Medical Forum WA 0918 Public Edn

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EDITORIAL Jan Hallam, Managing Editor

For the Record, It Stinks There must be something in the water that makes us pretty terrible at rolling out large-scale IT projects. Think NBN, My Health Record, and any number of hospital IT projects.

If you’re thinking this is a little harsh, think of the money that has been siphoned from GPs, mental health, preventative health to fund this mess we have to have, because there is little doubt that our health system is in desperate need of a high-functioning electronic health record that talks effectively with all layers of health care.

How can we build bright, shiny hospitals with robots whizzing around as if they own the spacestation, and still fax an imaging request to the department 50m down the corridor?

Doctors have been criticised for taking an over-cautious approach to IT, and the MHR in particular.

But they can hardly be blamed.

Not a month goes by when another alarming revelation is made that puts medicos on the back foot on ethical and legal grounds.

Why do our hospitals still have patient records in manila folders?

Why are our hospitals still working with 20-year-old software that is so incompatible it would fail to score a date on Love Island?

So how does one begin to contemplate the debacle that is the Personally Controlled Electronic Health Record (remember that doozy?) which morphed into My Health Record yet still unable to rid itself of the smell of rotting fish.

Billions of dollars has been spent on the project, and yet its progress on the evolutionary scale makes the New Zealand tuatara, the slowest evolving animal we know of (check it out, it’s a lot more interesting than the MHR), look positively racy.

The MHR stumbles and bumbles from one crisis to another.

The latest being the scandal of data sharing with law enforcement agencies without a by-your-leave from the record owners or their health care professionals. Wasn’t privacy and data sharing the very thing that brought the PCEHR to its knees three years ago?

When you stuff up once spectacularly, there’s no law (or oversight, it would seem) preventing you from stuffing up again in equally dazzling fashion.

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Marketing Manager Kirsty Fitzpatrick (0403 282 510) advertising@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

Building a system that has the confidence of the medical profession is a big job but it’s not an impossible one when approached with common sense and a genuine commitment to a national health record - with the emphasis on health.

The MHR is not a defacto Australia Card (a la Bob Hawke), or a Big Brother attempt to keep tabs on, and control of, the citizenry. It must never be allowed to become such a creature, no matter how much pressure the security agencies put on the government. Let them stick to spying on people on social media.

The electronic health record is needed to help people get appropriate and efficacious treatment quicker and easier, and with the appropriate health professionals. It is needed to save our overwrought hospital system from becoming the most expensive primary care system on the planet; hopefully, to give our famished primary care system a nourishing meal so they can continue being saviour of all for more than $37 a consult.

This is important.

So, the two questions we have to ask: who is in the ringmaster of this circus, and when will they start cracking the whip?

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

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

SEPTEMBER 2018 | 1

CONTENTS SEPTEMBER 2018

INSIDE 10 12 14 22

Spotlight: Dr Bernard Chapman Close-Up: Prof Steve Stick Cystic Fibrosis Update

Spirometry: Underused & Underfunded?

14

10

NEWS & VIEWS 1 Editorial: For the Record, It Stinks - Jan Hallam 4 Letters to the Editor

12

6 7 21

Bullying No-Go - Prof David Forbes Downside of Better Access - Dr Peter Maguire Have You Heard?

Beneath the Drapes Acne Expectations

LIFESTYLE 38 Travel: Picture Perfect Greece 40 The Funny Side 40 Wine Winner - Dr Georgi Pagey 41 Losing Weight is a Habit 42 Opera: Don Giovanni 43 Theatre: The Vibrator Play 44 Competitions

22 MAJOR PARTNER 2 | SEPTEMBER 2018

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MEDICAL FORUM

CONTENTS SEPTEMBER 2018 CLINICALS

5 Pertussis Diagnosis in 2018 Prof Miles Beaman

31 Bronchiectasis Case Study Dr Michael Prichard

33 Spirometry in Practice Mr Bill Smith

33 Managing Early Cirrhosis Dr Nicholas Kontorinis

36 Preventing Sepsis in Asplenia Dr Astrid Arellano

ASSISTED DYING DOCTORS RESPOND

16-19

Reduced Allergenicity Immunotherapy Dr Meilyn Hew

GUEST COLUMNS

9 Meth & Alcohol in Bunbury Dr Hugh Mitenko

37

25 Study the Study Drugs Prof Simon Lenton

27 Work Support: Medicine Keeping Up? Ms Dana Topchian

29 Language of Violence Ms Angela Hartwig

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician)

MEDICAL FORUM

SEPTEMBER 2018 | 3

LETTERS TO THE EDITOR Bullying no-go at WA Health

proactive requirements for all employees to uphold the highest standards of professional and ethical behaviour, and to be vigilant and report any instances of bullying witnessed.

Dear Editor, Re: The Good, The Bad & The Ugly (July edition) The WA Department of Health has a zero tolerance approach to bullying and harassment in our workplace. We have developed a variety of robust policies and programs designed to promote a culture of respect and inclusion throughout the organisation.

In 2017 the Minister for Health, Department of Health and the AMA (WA) collaborated to launch the SH-OUT campaign, to affirm zero tolerance for sexual harassment.

The Department also offers a 24-hour, 1800 ethical advisory line to support staff dealing with conduct issues, and advice for appropriate reporting pathways. I would encourage any staff member who feels they have been mistreated to avail themselves of any of the support mechanisms available.

Our junior doctors need extra support as they adjust to working in our hospitals, so we have put in place a variety of practical initiatives.

There is no place for bullying in our hospitals.

For example, Royal Perth Hospital’s Junior Doctor Wellbeing Office provides individual counselling and peer-group sessions, mindfulness programs, discussion groups focusing on bullying, harassment and sexual discrimination, clinical debriefing sessions and mentoring.

This service is well attended with more than 60% of interns, Resident Medical Officers and Registrars from Royal Perth Hospital accessing the support program. User feedback is overwhelmingly positive, with reports of improved personal health and wellbeing.

Furthermore, additional accreditation standards have now been added to JMO rotations that include a requirement for health services to demonstrate that support services and appropriate anti-bullying mechanisms are in place.

We have policies that define and prohibit bullying and harassment. They also specify

Professor David Forbes, A/Chief Medical Officer, WA Department of Health ......................................................................

The downside of better access Dear Editor, The ability for GPs to refer patients for psychological treatment under a Mental Health Plan has been of great assistance to many patients. It has also helped us offer something other than antidepressants to patients with various mental health diagnoses.

anyone presenting with a mental health issue, or even people who are distressed from life events.

If my impression is accurate, that's a very unfortunate outcome – it has created a huge psychology industry, at great cost to Medicare, with dubious benefit over standard GP care. By doing that, it has devalued the role of the GP in mainstream mental health treatment.

In the bad old days before Mental Health Plans, when access to psychology was very limited, most patients were managed by their GPs, with relatively unsophisticated counselling techniques, and most got better.

Have we forgotten the therapeutic potential of the doctor-patient relationship?

Many patients do not need to see a clinical psychologist for relief of their psychological distress. They just need someone to listen to them and respond with empathy and humanity, preferably in the context of an ongoing therapeutic relationship.

I would urge my colleagues not to reach too soon to do that referral. Sit back and take some time and you might find you have all the skills the patient needs. Scarce funds could then be redirected to fix the appalling mess we face in getting care for more severe mental illness.

I do not wish to return to the days when seriously unwell patients without private health insurance or financial means, waited a long time for an overstretched public clinic.

Dr Peter Maguire, Narrogin

However there is also a serious downside.

Having observed many doctors in practice, it seems to me that we are increasingly seeing referral to a psychologist as the preferred initial management for almost We welcome your letters and leads for stories.

Please keep them short.

He who has a 'why' to live, can bear with almost any 'how'.

Friedrich Nietzsche (1844-1900)

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4 | SEPTEMBER 2018

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Pertussis Diagnosis in 2018 Pertussis is a potentially-fatal infection which continues to occur despite worldwide access to an effective vaccine [1]. Annually there are ~48 million pertussis cases and ~300,000 deaths worldwide. The 10-year Australian average for annual notifications is 20,834 (1834 for WA).

Our state has experienced epidemics in 1997, 2004 and 2011 and 710 cases have been notified this year to date.

In the pre-vaccine era pertussis was an endemic disease with epidemic cycles every 3-5 years and most cases occurred in the 1-12 year age group. The illness classically had three clinical phases (catarrhal, paroxysmal and convalescent lasting up to 6 months) following a 1-3 week incubation.

Transmission is by aerosols and the secondary attack rate in households is 50-100%.

In the vaccination era, the epidemiology has shifted to involve infants <12 months (previously protected by maternal antibodies) and adults. The spectrum of disease now includes attenuated illnesses and later clinical presentations.

Laboratory testing Culture of Bordetella pertussis, is insensitive as the organism requires immediate culture on a selective medium.

The optimum specimen is a nasopharyngeal aspirate, as the organism is

B. pertussis colonies

only found in ciliated respiratory epithelium.

Nose and throat swabs have a significantly reduced culture rate.

Polymerase chain reaction (PCR) is a more sensitive test for diagnosis [2], but is usually only positive for the first three weeks of illness (which correlates with antibiotic responsiveness). The changing epidemiology results in many patients (especially adults) presenting late with negative PCR tests.

Blood serology with whole-cell antigen [WC] (similar to that used in the previous vaccine), has recently been replaced by a pertussis-toxin [PT] antigen because of low specificity of the WC assay. PT-IgA in serum is moderately sensitive but is used as an adjunct to PCR when an NPA cannot be performed. It is NOT a suitable test for immunity to pertussis (and no such test exists).

We previously offered B. pertussisspecific IgA antibody (WC) testing in naso-pharyngeal aspirate (NPA). This has a higher diagnostic yield than PCR because of the persistence of mucosal antibodies after the disappearance of nucleic acid [3]. NPA is well tolerated compared to alternative sampling methods such as nasopharyngeal swabs [4] and are collected in 11 of our community collection centres.

Recently we reported inferior sensitivity of WC B. pertussis-specific IgA assay compared to our new Pertussis-Toxin (PT) B. pertussis antibody assay in NPA [5]. Since implementation of the new protocol, we have tested 2386 samples and 851 definite cases of pertussis were identified. NPA IgA had sensitivity of 95.4% and specificity of 96.4% (compared to 9.7% and 100% for PCR). The average duration of cough in this study was 4.7 weeks, which explains the low rate of detection with PCR. This showed the superior diagnostic yield of NPA IgA testing compared to PCR alone (especially if only a respiratory swab is collected).

Laboratory investigations are assessed with the clinical case definition of pertussis (i.e. contact with a confirmed case, cough duration of 2 weeks or more, coughing paroxysms, or post-tussive whooping or vomiting).

Professor Miles H Beaman

Medical Director, Western Diagnostic Pathology Clin/Prof Universities of Western Australia and Notre Dame Australia

ABOUT THE AUTHOR Prof Beaman graduated from the UWA and trained in Clinical Microbiology and Infectious Diseases at Sir Charles Gairdner Hospital. He completed a Post Doctoral Fellowship at Stanford University under Professor Remington and then established the first Infectious Diseases Department in Western Australia at Fremantle Hospital. He joined Western Diagnostic Pathology in 2002, where he is Medical Director and Deputy CEO. He is also a Clinical Lead for SE Asia for Primary Health and Professor at both the University of Western Australia and University of Notre Dame Australia.

Treatment This is with macrolide antibiotics which achieve adequate levels in respiratory secretions (i.e. clarithromycin or azithromycin, NOT roxithromycin) [6]. As toddlers are at highest risk in an infected household, pre-emptive treatment on public health grounds is indicated.

References on request.

Key Messages • Pertussis is still a potentially-fatal prevalent infection despite a national vaccine program.

• The investigation of choice is NPA for PCR and mucosal IgA level. Where NPA is not available, nasopharyngeal swab for PCR plus serum for blood IgA level is reasonable.

• Dry throat or nose swabs are NOT adequate samples for diagnosis.

• Requests should include clinical data including fulfilment of the case definition of pertussis.

• Macrolides (clarithromycin, azithromycin) are indicated in PCR-positive cases and household contacts under 5 years of age.

General Enquiries: Ph (08) 9317 0999 Email: admin@wdp.com.au Website: www.wdp.com.au Results Enquiries: Ph 136 199 For a list of Collection Centres and Laboratories go to www.wdp.com.au

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SEPTEMBER 2018 | 5

HAVE YOU HEARD?

This was on the cards way back in 2015 when Healthway was reformed after some of its sponsorship policies fell short of the ethical standards test. Last month, the WA Government announced that Lotterywest (in the Premier’s portfolio) and Healthway (in the Health Minister’s) would share common board members. Can you be a servant to two masters or is this the next step in amalgamating the two? The Premier and Health Minister put out a joint statement announcing that existing Lotterywest board members Miriam Borthwick, Heather Zampatti and Stephen Carre would serve as board members for both organisations concurrently. Premier McGowan said the move would “build on synergies” and provide “expert stewardship across both organisations”. Interestingly, Roger Cook wanted to assure that “Healthway's independence has proven instrumental to its success and I've asked the new board members to continue to promote and maintain this independence while maximising opportunities for the best public health outcomes.” Both bodies have shared a CEO in Susan Hunt since December 2017.

Induction reduces stillbirth risk Former federal AMA president Dr Michael Gannon’s has called for pregnant women to be induced at 40 weeks to reduce the risk of still birth. He is reported to have made a submission to the Senate Inquiry into Stillbirth where he said the current policy at KEMH to induce labour once gestation reaches 40 weeks plus 10 days needed revision. He said a 40-week delivery policy would require a “massive cultural change” for public hospitals. He cited research in Canada and the US which he said showed the benefits of inducing at 39 to 40 weeks, including reduced stillbirths and caesareans.

He said other research and initiatives to be considered include routine ultrasound scans at 35 to 37 weeks gestation — a standard practice in private hospitals — and more involved assessments for women presenting with decreased foetal movements.

Gaps in research funds In Beneath the Drapes, we have put together a snapshot of WA universities’ standing in the last round of medical and health research grants announced last month. UWA fared best but compared to other states, WA struggled this year. The president of the Association of Australian Medical Research Institutes (AAMRI), Prof Tony Cunningham, says the funding system is not fair, though he didn’t wade into state rivalries. He was giving evidence at a Standing Committee inquiry into research funding and his beef is that grants left research institutes with funding gaps, particularly for indirect costs such as support services – IT, data analysis, utilities and the list goes on. “For every $1 spent on research, a further 54 cents of funds are needed for these indirect costs.” he said.

6 | SEPTEMBER 2018

Taking it to the streets A public campaign to raise public awareness of dense breasts has arrived in WA shopping centres with posters urging women to Be Dense Aware. It is being coordinated by the Sydney group Pink Hope which in turn was founded by Krystal Barter who was motivated by the devastation wreaked by BRCA1 on her and her family. Be Dense Aware is guided by an expert advisory committee led by Sydney radiologist Dr Mary Theresa Rickard, who was chief radiologist of the Sydney Breast Clinic.

BreastScreen WA is our state’s go-to organisation. It actively participates in community events, including Women’s Health Week in September.

HCHs call in sick An answer to a question raised in Senates Estimates in May has revealed that the Health Care Homes trial is in pretty poor shape. At the start of the year there were 190 practices signed up. That number has dropped to 175. A quick check at the WA state of play and it appears that Cottesloe, GP Superclinic Midland, Belridge, and Bayswater centres have pulled out, while Rudloc Rd and North Beach have come on board giving WA a total of 15 enrolled practices. But more serious concerns have been raised about the number of patients enrolled. We have no WA figures on that but it has been reported that Health Department figures show only 2075 HCH patients have been enrolled across Australia as of June 6 with just 99 of the 175 registered practices active. This is not what the Primary Health Care Advisory Group (PHCAG) had grandly envisaged in 2015. They hoped for 65,000 patients and 200 practices. When evaluating this soggy mess, the conclusion is likely to be what has been said all along – the government doomed it to fail by grossly underfunding it with money it stole from Peter to pay Paul.

DoH also revealed that $114.3 million had been allocated for stage one of the trial from 2016–17 to 2019–20, which has been redirected from Medicare chronic disease management payments. Participating practices receive an upfront $11,000 (GST inclusive) incentive grant, and a bundled monthly payment linked to each enrolled patient's level of complexity and need, such as: Tier 3 $1795 a year; Tier 2 $1267 a year; and Tier 1 $591 a year.

Fix complications; fix costs Dr Stephen Duckett of the Grattan Institute continues his welcome campaign to call out system failures – his work on fee gaps is just one of them. Just as we were going to press, he released his report on the cost

of hospital complications, which he said cost public hospitals more than $4 billion a year, and private hospitals more than $1 billion a year. One in nine patients suffered a complication and if all hospitals in Australia lifted their safety performance to match the best 10% of hospitals, an extra 250,000 patients would go home complication-free each year and the health system would save about $1.5 billion every year, freeing up beds and resources so another 300,000 patients could be treated. “Hospitals don’t need extra financial incentives to reduce complications. Instead, they need better information, and accreditation systems that encourage useful improvements rather than ticking boxes. Complication rates and accreditation outcomes should be public, so that governments are held to account.

And medical students should learn only in hospitals with lower complication rates,” he said. He advocates that the one-size-fits-all accreditation be replaced with a system based on measurable safety outcomes, tailored to each hospital’s situation.

P is for personalised The buzz word in health corridors is personalised medicine. There is much anticipation for the opening of the Australian National Phenome Centre at Perkins South from its current development phase at Murdoch University. It is a hub for the International Phenome Centre Network and will be headed up by the UK centre’s Prof Jeremy Nicholson (pictured). In a similar vein, the State Government announced last month that it would support WA patients with rare and advanced stage cancers to access trials, under the Australian Genomic Cancer Medicine Program,

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Lotteryway or Healthwest?

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without having to travel interstate. The decision follows seed funding from WA Health to the clinical trials facility, Linear Clinical Research, at Perkins Institute, to offer personalised cancer drug trials. This latest development is in collaboration with the Garvan Institute in NSW, which has been running personalised medicine trials for the past six years. Despite being open to patients outside of NSW, interstate patients were expected to meet their own travel expenses. Now WA patients already matched to one of the trials will be able to receive treatment at Linear's clinical facility. WA patients will also soon be able to undergo genetic testing locally through PathWest for potentially being matched to one of the cancer treatments available under the program.

Not for the record Another slippery slope is My Health Record, which has taken a hammering in public trust in the past month with the Government taking a backflip off the high board regarding data sharing.

Health Minister Greg hunt has agreed to change the My Health Record legislation to require a court order for any My Health Record access by enforcement agencies.

All the major doctor groups had some timely advice for the minister, and he listened. And as one group put it “public trust is hard-won, but easily lost” and the “potential benefits of My Health Record to personal healthcare and much-needed health system reform are too great to risk losing public trust in it”. What is deeply troubling is how poorly and recklessly all our information is treated by bureaucrats.

We all need to be more watchful and questioning.

Allergy work needs funds The National Allergy Strategy Steering Committee, of which A/Prof Richard Loh is

co-chair, is chasing $10m from the federal government over five years to continue its work with consumers, carers and the food industry, including developing a free online training course, All about Allergens. Richard is a paediatric clinical immunology/allergy specialist at PCH. It’s believed one in five Australians are affected by allergic disease and the committee says a national strategy is critical. “One in 10 infants now have a food allergy and food-induced anaphylaxis has doubled in the last 10 years,” Richard said. Teens are also being targeted with online help. ‘250K – A hub for the 250,000 young Australians living with severe allergies’ website aims to provide age-appropriate information and resources to help manage their allergies and make them feel more connected to each other. “We are excited that additional Australian Government funding for this project, which will allow us to establish a youth chat forum, conduct a youth camp and start a mentor program,” Richard said. The next step is for the National Allergy Strategy to receive ongoing funding to allow the work to continue.

Endometriosis plan The federal government has committed a further $1 million (on top of $2.5 million in the last budget) to establish a national action plan for endometriosis aimed at speeding up diagnosis and improving treatment. GPs can expect special focus with educational material and training on clinical guidelines and clearer pathways of care. The plan also recommends training for imaging specialists to identify features of the condition and to alert the patient’s GP when necessary. The hope is to reduce diagnosis time which literature puts at between seven and 12 years from symptom onset. There is an estimated 700,000 Australian women with the condition and endometriosis specialists

Ms Dale Fisher will take the helm of Silver Chain in December. Lyn Jones has been acting CEO since Chris McGowan departed in May. The WA Government has extended St John Ambulance’s contract for two years while a review of its services is undertaken. The contract price was not disclosed but the organisation registered an annual revenue of $280.6 million.

Dr Aime Powell and early postdoctoral researcher at SJG Subiaco Hospital has been awarded a twoyear fellowship from the Australian Gynaecological Cancer Foundation.

Her work will look at the impact of the WA Cervical Screening Program and the National HPV Vaccination Program on Aboriginal women’s health outcomes.

Grants to WA researchers from the Medical Research Future Fund, totalling $2.9 million, have gone to Dr Fred Chen (retinal degeneration); Prof David Mackey (glaucoma); scientist Dr Debra Palmer (nutrition on allergy prevention); Prof Gary Lee (lung research); Prof Tim Davis (diabetes and infectious diseases); and Prof Leon Flicker (geriatric health).

The NHMRC grants were also awarded to: Prof Alistair Forrest, A/Prof Aleksandra Filipovska and A/Prof Oliver Rackham (UWA/Perkins); Dr Edward Litton (UWA); Dr Ashleigh Lin (UWA/TKI); Tina Lavin (UWA); Nicola Bondonno (UWA); Dr Virginie Lam (Curtin); Dr Katherine Levett (UND).

Richard Hopkins is the new managing director of WA’s Zelda Therapeutics, which has several research programs running into medical cannabis on a range of health issues.

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SEPTEMBER 2018 | 7

HAVE YOU HEARD?

Breastfeeding by the book UWA researchers have compiled what they claim is the world’s first lactation dictionary. LactaPedia was created by Melinda Boss and E/Prof Peter Hartmann to address the lack of basic accessible science on lactation and help counteract some of the conflicting advice women receive when breastfeeding. LactaPedia is an online glossary of more than 560 terms associated with lactation including physiology, the composition of human milk and conditions that affect lactation. The dictionary can be freely accessed by medical professionals and scientists as well as the general public. Melinda said the tool would hopefully support effective lactation by eliminating inconsistencies in terminology and improve understanding of human lactation.

works wherever you are in the world. So it’s part exercise coach, part tour guide. The app is free.

said treatment and surgery were effective and could prevent years of pain and possibly infertility. Concerns regarding access to treatment were raised when bottlenecks of up to a year in the public system for laparoscopies were revealed.

Board overreaching

Norm goes digital?

Did you hear that public health tzars are considering the return of Norm – of Life Be In It fame? Well Norm this time around will have some serious gizmos and gadgetry to compete with. We were particularly taken with a Dutch IT entrepreneur’s app Imagine Run, which guides users into the habit of regular exercise while taking in some scenery. Two years ago, at age 42, Edwin Kuipers had a heart attack and during his recovering he came up with the concept for a Imagine Run, where you can select the distance you want to run or walk and the app will plan several routes. It apparently

WHEN EXPERIENCE COUNTS

Well it can be done. The Medical Board of Australia and AHPRA can reverse questionable decisions as the recent naming and shaming backflip suggests. It will only publish links to serious disciplinary decisions by courts and tribunals on the public register of practitioners when there has been an adverse finding against the doctor. It has removed links to tribunal decisions where there were no adverse findings, which have been published on the register since March 2018. Strange times, indeed, but it is a timely reminder that natural justice and rights need to be fought for. Chair of the MBA Dr Joanna Flynn said the decision struck a good balance between transparency and fairness. It’s

a shame that it took an outcry and five months of unfairness for the board to act.

Confounding pharmacies An off-label prescription was written by an ophthalmologist, for which a compounding pharmacy was required to make up two doses of a drug. I typed in “compounding pharmacies Perth” into Google search and 15 pharmacies were listed. One said the script would be $280 to fill, another quoted $110 and the other $20! It turns out the ‘other’ does compounding only and doesn’t have a drugstore shopfront. This may explain the price difference. Given the $90-$280 difference I drove the extra 20 minutes to the second pharmacist (on a Saturday before 1pm) who sent me an SMS immediately the script was ready to pick up. Try Oxford Compounding Chemist next time.

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INCISIONS

Dr Hugh Mitenko, an ED Physician at Bunbury Regional Hospital and researcher, says a closer look at methamphetamine use is warranted.

News reports and wastewater analysis studies tell us that rural and regional WA is a hotbed of methamphetamine use and abuse.

Wastewater studies avoid the difficult ethical issue of consent but only provide a broad-brush illustration.

Along with Steve Hartwig, an Emergency Medicine colleague of mine, we decided to examine methamphetamine use in our ED at Bunbury Regional Hospital to get a sense of not only how much methamphetamine use is occurring here in Bunbury but also who the meth users are.

Our Methamphetamine and Alcohol Prevalence pilot project was done over two weeks (May 2016) where all adult patients were offered a one page survey. We got a total of 499 surveys returned (41% of all adult patient presentations).

We didn’t really know what we were going to find, but our experience told us that meth use was as high as we had ever seen

it in a variety of EDs. Our sample gave us some interesting extra information.

Forty-nine percent of adults had taken alcohol in the last 7 days, and 9.1% in the 6 hours before presenting to ED. These alcohol-using and alcohol-affected patients were not difficult for the ED to handle, and in fact, most of them (88%, 234/265) presented to ED for reasons unrelated to their alcohol use.

Just 4.8% of adults had taken meth in the last 7 days (the ‘meth users’), and 1.7% in the 6 hours before presenting to ED (the ‘meth-affected’).

Meth users were younger and they were more likely to be men so among the 18-24 year - old men, a whopping 20% (7/35) were meth users (for reference, in the large National Drug Strategy Household Survey, only 2% of Australians reported using meth in the last year).

For meth users, often (73%, 18/26) their meth use was the main reason

they presented to ED. We found that meth users made up almost half of the psychiatric presentations (9 of 20) despite being only 5% of the ED presentations.

If meth users are only 10% as common as alcohol users, why does it feel like their care is such a problem? Well, despite small numbers, many meth users and methaffected patients come to us agitated and violent, and use up a lot of ED resources.

Often their presence triggers security attendance, and many staff members get involved to provide first physical and then chemical restraint.

Quantifying that resource use is one of several new priorities for us as we follow the information from this pilot and set up a larger and more robust study in our ED this coming summer.

ED. The MAP project was approved by the WACHS Research Ethics Committee and supported by the Lishman Health Fund.

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Meth and Alcohol in Bunbury

MEDICAL FORUM

SEPTEMBER 2018 | 9

SPOTLIGHT

A small island in the Solomon’s archipelago is a long way from the Moora Health Centre.

Dr Bernard Chapman and his wife, Julia, discovered the power of Atoifi.

“W

e were based at Atoifi, a Mission Hospital on Malaita Island,” said Bernard. “Julia and I arrived the easy way – a flight from Brisbane to Honiara and then, on a smaller aircraft, to a grass landing strip at the foot of a mountain.”

“The hospital, with a nursing school attached, is staffed by some very capable and locally trained people. The nurses triage all the patients and treat those who don’t need the attention of a doctor. And yes, when the doctor is absent or busy the nurses are the ones providing all the treatment.”

As Bernard points out, it’s more difficult for locals who need to visit the hospital clinic for treatment.

Predictably, there isn’t much in the way of sophisticated technology on Malaita Island.

“Getting to Atoifi often isn’t easy, it’s either by foot or canoe – with or without an outboard motor. Or, the really hard way, on a stretcher! There are no roads, just a lagoon, the sea and some very rugged mountains. For the locals who can access this medical service – and there are many thousands who are unable to do just that – it can take several days walking or paddling to receive treatment at the clinic.”

“So, if they are sick enough when they leave home to seek help, they can be very sick indeed on arrival at the hospital. This, combined with a large variety of tropical diseases on the island, makes the medical work both interesting and challenging.”

“There are X-ray facilities and a portable ultrasound but there isn’t one CT in the entire country. The hospital itself has a small laboratory with helpful staff and the pharmacy has a reasonable stock of drugs supplied by the Solomon Islands Government.”

“The doctor, and the hospital, desperately need our help, hence our visit to Atoifi.”

“There’s a national shortage of doctors in the Solomon Islands. The government has taken steps to address this, but it will be some time before the new trainees filter through to the outlying hospitals. Not all that dissimilar to rural Australia, when you think about it.”

“So, if there are any doctors out there reading this and interested in spending some time at Atoifi to help out, they would be most welcome. The local people are friendly, welcoming and very grateful.”

“To make the situation even more challenging, there is only one permanent doctor at the hospital. Unsurprisingly, he’s very busy with surgery, ward rounds, outpatients, urgent presentations, obstetrics and attempting to administer the entire organisation.”

“He’s a very capable doctor and an absolute pleasure to work with.”

Bernard is waving the ‘Please Help’ flag to all his medical colleagues in Perth.

“Yes, your medical skills will be tested and you will be both amazed and frustrated.

But you will come home feeling you’ve done something really worthwhile. And you might even feel like going back!”

ED: For more information contact Dr Bernard Chapman – bchapman@outlook.com.au or 08 96511881.

By Peter McClelland

Dr Bernard Chapman and the team from Atoifi hospital.

10 | SEPTEMBER 2018

MEDICAL FORUM

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SEPTEMBER 2018 | 11

CLOSE-UP BACK TO CONTENTS

Inhale the Future The treatment of cystic fibrosis has seen remarkable progress and now, says respiratory physician Prof Stephen Stick, people can focus on living well.

O

ne of the most satisfying achievements of Prof Stephen Stick’s professional life is witnessing young cystic fibrosis sufferers grow into old middle age.

It was a vastly different story when the paediatric respiratory physician and researcher began his work in the field 30 years ago. Back then the median age of survival was 12 and accompanying that sobering figure was the suffering of patients, their parents and those who cared for them.

The motivation to find better treatments, better drugs, better technology and better models of care has always been close at hand for those working in the field.

Steve has played a significant role in many of these children’s lives and now he hopes to make some impression on their care as adults.

One of his passions is seeing much of the care of patients with mild-to-moderately severe cystic fibrosis (CF) – and hopefully most patients with chronic conditions – being delivered in the community close to where they live and work.

12 | SEPTEMBER 2018

His submission to the Sustainable Health Review (SHR) detailed the plan but he told Medical Forum that it was not new.

“This particular issue, which we raised in the SHR, has been on the cards since 2007. It is the first recommendation of the Cystic Fibrosis Model of Care published by the Health Department of WA in 2008 and revised in 2013,” he said.

Old is new again “While we may have been 2½ years late in getting a new children’s hospital, it was achieved from whoa to go in five years, yet we’ve been trying to change the way we deliver care to cystic fibrosis patients for more than 10 years. There seems to be money for bright, new shiny hospitals but the real investment must be in the way we do business.”

“The models of care we are using are heavily dependent on the tertiary hospital system and there is no real investment in moving patient care closer to them.”

Steve said, like most dilemmas in health, the genesis of the problem was in the divide between state and commonwealth funding.

“We really need the state to say it will invest in primary care; not necessarily to pay

doctors but to facilitate doctor training, and build community capacity to treat mild to moderate chronic diseases where people live. These investments would make a huge difference to patients’ lives and would pay cost dividends to the state.”

“Sadly, most decisions in health are made out of fear and not from vision. Thinking 10 or 20 years ahead is not something you can do very well when there is a three-year political cycle and continual feet shuffling.”

In his submission, Steve emphasised that there is no better time than now: “…it can be anticipated that as care improves and new therapies become available, the absolute numbers of individuals at any age with milder disease will also increase. Even now, over 50% of young adults have relatively mild disease (defined by lung function) and most adults with CF are employed (67%) and many have undertaken tertiary education (37%).”

Currently there are 400 West Australians with CF, 4000 children and adults nationally, and one in 24 individuals are carriers of a CF gene mutation. Between 130 and 150 children with CF are diagnosed by newborn screening each year nationally.

MEDICAL FORUM

CLOSE-UP Right to be in control The majority of these patients are treated, regardless of severity in tertiary hospitals and Steve says in his submission, for those in the mild to moderate category, this often imposes burdens that materially affect quality of life (i.e. time lost from school/ work) when some of those services could potentially be provided closer to home.

For an initial trial Steve proposed a partnership between not-for-profit community providers Apollo Health (part of St John Ambulance with multidisciplinary facilities in Joondalup, Cannington, Cockburn and Armadale), consumer organisation Cystic Fibrosis WA (CFWA) and the CAHS respiratory service.

CAHS would be responsible for case management; clinical pathways; training of staff; spirometry training and quality control. It would also treat and manage individuals with complex and severe disease.

Apollo Health would take on the routine care of patients with mild/moderate disease with onsite physiotherapy, nutrition, psychology, imaging, pathology and pharmacy services; provide walk-in urgent care; supervised care for mild pulmonary exacerbations; and liaison with community care providers.

CFWA would look to consumer engagement/communication; delivery of training packages; home care for mild/ moderate exacerbations; and contribute to hospital-in-the-home services.

Leadership and evaluation would come from the deep well of academic and clinical expertise in the state.

Communication is critical However, critical to the success of the model is IT and ICT. Off-the-peg, financially viable solutions are available now.

“Our tertiary systems don’t communicate with general practice or community practitioners, so sharing a patient’s information is really difficult and that is exactly what is needed,” Steve said.

certain course of action is required and then we, as the experts, need to sit down with everyone to come up with a plan to do it.”

Doing things better “We need to make more imaginative use of highly skilled people than simply have them turn up to clinic every week and churn through the patients. In fact that was part of the problem with the morale at PMH in recent years. You had a notion of affordable FTE based on how many patients you churned through, not outcomes, which required a more imaginative and innovative approach.”

Steve has been an integral part of paediatric respiratory medicine in WA for three decades but the state has to thank Prof Lou Landau and especially Prof Peter Le Souef for drawing the Cambridge graduate to Perth.

“I did my clinical training at Thomas’s hospital, now part of Kings College in London, and then my paediatric training in Southampton where one of my bosses, Martin Radford, told me about Perth. He was a registrar at PMH when Lou Landau had arrived and was excited about the changes taking place.”

“I was an avid windsurfer, so with that double incentive, I came to Perth, originally for two years then I met Peter Le Souëf, who has been my chief mentor all my career. He got me interested in respiratory physiology, so I undertook my PhD at UWA. Peter is passionate about embedding research into clinical services. He really was the founder of the specialty in WA.” “I met my wife soon after and Perth became home.”

Steve may have given up surfing the wind but he still has a passion for the water and surf-skis four to five times a week on the river and ocean. He’s also an avid snow skier though his Type 1 diabetes is making that more hazardous.

“I have some lost some strength in my legs, so last February, when I broke my leg skiing, was perhaps my passing shot, but we’ll see.”

Steve said he was diagnosed with Type 1 diabetes at the age of 27.

DM revelation “That’s a little late for juvenile onset but that’s what it was. The doctor’s lifestyle made it hard to manage for many years. I reluctantly started using a pump 18 months ago and it’s been revolutionary. I don’t think the technology was quite there for me five years ago but I am an absolute convert.

With the continuous glucose monitoring and feedback pump, it’s made it so much easier to manage.”

Steve stepped down as head of respiratory at PMH in July 2016 after 18 years.

“I’ve now moved to half time clinical caring for patients and CF is a big chunk of what I do. This has been made possible by the generous philanthropic support of Northern Star Resources and has freed time for me to focus on establishing a new centre for respiratory research at Telethon Kids Institute. The centre will bring together all the groups in WA that have built up great reputations over the past 30 years.”

“We punch well above our weight in paediatric respiratory research and by bringing us together under one banner, we can be more recognisable and make our research efforts more efficient.”

There’s still much work for him to do. He’s passionate to see care for CF broaden into the community and he’s excited about his work on the epithelium, which he and his colleagues are confident is nearing the point of a clinical trial.

“This would be the first use of a tissue regeneration model to treat a chronic lung disease,” he said. “I would dearly love to see that come off.”

By Jan Hallam

“If we are going to convince CF patients, who have utmost faith in their tertiary service, that they are now going to receive services in the community, we will need perfect communication systems and strategies. That requires investment.”

There may also be barriers within the current system.

“There is natural scepticism among specialist practitioners that sufficiently high quality tertiary services can be transitioned into the community. This is an aspect that would need to be addressed and evaluated carefully as we implement any new model of care.”

“JFK didn’t know how to build a rocket when he made the claim he was going to the moon. You first of all have to agree that a

MEDICAL FORUM

SEPTEMBER 2018 | 13

FEATURE

Paediatric respiratory physician Dr André Schultz is excited by the rapid developments in the treatment of Cystic Fibrosis and there is action aplenty in WA.

D

r André Schultz has good reason to smile. The BEAT CF study, a multicentre clinical trial over five years of which he is clinical lead, was funded more than $3.4 million from the Future Fund. In line with Perth’s innovative thinking, the 400 or so Cystic Fibrosis (CF) patients in WA (in the US >30,000) will benefit from this and other CF initiatives. This includes: slower-thanexpected gene therapy in the UK, Iowa and Adelaide; and about 8 drugs in advanced stages of envelopment that includes phase 2 and 3 trials.

It is also hoped the PBAC will approve the combination drug (lumacaftorivacaftor) for people homozygous for the most common CF mutation (ΔF508).

“These patients constitute 50% of the CF population, so we are all hoping for a positive result. Ivacaftor, alone, in those with class III mutations – about 7% of the CF population – seems to significantly slow the decline in lung function, which translates into improved quality of life and increased survival,” André said.

Of the recognised CFTR gene mutations (and there are many, with about 200 definitely linked to Cystic Fibrosis Transmembrane Regulator [CFTR] gene expression), the classes of mutations look at six protein-making errors affecting things like transcription, protein folding, gating and synthesis.

Getting on top of infection In a nutshell, the CFTR gene mutations affect ion conduction, airway surfaces become dehydrated, and secretions are not cleared. The clearance of pathogens from the lung is impaired.

“Infections are important in CF – they are one of the main reasons why lung function deteriorates. It’s about optimising management of exacerbations of CF because about 25% of those affected by exacerbations don’t regain their previous lung function,” he said.

14 | SEPTEMBER 2018

With emerging resistance, the choice of antibiotics is changing and clinicians have their preferences, some of them not well informed by evidence, according to André. With about 2000 hospitalisations in Australia for CF a year and a Cochrane review in 2015 showing different antibiotic choices for the treatment of exacerbations, the burning question is how to get the best evidence ‘on the fly’ without spending lots of money. Research would be aimed at a rare disease, which necessarily needs multicentre studies that take a long time.

Head-to-head clinical trials would take many decades.

Enter the “Bayesian statistics informed adaptive platform trial, which allows more flexibility in randomisation, recruitment and efficiency in getting results quicker.” This relatively new statistical method in clinical trials, using a complex interpretation of probability requiring enormous amounts of computing power, which enables better treatments as time goes by.

“By participating in the BEAT CF trial, patients are more likely to be allocated to treatments that are performing better in the trial, partly because of the uncertainty about which conventional treatment is the best – you get to the answers quicker.”

Collaboration the key Of course, this needs to be imbedded in clinical practice, which requires a huge buy-in from clinicians around Australia, which André says they have and are now collaborating with clinicians in Boston who lead the world in this kind of trial.

Apparently, there are currently only four or five trials that use statistics in this way.

Dr Tom Snelling leads the investigation.

We talked more of the importance of maintaining a consumer focus in their research, his excitement that about eight disease-modifying drugs some of which are in phase III clinical trials, the work of Steve Stick (see P12), the increasing survival median age of 40-50 years for those with CF, the mental health of CF patients, and research into non-antibiotic ways to fight infection.

In this regard, gene therapy is the Holy Grail. But as André says, “the lung is designed to keep things out”. Getting the right vector to deliver the genetic payload to affected cells and the right animal model to do the research are difficult. Adelaide researchers apparently have a rat model with milder lung disease; the animals live longer so it's more suited to studying the effects of gene therapy.

Combat CF study is a phase 3 multi-centre randomised placebo-controlled study of azithromycin in the primary prevention of radiologically-defined bronchiectasis in infants with cystic fibrosis. It seeks to see if azithromycin, with both an antiinflammatory and antibiotic action, can prevent lung disease in very young children with CF. The children diagnosed with cystic fibrosis by newborn screening can be enrolled in the study by six months of age.

“If the study of infants doesn’t show good effect we have shown we can conduct multi-centred clinical trials across the world and have set up networks to do it.”

On a more personal level, he knows many of the 400 or so CF patients in WA and says it is not all doom and gloom. "I know many adults with CF and although it is tough they have meaningful lives typically characterised by incredible resilience."

By Dr Rob McEvoy

MEDICAL FORUM

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www.veinclinicperth.com.au SEPTEMBER 2018 | 15

FEATURE

As Medical Forum was going to press, the WA Parliamentary inquiry investigating the need for laws to allow citizens to make informed decisions regarding their own end-of-life choices delivered its report.

We could not confirm but had heard speculation that a minority report would also be tabled. Time will tell.

What is clear is that the committee of Amber-Jade Sanderson MLA (chair), Colin Holt MLC (deputy chair), Robin Chapple MLC, Nick Goiran MLC, Simon Millman MLA, Dr Sally Talbot MLC, Reece Whitby MLA and John McGrath MLA did some hard yards.

More than 650 written submissions were made and the committee met and heard 82 witnesses (including call-backs) from a wide range of interested groups and individuals – many were doctors representing an equally wide cross section of views.

In a statement prior to the report’s release, Amber-Jade Sanderson said the level of participation and interest in the inquiry reflected the importance of these issues for the community.

“These are literally matters of life and death and people have responded accordingly,” she said.

Medical Forum asked readers for some of their thoughts on the issue. Nearly half said they had provided a terminally ill patient with pain relief and/or sedation which also hastened their death and the majority of doctors were acutely aware of the shortcomings of the legal limbo in doing so.

It is only right that the inquiry consulted the medical profession widely as its outcomes will affect doctors directly. Whatever recommendations, if the end-of-life choices issue moves to a legislative phase, the road will be long and rocky. This is a difficult, emotional and complex issue for everyone concerned.

If it doesn’t, it will continue to simmer in the community and be a thorny political issue for elections to come.

16 | SEPTEMBER 2018

Assisted Dying – July 18 There were 219 responses within the one week window.

Respondents to the survey were given this preamble: “Medical Forum magazine presumes WA will get something similar to the Voluntary Assisted Dying (VAD) Bill passed in Victoria, to be enacted in 2019, and would like to know how you feel about this.

In 2019, Victorians will be able to ask for a prescription of a lethal substance, to hasten their death if: • They are over 18, have decision making capacity and request voluntarily.

• Their suffering cannot be managed by means acceptable to the patient.

• They are diagnosed with a progressive advanced terminal illness with a prognosis of less than 6 months (less than 12 months if they have a neuro-degenerative condition).

Apart from assessing patient eligibility and writing the prescription, a doctor may take no further part in the dying process. In effect, the Bill hands the decision, with safeguards, to terminally ill patients.”

Was there manipulation of results? ‘Prevent multiple submissions’ function was not turned on (because we had had complaints from people using the same IP to complete surveys at multiple attempts) but the number and pattern of responses, and the average duration on each did not suggest manipulation.

We did not ask if respondents were GPs or other Specialists. We do know that most respondents (92%) were over 40 years (age brackets 20-40 years 7%; 40-60 years 44%; 60+ years 48%; ‘ prefer not to say’ 1%), most were men (63%) with ‘females’ 32%, and ‘preferred not to say’ 4%.

Most importantly for the value of our results, a high proportion of experienced doctors responded saying “I attend terminally ill patients ‘Often’ 32%; ‘Infrequently’ 48%; ‘Not at all’ 18%; or ‘Uncertain’ 2%”.

Because of the emotive topic, we let doctors decide what ‘Often’ meant (rather than ask them to give numbers).

MEDICAL FORUM

BACK TO CONTENTS

End of Life Choices – Where to Now?

E-POLL Experiences with Dying

Q

Have you been concerned about the current legal aspects of terminal care?

Yes No Undecided

68% 24% 8%

ED: High levels of concern occurred across all levels of experience (i.e. no significant variation). There was no gender difference in responses. But the ‘Yes’ figure increased to 79% for those over 60 years.

Q

Have you heard of terminally ill patients not having enough pain relief and/or sedation because of fear of legal repercussions?

Yes No Undecided

53% 43% 4%

ED: This result is surprising in that just over half of doctors responded ‘Yes’.

Results were much the same for the more as well as the less experienced doctors. The results showing inadequate doses of pain relief or sedation increased to 61% of those doctors over 60 years but otherwise, there were no age group differences. There were no gender differences in response rates.

Q

Have you provided any terminally ill patient with pain relief and/or sedation that has also hastened their death?

Yes No Undecided

47% 42% 11%

ED: Terminal sedation or pain relief that hastens death is relatively common amongst doctors. In fact, the ‘yes’ percentage increased to 61% for those who attended terminally ill patients ‘often’ (25% said ‘no’ and 14% were ‘undecided’).

There was no variation across different age brackets. However, there was an almost identical reversal of roles when it came to gender differences with 55% females answering ‘No’ and 53% of males answering ‘Yes’ to this question (and 35% and 36% on the reverse answer, respectively). That is, we found that just over half our female respondents had not provided terminal sedation or pain relief that also hastened death, whereas males had.

Q

The 103 respondents who answered ‘Yes’ to previous question were asked: Was this done at the patient’s request, at least in part to stop their suffering?

Yes No Undecided

84% 12% 4%

ED: These results show that there are at least 103 doctors in WA who act to relieve patient suffering, at the patient’s request. The experience of attendees, their age groups and gender had no bearing on results.

Q

How familiar are you with these topics related to

end-of-life choices

Advance Health Directives?

Very familiar Know enough to get by No knowledge Undecided

43% 51% 5% 1%

ED: Amongst the more experienced doctors, about double the proportion (69% vs 33%) were very familiar with Advanced Cared Directives as those who were not. Among those who attended terminally ill patients ‘infrequently’ (that is 105 people) around 60% said they ‘knew enough to get by’ and 7% had ‘no knowledge’. Age groups and gender had no bearing on results.

MEDICAL FORUM

Current legal frameworks in relation to end of life care?

Very familiar Know enough to get by No knowledge Undecided

26% 56% 13% 5%

ED: As expected around 49% of the more experienced doctors were very familiar with current legal frameworks in relation to end of life care but among those who saw terminally ill patients infrequently, only 17% said they were ‘very familiar’ with these frameworks whereas 65% ‘knew enough to get by’ and 12% had ‘no knowledge’. Age grouping or gender did not influence these results.

If VAD were to become legal in WA for terminal patients:

Q

Would you consider extra training to assess a patient’s eligibility?

Yes No Uncertain

Q

56% 31% 13%

Would you consider referring anyone who requested further information on VAD to a website?

Yes No Uncertain

68% 16% 16%

ED: Among the 34 doctors who attended terminally ill patients ‘Not at all’, 87% said they would consider referring inquiries to a website. Age group and gender had no effect on results.

Q

Would you consider referring a patient to another doctor to assess eligibility for VAD?

Yes No Uncertain

74% 14% 12%

ED: Among the 39 doctors who attended terminally ill patients ‘Not at all’, 87% said they would consider referring a patient to another doctor to assess eligibility for VAD. Age group and gender had no effect on results.

KEY MESSAGES If these results reflect feelings within the whole profession in WA...

Most doctors are concerned about the legal framework of terminal care, particularly older doctors.

Most doctors have heard of terminal patients not getting enough pain relief/sedation for fear of legal repercussions.

Most doctors show compassion to patients by ordering pain relief/sedation that hastens death, often in response to the suffering patient's request.

It appears that the strongest need for updating on AHDs and the current legal framework is amongst those who attend dying patients ‘infrequently’.

Most doctors, particularly those inexperienced with terminal illness, would consider referral to a website or another doctor if someone requested information on VAD, particularly eligibility.

SEPTEMBER 2018 | 17

E-POLL

Assisted Dying – July 2018

Doctors’ Comments

‘assisted’ has the potential for abuse. One can dress up a wolf in sheep's clothing and make it sound good, but a wolf is a wolf. VAD is a wolf.

There were 99 doctors who responded to the comment invitation. Here is a selection of those comments, divided into For, Against and Neutral.

“I do not feel that I have studied medicine in order to hasten death.

Appropriate palliative care without active intervention to induce death, is in my opinion the role of the doctor. Suffering per se is not something to be avoided at all cost, since it has a greater purpose.

Suffering leads to perseverance, perseverance to strength in character – all great athletes know that. We are all in the race of life on Earth and should run it till death arrives in its own time.

Against the idea “Do not want to take part in murder. Palliative Care is appropriate.

Euthanasia models from Europe are dangerous and prone to abuse!!

“Once a law such as this is accepted then the only decisions from here on are how liberal the parameters allowing euthanasia become.

“I provide a lot of terminal care in nursing homes and see no benefits from the proposed VAD legislation, but clear indications that pressure would be put on vulnerable older people to seek it out.

“It concerns me that with the new legislation we will be treating people to end life not to relieve suffering. I feel this goes against the principles of medical practice.

“Every life is significant and valuable and to be lived to the fullness of every breath on earth, declaring His love, mercy, grace, glory and majesty.

“The focus in our society is on entitlements and rights, and nothing on responsibilities. On one hand we put ‘naturalness’ on a pedestal, and on the other hand we want to manipulate nature.

“Most of us at some stage in our professional lives have been faced with difficult end of life issues. But all of my life has been devoted to saving lives, comforting and easing pain. The medical profession should not be asked to reverse these aims and arbitrate on life or death. Our role is to alleviate suffering and to comfort at the end of life.

“Voluntary assisted dying puts very vulnerable people in a more vulnerable position. All proceeds of the patient's estate would have to be put in escrow for three years (apart from funeral costs and the like). This would protect patients from third parties who would gain from the death by influencing the patient in the direction of VAD. This is already happening where third parties discourage patients from taking active and sometimes curative treatment options.

“Dying people should be offered symptom relief even if it may secondarily hasten death. This is not the same as deliberately causing death, which I consider ethically unacceptable.

“I have grave concerns about legislating for VAD and feel that is a very dangerous path for our society to be going down.

“The treating Dr MUST take the decision in conjunction with the patient following full transparency of information to the patient about their illness. I fervently disagree with hastening death while at the same time the patient must be made comfortable and we have the medication to assist us with this. I do not believe we should have legislation to actively assist the dying process as it will be abused and used inappropriately albeit occasionally. Our function is to prevent suffering NOT killing patients.

“I treat my patients pain in order to relieve that pain i.e. decrease their suffering. If that also hastens death as a side effect that is not the intention and even the Catholic Church would support this view.

“Good palliative care is superior to euthanasia. Euthanasia is the choice of people who do not understand palliative care.

“Terminal care is a very important matter. There is always the risk and potential for a government or another person to attempt to sway individuals or public opinion so that involuntary becomes the accepted norm or indeed an expectation of an individual.

I am opposed to assisting dying on any basis. Likewise the word

18 | SEPTEMBER 2018

“Poor medical therapy and inadequate pain control is no reason to change the law. Changing the law to legalise homicide is no solution to bad medicine.

“Essential that neither doctors nor nurses play God.

Neutral and interested “Doctors need a clear legal framework to protect them from malpractice allegation.

“Have only met a couple of patients in my 26-year career who asked for Euthanasia. One died a few hours later. The other had appropriate analgesia and changed his mind. Most terminally ill patients I have met cling on to life, unrealistically at times.

“Question on pain to ‘hasten’ death is poorly worded. Pain relief is administered with intent to relieve suffering and improve quality of life (or the dying process). The intent is not to hasten death, even when it may have that secondary effect. The wording of the question may influence responses.

“Analysis of Dutch euthanasia figures revealed that the overwhelming majority (73%) were dying, and they received THE SAME end-of-life treatment methods that are used by Palliative Care in Australia; 25% died from treatment withdrawal, 25% received Palliative Sedation; and 50% were ‘double-effect’ deaths.

Hence Palliative Care provides the same service to dying patients as euthanasia in The Netherlands.

“98% of people die peacefully with Palliative Care. The remaining 2% receive Palliative Sedation, also used in NL under the classification of “Euthanasia”.

“26% of patients die without access to Palliative Care!

“Always worry that the safeguards against bureaucratic misuse will not be robust enough – who guards the guardians.

“During my career in general practice I have worked with hospice and have great admiration, particularly for the nursing staff. Palliative care is not always successful and patients should not be forced to endure unnecessary suffering and loss of personal dignity. I fear that patients may not ‘get it right’ and feel that attending physicians should have an obligation to assist in this process. I have been doing aged-care for 25 years.

“There is a fine line between relieving pain and distress and hastening the inevitable death. Anyone who has cared for a dying person has questioned themselves about this line.

“This is an issue of judgement. It is difficult and problematic to legislate for.

“I feel there could be improvements to the general medical care in end of life situations for some patients and their carers. I think this avenue should be improved for everyone before going down the avenue of VAD. Occasionally required to manage terminal care in patients (usually elderly) with end stage organ failure. Patient and family wishes remain paramount, which requires time, listening and discussion.

“The pressure for euthanasia is always from the relatives, rarely

MEDICAL FORUM

E-POLL

from the patient. The relatives want to be taken out of their misery, rather than the patient relieved of theirs.

“More funding for palliative care. This won’t stop requests but we must be sure desire to death is not because of lack of care.

“Patient, Doctor, and two witnesses need to sign an agreement that further treatment is not an acceptable option.

“I am not supportive of altering the framework to allow patient controlled death and do not agree with doctor involvement in this.

Strengthening the options to better facilitate supportive palliative care at the end of life is a preferred option. However if a patient requested that they wish to pursue this I would refer them to those who are prepared to assist with VAD.

time to suffer will be helped, but those who have prolonged suffering are denied. Where is the logic and comfort in that? I want the right to a dignified death at a time of my choosing without the ridiculous limitation of someone else making a guess about when I might die a natural death. This limitation still smacks of religious bigotry.

“The quicker the law is changed in WA, the better. It's utterly inappropriate for people in WA to organise flying to Switzerland to die, when similar legislation could be enacted here. If religious dogma is removed from the discussion, what reason do we have to deny members of our community their own choice of when to die?

“The discussion is quite polarised at present. I believe in Palliative Care at the end of life but it cannot always address all the symptoms that a dying person has. This is especially existential issues but also includes pain, dyspnoea etc. Also I do believe that for some people life is a ‘burden’ independent of the social, family and medical support that is available to them. Unfortunately, too often suffering and burden are not taken as ‘genuine’ as there are no quantitative measures but these are very subjective concerns that should be respected.

“Voluntary medical assistance in end of life is a missing part of Palliative Care and will be a compassionate measure for many who wish to have a dignified end of life at a time and place of their own choice.

“In some instances provision of relief unavoidably shortens life. If that is the patient's sincere wish, and they fall into the suitable category (i.e. terminally and irretrievably ill), then we as doctors should be able assist in the provision of this service.

For the idea “I am an advocate of VAD and hope it is legal if I have the need for it.

“I have witnessed plenty of people suffering with terminal illnesses over the years including members of my own family and feel very strongly that individuals in those situations should be able to choose the time, place and company in which they die.

“Huge problem in nursing homes that residents are not provided with adequate medication in case it is seen as an attempt to hasten death.

“Strongly feel that enhanced choices around end of life reduces patient's fear and anxiety, enhances quality of remaining life and reduces risk of suicide. When a patient does make a decision to end their life they should be able to have their family and friends present, if that is their choice, with no fear of prosecution. So tired of regressive minority holding tight to legislation that needs to change to enhance lives and deaths!

“Suicide is a right, not a privilege. So is assisted death in terminal illness.

“I have had a friend die suffering. He had planned to take his own life if it got too bad but was not capable of doing so due to his deterioration.

I would be willing to assist people in alleviating their suffering.

“Voluntary medically assisted suicide with appropriate safeguards is long overdue.

“Our society is barbaric to the extent that suffering people are prevented from access to assisted dying – at home, with family, sleep-like, fast – it is the offering that should be made.

“The general populous is in favour. Doctors have to be involved in the discussion.

“We need the option of VAD to reduce the number of suicides of patients with serious illnesses (currently one a week in Victoria according to the Victorian coroner).

“The current legislation in Victoria is far too limiting and still prevents assistance being offered to those whose life looks likes continuing to be intolerable for more than six months. Those who have a short

MEDICAL FORUM

“Some patients really want this legislation and it is up to the medical fraternity to assist them. Medical practice is not a retail market – we don't perform some practice just because a patient requests it or wants to pay for it. However, when most of society feels that legislation is reasonable, then we should reasonably engage with it.

“Some patients have lives that they, understandably, do not wish to continue. Others, such as those with MND, want the security of knowing that when the time comes they will have the means of ending their existence and not suffocate to death. Many a patient has said to me "when the time comes, I know you will know what to do". The Law has made me fail the expectations of those patients. Conversely, I counselled a depressed patient not to make the decision to stop his dialysis until his mood had stabilised. The legislation is about patient choice and the key word is 'voluntary'. The VAD proponents respect patient autonomy, the VAD antagonists do not and construct all manner of straw man arguments to press their case…I see VAD as a personal decision and its supporters as compassionate doctors. To me, the opponents of VAD are often dogmatic, deluded about their ability to relieve a patient's suffering and lacking in the compassion that is supposedly the hallmark of a good and proper doctor.

“I hope to have the option of VAD if I am terminally ill. I believe I should have the right to end my life under this circumstance.

“Let’s get on with equality in dying.

“Decision to execute VAD on patients should not be made by individual doctor but by a medical panel comprising treating doctor, relevant medical/surgical specialist and chaired by a doctor from the medical registration board “My experience is that palliative care is inadequate for many patients. Patients and families often suffer unnecessarily due to the strict current laws. I am pleased to see changes likely to happen.

“I hope that my GP will support me when I am in my final days, being a specialist myself, so that I do not have to suffer. The continuous references to our palliative care system does also not help me in my last hours.

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NEWS & VIEWS

Acne Expectations Some new things are on the horizon but there is no substitution for a deeper understanding.

There’s never a good time to have acne. The teen years present an intensely vulnerable stage in a person’s psycho-social development.

Painful, unsightly cystic acne doesn’t help. Adult onset can also put the brakes on what should be a woman or man’s most confident time.

similar ways as metabolic syndrome, which is interesting,” she said.

as well, managing their expectations and their own experiences.”

“Acne is the most common thing I see in teenagers. The prevalence worldwide is about 95%, so at some point most people experience acne, but having said that 75% would be classed as mild and only 1% overall would be severe.”

Sarah said that being in Fremantle, there is a demand for non-chemical treatments and she has explored a range of technologybased treatments such as light therapies.

So little wonder there has been a flurry of research and treatments emerging over the past five years to control acne vulgaris.

“Most of those with mild to moderate acne don’t seek help for it because there is a mindset that it’s just acne and they’ll grow out of it. But research also is showing how it affects people psychologically and contributes to anxiety and depression.”

Cannabis is being rolled out in labs across the world in all manner of trials. In June, it was announced that Sydney would be one of two sites for a phase 2 clinical trial for a topical treatment of BTC 1503 (with synthetic cannabidiol) after phase 1b results showed reduction in both inflammatory and non-inflammatory acne lesions. The next phase will seek results on patients with moderate to severe acne.

The maker, Botanix, is looking to test the topical drug against the current ‘gold standard’ Accutane or Roaccutane for its capacity to impact on the skin’s oil production.

“For teens when they are starting to develop their own identity, having acne can affect social integration and their psychosocial-sexual development. Going through something that is visible on the outside while you’re working on who you are on the inside can have a long-term impact so management strategies for acne need to address those issues as well.”

Sarah said she had a multi-faceted approach when treating younger people.

We spoke to Fremantle GP Dr Sarah Boxley, whose primary practice focuses on skin. She said research on the pathogenesis of acne was giving a greater understanding of its hormonal background.

“Six months is a long time for a person who is 14. So we look at topical treatments to prescription medications from antibiotics to hormonal pills. Spironolactone is coming back as a treatment of acne for its anti-androgen properties. It’s useful for teenagers who don’t want to be on the contraceptive pill, which is usually a parental choice rather than a patient choice.”

“There seems to be a link with inflammatory markers and insulin-like growth factors in

“When we are dealing with adolescent acne, we’re also often dealing with parents

Another wait and see moment for acne sufferers.

MEDICAL FORUM

“We use a photo sensitiser on the skin in similar ways as some skin cancers are treated. It switches off the inflammation response. It is quite painful and when you are doing a full face of a teenager, it is difficult for them to tolerate, but it is a short course and is a way of getting on top of things relatively quickly.”

There is also LED therapy using different light waves – blue wave lengths of 415 nanometres target the Propionibacterium acne while the red wave length at 630 nanometres tackles inflammation and increases vascular flow. For scarring, Sarah looks at 830 nanometres to stimulate collagen growth.

“The most recent development is biophotonics using a chromophore gel on the skin prior to light therapy which which is licensed for moderate to severe acne,” she said.

While treatments continue to develop, a generation of young people are no longer willing to put up with acne. Sarah sees a lot of parents who bring their children to see her because they suffered from acne themselves and they don’t want the same for their children.

By Jan Hallam

SEPTEMBER 2018 | 21

FEATURE BACK TO CONTENTS

Spirometry: Underused and Underfunded?

Medical Forum asks a selection of GPs how spirometry is used in primary care and the current financial incentive or disincentive.

I

ncreased funding for lung function testing starts in November this year. How much is unknown at this stage. The powers that be say asthma kills 400 people a year (and about one in nine people have it) while about 1.45 million Australians have some form of COPD. Spirometry testing rebate is $20.55 (lower if you bulk bill but higher if part of a preemployment medical). Doctors argue the rebate is still too low for the ½-hour service offered – the increased rebate coming on November 1 can only be claimed once a year per patient to make a diagnosis. It is hoped the higher rebate will encourage greater use of spirometry. Talking to GPs here, the word seems to be that the rebate will need to be much higher to fulfil this aim.

Asthma Australia CEO Michele Goldman said: “This increased rebate supports GPs to follow the guidelines and use lung function tests to ensure best care for people with asthma and other respiratory conditions.”

Will more spirometry have a reverse effect on “asthma”? Canadian research last year showed that misdiagnosis rates for asthma may be high – a third of the 600 participants may have been misdiagnosed with asthma and were able to gradually stop medication under guidance from doctors.

Lung Foundation Australia’s General Practitioner Advisory Group Chair Dr Kerry Hancock said the increased rebate was a step towards ensuring equitable access.

“An Australia study showed that 65% of people with COPD were only diagnosed on presenting to hospital with an exacerbation.

Well-performed spirometry is essential to avoid delays and misdiagnosis, and unnecessary cost to patients, achieving better symptom control, reducing the risk of exacerbation and maximising quality of life,” she said.

One female GP withdrew from making comment. Her story is interesting. As a part-timer at a practice with limited interest in doing medicals, she rarely uses spirometry though includes the acutely unwell in her uses to show parents that their child doesn’t have a lung problem.

22 | SEPTEMBER 2018

Of course, spirometry competes with iron infusions, ECGs and the like in the treatment room. Nurses mostly do the testing. She assumes they are accredited and the spirometer calibrated. In assessing a response to COPD treatment reliance on symptoms and signs, rather than spirometry, are often used.

Dr David Adam, Lockridge Medical Centre He uses spirometry “fairly frequently” mainly to monitor and diagnose asthma and COPD. The greatest impediments to use are time and space “because we are a reasonably busy practice and testing chews up the nurse’s time and space in the treatment room.”

He said spirometry could mean waiting for up to an hour, if testing on the spot. The practice doctors use it and the symptom profile to monitor COPD. The most common causes of unsatisfactory testing requiring a repeat are lack of adjustment of medications to accommodate spirometry

and patient technique, despite having well trained nurses who do the coaching. The clinicians in the practice want “repeatable and robust” results, particularly with COPD patients with limited lung capacity.

Dr Adebola Adeiye, Morawa Medical Centre The main use in his practice is pre-employment medicals, with other patients occasionally. Lack of trained staff is a problem. He usually books his own time where he allocates the ½ hour necessary with pre- and postbronchodilator response. “Because of the nature of bookings, you usually don’t have enough time to do it, so it is about once or twice a month.” He has problems relying on results so tends to rely more on symptoms.

“The key thing is to get adequate training initially and retraining once-a-year, and to get asthma and COPD patients in regularly because the more you do it the better you get at it,” he said.

MEDICAL FORUM

FEATURE Dr Stuart Adamson, Midwest Aero Medical Service, Geraldton Main use of spirometry is pre-employment medicals – “industrial medicals, mines mainly”. He has trained staff who do the testing (nurses who have done the course and are certified). The equipment has to be updated and revalidated (calibration checked) every 12 months.

“Getting people to understand how to do it can be a problem – some just don’t get it,” he said. Is testing financially viable as things stand at present? “You can charge for it as ‘medicals’ which is worthwhile if you have a good staff member and patient who can complete the testing in 15 minutes.”

Dr Jack Faigenbaum, Scarborough Beach Medical Centre “Assessing the need for ongoing management and the diagnosis of particular problems,” are his main uses though he said the barriers were time to do the test by experienced nursing staff. Spot checks are done mainly

and then patients rebook if necessary.

He averages about two spirometry tests a month. He agrees that many patients need coaching by accredited staff on their technique. Someone comes and calibrates the machine regularly. Tips for other users?

If the remuneration was better for the halfhour work involved, usage would be higher.

“It is probably as important as cholesterol and ECGs for hearts and is an underused test.” He includes spirometry on a GP Management Plan when indicated and he thinks the increased rebate in November is a good idea – “Doctors need an incentive as well,” he said.

Dr Andrew Fairhurst, Sonic HealthPlus, West Perth “We use it quite a lot (95% preemployment medicals, about 50 each month), and have several trained staff who are accredited and oversee calibration.”

Patient effort is the main problem and patients need coaching.

Tips for other users? “It’s all about the training of staff and making sure you are using it frequently. It’s one thing to go on a training course but like most things in medicine, you have to keep doing it to update your skills.” As a clinician he looks at the results for diagnosis and treatment

progress but like many things in general practice, the Medicare rebate is too small ($20.55). The impending rise in rebate in November would probably not attract him to do more spirometry. “I do it because it is needed, so financial rewards don’t change my practice.”

Dr Philippa Adams, Stirling Lakes Medical Centre What are the strongest impediments to use in her practice?

“It is mostly about nursing time and availability – we try and electively book people but it can be difficult if you want to do spirometry on the spot.” People have to wait for the test rather than seek the often more expensive and less convenient option of doing it through a laboratory. “I think you should do it often in your practice. We try and book them in when the nurse is available.

Of course, as clinicians, the doctors have to make sure the nurses know what they are doing. I tend to rely more on symptoms than spirometry in COPD, especially if they are feeling better and doing more.” She said getting the patient’s technique right was often tricky and, by the sounds of it, having a practice nurse with the time and skills to do spirometry was the way to go.

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GUEST COLUMN BACK TO CONTENTS

Study the Study Drugs When it comes to study drugs, the director of the National Drug Research Institute at Curtin University, Prof Simon Lenton, says there are risks and uncertain benefits.

Adverse side effects have been associated with all studied CEs, some of which are severe and/or permanent. Also, the effects of CE use are often mixed – enhancing some capabilities and impairing others.

Cognitive Enhancers (CEs) or ‘study drugs’ are substances that have the potential to improve intellectual abilities in healthy individuals.

Commonly researched potential CEs are prescription amphetamines, methylphenidate, caffeine and modafinil. Energy drinks, herbal supplements including ginkgo biloba and fish oil have also been investigated as potential CEs.

Harms may also occur as a result of legal consequences of illicitly obtaining CEs online or by accessing them via others’ diverted prescription medications. Many of the pharmaceutical CEs may be obtained online through unregulated websites selling drugs which may be counterfeit, containing ingredients not consistent with the packet labelling and putting buyers at risk of a serious drug importation charge.

Evidence of the effectiveness of CEs in healthy people and their efficacy beyond laboratory settings is mixed but growing.

Modafinil and methylphenidate have the most established evidence.

Recent studies with competition chess players and people learning a new language suggested that some CEs can improve performance. However, a recent longitudinal study of college students found no evidence that CE use increased Grade Point Average or provided advantages over non-using peers. Despite this, a number of studies have found that students who use them strongly believe they have the desired effects.

During 2016 we used a quantitative anonymous web survey that reached a self-selected convenience sample of 2133 students aged 18 to 29 across all five WA universities.

The survey investigated prevalence and frequency of use; student attitudes to use; self-reported benefits and harms experienced by users; and university system factors (e.g. exam scheduling) which may relate to use. Results are yet to be

published but 8% of our sample reported using a prescription drug without a valid prescription to enhance their study skills at least once in the past year.

Consistent with the existing literature, the vast majority of participants who reported using dexamphetamine, modafinil or caffeine pills as cognitive enhancers in the past 12 months reported positive effects associated with their use.

These included improved concentration, increased study motivation, decreased fatigue and ability to work faster.

Negative effects were reported by just less than half of modafinil and caffeine pill users but roughly nine in 10 dexamphetamine users. Sleeping difficulties, anxiety, loss of appetite, headache and irregular heart beat were the most commonly reported adverse symptoms.

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MEDICAL FORUM

GUEST COLUMN

Perhaps medicine’s shifting gender balance holds the key in providing a more nurturing working environment suggests workplace counsellor Dana Topchian.

Do you know a fellow doctor with anxiety, depression, burnout or substance abuse? Have you told anyone? Are you trying to help? Do you have a mental health problem?

Anyone can suffer from work-related stress, but medical workplaces often have the added pressures of unrelenting hours, patient expectations, changing technology, increasing paperwork, and inadequate funding. Long working hours conflict with family/social life and limit leisure activities.

Doctors with mental illness typically struggle alone, and in silence. Sure, there are counsellors, psychologists and psychiatrists a phone-call away. So why aren’t doctors calling?

Within medicine there still appears to be a stigma associated with asking for help.

So, who can doctors go to? What resources are available to help doctors get through difficult times? Back in the 1980s, prominent WA psychiatrist Professor Geoff Riley established a help-line service for doctors. This is still successful for the simple reason that it is discreet and

unhampered by bureaucracy or shackled by government funding.

The Doctor's Health Advisory Service provides 24-hour phone services to doctors and students. Calls are exempt from the mandatory reporting requirements of the Medical Board of Australia. The Australian and New Zealand College of Anaesthetists offers a Doctors’ Support Program: a free and confidential counselling service to fellows, trainees, SIMGs, and their immediate families. The Royal Australasian College of Physicians also offers counselling and coaching to help its members.

However, the effectiveness of counselling on its own as a long-term tool for mental illness is being questioned.

Recent studies have shown it offers only short-term benefits, and that therapies such as CBT are comparatively more effective. Perhaps peer support provides deeper engagement and improved longerterm results?

How does this compare with mental health support in other occupations? From my experience in Disability Employment Services, the government generously funds on-the-job support for diverse clients: older employees, disadvantaged youth, and those with physical or mental health issues. All receive regular on-site or off-site support and counselling.

As someone who has assisted those with psychological challenges and mental health issues in the workplace, I often questioned the effectiveness of counselling. Instead, sometimes helping people to take action, however small, encouraged greater change.

So where is change in medicine going to come from? Retired GP Dr Mike Daly observed that women are changing the culture of medicine. They are gradually breaking down the ‘macho’ world by working family-friendly hours.

Instead of lagging behind, perhaps the medical profession could support its personnel better by evolving into a more nurturing culture. Perhaps women can lead the way to better work/life balance?

References available on request.

3D Breast Tomosynthesis 2D Mammography

3D Mammography

Is 3D Breast Tomosynthesis required for breast cancer screening?

Digital Breast Tomosynthesis (3D mammography) uses a modified digital mammogram machine, with conventional X-rays taken at multiple projections and a digital detector with mathematical computations to create cross sectional images of the breast tissue. The slices reduce the issue of overlapping tissue and enhance the visualisation of lesion margins.

From 1st November 2018, a Medicare Benefits Schedule (MBS) Item will be available to women referred for diagnostic breast imaging. This is time-limited MBS funding. The new items are an interim measure (for two years) to enable an application for long-term funding to be lodged by the diagnostic imaging sector. Tomosynthesis can be utilised for diagnostic imaging in women with breast symptoms or for surveillance of women with a family history or past history of breast cancer.

There is no current evidence that Tomosynthesis is appropriate for population breast cancer

2D Mammography

screening through BreastScreen WA.

Author competing interests: nil relevant

Questions?

There is currently nodisclosures. evidence thatContact the editor.

Tomosynthesis; 1) leads to a reduction in breast cancer mortality superior to conventional screening mammography 2) leads to a reduction in interval cancers (cancers that present as symptomatic cancers within 2 years of a normal screening examination) 3) reduces the incidence of overdiagnosis of breast cancer (the detection of cancers that 3D Mammography would not have become clinically significant in a women’s lifetime).

BreastScreen Australia, is actively reviewing the published medical evidence on Tomosynthesis, and future decisions on breast cancer screening technology will be based on the best robust medical evidence as that evidence emerges.

At this time, two-view mammography continues to be the most effective population primary screening test for breast cancer.

Women may book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50 MEDICAL FORUM

Mar ‘18

BACK TO CONTENTS

Work Support: Medicine Keeping Up?

SEPTEMBER 2018 | 27

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GUEST COLUMN BACK TO CONTENTS

The Language of Violence Language used in conversation and reporting on domestic violence still anchors itself in the flaws of victims. This should change, says Angela Hartwig As the peak body for Domestic and Family Violence in WA, we at the Women’s Council are often asked to comment on articles that appear in the media. In a recent article in Perth Now, ‘Why She Finally Broke’ on 1 July 2018, taken from an extract from psychologist Dr Helen McGrath and journalist Cheryl Critchley’s, book, Mind Behind the Crime, circumstances which drove Geraldton GP Dr Chamari Liyanage to kill her husband in 2014 after many years of abuse were featured.

While the article highlighted the circumstances around the abuse and violence, we are concerned about the language used and explanations provided.

Terms such as Dependent Personality Disorder (DPD) and ‘learned helplessness’ – descriptions we believe contribute to a misunderstanding that the victim may have some deficit or flaw in their own character which facilitated the abuse to occur.

Drs Allan Wade and Linda Coates from the Centre for Response-Based Practice in Canada are experts in the area of the micro-analysis of language and violence.

They are regular visitors to Australia and their work provides a framework in which to understand the use of language to describe violent acts and the impact of victim-blaming responses.

Victims/survivors of domestic and family violence often do many things to oppose and/or resist abuse. They often face the threat of further violence, from mild censure to extreme brutality for any act of open defiance. Consequently, open defiance is the least common form of resistance.

The Women’s Council was also alarmed by the use of language such as ‘learned helplessness’, which renders a victim as passive, and not a responding agent.

Again, these types of theories, along with ‘the cycle of violence’, do little to examine the social responses to victims, which have historically been often negative. It is these types of responses from individuals, families and agencies that need to be explored.

We know that perpetrators will actively try to conceal and minimise their use of violence; and explicitly imply that the victim asked for it and/or was compliant in what acts took place, particularly in this case where the perpetrator used coercive control and manipulation as a way to implicate the victim as mutually responsible.

the only way to stop the horrific abuse was to kill the perpetrator. This act of resistance does not come from a woman who lacked confidence or who had some form of deficit disorder, but by one who realised that she needed to defend herself from more violence.

Once her husband had become aware that Dr Liyanage wanted to leave, he promised to change, lulling her into a false sense of security. He isolated her from her family, controlled finances and emotionally blackmailed her in order to maintain power and control over her. Instead of asking ‘why didn’t she leave’, we should be asking, what forms of violence allowed her husband to continue this pattern of abusive and degrading behaviour.

The Women’s Council strongly believes the story of victims’ resistance to violence should be told. It not only allows for a full and accurate description of the violence that took place, but also focuses on the perpetrator and their continued abuse, and less on a need to pathologise the victim.

ED Angela Hartwig is CEO of the Women's Council for Domestic and Family Violence Services (WA).

Where the threats of violence are so great, survivors have reported that often they felt

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CLINICAL UPDATE BACK TO CONTENTS

Bronchiectasis

Bronchiectasis is now more easily diagnosed, and therefore more frequent. However it is less severe than 50 years ago.

By Dr Michael Prichard, Respiratory Physician, Perth

How does bronchiectasis develop?

Case Report: A 58 year-old man presented with a life-long history of productive cough with recurrent infective exacerbations, usually with increased cough, dyspnoea on exertion, wheeze and malaise. Often causes were not apparent.

He had azoospermia (and was married with no children).

In most cases, the initiating event is acute respiratory infection, usually pneumonia or acute bronchiolitis, resulting in epithelial injury and desquamation and an intense neutrophilic response.

On examination he had bilateral basal coarse crackles, marked in the left lower lobe. Chest x-ray and CT thorax confirmed the diagnosis of bronchiectasis (Figure A).

Cardiac silhouette was left-sided.

He had severe chronic airflow limitation at diagnosis. Sputum culture identified Pseudomonas. Nasal fractional exhaled nitric oxide (FENO) was reduced and a saccharin mucociliary clearance test showed delayed clearance.

Conclusion: He had Young’s Syndrome (primary ciliary dyskinesia with azoospermia), with evidence of impaired mucociliary clearance. Exacerbations were managed with oral and IV antibiotics, occasionally requiring hospital admissions.

Changing pattern of bronchiectasis Bronchiectasis (originally described by Laennec in 1819) has evolved from being a debilitating chronic orphan airway disease to a relatively common cause of chronic cough, with multiple subtypes.

Two factors account for the significant change in clinical and epidemiological pattern over the past century: measles/ pertussis vaccination in early childhood has significantly reduced severe post infective non-Cystic Fibrosis bronchiectasis

and secondly, the introduction of HRCT thorax (High Resolution CT = 1-2 mm slice thickness). CT signs of bronchiectasis, first described in 1982, used 10 mm slices; both CXR and thick slice CT have a lower sensitivity.

Diagnostic imaging HRCT imaging remains the cornerstone in diagnosis of bronchiectasis: it is present when there is an increased bronchoarterial ratio (BAR >1.5); between 1-1.5 is less specific, affected also by altitude, vascular changes in COPD and PAH. Radiological signs include signet ring sign and tramtrack sign (figure B); other radiological changes include

Recent research suggests that intrabronchial neutrophils are “reprogrammed” during exacerbations: impaired phagocytosis and bacterial killing, delayed apoptosis and increased enzyme release (compared with blood neutrophils), contributes to the persistence of in-bronchial mucus and greater potential for airway damage. Antibiotic therapy attenuates these neutrophil changes.

Other recognised causes include: • Non-tuberculous mycobacterial infection (MAC) • airway obstruction (foreign body, endobronchial lesion, mucus plug) • impaired host defences (common variable Ig deficiency, neutrophil disorders) • impaired mucociliary clearance (primary ciliary dyskinesia, Young’s syndrome, Kartagener’s syndrome) • cystic fibrosis

• Bronchus visualisation within 1 cm of pleural surface:

• ABPA

• Bronchial wall thickening

• autoimmune disease (rheumatoid, Sjogren’s)

• Mucus impaction The radiological distribution of bronchiectasis is diagnostically useful.

Most basal cylindrical bronchiectasis is post-infective (e.g. pneumonia, pertussis); middle lobe and lingular bronchiectasis with peribronchial nodular opacities is more likely to occur with non-tuberculous mycobacterial infection; central airway bronchiectasis, especially with peribronchial opacification and mucus impaction is associated with ABPA (allergic bronchopulmonary Aspergillosis); upper lobe bronchiectasis is a typical sequelae of past TB.

• alpha-1 antitrypsin deficiency

• inflammatory bowel disease What investigations are useful?

Following diagnostic confirmation of bronchiectasis by CT thorax, usual investigations include sinus CT, sputum culture, pulmonary function tests, full blood count, liver biochemistry, IgE, IgG, IgA and IgG subclass levels, MBL, alpha-1 antitrypsin level and genotype, sweat test (genetic studies), and autoantibodies.

In some cases bronchoscopy is recommended.

Treatment Bronchiectasis exacerbations require specific antibiotics guided by sputum culture. NMTB requires referral to a specialist clinic. Maintenance therapy of bronchiectasis includes optimum sputum clearance (exercise, forced exhalation, nebulised hypertonic saline) and low-dose macrolide therapy.

Fig A. Prone CT thorax: severe bilateral basal cylindrical and cystic bronchiectasis, and ‘tree-in-bud” opacities consistent with chronic bronchiolitis.

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Figure B: signet ring sign, BAR>1.5 and tram track sign (arrowed).

Author competing interests - nil relevant disclosures. Questions? Contact the editor

SEPTEMBER 2018 | 31

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CLINICAL UPDATE BACK TO CONTENTS

Spirometry in practice Mr Bill Smith, CEO Respiratory Testing Services

There’s a lot of information available in the hot air expelled during spirometry.

For example, one study by Barton et al, showed that whilst 74% of the 247 practices had invested in a spirometer, only 12% used it – so perhaps equipment cost is not a factor.

Understanding the context Spirometry is the test everyone loves to hate (except respiratory scientists!). The test is clinically useful in the diagnosis of asthma, COPD, and in indicating the possible presence of other lung conditions e.g. IPF. On one side, practice nurses and GPs, who do the test relatively infrequently, approach it thinking it’s a quick test (a bit like Peak Flow, which should not be used diagnostically). It takes a good 15-20 minutes to obtain a decent pre and post result.

On the other side, for patients it’s a much more strenuous test than they thought.

Given that patients are often asymptomatic until they’ve lost 50% of their lung function, early testing benefits everyone.

Understanding the usefulness Usefulness depends on the quality of the effort by the patient and the coaching by

the operator. You need accurate measured height – don’t rely on patient’s estimate – and when they last used a puffer.

The patient should be seated upright, with both feet on the floor (not standing due to the possibility of syncope and dizziness) and encouraged to ‘blast’ out (not ‘blow’) and keep going for as long as they can.

Most modern spirometers signal the end of test when no more flow is detected.

Remember that many patients finish too early, because their sensitivity to final air movement is less than the machine, resulting in underestimation of FVC Give the patient time to catch their breath and repeat. You want three tests where the FEV1 and FVC are within 150mls of each other in anything up to 8 attempts. (It is not the best of three!)

Common problems are tongue in the mouthpiece, cough, sub-maximal effort and early termination.

A critical look at results Administer a bronchodilator via a spacer, wait 10 mins and repeat. A positive response is 12% and 200mls improvement in either FEV1 or FVC . The factory default of most spirometers give a welter

Actions speak louder than words.

This article talks of how to do spirometry properly. What happens in real life is in some ways often different (see P22). of parameters on the printout, most of which are of little value in general practice (and contribute to the under-utilisation of spirometry, so find the manual and turn them off!)

Three measurements need a careful look; FEV1, FVC and the ratio FEV1/FVC. Different flow diagrams (available elsewhere) assist in interpretation. Briefly, if the FEV1/FVC ratio is <lower limit of predicted, then look at the FEV1 to assess severity of obstruction. If the FVC is <lower limit of predicted, refer on for further testing and/or a physician’s review – it’s unlikely it’s asthma or COPD. If spirometry is normal but the patient still reports symptoms, refer them for more detailed testing - normal spirometry does not necessarily mean normal lung function!

ED. Bill Smith, who has over 40 years’ experience in lung function testing, is the principal technologist of a mobile service that visits 20 sites in rural and metropolitan locations.

Diagnosing and managing early cirrhosis

By Dr Nicholas Kontorinis, Gastroenterologist, Wembley The most common causes of cirrhosis in Australia include excess alcohol, chronic hepatitis B and C and nonalcoholic fatty liver disease (NAFLD).

Advanced cirrhosis with liver failure (de-compensation) is obvious due to the presence of complications such as ascites, variceal haemorrhage and hepatic encephalopathy. However, early cirrhosis is often hard to detect.

reveal spider angiomas, scratch marks, jaundice, hepatomegaly and splenomegaly.

Clinical risk factors for chronic liver disease include a history of heavy alcohol use, injection drug use, obesity and a long duration of type 2 diabetes. Symptoms in early cirrhosis such as malaise, fatigue and occasionally pruritis may be subtle and non-specific. Physical examination may

Liver ultrasound or CT scan will often demonstrate liver nodularity and other features of portal hypertension such as splenomegaly and intra-abdominal varices. Specific biochemical tests include APRI score (AST to Platelet Index) and Hepascore. Hepatic elastography

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Biochemical features include inversion of the ALT:AST ratio, and in more advanced stages low albumin and raised bilirubin.

Thrombocytopaenia and mild neutropaenia suggest hypersplenism secondary to portal hypertension. Coagulopathy with prolonged prothrombin time (INR) suggests impaired hepatic production of clotting factors.

Early cirrhosis (Childs-Pugh A) may often be asymptomatic. Recognition is important as specific therapies may stabilise, improve or even reverse cirrhosis.

(Fibroscan and ultrasound elastography) measures liver stiffness that correlating well with advanced stages of liver fibrosis.

Aetiology is usually established from the clinical history, risk factors and screening blood tests for chronic liver diseases. Liver biopsy and specialist review is sometimes required to confirm the diagnosis where the initial screening fails to determine

continued on page 35 SEPTEMBER 2018 | 33

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CLINICAL UPDATE continued from page 33

Diagnosing and managing early cirrhosis the aetiology. Screening tests include viral hepatitis B and C serology, iron studies, autoimmune markers (ANA, ASMA, AMA), immunoglobulin titres, alfa 1 antitrypsin levels and ceruloplasmin.

By Mr Peter Ammon Foot Ankle & Knee Surgery

The liver has considerable regenerative potential and “recompensation” and reversal of cirrhosis have been described by treating the underlying cause of liver disease. Strong emphasis should be placed on education and lifestyle modification to protect the liver from future harm. This includes avoiding hepatotoxic drugs (e.g. high doses of regular paracetamol) and alcohol cessation.

Significant improvements are seen following treatment of hepatitis B and C (particularly with newer antiviral therapies).

With diagnosis of cirrhosis established, surveillance is recommended for hepatocellular carcinoma which occurs in up to 2-3% of cirrhotic patients per year. This involves monitoring with liver ultrasound and serum alfa fetoprotein every six months.

Monitor oesophageal varices with endoscopy every two years. If varices are present with high-risk features for bleeding, prophylaxis with non-selective beta blockers (propranolol) is indicated.

The development of ascites, hepatic encephalopathy or variceal haemorrhage in a cirrhotic patient indicates de-compensation and are associated with imminent mortality. Refer for assessment by the liver transplantation service.

References available on request

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KEY MESSAGES Screen those with risk factors or chronically abnormal LFT’s for cirrhosis.

Hepascore, APRI, imaging and hepatic elastography are useful tests.

Implement lifestyle modification and screen for hepatocellular carcinoma and varices.

Author competing interests - nil relevant disclosures. Questions?

Contact the editor

Newborn genetic test marketed The NextGen genetic test for babies, which has been touted as the next big thing, is causing ripples of concern. The NextGen test, at $980 upfront, apparently screens for more than 60 genetic disorders linked to a range of cardiovascular, metabolic, neurological, respiratory, and musculoskeletal conditions.

It was developed by Sydney-based pathology business Genepath and they say it complements the traditional heel prick test for newborns. The Royal College of Pathologists of Australasia (RCPA) has sounded a warning to consumers that complex medical tests should “always be requested by, and after discussion with, an experienced medical practitioner”.

“It is particularly relevant for complex genetic tests that predict the medical future of a child,” said RCPA spokesperson Dr Graeme Suthers. “It is not appropriate for genetic tests that deal with significant clinical issues to be marketed directly to patients, or for professional support to be provided only after the testing has taken place.”

The RCPA acknowledged that expanded screening of newborns could provide information that may assist parents. However, ethical and social implications require appropriate professional oversight.

Non-invasive pregnancy testing (NIPT) and the 12-week scan are compared in the next edition.

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SEPTEMBER 2018 | 35

CLINICAL UPDATE

By Dr Astrid Arellano, Infectious Diseases Physician Anyone at risk of fulminant sepsis and death would want to know this could happen and moreover, they would want to know how to prevent it.

Unfortunately most individuals with non-functioning spleens* do not realise that their risk of overwhelming sepsis is lifelong and that these septic episodes carry a 50% mortality rate, even with optimal care. Those who recover have long term morbidity.

Through a number of mechanisms, including the loss of memory B cells; individuals with non-functioning spleens are vulnerable to sepsis due to encapsulated organisms such as Streptococcus pneumoniae (50% of cases), Haemophilus influenza type b, and Neisseria meningitides; vaccine preventable diseases.

An estimated 2500-7500 people in WA have non-functioning spleens. The annual and lifetime risk of overwhelming sepsis varies between reports but can be as high as 4% in splenectomised children under 16 years of age with the highest risk in the first three years after splenectomy. A recent study reported a rate of invasive pneumococcal disease in this population of 150 per 100,000 patient years which was reduced by 69% after patients joined a spleen registry, Spleen Australia.

Prevention of overwhelming sepsis The key to prevention is awareness, patient education and lifelong follow-up. Strategies such as vaccination and booster reminders, low-dose prophylactic antibiotics (recommended for three years post-splenectomy and lifelong in the immunocompromised), emergency stand-by antibiotics and medic alerts; can largely prevent sepsis and death.

We don’t see them often but functional asplenic patients may sometimes rely on their doctors to stay up-to-date.

The WA government refused to join Spleen Australia on account of the cost, approximately $70,000 per annum. The estimated cost of one episode of sepsis is $39,000 and according to the Australian Sepsis Network, the burden of death from sepsis is greater than the annual national road and deaths due to breast, prostate or colorectal cancer.

Preventable infections should be at the top of the health agenda and individuals when made aware of the risks and how to prevent fatal sepsis episodes are grateful for the advice and interventions that could save their lives. *Definition: splenectomised people and those with non-functioning spleens due to alcoholic liver disease, cirrhosis, sickle cell disease, lymphomas or splenic vascular events.

Prevention of overwhelming sepsis in functional asplenics

Vaccination

Unfortunately despite the availability of management guidelines, many functional asplenic individuals are unaware of the preventive strategies and overwhelming sepsis continues to occur.

Why WA should join Spleen Australia Spleen Australia provides education, a vaccine registry and reminder service for people with non-functioning spleens in Victoria, Tasmania and Queensland. Patients and their families are educated on signs of infection, when to take emergency antibiotics, and they receive vaccination reminders. Sepsis can be reduced significantly by joining this registry.

• • • •

Single conjugate pneumococcal vaccine (Prevenar 13®) Three adult 23vPPV, 5 years apart (Pneumovax 23®) Single Hib vaccine Two recombinant meningococcal B (Bexsero®) and two conjugate meningococcal ACWY (Menveo®, Menactra®, Nimenrix®) vaccines, 8 weeks apart • Yearly quadrivalent influenza vaccine

Prophylactic antibiotics

• Amoxicillin 250mg daily OR • Roxithromycin 150mg daily (penicillin allergy) • For at least 3 years post splenectomy, lifelong if immunocompromised

Emergency antibiotics

• Amoxicillin 3g stat, OR • Roxithromycin 300mg (penicillin allergic) • To be taken if signs of infection (fever, rigors, vomiting/ diarrhoea) and seek medical attention.

Patient education

• • • • •

Awareness of increased lifelong risk of infection Minor viral infections carry little risk Animal bites/scratches to be reviewed by doctor Dental procedures carry no additional risk Pregnancy/breastfeeding- risk of infection not increased

Source: Spleen Australia Recommendations for the prevention of infection in asplenic (splenectomy) or hyposplenic patients over 18 years of age (V31 May 2015) –see .

ED. The author wishes to acknowledge Dr Hannah Gooding’s and Ms Katie Jodrell's contributions and Spleen Australia.

Streptococcus pneumoniae on blood agar plate with optichin disc; photo courtesy Prof Miles Beaman

36 | SEPTEMBER 2018

Further reading: Spleen Australia guidelines for the prevention of sepsis for patients with asplenia and hyposplenism in Australia and New Zealand. Kanhutu et al. Internal Medicine Journal, 2017 (48):8, 848-855 A registry for patients with asplenia/hyposplenism reduces the risk of infections with encapsulated organisms. Arnott et al. Clinical Infectious Diseases 2018 (67):4, 557-561

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BACK TO CONTENTS

Preventing overwhelming sepsis in asplenia

CLINICAL UPDATE BACK TO CONTENTS

Reduced allergenicity immunotherapy

By Dr Meilyn Hew, Immunologist and Allergist Murdoch Atopic patients have a Th2 polarised response to low dose (natural) exposure to allergens. T and B cell interactions result in the production of allergen-specific IgE which binds tightly to the high-affinity IgE receptor (FcERI) expressed on the surface of resident mast cells and basophils.

Allergoid immunotherapy is one method to reduce allergenicity whilst retaining immunogenicity and can reduce the time to reach maintenance dose.

KEY MESSAGES

On re-exposure, allergens cross-link the surface IgE causing intracellular signalling and rapid release of preformed mediators and cytokines.

Allergen immunotherapy works through blocking antibodies, tolerance inducing cells and changes in mediator release.

Histamine, leukotrienes and neuropeptides cause rapid neuronal and vascular reactions giving itch, erythema and oedema. IL-13, IL-4 and IL-5 drives cellular recruitment, local IgE production and inflammation.

Immunotherapy is affected by patient compliance, in turn affected by treatment duration and possible allergic side effects.

Future immunotherapy may enable shorter treatment durations.

This results in a primed and rapid immune response to further allergen exposure, and hence to symptom chronicity and severity.

Allergen immunotherapy

Author competing interests - nil relevant disclosures. Questions?

Contact the editor

Allergen immunotherapy (AIT) is the repeated administration of a specific allergen over a prolonged period of time to induce longlasting tolerance to that allergen.

AIT causes immune deviation from a Th2 response to a Th1-driven response. There is very early desensitisation of basophils and mast cells, induction of allergen-specific regulatory T cells and regulatory B cells which suppress allergen-specific Th2 cells, and increasing Th1 cytokines such as interferon gamma, regulatory cytokines particularly IL-10 and inhibitory allergen-specific IgG4 antibodies.

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In this way, of blocking specific allergen responses thus attenuates the inflammatory response in tissues on further contact.

Allergen extracts are complex mixtures of allergenic and nonallergenic molecules. The ideal AIT has long-term cost efficacy, rapid up-titration, low allergenicity and high immunogenicity. AIT in practice is very dependent on patient compliance. It is given long term and can provoke allergic reactions during administration.

For Lease

Different extracts Different methods for allergen preparation are used to reduce AIT reaction rates. Allergoids are denatured or chemically modified allergens which form high molecular weight polymers. This reduces the availability of IgE binding sites reducing allergenic side effects.

However, with preservation of the T cell epitopes, the allergoid retains the beneficial immunogenic (T cell mediated) effects.

Allergoids are coupled with inorganic gels such as aluminium hydroxide creating a depot to slow absorption, and create an adjuvant effect for a larger immune response.

Some allergoid treatments can be up-titrated over the course of a few days instead of weeks or months sometimes seen with nonallergoid formulations.

Observation of patients for 20 years on pollen allergoid therapy shows a three year course of treatment comparable to five years of standard treatment, with long-term efficacy. Ten year observation of patients with dust mite allergy had tolerance of allergoid injectable treatment comparable to sublingual formulations.

Patients on allergoid AIT injections can have fewer up-titration visits, attain maintenance doses sooner, reduced allergic side effects with the similar efficacy and tolerance as non-allergoid treatments, and can potentially have long-term beneficial effects.

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SEPTEMBER 2018 | 37

TRAVEL

Picture Perfect Greece From the rugged beauty of the Cyclades to the cuisine of Crete and on to the Acropolis in Athens, there’s something for everyone in this jewel of the Mediterranean.

G

etting to Greece, or anywhere in Europe for that matter, is the hard part. Wedging yourself into an economy-sized seat for almost an entire day is no fun.

But then it’s all about the destination, isn’t it!

Shoulder season is definitely the best time to visit Greece with the peak months of July and August best avoided if you can help it. It gets hot, really hot! Also crowds of tourists from all over the world make it tough to get around sometimes and prices – for everything! – are significantly higher.

And be prepared to pay cash, too. The Greek economy is still reeling from crippling debt repayments imposed by the IMF and tax avoidance is the biggest game in town.

Santorini The flight from Athens to Santorini, one of the largest islands in the Cyclades group, was a short and comfortable flight of about 25 minutes and the rugged beauty of the landscape smacks you in the face. The entire island was destroyed by a volcanic eruption in the 16th century BC and, once you leave the airport, almost anywhere you stand is on the edge of a cliff. You’ll also be gazing out at the sapphire blue of the Aegean Sea with no shortage of beautiful views!

That’s probably why Santorini is touted as a ‘destination wedding’ island by hundreds of brides a year. Accomodation in Fira, one of two main towns – the other being the more expensive Oia – was reasonably priced, first in Scirroco Apartments with its whitewashed stone villas built into the cliff overlooking the harbour and then a short drive away at the Thermes Villas. The sunsets are spectacular!

There’s a long, steep, winding road from the ferry port to the top of the cliff that looks like a hill-climb at the Tour de France.

You’ll often see donkeys hauling goods and tourists up to Fira and it’s not the most pleasant sight. The donkeys are worked hard and don’t look particularly happy.

As you gaze out at the blue of the Aegean, you’ll see the occasional cruise ship in the bay. Their passengers are ferried to the base of the cliff and then hauled up via a funicular sky-train to enjoy the restaurant and shopping delights of Fira. The food in this rather tourist-driven area is generally pretty good and, if you’re selective, quite reasonably priced.

If you move away from the main locales of Fira and Oia there are some amazingly good restaurants. Metaxi Mas is one of them, a family-run establishment with long queues for lunch and dinner – it’s fabulous

but you need to book! Another one with great views is Pyrgos with barbequed squid and octopus.

Crete Next was one of the many inter-island ferries from Santorini to Crete, a journey of just over two hours and costing around 200 euros. It was a comfortable ride and you can stand on the outer deck and smell the sea air.

Crete is the largest and, with just over 600,000 people, the most populous island in Greece. The capital, Heraklion, is a little over-developed but has a fascinating archeological museum housing many of the Minoan artefacts from the nearby Palace of Knossos. A more relaxed stay is in the city of Chania, about 140km west of the capital. This 14th century Venetian harbour, narrow alleyways and Ottoman architectural influences are a delight.

Food drives the tourist industry and there are hundreds of restaurants in Chania. Back a couple of streets from the harbour there was relief from the heat in a restaurant called Tamam, which serves delicious food with a Greek/Turkish twist.

It was an old Turkish bathhouse complete with a large, rectangular tiled cavity in the floor. The water is long gone!

The Acropolis in Athens

38 | SEPTEMBER 2018

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TRAVEL Parasia is another family eatery in Vamos, a delightful village where we stayed in one of the most stunning Airbnb cottages you could imagine. Villa Eleonas is just beautiful with wonderful gardens and a small, crystal-clear swimming pool.

There are some stunning, sandy beaches at Elafonis and rugged gorges and rocky cliffs leading up to the White Mountains that run along the spine of Western Crete with peaks reaching 2200m. Yes, plenty of snow in winter! It’s stunningly rugged terrain with hundreds of gorges and caves, the latter’s most famous being Ideon Cave – the birthplace of Zeus, no less, and a scattering of goats shepherded home every evening and milked in the morning!

Crete has a fascinating history. From 1370 BC the Greeks themselves, the Romans, the Venetians and the Arabs all crossed swords to secure control of this highly strategic island. In 1941 there was an ill-advised airborne invasion by German paratroopers who, despite eventually taking control of the island, suffered huge losses as they were literally shot out of the sky by Allied troops and Cretan villagers. There is a cemetery marking Allied involvement near the port of Souda.

A modern amphitheatre on Crete

Crete’s history, perhaps in keeping with its harsh and rugged beauty, is drenched in blood.

Milos Another ferry to this delightful and smaller island, although this time the journey was less than pleasant. The boat was smaller than the one from Santorini, the wind was howling and there was a short, ugly chop on the open sea.

Sarakiniko Beach Milos

When it finally stopped the accommodation was a small, twobedroom villa that was, quite literally, a whitewashed cave. Probably not for anyone who is vaguely claustrophobic but Maria’s Cave House is certainly a unique experience and a short walk to the village of Trypiti with two wonderful bakeries.

A short drive brings you to the seaside town of Pollonia with a wealth of restaurants – Gyalos for seafood and Enalion for traditional Greek fare are just two of them. And if you’re keen to get out on the water, there are a number of charter boats taking passengers on day trips. With some boating experience, we hired a little run-around and headed off to the clear blue waters of Kleftiko with its white cliffs and pirate caves cut into the mountains.

There are plenty of must-see beaches on Milos. Paliorema is unique, there’s an abandoned sulphur mine behind the beach and the entire vista is surreal. Mytakas Beach has the clearest water you’ll ever see and boat ‘garages’ called ‘syrmata’ carved into the rocks.

Marathi Beach on Crete

And the sparkling white rocks of Sarakiniko are stunning! It looks a bit like a lunar landscape and it’s very popular with young women who spend hours posing on rocky outcrops while their longsuffering boyfriends strive for that perfect shot.

Athens Our final stop was the capital, a sprawling metropolis with nearly four million inhabitants and a recorded history going back 3400 years. It’s often referred to as the ‘birthplace of democracy and the cradle of civilisation’ and, standing at the base of the Acropolis, you can feel the ‘culture’ seeping into your bones.

There are world-famous museums such as the revamped and architecturally award-winning New Acropolis Museum and the National Archaeological Museum.

The Venetian harbour at Chania, Crete

The alleyways and side-streets are worth exploring for interesting places to eat, and there’s no shortage of them. An amazing meal of grilled octopus and Cretan sausage greeted us at Ergon, Syntagma, and just around the corner the best ice-cream shop in the universe – Dark Cioccolato with Prunes and Rum at La Greche is heaven in a cone!

The islands are a different story. Road surfaces and the standard of driving is patchy. A lot of tourists, particularly the younger ones, hire scooters and quad-bikes, most of them don’t wear helmets and it can be terrifying to watch. Nonetheless, a car (with seatbelts) is the best way to explore and you’ll be rewarded for your bravery.

Getting Around You’d have to be very brave or stupid, or both, to get behind the wheel of a car in teeming Athens. The public and tourist transport system is fine, with a circle underground train and buses and taxis galore.

MEDICAL FORUM

Greece is a wonderful country, the locals are friendly and the food is superb. You’ve never eaten a Greek salad until you’ve had one in Greece.

By Peter McClelland

SEPTEMBER 2018 | 39

unloveable, a long list of unmet needs she had endured over the course of their quarter century of marriage.

Finally, after allowing this to go on for a sufficient length of time, the therapist stood up, walked around his desk and, asking the wife to stand, embraced her and kissed her passionately on the mouth.

COOL HEADS A man speaks frantically into the phone, "My wife is pregnant, and her contractions are only two minutes apart!"

"Is this her first child?" the doctor asks.

"No, you idiot!" the man shouts.

"This is her *husband*!"

ON THE THIRD DAY A heavily overweight man visits his doctor who puts him on a diet.

"I want you to eat regularly for two days, then skip a day, and repeat this procedure for two weeks. The next time I see you, you’ll have lost at least 2kg."

When the man returns, he shocked the doctor by losing nearly 10kg.

"Why, that’s amazing!" the doctor said.

"Did you follow my instructions?"

The man nodded. "I’ll tell you though, I thought I was going to drop dead that third day."

"From hunger, you mean?" asked the doctor.

"No, from skipping."

RE-IGNITING THE FLAME A husband and wife came for counselling after 25 years of marriage. When asked what the problem was, the wife went into an angry tirade listing each and every problem they had ever had in the 25 years they had been married.

She went on: neglect, lack of intimacy, emptiness, loneliness, feeling unloved and

The woman shut up and, in a daze, quietly sat down. The therapist turned to the husband and said, "This is what your wife needs at least seven times a week. Do you think you can do this?"

The husband thought for a moment and replied, "Well, Doc, I can drop her off here on Mondays and Wednesdays, but on the other days I play golf."

ALL THE ANSWERS Q: Is Google male or female?

A: Female, because it doesn't let you finish a sentence before making a suggestion.

FINE FEATHERED FRIEND Late one night a burglar broke into a house and while he was sneaking around he heard a voice say, "Jesus is watching you."

He looked around and saw nothing.

He kept on creeping and again heard, "Jesus is watching you." In a dark corner, he saw a cage with a parrot inside. The burglar asked the parrot, "Was it you who said Jesus is watching me" The parrot replied, "Yes." Relieved, the burglar asked, "What is your name?" The parrot said, "Clarence." The burglar said, "That's a stupid name for a parrot. What idiot named you Clarence?"

The parrot answered, "The same idiot that named the rottweiler Jesus."

HYMNS FOR ALL PROFESSIONS Dentist's Hymn: Crown Him with Many Crowns

"A witty saying proves nothing."

- Voltaire (1694-1778)

Weatherman's Hymn: There Shall Be Showers of Blessings Builder's Hymn: The Church's One Foundation Tailor's Hymn: Holy, Holy, Holy Golfer's Hymn: There's a Green Hill Far Away Politician's Hymn: Standing on the Promises Optometrist's Hymn: Open My Eyes That I Might See Accountant’s Hymn: I Surrender All Gossip's Hymn: Pass It On Electrician's Hymn: Send the Light Shopper's Hymn: Sweet By and By Realtor's Hymn: I've Got a Mansion Just Over the Hilltop Massage Therapist's Hymn: He Touched Me Doctor's Hymn: The Great Physician

Wine winner

40 | SEPTEMBER 2018

There’s a pretty close connection between first-time Doctor’s Dozen winner Dr Georgi Pagey and her case of Singlefile wines. Georgi’s husband worked with Viv and Phil Snowden, the winery owners, in their pre-winemaking geology days and their own Denmark property is just down the road from the winery. Georgi – a GP who also works in women’s health and does rural locums – says, they were “firm Singlefile converts”, particularly of the Pinots, before she won the prize!

MEDICAL FORUM

NUTRITION

Losing Weight is a Habit Before you go for seconds, have a glass of water and wait five minutes before checking in with your hunger again, says researcher Dr Gina Cleo

M

ost people who diet will regain 50% of the lost weight in the first year after losing it. Much of the rest will regain it in the following three years.

Most people inherently know that keeping a healthy weight boils down to three things: eating healthy, eating less, and being active. But doing that can be hard work.

We make more than 200 food decisions a day, and most of these appear to be automatic or habitual, which means we unconsciously eat without reflection, deliberation or any sense of awareness of what or how much food we select and consume. So often, habitual behaviours override our best intentions.

A new study has found the key to staying a healthy weight is to reinforce healthy habits.

Imagine each time a person goes home in the evening, they eat a snack. When they first eat the snack, a mental link is formed between the context (getting home) and their response to that context (eating a snack). Every time they subsequently snack in response to getting home, this link strengthens, to the point that getting home prompts them to eat a snack automatically.

This is how a habit forms.

New research has found weight-loss interventions that are founded on habit-

change, (forming new habits or breaking old habits) may be effective at helping people lose weight and keep it off.

We recruited 75 volunteers from the community (aged 18-75) with excess weight or obesity and randomised them into three groups. One program promoted breaking old habits, one promoted forming new habits, and one group was a control (no intervention).

The habit-breaking group was sent a text message with a different task to perform every day. These tasks were focused on breaking usual routines and included things such as “drive a different way to work today”, “listen to a new genre of music” or “write a short story”.

The habit-forming group was asked to follow a program that focused on forming habits centred around healthy lifestyle changes. The group was encouraged to incorporate 10 healthy tips into their daily routine, so they became second-nature.

Unlike usual weight-loss programs, these interventions did not prescribe specific diet plans or exercise regimes, they simply aimed to change small daily habits.

After 12 weeks, the habit-forming and habit-breaking participants had lost an average of 3.1kg. More importantly, after 12 months of no intervention and no contact, they had lost another 2.1kg on average.

Some 67% of participants reduced their total body weight by over 5%, decreasing their overall risk for developing Type 2 Diabetes and heart disease. As well as losing weight, most participants also increased their fruit and vegetable intake and improved their mental health.

Habit-based interventions have the potential to change how we think about weight management and, importantly, how we behave.

Ten healthy habits (developed by UK charity Weight Concern) 1. Keep to a meal routine: eat at roughly the same times each day. People who succeed at long term weight loss tend to have a regular meal rhythm (avoidance of snacking and nibbling).

A consistent diet regimen across the week and year also predicts subsequent long-term weight loss maintenance/ 2. Go for healthy fats: choose to eat healthy fats from nuts, avocado and oily fish instead of fast food. Trans-fats are linked to an increased risk of heartdisease 3. Walk off the weight: aim for 10,000 steps a day.

4. Pack healthy snacks when you go out.

5. Always look at the labels for fat, sugar and salt content.

6. Caution with your portions: use smaller plates, and drink a glass of water and wait five minutes then check in with your hunger before going back for seconds.

7. Decreasing sedentary time. Time spent sedentary is related to excess weight and obesity, independent of physical activity level.

8. Choose water and limit fruit juice to one small glass per day 9. Focus on your food: slow down and eat while sitting at the table, not on the go. Internal cues regulating food intake (hunger/fullness signals) may not be as effective while distracted.

10. Always aim for five serves of vegetables a day, whether fresh, frozen or tinned: fruit and vegetables have high nutritional quality and low energy density.

ED: Dr Gina Cleo is a research fellow, Bond University. This article was originally published on The Conversation.

MEDICAL FORUM

SEPTEMBER 2018 | 41

OPERA

Like Good Wine Mozart’s Don Giovanni is one of the most-performed operas worldwide and for good reason. It has a bit of everything – drama, comedy, melodrama and a bit of spooky from the grave stuff as well as some of the most glorious music ever written. It’s the reason the crowds enjoyed it in 1787 and why they still come flocking.

It is also the staple of a bass baritone’s repertoire and one that Teddy Tahu Rhodes could probably sing in his sleep.

He’s played the Don – a lot. He has been pulling on the mantle of opera’s greatest rake since 2002 and has found himself in the centre of opera directors’ visions and revisions – but he never takes the role or the art lightly.

He returns to WA Opera in October to head the cast in the Perth season in Swedish director Goran Jarvefelt’s production – complete with leather hotpants, knee-high riding boots and fulllength leather jacket.

At 51, he feels that he brings some depth and wisdom to the role – something the character himself has none of – but there are ways of playing him smarter than say 16 years ago.

“It is a part, I think, which ages well. I like the fact that play him young and there’s a different feel, but there is greater depth with an older don since the whole concept of the piece is that he’s losing his appeal in a way. He’s constantly chasing and he’s no longer smart at it,” Teddy said.

Perhaps the slap and tickle of Lorenzo Da Ponte’s now very old libretto takes on darker tones as social standards shift and a rake remains a rake no matter how beautiful the music.

“We will find out in six weeks, when we walk out on the rehearsal stage,” he said.

Joining Teddy is the delightful James Clayton, who is also reprising his role as the Don’s disaffected sidekick, Leporello, Anita Watson as Donna Anna, Emma Pearson as Donna Elvira and Rebecca Castellini as Zerlina – as the ladies in question. Outraged boyfriend Don Ottavio will be sung by Jonathan Abernethy and Jud Arthur’s sepulchral bass gives life (and death) to Il Commendatore, who returns from the grave to serve Don Gionvanni his just desserts.

“The thing I love about this role is its drama, which is very powerful. I think it’s a perfect piece of staged Mozart and I’ve done several different productions. It is set in period and yet it is still edgy. You really get hooked up into the story.”

By Jan Hallam

Once you see this version, you never forget it.

Teddy told Medical Forum he wasn’t sure what rehearsal director Roger Press and Artistic Director Brad Cohen had in mind for the revival but he was sticking to his gym routine.

42 | SEPTEMBER 2018

MEDICAL FORUM

THEATRE

Thrill of Emancipation T

he quest for personal fulfilment both within and outside a relationship takes a wonderful twist in The Room Next Door – or That Vibrator Play, which opens at the Heath Ledger in October for Black Swan State Theatre Company.

Sarah Ruhl’s play opened on Broadway eight years ago but has just found its way to Perth under the direction of Jeffrey Jay Fowler, who has wanted to present the period piece for a number of years, but the cost has been, until Clare Watson’s stewardship of Black Swan, a little off-putting.

With the green light, Jeffrey is looking forward to presenting a play he believes is not just about female pleasure but also female agency in the male-dominated system.

The play is set in the 1880s when, as Jeffrey describes it, the world was at the precipice of the electrical age.

For the first time the world had electric lights – and the vibrator, which was conceived as therapeutic rather than erotic, was one of the innovations.

“The characters are terrified of electricity. Back then technology was changing the world and people were frightened and this is consistent even now. We have and will continue to experience the exponential growth of technology and we feel we are always on the edge of the future and what that means for us,” he said.

Accompanying the staging is an exhibition in the theatre foyer of 19th century vibrators, which would not be out of place in a medieval torture chamber. Given how ubiquitous sex toys and vibrators are in the 21st century, they will take your breath away.

These are heavy duty, utilitarian objects design to accomplish the job of “curing” women’s hysteria.

This correction of wrong emotions is very much at the heart of the play.

“Men succeeded in suppressing their emotions and the vibrator was an attempt to suppress women’s emotions. Women were told what was wrong with them and what to do about it. It was a man’s decision if they could have an orgasm. It’s telling that husbands brought their wives to doctor,” Jeffrey said.

“However, what emerges in the play is that women are not only seeking pleasure but meaningful communication and connection in their relationships. Things we all seek.”

While vibrators of the 21st century are more user-friendly and accessibly (and come in a range of attractive colours), Jeffrey suggests that it doesn’t mean we have better relationships.

“That can’t be simulated or stimulated,” he said.

Perth actress and WAAPA graduate Elizabeth Blackmore returns from Los Angeles where she has been making television such as The Vampire Diaries and Supernatural. Her husband Tom Stokes is also in the cast as is another husband-wife acting duo Rebecca Davis and Stuart Halusz.

“I have two couples in the cast but they are not playing each other’s spouse in the play. There’s a lot of intimacy between performers, so it’s a nice safe environment but I didn’t want to direct couples playing a couple. This way it’s a learning process for everyone,” Jeffrey said.

By Jan Hallam

MEDICAL FORUM

SEPTEMBER 2018 | 43

COMPETITIONS

Enter Medical Forum's competitions!

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link.

Movies: Lavazza Italian Film Festival A new crop of vibrant Italian films will be unleashed at the 2018 festival including comedies Nonnas on the Run and My Big Gay Italian Wedding and its feature director Turkish-Italian auteur Ferzan Ozpetek including his mystery drama Naples in Veils. Full program at Luna Palace. It’s always a treat to see top Italian cinema

Music: WASO – French and Fantastic October showcases some of France’s most talented musical exports in two exciting concert programs featuring a world premiere and a tribute to the sea.

Conductor Ludovic Morlot makes his WASO debut on October 5 and 6 when he will steer the orchestra firstly with acclaimed cellist Gautier Capucon in Tchaikovsky’s brilliant Variations on a Rococo Theme before taming the waves in the tone poems by Sibelius – Oceanides – and Debussy in La Mer. On October 12 and 13, Morlot returns to the podium with Capucon and piantist Jean Yves Thibaudet in the world premiere of Swiss composer Richard Dubugnon’s Eros Athanatos, which was commissioned by WASO with the support of Jude and Barrie Lepley. Morlot is topping and tailing this special event with the dazzling Debussy Images: Iberia and Rachmaninov’s Symphonic Dances. It will be a month of French music of the highest order.

Perth Concert Hall, October 5 and 6; October 12 and 13, 7.30pm. MF October 5 performance

Music - Tristan Und Isolde: Dr Christopher Lam

Movie: Venom No one plays the reluctant hero quite like Tom Hardy who suits up here to play one of Marvel's most enigmatic, complex and ‘badass’ characters – the lethal protector, Venom. The always intelligent actor Michelle Williams joins him to make this a classy instalment in the superhero franchise.

In cinemas, October 4

Theatre: In the Next Room, or The Vibrator Play Playwright Sarah Ruhl re-imagines the curious chapter in the early history of psychotherapy, when women were treated for hysteria with a vibrator. Set in the 1880s, a doctor’s wife discovers just what is happening ‘In the Next Room’ and changes the way she sees the world.

Heath Ledger Theatre, October 10-November 4

Winners from July Choral - Swoons: Dr John Masarei

Cinema Paradiso, Luna on SX, September 27-October 17

Life Challenges Men & Boys Doctors’ Wellbeing Prostate MRI; Hyperbaric Medicine; PrEP

MAJOR PARTNER

Theatre - Curious Incident: Dr Laura Dotto Movie - Book Club: Dr Palan Thirunavukkarasu, Dr Andrew Kam, Dr Riva Bassi Curtis, Dr Richard Riley, Dr Jenny Fay, Dr Fiona Sluchniak, Dr Celeste Trichardt, Dr Julia Charkey-Papp, Dr Vicki Westoby, Dr Fred Faigenbaum Movie - Mission Impossible Fallout: Dr James Lie, Dr Esther Eu, Dr Jenny Philip, Dr May Ann Ho, Dr Eric Khong, Dr Paul Laidman, Dr Luca Crostella, Dr Bridget Cooke, Dr Nai Lai, Dr Benjamin Jarvis

July 2018

www.mforum.com.au

Opera: Don Giovanni WA Opera’s final mainstage opera in the current season is Mozart’s classic tale of retribution on the licentious womanising Don Giovanni. Bass baritone Teddy Tahu Rhodes has made this title role his own and he returns to Perth with James Clayton as Leporello, Emma Pearson as and Anita Watson as Donna Anna.

His Majesty’s Theatre, October 20-27

Movie - The Breaker Upperers: Dr Helena Goodchild, Dr Brendan Collins, Dr Tricia Charmer, Dr Genevieve Robbins, Dr Rose Schuddinh

44 | SEPTEMBER 2018

MEDICAL FORUM

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