Aged Caring GP Insights; Consumer Choice; Bottlenecks Thrombectomy for Stroke Exercise; Nocturia; Retinopathy
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November 2018 www.mforum.com.au
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EDITORIAL Dr Rob McEvoy, Medical Editor
Ailments of the Elderly Doctors will soon be (if they are not already) swamped with the ailments of the elderly. Doctors and others who assist them may be seen as key to helping the elderly hold onto their faculties i.e. restorative rather than palliative solutions. What are the main problems doctors encounter (for the opinion of three doctors, see page 12)? Hearing loss in the elderly is no laughing matter despite the picture of an old bloke clutching a horn to his ear and saying ‘eh?’. Worldwide, disabling hearing loss affects 432 million adults, 165 million of whom are over 65 years. In Australia, disabling hearing loss is said to affect 3% of the 15-50 age group and 63% of people over age 71.
Stroke thrombectomy relies on the personal skill of the doctor removing the clot as much as anything else (see story page 16). Done in quick time with careful selection of patients it has the potential to relieve at least 25% of strokes. And relief can be quite profound. Repairing the hip or knee. According to a report on the prosthesis registry (remember the breast augmentation and metal-on-metal hip replacements?), 80% of those aged 80-89 survive at least five years after surgery, so revisions although unwelcome, are possible. Whole-of-population data reveals knee replacements have increased by 5% over the past 12 months. Of course, obese people do worse and need revisions and have complications more often. One of the important issues for the registry is how best to improve the results in patients with poor health or who are obese.
Memory and cognitive loss. Dementia used to be a thing of old age. Not so these days. GPs can expect to see more people for memory tests (there are a host of online tests). Will we will find out why it is happening at a younger age? Or is it that more people are admitting to the problem rather than slink off to the dark recesses of our memories.
AHPRA and doctors. Senior doctors may be getting a raw deal, according to the Association for Senior Active Doctors (ASADA). The problem is that most specialists organise their own stepdown in their later years. Getting these people motivated and organised into a cohesive lobby group is proving difficult. I am not sure what the answer is but the CEO of ASADA (page 27) is frustrated at the injustice.
CVS disease. Get in a room of 60-year-olds and it is hard to find someone without a coronary stent, it seems. It used to be a talking point but now it is old hat. I suspect if we scratch doctors, many are on statins, and so are their patients. Statins don’t show any benefit if consumed by 70-year-olds without some other strong indication.
Where does all this put the younger doctor? Buried under an avalanche of aged caring? There is much to learn from those with entrepreneurial spirit (page 31), because if we are to handle the tidal wave of aged care heading our way we have to do things smarter and share the load. Otherwise needs will get swamped and no amount of Royal Commission findings will help. Technology will certainly help the huge logistics of aged care.
As a profession we are good at starting drugs but not good at stopping them. Hence, polypharmacy amongst the elderly is common, particularly in ACFs where the RN ensures the patient takes their ‘blue ones’, crushed or not.
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
Most people who are elderly are well. Many elderly who die, are well, and asleep, having had a good life. Spare a thought for the older doctors, thinking of retirement. How are they positioned for a step-down?
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
NOVEMBER 2018 | 1
CONTENTS NOVEMBER 2018
INSIDE 12 16 20 27
GPs Working in Aged Care The New Stroke Frontier Reconnecting with the Elderly Senior Doctors – Step Down?
12
16
NEWS & VIEWS 1 Editorial: Ailments of the Elderly - Dr Rob McEvoy 4 Letters to the Editor
20
27 MAJOR PARTNER 2 | NOVEMBER 2018
6 7 11 19 26 34
Acne – What Works - Dr Chris Quirk Shoulder Imaging - Dr Arockia Doss Have You Heard? Beneath the Drapes Sport Life at Any Age Midland Research Symposium Medicolegal: Clinical Practice Guidelines - Mr Enore Panetta Qoctor and Sickie Monday
LIFESTYLE 40 Reaching Out to Vulnerable Teens 41 Wine Review: Deep Woods Estate - Dr Martin Buck 42 Social Pulse: World Mental Health Day; Core Medical 43 Theatre: Brainchild 44 Humour 45 Competitions
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CONTENTS NOVEMBER 2018 CLINICALS
5 High-Sensitivity Cardiac Specific Troponin Dr Johan Conradie, Dr Melissa Gillett and Dr Chanika Ariyawansa
28 Why is Exercise Medicine? Prof Robert Newton
31 Rethinking Aged Care Dr Scott Blackwell
34
The Doctors Health Advisory service of WA provides Medical Practitioners with a confidential health service around the clock.
Pathological Nocturia Dr Jeffrey Thavaseelan
How to contact: For doctors in crisis or for those wanting to speak with a DHASWA doctor:
33 Skin Cancer Treatment With Radiotherapy Dr Jeremy Croker
37 Diabetic Retinal Disease By Dr Tim Isaacs
(08) 9321 3098 24 hours/day, 7 days/week
Drs For Drs list is now live at
38
www.dhaswa.com.au
‘Incidentalomas’ By Dr Mark Hamlin
GUEST COLUMNS
8 Consumers Will Shape Future Care Adj Clinical A/Prof Bret Hart
22 Elder Abuse is Everyone’s Business Ms Diedre Timms
23 Not Just the What but the How Ms Lyn Martin
25 Is Pastoral Care Still Relevant? Rev Jeni Goring
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)
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NOVEMBER 2018 | 3
LETTERS TO THE EDITOR • Topical antibiotics: clindamycin and erythromycin.
Dear Editor,
• Systemic antibiotics (should be used for only a few months - doxycycline, minocycline, erythromycin, cotrimoxazole (bacterial resistance will see antibiotics used for acne phased out eventually)
RE: Article Acne Expectations September 2018 edition Acne is a very common and often very distressing illness. It strikes when young adults are feeling most vulnerable about their place in the world. Social media is full of teenagers with flawless complexions making the acne sufferer feel like a reject from the beautiful set. An internet search turns up dozens of clinics suggesting cures for acne: creams, masks, laser intense pulsed light, microdermabrasion, microneedling, chemical peels etc. Truth be known some of these clinics specialise in separating the client from their money rather than making a genuine effort to fix the problem, with misplaced optimism. The Cochrane collaboration has assessed several popularly promoted treatments and have concluded the treatments have either low efficacy or none. These include systemic spironolactone, photodynamic therapy, intense pulsed light therapy, blue and redlight phototherapy and laser therapy. What works in acne? • Diet: a low GI diet has been shown to help. • Avoidance of greasy (comedogenic) make-up. • Foaming cleansers remove sebum from blocked pores. • Cleansers containing benzoyl peroxide, salicylic acid (antibacterial washes have no role in acne).
• Oral Contraceptive. The OCP drops levels of free androgen; newer OCPs containing drospirenone have more of an effect on lowering androgens than older OCPs. • Istretinoin: this potent drug was introduced into Australia in 1983. Acne scarring is mostly due to a failure to use this drug early in the course of the acne. Treatment of acne scarring is unsatisfactory and seldom produces complete clearance. It is a teratogen: women with child bearing potential need to be warned pregnancy is to be avoided. It has a half-life of 17-50 hours so pregnancy is permitted a few weeks after discontinuing the drug. Acne has long been implicated in causing mood disorders and depression but a meta-analysis of all the studies on the subject concluded this was not true-partially because of the high background rate of depression in young adults. Dr Chris Quirk, Dermatologist, Ardross ......................................................................
Shoulder imaging Dear Editor I read with great interest the article Investigating The Painful Shoulder – A Pandora’s Box? by Dr Jonathon Spencer (October
2018 edition). He correctly points out there is overemphasis on MRI in orthopaedic conditions particularly in the ageing population. Sometimes there is too much information from imaging that is perhaps not relevant. The findings of ‘tear’ and ‘bursitis’ create anxiety and fear in patients. His article coincides with a review article in the 1 October 2018 edition of the Journal of Medical Imaging and Radiation Oncology, the official journal of the Royal Australian and New Zealand College of Radiologists. The review article provides information on the meaning of such findings of ‘tears’, ‘bursitis’ and ‘disc bulge’ in imaging reports. One will find that the vast majority of these findings are present in asymptomatic individuals. Without clinical correlation these findings mean very little and even worse, may lead to unwanted procedures, costs and risks. The review provides a table with a summary of most orthopaedic conditions. This is a must have desktop reference for referrers of medical imaging. They may use the information to reassure and inform patients on the real meaning of the findings in the radiology report. Radiologists should also include the information from that table about the natural history, prevalence and outcomes of actions taken on the basis of their radiology report. I applaud both Dr Spencer and the Medical Forum for bringing this important topic to the forefront so that we may use medical imaging appropriately, allay unnecessary fears and anxiety in our patients, and reduce both costs and medical risks. Dr Arockia Doss, Radiologist, Nedlands ......................................................................
• Topicals retinoids: tretinoin, tazarotene and adapalene. • Benzoyl peroxide: varying strengths from 2.5-10% available over the counter: the brand advertised on TV by movie stars is no better than the pharmacy lines. • Topical azelaeic acid: kills propionibacteria , which has a role in acne. It is a comedolytic. • Keratolytic lotions containing salicylic acid or sulfur.
SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.
4 | NOVEMBER 2018
We all agree that your theory is crazy, but is it crazy enough?" - Danish physicist Niels Bohr (1885-1962)
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High-sensitivity cardiac specific troponin in general practice By Dr Johan Conradie, Dr Melissa Gillett and Dr Chanika Ariyawansa Over the next few months Western Diagnostic Pathology will introduce the latest 5th generation hs-cTnI assay from Beckman. This assay demonstrates superior analytical, diagnostic and prognostic performance over contemporary cTn assays (4th generation). The new hs-cTnI has less analytical variability, <10% variability at the 99th centile upper reference limit (URL), and an ability to accurately measure very low levels of troponin, as low as 2 ng/L. As a result of improved performance there will be a corresponding change in reporting units and reference intervals (including adoption of gender specific reference intervals). Gender Specific Reference Interval for Beckman hs-cTnI:
one value above the 99th centile URL and at least one of the following: typical symptoms of ischemia, suggestive electrocardiographic (ECG) changes, or imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
Strong consideration should be given to referring patients to attend an emergency department for clinical assessment where:
Troponin may be elevated in the absence of an acute event. In these (general population) patients, the typical rise and fall of troponin with an ischemic event will not be seen.
• Patients with suspected acute coronary syndrome and symptoms >24 hours prior to high-risk features (heart failure, syncope, abnormal ECG).
Causes of elevated troponin Acute myocardial infarction. Coronary artery spasm (eg, due to cocaine or methamphetamine use). Takotsubo cardiomyopathy. Coronary vasculitis (eg, systemic lupus erythematosus, Kawasaki disease). Acute or chronic heart failure.
Female: < 11 ng/L Male: <21 ng/L
Tachyarrhythmia or bradyarrhythmia.
Western Diagnostic Pathology will be changing our reporting units as the new hs-cTnI (Beckman) is rolled out across WA and NT. Current (4th generation) troponin assays in WA report in ug/L will change to ng/L (see table) with the introduction of 5th generation (hs-cTnI) troponin assay to better reflect the analytical sensitivity of the new assay.
Cardiac contusion or surgery.
Frequent defibrillator shocks.
Unit conversion ug/L to ng /L: Old TnI (ug/L):
New hs-cTnI (ng/L):
<0.04
10
<0.04
20
0.04
40
0.05
50
0.1
100
1.0
1000
Troponin plays an important role in the evaluation of patients with suspected acute myocardial infarction. Fourth Universal Definition of Myocardial Infarction states that a diagnosis of myocardial infarction is made when there is a rise and/or fall of troponin with at least
Rhabdomyolysis with cardiac involvement. Myocarditis or infiltrative diseases (eg, amyloidosis, sarcoidosis, haemochromatosis). Cardiac allograft rejection. Hypertrophic cardiomyopathy. Cardiotoxic agents (eg, anthracyclines, trastuzumab, carbon monoxide poisoning). Aortic dissection or severe aortic valve disease. Severe hypotension or hypertension (eg, haemorrhagic shock, hypertensive emergency). Severe pulmonary embolism, pulmonary hypertension or respiratory failure. Dialysis-dependent renal failure. Severe burns affecting > 30% of the body surface. Severe acute neurological conditions (eg, stroke, cerebral bleeding or trauma). Sepsis. Prolonged exercise or extreme exertion (eg, marathon running).
• Patient presenting with suspected acute coronary syndrome with symptoms occurring within the previous 24 hours or
Careful consideration should be given when requesting a troponin on an outpatient basis, as this might delay a timely diagnosis and management of an acute coronary syndrome. However, a single troponin may be indicated (community-based) in patients presenting with a history of a possible acute coronary syndrome within the past 14 days (but only if symptom-free for more than 24 hours with no high-risk features) . It is important the requesting doctor ensures the sample is clearly marked as urgent, with a robust communication system in place to facilitate the laboratory relaying the result to requesting doctor as soon as possible. References: Carlton, E., Cullen, L. and Body, R., 2017. Appropriate Use of High-Sensitivity Cardiac Troponin Levels in Patients With Suspected Acute Myocardial Infarction—Reply. JAMA Cardiology, 2(2), p.229. Greenslade, J., Carlton, E., Van Hise, C., Cho, E., Hawkins, T., Parsonage, W., Tate, J., Ungerer, J. and Cullen, L., 2018. Diagnostic Accuracy of a New HighSensitivity Troponin I Assay and Five Accelerated Diagnostic Pathways for Ruling Out Acute Myocardial Infarction and Acute Coronary Syndrome. Annals of Emergency Medicine, 71(4), pp.439-451.e3. Marshall, G., Wijeratne, N. and Thomas, D., 2014. Should general practitioners order troponin tests?. The Medical Journal of Australia, 201(3), pp.155-157. Thygesen, K., Alpert, J., Morrow, D., White, H., Jaffe, A., Chaitman, B. and Bax, J., 2018. Fourth universal definition of myocardial infarction (2018). [online] European Heart Journal. Available at: <https:// academic.oup.com/eurheartj/advance-article/ doi/10.1093/eurheartj/ehy462/5079081> [Accessed 16 Oct. 2018]. Twerenbold, R., Boeddinghaus, J., Nestelberger, T., Wildi, K., Rubini Gimenez, M., Badertscher, P. and Mueller, C., 2017. Clinical Use of High-Sensitivity Cardiac Troponin in Patients With Suspected Myocardial Infarction. Journal of the American College of Cardiology, 70(8), pp.996-1012
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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HAVE YOU HEARD?
It’s been on agendas for years now but there seems to be increased momentum and political will for a floor price on alcohol sales. A McCusker Centre for Action on Alcohol and Youth (MCAAY) survey of 806 revealed three in five WA adults supported the WA Government introducing a minimum price on alcohol, with 78% believing more needed to be done to reduce the harm caused by alcohol-related illness, injury and death. The call for action was also taken up by Cancer Council WA CEO Ashley Reid and the Commissioner for Children and Young People Colin Pettit. The Health Minister Roger Cook has already thrown in his support but has called on the public health community to show the public why legislation is necessary.
Diet the key? Does diet cure diabetes in overweight people? Yes, perhaps, according to the largest observational trial of very lowcalorie diet in those overweight and with pre-diabetes. Over 2000 subjects across eight countries, including Australia and New Zealand, were followed for three years and followed an eight-week diet plan formulated with key vitamins, minerals, high quality protein, essential fats, fibre, and other nutrients to facilitate optimal weight loss. The ‘soups and shakes’ diet resulted in 10% weight loss on average after eight weeks and 35% of participants were no longer pre-diabetic according to blood sugars. Systolic blood pressure also improved, as did blood lipid profiles, fasting insulin and insulin sensitivity.
treatments. This will result in a window into environmental and social factors influencing health trends and providing generations with a crystal ball into their future health risks. In 2005, Medical Forum wrote about a less ambitious study of the Joondalup population by Prof Lyle Palmer, before he set off for Canada. Getting the project off the ground was a problem. We now have “internationally renowned pioneer in systems medicine and metabolic phenotyping”, Prof Jeremy Nicholson of the Health Futures Institute at Murdoch University. We wish them every success. Perth’s reputation for longitudinal population research, a steady population of 2.5m, and its isolation play some part. Murdoch’s Vice Chancellor Prof Eeva Leinonen said: “We are hoping to transform the way people are diagnosed and treated for diseases and health conditions in WA and around the world” WA Health Minister, Roger Cook said: “Having access to established academic superstars like [husband and wife team Prof Nicholson and Prof Elaine Holmes] and emerging talent such as Ruey [Leng Loo], will help drive WA’s competitiveness in a wide range of aspects of health and medical research and will ultimately lead to better health outcomes for Western Australians. Targeted, personalised medical treatment not only results in a more efficient health system but most importantly delivers more effective treatment for patients.” The minister flagged personalised care as a focus of the government at the last Doctors Drum. The ANPC will be based at the Harry Perkins Institute (South).
Midland scan successful People in the East Metropolitan and Wheatbelt regions will soon be able to access a fully rebateable MRI scanner closer to home, thanks to an announcement by the Federal Government that Medicare will fully fund a Midland-based MRI machine from November. The MRI will be operated by Perth Radiological Clinic at St John of God Midland Public and Private Hospitals. Perth Radiological Clinic CEO Lenka PsarMcCabe said previously, the MRI was only partially funded by Medicare, which meant some patients had to travel to a hospital with a fully funded MRI if they did not want to incur out of pocket costs.
More packages released As flagged in our story on p20, the Minister for Aged Care Ken Wyatt has announced an additional $100 million over two years to provide a funding boost for providers of the $5.5 billion Commonwealth Home Support Programme (CHSP) to grow five vital home services – domestic assistance; meals; transport; home maintenance; and home modifications. He said an extra $50 million per year will be offered to a targeted group of successful existing CHSP service providers to meet immediate growth needs over two years from 2018-19.
Investment at Peel The WA Government will invest $5 million into a redesign of the Peel Health Campus emergency department to improve patient flow. This is in addition to the $4.4 million promised in the Budget to improve parking,
Navigating aged care The Federal Government is calling for tenders for trials of a new aged care navigator network, including information hubs, community hubs and one-onone support from specialist workers, to streamline and simplify aged care service access. Trials will see 30 information hubs created to provide local information and build people’s understanding and engagement; 20 community hubs to enable people to support each other; and six individuals to offer one-on-one support. The trials to be conducted between January and June next year will focus on helping people with complex needs, including those with language and technology barriers, financial disadvantage or social isolation.
Phenome central A phenome fingerprint for all West Australians is the aim of research by Murdoch University through the Australian National Phenome Centre (ANPC). It is hoped relationships between genes will emerge for cancers, obesity, autism, dementia and Type 2 diabetes and will include animal health and agriculture. Diet, lifestyle and exposure to pollutants will be studied to help researchers better understand the underlying causes of disease and to develop personalised
6 | NOVEMBER 2018
Exercise physiologist Jo Milward with some of participants of the Intergrum Aged Care + trial.
Getting in the groove Last month, Silver Chain Medical Director Dr Daryl Kroschel wrote in the letters pages about a trial being conducted by Silver Chain to help people with chronic conditions stay out of hospital. The trial is looking to recruit up to 300 people who are 65+ (or 50+ if ATSI), have two or more chronic conditions, have been hospitalised within the past 12 months, live in their own homes and are 25 minutes by car form Belmont. Integrum Aged Care+ is exploring how a dedicated RN case manager and a multidisciplinary team, including exercise physiologist and social worker can work on improving self-management of their conditions. The trial is a collaboration between Silver Chain and WAPHA and is designed using a shared care, GP-partnership arrangement. Currently it is being funded by existing health and aged care funding streams including Home Care Packages, Commonwealth Home Support Packages and bulk-billed MBS. There are no additional costs for clients. Patients can be referred via the Silver Chain website or doctors can call 1300 513 535.
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Alcohol floor price
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RPH anaesthetist Dr Richard Riley (pictured) was named in the Class of 2019 Fellows of the Society for Simulation in Healthcare. He will be formally inducted at the International Meeting for Simulation in Healthcare in San Antonio, Texas, on January 26, 2019. Dr Martin Chapman has been announced chair of the WA Government taskforce in mental health and has moved from the Marian Centre to Hollywood Clinic.
Old drugs, new tricks Researchers from UWA and KEMH are exploring if the use of a pentoxifylline (also known as Trental®) which was developed in the 1970s to treat adults with poor circulation, can help sick pre-term infants. Dr Sam Salman and A/Prof Tobias Strunk are solving dosage issues after previous small studies have suggested the drug could improve survival and disability when added to the treatment of premature babies with serious infections. The study examined the use of pentoxifylline in 26 babies born between 23 and 30 weeks and weighing between about 500g and 2kg who were being treated for serious infections. Results have shown that not only did size impact the concentrations of the drug but that for every additional week of life there was a 30% increase in organ function that metabolised the drug, resulting in lower concentrations of the drug.
security and maintenance. The major upgrade will include a new fast-track patient triage zone; a redesigned and refurbished waiting room; new holding bays, designed to offer patients awaiting admission improved privacy; and reconfiguration of the existing triage area to facilitate early senior medical review and to improve patient privacy and comfort. There will also be eight extra beds in the short stay unit. Work will start early 2020.
400 people diagnosed with breast, lung, colorectal or prostate cancer from four rural regions of WA (Great Southern, Goldfields, South West and Mid-West) about five months after their diagnosis, as part of a bigger study investigating the cost of cancer treatment. Of the 387 participants who reported their costs, 94% experienced outof-pocket expenses with an average cost of $2179 per person.
Director of Communications and Development at Telethon Kids Institute Ms Elizabeth Chester has been named recipient of a PHAAWA health leaders award. The former Deputy CEO of St John Ambulance, Mr Anthony Smith, will become MercyCare’s CEO on December 3. The federal Minister for Health Greg Hunt has announced $37,130 worth of grants to men’s sheds in WA. Ms Elaine Darby is resigning from the board of AusCan Group Holdings while Mr Paul MacLeman has been appointed executive director. The National Centre for Asbestos Related Diseases (NCARD) is holding a community forum on Tuesday, November 20, as part of Asbestos Awareness Month at the Perkins Institute.
Scholarship support In May we profiled the life and work of WA’s Australian of the Year, psychologist Dr Tracy Westerman. She has recently announced that she will fund a $50,000 five-year scholarship for Indigenous students to study psychology at Curtin University. “As a proud Njamal woman from the Pilbara region of Western Australia, my vision is to support students with remote and rural connections through their university studies with the aim of becoming Aboriginal psychologists skilled in Indigenous-specific mental health and suicide prevention and intervention programs.” Applicants will be required to meet eligibility criteria, including connections to and a desire to continue their work in rural and remote communities on completion of their studies. For more information www. indigenouspsychservices.com.au.
Extra blow for cancer patients WA Rural cancer patients experience significant out-of-pocket expenses during cancer treatment according to a new study by researchers at UWA. The study surveyed
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INCISIONS BACK TO CONTENTS
Consumers Will Shape Future Care Preventative health will be the buzz word of the future and consumers will be in the driver’s seat, writes Dr Bret Hart. “Business as usual is not an option” announced Robyn Kruk when, as chair, she embarked on the WA Department for Health‘s Sustainable Health Review (SHR). The implication is that the business of illness will have to change. Some will perceive this as an opportunity; others a threat. It would be surprising if the final report, due to be presented to the Minister in November, did not incorporate international trends which prioritise population health in a community context to curb ever-growing sick care expenditures In the U.S. the Health 3.0 framework draws on evidence to optimise population health over the life span, in a communityintegrated health system. In the UK, previous NHS chief Lord Nigel Crisp recommends adopting practices from developing countries with limited resources which empower communities to obtain better health outcomes. While a recent report from the European Commission that emphasises the critical role of primary care in overall health outcomes, specified community-oriented care as one of the 10 domains of assessing primary care performance. Closer to home, South Australia established a Health in All Policies (HiAP) unit based on the European model that calls for a whole-government approach to strengthening health systems by influencing the social determinants of health. SA’s HiAP, which is supported by government mandate, seeks support from all departments to integrate population health into their policies and programs, even those traditionally not considered to influence health. This approach recognises that health is influenced by a wide range of determinants and tackling complex healthcare issues requires collaborative policy responses.
It is uncertain if the SHR will call for this approach as there has been a history of reluctance to the HiAP concept in WA.
In the CSIRO’s Future of Health report, it urges discussion on the need for, “…a fundamental shift in our paradigm of healthcare from treatment to prevention… [to]…reduce the financial burden on
8 | NOVEMBER 2018
healthcare and improve quality of life for all Australians.” The report was informed by the diverse perspectives and technical expertise of over 30 organisations who, like Ms Kruk’s review, indicate change is an imperative. Compared to other OECD countries, Australia spends more than any other on an average 11 years of ill health. Future of Health finds only 20% of a person’s life expectancy and quality of life influenced by clinical care, which equates to a poor return on investment given the nearly $200 billion spent on health in 2016-17. The recommended shift to a culturallytailored, proactive management and prevention model that addresses the inequalities in social and economic support, and the physical environment are hampered by our current fragmented and inflexible illness focused system. A practical example is demonstrated by the fact that less than 20% of GPs know when their patient was seen in an emergency department. And yet, care coordination seems like an achievable task in the face of designing a health system capable of addressing individual needs. The current one-size-fits-all approach to care is doing more harm than good. For instance, Australians living in rural and remote areas tend to have lower life expectancy, poorer mental health outcomes, and higher rates of disease and injury. While the CSIRO report supports a technologydriven, tailored approach, their “precision health solutions” may lead to further disparities.
The Inverse Care Law (ICL, see inset p24), introduced by Dr Julian Tudor Hart, could be applied to CSIRO predictions of the increasing prevalence of technology in improving health outcomes. The report includes several fascinating examples of using these technologies to help keep Australians healthy, to assist with chronic care and after-care including health apps (there are already 318,000), AI platforms, bots, virtual reality, augmented reality applications, robots, behaviour monitoring sensors, virtual counselling/ CBT/assistance and voice monitoring. Advanced applications of technology are unlikely to serve those who need the most care now. Borrowing from Dr Tudor Hart,
While the pursuit of technological advancements is well intentioned, there is no substitute for empathy, compassion and warmth provided by people. Furthermore, these digitally dominant scenarios are costly to develop and expensive to use.
I suggest a parallel law: the Inverse Digital Access Law i.e. those most likely to benefit from technological advances are the least likely to be digitally literate and able to afford access thereby increasing health inequity. First on the CSIRO’s list of several enabling themes is, ‘empowering the consumer’
continued on Page 24
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FEATURE BACK TO CONTENTS
The Sporting Life – At Any Age When you’re the physio on the road with a squad of Over 75s at an international hockey tournament, you have to be prepared to keep up!
Grand Masters Medical Team (Adam Smith, far left)
D
unsborough physiotherapist Adam Smith was something of a hockey novice before he accompanied the Australian Men’s Grand Master’s hockey team at the recent world championships in Barcelona but he came away with new insight what a fitter older body could do. “It was a great trip and a wonderful opportunity to do something a little bit different so, when it was offered, I wasn’t going to say ‘no’,” said Adam. “They might be Over 75s but they’re young in heart and mind and it’s quite inspiring to see them playing so competitively at that age.” “They tweak the rules slightly to accommodate the age-group but it’s still compliant with the regulations set down by the World Hockey Board. The team ended up with the gold medal and when England is involved that’s always a nice feeling! The Dutch were there, too, and they’re always a strong side.” “I’ve only done one of these tours before and that was a national championships in Hobart for Country WA Hockey. I’m heavily involved in sports physio so these trips are great, and travelling to somewhere like Barcelona was a real bonus.”
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“But I’ve never played hockey in my life, so it was a steep learning curve!”
The Grand Master Hockey Squad
The Australian Men’s Grand Masters team has players ranging in age from mid-70s to men in their 80s.
that to some of my older patients who need to move a bit more than they do.”
“On tour we were exposed to a wide range of aches and pains that we might only see once or twice a week at my clinic in Dunsborough. So I can take that experience back into the practice and build it into our rehab programs. Although having said that, given the age of these older players and the amount of running they were doing I was expecting a lot more injuries than we actually had in Barcelona.”
Adam describes a typical match-day in Barcelona. “There’d be a team walk at 7am, a good chance to look at the stunning architecture and have a coffee or two. I’d do some pre-game strapping and rub-downs, watch how the game progressed from the bench, think about any rotations across the four quarters and manage any obvious aches and pains.”
“We had a few joint issues and the heat was a factor, predictably.”
One day Barcelona, the next Ballina on the far North Coast of NSW.
“We were lucky to have a week in Lyon so that was a good way to acclimatise and we had a few scratch matches in Geneva, too. It turned out to be a lot of fun and a vital part of the team’s success.”
“I’m off to Ballina in a month’s time with the WA Country Hockey Team for the national championships. We’ve got seven teams with three physiotherapists and they’ll select the next batch of physios to travel for upcoming international tours from there.”
“We also had access to a team doctor who was there with a younger group and it was nice to be able to speak with him when we needed that next level of advice.” “It’s just so impressive the way these guys maintain such an active lifestyle, it’s a good lesson for life, actually and I try to convey
“But the take-home message from Barcelona was that, when it comes staying being fit and active, age really isn’t a factor.”
By Peter McClelland
NOVEMBER 2018 | 11
FEATURE BACK TO CONTENTS
Aged Care and the GP’s role We asked some rural and city GPs for their highs and lows of caring for patients in aged care.
Dr Ian Taylor, Geraldton
of care. GPs at his practice look after 70% of patients at RACFs.
dealing with problems before they go pear shaped.”
“I love my work in Geraldton. We literally look after people from cradle to grave. I do obstetrics and palliative care, and everything in between. Basically, I’ve got the best job in the world.”
“The waiting lists in Geraldton have crashed as a result of the extensions at the three nursing homes.”
Third is a potential problem with sharing information, particularly software at nursing homes, and there is a push for aged care to have its own medical record.
A steadfast Dockers member, Ian started aged care with his general practice in 1984, some 43 years after Nazareth House was established. “They had large dormitories that weren’t heated or airconditioned but the nuns gave the best care they could.” Now, the three residential aged care facilities (RACFs) at Opal Nursing Home, Hillcrest Lodge and Nazareth House each boast a host of beds allocated to all sorts
Nazareth House
12 | NOVEMBER 2018
“When you go into one of these places it feels like you are on a cruise ship – they’re beautifully looked-after people and have activities – it is really good to see,” he said. He only has four misgivings about aged care. First is the long (up to 12 months) commonwealth waitlist for an upgrade of aged care packages while at home that some elderly find themselves on. “When they finally get it, they have to go and find a provider.” Fortunately, there are a few to choose from in Geraldton. Second, is the funding stress that RACFs find themselves under. This shows as poor staffing ratios sometimes, or poorly trained carers who “don’t recognise when there is a problem or don’t know how to deal with demented patients”. This is not a huge problem in Geraldton, because everyone knows each other and the three quality nursing homes are all aligned with his medical practice, Panaceum, which provides extra training and 24/7 cover from their team of 7-8 doctors. This happens thanks to discretionary on-call funds through WAPHA and Ian feels an on-call allowance is now a prerequisite to getting doctors interested in afterhours. “This is a great advantage for the hospital –
“The problem with that is if doctors rely on someone else’s medical record, then if something goes pear-shaped and that medical record is altered or damaged, then that doctor is liable.” Ian is leaning towards My Health Record. There are two main provisos: “If we have the safeguards and security measures in place.” “As long as the data is uploaded accurately and carefully. We do have visitors to Geraldton and a lot of our patients travel. It might be hard work initially but once things are in place it should be easy, very much like going from paper record to electronic years ago.” Back at the RACF, the way around this problem of medical records is to access those at the surgery by VPN login to their server, with a copy of particulars of their patient visit or test results printed out or sent electronically to the RACF. Scripts and medication charts have long been a thorn in the side of those GPs covering RACFs. “The last thing we want is to write up the medication charts by hand, like the scripts. That makes such a difference – if we had
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to write up medication charts by hand we would refuse to do it.” “We can print out medication charts that are legible and signed, using their accurate list of drugs and doses at the surgery. It also means we can look out for drug interactions and potential deprescribing. My doctors are pretty cluey on this, and because we rotate doctors between different areas of the nursing home, they don’t get stale. That’s made it a lot easier for us.” “You get the continuity of care and a new broom approach – that system works very well for our practice.” “As well, if someone from an ACF rings me at home I can look up their notes at the surgery, and often deal with it by phone.” The fourth problem is remuneration, and he mentions afterhours MBS items and restricting medication reviews to every two years. “We bulk bill all nursing home patients. You don’t do it for the money. The big issue is afterhours visits. It is woefully inadequate and there is no way any of my doctors would be on call unless you paid them for that. WAPHA pay discretionary funds to doctors to be on call and it has been incredibly successful. Nursing homes love it and we have trained them to assess a patient before ringing us.” The shoe is on the other foot as far as any rural-urban divide is concerned. “I’m probably painting a fairly rosy picture. We are just fortunate in Geraldton to have such good relationships with our nursing homes. I talk to my colleagues in Perth who say they can be poorly treated by nursing homes – almost like they are an inconvenience.” Dr Kevin Carthew, Port Kennedy Before launching into any problems with aged care, Kevin gets positively personal. “The majority of staff in nursing homes really love their ‘oldies’. If more GPs took time to get to know them, they would find the experience not only rewarding and fulfilling, but lots of fun. Many still have a great sense of humour and a look at their past can be mind-blowing. Olympic gymnasts, opera singers, parents or grandparents to wellknown modern performers... the list is endless.” “How we attract young graduates to aged care, however, remains a dilemma.” “The biggest problem with nursing homes is the cut in government funding. We’re losing about half the RNs we used to have.
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They are putting in care workers, not even ENs, who are dishing out medications. The good nurses that used to know the patients have gone and we are left with skeleton staff, and agency staff on at night, who disturb us more often because they don’t know what the elderly want. There is nothing wrong with their qualifications they just don’t know particular patients.” “The ABC program [Four Corners Who Cares?] said GPs were being pressured to give diagnoses of depression and dementia. It happens all the time. We are regularly asked can you please add depression or dementia because it’s good for their funding. You can’t blame them but it certainly happens.” He relies on others to notice any delays in receiving home care packages, but he has noticed one major change. “When people eventually come into the RACF they are in a bad way. It is not unusual for you to lose a patient within a couple of weeks – they just come in for palliative care. I’ve had one or two instances where I didn’t have a chance to see them before they passed away! It’s a very high turnover. A lot more people are coming in a lot sicker and further down the track than they were. It’s getting harder to look after them,” Kevin said. Aged 73 years (“I was going to retire but they asked me back”), Kevin has to keep up CPD and visits his 200-odd patients weekly at four different nursing homes. He has no accident insurance (this ran out at age 67), and following a major health scare a year ago his wife accompanies him to enter information in any of the RACF computer systems that have iCareHealth software, a Telstra Health product. He doesn’t get called out because if something can’t be sorted out over the phone (which is about 95% of the time), the patient goes to hospital. “I’m still available 24/7 and one of the few who is. But the whole atmosphere has changed.” “Then you get a letter from the DG of Health saying you are using more opioids than 98% of your colleagues. I’m not surprised! Nearly all are on opioids when they come in from a hospital.” He says about 60-70% of his patients in RACFs are on opioids. He works from home and he can login at any time, and during visits he can login to the RACF computers. Armed with his own printer, his script load is said to be second to Peel Health Campus, so computers? “I couldn’t do without them.”. “One of the biggest problems we have is families complaining about the size of the pharmacy bill. It can be very difficult. They most often ask if there is an alternative on the freelist – the answer is often ‘no’. The
mental health people are meant to tell them that.” He refers to Ativan which is only on the freelist for schizophrenia. “Hospitals put them on it but there is an out-of-pocket expense when they are back in the ACF. Neither are the aperients or simple painkillers such as Panadol on the freelist.” He remembers a CPD meeting he attended that suggested residents of ACFs should be on calcium and vitamin D tablets, which, as it turns out, are neither on the freelist and both are very big tablets that residents and staff dislike. The joys of prescribing. Medication charts are printed out in the RACFs and the scripts at home, and the pharmacy that looks after his four RACFs call to verify. “It has taken some time and organisation to get things flowing smoothly.” Dr Jonathan Ramachenderan, Albany “The next step up is having GPs able to work with people at home so they can live and die there rather than in an ACF” As a hospital anaesthetist who has experienced palliative care and is younger to boot, Jonathan has a different take on aged care. “Older people need to be a priority,” is his simple but profound statement. By this he means that (in Albany) those in a RACF may not receive the GP’s full attention at the end of a busy day, even compared to someone visited at home or seen in the rooms. “If you prioritise calls and visit weekly, staff communication improves and you become a familiar face to the carers, not necessarily the RNs.” The spin-off is less calls from the RACF staff, less transfers to hospital, and families are better informed. Jonathan was able to overcome the poor remuneration for aged care in RACFs by robbing Peter (his well-paid anaesthetics work) to pay Paul. For him, education and training were important for job satisfaction. “Carers and nurses are hungry for sharing of information about skin conditions etc, why you are stopping a medication, or starting another – they really enjoy knowing why we are doing something. I enjoy that too.” What is the bed state down his way? “I work at the Albany Hospital, and pretty much every week they are working under
continued on Page 15
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FEATURE continued from Page 13
Aged Care and the GP’s role a code yellow, which means beds are at ‘over capacity’. Many of these are elderly patients who can’t go home because of carer capacity. I don’t see it getting better even if we have more beds.” We suggested that perhaps younger doctors like himself needed to get interested and shake the cage. “This is what has to happen even though there are sceptics and a lot of pessimism. Hopefully, the government will introduce MBS items that prioritise aged care for VR GPs, such as time taken to do advanced care planning, not reducing the item rebate when you see more patients, and providing palliative care. Aged care can be seen as a viable option then.” “I have friends who run an aged care business in South Australia and have recently expanded into Victoria because of demand. It’s called GenWise and is an aged care GP provider.” “Social media has been good as well. Doctors in Aged Care has sprung out of GPs Downunder, with nearly 1000 doctors providing aged care across Australia and sharing their stories. There are a number of younger GPs who are quite keen on continuing. Even though the AMA is saying a lot of people are leaving, I do think there is an opportunity there.”
Maybe the answer is to do it smarter? And is this the time to broach Advance Health Directives? “It comes down to first things first. One thing I learnt from palliative care, is that in aged care, goals are palliative, they are no longer curative or restorative. Within that, a lot of life-sustaining treatment is inappropriate so it helps them make a good choice later if you can have conversations about advanced care planning early on. It requires special skill and having a palliative care perspective.” We talked about government recognising the growth in aged care, whether it was ethical or harder to charge the elderly a gap, and the value of what we do, without reaching any conclusions. As far as ACF staff are concerned he believed you have to get “the right person with the right training for the job, rather than just a job, because they are looking after your loved one.” The same probably goes for GPs. So what is his philosophy when approaching someone in need of aged care? “You have to have good communication with that person and their loved ones because they are often in the palliative
phase of their life. We want to provide quality of life and establishing what their end-of-life wishes are, taking care of their symptoms and keeping them safe. Valuing the person for who they are.” He sees GPs who visit ACFs as their advocates, which in turn raises the level of care. Mind you, he says we need staff who truly love the job and are not burnt out, who are not in a revolving door. He offered an anecdote around a talk he gave and said RACFs who really care for residents will experience them dying so they needed to debrief and be sad. He encouraged them to have ‘anchors’, that they can look forward to, such as holidays, because “working in aged care depletes you both emotionally and physically”. He says Consumer Directed Care (CDC) is working in Albany because of the smaller town reputation. “Providers, who have been here for a while, have built a name for themselves. Word of mouth is the strongest marketing tool. So people at home get really good service. The next step up is having GPs who are able to work with people at home so patients are able to live and die there rather than an ACF.”
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NOVEMBER 2018 | 15
FEATURE BACK TO CONTENTS
Thrombectomy, the New Stroke Frontier Tissue clocks, logistics, stroke units, ‘ambos’, doctor burnout and bed availability – are all in the mix when it comes to stroke management,
A
cute stroke management epitomises how technological advances drive the practice of medicine. The Stroke Foundation says brain cells die at a rate of 1.9m a minute with no blood supply, so being able to start work ‘in the field’ is a potential game changer (and a reason why Melbourne has a stroke ambulance).
According to neurologist Dr David Blacker, who heads the busiest Australian stroke management centre at Sir Charles Gairdner Hospital, the ‘villains’ in this story are a lack of resources, a lack of patient awareness, distance and time (but thanks to thrombectomy, time has become less formidable). In fact, the longer time window associated with thrombectomy puts it top of the ‘heroes’ list, along with the ‘ambos’ and the doctors who manage stroke cases in WA 24/7. This is very much a team effort aimed at keeping stroke patients well and out of hospital.
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“A lot of this has been driven by clinical trials over the past couple of years that have shown that thrombectomy is definitely better than thrombolysis or conservative management. Two trials have looked at pushing out the intervention window from six to 24 hours and have shown that in carefully selected patients you might still have benefit in the much longer window than was previously understood,” David said. You still need quality imaging close to the patient and some way of delivering images to the neuroradiologist. “A fine-cut, good quality CT scan done in a country site can often enable us to make a decision about putting the patient into a plane to Perth. You can see if a clot needs removing from brain parenchyma. If there is profound ischaemia, or the brain is permanently damaged then unblocking the artery will provide little benefit.” So brain imaging is looking for large, artery clots, acute brain injury, non-salvageable infarcted brain, acute haemorrhage (a contraindication), and stroke mimics. The elderly person who doesn’t want to bother anyone and goes back to sleep despite the symptoms of stroke may be putting themselves outside the extended window. David gave an example of how things might work rurally.
Timely intervention “We had a call from a nursing post in Paraburdoo – a mine worker had had a big stroke in the morning and a very competent nurse was able to give an assessment via links to WACHS and relay the important information to me at SCGH. “The RFDS chopper transported the patient from Paraburdoo to Hedland and while in flight, I contacted the receiving staff at Port Hedland to tell them what was needed for the use of tenecteplase [off label use, another plasminogen activator inhibitor as used in thrombolysis]. “Within 15 minutes of arriving at Port Hedland, I was able to look at the images they took and give the instructions from Charlies.” The key technology necessary are the scanner and transmitter, not to mention the RFDS plane ready to transport the patient to Charlies for thrombectomy. “But about 10-20% recanalise with the tenecteplase and when he arrived in Perth about 4-5 hours later he was pretty unscathed!” He gives the ambulance paramedics a bouquet: “The ambos bring the relative along, which is what we need for consent.” David raised this scenario because the group he is on (the Stroke Care Advisory
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Group) has been advising all major players for years – WACHS, the Health Department, the teaching hospitals, St John Ambulance and RFDS – and, as he said, “the extended time window has opened the door for all of WA to be potentially available if everything lines up”. Rural sites also have some knowledge of tenecteplase, which is produced from tissue Plasminogen Activator (tPA) by recombinant biotechnology. It is given as a single bolus (or push) for acute myocardial infarction, with recanalisation rates about double (22%) that of another tPA, also given for thrombolysis. “We are not advocating that rural physicians do this unsupervised in unselected cases. These are the cases where we are going to bring them to FSH or Charlies; where we we have seen the scans and worked out the risks and benefits. The stroke neurologist is accepting responsibility for this.” “We have moved on from Stroke Units to Systems of Care. In the future, it may be possible to administer neuroprotective substances in the field en route, buying more time for the thrombectomy procedure to be performed. In WA we have long distances to travel, which provides a challenge, but also an opportunity to study this approach.” He sees similarities with the Canadian stroke service, particularly the Calgary service which is at the forefront in the world. David sings the praises of Dr Bruno Meloni and Dr Neville Knuckey and their stroke research group at the Perron Institute where he is Medical Director; their arginine rich peptide neuroprotective drug is highly promising and the most likely candidate as the first proven neuroprotective agent in humans. Neuroradiologist still the critical first step The system still needs a good neuroradiologist to read the initial films and someone on hand to do the thrombectomy. These are part of a cascade of decision makers in the Neurological Intervention & Imaging Service of WA (NIISWA), comprising four interventional neuroradiologists, support staff and a “particularly slick” anaesthetic service at Charlies. “It has to be a well-oiled service because we are getting five or six stroke calls a day. We assess the inevitable false alarms such as haemorrhagic strokes and seizures, and we are getting an explosion of demand so we have to find funding for extra staff to cover the work load.” Currently they intervene on about 3050% of cases (up from 5-10% about 5-10 years ago) partly because there has been extensive training in the field for ambulance paramedics in the past 2-5 years. “You don’t want to be activating the plane or dealing with a mimic of a stroke or a little stroke. Instead, a RACE (Rapid
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FACTS & FIGURES In 2017 the Stroke Audit, across 127 hospitals said regional Australians are 19% more likely to suffer a stroke than their city counterparts and the Stroke Foundation said the report showed a rural-metropolitan divide. • About 82% of over 3000 audited strokes were ‘ischaemic’. About 12% of strokes were classed as ‘haemorrhagic’ for which thrombolysis or thrombectomy were contraindicated. About 6% of strokes remain undetermined. • Clot retrieval. Research has shown benefits of clot removal (endovascular thrombectomy) in carefully selected patients up to 24 hours after the onset of stroke symptoms. Reducing benefits over time means that treatment still needs to be as fast as possible. • Thrombolysis. In WA, about 36% of patients reach hospital in the 4.5-hour window for thrombolysis though availability of thrombolysis in WA is just 31%. Thrombolysis is delivered in 13% (2017) of cases. The earlier the treatment is delivered the better the outcome for the patient. Thrombolysis given in hospital within 60 minutes is 30% of suitable cases in WA (compared with 62% UK and 59% USA). • The aftermath. In 2015, a national audit of stroke units showed that 35% of patients did not receive a discharge care plan, 41% did not receive a rehabilitation assessment and 30% did not receive risk factor education. This is despite 77% of metro patients receiving Stroke Unit Care. • About 80% of patients are independent prior to admission. Arterial Occlusion Evaluation) score is used to pick the high likelihood of a larger arterial occlusion that will respond to thrombectomy.”
overseas. Thrombectomy is the most potent treatment in terms of effect in all of medicine – it has a NNT [Number Needed to Treat to see benefit] of 2.4.”
“We are moving towards a tissue clock – what we see on the CT – up to the 24 hours window of opportunity.”
As if to emphasise, David has a good story from Midland hospital.
“Mind you, you can have someone with a big fat clot, lousy circle of Willis and a bad metabolic state that if you unblock the artery at 20 minutes it doesn’t matter much because the brain is already irreversibly damaged.” “At the other end of the spectrum you might have someone who has developed good collaterals, and has a good circle of Willis – perhaps someone who will benefit from clot retraction 16, 18 or 24 hours down the line. Rather than be limited by time we are trying to intervene at the longer time interval where patients might benefit.” Different blood biomarkers have come and gone, particularly working out if it is a haemorrhagic or thrombotic stroke but imaging remains the key. Logistics are important “The Calgary stroke service is central in a circular shaped metropolitan area, whereas we have 150km of urban sprawl along the coastline with two services at FSH and Charlies.” The FSH service only works in-hours. So Charlies gets the whole state after hours. They try to discharge patients to FSH the morning after any procedure to relieve bed pressure. Joondalup is investing in some services, with a similar ‘decanting’ of patients back to Joondalup from Charlies. David is not fazed by the expense of flying someone to the Perth service. “It is also expensive having someone sitting in a hospital bed waiting for three months for a nursing home bed. There has been a cost benefit analysis done already in Australia and
“Dr Tim Bates recently saw a woman in her 30s, 7/52 pregnant, with a metallic heart valve, and probably subtherapeutic Clexane. She had a stroke mid-morning, the husband whizzes her in his car to hospital and Tim travels with her in the ambulance to ‘Charlies’ and within 41 minutes she’s in hospital with a catheter in her arm extracting the clot from her brain. (It is relatively contraindicated giving thrombolysis in a woman who is pregnant.)” Burnout of stroke staff David came back from his stroke fellowship in the US in 2003 when thrombolysis was just starting but since then, it has gone the way anticipated. He describes it as “hard work, pretty intensive”. Put yourself in the shoes of someone doing the clot retraction. They access the femoral or radial artery, feed a fine bore catheter into the neck past elongated or angulated arteries, then pass a smaller catheter inside it into the cerebral circulation. Using a stent retreiver they grab the soft friable material that is the clot and, using a suction technique, draw it out. David said the people who do this “are world class”. He adds more staff is needed. “Our juniors are getting frazzled and burnt out. It is not uncommon to get multiple stroke calls within a shift, or 2-3 simultaneous calls in the night. And it is not unusual to see consultants coming in at night to help out. We are putting in business cases and other arguments to try and get a stroke registrar based in the hospital as well as a neurology registrar. We are after a good
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Midland Scores Some Goals The recent inaugural Health Symposium held at St John of God Midland Public and Private Hospitals showed some of the depth of its emerging research talent. The two-day event was held for hospital staff, medical consultants and local general practitioners to showcase clinical research being conducted and included 40 research posters submitted by staff. Staff awards were also announced, which recognised clinical excellence across the hospital. Winners were: • Clinical Teaching Appreciation Award: Dr Simone Bartlett, Consultant Emergency Medicine • Outstanding Nurse of the Year: Simone Uetake, Clinical Nurse Stroke Unit • Patient Journey Award: Kylie Cooper, Senior Social Worker • Allied Health Impact Award: Joanna Scheepers, Specialist Podiatrist • 2018 Valedictorian and Consultant Emeritus: Dr Glen Brand, Physician Consultant in General Medicine and Gastroenterology. A charity golf day was held in conjunction with the Symposium with 64 enthusiastic golfers raising $10,000 for Dreambuilders Care to support the hospital’s Christmas hamper program for the local community. Poster winners were: • First prize: Dr N E Velzeboer, Dr D Chan and Dr E Tiong, Anaesthetic Department – “Anaesthetic Management of Special
Poster winners (top): Emily Bennet, Joanna Scheepers, Dr David Manners, Dr David Prentice, Dr Ross ScottWeekly and Dr James Richardson. (Bottom left): Joanna Scheepers, SJG Midland CEO Michael Hogan, Kylie Cooper and Simone Eutake. (Right): Michael Hogan with 2018 Valedictorian Dr Glen Brand and Dr Mike Babon Needs Dental Patients”. • Second prize: Dr David Manners, Respiratory and General Physician; Mr Simon Jones, Respiratory Clinical Nurse Specialist; Dr Taha Huseini, Respiratory Registrar, Ms Erin Cecins, Respiratory Specialist Physiotherapist; and Dr Francesco Piccolo, Head of Service Respiratory and Sleep Medicine - “The Midland NIV Score”. Four teams tied for third prize: • Dr Lay Kun Kho, Consultant Neurology, Dr Tim Bates, Consultant General Medicine, Dr David Prentice, Consultant General Medicine, Andrew Thompson and Ferry Dharsono, (NIISwa, Royal
Perth Hospital) – “Cerebral Embolism and Flipping the Carotid Syndrome”. • Emily Bennett, Senior Dietitian, Dr Michelle Ross-King, ICU Head of Service, Vince Mazoue, Nurse Unit Manager, and Karen Crowther (HPS Pharmacies) - “Review of TPN Service Delivery”. • Joanna Scheepers, Specialist Podiatrist – “High Risk Foot Screening and the Braden Score”. • Dr Kevin Chan, Consultant Anaesthetist, and Dr James Richardson, Trainee Anaesthetist - “Anaesthesia For Caesarean Sections”.
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Thrombectomy, the New Stroke Frontier solid medical registrar who is interested in the neurosciences.”
An Advance Health Directive may need to be taken into account too.
“One thing we struggle with is that stroke was pretty interesting and sexy when all this started, but now it is becoming hard work and a lot of trainees are getting interested in less time-critical sub-specialty areas.
“It has to be discussed. One of the problems is we can intervene so tremendously with stroke. People may set up their AHD believing all strokes end in a bad outcome. I do urge the junior staff to take some time, speak with the relatives, see what everyone wants – maybe a non-interventional approach is appropriate.”
“The toughest thing is knowing when to stop.” David is talking about older people with comorbidities: "They might be able to remove the clot but if the patient has to go to intensive care for blood pressure monitoring or suchlike, they might have lost the race. “The ethics of pushing people with advanced aged and multiple co-morbidities is hard”, he said.
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On top of all this is modifiable risk factors such as AF, thromboembolic disease, alcohol and tobacco intake, hypertension etc. Either way, time is not on their side. Admission to clinical trials
said the big issue at present in WA was the lack of legislative guidelines to cover enrolment of subjects into clinical trials using proxy consent. “There is currently legislation before parliament to try and sort that out. As it stands at present, even if a surrogate can give consent to undergo a procedure, there is no structure for them to give consent to undergo a clinical trial.” “If there’s a patient with a dysphasic stroke that you want to put into an international trial of a neuroprotective agent, we don’t have anyone authorised to give legal consent.” Dr Gary Geelhoed is leading the charge through the translational research network.
Research is a drawcard to specialists. David
NOVEMBER 2018 | 19
FEATURE
People living with dementia in the community are often socially isolated, exacerbating their condition. It’s time to share something important with them – time.
Community Vision CEO Michelle Jenkins with Vince Gareffa from Mondo Butchers at the launch of A Roast to Remember.
A
few weeks back, notfor-profit Community Vision launched a campaign to raise awareness of dementia and the risks of social isolation that this can bring. A Roast to Remember is raising funds to put a bus into the community to reach people who need more information but don't know where to turn to for help. Community Vision CEO Michelle Jenkins said A Roast to Remember aimed to bring a sense of community back into communities. “It gives friends, family and neighbours a chance to talk about ageing and dementia while creating social connections over a good meal. People might even want to hold a street party and the ‘roast’ doesn’t have to be just a good old Roast Beef with Yorkshires, it can be a special meal from any cultural background,” she said. “We’re trying to keep this really simple because it’s about connecting people in the community.” Michelle also hopes that the message gets through that if people see an older person struggling to cope with life and exhibits signs of early onset, or dementia, itself,
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there are people in the community who can help them. “Organisations like Community Vision are here for a reason. We exist to help people and their families cope with the challenges of dementia,” Michelle said. Community Vision has been delivering services to the elderly, especially those with dementia and disability, for the past 16 years. Michelle said the organisation ran programs at the Woodvale Community Centre especially for those people with dementia living in their own homes. It not only gave clients stimulating activities, it also provided some respite for their carers. Aged care tricky for all The transitioning aged care landscape – from HACC services to Commonwealth Home Support and Home Care Packages – was challenging for all involved, she said. For service providers it was balancing the budget around services they can provide, given the new funding arrangements that have moved from block funding to an individual basis. “While the system is transitioning, there is a disconnect between the amount of funding available for services to the elderly both in
the community and in residential facilities and the wages bill. There is no direct correlation between the two,” she said. “If you are looking at award rates and the equal remuneration order that overlays that, the costs of providing services are going up, not down, yet there is only a flat fee which doesn’t recognise when that service is being delivered, whether it be during the day or at night. It’s hard to balance that budget in those circumstances.” “We are now reliant on individual funding per person, so it makes it harder for organisations to deal with people on a one-on-one basis, which means you have to look at providing some group services in order to balance that budget.” The worry, says Michelle, is that as blockfunded projects are phased out, some providers may decide it is not cost effective to deliver certain programs and ultimately consumers will lose out. “Overall, it will probably pan out OK, we are in transition, but we are perhaps 10-20 years away from seeing the norm and everyone has to adjust to that.” Those working in the aged care space, doctors included, find the navigating of this new landscape, complex, complicated and time consuming. If you are an old person, add frightening as well.
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Reconnecting with the Elderly
FEATURE BACK TO CONTENTS
Michelle urges all parties to reach out to service providers early because it is their job to know what the changes are and their implications. Early intervention pays “It’s awkward for doctors and nurses to get their heads around this with everything else they have to do. If older people can be encouraged to access services earlier, there is a lot more that can be done for them in their community and in their own homes,” she said. “There is a reluctance on the part of older people to ask for help early on. If they did, I am sure they would benefit. Tackling dementia and social isolation is a good start. The elderly and migrant populations who are bewildered by the system need support.” “Traditionally they would turn to their GP for help, but if the GP doesn’t know, where do they go? They could end up at Centrelink and they probably don’t know either. We certainly see this with people coming off HACC and onto aged care packages.” “With HACC, an elderly person may have had to contribute maybe $8 to their services and now being asked to give up 17.5% of their pension as well as being means tested to see what additional contributions they can make.” “They get frightened that they can’t afford to pay out all this money.” Michelle said the current generation, who have had 20 years of some compulsory superannuation investment, will not be in such an invidious position, but that’s not the case for those people now in their 80s and 90s. “They might be sitting in a home in which they have a lot of equity but they don’t have much income. In order to access the services they need to stay in that home, they may need to leverage their assets in order to generate income, which in turn will be means tested. If they are not prepared to disclose their financial information, potentially they will be asked to pay the highest level of means-tested contributions.”
to determine the level of care required and where that care will be delivered. The consumer signs off on who will deliver those services. The latter is assessed by a regional assessment team who will refer the person directly to a service provider. Michelle said service providers had to be on top of the nuances of the system and from their perch they can see where things are working and where they are not. “CHSP is very quick. A GP can ring or go online to the My Aged Care team and put in a referral and it will be processed through the database and comes to a service provider generally in about two weeks, sometimes quicker,” Michelle said. “We have had situations where the regional assessment person has been finishing off in the home and we have been there to put services on. These people may very well need long-term help but they need urgent support now and that can start almost straight away.” Controversial delays are being experienced around the allocation of the longer-term aged care packages, and Michelle says the delay varies, depending on where the individuals live. “Regional and remote areas wait longer than in metro but the time frames are blowing out there now as well. It can be a couple of months before someone can get an indication of their eligibility,” she said. Service bottlenecks “Even once they have been given the go ahead, they then have to wait until a package becomes available and that’s where the real delays are taking place because that can be anything up to 12 months in the higher levels.”
Medical Forum has heard that some people on Level 4 packages are waiting up to 18 months. The consumer directed care model is also creating some bottlenecks. “When someone has been given a referral they have a range of options. They might know who they want to deliver their services and that referral goes straight to that service provider. Or they may not know, so the referral is broadcast to all providers and one will pick it up, usually in that person’s area. Or it can be the consumer who says, 'we will seek out someone ourselves’ and shop around.” “They have a period of time before they have to act on the referral so it’s tentatively allocated at that point, but that impacts on the person behind in the queue who may need that referral more urgently. It has to create a bottleneck. The Minister for the Aged Ken Wyatt has recently announced the release of a new tranche of packages and it may be starting to be felt on the ground. Michelle told us that recently Community Vision has seen more higher Level 3 referrals starting to come through. Michelle urges doctors to give her and other service providers a call with their concerns. “If a GP has a patient who needs additional services, call and we can help that person to do a self-referral by liaising with the doctor. We are here to help people access services and the more we can work collaboratively to help people achieve this, the better.”
By Jan Hallam
Michelle says the medical profession also needs support to understand the aged care system. Cracking My Aged Care “Navigating through the My Aged Care website, getting someone to make a call or two and to get online and fill in all the paperwork, it takes time and there is a cost attached to that for the GPs.” In a nutshell, My Aged Care is a triage service, determining eligibility and suitability for either home care packages (HCP) for the long-term, or Commonwealth Home Support (CHSP) if only needed in the short term. The former requires an ACAT assessment
MEDICAL FORUM
How a bus will help to improve the quality of life for those with dementia.
NOVEMBER 2018 | 21
GUEST COLUMN
The community must play their part in surveillance and eradication of elder abuse, says Advocare's Diedre Timms. We have recently seen on our television screens incidences of shocking elder abuse in some residential facilities in Australia (ABC 4 Corners, September 2018). But what now? Who will champion quality care for some of our most vulnerable citizens? The federal government has called a royal commission and there has been a state government select committee report on elder abuse but we all need to support older people now, not wait for the outcomes of commissions and reports. As CEO of Advocare my job is to lead an organisation protecting the rights of older people in WA. We staff the WA Elder Abuse Helpline, we advocate for those needing our support in the home care and residential aged care systems, we educate the community on the complex aged care system and we support those trying to access that system. We hear more about elder abuse than most and please don’t think it only happens in residential facilities, it happens behind closed doors in family homes and often by family members. Abuse can take many forms, including financial or material abuse, intentional or unintentional neglect, emotional or psychological abuse, social isolation,
physical abuse, or sexual abuse. Often different types of abuse may be happening at the same time. For example, an older person might be deliberately socially isolated from others so that other types of abuse are not discovered. Elder abuse may sometimes be seen as a form of family and domestic violence, where someone in a relationship with the older person harms them or makes them feel unsafe. Family and domestic violence involves a pattern of abusive behaviour that aims to frighten or control the person, and this may take different forms in different relationships. The World Health Organization estimates that 15.7% of people 60 years and older in the community may have experienced abuse.
This means that potentially over 75,000 older West Australians are affected and this number may be a lot higher for people in ‘at-risk’ categories, including older people with physical or mental incapacity and people living in institutional settings. Figures of reported elder abuse are likely to underestimate prevalence due to the fact that only a small fraction of cases are reported.
Every week our advocates work with people who are experiencing elder abuse. Clients contact us on the Elder Abuse Helpline or via our standard advice line. We listen to their needs and concerns, assist in exploring the options, provide comprehensive resources and information and refer to other support services when needed. We support clients through conversations or actions they choose to take. At Advocare we can take up to 90 calls a month on our elder abuse helpline and many more on our general number, and due to the underreporting and shame associated with elder abuse we are only seeing the tip of the iceberg. Please don’t ‘walk past’ if you think someone may be experiencing elder abuse, no matter what form it takes. We have developed some protocols to help staff and professionals working with older people to identify and respond to elder abuse. If you suspect abuse, ask questions about that person’s situation and if you think the older person is in a danger, call the police (000). The police have staff trained within their family violence unit to respond to support older people. If the person is not in immediate danger refer them to the WA Elder Abuse Helpline 1300 724 679 and validate their feelings. ED: Diedre Timms is the CEO of Advocare.
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Elder Abuse is Everyone’s Business
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Not Just the What but the How Lyn Martin was her husband’s full-time carer until he moved into residential aged care. She is concerned about the lack of GP services to the sector. “It’s time consuming and patients don’t get better”, the GP said.
Outside of normal working hours, locums were used and this provided further opportunities for miscommunication and advice unsuited to the patient’s history.
“They’re reasons but not excuses! These are our senior citizens. They’ve a right to the same GP services as everyone else!”
Eventually, we had a critical incident. My husband’s INR soared and he suffered internal bleeding. The nursing home dealt effectively with the situation. So he’s OK: But what about other residents in facilities across Western Australia? Are their GP services suited to need and demand?
This is a snapshot of a conversation I had with a doctor over the availability of GP services in aged care facilities. Since my husband’s admission to a nursing home, I’ve become increasingly worried about continuity in his medical care. Use of locums has resulted in seemingly unnecessary hospital visits. “We don’t know why he’s here,” the Emergency Department staff said, when I rang to enquire. So they sent him home. Yet nursing homes have a duty of care and they must comply with the advice of locums making quick decisions often based on limited knowledge of patients. We chose to transfer to the GP practice providing a service to my husband’s nursing home. His former GP couldn’t be expected to attend home visits in a different suburb. We were hoping for continuity of care if we fitted in with their systems. The new GP service had an innovative structure that covered a number of facilities using nurse practitioners to coordinate services and needs. It sounded good. In reality, things didn’t play out so well, but this
may have more to do with how things were managed than with the innovative structure. In brief, it’s not just what you do, but the way that you do it. In our case, the transition processes mandated one month before a formal family conference. There was room for error in this and it’s when the first unnecessary hospital visit occurred.
The chain of communication from patients, to the enrolled nurses (employed by the nursing home) to the nurse practitioner (employed by the GP service) and from them to the GPs meant that much was lost in translation.
During subsequent enquiries we were told that it’s extremely difficult to secure GP services in nursing homes and that aged care organisations can’t influence the quality or style of service because they are not in a contractual relationship with GPs. They can only avoid using a particular service: Hard to do in a situation of limited supply. There is a huge and growing need for more and better GP services in aged care residences. There is also potential for innovative organisational structures possibly deploying locums and nurse practitioners. These could be stand-alone practices or attached to aged care organisations, geriatric specialist services or local GP medical centres.
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INCISIONS continued from Page 4
Consumers Will Shape Future Care as they are an underutilised resource. However, there is no mention of an acclaimed example of the health outcomes that can be achieved when the ‘consumer’ becomes the owner and manager of their own healthcare service. The South Central Foundation in Alaska has for years drawn the attention of global health leaders for its achievements such as a 36% reduction in hospital days, a 42% reduction in urgent and emergency care services, and a 58% reduction in visits to specialist clinics. The foundation established the ‘Nuka System of Care’ where people using the system are ‘customer-owners’ and the whole system is based on what customerowners want – trusting, accountable and long-term relationships that provide a better understanding of the context in which a customer lives. These relationships are the basis for the culture of trust that encourages the foundation’s shared decision-making, a critical component of consumer empowerment. The WA Primary Health Association seeks to empower consumers through the
promotion of a patient-centered medical home model. An essential component of the model is providing the right care at the right time driven by the patient’s preferences.
and implementing changes will make all the difference in what healthcare will look like in the future. Thus, It is a pertinent question to also ask ourselves, “What matters to you about the future of health?”
At a recent event convened by WAPHA entitled Working with Primary Care to Manage Demand, reference was made to the 10 Building Blocks of High-Performing Primary Care which was developed by Prof Thomas Bodenheimer, Amireh Ghorob Tolhurst and others at the University of California.
References available on request. The author wishes to acknowledge the suggestions provided by Amireh Ghorob Tolhurst. ED: A/Prof Bret Hart is a public health physician and an adjunct clinical associate professor at the Curtin Medical School.
Amireh has recently settled in Perth and brings from San Francisco a wealth of experience in training healthcare providers to engage with patients collaboratively so they ask "What matters to you?" and not "What's the matter WITH you?"
THE INVERSE CARE LAW
In Australia, the 10 Building Blocks model is guiding transformation efforts at WAPHA, the Agency for Clinical Innovation, and Coordinare South Eastern NSW Primary Health Network. While there is uncertainty as to precisely how the business of illness will change, the impact on providers is certain. Empowering providers to share in shaping
The availability of good medical care tends to vary inversely with its need within the population it serves. This inverse care law operates more completely where medical care is most exposed to market forces. The market distribution of medical care is considered an outdated social form, which would further exaggerate the maldistribution of medical resources.
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Is Pastoral Care Still Relevant? This weighty question is explored by aged care chaplain Rev Jeni Goring, who says supporting aged people is much more than religious dogma. There’s a perception among some that religion is becoming less important in today’s society; that we are living in a secular world where religion and its ideals have been rejected. For us working in aged care, this societal change might make us question whether pastoral care is still relevant to the people we support through their ageing journey. We think it is. While trust in religious organisations is declining and increasing numbers of people report as having ‘no religion’ is increasing, religion is still prevalent in Australia. Around half (52%) of Australians are Christian and this increases to 70% among the over 65s. Plus, Hinduism, Sikhism, Islam, and Buddhism are increasingly common. This means we still have a responsibility to meet the religious and spiritual needs of our residents and clients. What’s more, spirituality is more than religion. Spirituality is the way we seek
and express meaning and purpose. It’s the way we experience our connection to the moment, self, others, our world and the significant or sacred. And aged care is more than looking after a person’s physical health. It’s also about nurturing emotional wellbeing, making sure we nourish both body and soul. It can be particularly helpful during difficult times such as illness and trauma, where chaplains or pastoral carers provide a shoulder to cry on or simply a stress-relief valve. Family and friends are a vital emotional resource, but sometimes it can be more helpful to talk to a third party uninvolved in a situation.
What’s more, as we age, many of us start thinking about the meaning of life and preparing for death. This may include reviewing our life, repairing relationships, giving and seeking forgiveness, discovering peace and hope.
We are conducting 10-minute online surveys with GPs across Western Australia to explore any kind of care they provide to their patients in the last 12 months of life.
All participants receive $65 reimbursement for taking part in this project.
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These are weighty issues which a chaplain or pastoral carer can help people to explore, regardless of whether an individual practises a particular religion. For those aged care residents without any family, chaplains and pastoral carers can provide much-needed friendship. This is vital as loneliness and a lack of meaning or purpose can lead to depression or anxiety. They can also play an advocacy role, encouraging residents to speak up, or raise residents’ concerns themselves if the resident is uncomfortable or unable to advocate for themselves. They are also there for the person at the end of life. As long as people have spiritual and emotional needs, pastoral care will continue to provide much-needed spiritual and emotional support particularly as people age. So is pastoral care still relevant? Absolutely. ED Rev Jeni Goring is the Acting Senior Chaplain at Amana Living
Do you or your practice provide any kind of care for patients in their last 12 months of life? If you are interested in finding out more about this study or being sent the online survey link, please contact me at:
angus.cook@uwa.edu.au or phone (08) 6488 7805 Professor Angus Cook The University of Western Australia
NOVEMBER 2018 | 25
MEDICOLEGAL
By Enore Panetta, Panetta McGrath Lawyers The NSW Court of Appeal recently overturned the decision of a judge who found that a doctor was negligent for failing to prescribe gentamicin as part of an antibiotic regime for a child with a fractured thumb. The child’s thumb developed gangrene and was later amputated, after which his father brought a negligence claim against the relevant health district over the treatment. At first instance, the judge stated that the health district’s peer opinions, that the antibiotic regime was competent professional practice because it was in line with Therapeutic Guidelines – Antibiotic 14th edition, were “without soundly basedsupporting reasoning” and irrational.
Whilst the rise of CPGs has largely been reflective of the increased emphasis on evidence-based practice, not all CPGs are created equal or even intended to be equal with other CPGs. For example, hospital or regional specific protocols and guidelines might be reflective of local factors, such as the availability of resources or the training or skills of the practitioners involved.
legal and ethical) to use good professional judgment – this requires a practitioner to be aware of any authoritative CPGs which may apply to their clinical decision-making, but also to be prepared to depart from the guidelines when it is in the best interest of the patient.
Some CPGs are drafted as "minimum standards" (e.g. using terms like "must" and "shall"), some raise discretionary matters for consideration (e.g. "may" or "should consider"), whilst many are drafted with both concepts. CPGs only reflect a mere fraction of medical knowledge and slavish compliance with CPGs devalues the clinical experience, and the decision-making autonomy of both
The Court of Appeal however found on appeal that, taking into account the guidelines, the antibiotic regime prescribed by the health district was widely accepted practice in Australia and overturned the initial decision. This decision illustrates how clinical practice guidelines (CPGs) can potentially act as both sword and shield for practitioners in medical negligence claims. A practitioner may be inculpated by a failure to comply with a relevant CPG, or exculpated by demonstrating compliance with the CPG. The appeal of CPGs to lawyers is clear. CPGs can represent an authoritative, accessible and evidence-based medical opinion which enjoys wide support from a practitioner’s peers. Depending on which side of the fence a lawyer sits, a CPG may demonstrate the extent to which a practitioner’s care has fallen below an accepted standard or it can stand as a ready reckoner to demonstrate the propriety of clinical decision-making. However, that is not to say that CPGs should be slavishly applied by medical practitioners or replace expert opinion evidence. In many instances, a CPG will not necessarily cater for all the specific prevailing factors relevant to the practitioner’s clinical decision-making. Then there is the fact that not all CPGs have the same level of evidential integrity. Some are very authoritative and comprehensively endorsed by leading professional bodies – others have a far more limited value – sometimes even questionable value. A CPG is only ever as good as the evidence-base that underpins it.
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patients and practitioners. Nevertheless, particularly when departing from authoritative CPGs, medical practitioners should be careful to record their reasons. Courts have always determined the standard of care required by practitioners, notwithstanding the testimony of expert witnesses. As such, there is little risk of CPGs becoming the sole determinant of the standard of care in medical negligence matters. A CPG is in reality no more than another form of expert opinion, albeit one which typically represents a collective expert opinion. The lesson to take away is that a practitioner always has an obligation (both
ED. The Institute of Medicine (IOM) defines CPGs as "statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options". By definition, following a guideline is never mandatory. Guidelines are not binding and are not enforcable. Recent arguments against hypertension and PSA guidelines, show there are differences of opinion within the profession. There is even a suggestion of professional bias amongst some groups of doctors through not giving enough consideration to related health issues. How much authority professional bodies have when they argue the point depends on their standing in the profession.
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Clinical practice guidelines – the new expert witness?
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Senior Doctors – Step-Down?
A
Are senior doctors getting a raw deal because of the few? Medical Forum spoke with ASADA CEO Stephen Milgate.
ustralian Senior Active Doctors Association (www. asada.net.au) has a pool of about 30,000 doctors nationally – those aged 55 and over who want to maintain and use their doctoring skills. But many senior doctors want to step down from clinical work and restrict their interests. This raises many unanswered questions and puts AHPRA squarely in the spotlight.
“A doctor never retires in the same way as a bank employee does. Doctors will act at any age to help a person in need, medically. The idea that a doctor can be a ‘retired doctor’ in the sense that they never use their medical knowledge again is absurd. The only retired doctors are deceased doctors.”
Is it important to make it easy for retiring doctors to contribute something, if there is a need? Should someone with years of professional experience and knowledge be allowed to comment on any health matters? Why does the RACGP support only broad generalists when some senior GPs want to restrict how they work, mainly so they can stay safe and current? Does CPD maintain a doctor’s skills or is revalidation required?
The problem appears to be that the current system of registration does not reflect modern career practices where someone steps down gradually from professional life. For example, doctors attend to family members throughout their working life and some would like to afterwards. Afterall, they say, there is no evidence that senior doctors are more of a health hazard.
AHPRA wants doctors either registered as non-practising doctors (still accountable to AHPRA for a much smaller fee) or to give up their profession (but keep their title). Those who remain registered as nonpractising are ‘parked’ ready to resume (with appropriate CPD) but will maintain recency of practice. ASADA says it is unnatural that AHPRA through its definition of practising forbids doctors from any action on health if nonpractising and senior doctors are being unfairly targeted. “Senior doctors, like many other groups in society, are unsupported despite their valuable contribution to the health and welfare of all Australians. They continue to be a valuable source of knowledge and experience acquired during long careers.”
As ASADA pointed out “professional knowledge” does not disappear with calling it a day.
“The Australian Doctors Federation (ADF) and ASADA’s step down category of registration for senior doctors acknowledges these realities. Having the ability and pathway to step down in registration category to less onerous regulatory requirements and lower registration cost, encourages doctors to consider how they will complete their medical careers.” Both organisations believe that senior doctors should maintain clinical privileges of referral and test ordering and limited prescribing under certain conditions. “At present, doctors in the ‘non-practising’ category can exercise no clinical privileges (prescribing, ordering tests, or referring). They have ceased to exist as doctors, regardless of their functionality,” he said.
practising registration must not provide medical treatment or opinion…They are not able to prescribe or to formally refer to other health practitioners. People with this type of registration remain subject to the Medical Board’s jurisdiction in relation to their professional conduct.” Stephen comments: “The definition of practice means that any doctor imparting knowledge is ‘practising the profession’. So any conversation involving a doctor’s knowledge could be classified as practising the profession. If a senior doctor without registration or with non-practising registration even mentions anything about medicine to anyone, they could be accused of practising the profession and be disciplined. This is clearly stupid. But AHPRA in its wisdom pretends it is OK.” This all-or-none policy seems contrary to the policies oif both major political parties whereby senior Australians are encouraged to continue to contribute to the community. According to ASADA, MDOs may have a conflict of interest. They want senior doctors to quit as it takes away any late liability issues that might flow from matters taken on by plaintive lawyers who know the doctor is still insured. And doctors who have completely ‘dropped out’ of practice enter the ROCS (Run Off Cover Scheme) paid for by the tax payer not the defending MDO. ASADA says, this is why MDOs have not supported senior doctors as they should or advocated for step down registration because it’s not in their commercial interests to.
By Dr Rob McEvoy
According to AHPRA, “anyone with non-
Dr Stephen Chan retired from operative plastic surgery about 2016. He maintained his registration with the RACS in consultation-only so that his previous patients had access to their information and his advice. He also maintained his privileges as a professional assistant so that his younger colleagues could be mentored in the operating theatre. This gave him a gentle step down from full operative practice. It was particularly suitable for him as the CPD requirement was much less onerous than being in full practice. The medical insurance premiums were $1600 a year compared to $40,000 for an operating plastic surgeon.
Dr Stephen Chan (retired)
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Stephen is looking forward to “smelling the roses” and living the rest of his life to the full. He has kept some of his vintage cars and enjoys the aroma of fine British Connelly hide when there are no roses!
NOVEMBER 2018 | 27
CLINICAL OPINION BACK TO CONTENTS
Why is exercise a medicine? By Prof Robert Newton, Exercise Medicine Research Institute, ECU
When we exercise multiple organ systems in the body perform autocrine, paracrine and endocrine functions to dramatically alter cellular and systemic chemical milieu effecting all other cells and tissues – producing endogenous medicine so that exercise is truly a medicine. How it all works In fact, the skeletal muscle system is recognised as the largest endocrine organ in the body, producing a vast array of hormones and cytokines critical for maintaining health. Adipose tissue is also secretory and much of the chronic disease epidemic is driven by the imbalance of dominance between muscle and fat mass and regulatory activity. As a result of exercise, the chemicals produced ameliorate the imbalances that cause diseases, reversing decline in health and in some cases with chronic exercise actually curing the disease. Unfortunately, Australians in the vast majority have a high volume of fat tissue and low muscle tissue due to sedentary lifestyle and inappropriate nutrition. A key priority for improving health is to increase muscle mass and stimulate it to dispense beneficial medicine regularly. (The analogy is build a pharmacy and visit it regularly but ensure the appropriate medicine is provided.) A large fat mass provides detrimental chemicals into the system with sedentary behaviour stimulating release.
Patients exercising on Technogym equipment, positioned for the tech-savvy wanting to maintain fitness or wellness through exercise. Getting the balance right
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Interestingly, there is quality research indicating that aerobic and neuromuscular fitness, including higher muscle mass, is more protective against poor health than striving for normal body fat levels. High body fat remains a major risk factor. However, a greater health benefit will be derived by focusing on exercise rather than fat loss.
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Of critical importance, dietary restriction or bariatric surgery, while generally effective for fat loss, also produces decline in muscle and bone that can result in worse health problems than the obesity may cause. Any fat loss program MUST include an exercise prescription to maintain muscle and bone health and increase physical fitness. Exercise and cancer
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Exercise is increasingly being prescribed across the cancer continuum as part of management: from diagnosis and leading up to surgery, chemotherapy or radiation; as rehabilitation posttreatment, to enhance longer term survival and reduce risk of recurrence; and to maintain function and quality of life in patients with incurable disease.
*Approx
Preclinical trials have demonstrated specific exercise enhances the effectiveness of chemotherapy and radiation therapy. Recommended practice is for patients to complete an exercise
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CLINICAL OPINION
bout immediately prior to their therapy session to increase blood flow through the tumour, delivering more chemotherapy or enhancing radiation effectiveness.
exercise physiologist (AEP) per year. Compared to pharmaceutical therapies, exercise medicine is relatively inexpensive, has no side effects and benefits a range of health aspects beyond the primary disease being treated. This has been demonstrated very effectively through Medicare support of exercise medicine for patients with Type 2 diabetes. However, to improve patients with other diseases and reduce health costs overall, the Medicare rebate for group exercise must include all chronic conditions.
Where is exercise medicine heading? Increasingly we are coming to understand through research and clinical practice that the mode and dosage of exercise varies considerably, as do indications and contraindications. Take walking as an example. Too often walking is recommended to patients in a non-targeted way possibly because it is free and easy to access. But walking does not benefit the patient suffering from osteoporosis or sarcopenia. For a patient with cachexia secondary to cancer, walking is contraindicated as it will increase energy deficit and drive further weight loss and functional decline. Exercise medicine is moving towards a tailored prescription where the health issues are given priority according to morbidity and risk of death. There is no point putting new seat covers on when the engine is about to explode! We must discard the belief that exercise must be fun. Statin therapy is not fun. Having your prostate blasted with radiation for six weeks is not fun. But informed patients choose to receive these treatments. Exercise medicine must be promoted in the same vein, a necessary part of medical management.
The AEP seems well placed for exercise assessment and prescription – a minimum four years university trained, accredited through Exercise and Sports Science Australia and can be registered providers through Medicare (see www.essa.org.au/find-aep/) References available on request.
Further Reading: 1. Hart N.H., D.A. Galvão and R.U. Newton. Role of exercise in advanced prostate cancer. Current Opinion in Supportive Palliative Care. 11(3): 247-257. 2017. IF 2.070. 2. Newton, R.U. and D.A. Galvão. Accumulating Evidence for Physical Activity and Prostate Cancer Survival: Time for a Definitive Trial of Exercise Medicine? European Urology, 70(4): 586-587. 2016. IF 13.938.
A major barrier to patient access to quality exercise medicine is that Medicare only funds up to five consultations with an accredited
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Author competing interests: no relevant disclosures.
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Rethinking aged care By Dr Scott Blackwell, General Practitioner, Joondanna
Good care in Residential Aged Care (RAC) starts with understanding what "good" residents would wish for themselves. What is a good life and happiness to a person no longer living independently? High levels of cognitive decline in the RAC population means we must consider what constitutes a good life in their terms. Family, friends and food often rate high. Dignity (sensitive attention to continence issues and personal care) is paramount. As is respect for autonomy within each resident’s capacity. The contribution of a resident’s families and friends cannot be understated but good intentions can also be misdirected, something that clinical care providers must become aware of and address. Desertion, over attentiveness and family discord can be equally damaging. Do not underestimate the role of the Aged Care Facilities to the good life of residents. Dignified personal care and attention to issues such as continence, pain and other distress are the foundation without which the good life cannot exist.
directing the clinical need of the residents and reducing unnecessary ED visits for trivial and futile issues. Though not funded through Medicare we have been able to support it internally. The recurrent cycles of assessment and planning carried out by the NPs enables clinical status change to be identified and addressed early. This enables priority to be given to how the resident feels, maximising their quality of life. We have found that early interaction with the family is paramount so we can all be on the same page with the same realistic expectations. Advanced care planning has become an essential part of the conversation with the family and is indeed the game changer in terms of being able to maximise the quality of life of the resident. When their inevitable deterioration occurs to shift in focus is to minimise suffering. We have to be competent, in fact expert, at providing palliative care appropriate to the person and this is achievable within the collaborative structure.
Person Centred Care (that leads to greatest happiness, a good life) is often not well implemented. The terms of a ‘good life’ must often be set by those in Residential Aged Care – GPs are well suited to dealing with any complexity.
own good life. This is best achieved by maintaining the good life for their elderly, and can focus on minimising their suffering as it occurs. We believe through experience this requires a team approach and a dedication to person centred care. ED. For the ‘nuts and bolts’ of how this model works, we can refer you to Dr Blackwell who can discuss his private practice model.
Author competing interests: the author works in aged care. Questions? Contact the editor.
The final KPI for good clinical care in aged care is that the family grieve well when their loved one dies and return to living their
Multiple comorbidities are the rule for residents entering RAC and quality of life depends upon a good health maintenance program. No longer is it enough to just respond to requests for attention to things that go wrong. There needs to be a consistent program of cycles of assessment, planning and case conferencing to consolidate the good life and happiness of the resident. Seven years ago, we considered these issues and developed a model of care with three goals. These are maintenance of quality of life, minimisation of suffering and inclusion of the residents (where appropriate) and their family in the conferences (to help them understand and to establish a conversation about advanced care planning). To achieve Collaborative Health Care (CHC) a private practice entity where GPs and Nurse Practitioners (NP) work together was formed. Each resident has a GP and a NP who collaborate in real time to develop the care model for each resident and work towards achieving the goals set. It became evident early there was a need for clinical advice from the team at all hours and an after-hours advice service was implemented. This has been helpful in
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NOVEMBER 2018 | 31
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Non-melanomatous skin cancer treatment with radiotherapy By Dr Jeremy Croker, Radiation Oncologist, Wembley Non-melanomatous skin cancer affects at least 2% of the population, with an increasing incidence because of our aging population and longer life expectancy. Many patients require repeat procedures for skin cancer. Surgery, topical treatments, photodynamic therapy and radiotherapy all play an important role. Recent advances in accuracy and delivery of radiotherapy and the increasing use of Volumetric Modulated Arc Therapy (VMAT) now provides further options for patients, particularly in difficult anatomic areas.
There is more confidence and certainty now about delivering a tumouricidal radiation dose to the target whilst sparing adjacent critical organs and normal structures. Moreover, the advent of VMAT permits dose to be sculptured around curved surfaces, enabling complex topographical shapes such the scalp, nose and legs to be treated, whilst sparing internal structures such as the brain, nasal septum and lymphatics (see Images). As well as excellent control rates, radiotherapy is non-invasive making it easy to administer in a population with multiple
Smart technology is leaving patients more comfortable when it comes to radiotherapy for skin cancers.
Early published outcomes for using VMAT radiotherapy for both invasive disease and field cancerisation is encouraging but robust data remains sparse at present. There is a need to collect prospective data and to this end, GenesisCare, along with dermatologists throughout Australia have developed a National Dermatology &
Efforts are underway to establish if these new radiotherapy techniques can treat the difficult problems of wide-field cancerisation and widespread in situ disease. Extent of the problem Non-melanomatous skin cancers (NMSCs) comprise primarily squamous cell carcinomas (SCC) and basal cell carcinomas (BCC). They are the most common cancer in people with fair skin and Australia has the highest incidence in the world. Risk factors include age, fair skin, male gender, chronic sun exposure and immunosuppression. Common anatomic regions for NMSCs are sun-exposed areas of the head and neck, along with the extremities - sometimes challenging areas to treat in terms of cosmesis and wound healing. Once an individual develops a NMSC, there is a significant risk of developing a second NMSC (the three-year risk for BCC and SCC is 44% and 18%, respectively). Field cancerisation refers to the problem whereby large areas of skin have altered tissue, ranging from dysplastic through in situ to invasive carcinoma. It is within these regions that patients may develop multiple cancers over time. Where radiotherapy fits in Surgery remains a mainstay of treatment, and radiotherapy has been a useful therapeutic option for 120 years. Radiotherapy has an approximate 90% local control rate at five years. In the past decade, advances in computing have fuelled parallel advances in imaging technologies, radiotherapy planning and delivery and treatments can now be delivered with submillimetre accuracy.
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Left to right; New VMAT technique limiting dose to internal structures, Old Radiotherapy techniques with dose to entire nose.
Left to right; New VMAT technique â&#x20AC;&#x201C; scalp minimising dose to brain, Older technique â&#x20AC;&#x201C; increased radiation to deeper structures. co-morbidities or contraindications to surgery or anaesthetics. Radiotherapy for skin cancer is generally well tolerated with a usual limited side effect profile that can include alopecia, pigmentary changes, telangiectasias, fibrosis and atrophy. The rare more serious side effects are generally limited to larger dose per fraction treatments and include soft tissue or bone necrosis, cataracts, conjunctival scarring and eyelid deformity. In a large 2017 review, 90% of patients self-reported good or excellent aesthetic outcomes following skin radiotherapy.
Radiation Oncology Registry with the aim of prospectively collecting local control, acute and late toxicity data, along with patient satisfaction outcomes. As the data matures it is hoped that in a carefully selected population, radiotherapy will offer increasing benefit in patients with skin cancer. References available on request
Author competing interests: No relevant disclosures.
NOVEMBER 2018 | 33
CLINICAL UPDATE
By Dr Jeffrey Thavaseelan, Urologist, Murdoch
Nocturia - the complaint of waking one or more times to void - is highly prevalent in both men and women, with almost 60% over the age of 60yrs affected. It is important not to assume it is purely a urological problem and a more holistic approach to its diagnosis and management is crucial. The greater picture Nocturia impacts on a patient’s quality of life, and is associated with increased morbidity such as obesity, heart disease, hypertension, diabetes, depression and in the elderly, increased falls and hip fractures. From the urologist’s standpoint, nocturia may be a symptom of benign prostatic enlargement or its consequences (either reduced functional bladder capacity from bladder overactivity or incomplete emptying from obstruction).
Figure 1
No Action Required
How to differentiate To differentiate whether nocturia is part of the symptom complex of benign prostatic enlargement or secondary to other nonurological courses, use a simple algorithm (see Figure 1). Firstly, are lower urinary tract symptoms (LUTS) present or not – obstructive symptoms such as hesitancy, slow flow, and feeling of incomplete emptying or irritative symptoms such as frequency, urgency and urge leakage.
NOCTURIA
Manage fluids at night. Decrease caffeine/alcohol intake.
Lifestyle
Improved
BLADDER DIARY
24 Hr Vol>40 ml/kg
Noct. Vol >33% (incl. first am void vol.)
Global Polyuria
Nocturnal Polyuria
However, this is not always the case. Causes are more often multifactorial and can include behavioural factors (amount, type and timing of fluid intake), sleep disturbance (insomnia, mental illness, chronic pain), obstructive sleep apnoea, underlying systemic disorder (congestive cardiac failure, poorly controlled diabetes), and drugs (e.g. lithium-induced diabetes insipidus).
This condition is where the ‘whole person’ approach wins every time, What can appear at first glance to be a purely urological problem, may not prove to be.
Only nocturia without associated LUT symptoms requires considering the possibility of non-urological causes. A detailed history that includes voiding behaviour, medical and neurological abnormalities and other reasons for sleep
Apparent Bladder Storage/Emptying Problems
Urological Path
Sleep Disturbance
Figure 3 GLOBAL POLYURIA Diabetes mellitus
NOCTURNAL POLYURIA Peripheral oedema (CCF, sympathetic neuropathy, venous insufficiency, etc) Diabetes insipidus Excessive fluid intake – evening Primary polydipsia Defiency of daily vasopressin secretion (CNS pathology, Parkinson's, MS) Hypercalcaemia Sleep Apnoea Medication (diuretics, SSRI, Ca Idiopathic channel blockers, lithium
UROLOGICAL PATHOLOGY SLEEP DISTURBANCE Bladder outlet obstruction Primary sleep disorder (eg. insomnia) Overactive bladder Neurogenic bladder Painful bladder syndrome
Secondary sleep disorder (COPD, CCF) Neurological disease (Parkinson's, Dementia) Chronic pain Mental illness (Depression, anxiety disorders) Alcohol / Drug abuse
Sickies are Big Bickies Two Qoctor media releases have recently come our way announcing high sickness certificate rates in August for three years running with 17,000 sick notes issued in that time apparently saving patients “over 25,000 hours”, and Medicare “over $750,000”. The team is made up of eight experienced, fullyqualified GPs. The Qoctor website has a national reach where health consumers from any state can get a sickness certificate for $19.99 out of pocket. “Because it's affordable and convenient, the lack of Medicare rebate
34 | OCTOBER 2018
does not seem to deter patients,” Dr Aifric Boylan, CEO of Qoctor said. Callers must first have a video consultation and a sickness certificate will be emailed at least 95% of the time (in 2-5% of cases, if the on-call doctor says the caller needs a physical examination, they will be advised to see a doctor in person. This applies to prescriptions and referral letters as well). Dr Boylan says Mondays are the busiest day. Is this formalising ‘Mondayitis’? According to the Employsure website: “It’s
part of Australian working folklore, and while most people can honestly admit to ‘chucking’ the occasional sickie, others can stretch the limits of their employers.” Dr Boylan told Medical Forum she believes the standard process to gain a medical certificate is often a waste of a patient’s time, can prolong recovery and also uses up appointments in busy clinics. By the end of the year, it plans to expand to online consultations with GPs, specialists and other allied health professionals.
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Pathological nocturia
CLINICAL UPDATE BACK TO CONTENTS
disturbance (i.e. waking not due to bladder sensation) will help. General examination pays specific attention to peripheral oedema.
• Urinalysis - to exclude microscopic haematuria that indicates other intravesical pathology (e.g. bladder cancer). Medical or urological?
Treatment is aimed at the underlying causes and is beyond the scope of this article, however, let’s look at idiopathic nocturnal polyuria.
What to recommend
Look at the three-day bladder diary.
Idiopathic nocturnal polyuria
Where there is no obvious pathological cause it is reasonable to recommend lifestyle changes such as reducing fluid (particularly caffeine and alcohol) intake in the evening.
• If 24 hour urine volume > 40 ml/kg – consider polyuria and its causes. (Fig 3)
If it doesn’t respond to simple measures it can be managed with desmopressin, a synthetic analogue of the human hormone vasopressin (syn. antidiuretic hormone), produced by the posterior pituitary gland. Its antidiuretic activity is through vasopressin V2 receptors, influencing water reabsorption in renal tubules.
At review, if these simple measures don’t work then further evaluation is required. • A 48-72 hour bladder diary is essential, measuring input and output (see Figure 2). • Document bladder emptying with a post-void renal US, looking for raised (>100 mls) residual urine (and remembering an over-full bladder always gives a spurious result).
Figure 2
• Nocturnal urine volume (NUV) – this includes the first void of the morning, which if >33% of 24 hour volume (or > 20% in the young patient), consider nocturnal polyuria and its causes. (Fig 3) • Individual voiding volumes can hint at diminished global and/or nocturnal bladder capacity, indicating either sleep disturbance, anxiety disorders, learned voiding dysfunction and urological disease. Remember the cause may be multifactorial and treatment tailored for each patient may well be multimodal.
NocdurnaTM which contains desmopressin is approved for idiopathic nocturnal polyuria in the adult. Taken an hour before bedtime as a wafer, there are gender-specific recommendations of 25 mcgm a day for women and 50 mcgm a day for men. The most commonly reported side effects of desmopressin include headaches, dry mouth, nausea, oedema and hyponatraemia (which is due to fluid overload and most significant in those >65 years age; sodium level is measured before starting the drug and 4-8 days after starting and 1 month later; regular monitoring after this is recommended). References available on request
Author competing interests declaration: nil relevant. Questions? Contact the editor.
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Diabetic retinal disease By Dr Tim Isaacs, Ophthalmologist, West Leederville Diabetic retinal disease could become a major public health challenge. About 1 in 20 Australians are now diagnosed with diabetes, and Australiaâ&#x20AC;&#x2122;s diabetic population is expected to reach 3 million by 2025. This will lead to a steep rise in diabetic eye disease, the leading cause of vision loss in the workingage population.
As the incidence of diabetes grows, so do the side effects. Retinopathy is one and the changes in recent years, particularly pharmacotherapy, mean a lot to patients. Management of diabetic retinopathy
Fig 2. Fluorescein angiogram: widespread retinal capillary ischaemia and PDR.
Significance increases when you consider one third of patients with diabetes have diabetic retinopathy, and in one third of these cases vision is threatened, requiring prompt treatment. Visual impairment in diabetes results from microvascular damage to retinal capillaries via distinct pathophysiological pathways: 1. Diabetic macular oedema (DMO): leakage from capillaries within the central macular area of the retina causes retinal thickening and loss of function. Vascular endothelial growth factor (VEGF) has been shown to increase vascular permeability in vivo and is an important mediator. VEGF levels are increased in the retina and vitreous of eyes with diabetic retinopathy and DMO, and inhibition of VEGF therefore targets the underlying pathogenesis. 2. Proliferative diabetic retinopathy (PDR): blockage of retinal capillaries causes ischaemia, stimulating new blood vessel growth with resulting haemorrhage and retinal traction.
Fig 3. Fundus â&#x20AC;&#x201C; same patient as Fig 2 after anti-VEGF injections and laser photocoagulation. How often? Current NHMRC guidelines recommend an eye examination every two years for non-Indigenous Australians with diabetes, and annual examinations for Indigenous people with diabetes and patients with another risk factor. Optometrists, ophthalmologists or suitably trained GPs can perform screening. Automated retinal image analysis using algorithms capable of detecting diabetic retinopathy lesions in fundus photographs, may in future lessen the clinical screening burden, though they have not been widely adopted due to inadequate sensitivity and specificity.
Almost all cases of severe visual loss due to diabetic retinopathy can be prevented. Optimal glycaemic control, and management of hypertension and plasma lipids, reduce the risk of retinopathy progression. Laser photocoagulation: In PDR cases, the landmark Diabetic Retinopathy Study showed that photocoagulation reduced the risk of serious visual loss by more than half, and this remains the most economical and efficient treatment for proliferative disease. Recent clinical trials have shown anti-VEGF injections to be non-inferior to photocoagulation, but the requirement for ongoing treatment is expensive and onerous. Pharmacological therapy: In DMO cases, there has been a paradigm shift in management. Laser photocoagulation is no longer recommended, and anti-VEGF intravitreal injections have emerged as first line therapy. Aflibercept and ranibizumab are listed on the PBS for management of diabetic macular oedema, and numerous clinical trials have demonstrated safety and efficacy. Intravitreal corticosteroids have maintained a role in management of chronically persistent DMO.
Screening for diabetic retinopathy Appropriate treatment of sight-threatening retinopathy requires identification of patients at risk. Fewer than half of all Australians with diabetes and only one in five of Indigenous Australians receive the recommended eye examinations. The two primary risk factors predicting retinopathy severity are duration of diabetes and poor glycaemic control. Secondary factors include hypertension, elevated plasma lipids, pregnancy and microalbuminuria.
Fig 1. Fundus - diabetic retinopathy including haemorrhages and exudate at the macula.
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Fig 4. Optical coherence tomogram (OCT) pre-treatment: diabetic macular oedema (DMO).
Fig 5. OCT post treatment with anti-VEGF injections: resolution of DMO.
NOVEMBER 2018 | 37
CLINICAL UPDATE
By Dr Mark Hamlin, Radiologist, Claremont
American College of Radiologists (ACR) guidelines for the management of ‘incidentalomas’ (i.e. incidentally discovered abnormal imaging on radiology) form the basis for this discussion. ‘Incidentalomas’ appear on up to 50% of CT, MRI or PET scans, depending on the body area scanned. The majority of time these findings are benign. For the radiologist, preparing his/her report, there may be a risk of cancer and the risk depends upon the organ in question and patient factors (perhaps unknown by the radiologist).
CASE REPORT 1: Liver lesion on CTCA for atypical chest pain. Mrs Jones, 62 years and usually very well, attends her GP feeling a right sided chest pain extending to her jaw. In addition to a thorough clinical assessment, ECG, FBC, U+E, TFT, LFT, D-dimer and troponin enzymes (all normal range), she was
There are no “standards of care” to manage incidentalomas as patient care varies depending on the individual circumstances, the clinical environment, available resources, and the judgement of the practitioner.
The main message is the patient’s family doctor is responsible for how ‘incidentilomas’ are pursued. This is not easy in a litigious world!
referred for calcium score and CT coronary angiography (CTCA) to “rule out IHD”. The CTCA images also showed a low attenuation liver lesion (left). The report described the lesion – 14 mm well defined low attenuation lesion in the left lobe of the liver with a density of 3HU and no further investigation is required. The radiologist had used the flow chart shown here to guide the management of this finding (Fig. 1). CASE REPORT 2: Pancreatic cyst on a CT-IVP for haematuria.
However, the first goal is for radiologists and referring clinicians to communicate using the same standardised terminology. Agreed algorithms or flow charts can help guide management. Important points are highlighted by two case studies:
Left lobe hepatic cyst measures 14 mm.
A 55 year old man presents to his GP with painless microscopic haematuria. He is referred for a CT-IVP examination to help exclude CA. The CT report describes normal renal tract appearances with no cause
Figure 1
38 | NOVEMBER 2018
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‘Incidentalomas’
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1
pancreatic head cyst
SUDDEN SENSORINEURAL HEARING LOSS; AN OTOLOGIC EMERGENCY Anne Gardner
Post Dip. Aud., BSc
Andre Wedekind M.Clin.Aud., BHSc (Physiotherapy)
Dr Vesna Maric AUD., M.Clin.Aud., BSc (Hons)
Sudden sensorineural hearing loss affects 5-20 per 100,000 persons per year. It is defined as a hearing loss >30dB in ≥3 frequencies occurring within 3 days. It may be accompanied by aural fullness, tinnitus, vertigo and sound distortion.
Pancreatic cyst on a CT-IVP for haematuria. for haematuria identified. However, there is a 17 mm cystic lesion within the pancreas head. The lesion is not well demonstrated as the examination protocol was renal tract rather than high resolution pancreas CT protocol (equivalent of dedicated MRI pancreas protocol). The radiologist reviewed the literature for guidance and proposed on the report that the GP repeat CT (or MRI) each 6 months for 4 years, then annually for 2 years, and then in 2 years as per the chart recommendations. The radiologist was sure to describe the absence of any “worrisome features” in relation to this cyst, to prevent further specialist review and EUS/FNA prior to surgical consideration. The patient was followed up for 9 years and although there was slight growth (<1mm per annum) the cyst remained below 25 mm and therefore no intervention was undertaken. There has been development of 4 flow charts by the American College of Radiologists as guidance for management of these pancreatic cysts. There is a consensus that pancreatic cysts ought to be considered mucinous unless proven otherwise, certain cysts will have criteria indicating need for EUS/FNA, otherwise follow-up should be for 9-10 years in most patients, and management is modified if >80 years. Decision making should be shared by physician and patient for management of incidental pancreatic cysts (present in about 20% of abdominal MRI examinations). Further Reading: www.acr.org/Clinical-Resources/Incidental-Findings
Author competing interests; nil relevant. Questions: Contact the editor.
KEY MESSAGES Radiologists have a duty of care to identify, describe and interpret all abnormalities irrespective of their importance. Flow charts are available that depict management algorithms, and protocols cover most situations. Radiologists will be exposed to medicolegal risk for not reporting ‘incidentalomas’ (as happens in about 0.25% of cases); however, there is also a chance of unnecessary investigations in patients who are at low risk. Clinicians will need to “correlate with clinical details” when it comes to interpreting the significance of the abnormality. Patient and clinician agreement is essential for ongoing management of these findings, which will likely become more prevalent in the future.
Patterns of sudden SNHL Sudden sensorineural hearing loss (SNHL) generally occurs unilaterally, but after the initial insult, patients are at an increased risk of loss in the contralateral ear and ipsilateral relapse. Suspected aetiologies are genetic causes, viral infections, autoimmune diseases and vascular insults. A lack of good diagnostic tools results in around 80% of cases being defined as idiopathic. Many of the identifiable causes of sudden SNHL (e.g. bacterial meningitis, diabetes mellitus, syphilis) have broader health implications for the patient, warranting thorough investigations in all cases for reasons beyond hearing recovery alone. Many aetiologies cause irreversible damage to the outer hair cells and cochlear support structures. In some cases, further damage can be prevented by timely diagnosis and treatment of the underlying condition. The most common medical treatment for idiopathic sudden SNHL are systematic corticosteroids. There is some evidence for the additional inclusion of hyperbaric oxygen therapy. Intratympanic steroid injections have been used successfully in some cases as a salvage treatment following initial unsuccessful systemic steroid treatment. Hearing recovery may not occur, can be complete or partial. The likelihood of recovery varies with a number of factors. Better recovery rates are seen at milder levels of hearing loss, in cases of low-frequency sloping hearing loss, and in cases without vertigo.
An urgent ENT referral is needed in cases of suspected sudden SNHL. The greatest recovery is seen if oral corticosteroids are administered within a week of symptom onset. Rehabilitation may be long-term Long term rehabilitation options look at treating the residual symptoms of sudden SNHL. Monitoring of hearing is recommended at 2, 6 and 12 months to document recovery and guide aural rehabilitation (hearing aids or cochlear implants). Physiotherapy may be required for vestibular rehabilitation, and a structured tinnitus management program may be required for persistent tinnitus distress. Patients with sudden SNHL are at risk of psychological adjustment problems given its rapid nature, sudden change in lifestyle, lack of information and possibly delayed diagnosis and treatment. Tinnitus and vertigo are common accompanying symptoms that often result in psychological distress in their own right, and further hinder the patient’s coping. Psychological referrals are underutilised, but may be an important part of the adjustment process, improving quality of life and may influence the success of other rehabilitation programs.
51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au
MEDICAL FORUM
NOVEMBER 2018 | 39
COMMUNITY
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Reaching Out to Vulnerable Teens When you’re young and struggling to negotiate the vicissitudes of life it’s easy to slip through the cracks, says Shane Johnstone.
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t’s hard enough having to negotiate a disadvantaged background at a young age without adding chronic illness or major trauma to the mix. Shane Johnstone, a clinical exercise physiologist, decided to do something about it and started the Be Inspired Foundation nine years ago. The program revolves around exercise, diet and counselling and lives are being changed for the better. “Working as an exercise physiologist I could see that some of these young people were slipping through the cracks, they just weren’t getting the services they needed,” said Shane. “The other big motivator for me was the experience of a close friend. He was diagnosed with cancer at the age of 17 and I saw firsthand the effects of the treatment on both him and his family. He died two years later without doing the things he wanted to do.” “I know I’ve been lucky to do those things.” “Be Inspired has a particular focus on young people, and many of them are finding things pretty tough, as are their families. A recent study has found many people in this demographic would really struggle to find even a small amount of extra money if chronic illness hits a family member.” “It’s important to say that most of these kids get great care in hospital as inpatients but once they step outside the system it’s not so good. We’re talking about young people with chronic illnesses like cancer, major trauma and disabilities, and they’ve often had these conditions for an extended period.” Shane’s experience with Be Inspired has
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shown him the positive impact of active rehabilitation involving exercise, diet and counselling gives these young people. “Be Inspired ensures that participants of the rehab program meet the criteria. Firstly, they must be under the age of 18 and they need to be referred to us by a GP. They also need to have made some effort to access pre-existing services such as Medicare and other similar pathways. We also make sure that they’re aware of a Chronic Disease Care Plan.” “That gives them five discounted sessions and our program complements that by, in some cases, providing another 35 sessions a year. So, when you’re talking about 40 sessions, that’s giving them a big helping hand.” As Shane points out, some of these young people are coming from pretty difficult places in their lives and it can take some time before they can fully embrace new opportunities. “It’s quite often the case that family life is a little disjointed for some of these young people. And that can mean that it takes them a while to get into the swing of the program, so the 12-month duration works really well. We make it quite clear that this isn’t something that’s intended to last until they’re 65 years-old!” “We want to encourage their independence, see that that they are engaging socially and moving along a pathway from school to community and on to stable employment. It is confidence building for them and will reduce the burden on the public health system.” A personal story often puts the reality of someone living with these challenges into perspective, says Shane.
of 70. Consequently, it’s pretty hard for him to engage in aerobic activity but he’s exceptionally strong for his age so we get him doing weights in the gym, which is boosting his confidence. And this is a kid who was so ashamed of his body that at one stage he was too embarrassed to get out of the car, so the clinician would often have to come to the car to talk to him.” “He’s into the program now and going to group exercise sessions twice a week and doing better at school. There’s been a massive shift in the way he lives his life. He may need further intervention down the track but his future is looking much brighter.” Such interventions don’t come cheaply and Shane explains the funding arrangements. “We generate the majority of our requirements through fundraising but we’d like to secure some grants and networking is a big part of that. On a more personal note, I did a charity run along the Bibbulmun Track a few months ago that raised $17,000 and broke the record by four days and that was fun.” Shane is adamant that the Be Inspired program is underpinned by the medical community and is always seeking closer involvement. “Most of these kids are referred by a GP and when they’re in the program we’ll often find ourselves engaging directly with hospitals. Once we’ve captured the data we need in a ‘testing’ session, we send a treatment plan to the referring medical practitioner.” “It’s important that doctors are onboard with the rehabilitation pathway these kids are on.”
By Peter McClelland
“We’ve been working with a 15-year-old young man who weighs 194kg with a BMI
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WINE REVIEW BACK TO CONTENTS Deep Woods Estate is located in the Margaret River sub-region known as Yallingup Hills. The original vineyard was acquired by the Fogarty Wine Group in 2005 and has undergone a major transformation turning it into a major player in the West Australian wine scene.
By Dr Martin Buck
Winemaker Julian Langworthy has been in the news recently with a swag of gold medals and trophies at the Perth Royal Show wine
awards. Following up on a stellar year with Winemaker of the Year and a recent Jimmy Watson Trophy. I really enjoyed the wines and they are lifting the bar in terms of Margaret River wine styles. Great wines are a partnership between sensational fruit and a talented winemaker and Deep Woods Estate has both.
2017 Deep Woods Estate Chardonnay
2018 Deep Woods Estate Rose
Not surprisingly both the Chardonnays for tasting are packed full of sublime Margaret River fruit. The 2017 Estate Chardonnay is still young and uses select parcels of fruit from the region with a wild yeast ferment and only six months of oak maturation. There are aromas of stone fruit and hints of oak with a great palate of grapefruit, crisp acid and light oak. A good package for the price.
Rose is making a comeback and the Deep Woods Estate 2018 is all about the new direction of Rose styles. It’s made from small parcels of Tempranillo and Shiraz with a little barrel aging to add complexity. There are some savory aromas and cherry hints with a clean soft palate with a refreshing finish. A great wine for summer.
2017 Deep Woods Reserve Chardonnay
Margaret River Shiraz is fast becoming the “go to” Shiraz as the region is now recognised as producing some amazing wines that are stylistically different from the Barossa. The 2015 Reserve Block 7 Shiraz is a lively vivid purple wine, full of spice and berry aromas. Plenty of plums, berries and spices on the palate and just a sensational Shiraz.
This is a much more complex wine with hand-picked fruit, whole bunch pressing and a minimalistic approach, letting the fruit do the talking. Once again the oak has been used for complexity, not to dominate the wine. Wonderful aromas of peach and nectarine with a long palate packed with fruit, lime and an acid backbone. I can see why it is their most popular wine!
2015 Deep Woods Reserve Block 7 Shiraz
2016 Deep Woods Reserve Cabernet Sauvignon The flagship 2016 Reserve Cabernet Sauvignon was the wine I was looking forward to tasting. A proven trophy winner in previous vintages and a Jimmy Watson for the 2014. The wine is made in small parcels with a lot of hands-on work in the winery. Individual barrels are carefully pumped over twice daily and then matured for 16 months. The final wine is sensational. Aromas of dried berries, cigar box oak and a hint of eucalyptus. The big palate is full of balanced fruit and delicate tannins with a long finish. A great wine to cellar and try regularly.
MEDICAL FORUM
NOVEMBER 2018 | 41
Photography: Freedom Garvey
Into the Deep Woods
SOCIAL PULSE 1
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World Mental Health Day healthe.care (Abbotsford Private Hospital and the Marian Centre) put on an event at Fraser’s Restaurant to mark World Mental Health Day. Event sponsor was INDIVIOR, manufacturer of drugs to treat addictions and overdoses. Founding Patron of ScriptWise Kim Ledger, father of the late Oscar-winning actor Heath Ledger, spoke about his experiences with his son’s overdose. He and ScriptWise are pushing for real-time reporting of scripts (to reduce harm from prescription drugs). Psychiatrist Dr Stephen Proud and Harm Reduction WA’s Paul Dessauer covered the many faces of illicit drug use, destigmatisation, and regaining a sense of community, as well as tips for engaging drug users.
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1. Decriminalisation of drug abuse was one possibility canvassed by the meeting on World Mental Health Day. Paul Dessauer (inset) said it was no answer to take the ‘Hard on Drugs’ political stance because over 70% of funding went into policing drug use, to no avail. 2. Mental Health Commissioner Timothy Marney is flanked by Marian Centre CEO Dale Nelligan (left) and Katherine Houareau (right) 3. Some of the audience who attended the World Mental Health Day event.
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1. Medifit Managing Director Sam Koranis, left, and Dr Eoin McDonnell, practice owner of Core Medical.
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Core Medical gets Medifit Port Kennedy GP Dr Eoin McDonnell’s medical centre, Core Medical, got the tick of approval from the Australian Shop and Office Fitout Industry Association’s (ASOFIA) at its recent Interior Fitout Awards taking out the prize for the Best Professional Suite Design. It was one of three awards for Medifit Design & Construct. It also took off two awards for its work at Melbourne Comprehensive Eye Surgeons. Medifit managing director Sam Koranis said the awards for an exciting recognition of the company’s tailored approach to his health care clients and their patients. His tips for a successful fitout were easy navigation for patients, a calm professional ambience and good staff facilities.
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THEATRE BACK TO CONTENTS
Brainchild – The Monster Within
T
a prototype but monsters have littered history and created havoc throughout it. We are now in another stage of history where monsters are on the rise.”
his year marks the 200th anniversary of a young woman’s breakthrough novel. Remarkable firstly that a woman should have the literary world talking and then, of course, there was its controversial subject matter.
The collaboration with Steve Richter will be an interesting one to witness. Both men’s artistic output is eclectic. Surely this is a collaboration over time?
The woman was Mary Shelley and the book was Frankenstein, a work imbued with the angst of its times and since, an essential consideration in explorations of our own. Most come to Frankenstein as adolescents, where audacity and ghoul, monsters and slayers, love and tragic romance force themselves in. Yet returning to the novel with life under the belt, those elements shift and darken to create a work of immense depth and insight into humanity’s capacity for nobility and savagery, mixed so subtly among Shelley’s characters. Then of course, there’s Hollywood’s Boris Karloff … but that’s another story. Next month, the fascinating actor/writer Brian Carbee and captivating composer Steve Richter bring a new interpretation of the Frankenstein behemoth to the Subiaco Theatre Centre in a collaboration that will no doubt add to the cultural collection. Brainchild will have its world premiere here in Perth due to those serendipitous connections the artistic community survive on. Brian spoke to Medical Forum about some of the ideas he and Steve have been working on. “As I started putting down ideas for Brainchild, it seemed to me as things never really change. We are in a similar situation as we were 200 years ago. When Shelley began writing Frankenstein in 1816, it was known as the Year Without Summer. There
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“We only met in person last weekend,” Brian laughs.
Steve Richter, left, and Brian Carbee had been an enormous volcano eruption in Indonesia and there was mass starvation in Europe with people dying in the hundreds of thousands,” he said. “It was a horrendous situation and that was hard on the heels of the Napoleonic Wars and Europe was a wasteland. Then you consider Mary Shelley’s circumstances in the circle of her poet husband Percy Shelley and Lord Byron – highly privileged men who exercised their privileges freely. That’s the environment in which the story germinated.” “We are also in a kind of scary situation right now when it comes to the environment and the futures of world’s economies and all the existential angst that creates.” “We realise that Shelley’s work is really a zeitgeist, which is making everyone reexamine her story.” In Brainchild, Brian is concerned with how society creates its own monsters.
The pair were united by producer Maree Laffan, an “arranged marriage” as Brian puts it, and until their first physical meeting have been exchanging ideas over the internet. “When we met, things really started to happen. We could see how the words and music would interplay and it’s thrilling – it’s going to work. There’s always some anxiety in the early stages, it’s about finding the language and the ideas,” he said. “And best of all, we will be performing on stage together and that’s a relief because it can be hard out there on your own. It’s really good to have a partner you can have fun with.” For Brian, a life of dancing (Sydney Dance, Chunky Moves), acting, screen and stage writing and filming has seen a fascinating body of work – check out his short film In Search of Mike, which was shown at Sundance, and his feature film Accidents Happen. Is there any one genre he prefers? “As I get older, writing is a little bit more appealing. Dance is a little harder to maintain but but while I can I’ll keep doing it. And the beauty of writing my own performance pieces – I can write in the rests!”
By Jan Hallam
“Shelley created a monster that became
NOVEMBER 2018 | 43
UNRULY CANCER Mundaring GP Dr Dawn Lithgow found this ironic typo in a recent specialist report: “It stated that the patient had a ‘mutinous adenocarcinoma’ ( instead of mucinous). We know that cancer cells are not well behaved so this was appropriate!”
Carl Sagan-(1934-1996)
QUIZ TIME You only need four correct answers to pass. How long did the Hundred Years' War last?
2.
Which country makes Panama hats?
3.
From which animal do we get cat gut?
4.
In which month do Russians celebrate the October Revolution?
5.
What is a camel's hair brush made of?
6.
The Canary Islands in the Pacific are named after what animal?
7.
What was King George VI's first name?
8.
What colour is a purple finch?
9.
Where are Chinese gooseberries from?
10. What is the colour of the black box in a commercial airplane?
1. 116 years; 2. Ecuador; 3. Sheep and Horses; 4. November; 5. Squirrel fur; 6. Dogs; 7. Albert; 8. Crimson; 9. New Zealand; 10. Orange (of course)
1.
THE PARROT SKETCH A magician was working on a cruise ship in the Caribbean. The audience was different each week so he did same tricks over and over. The problem was, the captain's parrot saw all the shows and began to understand how the magician did every trick. He started shouting in the middle of the show: 'Look, it's not the same hat. Look, he's hiding the flowers under the table. Hey, why are all the cards the ace of spades?' The magician was furious but, as it was the captain's parrot, he could do nothing. Then one day the ship sank and the magician found himself floating on a piece of wood with the parrot. They glared at each other but said nothing. Finally, after a week, the parrot said: 'OK, I give up. Where's the boat?'
SHORT AND SWEET I was in the six item express lane at the store quietly fuming. Completely ignoring the sign, the woman ahead of me had slipped into the check-out line pushing a cart piled high with groceries. Imagine my delight when the cashier beckoned the woman to come forward looked into the cart and asked sweetly, "So which six items would you like to buy?"
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Patient: Doctor, doctor. I've come out in spots like cherries on a cake. Doctor: Ah, you must have analogy. A man goes to the vet about his dog's fleas. The vet says: 'I'm sorry, I'll have to put this dog down.' The man is incredulous and asks why. The vet says: 'Because he's far too heavy.' Why is television called a medium? Because it is neither rare nor well done. China has a population of a billion people. That means even if you’re a one in a million kind of guy, there are still a thousand others exactly like you. “Feminism is not a fad. It’s not like Angry Birds. Although it does involve a lot of Angry Birds. Bad example.” – UK comedian Bridget Christie “If you arrive fashionably late in Crocs, you’re just late.” – UK comedian Joel Dommett
WELCOME TO THE UK: “The UK has one of the most stressful border controls I've ever come into in my life. They ask you so many questions. The guy looks at me as says: 'So you're a comedian, you don't look funny.' So at one point I stopped and I said: 'Look man I've given you the paperwork, I've told you why I'm here, why don't you believe me?' He said: "Well, the truth is, we can't just believe everybody that comes into the UK, we can't just believe that you're gonna do what you say you're here to do, you might do something totally different'. I thought: 'Fair enough, that makes sense.' I just wish, as Africans, we'd thought of that when the British arrived. That would have served us well." – South African comedian Trevor Noah
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"It is far better to gr asp the Universe as it really is than to persist in delusion, however satisfying and reassuring."
COMPETITIONS BACK TO CONTENTS
Enter Medical Forum's competitions! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link. WASO: Messiah Christmas must be just around the corner because it’s Messiah season. WASO is first up with the Handel masterpiece under the direction of Christian Curnyn. He leads the orchestra, WASO chorus and soloists Sara Macliver, Fiona Campbell, Henry Choo and Morgan Pearse. Perth Concert Hall, December 7 & 8, 7.30pm
Movie: Robin Hood This new incarnation of the man who robs from the rich to give to the poor is an action-packed, political adventure starring Taron Egerton as Robin Hood and Jamie Foxx as a feisty commanding Little John. The story picks up with the return of Robin of Loxley from the Crusades to find his land and people suffering under the yoke of Prince John and his henchman, the Sheriff of Nottingham (a silvery tongued Ben Mendelsohn). Little John in this retelling is a former enemy, a Moor Commander who admires Robin’s valour on the battlefield and provides him with safe passage back to England. Maid Marion (Eve Hewson) believes her love Robin is dead and is being pursued by corrupt politician Will Tillman (Jamie Dornan) so Robin and Little John launch a crusade against the corrupt Sheriff and Church, hijacking the tax collectors and handing over the money to Marion, now a leader of a clandestine grassroots rebellion. Enter Friar Tuck (none other than WA’s own Tim Minchin) and all the ingredients are there for a fabulous romp. In cinemas, November 22
Cine Latino Film Festival The inaugural Cine Latino arrives in Perth this December bringing the best of Latin America’s exciting cinema industry. The 2018 festival will open with Mexican director Alfonso Cuarón’s hotly anticipated film, Roma, which won the Golden Lion at this years’ Venice Film Festival.
Spider-Man returns to his comic roots in this new animated film of the normal guy who can transform into a gravity defying, wall climbing web spinning superhero. This narrative introduces the concept that there can be more than one Spider-man in the Spider-Verse.
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Clear Air
In cinemas, December 13
Inside Spirometry Cystic Fibrosis Breakthroughs e-Poll on Assisted Dying Bronchiectasis; Cirrhosis; Asplenia
S E P T E M B E R 2 0 18
Movie: Venom – Dr Sue Budd, Dr Lyn Minsker, Dr David Graham, Dr Mandy Croft, Dr Christine Archer, Dr Peter Griffiths, Dr Katherine Ng, Dr Jenny Tu, Dr Germain Wilkinson, Dr Derek Johns
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Movies: Lavazza Italian Film Festival – Dr Smathi Chong, Dr Stuart Paterson, Dr Michelle Rooke, Dr Bev Hewitt, Dr Ashley Irish Music: WASO – French and Fantastic – Dr Keith Grainger Opera: Don Giovanni – Dr Rob Kirk Theatre: In the Next Room, or The Vibrator Play – Dr Ruby Chan
MEDICAL FORUM
In cinemas, November 15
Movie: Spider-Man: Into the Spider-Verse
M E D I C A L F O R U M $ 12 . 5 0
Winners from September
WESTCOAST BMW 17 Luisini Road, Wangara. Tel 9303 5888. westcoastbmw.com.au
This film is based on the true story of Forrest Tucker (Robert Redford), from his escape from San Quentin prison at the age of 70 to a string of heists that confounded authorities and captivated the public. Of course, there is a detective in hot pursuit.
Palace Raine Square & Cinema Paradiso, December 6-16
A LITTLE SOMETHING TO GET YOU MOVING.
AUTO CLASSIC 48 Burswood Road, Victoria Park. Tel 9311 7533. autoclassic.com.au
Movie: The Old Man and the Gun
September 2018 www.mforum.com.au
Theatre: Brainchild In the 200th anniversary year of Mary Shelley’s masterpiece gothic novel, actor, writer, dancer Brian Carbee joins forces with composer Steve Richter to assess the cultural collateral of Shelley’s Creature and the man who made him. Subiaco Theatre Centre, December 14 & 15, 7.30pm
NOVEMBER 2018 | 45
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