Medical Forum WA Public Edn September 2019 by Medical Forum WA

Deadly Dust The Return of Silicosis Respiratory Health Vaping: Virtues and Vices Asthma, Sleep Apnoea & Lung Cancer

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September 2019 www.mforum.com.au

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EDITORIAL By James Knox

It Takes Your Breath Away September is our respiratory edition and this month we delve into why silicosis, a disease we thought was consigned to the bad old days of unregulated industry, has returned with a vengeance. It is natural to have a visceral reaction on learning of the re-emergence of silicosis. After all, it is a death sentence for those who have the accelerated and acute forms of the lung disease. Thousands of workers have been dangerously exposed to occupational respiratory crystalline silica dust while the numbers who have developed silicosis are unknown.

The answer to those question is yes, just as it was for respirable crystalline silica. So why aren’t we asking these questions before it’s too late for workers. Until the regulators are provided with sufficient funding to assess and audit potentially harmful work practices, we can only assume these occupational disasters will keep on happening.

However, it is imperative we investigate what went so wrong that we failed to see this coming. We only need to look back a few years to see the devastation that asbestos wreaked on workers. We’ve seen these types of occupational diseases all before.

We also need politicians to lead before they are led in regards to giving regulators the muscle to enforce policies that are already in place.

In what we thought was such a controlled regulatory environment with stringent occupational health and safety standards, silicosis should still be firmly in the past, yet through apathy, assumptions and a lack of investment, we are again left to reckon the human and social cost of an avoidable occupational disease.

PUBLISHERS Karen Walsh - Director Chris Walsh - Director ADVERTISING Marketing Manager Felicity Lockyer (0403 282 510) mm@mforum.com.au

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So, while the regulators move on the silica hazards, shouldn’t we use this experience and a little foresight to predict other potential occupational diseases – for instance, occupational exposure to toxic levels of diesel exhaust particles which lead to chronic obstructive pulmonary disease. Are preventative measures are in place? Are there health surveillance policies for these employees? Are there regulatory standards and auditing of at-risk workplaces?

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au

In the meantime, much of the silicosis burden will fall to primary health care providers, to know enough of their patients’ occupational history to encourage them to be aware of the health risks in their workplace. Here is a great opportunity to leverage knowledge GPs have about their patients to alter the rather grim outcomes for workers in these industries.

Journalist James Knox (08 9203 5599) james@mforum.com.au

GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

SEPTEMBER 2019 | 1

CONTENTS SEPTEMBER 2019

INSIDE 10 Head for Business 14 The Vaping Balancing Act 20 Silicosis: A Fatal Cut 24 Close-Up: Immunologist Dr Michaela Lucas

NEWS & VIEWS 1 Editorial: It Takes Your Breath Away – James Knox 4 Letters to the Editor:

6 8 9 27 33 41 47

Climate is a Health Issue – Dr Richard Yin VAD Bill Gets the Balance – Ms Dinny Laurence Where’s the Compassion – Dr Peter Beahan et al John Murtagh: Teller of Tales Have You Heard? Beneath the Drapes Nuts & Bolts of VAD Financial Consent GP2GP Records How to Live Lighter

LIFESTYLE 48 Glamping it up on Rotto 50 Social Pulse: HealthEd Women’s Day 50 Wine Winners 51 Wine Review: Schild Estate – Dr Craig Drummond 52 Opera’s Antoinette Halloran as Lady Macbeth 53 Margaret River Guitar Festival 54 Competitions www.mforum.com.au

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CONTENTS SEPTEMBER 2019 CLINICALS

5 Infective Exacerbations of COPD Dr David New

35 Pneumococcal Vaccination Update C/Prof Fiona Lake

41 Exercise after Lung Surgery Dr Vinicius Cavalheri

36 Management of Pulmonary Embolus Dr David Manners

42 Asthma and Obesity Dr Michael Prichard

New Approaches to Metastatic Lung Cancer Dr Wei-Sen Lam

Childhood Asthma – Obstetrics Role? Dr Joo Teoh

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

Osteonecrosis of the Jaw Dr Amanda Phoon Nguyen

Assessing Asthma Dr Sina Keihani

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2019

DO YOU HAVE A PASSION FOR DOCTORS’ HEALTH?

AUSTRALASIAN DOCTORS’ H E A LT H C O N F E R E N C E 22-23 NOVEMBER 2019 PERTH AUST R ALIA

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GUEST COLUMNS

19 Coal Has to Go Dr George Crisp

28 Residents’ Rights in Aged Care David McMullen

31 e-Cigs Cloud the Scene Nicholas Wood

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

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SEPTEMBER 2019 | 3

Climate is a health issue

Bill’s balancing act

Dear Editor,

Re: WA’s Climate Health Inquiry (August edition)

On August 6 this year the Voluntary Assisted Dying Bill 2019 was read into the Legislative Assembly. By the end of 2019, if it has passed in both houses of Parliament, it will become law in Western Australia.

Across the globe and among Australian medical organisations including the World Health Organisation, the RACP and the Public Health Association of Australia, climate change is seen as a public health emergency. Western Australia is one area of the world most vulnerable to its effects and we are already seeing its impacts now. From heatwaves, increased frequency of bushfires, droughts and its impact on food production and the mental health impacts on farmers, there will be profound and widespread local effects. It behoves the health sector, as with any other public health threat, to prepare itself and respond both in terms of adaptation and mitigation. Current timelines to prevent catastrophic warming demand urgent action and deep cuts to emissions yet Australia’s emissions continue to rise driven to a substantial extent by WA’s LNG sector. We remain the only state without a net-zero emissions target nor a renewable energy target. It’s important that doctors as health advocates participate and help shape the outcomes of the inquiry to protect the health of the community and be advocates for systemic change both within and outside of the health sector. Dr Richard Yin, GP, Doctors for the Environment Australia (DEA) ....................................................................

The Bill has been more than two years in the making. The long and thorough process included a year-long inquiry into end of life choices by a cross-party parliamentary committee, and a state wide consultation by the Ministerial Expert Panel appointed by government to guide the development of the legislation. The Bill is an amalgam of the recommendations of those two bodies with further input to government from other stakeholders and agencies. The result is a Bill that balances clear eligibility criteria and safeguards against coercion or undue influence with a humane choice for those suffering at the end of life. This legislation gives members of parliament perhaps the biggest responsibility of their careers. They must decide whether having a conscience vote means they should vote in accordance with the will of the overwhelming majority of their constituents, or reflect their own belief if that differs. Or abstain. We will all die one day. Many of us do not fear death, but fear the possibility of suffering as we die.

At present, the only legal ways to prevent or end such suffering are to refuse treatment, food and water or to commit suicide by other means. Coronial statistics in WA show that about 10% of terminally ill people take their own lives, often by violent means and almost always alone so as not to implicate others. These legal methods of ‘self-determination’ are distressing and traumatic for the dying and their loved ones, and for those involved in the aftermath, such as police officers and ambulance workers. Voluntary assisted dying will give terminally ill people who satisfy the eligibility criteria a different alternative to end suffering at the end of life – a choice in how and when they die. As both an ethical issue and a practical one, and a fundamental change in our society, this will affect everyone. It is often stressed that there is an exemption for those who have a conscientious objection to voluntary assisted dying, but it is in fact an opt-in’ rather than an ‘opt-out’ process. Only those health practitioners who have the requisite qualifications and have completed the mandatory training will be eligible to participate directly. Doctors and nurses will be in the front line if this law passes. There will be an 18-month implementation period to get to grips with the process and reporting requirements in the Bill. With the support of the medical profession, this law can work as successfully in WA as its blueprint has in Oregon for more than 20 years. References on request

Dinny Laurence, Dying with Dignity WA ....................................................................

continued on Page 6

Your Magazine Seeks Your Views Medical Forum has been reflecting the insights of the WA medical profession for more than 20 years. Now we’d like to hear what you think about the magazine – what you love, what you don’t and what you’d like to see included. Look out for the survey link which we will email to you in early October.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia.

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The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that

advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

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LETTERS TO THE EDITOR

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Major Partner: Clinipath Pathology

By Dr David New, Clinical Microbiologist

Infective exacerbations of COPD What is an exacerbation? The GOLD (Global Initiative for Chronic Obstructive Lung Disease) report, updated in 2019, defines an exacerbation as “an acute event characterized by a worsening of the patient's respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.” Respiratory infections (predominantly viral), cause the majority of exacerbations. Other causes include pollution or heart failure or rarely pulmonary embolism or myocardial ischaemia. Role of antibiotics? Antibiotics have the greatest benefit (in morbidity and mortality) in more severe exacerbations (with the greatest evidence in the ICU population). The Anthonisen criteria, endorsed by the GOLD initiative, recommends antibiotics

KEY MESSAGES Antibiotics have a limited role in mild cases of COPD Talking about expectations with your patients is the best way forward (see box) Sputum cultures are not recommended unless hospitalisation is required

only for a severe exacerbation requiring mechanical ventilation (noninvasive or invasive) or an exacerbation with increased sputum purulence plus either increased dyspnoea or increased sputum volume. Even in hospitalised patients, the use of antibiotics has not been consistently shown to demonstrate benefit. A meta-analysis in 2012 showed that antibiotics had no statistically significant effect on mortality and length of hospital stay in inpatients. In the community setting, the same metaanalysis showed low-quality evidence that antibiotics reduced the risk of treatment failure by 25% at one month. However, if the included trials were restricted to currently available drugs (they removed old studies that used chloramphenicol and oxytetracycline) there was no benefit shown. Viral causes should always be considered and empiric oseltamivir be prescribed in flu season. If used, antibiotics should be targeted against Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. Infections with Pseudomonas aeruginosa and Enterobacteriaceae species are rare, often occurring in patients with underlying bronchiectasis. These patients tend to be sicker with pneumonia and require hospitalisation.

About the Author David is a consultant specialist in Infectious Diseases in Microbiology and has just returned to Perth after training in Melbourne. He works at Armadale and Royal Perth Hospitals and also sees private patients at Clinipath in Osborne Park.

Managing expectations: Talking to your patients about what to expect during an exacerbation is very important. The Box below is taken from the Australian Therapeutic Guidelines.1 Summary: Overall there is mixed evidence for the benefit of antibiotics in mild cases of COPD exacerbation. It is a difficult situation, and talking to your patients about the expected course of the illness is important. References: 1. Reproduced with permission from: Shared decision making for antibiotic treatment in exacerbations of COPD in the community [published 2018 April, amended 2019 June]. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2019. Other references available on request

Shared decision making for exacerbations of COPD in the community To engage in shared decision making with patients and carers: • Ask about the patient or carer’s expectations for management of exacerbations of chronic obstructive pulmonary disease (COPD). • Explain that the duration of a COPD exacerbation is related to the severity of underlying COPD. For patients with mild COPD, symptoms of the exacerbation can last 7 to 10 days. In patients with more severe COPD, symptoms can persist for weeks. • Explain that inhaled bronchodilators and corticosteroids are the standard treatment for exacerbations of COPD. Additional treatment with antibiotics should only be considered if all three of the following clinical features of a bacterial infection are present: • increased sputum volume • sputum purulence or a change in sputum colour • fever. • Discuss the limited benefits of antibiotic therapy for nonsevere exacerbations of COPD, even when a bacterial cause is likely. • For patients managed in the community with less severe exacerbations, antibiotics do not consistently improve outcomes. Currently used antibiotics do not reduce the rate of treatment failure or prolong time to the next exacerbation.

• Discuss the potential harms of antibiotic therapy. • Adverse effects of antibiotics include diarrhoea, rash or more serious hypersensitivity reactions. • Antibiotics disrupt the balance of bacteria in the body (the microbiome). While the consequences of this are not fully understood, it can cause problems ranging from yeast infections (eg thrush) to more serious infections (eg Clostridium difficile infection). • Antibiotics can cause bacteria in the body to become resistant to antibiotics so that future infections are harder to treat. Multidrug-resistant bacteria (known as ‘superbugs’) can be spread between people, affecting other family members and the community. • Ask about the preferences, values and concerns of the patient or carer, and answer any remaining questions. • Make a joint decision about whether to add antibiotics to standard care (inhaled bronchodilators and, where necessary, oral corticosteroids); if a decision is made to use antibiotic therapy, see eTG complete for treatment recommendations. • Discuss criteria for patient follow-up and reassessment.

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

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continued from Page 4

Where’s the compassion? Dear Editor, In his letter (Don’t Follow Canada, August edition), Dr John Hayes appears to be creating an atmosphere of panic and alarm. Dutch figures in 2017 showed 6,585 reports of euthanasia. In 2017 a total of 150,027 people died in the Netherlands. That is 4.4% of patients died using some kind of assistance. This figure compares well with what we know in WA, that is that some 5% of patients dying in palliative care units experience overwhelming suffering at the time of death. It is strange that Dr Hayes focuses on the experience in the Netherlands and in Canada. These are not the jurisdictions chosen as models for Australia. Rather the proposals for WA are modelled on the Victorian legislation, which in turn was modelled on the Oregon legislation – both regarded as conservative and well safeguarded.

Furthermore, since his letter was received for publication, the Voluntary Assisted Dying Bill 2019 has been released. Some of his guesses about what it would look like are wrong. In fact, the life expectancy timelines mirror the Victorian law exactly. Furthermore, it has more forms to be filled out and filed with the Voluntary Assisted Dying Board before a patient’s request for VAD can be granted, than is the case in any other legislation in the world. In another world first, the WA Bill bans any relative from witnessing the patient’s written request for voluntary assisted dying. Anyone who coerces a patient into taking lethal medication can be jailed for life. In regards to “a universal palliative care service”, we all want to see improvements, but improvements come at a cost that needs to be justified against the background that this country already has the second best palliative care system in the world (second only to the UK). This only makes the Government’s plan for palliative care over the next four years all the more remarkable. A 30% boost in funding will bring the total for that period to $206 million. There will be a special emphasis on increasing services in the rural and remote areas. None of this could be perceived by reference to palliative care funding in Dr Hayes’ letter. And

Keep patients up to date with your practice news while they wait Bi-monthly Flexible order options • Written by a GP • Evidence based • Meets AGPAL Guidelines

nowhere do we see a sense of compassion for the patients, their families or the general population of WA who, by a large majority, seek the possibility of the choice of VAD, in their time of greatest need. References on request

Dr Peter Beahan, Dr Richard Lugg, Dr Johan Rosman, E/Prof Max Kamien, Dr Ian Catto, Dr Roger Paterson & Dr Alida Lancee ....................................................................

Clarification In the August edition of Medical Forum, we published a profile of advocate Mr Bruce Langoulant. In the story we described him as being chairman of the Disability Services Commission board for 16 years. Mr Langoulant continues to hold that position. ....................................................................

Correction In the July edition we published an article, Cultural Competence in Health Care, coauthored by Prof Sandra Thompson and Dr Rosalie Thackrah. Instead of publishing a picture of Dr Thackrah, we published a picture of Dr Barbara Nattabi. Medical Forum apologises for the error.

Teller of Tales The third edition of Dr John Murtagh’s Cautionary Tales has just been published with some interesting legal input from GP Dr Sara Bird, who is also MDA National’s executive manager of professional services. John’s case studies have been invaluable and entertaining reading and learning for GPs, students and the general public alike. The new edition of Cautionary Tales builds on John’s four decades of experience. The project began life as recounting cases from his own practice in rural Victoria. John's connection to WA is as an Adjunct Clinical Professor at the Notre Dame medical school. With each edition, the casebook has grown but still carries cautionary tales relayed with compassion and humour. There may be the odd mistake or two but recounted with wisdom and insight only experience can produce. After each study, Sara has contributed a section called “Discussions and lessons learned” which explores the episode through the prism of minimising legal risk.

www.healthnews.net.au/trial-offer T: (08) 9203 5599 E: info@healthnews.net.au

6 | SEPTEMBER 2019

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LETTERS TO THE EDITOR

At home palliative care support

Helping GPs care for their patients We give people with a life-limiting illness the choice of specialised palliative care in the safety, comfort and privacy of their own homes. Respectful support

Specialist care

We ensure that every part of your patients’ wellbeing is understood and looked after with respect and dignity.

Care is provided by a team of nurses, medical practitioners, care aids, social workers, counsellors and spiritual care workers.

This includes medical care and any psychosocial and spiritual concerns they may have.

Our team ensures the rights of your patient are upheld and deliver a fully integrated and adaptable service based on their requests and changing needs. This includes working closely with you, the referring GP.

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How to refer your patients If your patient is eligible simply call 1300 466 346 or complete the referral form at silverchain.org.au SEPTEMBER 2019 | 7

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The care we provide typically moves from planned periodic visits to daily support as needs change. This care includes:

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HAVE YOU HEARD?

The building continues St John of God Murdoch Hospital has entered into a $17 million agreement with GenesisCare to engage Heathley, a specialist healthcare real estate manager, to develop by mid-2021 the first private integrated radiation oncology facility in the southern metropolitan area. The facility will include theranostics and nuclear medicine services, with an initial focus on providing treatment for late stage prostate cancer and neuroendocrine tumours. The centre will

have capacity to treat up to 1000 cancer patients a year. The hospital’s head of Oncology, Haematology and Palliative Care, A/Prof Kynan Feene, said access to additional radiation therapy and theranostics services would create integrated care in the one location. For those who are too unwell to travel, including patients who receive palliative care at the campus hospice, it will mean being able to easily access services onsite at Murdoch.

Dust diseases taskforce

Humans seem the problem

In this issue we explore the re-emergence of silicosis, which is also one of the primary focuses of the nascent National Dust Disease Taskforce. The taskforce is focused on “developing a national approach to the prevention, early identification, control and management of dust diseases in Australia.” During the 2019 federal election, the Morison Government promised the establishment of the taskforce and $5m in funding, both promises have materialised. The taskforce is to deliver preliminary feedback by the end of the year with a final report to COAG by December 2020.

MedicineWise’s Australian Prescriber has released a report analysing the potential benefits and detriments of hospitals migrating to computerised prescribing. The benefits of electronic prescribing include improved legibility and availability (e.g. cloud based), improved continuity of care (e.g. access to prior admissions and medications prescribed), and reduced medication errors. The downsides were the potential for new types of errors. The report goes on to say that an electronic prescribing system could significantly reduce the frequent medication errors in hospital, yet this was contingent on “well-designed systems that provide contextrelevant information to prescribers”.

Strategy support splinters Despite the National Alcohol Strategy being still under wraps, the ABC and the Foundation for Alcohol Research and Education (a health industry group) have seen leaked copies of the latest draft with numerous noteworthy alterations to the original. Campaigners for action on alcohol abuse say the draft has been too heavily influenced by the industry group Alcohol Beverages Australia. It has attracted the ire of state ministers, including Roger Cook who told the ABC that Greg Hunt must reexamine his conscience and the evidence of the social and economic cost of alcoholrelated harm. “If the report discomforts the alcohol industry, then that’s just a fact of life.” ACT Health Minister Rachel Stephen-Smith said the alcohol industry involvement in the draft amendments "presents a commercial conflict of interest". Adding the amendments have "significantly reduced the quality of the document". Alcohol Beverages Australia says they were participating in an “open and transparent consultation process”. The industry has managed to have inserted in the draft that alcohol is an intrinsic part of the Australian way of life. Mr Hunt said the federal government was committed to minimising alcohol-related harm.

8 | SEPTEMBER 2019

NSW abortion debate As we go to press the NSW parliament has deferred the debate on decriminalising abortion with the Bill which would amend the 119-year-old criminal code. Other states have their own legislation with variances in timeframes and approval processes. Medical Forum looked at each state’s requirements and limitations on abortion and found: • ACT: Legal on request. Accessible up to 14 weeks; 14-24 weeks terminations must be approved by a doctor. • NT: Legal on request. Accessible up to 14 weeks with the approval of one doctor; 14-24 weeks, the approval of two doctors is required. • QLD: Legal on request. Accessible up to 22 weeks. After 22 weeks, the approval of two doctors required. • SA: Legal but restricted up to 28 weeks with the approval of two doctors who agree a woman's physical and/or mental health is endangered by pregnancy, or for serious fetal abnormality. • TAS: Legal on request. Accessible up to 16 weeks. After 16 weeks, the approval of two doctors is required.

• VIC: Legal on request. Accessible up to 24 weeks with the approval of two doctors. • WA: Legal on request. Accessible up to 20 weeks. After 20 weeks, the approval of two doctors is required.

Cancer care spotlight An international survey of cancer patients and carers asked for perspectives on their cancer care and has revealed inadequacies in four key areas. They called for swift, accurate and appropriately delivered diagnosis; information, support and shared decision-making; integrated multidisciplinary care; and the financial impact of cancer. The survey findings offer a detailed look at the lived experience of cancer patients both in Australia and internationally. The survey, one of the largest of its type to be conducted, included more than 4000 people with 850 Australians participating.

Curbing violence in hospitals Health Minister Roger Cook organised a Stop the Violence Summit in June, which was in response to increasing aggression against hospital staff. The summit findings have led the McGowan government to allocate $5m to establish some key short, medium and long-term strategies, including increased security staff in hospitals, with further security training provided to staff; a review of procedures; additional alcohol and drug specialists; and the development of a public awareness campaign for patients and visitors to WA hospitals.

ACCC pursues HealthEngine The ACCC has initiated Federal Court proceedings against HealthEngine over alleged manipulation of user reviews and misuse of user information. The ACCC alleges HealthEngine provided personal information from more than 135,000 online bookings to private insurance brokers

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as a commercial transaction without appropriately disclosing this to the users. The personal information included such as names, phone numbers, email addresses and dates of birth. The ACCC also alleges that HealthEngine manipulated the user reviews in the application by not publishing around 17,00 negative reviews and altering around 3000 reviews by remove negative aspects and/or embellishing what was written. The timing of the ACCC action is a little mystifying given that HealthEngine episode was 12 months ago and prompted procedural change within the company. Some commentators believe ACCC want to road test their new digital teeth. The case will be closely watched.

Plastic not so fantastic A study examining atmospheric transport of microplastics (MPs) has brought into question the potential health impacts of airborne MPs. Researchers analysed snow samples from the Arctic Circle (Fram Strait) and compared them to snow from an unpopulated region of the Swiss Alps and more populated European sites of Bremen and Bavaria. The researchers found MPs in 20 of 21 samples. The concentration

of MPs in the the Arctic samples was much lower than in the European sites but was still considered substantial, with the researchers suggesting they were blown there by wind currents. Separate research has found inhaled microplastics are likely to be biopersistent, carry pollutants which may lead to genotoxicity and potentially lead to carcinogenicity and mutagenicity.

PainChek heads to Singapore The Perth-based PainChek app will enter the aged care system in Singapore. Approval has been received to use the app in the Allium Care Suites, a giant leap for the company, which has also been given the tick in Australia and Europe. The application uses artificial intelligence and facial recognition technology to assist patients who cannot verbalise their pain. PainChek has three primary benefits for patients and clinicians: pain identification when pain isn’t obvious; quantify pain severity when pain is obvious; monitor treatment efficacy to optimise care. We reported on the breakthrough in our June edition.

2019 Premier's Science Awards saw medical and exercise expert Prof Robert Newton (ECU) share top honours with planetary scientist Prof Phil Bland (Curtin). Ms Sharynne Hamilton (UWA and Telethon Kids Institute) took out the Shell Aboriginal STEM Student of the Year. Prof Carol Bower was recognised for her lifelong contribution to child health, most notably her research on folate and neural tube defects which has saved hundreds of children from debilitating birth defects. Clin A/Prof Deborah Lehmann, right, was nominated for a Eureka Prize for Outstanding Mentor of Young Researchers. We went to press before the results were announced. We will update next edition. Jennifer McGrath is acting Mental Health Commissioner after Tim Marney’s resignation. Mr Marney has been appointed a principal at the Nous consulting group. Julia Stafford and Miriam Rudd are newly appointed to the Alcohol and Other Drugs Advisory Board joining existing board members Dr Rosanna Capolingua, Dr John Edwards, Prof Colleen Hayward (Chair), Jill Rundle and Superintendent Mick Sutherland.

Eat or not to eat This research may be academic for a score of medical shift workers who may struggle to find time for a comfort break let alone a mealtime. However, research from across the Nullarbor is looking into whether altering food intake during the nightshift could optimise how workers feel during the night and perhaps reduce their sleepiness. Testing the impact of either a snack, a meal, or no food at all, the study found that a simple snack was the best choice for maximising alertness and productivity. Lead researcher Charlotte Gupta said most night-shift workers found it challenging to manage alertness when the body was naturally primed for sleep. “We know that many night-shift workers eat on-shift to help them stay awake, but until now, no research has shown whether this is good or bad for their health and performance,” she said. Over a seven-day simulated shift-work protocol, the study assessed the impact of three eating conditions (a meal comprising 30% of energy intake over a 24-hour period (e.g. a sandwich, muesli bar, and apple); a snack comprising 10% of energy intake (e.g. just the muesli bar and apple); and no food intake at all. Those who were eating consumed their food at 12:30 am. The results showed that while all participants reported increased sleepiness and fatigue, and decreased vigour across the night-shift, consuming a snack reduced the impact of these feelings more so than a meal or no food at all. The snack group also reported having no uncomfortable feelings of fullness as noted by the meal group. Gupta says the next step in the research is to investigate the different types of snacks and how they affect shift-workers differently. “Ultimately, the goal is to help Australian night-shift workers to stay alert, be safe, and feel healthy.”

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Curtin University and the Lions Cancer Institute Inc. have announced a new PhD scholarship that aims to improve the outcomes of people living with liver cancer around the world. The LionsLotus PhD Scholarship has been fully funded by the Lions Cancer Institute and will be based in the Curtin Health Innovation Research Institute (CHIRI) at Curtin University. The scholarship recipient, who will be supervised by A/Prof Nina Tirnitz-Parker from CHIRI and Curtin’s School of Pharmacy and Biomedical Sciences, will conduct cutting-edge research dedicated to the prevention and treatment of liver cancer. The newly appointed chair of the Telethon Kids Institute Julie Bishop has been appointed to the board of the Human Vaccines Project based in New York. Medical indemnity insurer MIGA was recognised as a 2019 Aon Best Employer, one of only 12 companies in Australia and New Zealand to receive this award. Aon Best Employers certification evaluates employee opinions to measure effective leadership, talent focus, organisational agility and employee engagement.

SEPTEMBER 2019 | 9

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FEATURE

Having a Head for Business Medicine is full of extraordinary stories. Most of them occur bedside, benchtop, diagnostically – and occasionally they happen in boardrooms.

n late July, the board of the 45-strong partnership-led Perth Radiological Clinic entered into a buy-in agreement with private equity firm Allegro. This was no little deal for the privately-owned radiological practice which has been doctorowned and led for almost all its 71 years in business. Apart from a disappointing (but ultimately instructive) dance with the I-MED radiology network that culminated in 2011 with the PRC doctor partners buying back their business, it has been run almost like a family business since. PRC chair Dr Martin Blake spoke to Medical Forum not long after the ink had dried on the Allegro agreement and, while exhausted after three months hunched over legal detail, it was clear he was proud of a deal that he and his partners believe will bring security to PRC but also offer an exciting new model for doctor practices to do business. “Allegro worked with PRC for two years in 2011-12 while they undertook the restructure of the I-MED group and had representatives sitting on our board, so they clearly saw the attraction to our doctor-based business model and our leadership team,” Martin said. “We wanted to keep our partnership model but we also saw the benefit of being able

10 | SEPTEMBER 2019

to access the long-term benefits of capital by introducing new investment partners without diluting earnings and providing retiring partners an ability to unlock the value they had created.” Allegro has brought investment entities First State Super and the Accident Compensation Corporation of New Zealand with them to the table which opens a network of investment opportunities for PRC. The investment is bespoke, in that the investment partner has interests aligned directly with the partnership and the business. There have also been 35 of the 45 doctor partners who have reinvested part of their capital back into Allegro’s investment vehicle. “We have kept to the doctor partnership model and increased the market value of the company. There is now an easy path for retiring partners to extract some of the value they have created in their lifetime of being with the business without having to sell the farm.” Martin has been straddling the two worlds of radiology and nuclear medicine with business for the past 20 years. He did an MBA in 2006-07 and it has held him in good stead. “I have always been interested in the business process since we first did the I-MED transaction in 2002. I became one

of three directors, along with Dr Rodney Greenberger and Dr Stephen Davis, who have served as board members continuously for the last 17 years,” he said. “This is one of the reasons why we started looking at opportunities because we need to refresh the board and not all of the younger doctors are as interested in assisting with the management side of the business. If we hadn’t found a partner like Allegro, we probably would have been looking at bringing external people onto the board to get outside expertise into the company and to avoid ‘group think’ around the board table.” PRC’s structure is not dissimilar to a big family company and WA has certainly seen some interesting examples of those over the years – think Perron Group and BCG. Those two companies have demonstrated two models of succession planning – with vastly different outcomes. Perron Group which invited outside expertise on to their board a decade ago continues to enjoy a rosy future. The autocracy that was BCG, sees the company being sold off to satisfy the 12 beneficiaries of the founder, the late Len Buckeridge. While PRC is not a property developer nor a construction giant, it has worked hard

continued on Page 12

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during this process with Allegro, who have been similarly approached to list or trade sale, but we explained that we had a different model that can retain substantial doctor ownership and they have been attracted to what we’re doing.”

“At this point in time, there are a number of senior partners and members of the management team who still have a few years of work left but we thought that if we are going to go through this process, it’s better to plan steadily and thoroughly now, rather than wait and dump it on those young partners coming through,” he said.

“We have hosted a couple of those businesses here over the past six months so they can see how our model actually works and it may be that in the future we end up building an investment network with these groups but that may not come to fruition and it’s certainly not our primary aim. Our prime focus is to see PRC doctors benefit from the Allegro investment with future clinical developments alongside sound business development.”

“This way we can bed down this process with them. We are hoping that with Allegro’s expertise, which they’ve gained by working across more than 30 companies in various industries, our systems and processes will improve further.” “Allegro being a private equity company will have to move on at some stage and we’re hoping, as we build a deeper relationship with their partners at First State and ACC, that they both will take on a greater investment and remain as shareholders alongside the doctors. These entities both have long-term investment horizons and our business fits their Environmental Social and Governance (ESG) profile.” “We also intend to continue to offer our associates the opportunity of partnership – starting with three in January – an opportunity which we think attracts the best radiology talent available. The investment partner along with the existing partners will get progressively diluted as more partners come into the business, so there will be a natural tendency for the investment partner to want to maintain or increase their stake as doctors retire.” “This has given us a retirement pathway for our doctors to leave in a way that doesn’t mean the remaining partners have to take on debt to pay out a retiring partner – it’s an area that can cause grief for a lot of businesses, and can cause some partnerships to stagnate.” The radiology is an expensive business

Dr Martin Blake and Martin says it’s one of the reasons for market rationalisation over the past few years. “The WA market has several major players alongside us – publicly listed companies; Sonic (SKG), Integral Diagnostic (IDX also trading as Global Diagnostics) and Capital Health, which has bought up several smaller local practices recently; as well as I-MED, which purchased Insight Clinical Imaging last year, they’re all making statements,” he said. “The companies on the stock exchange have to have a growth story and generally this is by acquisition. We didn’t want to compete in that space. If there are some smaller businesses in Perth who want to speak to us, we’re happy to speak to them but that’s not our growth strategy.” “We want private practices to stay in the hand of doctors and have spoken to a number of the larger privately owned partnerships interstate and in New Zealand

It is significant that 35 of the 45 doctor partners are reinvesting some of their proceeds into the Allegro investment entity. The partners see this as a means to diversify their investment while buffering the private PRC business from hungry listed companies. And when it comes to the PRC footprint? “Well we have been Perth Radiological Clinic for 71 years – literally. We have only operated in Perth. We have never ventured outside the metro area, so we may dip our toe outside of the metro area before planning global domination any time soon,” Martin said with a smile. “Seriously that is not what we want to do. We have all chosen to be in Perth and I don’t think any of us want to be flying off around the country telling other people how to run their businesses. People can run their businesses pretty well. However, with our model, they can retain majority doctor ownership and we both can share our knowledge and systems. We are very happy with where we are going.

By Jan Hallam

Allegro Statement Together Allegro and PRC are looking to build a long-term sustainable and renewable investment model that could reshape not only investment into other doctor partnerships but other professional service businesses as well. Allegro Managing Director Chester Moynihan said the firm had an existing relationship with PRC through its prior ownership of I-MED Network (an Allegro investment from 2011 to 2014), of which PRC was a subsidiary.

12 | SEPTEMBER 2019

“This previous involvement armed us with an understanding of the strength of the business and the growth potential of the sector. And probably, more importantly, we had existing relationships with many of the doctor partners and a strong level of trust existed, which is always critical in any transaction,” Mr Moynihan said.

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FEATURE

The Vaping Balancing Act Does vaping help addicted tobacco smokers kick that habit? Is vaping safe? Will young people be drawn to vape when they wouldn’t have smoked? All thorny questions we put to the experts. Clearing the air E-cigarettes containing nicotine are becoming increasingly popular in Australia, despite restrictions that prohibit the domestic marketing of the product and sale of the liquid nicotine required to vape them. The health debate around vaping is polarising, and muddying the waters further is the disparate findings from e-cigarette research, some of which says nicotine e-cigarettes are as carcinogenic as tobacco, while other papers claim nicotine is safe and vaping is the ultimate solution to smoking cessation.

“People attribute a lot of health concerns to nicotine, for which there is no evidence. There is no evidence it causes cancer, or lung disease, it has only a minor role in cardiovascular disease and there are some other minor effects,” he said. “It’s the drug people are addicted to but because they have always associated it with smoking, they think nicotine, and not tobacco, is the problem. People use nicotine as the argument against vaping without any evidence.” Furthermore, he suggests that vaping is relatively harmless compared with tobacco smoking.

not a lot to gain – I think there is still a lot of money being made from tobacco taxes.” “If we look at the evidence dispassionately, the smoking rates in Australia have not fallen in six years and in other countries they are falling faster than ever and the only difference is vaping.” Not approaching e-cigarettes as a harm reduction method, he says, is doing a disservice to those who can’t quit. “We are failing these people. We are not giving them a valid treatment option that is working overseas and could save lives.” Colin cites literature from the UK which supports the claims that e-cigarettes are effective smoking cessation devices.

Medical Forum canvassed a variety of opinions and attempted to follow the current evidence trail to address three questions: • Are e-cigarettes effective smoking cessation or harm reduction devices? • What harm is causal to e-cigarette usage? • Are young people starting to vape in lieu of tobacco smoking?

“There are no serious known health effects from vaping. No one has died from vaping; it has been available since 2003. Sure, we might find out one day there might be problems but from what we know of the chemistry and the science so far, the risk is small.” Colin’s message to GPs is to focus on the best outcome for a patient who can’t or won’t quit smoking.

With regards to young people taking up vaping, Colin does not think it’s the issue it is made out to be.

Reducing tobacco harm

“If you have a patient in front of you, your responsibility is to deliver the best care for that patient. If the patient is going to smoke anyway and the risk of vaping is 5% that of smoking, how can you ethically justify not recommending vaping to the smoker.”

“There is a moral panic in the US that is not evidence based. Yes, vaping has increased in the past 12 months among young people, but the smoking rate is falling faster than ever. We think that what is happening over there are kids being diverted from smoking to vaping.”

Colin believes the reluctance of the Australian government and the medical establishment to embrace e-cigarettes comes down to an inherent conservative culture.

E-cigarettes as cessation devices

A/Prof Colin Mendelsohn of the University of New South Wales and chair of the Australian Tobacco Harm Reduction Association (ATHRA) sees vaping as a legitimate form of tobacco harm reduction and especially helpful to assist smokers who can’t quit via traditional nicotine replacement therapies. “There is a huge reduction in risk and if the alternative is for the person to continue smoking, then vaping is a no brainer,” he said. Australia has some of the strictest laws for e-cigarettes in OECD countries and Colin believes this is based on a misconception.

14 | SEPTEMBER 2019

“We have no tolerance for people using nicotine or anything that looks like a cigarette, or people being addicted to any drug. There is significant political risk to take on the legalisation of e-cigarettes and

“E-cigarettes are twice as effective as our currently best available treatment,” Colin said. “What that shows is a causal relationship between e-cigarettes and quitting.”

Medical Forum spoke with addictive behaviour and smoking cessation researcher Prof Peter Hajek, from the Wolfson Institute of Preventive Medicine and the London School of Medicine. He has found e-cigarettes, at a population level, helpful to tobacco smokers to quit and particularly so for highly dependent smokers.

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Yet, are e-cigarettes more effective than other nicotine replacement therapies?

smoking-related disease and death than ever before.”

“They are more effective than nicotine replacement medications, but they have not yet been compared with varenicline, which is the most effective drug treatment for smokers,” Peter said.

“Most smokers do not have a death wish and if a safer alternative to cigarettes is available, they will, of course, switch to it.”

Peter sees vaping as a better alternative because it “represents a dramatic reduction in health risks and there are also signs that many smokers who quit with e-cigarettes stop vaping eventually as well.”

When it comes to vaping and young people, the dilemma is whether it prevents them from smoking or starts them smoking.

“If e-cigarettes prove to be effective cessation devices, there will be huge benefits to public health. We are now much closer to the goal of eradicating

MEDICAL FORUM

The gateway hypothesis

Curtin University’s Dr Michelle Jongenelis is a behavioural and physical health promotion researcher and has published a number of papers on user behaviour and e-cigarettes. In one of her studies, Michelle and her colleagues look at the

susceptibility and inclinations of young adults aged 18-25 years to vape and smoke. The findings, which correlate with studies in the US and UK, suggest young adults who had used e-cigarettes were significantly more susceptible to tobacco smoking than young adults who had not vaped. “Young adults and adolescents who have never smoked and begin using e-cigarettes are more likely to go on to smoke tobacco cigarettes – establishing a gateway hypothesis,” Michelle said.

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The Vaping Balancing Act Her researched also indicated that young people were taking up vaping instead of smoking, so a gateway was being provided for non-smoking young adults and adolescents. “It’s a whole new cohort being attracted to these devices and who could end up smoking later on.” The Australian debate around e-cigarettes is vastly different to that in the US, which has little in the way of barriers to access. Companies such as Juul, which had nearly a 40% stake in the US e-cigarette market in 2017, can market their products freely and consequently the North America e-cigarette market is the biggest in the world. It comes as no surprise then that most of the current academic literature is from the US and it reports a spike in e-cigarette use among adolescents. “And, for the first time in recent years, there has been a corresponding increase in tobacco cigarette use, which had been declining. This increase is being attributed to the growing use of e-cigarettes,” she said.

Michelle’s research found that few people aged between 18 and 25 took up smoking.

damage, mutations and tumorigenic transformation in human cells,” he said.

“Most who are going to smoke will start before they are 18 with 80% of young adults saying they never intended to smoke, but this cohort was at risk, due to e-cigs,” she said.

“Our results show that nicotine can cause all these carcinogenic effects. We then tested whether e-cigarette smoke can cause similar effects in mice. We found DNA damage in lung, bladder and heart in mice exposed to e-cigarette vapour for 12 weeks, which is equivalent to a human smoking e-cigarettes for several years.”

Given her research and knowledge of overseas literature, Michelle said the evidence at this time did not support the use of e-cigarettes as a smoking cessation method and recommended GPs to follow the recommendations of the NHMRC and the WHO. What about nicotine? Nicotine itself is a contentious topic among researchers. Medical Forum spoke with Dr Moon-shong Tang, a professor at the New York University School of Medicine and a DNA researcher. Moon-shong’s published paper suggests a correlation between e-cigarette usage and DNA harm. “The question is whether nicotine is carcinogenic in humans? Can inhaled nicotine be nitrosated in human organs? To address this question, we first must determine if nicotine can cause DNA

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These results were not what Moon-shong and his colleagues expected. “We are very surprised by our findings. Nicotine has been studied for decades. How could nicotine’s effect on DNA, its ability to repair and mutagenesis escape the attention of scientific community? It’s a puzzling question.” Moon-shong fears that e-cigarettes could be a public health issue in years to come. “It takes about two decades for tobacco smokers to develop cancer. So, I expect human cancer caused by e-cigarettes may be unravelled in decades to come. Scientists and health policy makers must think carefully before making recommendations,” he said. This evidence is counter to how Professor Peter Hajek views nicotine, referencing data from Swedish research on snus which largely replaced smoking. “Snus is oral tobacco that delivers nicotine but, outside pregnancy, carries very few, if any, health risks. The key point is that the snus experience suggests that nicotine on its own carries limited health risks, not much different from the risks of caffeine.” Name your flavour? Another unknown with e-cigarettes is the flavourings, which are largely unregulated. Medical Forum spoke with A/Prof Dr Jessica Fetterman from Boston University School of Medicine and a tobacco and e-cigarette researcher. Jessica found a relationship between e-cigarette flavourings and endothelial cell dysfunction. “Five flavouring additives – vanillin (vanilla), menthol (mint), cinnamaldehyde (cinnamon), eugenol (clove), and acetylpyridine (burnt flavouring) – all impaired the ability of the endothelial cells to produce nitric oxide. The inability of these cells to make nitric oxide is one of the early changes we see in the development of heart disease,” she said. “We already know that some of the additives such as cinnamaldehyde and diacetyl cause respiratory symptoms and, if inhaled at high enough doses, pulmonary diseases. The vast majority of e-cigarette liquids contain

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“We identified a cohort of e-cigarette users who had never smoked tobacco reporting wheezing and related respiratory symptoms,” she said. These symptoms were worse for current vapers who were smokers, but not isolated to them. Conflicting findings, similar outcomes We found a vast gap between the evidence, depending on which data set we drew on, with some academics finding e-cigarettes to be damaging and others finding nicotine to be harmful. In fact, depending on who you ask, we could be facing a public health dilemma in decades. While others believe nicotine is safe and vaping presents a low health risk (some say 95% less harmful), especially in comparison to cigarettes. But does this address the potential harm of that 5%? What we heard repeatedly was: “it is better to not vape, if you can help it, as the evidence is not clear.” However, the reality is that upwards of three million Australians are smokers and this figure has stagnated over the past few years, so the question really comes down to this: Is it better to vape than smoke? nicotine and we’ve found that the newer pod-style e-cigarettes further enhance the absorption of nicotine, which raises serious concerns for heart health.”

the long-term effects of e-cigarette use, the early studies are indicating that they are not a reduced-harm product when it comes to heart health.”

With regards to long-term users, Michelle believes e-cigarettes may increase the risk of heart disease later in life.

Harm to the lungs

“The levels of carcinogens appear to be lower in e-cigarettes but many other chemicals in the liquids are known to have significant cardiovascular toxicity. While it is likely to be some time before we know

Medical Forum spoke with A/Prof Dongmei Li from the University of Rochester School of Medicine and Dentistry and Center for Research on Flavored Tobacco Products. She said there was evidence at a population level of potential harm of vaping on lung tissue.

The science jury is still out. What we do know is nicotine is extremely addictive and tobacco smoking is a major public health issue. So, if vaping is useful for smoking cessation, then it may well be a “no brainer” like Colin Mendelsohn says. But when it comes to a new generation of long-term vapers, the evidence might be many years away.

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INCISIONS

Coal Has to Go The WA Government has announced the shutdown of two old coal-fired power generators at Muja. Dr George Crisp urges more action for our health’s sake. It is not a question of if, but when. Whether as a consequence of action to reduce greenhouse emissions, or due to newer, cheaper energy generation technologies, coal-powered electricity will inevitably be phased out. Our coal-fired power stations are mostly old and have poor – by international standards – outdated emissions control systems, meaning they produce more air pollution per kilowatt hour of electricity generated than similar plants overseas. These pollutants – particulate matter, oxides of nitrogen and sulphur – are known to be toxic in both the short term and with chronic low-level exposure. While the occupational risks of silicosis and ‘black lung’ are well known, it is actually fine particulate matter (PM2.5) predominantly produced from coal combustion that is responsible for the vast majority of health impacts related to this industry. PM2.5 causes heart disease, strokes, asthma, lung cancer, preterm birth and type 2 diabetes.

There is no safe level of exposure, or threshold, meaning that harm occurs at even low levels such as those found in Australian cities and towns.

The recent announcement by the WA government that two of the four units at the Muja power station will be closed in October 2022 is therefore potentially good news for the health of both the local communities and regional population centres as far away as Bunbury and Perth (as particulate matter is stable in the atmosphere and travels large distances).

Particles are produced directly by coal combustion (and mining) but also form secondarily in the atmosphere from tiny carbon nuclei absorbing airborne nitrates, sulphates, heavy metals and hydrocarbons. It is the size of these particles, rather like those produced by asthma inhaler devices, that determine the site of deposition in our respiratory system and thus enabling them to deliver toxic compounds deep into our lungs and into our circulation.

However, this impending energy transition, with consequent loss of employment and income and secondary impact on communities, has potential social costs; the more unexpected and rapid, the greater the impacts, whereas, early recognition and forward planning and community involvement can avert them.

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Minimising social harm can also be mitigated through policies to strengthen the local economy by supporting new industries, training and entrepreneurship, by investing in physical infrastructure such as housing, transport and mine site rehabilitation, as well as measures that support local culture and community cohesion.

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FEATURE

Silicosis: A Fatal Cut Silicosis, a once forgotten group of dust diseases, has reared its ugly head again with incidence rates in Australia escalating at an alarming rate. But why?

ilicosis is a group of lung diseases caused by exposure to respirable crystalline silica, a biologically active dust that can accumulate in the lungs and, depending on the level of exposure, can cause terminal damage.

The severity of silicosis is defined by three clinical categories: • chronic/classic silicosis, which can occur after 10-30 years of low levels of exposure • accelerated silicosis, which can occur within 10 years of high levels of exposure – this type of silicosis is being most commonly diagnosed in this new generation of cases • acute silicosis, which can occur after a few weeks of extremely high levels of exposure. There is no effective treatment and it usually presents asymptomatic until the level of exposure has caused significant damage. Often people with silicosis don’t know they have it until it is too late. The silicosis cases in Australia have mostly come from occupational exposure, particularly in the stonemasonry sector, where stonemasons are working with products containing silica, such as sandstone, tiles, bricks, concrete, granite and, most significantly, engineered stone. Workers who are exposed to crystalline silica dust particles tend to polish, cut, sand, drill or blast silica-based materials. Some of the highest risk workers are those working with engineered stone products commonly installed as household benchtops. Those who are working on site and dry cutting without vacuum extraction are especially at risk. The most concerning product is engineered

20 | SEPTEMBER 2019

stone which can have a silica concentration of up to 90% or higher. This material features a small percentage of stone bonded by adhesives. Natural stone products have a silica concentration of about 40%. It has been estimated that 6.6% of Australians are being exposed to occupational respirable crystalline silica dust, with 3.7% being highly exposed. Union action Medical Forum spoke with Owen Whittle, the assistant secretary of Unions WA, who said the spike in silicosis cases was not unexpected. “We’ve long held concerns about dust management in the industry. There seems to have been a loss of focus in regards to dust. We have been agitating for action around monitoring and regulation,” he said. The first cases in this new wave of silicosis occurred in the eastern states of Australia, in particular Queensland, which has so far recorded the most cases of the disease. “That sent shockwaves through the union movement, with our concerns around dust management coming to bear in the unique circumstances of manufactured stone industry,” he said. In WA, Owen places some of the blame on the defunding of the occupational health and safety regulator, WorkSafe.

understanding of their processes is that while they have had a range of inspections in workshops, there hasn’t been much, if any, on-site installations in people’s homes.” It is in these uncontrolled environments, says Owen, that pose the greatest exposure risks. “In a workshop it’s easier to control dust management, even though I think it has been done really badly in a range of places. Normally the workers who are sent out to install the artificial stone aren’t given the appropriate tools or time to install it in a way that it is safe.” “Silica, or dust, is not a new occupational hazard. This is an issue that has been around for a very long time and there is no excuse. The importers of artificial stone know that it has anywhere between 9095% silica content. There is no excuse for ignorance here, it merely comes down to cost cutting.” Regulation exists Another sobering fact is that existing regulations are in place with employers obligated to ensure employees are operating in safe working environments. However these regulations have have not been enforced and there has been little in the way of employee education.

“Successive governments have reduced the resources available to WorkSafe to do proactive inspections, not just on silica and dust, but on any other occupational safety issue,” he said. “Worksafe has begun an inspection regime for artificial stone benchtops, which is encouraging but I think there are still a lot of elements of the industry that are yet to be touched by the regulator. And my

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FEATURE “Talking to workers in the industry, some have been diagnosed or have precursor conditions to silicosis and are still working. It’s their trade, it’s their livelihood, they just can’t afford to walk out and be unemployed,” said Owen.

silica has been known as a respiratory hazard. It was quite a problem in mining many years ago. Those industries which had problems introduced controls and there were very few cases of silicosis after that time,” Sally said.

“What’s concerning for us, industry is not moving fast enough to protect their workers; workers are being left in the lurch and are going through mental stress fearing their future health.”

When silicosis cases appeared in Queensland in 2017, WorkSafe began enforcing safe working standards in specific industries.

Although it may be easy to draw parallels with the asbestos disaster, Owen sees a clear point of difference. “The regulations to prevent silicosis are there, it’s just a matter of the appropriate compliance. That’s the main difference between now and when asbestos was emerging as an issue,” he said. “There is power for the regulator to act and there are also very strict requirements on employers to conduct health surveillance on their workers when they are exposed to silica. It was just never done.” WorkSafe action Sally North, Director of WorkSafe Service Industries and Specialists Directorate, said although the danger of crystalline silica dust particles was known to WorkSafe, the regulator was caught blindsided like the rest of the industry. “We have had information about silica hazards on our website for years because

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“Anecdotally we knew these benchtops and similar products were becoming increasingly popular, so we started to take regulatory action across the last financial year. We began visiting targeted workplaces to see how compliant they were with the existing OHS legislation.” “There were and are regulations around silica substances with requirements to pick up on hazards, do risk assessments and conduct air monitoring, where the need is identified.” Yet, without enforcement, the industry has been operating too long with too little oversight and the result has been the rise in individuals with silicosis. “If the regulator isn’t proactive in doing its own monitoring of silica dust and not carrying out ongoing inspection campaigns, we will continue to see cases of silicosis and still see workers exposed

to 90-95% silica dust without any personal protective equipment.” WorkSafe has visited around 30 workplaces and found many to be noncompliant, according to Sally. “We have undertaken a fair amount of compliance enforcement and do hold some concerns that the compliance in the industry isn’t as good as we would like to see it, which is why we are continuing and expanding the project.” “Employers should be providing health surveillance medicals with an appointed doctor for these employees. Not all employers might be doing this, so if someone presents to their GP and they have a concern about silica exposure, the GP can contact Worksafe to get some further information regarding medical screening.” https://www.safeworkaustralia.gov.au/doc/healthmonitoring-exposure-hazardous-chemicals-guidemedical-practitioners

Indexed case redux To understand just when and how silicosis re-emerged as a health problem, Medical Forum spoke to Deborah Yates, a respiratory physician at St Vincent’s Hospital and University of NSW. “The re-emergence of such an old group of diseases is a lesson to us in terms of

continued on Page 23

SEPTEMBER 2019 | 21

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Silicosis: A Fatal Cut complacency because wherever there is silica exposure there is likely to be disease. Australia has quite a lot of industries such as mining that exposes workers to silica.” “We described the first indexed case in a patient in NSW. It was about 2016 when I first saw him. And he was referred to me by some colleagues in Bankstown and I was shocked, I have to say. I saw a lot of cases of silicosis in England but not with bad disease. This man had terrible disease, the sort of disease I hadn’t ever seen.” Conferring with her colleagues, Deborah discovered they all had silicosis cases. “It was at that stage we thought we should write them all up and put our cases together. That was pretty frightening because when did that, we found that all the cases were from exposure to artificial stone. It was evidence that these people were getting much worse, more quickly, than we would expect from classical silicosis.” To date, Queensland has the most reported cases of silicosis, which Deborah attributes to that state’s health department having the systems in place from dealing with the re-emergence of pneumoconiosis (black lung) from the increase in coal mining activity. Message for GPs Although silicosis can present asymptomatically, one of the key indicators in identifying an at-risk patient is the relationship with their GP who has a working knowledge of their patient’s employment history. “The GP is the key player in preventative health and that’s the most important thing really. Catch it early. Look for any history of silica exposure, working in the mines or with artificial stone benchtops – any industry exposed to silica and there a so many of them, concreting, tunnelling, road making,” Deborah said. “Those are the traditional industries; artificial stone is one of the newer ones. Any industry that involves cutting of stone or moving sand or using silica in industrial processes is potentially a risk.” Federal recognition? The Morrison government went to the last election with a promise of action to tackle the issue of occupational dust diseases and in July the Taskforce to Tackle Silicosis and Other Dust Diseases was launched with a $5 million commitment to developed a national strategy to prevent, identify early, control and manage dust diseases, in particular silicosis. With the formation of the taskforce, numerous specialists have become

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involved on a national policy level. WA respiratory physician A/Prof Fraser Brims, Deputy Director of the Institute for Respiratory Health and chair of the Western Australian Mesothelioma Registry, is on the taskforce. Fraser says the taskforce will examine the issues at a national level, both from an occupational health and safety perspective to reduce exposure and also from a clinicians’ response perspective. “How do we screen and case find, and what do we do with people down the line,” he said. The taskforce was an opportunity for the medical community to work together in addressing silicosis by using a national register which would identify trends in diagnosis. “Seeing trends emerging, means faster response and, of course, identifying occupational groups,” he said. Fraser has, himself, seen one silicosis case in WA – a stonemason, but said WA hasn’t quite got up and running yet with a formal screening program to case find. “I hope this will be happening in the next couple of months, in partnership with WA WorkSafe.” Difficulty in diagnosis Fraser said the real challenge of silicosis was that patients could be asymptomatic. “They can have normal lung function but still have radiological signs of disease. Common sense would be chronic cough and breathlessness on exertion. Lung function can be variable but there could be an obstructive ratio, so reduced FEV1 (forced expiratory volume),” he said. “Many of these people are relatively young – often in their 20s and 30s. So it’s starting when symptoms don’t really fit in – it’s too early potentially for COPD and smokers.”

Again, the relationship with the GP is so important. “It’s actually more about identifying what their occupation and exposures are, considering many might not have symptoms but they could be exposed and could have early signs of disease.” “The frustrating and honest truth about silicosis is there is no treatment. We need to stop exposure, and stop any tobacco smoke exposure. We have to find it early so vigilance of chronic symptoms that can’t be explained is required.” “I urge GPs to ask their patients ‘what’s your job? Do you breathe in any of these chemicals or dust?’ and if they are stonemasons and have been exposed to silica dust, to adopt a very low threshold for investigation.” Testing risk in court A legal class action has been mounted to test if the suppliers of engineered stone are responsible for occupational exposure to respirable crystalline silica in plaintiffs suffering from silicosis. The previous national exposure standard for crystalline silica was 0.1mg of airborne particles per cubic metre, which was considered to be dangerously high. A new national standard has been agreed to lowering the exposure level to 0.05mg/m3. Owen Whittle said the new standard was a step in the right direction though even at that level, some workers still risked silicosis. “What we need is a standard that is based on the science which says quite clearly that 0.02 is preferable even though there is no safe level of silica exposure. We need to get it down to the lowest possible level of exposure to protect workers.”

By James Knox

SEPTEMBER 2019 | 23

Countering Fear of Drug Allergy Drug allergy is keeping our allergy services increasingly busy, but Dr Michaela Lucas believes general practice could save the day.

he famously tragic case of David Vetter, the Texan child whose Severe Combined Immunodeficiency (SCID) resulted him living out his 12 short years of life inside a sterile bubble, made global headlines in the 1970s and 80s.

Despite his condition being the awful luck of genes and exceptionally rare, David Vetter’s SCID and his doctors’ novel treatment approach may have done much to fuel parents’ angst that the modern world was harming their children. So have food, drugs and air quality changed so drastically that we are becoming ultra-sensitive to allergens? Or is it that human biology has changed? Or has it simply always been so and we are only now discovering the science to name it? Clinical immunologist and allergist Dr Michaela Lucas, who is based at Sir Charles Gairdner and the Perth Children’s Hospital working on drug allergy, believes it is a combination of all those things. “There has been a true increase in allergies as a result of our modern lifestyle – allergies across the board, from food to medication,” she told Medical Forum. “It was led by the increase in diagnosis of (allergy-related) asthma which has since plateaued but there remains a level of concern among consumers and some within the health profession.” “Doctors are concerned about protecting their patients from harm, including medication intolerance, which is not the same as immune-mediated drug allergy. In particular, doctors and patients may overestimate the likelihood of a true allergy to an antibiotic, commonly penicillin, leading to an avoidance of that drug needlessly.” “This avoidance is leading to the increased use of broad spectrum antibiotics which has been linked to the emergence of antimicrobial resistance. However, lack of clinical testing and failings in current documentation practices may not protect patients with true allergy nor those who mistakenly believe they are ‘allergic’.” “There is a lack of consistent education in

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the antibiotic allergy field, and no clinical pathways to guide practitioners if someone with a selfreported penicillin allergy walks through their door.” Michaela, along with colleagues Drs Richard Loh (Perth Children’s Hospital) and William Smith (Royal Adelaide Hospital), published an article in the February issue of Medical Journal of Australia highlighting the importance of national registries for people with verified drug allergies to increase patient safety, particularly in emergency situations. They wrote: “In Australia, drug allergy is the most common cause of fatal anaphylaxis. Drugs implicated in anaphylaxis deaths are antibiotics, anaesthetic agents, non-steroidal anti-inflammatories and radiocontrast media. Anaphylaxis and other serious drug allergy reactions are largely unpredictable; however, the risk is clearly elevated in patients who have had a previous reaction, offering an opportunity for prevention. In limited situations, genetic testing for risk of severe cutaneous drug reactions (e.g., abacavir, risk allele HLA-B*57:01) is also predictive.” “A review of coronial findings in four drug allergy-related deaths between 2011 and 2013, conducted by the Australasian Society of Clinical Immunology and Allergy Drug Allergy Working Party, identified deficiencies in the knowledge and skills of health care professionals, including: • a lack of knowledge in recognising and appropriately managing severe allergic drug reactions; • unclear documentation of drug allergies; • a lack of knowledge with regards to generic versus trade names of drugs, and the potential cross-reactivity of drugs;

• poor communication of known allergies (e.g. ignoring medical alert jewellery); and • misuse of terminology (e.g., “sulpha” instead of a specific drug name such as sulfamethoxazole). “Therefore, improved education, communication and documentation are essential to prevent further fatal outcomes.” Michaela says that while these deficiencies make it more difficult to get a true picture of the extent of drug allergy, there is no doubt that there is a true increase in incidence of allergic diseases. While she said the allergy community in WA was small, it was growing with allergy services being established at PCH, SCGH and Fiona Stanley Hospital. “We started from humble beginnings but now the clinics are busy and drug allergy comprises about a third of all the work we do,” she said. “At SCGH we have implemented a drug allergy training module for registrars and other colleagues. Going by the number of emails I get from other public and private hospitals, there is a growing need for dedicated drug allergy services,” she said. “Of course these services go hand in hand with antimicrobial stewardship practices because much of the drug allergy assessment concerns putative penicillin allergy which is commonly reported by patients.”

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“The US is leading the way here, tackling the problem of incorrect antibiotic allergy labels, but in Australia we have taken a similar approach and have proposed an evidence-based risk assessment strategy to determine how and when to test for antibiotic allergy. This approach will be published shortly in the Journal of Allergy and Clinical Immunology in Practice.” “I personally feel that other than having more time to take a detailed history, there is not a lot of difference between what a specialist can offer and what a GP can provide.” “In our current paper, we propose an algorithm to determine who would benefit from skin testing and who could be treated directly, in a way similar to a risk assessment for any vaccination or iron infusion. GPs treat some severe reactions to vaccination, so assessing drug allergy in many cases wouldn’t be much different.” “The paper provides good evidence that with models and standards of care, GPs can take on these cases. However, we need to access sustainable funding from within the MBS, because GPs are not reimbursed for this kind of care.” “It’s one thing to empower GPs to take on

this work and another to make it viable, and it can only be viable if it is funded.” In the MJA article, the authors recommended that among the priority areas for GPs to address was an improvement in the quality of the drug allergy history, which should be complete with contemporaneous details of the reaction, culprit drug, reaction type and severity. Michaela suggested that standardised formats for electronic health records would facilitate the accurate documentation of adverse drug reactions including allergy. A more extensive understanding of the mechanisms of drug allergy and the likelihood of cross reactivity was also highlighted together with the confidence to understand the risk of reaction. With so many antibiotic reactions being self-reported, the paper asserts the importance of verifying or dismissing drug allergy labels. “Communicating drug allergy information and drug avoidance advice, such as degree of contraindication, is of central importance, particularly in emergency and perioperative situations as well as in any clinical context, including community

c e s t r a Sm

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practice, hospitals and pharmacies. This could be achieved through well designed, linked and reconciled local or national EHRs, national registries of verified drug reactions, and validated medical alerting devices,” they write. Time is of the essence. With antimicrobial resistant bacteria becoming a growing spectre, a lot of work on drug allergy is being done in this context. Michaela points to a paper by a US colleague, Kimberley Blumenthal, who suggested that a patient with a penicillin allergy admitted to hospital stands a greater chance of developing an infection with multi-resistant bacteria. To have these patients identified and tested in primary care will help. “We might be OK now but if we don’t make changes to our system now and preserve our antibiotics we will definitely run into trouble in 50 years’ time. And patients who have complex drug allergies who have to avoid antibiotics are often those most vulnerable,” she said. ED The 30th annual conference of the Australasian Society of Clinical Immunology and Allergy will be held in Perth at the PCEC starting on September 3. Dr Michaela Lucas is the conference chair.

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*Approx

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How to refer a patient for a sleep study From 1 November 2018, MBS items for sleep studies changed to ensure patients with proven sleep disorders are better identiﬁed and more appropriately managed. The changes help doctors refer patients for the most suitable test for them, depending on how likely they are to have a sleep disorder. Below is a guide for Medicare compliant sleep study referrals.

Investigation of Obstructive Sleep Apnoea (OSA) Option 1

Option 2

Refer for a Sleep or Respiratory physician consultation

Complete ESS & Stop-Bang screening tools Both screening tools meet criteria

Only one screening tool meets criteria

Refer for sleep study. Ensure co-morbidities are listed

Refer for a Sleep or Respiratory physician consultation

GenesisCare team will book patient for appropriate test as per MBS requirements

Neither screening tool meets criteria

Review need for sleep testing

No investigation

Redo screening tools in future if symptoms or risk factors change

Refer for Sleep or Respiratory physician consultation

All other sleep tests � investigation of non-OSA sleep disorder � CPAP initiation study � all treatment review studies (CPAP, MAS, post-weight loss, post-surgery)

Option 1 ONLY

Refer for a Sleep or Respiratory physician consultation

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Nuts and Bolts of VAD With heightened emotion swirling around Voluntary Assisted Dying legislation, some of its details are being lost. Here are some of the key points.

n 2017, the Victorian Government passed the Victorian Voluntary Assisted Dying Act, and the legislation came into effect in June 2019.

to the legislation, while the AMA is opposed to voluntary assisted dying.

Victorian woman Kerry Robertson, 61, was the first person under the Victorian legislation to choose a voluntary assisted death after battling cancer since 2010. She died on 15 July.

Eligible patients will need to fulfil the following criteria:

Western Australia may soon follow Victoria with the Voluntary Assisted Dying Bill, which is scheduled for debate in the WA parliament at the time of going to press. All members will be given a conscience vote. The proposed WA bill closely follows the Victorian law with regards to patient request, assessment process and eligibility criteria. When the Victorian law was passed the RACGP published a statement supporting GPs’ role in VAD but insisted they must be protected from coercion from either direction. GPs who wish to assist under these laws must be vocationally registered, and complete a six-hour online training course to secure a permit. About 100 GPs had registered in advance of the laws coming into effect on June 19, with others expected to register only when they received a request from a patient. The college has given its cautious support

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Medical Forum has complied some of the key points for patient eligibility and health care providers.

• Patients would be in the advanced stages of a medical condition in which it is expected they would die within six months; that time criteria stretches to 12 months for patients with neurodegenerative condition. • Patients would be Australian citizens and residents of WA for at least 12 months. • Patients would be aged over 18 and be assessed by two doctors. • Patients must make three clear requests to die; two verbal and one written. The requests would have to be signed off by two doctors independent of each other. • Patients would have to have decisionmaking capacity; patients with Alzheimer’s disease or dementia would not be eligible. • Two witnesses would be required for any VAD request and they would need to demonstrate they would not benefit financially from the person’s death. • A review process regarding application can be requested by either a patient or a health practitioner.

Information for health care providers: • Doctors could raise the subject of VAD with patients. This differs from Victoria where the patient must raise the subject. • Doctors would be the only health professionals allowed to sign off on an assisted dying request • Doctors or nurse practitioners could administer the VAD medication at the request of the patient, or the patient could choose to self-administer. This differs from the Victorian legislation and is included on primarily equity of access grounds given the size of WA. • A VAD board would manage the system to ensure the VAD process has been lawfully followed through each stage of the procedure • Doctors could decline to partake in the VAD process but they would be required to immediately inform the patient of their conscientious objection. • Doctors could be required to provide standardised information to patients. • There would be a minimum of nine days from the initial request to approval for VAD. • To ensure patients are not coerced into requesting VAD, new criminal offences would be introduced.

SEPTEMBER 2019 | 27

Residents’ Rights in Aged Care With the Berrington group going into voluntary administration, Special Counsel David McMullen explores what safeguards residents have. On 4 July 2019, Berrington Care Group Pty Ltd and Berrington Group Pty Ltd went into voluntary administration. Berrington is a well-known provider of residential aged care to the premium end of the Perth market, and its voluntary administration has attracted considerable public interest. Far from being a poor not-for-profit, Berrington is reported to have collected about $120-134 million from residents for their accommodation. The Berrington situation is a springboard for a broader discussion about what happens when an aged care facility goes into administration (voluntary or otherwise). Many readers will have dealings with aged care facilities – either in a professional or personal capacity. Among the refinancing, legal responses, media coverage and regulatory activity that ensues when an aged care provider encounters financial difficulty, there are vulnerable elderly residents relying on the provider for their care needs. When Berrington’s administrators were appointed, they acknowledged the uncertainty that their appointment might cause, and they undertook to work closely with the companies’ senior management team, secured creditors, suppliers and the Commonwealth Department of Health to ensure that quality of care was maintained and the health and wellbeing of residents was protected. While on an operational level it may be business as usual for now, detailed assessment of the finances and business of the companies is going on in the background. In the Administrators’ words: ‘The Administrators are immediately seeking a sale of the business as a going concern or restructuring of the company through a Deed of Company Arrangement. The future of Berrington is likely to involve either: 1. Berrington being sold to an alternative aged care provider. 2. Berrington continuing under its existing or alternative ownership structure through a Deed of Company Arrangement. 3. Berrington’s operations are wound up’. The outcome remains to be seen but Berrington’s voluntary administration will not be the only one likely to affect the

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aged care sector in the foreseeable future. Industry analysis suggests that for the three months to 31 March 2019, more than 45% of aged care facilities operated at a loss before tax. What about the residents? The Administrators’ apt summary of the main options – sell, refinance and/or restructure, or wind up operations – offers a way out of a difficult situation for the owners, but what of the residents caught in the middle? What happens to them? There are some outcomes that could be relatively seamless from a resident’s perspective. For example: • The provider could refinance (even if that involved bringing in a new part-owner as an additional source of capital) and continue operations. • The business could be sold as a going concern to another provider, with assets and liabilities – as well as all operations and responsibility for residents – passing from one owner to the next. However, the commercial reality could be different. An approved provider might ultimately find themselves having to wind up, putting residents in a precarious situation. While residents do enjoy security of tenure at law, there are a limited number of circumstances in which they may be asked to leave a care service. These specifically include where the service is closing. Fortunately, although a facility closure would certainly be disruptive and distressing, the practical reality is that residents might not necessarily be left searching for a new home. There are least three reasons: Firstly, part of security of tenure means a provider must not take action to make the care recipient leave the residential care service, or imply that the person must leave, before suitable, affordable alternative accommodation is found. Secondly, each residential aged care place has a certain monetary value. There is in fact a market for the buying and selling of these places. Buyers may be new entrants to the aged care industry, or existing providers looking to upscale or expand into a new region. The transfer process is prescribed in the Aged Care Act, with resident care and wellbeing very much at the forefront. In summary: • An approved provider may give the

Secretary of the Department a transfer notice, in order to transfer an allocated place to another person who is (or who is to become) an approved provider. • On receiving a transfer notice, the Secretary will consider matters such as the suitability of the transferee; their financial viability; suitability of their premises; adequacy of the standard of care, accommodation and other services; adequacy of proposals to ensure that care needs are appropriately met; and any evidence of past satisfactory conduct and compliance. • The transferor must give such records as are necessary to ensure the transferee can provide care in respect of the places being transferred. • The Secretary retains a right of veto. (So long as the transferee is an approved provider on the transfer day and the transfer has not been vetoed, the places are allocated to the transferee.) Thirdly, there would be significant political pressure to ensure all residents were safely relocated. This was achieved in the recent example of Earle Haven – a co-located campus with a big retirement village and an aged care facility in Nerang, Queensland. The facility abruptly closed on 11 July 2019, forcing 68 elderly residents to relocate to other residential facilities and hospitals. Protection of residents’ money Since 1 July 2014, residential aged care accommodation has been payable by way of a Refundable Accommodation Deposit (RAD), a Daily Accommodation Payment (DAP) or a combination of both, replacing the previous accommodation bond and charge arrangements. As their name suggests, RADs are refundable when a resident leaves an aged care facility (subject to deduction of any applicable costs and charges). Where an aged care provider goes into administration, thoughts will quickly turn to resident funds held by the provider. RADs are not quarantined or held on trust like a residential tenancy bond, for example. RADs can in fact be applied to a range of permissible uses under the Aged Care Act such as capital works, making loans or even investment in financial products. They are in essence an interest-free source of funds to a provider for the duration of a resident’s time at a facility. (RADs are discussed further here: https://www.pmlawyers.com.au/articles/ news/permitted-use-of-refundableaccommodation-deposits/ )

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Residential care recipients who pay for their accommodation (in whole or in part) by way of a RAD may, however, have protection under: • Australian consumer law; • contract law (specifically, the terms of their agreement with the aged care provider); • the Corporations Act; • provisions of the Aged Care Act and related principles relating to the payment, management, permitted use and refunding of RADs. The last line of defence is the Commonwealth Accommodation Payment Guarantee Scheme under the Aged Care (Accommodation Payment Security) Act 2006. The Guarantee Scheme covers all residents of Australian Government subsidised aged care services who have paid a RAD to an approved provider. The Guarantee Scheme is necessary because RADs do not have special priority in the administration process. They cannot simply be paid out on demand by administrators because they must compete with other debts and liabilities owed by an aged care provider. In short, the Guarantee Scheme protects a resident’s right to be repaid a RAD, but it is important to understand the nature of this protection: • The Guarantee Scheme is not automatically triggered when an aged care provider encounters mere financial difficulty. • The Guarantee Scheme is triggered when an ‘insolvency event’ occurs and the repayment of at least one RAD balance is overdue. In brief, an insolvency event as defined in the legislation would usually occur by the winding up of a company. Involuntary

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administration such as Berrington’s is not an insolvency event. • As soon as practicable after becoming aware of an insolvency event and there being at least one outstanding RAD balance, the Secretary of the Department must make a default event declaration. As soon as practicable after determining the amount of any outstanding RAD balance, the Secretary must then make a refund declaration (declaring the amount that is to be repaid, with interest). The Commonwealth then pays the refund amount within 14 days after making the refund declaration. So there is a statutory process to follow where the Guarantee Scheme is to be enlivened but this process takes time. Berrington’s Administrators, for example, have successfully obtained an extension from the Supreme Court of Western Australia to hold a second creditors meeting by early November 2019, which will be almost four months after the companies went into voluntary administration. So, while the Guarantee Scheme may ultimately protect a RAD, if monies were needed in an emergency, there may not be any assurances as to how quickly this would occur. Note also that the Guarantee Scheme does not cover every type of sum that aged care providers collect from their residents. On our reading of the terms of the Guarantee Scheme, the Commonwealth would not be obliged to cover fees paid on a daily basis (for example DAPs, or other fees payable for care and services in addition to a RAD or DAPs). It is not uncommon for such fees to be paid monthly in advance, which in the aggregate

can amount to significant balances being left unprotected by the Guarantee Scheme. Other implications Despite all these protections, if a care provider goes into administration (or worse), one might still anticipate: • problems between the aged care provider and their suppliers and contractors, where security of payment is in issue; • anguish for residents and their loved ones at the prospect of relocation – even if this never eventuates; • concern at the potential loss of sums paid to the provider (even if RADs are covered by the Guarantee Scheme); • concerns around ongoing quality of care, particularly where a provider is straining to cut costs and achieve efficiencies; and • decreased staff motivation and morale. An administrator’s duties are not necessarily incompatible with the smooth operation of a residential aged care facility. In Berrington’s case, we are not aware of any concerns reported by the Department in relation to a decline in quality of care attributable to the voluntary administration. Nevertheless, at times, the priorities of an aged care provider will inevitably diverge from those of an administrator. While there may not be cause for immediate panic when these circumstances arise, it is important to understand the potential impacts – and the safeguards – for residents. ED: David McMullen is Special Counsel at Panetta McGrath Lawyers and has a particular focus on retirement villages, health and aged care. Disclaimer: The content of this article is intended to provide a general overview and guide to the subject matter. Specialist advice should be sought about your specific circumstances.

SEPTEMBER 2019 | 29

30 | SEPTEMBER 2019

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GUEST COLUMN

When e-Cigs Cloud the Scene… Nicholas Wood from Cancer Council WA says it’s safer to keeping the focus on proven methods for smoking cessation. Buoyed by an addictive nicotine-based recipe, e-cigarettes and other novel products are proliferating, notably among young people. It’s important to point out that here in Australia these products have not been approved nor recommended by the Therapeutic Goods Administration. A minority of advocates argue that e-cigs are harmless, and that they could be “the missing cessation element” for individuals wanting to quit smoking. For some then, there may be questions at large. While no long-term data is available, there are concerns regarding their safety. Nicotine has been linked to cancer, cardiovascular, respiratory, and brain development issues. Even flavourings in ‘non-nicotine’ e-cigs have been found with traces of carcinogens. Large reviews conclude then that e-cigs are likely to be detrimental to health, only the degree to which is yet unknown.

Further research will likely show. As a cessation aid, the evidence for e-cigs is mixed. There is limited evidence of successful long-term cessation, and shortterm success is varied too. Australian data shows that only 13% of young adult e-cigs users do so for smoking cessation. In fact, the most common reason is that they are perceived as “fun, enjoyable or cool”. Lessons from North America where regulation is lax suggest that this might be creating a gateway phenomenon; that is, where e-cig usage occurs, combustible cigarette usage increases and normalises too. The public health consequences of reversing tobacco trends would be devastating. So given these unknowns, there are tried and proven methods for cessation. Cancer councils advocate for a succinct model when supporting smokers. After offering brief quitting advice, the best evidence suggests helping patients by:

• Referring to multi-session behavioural interventions conducted by the Quitline (referrals can be made online) • Explaining and providing appropriate pharmacotherapy.

While doctors identify most smokers, as few as one in 10 arrange follow-up support. With the time-efficient process above, this need not be the case.

Some smokers may feel disenfranchised by pharmacotherapy, and may be tempted to try e-cigs. Combination nicotine replacement therapy, however, is likely to remedy this.

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With advice and the support of the Quitline, patients have a 16% chance of abstinence using one type of nicotine replacement product. When combining products – such as a long-acting patch with a short-acting lozenge or gum – abstinence increases to 21%. A prescription of Varenicline can further increase effectiveness to as much as 25%. Common pitfalls for failed quit attempts are constant withdrawal symptoms or acute cravings. Combination therapy seeks to address both of these adequately. With only around one in five Australians using best practice for smoking cessation, there’s a lot of room for improvement. Cancer Council’s easily applied model should lead to better success without recourse to e-cigs. ED The author acknowledges the assistance of Doris Neuwerth, from Cancer Council WA.

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NEWS & VIEWS

Spotlight on Fees and Gaps A collaboration between the AMA and the federal government has resulted in a financial guide to help patients find out what they need to know from their doctors.

he AMA and the Morrison government have launched the Informed Financial Consent (IFC) information guide with the objective of demystifying the costs associated with how health care is funded and ultimately what it will cost for patients.

The guide includes an Informed Financial Consent Form for doctors and patients to use together; information on fees and medical gaps; and questions for patients to ask their doctors about costs. Although the guide was an AMA initiative, it has since gained traction and been developed in collaboration with the medical colleges. National AMA President Dr Tony Bartone said his organisation supported and actively encouraged full transparency of doctors’ fees. “We unreservedly condemn egregious billing, which occurs in a very small percentage of cases. In fact, the AMA

is taking extra steps to help patients understand medical fees,” he said. The guide breaks down the costs of medical services, which could potentially shape patient choice when it comes to which health care provider. “The guide explains to patients that the same doctor performing the same procedure can be paid significantly different rates by each fund. This is often the untold story behind patient out-of-pocket costs, and one that is hidden by high levels of no gap and known gap billing statistics.” While the guide is focused on the specific prices of services, the AMA hopes it will empower patients to develop greater financial literacy to “be equal partners in fee conversations with their doctors.” Alongside the guide, the Health Department hopes to have a website up and live by the end of year, focusing on transparency of specialist fees, MBS benefits and gap payments. There is no obligation for healthcare

providers to be in the guide or to make their prices transparent. However, Health Minister Greg Hunts added: “Those who don't, will have a very clear light shone upon them, and they will have to explain why they don't want to participate. I do expect doctors to participate and we've had a very positive response. Medical organisations have been the leaders in this because they want to make sure that anybody who has egregious practices is exposed.”

A NETWORK OF HIGH-QUALITY CT LOCATIONS Western Radiology offers the latest Cardiac capable CT technology with minimum 128-Slice scanners at every branch. These new-to-market systems provide exceptional image quality while simultaneously lowering radiation. Coupled with same-day appointment availability, our service culture and patient care, we exceed the standards of other community operators.

GPs and Specialists can readily access: CT Chest assessments with and without contrast at inherently low radiation. Comprehensive CT vascular imaging – Body and Peripheral Angiogram, Aortogram and Venogram. Cardiologist reported Calcium Scoring and CT Coronary Angiogram.

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

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SEPTEMBER 2019 | 33

NeuroSpine Institute Now Offering: Specialised Physiotherapy Treatment

neurospineinstitute.com.au

We welcome Dr Vijaya Venkataraman to the team, who is an experienced Consultant Physician to compliment our surgical services.

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

Consultant Physician

Multi-disciplinary specialist practice offering advice and treatment across the full range of spine and brain conditions.

Dr Paul Taylor Spinal Surgeon

Neurosurgeon

Dr Michael Kern Neurosurgeon

Dedicated Acute Disc Service We prioritise patients with newly referred arm or leg pain with proven nerve compression on CT or MRI.

3 CONVENIENT LOCATIONS

Also offering outlying clinics in Mandurah, Vasse, Albany and Geraldton. Perth Suite 7, Level 4 140 Mounts Bay Road Perth WA 6000

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

Dr Andrew Miles

Wembley Suite 10, First Floor 178 Cambridge Street Wembley WA 6014

APPOINTMENTS P 1800 NEUROSPINE | F (08) 6147 8200 (1800 638 767)

E info@neurospineinstitute.com.au

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

Dr. Michael Kern FRACS

Dr. David Holthouse FRACS

Dr Paul Taylor FRACS

NEUROSURGEON

INTERVENTIONAL PAIN SPECIALIST

Guardian EXERCISE REHABILITATION

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34 | SEPTEMBER 2019

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Update on pneumococcal vaccination By Clin/Prof Fiona Lake, Respiratory Physician, Nedlands Vaccination is one of the most important medical advances yet remains controversial. News headlines distract us from the important benefits for individuals and communities and focus on the small or potential harm for individuals. Most concern relates to children but in Australia, 91% of children meet vaccination recommendations whilst in adults the rate is low, around 51%. Pneumococcal vaccination for adults remains low and much lower than for influenza (47% versus 71.6% in over 65 respectively). With the Australian guidelines, the 23-valent pneumococcal polysaccharide vaccine (23vPPV) is provided free for adults over 65, for Aboriginal and Torres Strait Islander adults over 50 (repeated once after five years) and adults with medical problems (more complex recommendations, see schedule). In these adults, invasive pneumococcal disease (IPD), has a high mortality, with, for example, a 16% mortality from pneumococcal pneumonia even in healthy elderly people. So, why do we not use it? Low vaccination may be because of pessimism about whether it works or about the impact (“pneumococcus only accounts for 20% of pneumonias”) and confusion due to changing recommendations (single or repeated doses). Does it work? KEY MESSAGES Results vary but a Compared to children, adult Cochrane review (2013) vaccination rates are low. based on randomised controlled trials found Vaccination is effective in reducing overall protective invasive pneumococcal disease efficacy of 74% in adults against IPD and 52% Follow the current Guidelines effectiveness in older adults. The results were less clear for pneumonia overall or IPD in patients with at risk medical conditions, though observational studies supported use in the latter. How long does it last? Studies show a 23vPPV vaccine effectiveness against IPD in adults of 48% within two years but insignificant after five years. In healthy adults with no risk factors, effectiveness was higher at 65% at two years and remained for longer. Common adverse effects were mild local swelling, redness, pain and a low fever, worse on a second dose. Only one dose is now recommended for well elderly people. Data shows the introduction of the 13-valent pneumococcal conjugate vaccine (13vPCV) in children resulted in a reduction in adults of disease from the serotypes contained in the vaccine (herd cover). Subsequently, the introduction of the 23vPPV (containing an additional 11 serotypes) in adults resulted in further falls in illness from those serotypes, but the serotypes not covered expanded. As most disease is due to serotypes in the 13vPCV, the current debate is whether 13vPCV should replace 23vPPV in adults. Influenza and pneumococcal infections are often combined. New research from South Australia, published in Nature Microbiology, trialled whole inactivated vaccines (which may resolve what serotypes to include) with influenza A and pneumococcus, co-administered in mice and showed the presence of both enhanced the response to each of them. So maybe in the future we will be using different types of vaccines in combination. Till then, keep following the Guidelines. References available on request Author competing interests- nil.

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Introducing Western Australia’s first dedicated reconstructive urology practice. At Perth Reconstructive Urology, located at our new facility at 4 Antony Healthcare, Palmyra, we offer a holistic approach to the care of people with urological conditions requiring reconstructive surgery. Incorporating a dedicated team approach including fellowship-trained reconstructive urological surgeons, urodynamics, on-site outpatient cystoscopy, physiotherapy, sexual health, medically supervised weight loss and gym programs, our mission is to restore quality of life to those suffering from: Urinary incontinence – AdVance sling, ATOMS, Artificial urinary sphincter Erectile dysfunction – medical therapies and penile prosthesis surgery Urethral stricture disease Penile curvature(Peyronnie’s disease) – minimally invasive correction Penile cancer – penis preserving surgery, minimally invasive lymph node dissection Infertility – vasectomy reversal, varicocoele ligation BPH – minimally invasive therapies including Urolift and REZUM Robotic assisted laparoscopic reconstruction including pyeloplasty, ureteric injuries, and reimplantation. Our emphasis is always on utilising the best available techniques to restore form, function and quality of life. OUR TEAM Dr David Sofield

Dr Mikhail Lozinsky

Dr David Millar

Dr Yin Min Yew

Jo Milios

Dr Emily Calton

MBBS (WA), FRACS, FRCSE MBBS FECSM

BSc. (Physiotherapy) PhD

FRACS, FEBU MBBS

BSc (Nutrition) PhD

Denielle Rankin Practice Manager Urgent referrals will be seen within 48 hours and we welcome calls for advice anytime on 0419151050 (David Sofield) Or 0426255629 ( Mikhail Lozinsky)

All other enquiries and referrals to Level 1 4 Antony St Palmyra 6157 | Ph 93391932 Fax 93391832 | Email Denielle@sofield.com.au

SEPTEMBER 2019 | 35

Long-term management of pulmonary embolus By Dr David Manners, Respiratory Physician, SJG Midland Public Hospital While initial management of Pulmonary Embolus (PE) focuses on short-term risk stratification and anticoagulation, long-term management decisions include relative benefits and harms of ongoing anticoagulation, being vigilant for complications and addressing comorbidities. Most venous thromboembolic (VTE) events, including PE, require a minimum of three months of anticoagulation therapy. Indications for longer or indefinite anticoagulation relates primarily to the risk of recurrence. Individuals with recurrent VTE events, active cancer or antiphospholipid syndrome have the highest recurrence risk. Indefinite anticoagulation is recommended. Previously, in VTE with active cancer, enoxaparin was preferred over warfarin, but newer evidence reports that Direct Oral Anticoagulants (DOACs) have a lower risk

KEY MESSAGES Long term management after PE involves addressing risk of VTE reoccurrence Be vigilant for the uncommon complication of CTEPH Recently released VTE management guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand is a useful resource

of VTE recurrence than enoxaparin at the expense of increased bleeding, especially with gastrointestinal malignancies. In contrast, provoked PE in the context of transient risk factors (e.g. surgery, longhaul travel, oral contraception use) have the lowest recurrence risk and are unlikely to benefit from indefinite anticoagulation. The most challenging situation is for those

with an intermediate risk of VTE recurrence, typically after a first unprovoked PE. The risk of VTE recurrence following initial unprovoked PE is approximately 10% within the first year and 30% after five years. Risk factors for recurrence include male gender, younger age, ‘high-risk’ thrombophilia including protein S, C or antithrombin III deficiency, homozygous factor V Leiden or prothrombin mutations, and elevated d-dimers following initial anticoagulation. Whether to continue indefinite anticoagulation becomes a shared patientclinician decision based on risk factors for recurrence, bleeding risk and side effects from anticoagulation and patient preferences. For those opting to continue indefinite anticoagulation, ‘low-intensity’ anticoagulation with either Apixaban 2.5mg BD or Rivaroxaban 10mg daily is effective at reducing recurrence with similar rates

For your patients, a good night’s sleep begins with comfort. Get in touch today Murdoch Specialist Centre 78 Farrington Rd Leeming 6149 At SleepMed, we understand the value of a good night’s sleep. As Perth’s first accredited and licensed sleep investigation centre outside of a hospital, we focus on individual and holistic care to diagnose sleep disorders including snoring, sleep apnoea, and insomnia. Our highly trained sleep experts and therapists then develop personalised treatment solutions, prioritising the comfort of our patients at all times.

T (08) 6161 7647 F (08) 6162 0547 E info@sleepmed.com.au Online referral welcome: www.sleepmed.com.au

Both insured and non-insured patients can access our professional Level-1 sleep studies, now in the comfort of a non-hospital environment. Accredited by:

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36 | SEPTEMBER 2019

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of bleeding and are PBS approved for this indication. If indefinite anticoagulation is used, re-evaluate relative benefits, harms and preferences annually. Long-term complications of PE include Chronic Thromboembolic Pulmonary Hypertension (CTEPH) which occurs uncommonly (estimated incidence 1-5% within two years after a PE). CTEPH should be suspected if breathlessness persists despite adequate initial anticoagulation.

Ventilation/Perfusion (V/Q) scans are the preferred investigation due to greater sensitivity than CT Pulmonary Angiography. If CTEPH is suspected, specialist respiratory referral is warranted for advanced diagnostic and management interventions, potentially including surgical thromboendarterectomy. Up to 10% of people will be diagnosed with malignancy in the first year following an

unprovoked VTE. Unfortunately, intensive cancer screening following an unprovoked PE does not reduce mortality nor reduce clinically-apparent cancers. Additional screening investigations on top of routine, age- and sex-appropriate cancer screening is not recommended. Author competing interests â&#x20AC;&#x201C; nil relevant disclosures. Questions? Contact the editor

Table 1. Estimated VTE reoccurrence rates and indefinite anticoagulation recommendations. Type of VTE

Reoccurrence rate at one year after stopping anticoagulation

Reoccurrence rate at five years Indefinite anticoagulation recommendations

First VTE provoked by major surgery or trauma

Not recommended

First VTE provoked by transient non-surgical risk factor

15%

Not recommended

Frist unprovoked PE

10%

30%

Shared-decision based on individual risk factors, bleeding risk and patient preference

Provoked VTE with persistent risk factors e.g. active cancer

15%

45%

Recommended

Second episode of unprovoked VTE

15%

45%

Recommended

Adapted from Chest guidelines

SPECIALISTS IN PROSTATE CANCER AND BPH

Mr Tom Shannon FRACS

Robotic and Laparoscopic Surgeon Surgical Results

In organ confined disease 100% primary resection success (Literature averages 60-85%) In extra prostatic disease 90.1% complete rescection (Literature averages 40-65%)

Cancer Control (PSA over 0.2 after surgery)

Confined disease - 3% (One third of published average PSA failure rates) Extraprostatic disease - 16% (Half the rate of published average PSA failure rates) Source Uropath WA Radical Prostatectomy Database

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LT S

Patient Support and multidisciplinary team

Extensive website Prostate cancer specialist nurse - education and support Sexual health nurse practitioner - rehabilitation programs Dietitian - rapid weight loss programs Exercise physiologist - weight loss programs, exercise in cancer programs

Nedlands Phone: 9389 7696 Fax: 9386 1799 drtomshannon@theprostateclinic.com.au www.theprostateclinic.com.au

SEPTEMBER 2019 | 37

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

Dr Michael Allen

Dr Julia Barton

MBBS, FRANZCOG, FRCOG

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BMedSc, BSc (Hon), MBBS, FRANZCOG

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Dr Simon Turner

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

Genea Hollywood Fertility means high success rates, understanding staff and individual care. Genea Hollywood Fertility Level 2, 190 Cambridge Street, Wembley WA 6014 P (08) 9389 4200 W wa.genea.com.au 38 | SEPTEMBER 2019

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New approaches to metastatic lung cancer By Dr Wei-Sen Lam, Oncologist, Perth Lung cancer is the fifth most common cancer in Australia and the leading cause of cancer deaths, accounting for 20% of the total. There has been limited treatments for metastatic lung cancer previously, with chemotherapy being the mainstay of treatment. Fiveyear survival for stage IV lung cancer was 1%. However, better understanding of lung cancer biology has resulted in many new treatments including immunotherapy and targeted treatment and as a result patient prognosis has improved. Genetic mutations during cancer growth can lead to the initiation of neoantigens which can evade the immune system. Immune checkpoint inhibitors can amplify the host immune response to tumours, leading to durable response rates with a favourable safety profile. Immunotherapy drugs can be used in various indications in first and second line settings. The pooled analysis of two Phase 3 trials (CheckMate-017 and -057) showed 58% of patients treated with nivolumab who achieved a complete or partial response were alive four years later. There is also emerging evidence that these drugs in combination with other drugs including

KEY MESSAGES New treatment for metastatic lung cancer improves prognosis Be vigilant for side effects, which may be serious The challenge is to use these agents in earlier stages of disease chemotherapy can improve response rates in certain scenarios. These drugs have very different side-effect profiles to chemotherapy. These side effects, termed immune mediated adverse events, arise from increased activity of the immune system and can affect any organ. If left untreated they can be life-threatening. The most common side effects include fatigue, rash, colitis, pneumonitis, hepatitis and endocrinopathies. Corticosteroids are the mainstay of treatment for immunemediated adverse events. Corticosteroids should be tapered over at least four to six weeks. Infliximab or mycophenolate may be considered in some toxicities that are not responding to high-dose steroids within 48-72 hours. Some toxicities can occur even after cessation of immunotherapy. Clinicians

should have a high level of suspicion of immune-mediated adverse events if new symptoms occur and early discussion with the treating oncologist is key to treating patients appropriately Targeted treatment Traditionally lung cancer was divided into non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Within NSCLC, the main subtypes are adenocarcinoma, squamous cell lung and large cell. Traditionally, this distinction has occurred to guide decisions on chemotherapy. However, there are some cancers with a driver mutation that are highly responsive to targeted treatments. These driver mutations include epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK) and receptor tyrosine kinase encoded by the ROS1 gene. Agents targeting these mutations are oral, allowing patients the freedom to travel. These drugs often have high response rates. Over time, resistance can occur. Newer drugs, such as osimertinib, a third generation EGFR inhibitor, can overcome T790M resistance mutation following use of a first or second generation EGFR inhibitor. Author competing interests - nil

Left â&#x20AC;&#x201C; Baseline CT scans of liver (top) and lung (below). Right â&#x20AC;&#x201C; CT scan after 9 weeks demonstrates response to liver and lung lesions

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SEPTEMBER 2019 | 39

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40 | SEPTEMBER 2019

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Exercise after lung surgery important for recovery By Dr Vinicius Cavalheri, Curtin University and Cancer Council WA Postdoctoral Fellow Lung cancer is the most commonly diagnosed cancer in men and third most commonly diagnosed cancer in women. Specifically, in Australia, lung cancer is the leading cause of cancer death and the fourth most common cancer diagnosed in both men and women. The treatment offering the best chance of cure for people with early stage nonsmall cell lung cancer is surgical tumour resection (with or without adjuvant chemotherapy). However, this treatment compounds the decrements in exercise capacity and quality of life that patients commonly have when diagnosed. Our Cochrane systematic review updated the evidence about the effectiveness of exercise training after lung resection for non-small cell lung cancer to improve exercise capacity, quality of life, muscle strength, symptoms of breathlessness and fatigue, feelings of anxiety and depression, and lung function. Eight studies (from the UK, Denmark, Australia, Norway, Spain, Belgium and the Netherlands) on 450 participants were included. Our results showed that people with non-small cell lung cancer who undertook 8-20 weeks of exercise training after lung resection had better exercise capacity (measured by both VO2peak and 6-minute walk distance) and strength in their leg muscles compared to those who did not exercise.

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It was also demonstrated that those who exercised had better quality of life and less breathlessness. The effect of exercise training after lung resection on fatigue and lung function was uncertain and insufficient evidence was found for improvements in feelings of anxiety and depression.

KEY MESSAGES Lung cancer is a common diagnosed cancer in Australia Exercise, post-surgery, can improve quality of life Patients can be referred to exercise classes The systematic review emphasised the importance of exercise training as part of the postoperative management of people with non-small cell lung cancer. A survey conducted by the research team at Curtin University (published 2013), which described management of people with lung cancer across Australia and New Zealand, reported only a small proportion were referred to exercise training programs following lung resection.

This new review suggests that referrals to exercise programs should be considered for this population, including pulmonary rehabilitation programs run by physiotherapists, and exercise training programs (such as Cancer Council WA Life Now) run by exercise physiologists. A list of pulmonary rehabilitation programs that accept referrals can be found at the Lung Foundation Australia webpage (link: https://lungfoundation.com.au/exerciseclasses/). A list of exercise training classes run by exercise physiologists, as part of the Cancer Council WA Life Now program, that may accept referrals (eligibilty criteria applies) can be found at the Cancer Council WA webpage (link: https://www. cancerwa.asn.au/patients/support-andservices/life-now/exercise-classes/). Author competing interests – Dr Cavalheri was the lead author of the Cochrane review described.

GP2GP sharing records Transferring patient records from one general practice to another isn’t exactly a straight forward and efficient process in Australia. Yet, it soon could be as the CSIRO’s Australian eHealth Research Centre is working on a practice-to-practice transfer system using the FHIR standard (Fast Healthcare Interoperability Resources). It could see GPs being able to access

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complete, searchable and structured patient records, as long as the patient’s previous GPs are on-board. Across the Tasman, a New Zealand based IT non-profit, Patients First, developed a secure electronic medical record transfer system, GP2GP, that allows for the secure transfer of medical records between general practices, the system has been in use since 2014 with over 375,000 patient records being transferred annually.

The GP2GP records are transferred in a structed and searchable format. The NHS in the UK has also been using a similar system, also called GP2GP, since 2007 with a reported uptake of 99% of England’s general practices using the system.

SEPTEMBER 2019 | 41

Asthma and Obesity By Dr Michael Prichard, Respiratory Physician, Perth The prevalence of asthma in adults in Australia is about 10%; obesity about 20%. We know that long-term oral steroid therapy often causes weight gain, sometimes obesity. Is the relationship between asthma and obesity bidirectional? Asthma is more common in obese individuals. Weight loss has a net positive effect on lung function and asthma symptoms. Moreover, asthma is generally more difficult to control in obese individuals. It is more symptomatic for a greater percentage of time, and results in more reliever therapy usage. Obese individuals with asthma have more frequent symptoms when they gain weight; and obesity increases the odds of adults developing asthma for the first time. Obesity does not cause airflow limitation or eosinophilia, but may increase bronchial reactivity. Most of the association is at the milder end of asthma severity spectrum. The reason(s) are not clear, however, given the phenotypic variation of both conditions, it is not surprising that there would be inconsistent results in research into the association. There are a number of possible mechanisms to account for the increased prevalence and severity of asthma in obese individuals. Obesity is a chronic lowgrade pro-inflammatory state. Potentially,

KEY MESSAGES There is an association between asthma and obesity The mechanism may be via co-morbidities Weight loss can improve asthma control systemic inflammation may affect airway inflammation, through pro-inflammatory mediators such as leptin (evidence limited). Obesity has direct mechanical effects on lung volumes – the most common functional abnormality is reduced functional residual capacity (FRC). However, in some cases, ventilatory capacity may be reduced (i.e. a heterogeneous relationship between BMI and lung volumes). The effect of obesity on asthma may be mediated by other co-morbidities such as gastro-oesophageal reflux and obstructive sleep apnoea (both are more common in obese individuals). The association between gastro-oesophageal reflux and asthma is only partly related to BMI. Some studies show that PPI treatment for patients with both asthma and gastrooesophageal reflux had no effect on the frequency of asthma symptoms, but reduced asthma exacerbations and improved quality of life.

The presence of obstructive sleep apnoea (OSA) in asthmatics is associated with poorer asthma control and over 80% of severe asthmatics have at least moderate OSA. The relationship between OSA and asthma is often independent of BMI. CPAP therapy usually improves asthma symptoms in obese individuals with OSA, however, positive airway pressure not only supports a collapsible pharynx, but also intrapulmonary airways. There are more questions than answers in the relationship between obesity and asthma, however, the association appears real. Therefore, it is important to exercise caution in the use of high-dose intermittent or medium-long term oral steroids in managing asthma, in order to prevent weight gain. Weight reduction in obese asthmatics and management of comorbidities is likely to lead to better asthma control and improved quality-of-life. While obesity probably reduces the effectiveness of asthma therapy, you should reconsider the diagnosis if asthma symptoms do not respond to inhaled or oral steroids.

Author competing interests – nil

Childhood asthma – what has obstetrics got to do with it? By Dr Joo Teoh, Obstetrician and Gynaecologist, Subiaco Asthma is a common chronic childhood condition affecting potentially one in five children. This illness can limit a child’s ability to participate in educational and social activities, and may also adversely affect school attendance. Parents have to spend more time taking children with asthma to medical appointments resulting in lost work time. There is emerging evidence that epigenetic paradigms, particularly DNA methylations

42 | SEPTEMBER 2019

affecting gene expression, influence the likelihood of children having asthma and other allergic diseases. Researchers have found the link between a number of prenatal factors and childhood asthma; even preconception events can influence the chance of children developing asthma. A growing body of evidence associate subfertility with childhood asthma; one study discovered children born from subfertile parents have a significantly higher chance of developing asthma (OR 1.39). Children born after IVF have even more

significant likelihoods of developing this illness (OR 1.28 - 2.65). In absolute risk term, the risk increase is not large (from 4.4% to 5.6%). Childhood asthma has been linked to multiple triggers during pregnancy; environmental exposure, lifestyle, medications, and even psychological stress have all been shown to influence the possibility of developing childhood asthma. One group suggested that fetal events (antepartum haemorrhage, threatened

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Assessing asthma By Dr Sina Keihani, Respiratory Physician, Murdoch Approximately 10% of the adult asthma population have severe asthma, which if uncontrolled is associated with substantial physical and mental consequences as well as airway remodelling leading to an estimated 32-fold risk of chronic obstructive pulmonary disease. Direct systematic questioning is essential at every interaction. Many patients do not fully understand how to gauge asthma control, may forget past events or selfimpose activity limitations. Probing for specifics about exacerbation episodes, exacerbation risks and symptom control provides a more complete picture of the patient’s level of control. In well-controlled asthma there are daytime symptoms no more than twice per week, night-time symptoms no more than twice per month, SABAs for relief of symptoms needed less than three days a week (not including usage prior to exercise), no interference with normal activity and peak flow should remain normal or near normal. Quick, validated questionnaires addressing these measures include the ACT (Asthma Control Test), and Asthma Control Questionnaire (ACT). Exacerbation risk assessment should be considered with the most important risk being an exacerbation in the preceding year. Adherence to

preterm labour, growth restriction) but not maternal conditions (hyperemesis, preeclampsia) increase the risk of childhood asthma (OR 3.0). Stressful life events during pregnancy, for example divorce, mourning, or job loss, have also been shown to increase the incidence of childhood asthma (8.9% vs 5.6%). Maternal smoking increases the risk of asthma in childhood up to seven years of

KEY MESSAGES Asthma severity and control are distinct issues Accurate diagnosis and assessment are critical New biological agents can improve patient outcomes and require early referral preventers and smoking are additional important risks. Ongoing airway inflammation is a hallmark of asthma, even in patients with occasional symptoms. Patients who may not recognise or report symptoms until airflow has become severely obstructed. Pulmonary function testing or spirometry is therefore essential. Defining severe asthma The frequency of symptoms and exacerbations are considered elements of asthma control. Disease severity is defined by the medication type and dosage a patient requires to maintain adequate control. Severe asthma in adults is generally taken as asthma needing treatment with medium-high dose inhaled corticosteroids (ICS) and one or more additional controller mediation (e.g., LABA) or systemic

age. Children born to mothers classified as obese are more likely to have childhood asthma, with 1kg/m2 increase in maternal BMI associated with a 2-3% increase in the odds. A high gestational weight gain has also been linked to this condition. Good dietary intake, namely oily fish at least once a month, adequate vitamin D intake, is preventative of childhood asthma. Interestingly, antibiotic usage and also folic acid supplementation in pregnancies have been associated with an increased risk of asthma in children. In summary, childhood asthma risk is increased by a small margin in IVF. Prenatal exposure also has an important role in affecting the chance of developing childhood asthma. Most studies have used cross-sectional statistical analyses; we have to interpret individual studies with caution before providing advice and recommendations to our patients.

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corticosteroids for at least half the previous year and asthma remaining uncontrolled despite this therapy. ‘Uncontrolled’ requires the presence of at least one of the following: poor symptom control, frequent or a serious exacerbation, or airflow limitation. Accurate asthma diagnosis and exclusion of other possible conditions with similar symptoms is important with studies showing up to 40% of referred patients may not have asthma. Severity can be determined by the treatment the patient is receiving and how well that treatment is managing the asthma. For instance, a patient receiving high-dose ICS and two other controller medications continuing to experience exacerbations and/or require oral corticosteroid bursts has severe asthma Severe asthma patients result in 60% of overall treatment costs of all asthmatics and have high morbidity and mortality. They are commonly encountered in primary care. Recognition is critical to facilitate early intervention and collaboration with a specialist with advent of new, targeted therapy such as omalizumab (ani-IgE) and mepolizumab (anti-IL5) that can significantly improve patient outcomes.

Author competing interests- nil.

KEY MESSAGES Infertility and risk exposure during pregnancy increases risk of childhood asthma In absolute risk terms the increase is small for infertility A healthy lifestyle and diet in pregnancy reduces risk of childhood asthma It is increasingly evident that a healthy lifestyle and diet in pregnancy improve maternal and fetal health in the short and long term including childhood asthma risk reduction. References available on request

Author competing interest – nil.

SEPTEMBER 2019 | 43

EOS IMAGING Expanding Our Market Leading Service EOS Weight Bearing Spinal and Lower Extremity Imaging Now Available at SKG Radiology WHAT ARE THE BENEFITS OF EOS TO PATIENTS?

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44 | SEPTEMBER 2019

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CLINICAL UPDATE

Medication-related osteonecrosis of the jaw By Dr Amanda Phoon Nguyen, Oral Medicine Specialist, West Leederville, Jandakot & Bunbury Patients commencing therapy on certain classes of medications should be counselled regarding the risk of medication-related osteonecrosis of the jaw (MRONJ). This is also known as anti-resorptive drugrelated osteonecrosis of the jaw (ARONJ) and bisphosphonate-related osteonecrosis of the jaw (BRONJ) when associated with those medications. MRONJ is a condition occurring in a patient who has received a bone-modifying agent (BMA) or an angiogenic inhibitor agent, with no history of head and neck radiation, where bone can be detected through an intraoral or extraoral fistula/e in the maxillofacial region that does not heal within eight weeks. In the past two decades, there has been a steady increase. MRONJ occurs in about 1-9% of patients with advanced cancer who are receiving a BMA, in contrast to a much smaller percentage of patients who receive BMA pharmacotherapy for osteoporosis. While it is well-recognised that bisphosphonates and RANKL inhibitor

denosumab are implicated, several drugs carry the risk of this debilitating adverse effect. These include anti-angiogenic agents, monoclonal antibodies, tyrosine kinase inhibitors and variant fusion proteins, radiopharmaceutical Radium 233, methotrexate, prednisolone and selective estrogen receptor modulator Raloxifene. The risk appears to be higher when used in conjunction with bone-modulating therapies. MRONJ can be challenging to treat and can cause significant pain and reduced quality of life. Treatment depends on the stage of disease and the patientâ&#x20AC;&#x2122;s underlying medical history. With bisphosphonates, a drug holiday is often not useful due to the incorporation of the drug into bone tissue. In contrast, many newer medications have a shorter half-life, and a drug holiday may be considered. Management is often multidisciplinary. Treatment, according to the stage of the disease, may include conservative measures such as antimicrobial mouth rinses, antibiotics, effective oral hygiene, and

conservative surgical interventions, such as small sequestrum removal. More aggressive surgical intervention may be indicated for more severe cases. Possible adjunctive therapies include hyperbaric oxygen therapy, platelet rich plasma, bone morphogenic protein, and parathyroid hormone. Preventive oral care combined with effective oral health practices are associated with a lower rate of MRONJ. It is strongly recommended that patients see a dentist prior to therapy to ensure that any teeth of questionable prognosis are assessed and extracted if necessary, with adequate healing time. Any dental prosthesis should be well fitting in order to reduce trauma. Dental screening, prophylaxis, oral hygiene instruction, tobacco and alcohol cessation counselling, and timely treatment is recommended to reduce MRONJ risk. References available on request

Author competing interests -nil

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NEWS & VIEWS

How to Live Lighter

eight and weight control are difficult conversations to have with patients, both young and old, but vitally important for their health and the health of an ageing nation. Last month we looked at the complex problem in some depth and how the subject can be made easier for both doctor and patient alike by clear, non-judgemental communication. Charlyn Ooi is a paediatric dietitian and a credentialed diabetes educator, so her focus is on childhood obesity and encouraging more understanding of how children become overweight. “It can be attributed to a variety of genetic, behavioural and environmental factors including: • Excess caloric intake • Poor food choices including regular intake of nutrient-poor foods such as chips, pies, confectionary and sweetened drinks • Easy access to processed and fast food • Sedentary lifestyle • Increase in screen time • Epigenetics and obesogenic gene “Addressing weight concerns in children and teenagers is a sensitive subject and can be a challenge to address. For health professionals, it is important, first and foremost, to establish a positive, trusting relationship with the child and their parents to create a safe space for discussing weight concerns.” “Avoid making a diagnosis based on single anthropometric measurements. Use a minimum of three data points on the growth chart to make an accurate

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FREE LIVELIGHTER RESOURCES Online meal planners. Please note, people with a BMI of 40-50 will be asked to speak to their doctor before starting the 12-week program. Other programs are available. Eat Smart/Shop Smart booklets. Eating well on a budget Physical activity guides and workouts. Recipes. Training. In late 2019 LiveLighter will be delivering RACGP accredited faceto-face workshops for GPs to build their skills and confidence to discuss weight management with patients observation of the child’s growth and while approaching the discussion in an objective manner, avoid using negative terms which label the child as ‘overweight’, ‘obese’ or ‘chubby’.” Charlyn recommends the taking of periodic weight, height and waist circumference measures for progress tracking, but warns against frequent weight checks and putting all the emphasis on weight loss. It’s about all-round health. She also suggests avoiding labelling food as ‘junk’ or ‘treats’. “We want children to develop positive relationships with food and focus on eating every day foods from the five core food groups that will nourish their bodies. High calorie, nutrient-poor foods are ‘sometimes food’ or ‘for special occasions only’,” she said. “Creating new habits can be challenging and parents and children need collaborative support of a multidisciplinary approach.” Sandra Stevenson, from the Cancer Council of WA, says the Live Lighter campaign, which has been running now for several years, is about raising awareness of

the severe health risks on unhealthy body weight. “It exposes people to an increased risk of chronic diseases such as type 2 diabetes, heart disease and 13 cancers. We know many people want to manage their weight and they look to their GP for advice. When done the right way, initiating a brief discussion could make the world of difference to them,” she said. “Time is tight in general practice, but evidence shows it’s possible to have effective, brief interventions within a normal consult length, by perhaps starting the conversation by asking how a patient feels about their current exercise behaviours, diet and weight.” “This provides an opening for the patient to articulate aspects of their lifestyle they would like to change. Together you can create goals to address these issues. Patients are much more likely to adhere to goals they set themselves.” How you communicate can be as important as the information itself. “The aim is to empower individuals to make changes, not make them feel bad. Fundamental to this is avoiding language that reinforces weight stigma. When people experience weight stigma in a health care context it may lead to them delaying or avoiding accessing health care services in the future. Rather than blame, focus on solutions.” As anyone who has consciously lost weight, keeping it off is another significant challenge. “Long-term weight loss can be very difficult – especially through lifestyle alone,” Sandra said. “The typical weight-gain trajectory is gradual – about 0.5kg a year. Check if patients are happy to be weighed on an annual basis to monitor this. Early adulthood in particular is a key time for weight gain, so it’s important to emphasise weight maintenance in this group.”

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TRAVEL

Glamping it up at Rotto Doing it tough at the Discovery Rottnest Island Village at Pinky Beach.

ention the word camping and it makes me think of holidays spent in cramped conditions, either freezing cold or stiflingly hot. Having to trek out to the shared ablution block and dealing with all types of creepy crawlies and wildlife. It’s just not my thing. So, when a friend suggested a camping weekend on Rottnest in July, I wasn’t enamoured with the idea.

However, when the idea of ‘glamping’ was raised, I immediately started to imagine fresh salty air and the calming mindfulness that can be found on an island; that intimacy with nature is like chicken soup for the soul and I began to warm to the notion. I was willing to take the opportunity for an island getaway. A comfortable 30-minute ferry ride from Fremantle brought us to Rottnest where we were welcomed by a spectacular double rainbow stretching across the island.

Stepping from the ferry into the crisp island air immediately invigorated the senses. We made our way through the main settlement picking up some fresh-baked Danish pastries and stepping around tourists perfecting the ‘Quokka Selfie’. After an easy walk past the old cabins and camp site, we reached the Discovery Rottnest Island Village, nestled behind the dunes of Pinky Beach. Described in the promotional brochure as “an eco-resort with a difference”. On top of the dune elevation sits the reception desk and the casual café area where breakfast, lunch and dinner can be enjoyed overlooking the lighthouse, the crescent of white sand and aqua water and out to the mainland. Beside this is the lovely Pinky’s Beach Bar and swimming pool with chill-out area and outdoor showers for those who don’t enjoy the sand between their toes!

Our personal base camp is a Deluxe category ‘tent’, the finest accommodation option for two people. There are only eight of these, and they come with arguably the best views of the ocean.

The 83 eco-tents, in muted grey/ beige shades, are all protected from the elements by strong white flysheets and sit atop wooden platforms and connected by raised boardwalks, sensitively minimising the impact to the land. A variety of sizes and bedding configurations are available to suit most visitor requirements and they all have a lovely entertainment deck. There are also well maintained and equipped communal barbecue and kitchen facilities.

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TRAVEL

Each tent has a front door with a key which opens to a small entrance area and a compact kitchenette, well-equipped with a small refrigerator, microwave oven, toaster and tea and coffee facilities. Inside the large main room is a very comfortable king size bed, a desk and sofa.

To the right of the main room is a walk-in dressing room with storage and hanging space. To the left is a bathroom, a proper bathroom! Complimentary toiletries and soft towels are provided. His and her wash basins, a lovely hot shower and private toilet. Oh, the luxury of not traipsing to the ablution block! The icing on the cake is the view – the tufty dunes and the magnificent, uninterrupted vista of the ocean and the island coastline, seen from the spacious deck. It’s a perfect spot to relax on the lounge, or enjoy a meal at the dining table cooked on the barbecue provided. Beach access is just a few steps along the boardwalk in front of us. Although we could see Perth in the distance, we could have been a thousand miles away with only the sound of the birds and the wind whispering around us. It’s a slice of island paradise,

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right on our doorstep. This is glamping. I can glamp but I’ll never camp again.

Words: Karen Walsh Pictures: Chris Walsh

SEPTEMBER 2019 | 49

SOCIAL PULSE 1

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GPs swatting up More than 500 doctors and other health professionals headed to PCEC for HealthEd’s annual Women’s & Children’s Health Update to hear a range of speakers from WA and the east coast, including WA children’s allergy specialist A/Prof Richard Loh and Prof Peter Richmond on meningitis as well as Dr Rosie King on sexual health. 1 Prof Ego Seeman discussing osteoporosis 2 Dr Jo Keaney and Dr Uschi Gruber 3 Mike Gill (Inova) and Dr Belinda Wozencraft 4 A/Prof Jenny McCloskey, Dr Pauline De Boer, Dr Fiona Cameron and Dr Janet Campbell

5 Dr Same Oparah, Dr Asomugha Kenechukwu and Dr Alexander Utuk 6 Cystic Fibrosis workers Sam Wallace and Sharon Dewar 7 Dr Alison Philpott, Dr Lucy Rosman, Dr Kathryn Cooper, Dr Mary White and Dr Roslyn Rice

Wine

winners

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Joondalup GP Dr Rob Hendry, far left, and Woodlands GP Dr David Jameson had reasons to smile, having won the Doctors Dozen wines. Rob took home the St Hallett selection (which reviewer Dr Louis Papaelias described in the June magazine as containing some fine expressions of Barossa Shiraz) and David the Vasse Felix (which impressed Master of Wine Dr Craig Drummond in the July magazine).

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WINE REVIEW

Schild Estate: Quintessentially Barossa It is more than two years since I last reviewed the wines of this wellrecognised Barossa Valley producer and it is indeed a pleasure to revisit them. Their story began in 1952 at Rowland Flats where forebearer Ben Schild purchased land and established a mixed farm which included vines for viticulture. Now three generations of the family have amassed 163ha of vines across the cooler southern end of the Barossa, focused around the town of Lyndock. In 1998 they progressed from selling fruit to producing their own wines and haven’t looked back since. It is fortunate they own

By Dr Craig Drummond Master of Wine

plantings of wonderful 150-year-old Shiraz and Grenache vines which survived the alarming government-sponsored 1980s Vine Pull Scheme, initiated when grape prices plummeted due to oversupply. These dry-grown, deep rooted,, old-bush pruned vines give very low wields of inky dark purple essence resulting in the most wonderfully concentrated wines. The jewels in the crown are the 150-year-old famous Shiraz vines on the Moorooroo block. The wines tasted are highly recommended and the reds will all reward cellaring.

Schild Estate Alma Schild Reserve Single Vineyard 2016 Barossa Valley Chardonnay (RRP $26)

Schild Estate Pramie 2015 Liebich Vineyard 2015 Barossa Valley Shiraz (RRP $50)

The limpid mid-gold colour is striking. Aromas take me back to the more traditional style of ‘Aussie Chards’ – big , ripe, and oaky. Melon and fig aromas lead into a generously fruited palate with flavours of ripe stone fruits, mango and melon, all coated in oaky/ nutty characters. Plenty of winemaking influence here with partial barrel ferment and lees stirring giving a buttery texture, and 6-9 months French oak maturation giving structure. The cool vintage has resulted in enough acidity to give a clean finish. A drink now wine currently showing optimum maturity.

From the famous Liebich site purchased in 1952 by Ben and Alma Schild. Selected as a flagship wine due to the vine age and unique characters of this site. Similar to the 2015, but a step up in quality by way of fruit selection and intricate handling in the winery. Aged in oak up to 24 months. Nose is integrating, mellow and complex. Black fruits, allspice, a touch of white pepper. Palate shows blackcurrant, soy and wild mushrooms. A huge wine with a long finish. As wonderful as this wine is, it’s still a baby and I am going to leave it another five years. Will drink well for another 20 years.

Schild Estate Ben Schild Reserve Single Vineyard 2015 Barossa Valley Shiraz (RRP $36) This is Barossa through and through. A big wine, deep black in colour, rich, ripe and generous on the nose. Oozes oak. Tobacco and dark chocolate aromas, blackberry, black olive and liquorice flavours. Firm drying tannins. Integrating oak. Now four years old, it will mature nicely for a further 10-12 years.

REVIEWER'S

Schild Estate Edgar Schild Reserve Old Bush Vines 2017 Barossa Valley Grenache (RRP $36)

PICK

My wine of the tasting. A survivor of the Vine Pull Scheme and it is just as great Grenache should be. Shows beautiful ruby/beetroot colour – typical of this variety. Aromas are confectioned and pastille, yet at the same time savoury and earthy. The palate is complex and concentrated, with gamey characters, black plum and redcurrants. Supple velvety tannins lead to a juicy finish. A complete wine with personality. Drinking well now but has a few more years in it yet.

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OPERA

A Great Dame of Opera

oprano Antoinette Halloran was in Perth in July playing the scheming widow Mrs Lovett in WA Opera’s sell-out season of Sondheim’s Sweeney Todd. The Melbourne-based singer is back in Perth next month to sing the role of Lady Macbeth in Verdi’s Macbeth. Medical Forum put these questions to her. You are a mother of two, an extremely busy singer of renown. How do you manage life-work balance? There is a strange dichotomy in this job where you are either completely absorbed in the preparation and performance of a role, or you are in between shows. So, I swing from being a flat-out working mother, to a mother who is home for school dropoffs, after-school snacks and homework. My children have grown to understand my work and, luckily, they are supportive and is my partner, James Egglestone. He is also an opera singer, so he knows I have to take these fabulous opportunities when they arise. I know the family will be OK until I am back in my Ugg boots driving them to guitar lessons and basketball again. Did music and theatre accompany you growing up? It definitely found me! I was five when I went to see the dress rehearsal of my big sister’s school musical, The Boyfriend. It was an all-girls school – Our Lady Of Mercy College – and I fell in love with the show. So much so that I remember holding onto my mum’s legs and crying as she left to see the opening night without me. My sister was in the role of the school mistress and sang a love duet with another girl who was

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playing a boy with a fake moustache. For my birthday I received the cast recording of the Broadway show and was devastated on listening to it that it wasn’t the Our Lady’s girls. Yet within a day of listening to the recording I had every role down – including a fabulous American accent! Can you pinpoint the moment when an interest became a lifestyle, or did it steal upon you? It took me so long to own that I was an artist. I spent so long waitressing and pulling beers in pubs waiting for the work that I never let myself tell people that I was a performer. For so long I thought of myself as a waitress with a B Mus Honours who just couldn’t get a gig. My voice took a long time to cook as it is quite a large instrument and they tend not to be ready until about 30 years’ old. Once I was living solely on performing, I allowed myself to say, “Me? I am a performer.” It was a beautiful feeling. Your confidence on stage is palpable, why do you feel so at home there? I love the stage. I, Antoinette, disappear and for the duration of the performance I get to walk in someone else’s shoes. I love seeing life through other people’s eyes, feeling other motivations and emotions. It is fascinating for me to explore these other worlds. I get a bit sick of myself sometimes and on the stage I can forget me and take a holiday from myself. It is addictive. Some people might call this psychosis? I call it acting. You play Lady Macbeth for WA Opera – is she bad, or just misunderstood? O she is BAD. Bad, bad, bad! The challenge for me is to make the audience care about her. It’s a bit like Mrs Lovett

(Sweeney Todd) but at least she had jokes to win the crowd over. I am hoping to find a window into Lady Macbeth’s soul so that the audience may glimpse something gentler for her. It must have been difficult for a strong, intelligent, and ambitious woman to exist as only a wife and mother with no ability to have a career and reap all the self-worth and power that comes with success. She is a desperate housewife trapped in the constraints of a medieval society. We start rehearsals soon, so all these ideas will be fleshed out. You return to Perth to be joined by Stuart Maunder (director) and James Clayton (who plays Macbeth) and conductor Brad Cohen. What do these artists bring to the production and to your performance? I have enormous respect for all these men. Without Stuart I don’t know where I would be. He has seen me grow into each new opportunity. To have the insight to cast me as Mrs Lovett, and the courage to do so, is gold to me. I adore and cherish him in this industry. He is the real deal. James is an artist that I take my hat off to. Impeccable in his preparation, fiercely intelligent in his dramatic readings and with a voice like honey and steal. I am very excited to see this Macbeth! Brad Cohen is a conductor with whom I am really keen to work with again after we did Tosca together in Perth

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MUSIC

Strings and Things

t’s not often you get the best practitioners of an instrument alongside the makers of the instrument. At this unique festival in Margaret River in October, that’s exactly what will happen. The Strings Attached: The West Australian Guitar Festival kicks off on October 11 for a weekend of some of the best guitar and strings music, from Blues to Roots to Classical and World, Country, Metal, Jazz and Rock. If it’s got strings, there’ll be someone if Margaret River who can play it – or make it! When you’re not marvelling at the stellar line-up of performers you can wander around the exhibitors’ stalls. The Exhibitors line-up includes Ormsby (the largest producer of electric guitars in Australia), Donmo, who is South Australian Don

Morrison, maker of resonantor guitars, mandolins and ukuleles, Australian Tonewoods, Fremantle guitar maker and luthier Simon Rovis-Hermann, Small Island Amps, Dog Box Guitars and Guitar Repairs South West among many others. Bring your guitar down for an inspection. The music makers performing over the weekend is a gourmet line-up from near and far. Just as a sample John Butler, Larry Mitchell (USA), Grammy awardwinning producer, engineer and performer, George Bechlivanoglou (Greece), classical guitarist and founder of MOOV Guitars, Kav Temperley, songwriter and frontman of four times platinum, multi ARIA Award band Eskimo Joe, blues & roots stalwart Ash Grunwald, Abbe May, Grammy Award winner Lucky Oceans, Kimberley singersongwriter Stephen Pigram, ARIA award winner Glenn Sarangapany (Birds Of

Tokyo) and world fusion phenomenon Kate Pass Kohesia Ensemble. And just so things keep local – the Busselton Ukulele Group will be out in force. Renowned maker of guitars, mandolins, violins in the South West, Scott Wise, is the festival patron. Some of his clients include Eric Bibb (guitar), Del Rey (ukulele), Loudon Wainwright (ukulele) Douglas Tolentino (ukulele) , the West Australian Mandolin Orchestra, Dave Mann and The Pigram Brothers Dan White is the festival director who knows everyone in the industry and has managed to draw some serious talent to Margaret River. It will be taking place in and around Margaret River’s world-class new venue, Hub of Entertainment, Arts and Regional Tourism (HEART).

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A Great Dame of Opera a few years ago. He is intellectual in his approach, yet has enormous heart in his interpretations. There is a synergy that exists between conductor and artist that is rare. I think Brad and I share this. It was his idea to cast me in the role of Lady M. Another big call, and I want to do him proud. Perth has seen you sizzle in Tosca, Sweeney now Macbeth, the roles and musical styles are dramatic and dramatically different. How hard is it on your voice?

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It is amazing for my technique. Some singers get to rest on their laurels singing just one kind of music. In my career I have been stretched enormously from soubrette to dramatic soprano to Broadway belter. I love working out how these tiny vocal cords can be manipulated to make all these different sounds and textures. The dramatic challenges are one thing, but to belt Sondheim and then to sing the fiendish scales and relentless tessitura of Verdi ... well that is a challenge that never leaves one feeling bored!

You have sung some of the great dames of opera and musical theatre. Do you have a favourite? How could I choose between Butterfly and Tosca, Mimi and Musetta, Rusalka and Tatiana, Mrs Lovett or Desiree? I just feel so lucky that my sister was in that production of The Boyfriend, otherwise I would never have walked in all these wonderful ladies’s shoes. or tabi, where Butterfly was concerned. Hold on, I still have never played the school mistress in The Boyfriend. I will put it on the bucket list!

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Enter Medical Forum's competitions! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link. Movie: Ride Like a Girl Rachel Griffiths (Muriel’s Wedding, Six Feet Under and much more) makes her directorial debut in the biopic of the first female jockey, Michelle Payne, to win the Melbourne Cup. Teresa Palmer plays Payne and tells the story how the youngest child of 10 rose to win the premier horse race in the country. In cinemas, September 26

Elegant Theft: Duruflé’s Requiem The Perth Symphonic Chorus can be relied upon for bringing exciting musical programs into wonderful locations. Next month, PSC under the direction of Margaret Pride presents the exquisite Duruflé Requiem within the picturesque Christ Church Grammar School chapel overlooking the river. With the brilliance of Stewart Smith on the organ, it will be something very special to witness. Durufle, who was an esteemed French organist, used the medieval Gregorian chants as the superstructure from which he built this towering work. He adds impeccable French flair, of course, by way of glorious melodies and luxuriant harmonies of the Impressionists to produce what Margaret describes and a “meditative and personal experience for the listener”. Soloists in the requiem are drawn from the ranks of the choir and in some cases ‘solo’ work is performed by a section of the singers.

Movie: Gemini Man Director Ang Lee and producer Jerry Bruckheimer don’t often show up in a sentence together but here they are with this action action-thriller starring Will Smith as an elite assassin, who becomes the hunted. Cast also includes Mary Elizabeth Winstead, Clive Owen and Benedict Wong. In cinemas, October 10

Movie: Zombieland Double Tap The first iteration made us laugh and the sequel, with the returning Woody Harrelson, Jesse Eisenberg, Emma Stone and Abigail Breslin, promises to do likewise. The comic mayhem starts in the White House with a new gaggle of bigger and better zombies and a few new human survivors. In cinemas, October 17

Sure to create some memorable musical moments.

Opera: Macbeth

Christ Church Grammar School Chapel Claremont, October 20

Shakespeare’s blood fest Macbeth is captured by the great Giuseppe Verdi into a wildy tragic and dramatic tale of the loyal general who is corrupted by his own greed and a little bit of that old black magic from his good lady wife.

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Other works on the program include Fauré and Debussy which will both make good use of the solo harpist.

July Winners

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

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Choral: Swoons – Dr David Storer

July 2019

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The talented Sukhjit Kaur Khalsa’s wonderful, poetic snapshot of her life in the Perth ’burbs. She made headlines when she performed a rousing poem confronting racism on Australia’s Got Talent and now has hit the stage in this not-to-be missed show. Studio Underground, October 10-27

Theatre: Much Ado About Nothing – Dr Andrew Lim Kids Theatre: Revolting Rhymes & Dirty Beasts – Dr Mark Strahan Dance: Bangarra 30 Years of Sixty Five Thousand – Dr Indrani Saharay

54 | SEPTEMBER 2019

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