further conversations.” Details Completely free. No in app purchases. For iPad only. No internet connection needed. Details at https://www.dementia.org.au/ abettervisit Simple to use. Easy to navigate. No wi-fi connection needed.

MAY 2019 | 37

THE VEIN CLINIC CELEBRATES 5 YEARS

A dva nc e d Va r ic os e Ve in Tr eatmen ts

The Vein Clinic is thrilled to be celebrating its 5th anniversary and wishes to acknowledge all of our valued referrers. Venous Eczema

BEFORE

Varicose Veins

AFTER

BEFORE

AFTER

Why refer to us?

Key milestones to date

We are Perth’s only dedicated Varicose Vein Clinic and as such our advanced treatments overcome many of the limitations associated with traditional sclerotherapy and surgery.

• Over 1,500 new patients consulted

We have a laser focus on excellence in the diagnosis and management of superficial venous disease. Our results speak for themselves with a 99.5% initial closure rate being achieved with laser (EVLA) treatments on Saphenous Veins.

• Over 1,000 procedures performed • Eight new/improved vein treatments developed/introduced We have come a long way in five years and with your support will continue to grow and deliver optimum results and patient outcomes over the next five years and beyond. Could you or someone you know benefit from our services?

What we offer patients Highly tailored multimodality treatments (ie. EVLA/Glue/Foam/Phlebectomy) Short waiting times

Clinic based diagnosis and treatment Walk-in walk-out procedures

Streamlined assessments

Central convenient location (opposite Subiaco Station)

Value and convenience

Private health insurance is not required

Advanced modern treatment options

Medicare rebates apply

Call us today on 9200 3450 or visit veinclinicperth.com.au 38 | MAY 2019

Unit 6, 28 Subiaco Square Road, Subiaco | admin@veinclinicperth.com.au

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CLINICAL UPDATE

Binge eating disorder – the new kid on the block By Dr Vash Singh, Consultant Psychiatrist, Clinical Lead - Inpatient Eating Disorder Program Everyone has ideas on what causes eating disorders. What about this disorder?

Primary care physicians should be aware that Binge Eating Disorder (BED) is common and is highly prevalent, especially in people seeking weight loss treatment. If BED goes unrecognised, it results in significant psychological distress and medical comorbidities.

physical and mental health comorbidities, that patients suffer in silence, and that treatment is available. Initiating a conversation about BED: • Be sensitive to negative weight-based biases and terms • Be sensitive to shame and embarrassment • Ask about whether the patient feels concerned about eating behaviours or pattern • Ask whether certain eating episodes “feel different” or if there are times when the “eating feels out of control” (e.g. you feel like “you can’t stop” or “you are driven”?) • Ask if eating episodes occur when not hungry or already full.

Furthermore, if BED is untreated and these patients are referred for bariatric surgery, their outcomes are likely to be poor, so early detection and evidence-based treatments remain the preferred option. Revision of the DSM-5 means that Binge Eating Disorder (BED) is now a fully-fledged diagnosis that parallels the other main eating disorders of Anorexia Nervosa (AN) and Bulimia Nervosa (BN). This seems appropriate, given that BED is more common that AN and BN combined. BED is thought to affect approximately 430,000 people in Australia which makes it the most prevalent eating disorder in adults. Unlike other eating disorders, it affects men and women in a more equal distribution and it has a later average age of onset in late adolescence to early 20s. What does the disorder involve? • Recurring episodes that take place at least once-a-week (on average) for 3 months. • At least 5 of the following: • Eating much faster than normal. • Eating until uncomfortably full. • Eating without physical hunger. • Eating alone due to shame. • Feeling disgust or guilt afterwards. • Significant distress after binge eating. • No compensatory behaviours; bingeing does not occur exclusively during anorexia nervosa or bulimia nervosa. • Eating larger than normal amounts of food within short time periods with a perceived lack of control.

KEY MESSAGES Binge Eating Disorder (BED) results in poor outcomes for those undergoing bariatric surgery. BED affects men and women in a more equal distribution and has a later age of onset compared with other eating disorders. It is important for clinicians to initiate a conversation about BED, bearing in mind the patient may be shameful and embarrassed.

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Screening tools include the BED-7 and the Binge Eating Scale. In terms of the neurobiology, BED is thought to be related to maladaptation of the corticostriatal circuitry regulating motivation and impulse control. This leads to altered reward sensitivity and food attentional biases and changes in neurotransmitters networks including the dopamine and opioid systems. This differs somewhat from other eating disorders in that it has some similarities to substance misuse disorders and this has implications for treatment. While genetic studies show that BED tends to aggregate in families, the genetics are complex and likely to involve interactions with multiple environmental factors, incl: • Trauma • Poor distress tolerance and coping skills • Mood disorders, including depression and anxiety • Desire for weight loss and dietary restraint Broaching BED with patients Clinicians should screen patients presenting with weight issues seeking treatment for obesity, remembering that 25% of BED sufferers have a weight that falls within the normal range. It is a difficult subject for both patients and clinicians to talk about, with sufferers experiencing high levels of shame and embarrassment. Clinicians may also find it a difficult subject to raise, especially if this is not the presenting complaint. It is important to note though that BED is associated with multiple

Therapy available Once a diagnosis of BED is made, it is important to provide support and hope and most patients say they are relieved to learn this is a real illness and there are available treatments. First-line therapy include psychological treatments such as Cognitive Behavioural Therapy, Interpersonal Therapy and Behavioural Weight Loss (BWL). Psychological targets include reducing the frequency and intensity of binge eating episodes, achieving sustainable weight loss and/preventing excessive weight gain and increased ability to cope with negative affect. In terms of pharmacological treatment, Lysdexamphetamine (marketed as Vyvanse), is indicated for the treatment of moderate to severe BED (i.e. more than three episodes of bingeing a week), in conjunction with psychological treatment. Pooled analysis of three pivotal studies for Vyvanse showed that it had an effect size of 0.83-0.97 for a reduction in binge eating days/ week. It is generally well tolerated, with headache and dry mouth, insomnia and appetite suppression being the main side effects. However, the usual precautions for stimulant prescription would apply. Other pharmacological treatment options, include high dose Fluoxetine, Topiramate and anti-addiction drugs such as Naltrexone. References available on request.

MAY 2019 | 39

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CLINICAL UPDATE

How to triage patients with chest pain? By Dr Michael Muhlmann, Interventional Cardiologist, Nedlands More emphasis will be placed on Chest pain assessment in accurate triaging of chest pain, as general practice the population ages. These notes is challenging will help. and common (1-3%); most GPs see 1-2 patients each week. While the differential diagnosis is broad, acute life-threatening disease is uncommon; severe diseases such as acute coronary syndromes, pulmonary emboli and acute aortic dissection are greatly outnumbered by musculoskeletal chest pains and gastroesophageal reflux. Thus, clinical judgement and triage remains paramount. The incidence of chest pain in general practice is not decreasing. However, the percentage makeup of acute coronary syndromes is. Moreover, atypical complaints lead to more uncertainty. Acute coronary syndrome (ACS) is life-threatening and needs to be considered in all patients with chest pain. A history and examination will define high risk patients and an ECG is a key immediate investigation. Guidelines say GPs should refer all patients with suspected ACSs to tertiary centres as soon as possible. Of course, if every case of chest pain was referred, tertiary facilities would be overloaded. The GP’s gatekeeper role means that only a minority are referred. Besides clinical findings, GPs use gut feeling and the clinical backgrounds of their patients to make referral decisions. Patients are referred for safe exclusion of ACS and about 1 in 5 are found to have severe disease. Chest pain history, clinical examination, determination of cardiac risk factors and initial ECG all provide immediate cardiac information to GPs. There is conflicting data about chest pain history. Certain characteristics increase the likelihood of ACS - chest pain radiating to shoulders or one or both arms and pain precipitated by exertion. Conversely, pains on palpation, pains described as stabbing or positional reduce the likelihood of ACS. Those with previous cardiac disease are clearly at risk of a further event. All patients with chest pains receive an ECG at outset. However, this is not always practical and there are concerns about the diagnostic accuracy for the detection of abnormalities by doctors (measured at up to 70% for GPs). Please note, when ECG machines interpret tracings treat with extreme caution, particularly when diagnosing key findings. For a suspected ACS, community troponin testing should not delay ED referral. It is reasonable for a GP to order a ‘retrospective’ troponin in a patient who is low risk and asymptomatic and in whom symptoms have completely resolved 24 hours prior. Mark any acute troponin as ‘urgent’ and ensure the patient is contactable but generally, troponin has little role in the primary setting and suspected ACS needs to be transported to the nearest ED. Patients with ST elevation or ongoing chest pains should be transferred via ambulance. In all other scenario’s patients should be advised not to drive themselves. All patients should be given aspirin and GTN +/opioids for pain. Oxygen is no longer recommended for routine use unless saturations show <93%. References available on request.

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OTOSCLEROSIS: A LEADING CAUSE OF EARLY ONSET HEARING LOSS IN WOMEN

Anne Gardner

Andre Wedekind

Post Dip. Aud., BSc

M.Clin.Aud., BHSc (Physiotherapy)

Otosclerosis is an abnormal bone growth of the ossicular chain, most commonly the stapes. This growth prevents the stapes from moving normally in response to sound. It is seen in 1-2% of people. Hearing loss is predominantly bilateral and usually begins between the ages of 10 and 30. When otosclerosis is limited to the ossicles, a conductive hearing loss is present. It can progress to the bone surrounding the inner ear (the otic capsule), causing a sensorineural component. RISK FACTORS The cause of otosclerosis is largely unknown, but there are a number of risk factors: 1. Gender: women are twice as likely to develop otosclerosis than men 2. Family History: otosclerosis tends to run in families, which suggests a genetic susceptibility 3. Pregnancy: women are more likely to develop otosclerosis during pregnancy 4. Osteogenesis imperfecta: Those affected by this genetic disorder are at an increased risk of developing otosclerosis 5. Measles virus: there is some evidence that the measles virus may contribute to developing otosclerosis DIAGNOSIS AND CLINICAL PRESENTATION Diagnosis is usually made based on family history, progressive conductive hearing loss and exclusion of alternatives. A CT scan of the temporal bone is specific, but insensitive. Variable tinnitus may be present. Dizziness is prevalent in 15-25% of cases. However, the mechanisms for dizziness is unknown. TREATMENT • Hearing aids provide a conservative approach for hearing restoration, but do not alter the course of progression. • Surgical Treatment o Surgical options aim to correct the abnormal bone growth by either removing the affected section and replacing it with a small implant (stapedotomy) or replacing the entire stapes (stapedectomy). o In some cases, if a large sensorineural hearing loss is present, then cochlear implants may be the only hearing rehabilitation option if the cochlear is patent.

51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au

MAY 2019 | 41

Genea Hollywood Fertility provides a comprehensive individualised range of fertility treatments for Western Australians. Our specialist team has up to 30 years’ experience in fertility treatments. Our patients have access to Genea’s world leading science. All patients have individualised assessment and treatment. Genetic testing is available where needed. Our treatment charges are transparent. Our clinicians, scientists and support staff are committed to achieving successful outcomes.

Dr Michael Allen

Dr Julia Barton

MBBS, FRANZCOG, FRCOG

MBBS (UWA), FRANZCOG, MRMed

MBBS, FRANZCOG

Prof Lincoln Brett

Dr Joo P. Teoh

BMedSc, BSc (Hon), MBBS, FRANZCOG

FRANZCOG, MRCP (Ire), MRCOG, MBBCh, Msc (Lon), MD (Glasgow) Subspecialty Repromed (UK)

Dr Simon Turner

We have moved to Wembley Genea Hollywood Fertility is now located in a newly developed building, ideal for our patients’ needs and conveniently located close to Subiaco train station. We have also partnered with Cambridge Day Surgery, located next door, where our doctors will conduct all their procedures in their state of the art theatres.

Genea Hollywood Fertility means high success rates, understanding staff and individual care. Genea Hollywood Fertility Level 2, 190 Cambridge Street, Wembley WA 6014 P (08) 9389 4200 W wa.genea.com.au 42 | MAY 2019

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CLINICAL UPDATE

Nausea and vomiting in pregnancy By Dr Chris Gunnell, Obstetrician and Gynaecologist, Murdoch NVP, in textbooks, is seen as a 'minor complaint of pregnancy'. Those who had this problem, or work with women in early pregnancy, know it can significantly affect quality of life. GPs will most often manage women with NVP and may be unsure how to treat them; fearing medications with possible effects on the developing fetus. It is important to discuss some basic lifestyle and dietary changes to alleviate symptoms: these include frequent and small meals, adequate hydration, avoiding spicy or fatty food, and smells that trigger nausea. Fresh air, exercise and adequate sleep (fatigue can aggravate symptoms) can help. Consider discontinuing certain supplements such as those containing high iron doses and treating gastric reflux with antacids or ranitidine Studies have shown ginger (500 mg bd) to be superior to placebo in reducing NVP. No increased risk of malformations has been shown, however it can have an anticoagulant effect.

85% of women have some nausea and vomiting in pregnancy (NVP) but only around 2% have extreme hyperemesis gravidarum (HG).

KEY MESSAGES Is common and can be distressing. Use lifestyle changes first. Pharmaceutical options are numerous. Used together, pyridoxine(B6) and doxylamine can be effective, however they cannot be obtained as a combined preparation in Australia. Doxylamine is a sedating antihistamine so caution needs to be used in those women working or driving. Dosage is B6 50 mg qid and Doxylamine 12.5mg slowly increasing up to 25 mg tds. Promethazine (10-25 mg qid orally or 12.5 mg qid IM) has been shown to be effective and safe but also causes drowsiness. Many studies have shown metoclopramide to be safe and effective but beware of extrapyramidal effects. Maximum daily dose is 30 mg. The TGA recommends the duration of treatment be limited to 5 days.

Prochlorperazine (5-10 mg tds orally or 12.5mg tds IM) is sedating and prolonged use can cause tardive dyskinesia. Ondansetron is effective but expensive and causes constipation. Evidence suggests this drug is safe but there is limited data so it should not be considered first line treatment. Dosage 4-8mg orally BD or by im/iv injection. Maximum 16mg in 24 hours. Reserve steroids for severe cases where standard therapies have failed. Most studies show no increased risk to the fetus but early reports suggested an increased risk of cleft lip and palate. In general, treatment should be started intravenously as an inpatient. Dosage 100mg hydrocortisone iv BD then oral

continued on Page 45

COMPREHENSIVE COMMUNITY RADIOLOGY Western Radiology, high-quality imaging and intervention services available across Perth. With a focus on state of the art equipment, procedures and scans we deliver a higher standard of care in the community. Daily appointment availability at each branch, direct access to our clinical team and affordability set us apart.

Catering for GPs and specialists with: Comprehensive vascular, interventional and cardiac services. Plus level-2 interventions: C-Spine, Epidural, Rhizotomy, P.R.P., plus oncology procedures. Cardiac MRI, CT Coronary Angiogram & Calcium Scoring.

Staff are highly trained, experienced and service focussed. Results available online, with 24 hour turn-around. A strong, growing list of radiologists and a policy to bulk-bill all Medicare rebatable items rounds out an exceptional service.

9200 2777

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9200 2778

www.wradi.com.au

MAY 2019 | 43

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CLINICAL UPDATE

Breathlessness, cardiac or respiratory? By Ms Cia Connell, Clinical Policy and Evidence, Heart Foundation When identifying the causes of breathlessness the checklist of possibilities cover most of the biology of the respiratory and cardiac systems, mental health, and haematological and renal factors. Breathlessness might occur at any point on the continuum from oxygen supply to the lungs to its consumption by the tissues. For the clinician trying to sort out a predominant cardiac cause of breathlessness from a respiratory one going through Table 1 may help – it contains a non-exhaustive list of possible mechanisms. Breathlessness assessment Evaluation of a patient presenting with breathlessness will vary dependent on clinical situation such as acuity, age of the patient and their prior medical history. The case history should determine the duration and severity – based on the New York Heart Association functional classification – of breathlessness and

If heart failure is suspected, the GP should enquire as to whether the patient has orthopnoea, paroxysmal nocturnal dyspnoea or associated symptoms such as chest pain, palpitations, dizziness, syncope, swollen ankles and abdominal bloating. Physical examination should include assessment of vital signs (heart rate and rhythm, blood pressure, respiratory rate and temperature), peripheral perfusion, volume status (JVP, peripheral and sacral oedema, ascites and hepatic congestion), cardiac palpitation and auscultation (apex beat, gallop rhythm and murmurs) and auscultation of lung fields (air entry, crackles and wheeze). Basic investigations include non-invasive measurement of oxygen saturation, 12-lead ECG, chest X-ray, serum biochemistry (electrolytes, renal function and liver function) and full blood count. Further investigations will depend on clinical circumstances and findings from the initial clinical workup.

Table 1. Causes of breathlessness Cardiac

Respiratory

• • • •

Increased left-sided intracavity filling pressure – heart failure due to myocardial dysfunction (HFrEF, HFpEF)* – left-sided valvular dysfunction (aortic or mitral stenosis or regurgitation) acute or recent myocardial ischaemia* Arrhythmia* (tachyarrhythmia, bradyarrhythmia, ectopy, AF, atrioventricular disassociation) Low cardiac output (left-sided): – pulmonary hypertension – hypovolaemia – cardiac shunt – cardiac compression (pericardial constriction, cardiac tamponade, tension pneumothorax)

• Hypoxia – pulmonary parenchymal abnormality – infection (pneumonia*), fibrosis, destruction (emphysema), oedema, alveolar haemorrhage and compression (pleural effusion and pneumothorax) – airway obstruction (asthma*, bronchitis, upper airway) – ventilation–perfusion mismatch (pulmonary embolus and pulmonary shunt) • Central respiratory drive abnormality (pharmacological, metabolic) • Musculoskeletal respiration abnormality – skeletal myopathy – respiratory muscle fatigue – chest wall abnormality (kyphoscoliosis, thoracic skeletal pain and obesity*)

Peripheral muscle oxygen extraction • Poor physical fitness* abnormality or inefficiency • Myopathy Anxiety

• Panic attack, chronic anxiety state

Anaemia, iron deficiency* Hyperventilation

• Acidosis (renal failure, ketoacidosis, shock) • Pharmacological cause • Thyrotoxicosis

* Common and potentially reversible factors that contribute to breathlessness; AF=atrial fibrillation, HFpEF= heart failure with preserved ejection fraction; HFrEF= heart failure with reduced ejection fraction.

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It’s a common clinical dilemma – working out if breathlessness is cardiac or respiratory!

whether there are predisposing factors (e.g. effort and emotion).

Requirement for more urgent evaluation or referral

Table 2. When to consider early referral (red flags) Symptoms

• Orthopnoea • Paroxysmal nocturnal dyspnoea • Syncope • Ischaemic chest pain Signs • Tachycardia (heart rate >100 beats/min.) • Bradycardia (heart rate <40 beats/min.) • Hypotension (systolic BP <90 mmHg) • Hypoxaemia • Gallop rhythm • Significant heart murmur Investigations • Evidence of ischaemia or infarction on 12-lead ECG • Pulmonary oedema on chest X-ray • Raised cardiac troponin level • Moderate or severe valvular heart disease on echocardiography • Left Ventricular Ejection Fraction ≤40% • Ischaemia on stress testing BP=blood pressure, ECG=electrocardiogram, Both tables Reproduced from National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018.

To assist identifying patients with Heart Failure and then to focus on how to manage worsening symptoms refer to the updated national guidelines. www. heartfoundation.org.au/for-professionals/ clinical-information/heart-failure. For the full text see https://www.heartlungcirc.org/ article/S1443-9506(18)31777-3/fulltext Author competing interests: No relevant disclosures. Questions? Contact the editor. The author acknowledges the input of A/Prof Tom Briffa, Director, Centre for Health Services & Cardiovascular Research Groups, Perth.

continued from Page 43

Nausea and pregnancy prednisolone when tolerated. Start orally at 50mg daily for 3 days then reduce by half every 3 days to reach lowest maintenance dose that controls symptoms. Exclude other significant causes of vomiting or factors that could aggravate hyperemesis e.g. UTI, thyroid disease, gastro-oesophageal reflux/ulceration, viral illnesses. Monitor electrolytes. In the home iv therapy or hospitalisation may be needed in severe cases.

MAY 2019 | 45

FEATURE

Battling Antarctic Winds to Save Lives

iver transplant surgeon Prof Luc Delrivière and his wife Bronwyn sailed to the Antarctic to be the first to cross the Narrow Plateau of the Antarctic Peninsula. Fellow adventurers included Maria Witchell, camerawoman Caroline Cote and guides Vincent Collard and Phil Wickens. No dog sleds, which are banned, just human legs took them across the vast plateau. “Antarctica is full of beauty and charm but along the coast and in seconds it can throw so much temper, fury and roar at you. Yet even between the avalanches tumbling to the sea, the crackling sound of ice beneath our skis, and the fierce sound of the chunks of glacier breaking off the mountains, Antarctica left us with a beautiful memory,” Bronwyn said. “On the plateau, between storms, you experience a pristine silence. The kind of silence you’ll hear nowhere else but there. It's very difficult to describe. It's a peace that both Luc and I reflect on every day since arriving home.” Genesis and the journey

then the Narrow Plateau of the Antarctic Peninsula from Hope Bay to Portal Point. “Our man-hauling expedition was going to use a new route to reach the plateau from the Gerlache Straits and cover 200km of the Narrow Plateau,” Luc said. “The team met in Ushuaia on Boxing Day 2018. A lot had to be done before the departure of the boat three days later when a good weather window appeared at Drake passage. Food had to be bought and daily rations organised, the sledges had to be prepared with bags and tents, rescue skills had to be refreshed and harmonised across the group,’ Luc said.

“The night was eventful as small icebergs were getting entangled in our anchoring lines and we had to fight all night to avoid damage to the boat.” To access the plateau via the new route, from sea level to 2000m on the Breguet glacier, it became an immense physical challenge for the team as the sledges were at their heaviest (close to 70kg). The entry point was spectacular and steep. It took seven days to achieve that first part of the expedition “After one day of travel, we could see down glacier valleys and eventually we reached

“After zig-zagging among smaller icebergs, we anchored in Cierra Cove next to a penguin rockery. The smell is infamous but we spent a nice evening surrounded by seals, penguins and passing humpback whales. Such a stunning contact with nature!”

Over five years ago, the idea of this project came to Luc after reading A World of Men: Exploration in Antarctica by Sir Wally Herbert. In 1955, Wally Herbert was 21 years old and worked as a cartographer with the Falkland Islands Dependencies Survey. His first major expedition, described in his book, was in 1957 along the frozen ocean of the Weddell Sea and

46 | MAY 2019

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Luc and Bronwyn Delrivière with their team braved flying ice blocks and murderous chasms to achieve a world first and to help others.

FEATURE

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Prof Luc Delrivière and his wife Bronwyn

the straits and the large islands of Brabant and Anvers. Over the next three days, we had majestic views of the Gerlache Straits on one side and the Weddell Sea on the other,” Luc said. “Deep snow, white-out conditions, blizzard…nothing was going to stop us. By January 13, we were close to the narrowest point of the plateau, The Cat Walk. It is a mythical place that many explorers have heard about but no one had documented. We expected a spectacular place. It did not disappoint.” “We waited two days under heavy snow for a good weather window. We were up by 4am on January 16 but we still had to wait longer for the clouds to further disperse.”

never seen before. More people have walked on the moon than across The Cat Walk.” Celebrations at Wally’s hut

going to pick us up and drop us back to our boat, Icebird, which was temporarily immobilised for repairs to the gear box.” Luc said.

Despite a team member recovering from snow blindness, 36 hours of howling winds violently shaking the tents, walking through the hardest part of the descent of the Reclus Peninsula, risking frostbite and food shortages, the expedition finally arrived at Portal Point, the location of Wally Herbert’s old hut.

“In Charlotte Bay, large icebergs and whales were watching us make our way through the last slopes. It was a superb place to finish the trip. We celebrated the achievement with beers and champagne, gathering on the rocks where the concrete base of Wally Herbert’s old still stands. It was very emotional. We had made it!”

“We were on cloud nine but we had to move fast. We were told that at around 5pm, a Polish boat called Thelma, was

Contributions to the Liver Foundation www.liver.org.au/expedition.

“Crossing The Cat Walk was an amazing experience. The clarity of the air that day allowed us to see over 100km on each side. We were seeing complete horizons

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MAY 2019 | 47

LAUGHTER EPIDEMICS Monty Python’s skit about the funniest joke in the world, slightly aged now, does in fact touch on something that really happens – laughter epidemics. The Guardian in its 2012 piece Beyond a joke: the truth about why we laugh discusses one of the most famous cases of a laughter epidemic in Africa. Over 1,000 people were affected by a joke that started among a group of teenager girls in the village of Kashasha, Tanzania. We do not know what the joke or jokes were, but it required the closing of 14 schools and went on for an incredible 2 years. Now, stop here. Scientists argue that the longest we can laugh is 20 seconds, because genuine laughter is taxing.

But that does not explain Christian worshippers like the Shakers who go into fits of laughter and in the 1800s went into very big fits of laughter in the US and internationally. While the Shakers have shrunk as a religious movement, today people can join secular laughter and yoga clubs to release their inner laughter.. Is laughing, though, going to do you any good in the long term? A study in the 2011 journal Heart & Lung “Effects of humour and laughter on psychological functioning, quality of life, health status, and pulmonary functioning among patients with chronic obstructive pulmonary disease: A preliminary investigation” concluded that sense of humour among patients with COPD is associated with positive psychological functioning and enhanced quality of life, but laughing aloud may cause acute deterioration in pulmonary function secondary to worsened hyperinflation.

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The epidemic could not have involved continuous laughter for two years. Moreover, these epidemics are taken to involve a combination of laughing and crying, perhaps as a result of stressors of some kind. Mass Psychogenic Illness (MPI) normally involves stressors among the powerless. Laughter is a good way for poor people to express themselves.

What about the internet? Are there epidemics of laughter in cyberspace? There are few studies to cite on epidemics, but sense of humour is a must if you want to find a partner on an internet dating site. Women associate humour with intelligence. A 2013 study by anthropologist and psychologist Gil Greengross investigated in detail 260 internet dating profiles of women and men. She found that women who added humour to their profile got no particular gain in the dating game, but men adding humour to their profile, including jokes, increased their chances with women. In summary, it is unlikely that readers who participate in a laughing epidemic are going to be the worst for it, although laughing aloud might cause some problems. If readers are looking for a partner online, then they need to scrub up on their jokes, especially if they are men.

By Mark Balnaves

Ouch. Don’t laugh aloud.

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WINE REVIEW

Houghton Rich in Heritage and Class

By Dr Martin Buck

Houghton winery and vineyards are an integral parts of the story of viticulture in Western Australia and reflect the beginning of the tradition of Swan Valley wine making. The property was established by a trio of British army officers in 1836 who purchased a large land holding in the Swan Valley and it was named after the senior officer – Lieutenant Colonel Richmond Houghton. Another of the officers, Thomas Yule, oversaw the planting of the first grape vines. Since that

time the vineyard has been expanded and the winery has seen many famous winemakers produce some classic Swan Valley wines. I was fortunate to taste this quartet of magnificent wines that reflect the best that WA has to offer from our unique viticultural and winemaking heritage. All these wines are strongly recommended and will reward further cellaring for that special occasion.

Houghton Winemaker Ross Pamment

2016 C.W. Ferguson Cabernet Malbec

2013 Thomas Yule Frankland River Shiraz

The Iconic series of red wines reflect the breadth and quality of the vineyards in WA. The C.W. Ferguson Cabernet Malbec has fruit sourced from Frankland River, hand-picked and crushed into open fermenters and with a wild yeast ferment. Aged in French oak for 16 months and then the best barrels blended for the final wine. It’s a deep red and purple with cigar box and ripe berry aromas. The palate is full of balanced fruit, savoury, mocha and spice characters with gentle tannins. This is an awesome example of the cool climate Frankland River red wines.

The Thomas Yule 2013 Frankland River Shiraz is another handcrafted wine made with respect to the almost 50-year-old vines. A combination of French oak barriques and puncheons have ensured that the intense shiraz fruit characters shine through. A deep purple wine with amazing spicy, plummy characters with hints of liquorice. A medium-bodied style with a long fruit driven palate and soft, gentle tannins – a wine with a lot left to give with further cellaring.

2016 Gladstones Cabernet Sauvignon Travelling to Margaret River, the 2016 Gladstones Cabernet Sauvignon is sourced from a single vineyard in Wilyabrup from 25-year-old dry grown vines and is a testament to the foresight of Dr John Gladstones in predicting the quality of wines that would eventually come from this region. Another intense wine with a deep crimson colour, aromas of spice, eucalyptus and vanilla. The use of barriques has given the fruit a chance to shine through the delicate tannins. Although without the depth of the Frankland River wines, it is an elegant wine with great balance.

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2016 Jack Mann Cabernet Sauvignon The 2016 Jack Mann is a limited release wine of extraordinary quality. Made from a single vineyard in Frankland River it is hand harvested from 47-year-old vines. In the glass, the wine is a smouldering intense red with notes of aged berries, oak and spice. An amazing palate of rich fruit depth, plummy characters, mocha and a soft, long profile. An excellent wine respecting the masterful winemaking of Jack Mann and his legacy in our state.

MAY 2019 | 49

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FILM

In the Year 2040 Climate change and environmental degradation will be two of the hottest topics of this month’s federal election – and the pun is definitely intended.

“I also got very miserable at the dystopic narrative if we don’t take action, and I think a lot of people share that feeling,” he said.

Filmmaker Damon Gameau, who Medical Forum featured several years ago when he released his expose of sugar in That Sugar Film, has also been swept along, or at least hugely inspired, by the youth movement in his new film, 2040.

The film, therefore is part investigative as Damon goes around the world looking at solar panels in a Bangladesh village, to permaculture to waste reduction. And part dramatisation of a future that has had the benefit of 20 years of positive action and what effect it will have on Isabella’s society of 2040.

here seems mounting evidence that voters want our politicians to state where they stand on these issues, and the world’s youth taking to the streets in big numbers must take a large part of the credit for that.

It is a simple premise – his four-year-old daughter Isabella will be 21 in the year 2040 and he wanted to give her some skerrick of hope that the life he has enjoyed would still be possible if action was taken on climate change now.

Wine winner

“So the premise of the film is to explore what strategies exist now and see what affect they would have 20 years from now.”

The film opens in Perth on May 23 but it has had outings at some major film festivals. In February it was screened in front of 500 children aged between 12-20 years to rock star reception. It has been a

hit at the Gold Coast Film Festival where educators were keen Damon develop curriculum material. Damon said it will be the kids of today who will shape the future and it’s time the country’s and the world’s leaders started to listen.

For Subiaco gastroenterologist Dr Sandra Henderson, the prospect of taking home a dozen bottles of Evans & Tate wines was a glorious trip down memory lane. “Evans & Tate were the first wines I really began to like in those days when you used to go down south for a weekend. I have such fond memories of them,” she told Medical Forum. Sandra’s now developed and keen wine palate only slightly favours chardonnay and riesling over cab sav and shiraz but, like most people, bubbles are irresistible.

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COMPETITIONS

Enter Medical Forum's competitions! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link.

Music: Goran Bregovic – Three Letters from Sarajevo Hang on to your hats, Balkan firebrand Goran Bregovic is bringing his Gypsy-fuelled fun to the Perth Concert Hall along with his lively Wedding & Funeral Band, which combines brass, percussion and lively Bulgarian vocals. The concert celebrates his 2018 album Three Letters From Sarajevo, inspired by the history and memories of his hometown of Sarajevo, exploring its different faiths, special identity, fusions and complex paradoxes. Bregovic has sold more than 6 million albums representing a kaleidoscope of musical styles from rock, Balkan folk to indie and collaborations with the likes of Iggy Pop, Scott Walker and the Gipsy Kings. He says music in the only international language that crosses borders and cultures in a single strike. So expect a night of gypsy brass band, traditional Bulgarian polyphonies, electronica, traditional percussion, strings and Orthodox Church male singers – name it, the band plays it and audiences can’t resist dancing. Perth Concert Hall, May 12

The rise of bespoke travel Dan Knox and his colleagues at UWE Bristol reported in a 2017 study that bespoke travel demand was exceeding supply. Australian bespoke ‘travel tailors’ catering for the health professionals, however, have known this for some time. Managing Director of Amaco Mathew Lazarow calls the bespoke work as ‘moneycan’t-buy-experiences’. His company is a specialist provider of accredited CPD activities and an accredited provider with the RACGP Accredited Education. It is also registered with ACRRM. “We limit the size of our conferences to groups of 30-40 people, which means we are large enough to negotiate from a position of strength with suppliers, but small enough to fit into the most intimate of venues, and nimble enough to vary the itinerary at the last minute if necessary,” Mathew said. Locations have included the Kimberley to the Serengeti Plains; from Oslo and the Norwegian Arctic to Costa Rica, Panama and the Caribbean.

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Movie: Red Joan Judi Dench leads a strong cast in this good old fashioned English spy thriller. Joan lives in contented retirement until she is arrested by MI5 and her past as a spy and her past comes pouring out. In cinemas, June 6

Movie: Never Look Away Inspired by real events, Never Look Away tells the story of a young art student, Kurt (Tom Schilling) who falls in love with fellow student Ellie (Paula Beer). Ellie's father, a famous doctor, vows to destroy the relationship but Dad is carrying a few secrets of his own. Intriguing film that was nominated for an Oscar. In cinemas, June 20

Movies: German Film Festival Palace Cinemas present the best of German cinema at the German Film Festival, which kicks off with Balloon (Ballon) – a thrilling true story of two families’ extraordinarily escape from East to West Germany in a homemade hot air balloon. Cinema Paradiso, May 28-June 12

Movie: Men in Black: International Chris Hemsworth dons the sunglasses for the next exciting instalment of the MIB team protecting the Earth from big bugs and scary baddies of the universe but this time it looks like the threat is from within! In cinemas, June 13

Movie: 2040 Award-winning director Damon Gameau (That Sugar Film) explores what the future could look like by 2040 if we embrace the best solutions available now to tackle environmental and social issues. In cinemas, May 23

MAY 2019 | 51

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

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