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September 2016 www.mforum.com.au

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Editorial

This is Your Life Midway through last month, the Medical Board of Australia’s Expert Advisory Group released its discussion paper on revalidation and flung open its feedback portal to the world enabling it to have a say on the subject. Within hours comments were flowing thick and fast. It won’t surprise many that much of its tenor was negative, which probably accurately reflects the majority opinion in the profession, particularly among GPs. While we have looked at the subject of the EAG discussion paper a little more deeply on P6 and there’s still much water to flow under this particular bridge, the methodology of the ‘consultation process’ gave us serious pause for thought. It’s undeniable that we are sharing just about every aspect of our lives with the online ‘community’, whoever and wherever they may be. And there is something commendable how the internet has facilitated such unprecedented access to information and provided unlimited platforms for the giving and receiving of opinion, so freely and unselfishly bestowed. Never was so much wisdom unleashed by so few on so many*. But a consultation process it is not and, perhaps, if we were to put on our crusty sceptic’s hat, it could be interpreted as merely a box ticked on the inexorable march to a predetermined destination. If that is the case, it’s a lost opportunity on the part of the Medical Board to do some much-needed PR with its fee-paying stakeholders. They most definitely deserve a little loving care after nearly seven years of rough-shod handling by the AHPRA attack dogs. And, more significantly, there are some things to admire in the EAG’s endeavours. For a government report it is, dare we say, courageous. It goes to some lengths to investigate a model that uses the strengths of the current system while offering alternatives to its weaknesses. One presumes that the EAG consulted widely with the ‘suits – particularly the colleges – who would be, one speculates, the incidental beneficiaries of a “strengthened” CPD process. Also, too, it would no doubt have had discussions with professional groups such as the AMA. Its national president Dr Michael Gannon went so far as to thank the EAG for its “modest approach”, which implies that the AMA and perhaps the colleges, as well, were expecting much worse.

So why doesn’t the Medical Board show the courage of its convictions and a belief in its own EAG’s report to consult more personally with doctors who alone (GPs arguably are even more exposed than their specialist colleagues) bear the brunt of its proposals? Why not use this moment in history to win hearts and minds, and persuade with the strength of ideas? It’s been forcibly argued that revalidation is an attempt by bureaucracy to breach the gap left by the profession’s poor attempt at self-regulation. But, where to start? Well the beginning is always a pretty good place and the spotlight should turn to training doctors who are resilient but not damaged in the process. The next Doctors Drum breakfast on September 29 will throw some of these ideas around. The profession should be responsible for keeping itself safe and knowledgeable. In an ideal world, the Medical Board should be supporting it in that complex endeavour. Instead it has opted to open the portcullis to let everyone have a say while it retires for a couple of months feeling self-satisﬁed that a consultation is taking place. School-yard tit-for-tatting between a doctor (anon) and a consumer (anon) (who else?) on its site is not constructive. Nor is it consultation, but through a combination of sleight of hand and smoke and mirrors it is most certainly taking the place of one. The issue is far too important for this quality of ‘feedback’.’ There are some interesting dimensions to the EAG’s proposals and there are others that need to be energetically challenged. You pay the fees. You are the ‘stakeholders’. You deserve to be heard. It’s also your career and your livelihood. Talk to the people who’ll take you seriously.

Ms Jan Hallam

The process is open until November 30. That’s time enough to read the proposals and make your feelings known to those who represent you. By Jan Hallam *Apologies to Sir Winston Churchill, cheap but irresistible!

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

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

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

SEPTEMBER 2016 | 1

September 2016 16

Contents 26

FEATURES 16 Proﬁle: Kununurra GP Dr Catherine Engelke 18 Asbestos Update 22 IT Scramble in Health 26 E-cigs for and against

52 53 54

NEWS & VIEWS 1 Editorial This is Your Life 4

6 6 10 12 14 33 40

Ms Jan Hallam Letters to the Editor Positive FASD Initiative Prof Dawn Bessarab Online Stalking Ms Kayelene Kerr Kids in Sport Mr Ron Alexander Revalidation Curious Conversation Dr Kimberley Minas Have You Heard? Cystic Fibrosis Research Spotlight: Olympian Fergus Kavanagh Inhaler Use Campaign Beneath the Drapes

MAJOR SPONSORS 2 | SEPTEMBER 2016

LIFESTYLE 48 Tale of Two Jags 50 Funny Side 51 Wine Review: Upper Reach

Perth Pathology

Dr Craig Drummond Opera: Sam Roberts-Smith Competitions Cabaret: Cole

Enjoy breakfast and a Q&A Panel “Training and ‘Dud’ Doctors?” Ask the Panel what they think... Thurs Sept 22, 7.15-8.50am Royal Perth Yacht Club

Breakfast sponsored by… Curtin Medical School

www.doctorsdrum.com.au

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Clinical Contributors

Dr Mike Armstrong CMV in Inﬂammatory Bowel Disease

Dr Sina Keihani Inhalers for COPD Patients

Dr Michael O’Sullivan Dubious Autoantibody Results

Ms Sharon Boxhall Venous Leg Ulcers

Dr Michael Prichard Respiratory Case Reports

Dr Michaela Lucas Penicillin Allergy: Next Step?

Dr Colin Somerville Spring ‘Hay Fever’

Dr Christiane Remke Winter: Fevers, Coughs & Runny Noses

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Dr Jason Tan Sex After Gynaecological Surgery

Guest Columnists

Mr Paul Brennan Prescribed Burns

Mr Terry Sleven & Ms Fiona Phillips E-Cigarettes: Help or Hindrance?

A/Prof Iain Murray New Way of Seeing

Ms Linda Cann The Digital Dilemma

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM SEPTEMBER 2016 | 3

Letters to the Editor

Positive FASD initiative

increasing numbers of children in Perth addicted to pornography, sending nudes and being groomed online.

Dear Editor,

The internet is not new, nor are the predators that lurk in cyber space. What is new and has delivered this issue into homes across Australia is the accessibility to the internet made possible by portable devices. The internet is the pen and paper of the 21st century and children are spending increasing amounts of time online. As such parents today need to understand how the technology their children use works.

Regarding the story Looking for FASD Solutions (August edition), moving into a partnership with the criminal justice system particularly in relation to young people in detention to assess and determine if any of them are FASD is a really important intervention. This has the potential to be a game changer in that recidivism, anti-social behaviour, criminality all tend to be used to blame young Aboriginal people and raises the issue of why they keep doing what they are doing. If this project is able to provide evidence that many young people in detention have FASD it provides another understanding to those behaviours which need different types of intervention and management. Prof Dawn Bessarab, Director of the Centre for Aboriginal Medical and Dental Health, UWA ........................................................................

Knowledge is power Dear Editor, RE: The Dark Side of the Web (August edition). lack of knowledge and understanding about what children and young people are doing online is resulting in parents and carers feeling ill-equipped to deal with the vast array of applications their children use, games they play and websites they visit. Protective Behaviours WA is working with

There appears to be a disconnect between the way parents ‘parent’ in the real world and the online world. Children are being given access to devices before they are taught personal safety and strategies to keep themselves safe. We don’t allow our young children to cross the road or swim without instruction and supervision, yet we allow them into an environment in which they can come into contact with billions of people they don’t know and their potential mistakes are permanent and can have long-lasting implications. The Protective Behaviours program that has been taught in Western Australia for over 20 years needs to be extended to include the online world. Before a child has access to the Internet parents need to educate their children about public and private information, behaviour and body parts. Parents need to be their child’s training wheels while they are learning to be a good digital citizen. Assisting children to think critically and problem solve different situations they may encounter, and establishing a network of trusted adults they can speak to if they feel unsafe or see something that makes them feel uncomfortable are essential. Ms Kayelene Kerr, Protective Behaviours WA ........................................................................

My deﬁnition of an intellectual is someone who can listen to the William Tell Overture without thinking of the Lone Ranger. Billy Connolly

Good sport and being good at sport Dear Editor, At the Department of Sport and Recreation we constantly and enthusiastically advocate for participation in sport and active recreation. In relation to the column, Kids’ Sport Specialiation Pressures, by Dr Dylan Warner (August edition), which cautions streaming young people into specialist sports too early, the Department’s policy is that early specialisation is not necessary or appropriate for children 12 and under. Evidence shows that diversity (instead of specialisation) during childhood has a positive effect on future elite performance as well as long-term participation in the sport. It’s great that parents are enthusiastic about their children playing sport, but let’s make sure they lead a balanced life and don’t train for too many hours a week. As a Department we agree that physical activity should focus on “developing healthy, capable and resilient young athletes” whether you play community grassroots sport or are on a pathway to elite competition. Equally, we also support well-rounded development by encouraging children to be involved in activities like dance and the arts, which also help them perform better at school. At the Rio Olympics numerous athletes actively promoted the joy of simply participating and doing their best which no doubt will have great influence on young people striving to achieve their own personal best while never forgetting the element of fun. We are blessed with an amazing landscape, excellent facilities and well-run clubs so young Western Australians have the opportunity – and should be encouraged to – experience a wide range of sports. Anyone who is active will tell you that while the physical benefits of sport and active recreation are great, they are matched by the benefits of a positive mental outlook, calmness and a greater connection to self and others. Playing sport is more than just turning up to training or playing a game. It’s about

continued on Page 6

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MEDICAL FORUM

0RXQW +RVSLWDO·V IRFXV RQ 5HKDELOLWDWLRQ Empowering Patients to Get Home Mount Hospital’s rehabilitation unit, Tuart Ward has more than 40 licensed rehabilitation beds with a focus on empowering our patients to get home. We offer individualised and comprehensive programs to encourage all patients to regain their independence. Our extensive multi-disciplinary team includes: : : : : : : : :

Specialist Physicians 24 hour medical cover Highly skilled nurses Physiotherapists Occupational Therapists Speech Therapist Dieticians Discharge Co-ordinator

Introducing our new Director of Rehabilitation Services, Dr Larry Liew We are excited to announce the appointment Dr Larry Liew to the newly created role of Director of Rehabilitation Services. The new role positions us as a leading provider of complete rehabilitation services for patients.

In 2014 we introduced a program which allows us to benchmark our outcomes against all Australian hospitals using data from the Australasian Rehabilitation Outcomes Centre (AROC). The program measures length of stay and patient outcomes, with Mount Hospital’s results being exceptional.

Easy Referral Any Doctor may refer their patients by speaking with Dr Larry Liew on 9400 9723 or by emailing Larry.Liew@healthscope.com.au Our friendly ward staff will arrange for your patient to be assessed for suitability and transferred when ready.

Dr Liew is a graduate of the University of Western Australia’s Medical School and has over 10 years of experience and specialised training in Geriatric and Palliative Care medicine. He has gained experience at both Osborne Park Hospital and Glengarry Hospital. “I am looking forward to building on the reputation and skills of the team at Mount Hospital to provide the highest level of ongoing care for our patients” said Dr Liew. Hospital General Manager, Carl Yuile says “This new position is an important step for Mount Hospital in cementing our commitment to providing exceptional, high quality and full service care for all of our patients.”

Mount Hospital 150 Mounts Bay Road, Perth WA 6000 | Phone: (08) 9327 1100 | Fax: (08) 9321 2208 www.mounthospital.com.au A Healthscope hospital.

Letters to the Editor continued from Page 4 being humble when you win, being a â&#x20AC;&#x2DC;True Sportâ&#x20AC;&#x2122; and accepting when you donâ&#x20AC;&#x2122;t, learning discipline, turning up on time, being dependable and communicating with your team. Joining a team can help young people come out of their shell, develop a strong sense of community and connect over a common interest. When they join a club, theyâ&#x20AC;&#x2122;ll also meet coaches, ofďŹ cials and volunteers who can become positive role models and mentors. Being part of a team nurtures a sense of fair-play and good sportsmanship, forging friendships which can last a lifetime. Mr Ron Alexander, Director General, Department of Sport and Recreation ........................................................................

We welcome your letters and leads for stories. Please keep them short. Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. Letters, especially those over 300 words, may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.

What Revalidation Might Look Like At some point on August 16, the Medical Board launched its discussion paper on revalidation urging medical practitioners to offer their feedback online. It gave the media organisations just enough time to formulate the next morningâ&#x20AC;&#x2122;s headlines such as â&#x20AC;&#x153;Shonky doctors who put patients at risk face Medical Board crackdownâ&#x20AC;? and â&#x20AC;&#x153;Medical Board of Australia's proposal to root out underperforming doctorsâ&#x20AC;?. At precisely 10.55am EST on August 17, the feedback started ďŹ&#x201A;owing in. The process is open to everyone and you can leave your name or post anonymously until November 30. You just canâ&#x20AC;&#x2122;t be obscene as the site is moderated, though it hasnâ&#x20AC;&#x2122;t stopped a cascade of forthright views. You may see names of doctors you might know but you wonâ&#x20AC;&#x2122;t read anything you havenâ&#x20AC;&#x2122;t read before or many endorsements of the plans. We did see one from some poor lone voice from the general public who was challenged by a medico to confess he was a stooge of AHPRA. The quick comeback by John or Jo Doe was to suggest they could be the doctorâ&#x20AC;&#x2122;s patient! Apart from the commentâ&#x20AC;&#x2122;s general entertainment factor, there is much to ponder, not least of all the consultation process itself. Nonetheless the discussion paper is well laid out and there seems to be a genuine attempt to formulate a revalidation process that will not be too cumbersome and will use systems already in place. However, there is no suggestion minds will be changed on the core need for revalidation.

The AMA president Dr Michael Gannon told the SMH the medical profession welcomed the board's â&#x20AC;&#x153;modest approachâ&#x20AC;? to the issue. â&#x20AC;&#x153;I don't think there's a great deal of evidence that the professional development system is broken," he said. The sticking point is and always will be identifying at-risk doctors. On this issue the Expert Advisory Group has gone out on a limb. It has identiďŹ ed the subset of practitioners based on these risk factors: sĂĽ AGEĂĽ FROMĂĽ ĂĽYEARS ĂĽINCREASINGĂĽINTOĂĽMIDDLEĂĽ and older age) sĂĽ MALEĂĽGENDERĂĽ sĂĽ NUMBERĂĽOFĂĽPRIORĂĽCOMPLAINTS ĂĽANDĂĽ sĂĽ TIMEĂĽSINCEĂĽLASTĂĽPRIORĂĽCOMPLAINT ĂĽ Additional individual risk factors found in certain studies include: sĂĽ PRIMARYĂĽMEDICALĂĽQUALIlCATIONĂĽACQUIREDĂĽINĂĽ some countries of origin sĂĽ SPECIALTYĂĽ sĂĽ LACKĂĽOFĂĽRESPONSEĂĽTOĂĽFEEDBACKĂĽ sĂĽ UNRECOGNISEDĂĽCOGNITIVEĂĽIMPAIRMENTĂĽ sĂĽ PRACTISINGĂĽINĂĽISOLATIONĂĽFROMĂĽPEERSĂĽORĂĽ outside an organisationâ&#x20AC;&#x2122;s structured clinical governance system sĂĽ LOWĂĽLEVELSĂĽOFĂĽHIGHĂĽQUALITYĂĽ CPD activities, and sĂĽ CHANGEĂĽINĂĽSCOPEĂĽOFĂĽPRACTICE ĂĽ Give your concerns voice at www. medicalboard.gov.au/News/CurrentConsultations.aspx by November 30.

Curious Conversations

Opportunities Galore! Lifeâ&#x20AC;&#x2122;s all about accentuating the positive for Dr Kimberley Minas, a doctor with a brand-new stethoscope. One of the happiest days of my life wasâ&#x20AC;Ś about six years ago when I decided to enrol in a postgraduate medical course on the other side of Australia. The drive across the country was an incredible experience in my beaten-up Holden Astra. Since moving to Perth I haven't looked back and most days, with the exception of Monday perhaps, are pretty happy. It looks like I'm here to stay! If I could change one thing about my medical training it would beâ&#x20AC;Ś to do more international electives. I went to a small village in rural Ireland and communicated with refugees using interpretive gestures on the Thai-Burma border. To experience vastly different cultures and try amazing cuisine was such a unique opportunity. I learnt a lot more than just medicine.

6 | SEPTEMBER 2016

A person I really admire isâ&#x20AC;Ś Malala Yousafazi whoâ&#x20AC;&#x2122;s shown the world the power of one voice. Sheâ&#x20AC;&#x2122;s been advocating on behalf of womenâ&#x20AC;&#x2122;s rights from a young age and her focus on education has changed lives. Itâ&#x20AC;&#x2122;s made me realise just how lucky I am to have had so many opportunities. If I had to choose one CD to take to a desert island it would beâ&#x20AC;Ś any music from the â&#x20AC;&#x2122;50s would suit me just ďŹ ne. I'd happily sing my heart out and no-one would have to endure the agony. The book on my bedside table isâ&#x20AC;Ś The Little Old Lady Who Broke all the Rules. The main character is Martha who lives in a retirement home. Sheâ&#x20AC;&#x2122;s feisty with an adventurous spirit and the message is that getting older can be the beginning of a new adventure. Yes, Mum, I am looking at you!

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SEPTEMBER 2016 | 7

Incisions

Where There’s Smoke… Prescribed burning is a controversial topic for some but Mr Paul Brennan from Parks and Wildlife says the practice is underpinned by scientiﬁc research. In just the same way that science underpins medicine, a long track-record of research shows prescribed burning is an effective method of mitigating the severity of bushﬁres, which helps to protect both lives and property.

very aware that it’s critically important to take advantage of optimum weather conditions when igniting a designated burn. It’s also worth noting that a stringent daily ignition approval process is in place to ensure that each burn meets its intended objectives.

So, just what is ‘Prescribed Burning’?

To determine where and when a burn is to be held, many factors are considered. One of the most important aspects, and one that any medical professional in the respiratory area will be gratiﬁed to hear, is smoke and its potential impact on individuals and communities.

It’s the process of planning and applying fire in a controlled way under specific environmental conditions to reduce the build-up of flammable vegetation. It’s also referred to sometimes as ‘Fuel Reduction’. Bushfires are less intense and spread at a slower rate when they enter a reduced fuel area, allowing firefighters greater opportunity to combat fires and to limit their impact. Prescribed burning is the principal tool used by the Department of Parks and Wildlife to manage fuel loads on land that it manages, which includes National Parks, State Forest and Conservation Reserves. Of course, this process is not confined to DPAW. Local governments and private landowners also carry out fuel reduction activities. The heavily populated south-west corner of WA, and that includes Perth, is a significant focus for DPAW’s prescribed burning program, which is usually conducted in spring and autumn each year. Prescribed burns are always carefully planned. DPAW prepares three-year indicative Burn Plans, annual Burn Programs and detailed plans for individual prescribed burns.

In all the planning we do, Parks and Wildlife always tries to minimise smoke impact, while endeavouring to take advantage of suitable weather conditions so that a burn can be conducted safely. We freely acknowledge that this can be something of a balancing act and this does sometimes result in smoke haze for limited periods.

Consultation occurs with key stakeholders and, in particular, local governments. Prior notiﬁcation is also given to neighbours and other groups known to be using the area.

However, the consequences of not conducting prescribed burns can be much more serious than the temporary discomfort they might cause.

However, the consequences of not conducting prescribed burns can be much more serious than the temporary discomfort they might cause. To borrow a medical analogy, if an out of control bushﬁre is a serious disease then prescribed burning is the preventative treatment.

Parks and Wildlife combine specialist knowledge about ﬁre behaviour with information gained from other sources, and in particular the Bureau of Meteorology. We’re

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By Dr Mike Armstrong Pathologist

Perth Pathology (Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 26 Leura St, Nedlands WA 6009 Ph 9433 5696 Fax 9433 5472

www.perthpathology.com.au

Mike is a graduate of UWA, and fellow of the RCPA. He worked as a consultant pathologist at RPH 19961999, then worked in private pathology. He has been at Perth Pathology since Jan 2007. He also holds a consultant post (part-time) at PathWest KEMH. He has interests in GI, skin, gynaecological pathology and cytology.

There are 52 collection centres across inner and outer Perth, Mandurah, and Secret Harbour. Please refer to the website for opening hours and addresses

CMV in Inflammatory Bowel Disease Cytomegalovirus (CMV), a double stranded DNA virus of the Herpes viridae family, is usually asymptomatic in immunocompetent individuals. There may be a mononucleosis-like disease but this is rare. The virus enters a latent phase but can re-activate later in the healthy adult, usually asymptomatically.

CMV appears to inďŹ&#x201A;uence the clinical course of some ulcerative colitis (UC) patients but does not appear to inďŹ&#x201A;uence the outcome of Crohnâ&#x20AC;&#x2122;s disease (CD). Prevalence - Pathogenesis In cases of severe UC (including those steroid resistant), serological testing and rectal biopsy histology with immunohistochemistry and PCR for CMV DNA, found a CMV prevalence of 20-40%. It is postulated that colonic inďŹ&#x201A;ammation and immunosuppression together re-activate CMV, mediated by cytokines including TNF alpha. Other factors implicated in this reactivation include steroid treatment, use of cyclosporine, age >30yrs, presence of ulcers at endoscopy, and longer duration of disease (>60 months). CMV Pathologic Findings and IdentiďŹ cation in Colonic Mucosa CMV causes a variety of gross lesions. Ulceration is common, whether single or multiple, superďŹ cial or deep, small or large, with perhaps a well-deďŹ ned 'punched out' appearance. Linear ulcers, segmental inďŹ&#x201A;ammation, pseudomembranes, polyps, masses and mucosal haemorrhage have also been described. Histology remains the gold standard for diagnosing CMV in the GI tract though

sĂĽ 3CREENINGĂĽFORĂĽ#-6ĂĽINFECTIONĂĽISĂĽ unnecessary before starting immunomodulator therapy. sĂĽ )NĂĽACUTEĂĽSTEROIDĂĽRESISTANTĂĽCOLITIS ĂĽ exclude CMV using tissue PCR or immunohistochemistry before increasing immunomodulator therapy. sĂĽ )NĂĽSEVEREĂĽSTEROIDĂĽRESISTANTĂĽCOLITISĂĽWITHĂĽ CMV detected in the mucosa during immunomodulator treatment, antiviral therapy should be initiated and discontinuation of immunmodulators considered.

In immunocompromised people, various organ systems can be symptomatically involved, including the GI tract. In patients with inďŹ&#x201A;ammatory bowel disease (IBD) on immunosuppressive treatment, CMV infection can develop with signiďŹ cant morbidity. The exact relationship between CMV and IBD is unclear, complex and controversial. CMV infection has been associated with exacerbations of IBD causing severe colitis, steroid refractory disease, toxic megacolon and increased mortality rates. It is unclear if CMV is actively involved or an innocent bystander.

Below are guidelines outlined by ECCO (European Crohn's and Colitis Organisation) in 2014.

Intracellular CMV inclusions, high magniďŹ cation, H&E stain

microscopic changes are highly variable and share many features with other forms of colitis. The features include active inďŹ&#x201A;ammation, superďŹ cial and deep ulceration, cryptitis, crypt abscesses, crypt atrophy, enterocyte apoptosis and vasculitis. Most characteristic are so called â&#x20AC;&#x2DC;owls eyeâ&#x20AC;&#x2122; intranuclear viral inclusions and basophilic granular intracytoplasmic inclusions, seen on routine H&E stained sections. These inclusions are found in endothelial cells and stromal cells, rarely in glandular epithelial cells. For histology, several colonic biopsies should be taken from inďŹ&#x201A;amed mucosa near or within the ulcer. Carefully targeted biopsies for histology together with CMV immunohistochemistry can be highly speciďŹ c (95-100%) and sensitive (78-93%). Qualitative PCR for CMV DNA on colonic biopsies often correlates poorly with histology and clinical features â&#x20AC;&#x201C; mainly false positives from detection of small amounts of viral DNA (?latent CMV). To overcome this problem, quantitative PCR (qPCR) is being done to assess the â&#x20AC;&#x153;viral loadâ&#x20AC;? in the colonic mucosa. Results are quoted in copies of DNA per mg, with arbitrary thresholds for a so-called positive result (e.g. 250 DNA copies/mg). This is still a â&#x20AC;&#x2DC;work in progressâ&#x20AC;&#x2122;. Treatment of CMV Colitis in UC Despite conďŹ&#x201A;icting results, there is increasing evidence to suggest CMV reactivation is a factor in ďŹ&#x201A;are-ups of refractory UC, especially in patients >30yrs age, with high density infection or with stigmata of severe disease. Treatment with gancyclovir is recommended in association with antiTNF mAb therapy.

Response rates to antiviral therapy in these clinical settings have been variable (reported at 50-83% ) however â&#x20AC;&#x2DC;responseâ&#x20AC;&#x2122; is often not clearly deďŹ ned in many studies â&#x20AC;&#x201C; further wellconstructed studies are needed.

Perth Pathology General Pathologist / Managing Partner: Dr Wayne Smit Histology / Cytology: Dr Michael Armstrong Dr Tom Grieve Dr Jason Lau Dr Chanh Ly

Dr Tony Barham Dr Peter Heenan Dr Stephen Lee

Infectious Diseases (Microbiology): Dr Laurens Manning Haematology: Dr Rebecca Howman Laboratory Director: Paul Schneider Providing phone advice to clinicians and a comprehensive range of medical pathology investigations, including: sĂĽ (ISTOLOGYĂĽ 3KIN ĂĽ') ĂĽETC sĂĽ #YTOLOGYĂĽ INCL ĂĽ0APSĂĽANDĂĽ&.!S sĂĽ (AEMATOLOGYĂĽ YES ĂĽWEĂĽDOĂĽLAB controlled INRs) sĂĽĂĽ"IOCHEMISTRYĂĽ INCLUDINGĂĽHORMONES and markers) sĂĽ-ICROBIOLOGYĂĽANDĂĽ3EROLOGY Professional personalised service from a non-corporate, pathologist owned and operated laboratory practice

Have You Heard?

POC testing for ABX

Louise’s leadership lauded Panaceum’s Louise Turner has been awarded WA AAPM State Practice Manager of the Year – and with 19 GPs, 30 administration and nursing staff across two practices in Geraldton to coordinate, it would appear well deserved. In the citation at the annual awards night, guests heard how important Louise’s contribution had been to positive culture change in the practice. “Louise constantly researches innovations for potential to improve the ﬂow of the practice and develops strategies to implement those that will achieve the best outcomes.”

Things have changed. ‘Just in case’ antibiotics may be a thing of the past in remote communities. The media release said “on-the-spot blood test is ﬁghting superbugs”. It was talking of promoting a point-of-care (POC) pathology test as helping doctors do the right thing: a result within 15 minutes means more accurate prescribing of antibiotics for respiratory infections, which in turn means less antibiotics overall (a 23-36% drop in Europe) and probably fewer resistant superbugs. PathWest’s Network Director of Regional Service Dr Narelle Hadlow supported the claims, quoting a BMJ review that showed CRP (the test in question) and procalcitonin (if you are in hospital) can help direct correct use of antibiotics. She said 70% of medical decisions rely on pathology results. A CRP<20 mg/L likely means a selflimiting viral infection for which antibiotics can be withheld (unless complications likely). She said the clinicians using the POC devices at Esperance, Busselton, Margaret River, Augusta, Exmouth, Fitzroy Crossing and Halls Creek are trained and the testing is monitored by PathWest for quality. The test is a good backup for remote hospitals and nursing posts, which they say might decrease hospital bed-stays.

Pharma payments hit sunlight For pharma members of Medicines Australia, it will be mandatory from October 1, under the ACCC-inspired new Code, to publish names and amounts of payments and transfers of

smithcoffey

10 | SEPTEMBER 2016

MEDICAL FORUM

Have You Heard?

value to individual healthcare professionals. Pharma companies have been collecting the information for the past 12 months but health professionals could opt out of disclosure. The RACGP says the mandatory changes mean greater transparency. Published information relate to payments for services (e.g. giving a lecture, chairing an educational meeting, serving on an advisory board or consulting) and airfares and/or accommodation bundled with educational or consulting services and conference registration fees. In the nine months from January 1 to September 30, 2015, 689 consultants were paid an average of $2,642.95 each by 33 companies. Mind you, during 12 months until December 30, 2015, an average of $33,174 was provided by 33 companies to 276 health consumer NFP organisations. For instance, Astrazeneca gave $90,750 to the Lung Foundation to assist it to develop patient materials for its national COPD program and two other campaigns. Some say whoever pays the piper calls the tune but Medicines Australia sets rules of engagement and talks of enhancing quality use of medications.

plan is to grow the government-subsidised home care side. Catholic not-for-proďŹ t provider, MercyCare, has purchased Belrose Care which has four aged care homes in Joondalup, Kelmscott, Maddington and Rockingham, which when added to MercyCareâ&#x20AC;&#x2122;s Wembley ACF, increases resident numbers from 113 to 500.

Aged care business

Is there a mesh mess?

Aged care in WA is preparing for the February 2017 changes promoted by government where the health consumer will hold the government subsidised package of aged care help at home, and is free to choose which provider to spend it with. The RAC insurance mutual now has an equal share in its St Ives Home Care business with Sydneybased private equity group Quadrant. The

The TGA is urging doctors and health consumers to report adverse events with urogynaecological surgical meshes, believing events are under-reported perhaps because some patients have not joined the dots. Urogynaecological meshes (supplied as a 'sling', 'tape', 'ribbon', 'mesh' and 'hammock') are used to treat pelvic organ prolapse and stress urinary incontinence. The TGA

AMA moves on freeze The AMA, whose GP membership is relatively low, has ďŹ nally launched a web resource for GPs caught out by the Medicare freeze. www.futurepractice.com.au is the brainchild of the NSW branch. It afďŹ rms that most people will come to rely on a single GP for complex issues but access corporate practices for more routine consults. What their dream practice includes, apart from the fundamentals of private medical practice outside of poorer areas, is a belief that the public is â&#x20AC;&#x153;open to paying an appropriate fee for those who can afford it, providing those in need retain access to servicesâ&#x20AC;?. Quality care costs but the government isnâ&#x20AC;&#x2122;t paying, their slogan says.

says between July 2012 and June 2016, 99 adverse reports were received, most frequently pain and erosion. It lists a stack of adverse events in 30 bullet points which makes the reader wonder what is the upside of this surgery?

Genesis eyes Asia GenesisCare Limited, which owns cardiology, radiation oncology, and sleep disorder services in WA, has sold a controlling stake of its business to a new investment consortium comprised of a Hong Kong-based China Resources Group and Macquarie Capital, an advisory arm of Macquarie Group. According to the Australian Financial Review the sale price equates to an enterprise value of $1.7b a big step-up from August 2012 when the companyâ&#x20AC;&#x2122;s enterprise value was put at $550m. The sale will require sign-off from the Foreign Investment Review Board. The consortium is investing with management and 150 or so doctors for a stake in the business of between 50 per cent and 70 per cent. The deal also requires shareholder approval. GenesisCare Chairman said Australian expertise and technology will enter new markets that include China from an Australian base with the management team remaining in Sydney. He reassured investors that clinical governance will not change, and the GenesisCare MD said the company will continue its expansion plans into Western Europe (it says it is the largest provider of private cancer services in Spain and the UK), and under new arrangements, accelerate plans for Asia.

Best Practices

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SEPTEMBER 2016 | 11

News & Views

Every Breath She Takes Dr Ingrid Laing knows firsthand how science has improved life for those with cystic fibrosis and how precious organ donation is to fulfil that life promise. Telethon Kids Institute respiratory researcher Dr Ingrid Laing draws a deep breath as she contemplates how her life was not only transformed but literally saved by a double lung transplant in 2011. Ingrid has cystic fibrosis (CF) and at the age of 38 was struck down by a particularly nasty infection that affects some CF sufferers leaving a transplant her only hope. She moved to Sydney where she waited five weeks for a donor. “The infection presents a higher risk for transplant because your new lungs can be affected when your immune system is suppressed. Perth’s transplant service was fairly new back then and they were a bit nervous taking on this particular contraindication so that’s why I went to Sydney. They had a little more positive experience with this infection,” Ingrid said. “All my life, I had coughed. As I got older and sicker I struggled to do simple things. I couldn’t climb stairs or laugh without coughing. As soon as I woke up from surgery that cough was gone. Often it’s the little things that make you so happy with what you have been given.” Science had the answers Despite her disrupted schooling, Ingrid was inspired to study biotechnology at Murdoch University which led to a PhD at UWA. Her work at UWA and Telethon Kids is focused on asthma. “We’re studying children who present to the emergency department with an asthma attack. About 95% of them are infected with a virus and we are investigating their immune responses to those viruses as well as the childrens genetic susceptibility to see how those elements

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Dr Ingrid Laing

may be related why they get asthma attacks and also to the severity of the attack.” While CF and being an organ recipient has not deterred her living a full and rewarding life, Ingrid has had the eyes of the world – or at least the media – watching her since she was a small child. “My parents were not ashamed of my health condition but were open and honest about it from the start and that’s always sat quite well with me. This is what I have, this is what I live with, I am not alone and there are a lot of us out there with this condition. We’re just trying to get on with our lives and make the best of it,” she said. Ingrid generously gave her time to be a spokesperson for the recent Donor Awareness Week for Donate Life because she knows firsthand what an extraordinary gift a donor organ is but she can also relate to just how complex the emotions are that surround the giving and receiving of such a gift. Emotional times “I am extremely grateful but nervous of the emotional consequences of knowing who my donor was – to connect to a real life. I have written to the donor family expressing my gratitude but to meet them I think would be personally too confronting for me. This is not to say that other people shouldn’t have the opportunity to meet if that is what they both want.” She views the past 12 months in which the organ donation process has been mired by criticism and an inquiry with some frustration. “Some people are not holding to the higher purpose of the process. They forget why it happens and why people do donate and why people need organs. Anything that inhibits that process makes me sad because people may not get the opportunity I had and it could cost them their lives.” “I’ve read on the donor and recipient facebook page that from the donor family perspective, those who decide to donate usually get some comfort and solace from the fact that their loved one’s lives have not completely ended.” While asthma is mostly in her research sights, Ingrid is involved in the Australian Respiratory Early Surveillance Team for Cystic Fibrosis (AREST CF), which is leading the world in cystic fibrosis research. She is supervising a PhD student who is investigating how some children with the same CFTR mutation have a more severe experience of the disease than others and how environmental oxidants may play a role in that regard. The satisfaction for Ingrid is seeing the progress that inch by inch makes life longer and more fulfilling for the children and adults with CF.

9203 9 203 20 03 5599 5599 99

www.healthnews.net.au/trial-offer/ www. ww w.heal w.he w. hea he alth al lth lth thne thne news news ws.net ws.n .n net et.a t.a .au/ au/ u/tr tria tria all-of l-of offe fer/ r/

“It’s sometimes hard to have inside knowledge of CF. I have other research interests that help me but I can’t help myself. I ﬁnd myself quite inspired by the work of AREST CF which makes me what to be involved.”

By Jan Hallam 12 | SEPTEMBER 2016

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BOQSA00602 SEPTEMBER 2016V2| 06/16 13

Spotlight

No Laughs for the Kookas All our eyes have been on the Olympics but for the national hockey team it is a big event on their ever-expanding calendar. The spotlight on world hockey will have shifted from the Rio Olympics to the next World Cup by the time this story appears in Medical Forum. But one thing’s for sure, veteran Kookaburra defender Fergus Kavanagh isn’t thinking about hanging up the stick just yet. “One of the best things about hockey is that it has taken me all around the world. I’ve travelled to some really interesting places and I met my Dutch partner when I was playing in Holland. The time I’ve spent playing in the Indian league has been wonderful and getting paid for it is an added bonus.” “I pretty much knew when I ﬁrst starting playing hockey in a serious way that money wasn’t going to be a big part of the equation. I’m happy with the amount I earn but I do look at the cricketers and their salary packages. If I could get 10% of that it’d be amazing! But I do have an Engineering/Commerce degree so there is life after hockey.”

Thrill of the Olympics When we spoke with Perth-based Fergus his focus was very much on Rio and a gold medal for the the Kookaburras, the topranked men’s hockey team in the world. “I’m one of the more senior members in the side but I still get excited before an international tournament. There’s always a big buzz around the Olympics, it’s the pinnacle of a hockey career and the fact that [this current team of players] have never won gold is something that always comes up when I give a talk about playing international hockey.” As it turned out, the Olympics campaign was a bit of a nightmare for the Kookaburras who entered the Rio Games as world number one. They came crashing out of the competition losing 4-0 to the Netherlands in the quarter finals. It is the first time since the Seoul Games in 1988 that the Kookaburras have failed to pick up an Olympic medal. Commentators are already invoking the ‘Curse of the Kookaburras’ as a team who can beat anyone between Olympic years but can only hold up one gold medal from the 2004 Olympics. The most disappointed people of all, apart from the players, would have been the three psychologists the team hired to work with them after their semifinal defeat against Germany at the London Olympics four years ago. Before he left for Rio, Fergus put it in perspective. “One small thing that’s not quite right at a critical moment can be very costly at this level.” Travel alerts The Kookaburras are always well briefed on medical and security matters before leaving for an overseas tournament, says Fergus.

14 | SEPTEMBER 2016

“My girlfriend and I were a little concerned about the Zika virus because we plan to have children at some stage but we’ve had a reassuring advice from our medical staff and the Australian Olympic Committee. Nonetheless, we’ll be taking things carefully.” “We’ve got measures in place regarding the security situation but a lot of it is just plain common-sense. If we go outside the village we’ll go as a group and make sure we don’t draw any undue attention to ourselves. I’ve been to Rio before so I know what to expect.” The hockey stick is designed to be wielded hard and fast and the ball is akin to a small missile. Injury hazards “The game’s full of broken hands, split eyebrows and knee injuries but so far I’ve been pretty lucky. No surgery, but I did have a back injury that kept me on the sidelines at the beginning of 2013. My form’s been quite consistent so I’ve been selected to play for the national side on a regular basis.” “I’m not sure if I’ve got another Olympics in me, I’ll have a think about that after Rio and a lot will depend on how my body’s holding up. There’s a World Cup in India around the corner and then the Commonwealth Games on the Gold Coast.” “But I will admit, I still get butterﬂies thinking about the Olympics.”

By Peter McClelland

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SEPTEMBER 2016 | 15

Close-Up

Best Care IS Best Practice On September 29 Dr Catherine Engelke will be at the RACGP conference in Perth sharing her experiences as a doctor working in some of the remotest parts of the country.

The experience of being on Health Minister Sussan Ley’s Primary Health Care Advisory Group was a rare opportunity for GP and Kununurra’s District Medical Ofﬁcer Dr Catherine Engelke to take a step back from the bear pit of modern medical practice and appraise the current system in order to ﬁnd ways to do it better. “We are all so busy working in our own environments that it was an amazing opportunity to see the bigger picture and to have the space to think creatively about how we can better use the money we have for health,” she told Medical Forum. The result of the group’s six months’ work was the report, Better Outcomes for People with Chronic and Complex Conditions. “There was a genuine belief that a good primary care service was the best way to improve health care and the health particularly of our patients with complex conditions and there are sites already engaging in aspects of the reform. It is an exciting time.” Change is coming Having this new perspective has also spurred Catherine to embrace change. “Rather than be frustrated by the limitations of my practice, I’m trying to address the things I can change now rather than wait for the reform process to occur. We are creatures of habit and change can be challenging, but we have a plan and we should give it the best go we can, or we risk being left behind.” “Our patients are the consumers of the health service and they talk. I suspect there will be a community push and rightly so. But it will also be hard work and it won’t happen overnight. I’m not unrealistic.” While reform may take certain shapes in the metropolitan area, how will it look from a remote health service’s perspective? “It is quite different to anything else out here and it is essential to have community participation and engagement. Aboriginal people respond particularly well to be engaged – they’re actively passive or passively active. If the health care they’re getting is culturally safe and appropriate, they will come, if it’s not, they will stay away.”

16 | SEPTEMBER 2016

Deep personal experience Catherine is in a perfect position to know. She is a Kija woman, who was born in Derby and grew up in Halls Creek. Her uncle was parliamentarian Ernie Bridge. In an interview with the ABC, Catherine said her parents were determined she would be educated. So after she had gone as far as she could go at the Halls Creek Special Aboriginal School, Catherine went to school at St Brigid’s Ladies College in Perth and then studied to become a registered nurse and midwife. She returned to work in the Kimberley, marrying Jim Engelke and nursing around the region. But in 2003, the dreams to become a doctor, shared with a medical friend Stephanie Trust, became a reality. She entered medical school; Catherine's two daughters were 2½ and 10 months at the time. “I completed my training in 2008 and as soon as I acquired the extra skills in emergency medicine and paediatrics that I needed to practise in the Kimberley, we came back,” she told Medical Forum. In fact both she and Stephanie returned to Kununurra to practise – Stephanie is the practice principle of the town’s only private general practice, Kununurra Medical. It joins a fairly complex GP headcount that swells as GP registrars join the ranks of the town’s permanent and locum GPs located at the district hospital, Kununurra Medical and the local Aboriginal Medical Service. Training roles Catherine is also a medical coordinator for the UWA Rural Clinical School which sees her supervise at least three medical students throughout the year. As DMO and GP, Catherine is rarely still. While the hospital no longer provides GP services, she manages emergency, on-call and inpatient medicine at the hospital. However, she conducts a remote primary care clinic at Warmun about 200km south of Kununurra usually once a week and this can include providing acute, chronic or emergency care. “It’s important to understand the community and having the insight and knowledge of the families and the resources available. My colleague

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Close-Up

for me, that’s good enough for me’. Then the anxiety is transferred back to us GPs because of our need to provide the best care for the patient. We can handle the majority of issues but specialist input is important.”

Dr Ann Ward has been going to Warmun now for 23 years. This understanding is a vital component of our role.” Culturally appropriate care is a term earnestly tossed about by bureaucrats but rarely explained or nurtured. While Catherine’s own heritage makes much of her engagement with her Aboriginal patients instinctive, having medical students and GP registrars looking to her for leads, it’s become important to communicate just what culturally appropriate care looks like and how essential it is to providing quality practice in remote communities.

“We do telephone consults – telehealth is certainly playing a role – but it doesn’t replace that personal touch and engagement. WACHS Kimberley has a fabulous service with a team of exceptional specialists including regional physicians, gynaecologist/ obstetricians, general surgeons, psychiatrists and paediatricians as well as other visiting specialists from Perth.” “Visits to Perth are more problematic but it just requires discussion. Once we make a patient’s sensitivities clear and it’s not an unreasonable request and it’s based on best practice, we are all on the same page.”

Time and trust And as Catherine explains how she goes about a clinic, it’s clear that the magic ingredients seem to be time and respect. Time to explain by a variety of means, from Google to mirth-making drawings on butcher’s paper; and respect for the patient’s intuitiveness of their health issues in the context of the lives they lead. “When I talk about culturally appropriate, it’s supplying information that’s not simplified but delivered in a way that is familiar to my patients but won't make them feel awkward or embarrassed. They need to feel secure to be able to ask. Warmun is a very traditional community and there’s definitely a time and a place.” “All my consults start the same way – I find out what they know first, what their agenda is and why they are here. Sometimes I have to say, ‘I know what you’ve said to me, but it doesn’t make sense to me, I think I’m missing something’.” At this critical moment, it’s a weighing up of trust. If a doctor has the patient’s trust they fill in the missing links. “It is a difficult thing to teach. Being Aboriginal I’m fortunate to be able to go back to the communities and people who have been significant in my life. I have an inherent knowledge if things are not quite right. I try

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Dr Catherine Engelke receiving her GP Registrar of the Year award from then RACGP president Dr Liz Marles in 2012.

“There’s always more medicine you can do, but maybe that’s not what the patient is wanting. We have to be mindful and be prepared to ask our patients.”

to impart that to registrars. It’s not a difﬁcult thing to get if you are open to it.”

“I had a patient tell me they would come to Kununurra Hospital for treatment but that they wouldn’t be sent anywhere else. I was uneasy with that and I had a number of conversations with them but they were very clear. They understood their medical issues and what was being done about it. But they described realistically their place in the world and where their priorities lay.”

“I also say to a patient, this is your story, you have to be responsible for this. I’m not here all the time. If another doctor is sitting in the same chair, you have to tell them straight. They can’t read your mind, and neither can I. It’s about empowering your patients.” Challenges of culture While it may sound simple enough, culture poses signiﬁcant trials for doctors in remote WA when it comes to ‘best practice’ and ‘culturally best practice’. “Knowing a patient’s experiences with the health system can make it tricky. If we need patients to go to Perth to be reviewed by a specialist and there has been a bad experience by someone in their family, you can anticipate potential issues. Some people say they won’t go.”

“Having that deep level of engagement only comes with time. The patient knew I had listened and I was truly interested and would respect their decision even though they were telling me something I didn’t want to hear. I thanked them for telling me ‘straight’ and noted their wishes.”

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MEDICAL FORUM

SEPTEMBER 2016 | 17

Feature

Asbestos Vigilance Still Needed Despite banning asbestos 13 years ago, the deadly material still poses health risks that has clinicians, researchers and regulators ever vigilant. The discovery of asbestos in imported building materials on the construction site of the Perth Children’s Hospital last month was a sobering reminder that despite the material being banned in WA since 2003 and the myriad agencies established to control it, the continued risk of asbestos exposure is real. While two scientists from the National Centre for Asbestos Related Diseases, based at the Perkins Institute in Nedlands, write here of their treatment research focus, it’s timely to look at the broader picture of how the use of the material is being monitored and how effective the asbestos-related disease surveillance has become. Last year, A/Prof Fraser Brims wrote in Medical Forum about the Asbestos Review Program (ARP) based at SCGH and funded by WA Health. Its objectives are to monitor the health of people who have had a minimum of three months continuous exposure to asbestos and provide health and clinical advice with the aim of early detection of cancers. WA’s unique perspective The program is unique to WA, which perhaps reﬂects the unique relationship the state has had with asbestos mining and the resulting rise of asbestos-related diseases over the decades. More than 5000 people since 1990 have visited the program at least once. Most attend annually (about 1200 people currently)

18 | SEPTEMBER 2016

A/Prof Fraser Brims

and cancers in about two patients a year are diagnosed.

per 100,000 population, with Queensland next with 3.1.

“Collaboration with the University of WA over the years has meant that observations in this cohort have translated into world-renowned research and the SCGH respiratory clinic has unparalleled experience in managing mesothelioma and other asbestos-related diseases,” Fraser said.

Of the 641 cases of mesothelioma, 597 (93.1%) were tumours of the pleura (a combined term used here to represent pericardium, pleura and mediastinum) and 38 (5.9%) of the peritoneum.

The ARP has been offering low dose CT scans and identifying treatable early stage lung cancer for four years and Fraser is hopeful that WA Health’s commitment to the program will continue. He added that a grant from the NSW Dust Diseases Board is facilitating research to establish who is at raised risk of lung cancer following asbestos exposure. “We are trying to look at the combination of other risk factors along with asbestos to help us understand who we should be concentrating on.” Sobering stats According to the latest Australian Mesothelioma Registry (AMR) ﬁgures (2014), 641 people nationally were diagnosed with the disease that year. It was the lowest ﬁgure in the four years of the registry. In 2011 there were 692 cases diagnosed, 2012, 713; and 2013, 676. In WA 94 new cases were diagnosed in 2014 (77 men and 17 women) giving the state the highest rate of 3.6 people

“The elderly workforce offers a natural decline in that respect but we are also recruiting new people into ARP every week,” Fraser said. “The asbestos issue at the Perth Children’s Hospital site is an opportunity to ﬂag to the community that this program exists and people who have had an exposure to asbestos for more than three months are entitled to be part of it. It is all bulk billed.” “Text books and the internet give the impression nothing can be done but in WA we have a unique service so there is something doctors can do. You can refer people to the ARP where we will review them annually and treat lung cancer early. It makes a big difference to these people.”

WorkSafe on Asbestos WorkSafe was one of several government agencies (Comcare, the WA Building Commission and the Department of Environment Regulation were others) called in to the Perth Children’s Hospital. We spoke to Ms Sally North, the Principal Scientiﬁc Ofﬁcer of WorkSafe’s Occupational Hygiene and Noise Control Team.

MEDICAL FORUM

Feature

While she was not able to comment on the details of the hospital audit, which is being led by WA Building Commissioner Peter Gow, she said that awareness of the use of asbestos in WA needed to improve. “There are still buildings, plant and equipment where asbestos is present. Workplaces must be able to manage it. If asbestos is maintained in good condition and people know where it is and don’t inadvertently disturb it when renovating or demolishing, it can be properly managed,” she said. “While workplaces are heavily scrutinised and regulated, I think we tend to forget just how many asbestos products were used domestically in Australia. WorkSafe does not control unpaid DIY work, so people who embark on these projects need to consider the possibility of asbestos being present.” Global perpsective When building panels supplied to the hospital’s builder John Holland by the Chinese company Yuanda were found to contain asbestos, it highlighted a problem that extended outside of Australia. The Minister for Immigration, Peter Dutton, told The Australian newspaper it was “ridiculous” to suggest Australian Border Force could inspect all 2.4m containers entering Australia, while John Holland said Yuanda had provided certiﬁcates stating the 150 roof panels did not contain asbestos. It reveals the dichotomy of views on the safety/efﬁcacy of asbestos as a building material around the globe. While frantic alarm bells ring in countries such as Australia, the US and the UK when asbestos is detected,

Table 4.6: Trades JSM exposure assessment results (probability and estimated level of exposure only) for largest categories of job titles

Job title

Assessed probability of exposure (no. participants for whom asbestos exposure was assessed)

No. participants allocated this JSM at least once Unlikely

Construction (carpenter, joiner, builder, bricklayer etc)

(a)

Possible

Probable Low

Medium

High

—

101

—

Electrician

—

Plumber

—

Boilermaker, welder

—

Other metal & mechanical trades (including fitters, turners, machinists)

—

Engineer

—

Telecommunications technician

—

Other

—

Total participants given Trades JSM

258

(a) These categories refer to the estimated level of asbestos exposure.

Source: Australian Mesothelioma Registry Annual Report *JSM = Job - Speciﬁc Module

other countries continue to comfortably mine and manufacture Chrysotile (white asbestos). “Many countries have banned asbestos industries but Russia and some Asian countries continue to mine and manufacture; it is perceived as a standard, cost-effective building material. Canada only stopped mining white asbestos in 2012,” Sally said. It leaves regulation, awareness and education as the main weapons in the local ﬁght being waged by a number of organisations in WA and Australia whose job it is to create systems

to keep the community safe and informed. “If the systems are poor, the risks are greater. Isolated incidences in themselves may not be a big issue, depending on the circumstances. But where people work in an industry where they may have a number of exposures, the more that happens the more the risks are increased. Mesothelioma is a unique cancer – it is easy to count. We are still waiting for those numbers to turn around and decline.”

By Jan Hallam

A Gene Approach Prof Gary Lee, head of the Pleural Medicine Unit at the Institute of Respiratory Health, is leading a team that is exploring a gene therapy to slow tumour growth. Malignant pleural effusion (MPE) can complicate most cancers, especially lung and breast cancers. In addition, Western Australia has one of the world’s highest incidence of mesothelioma, and the majority of these patients present with an MPE. Prof Gary Lee

The inpatient management of MPEs in WA alone involves over 2000 bed days and an estimated cost of over $12m a year. The Pleural Medicine Unit at the Institute of Respiratory Health and Sir Charles Gairdner Hospital (SCGH) leads several multi-national randomised trials to improve management of MPEs, including the AMPLE (Australasian Malignant Pleural Effusion) studies which involve centres in Australia, New Zealand, Hong Kong, Malaysia and Singapore.

MEDICAL FORUM

Their recent work has shown that indwelling pleural catheters (IPC) are as effective as conventional pleurodesis in relieving symptoms and can significantly Prof Jenette Creaney reduce time these patients have to spend in hospital throughout their illness. The latter is significant as patients with MPE often have a limited lifespan. The ongoing AMPLE-2 trial now aims to optimise the drainage regime for MPE patients treated with IPCs to maximize the benefits in relief of breathlessness. The unit is also active in its translational research for pleural malignancies. Together

with Profs Anna Nowak, Jenette Creaney and Michael Millward, the unit and the National Centre for Asbestos Related Diseases (NCARD) have recently begun a new phase II clinical trial for patients with malignant mesothelioma. The FRAME (Fibroblast Growth Factor Receptor Antagonist for Mesothelioma) study is a product of an integrated laboratory and clinical research program and exemplifies the “bench to bedside” research pathway whereby original laboratory findings from WA can be brought through to human testing. This work began with analysing the global gene expression profiles of over 22,000 genes on pleural biopsies the group collected during medical thoracoscopies. The results revealed that a specific growth factor, FGF-9, was overexpressed in mesothelioma but not in other cancers or benign pleural tissues. Further analysis of pleural fluid samples

SEPTEMBER 2016 | 19

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OUTPATIENT REFERRALS You can refer your patient for non-acute assessment to one of a growing number of physicians practising at St John of God Mt Lawley Medical Centre. To view our list of physicians and other regular admitting specialists, please visit www.sjog.org.au/mtlawleyreferrals Hospitality l Compassion l Respect l Justice l Excellence 20 | SEPTEMBER 2016

www.sjog.org.au/mtlawley MEDICAL FORUM

Feature continued from Page 19

New Trial to block Checkpoint Inhibitors Perth trials combining Immuno and Chemotherapies will push boundaries in the mesothelioma treatment. Prof Anna Nowak from NCARD explains rights. The asbestos-related cancer, mesothelioma, is a stealthy killer, usually developing between 30 and 50 years after exposure to the fibre. While only a small proportion of people exposed to asbestos will develop the disease, there is no screening or early detection which can alter the course of this invariably fatal cancer. The mainstay of current standard treatment is palliative chemotherapy, which increases survival by a matter of only months. I have been working on improving chemotherapy for mesothelioma since 1999, when I started researching the effect of chemotherapy on the immune response to tumours, and how immunotherapies could best combine with chemotherapy. Findings from early laboratory work with the National Centre for Asbestos Related Diseases (NCARD) included significant benefits of the combination of chemotherapy and immunotherapy in curing mice with mesothelioma. This work has led to several clinical trials of chemotherapy and immunotherapy, with the most recent being a national clinical trial led by me out of NCARD and run through the Australian Lung Cancer Trials Group. In the past five years, immunotherapy has moved from early clinical trials to mainstream therapy for melanoma and non-small cell lung cancer, with a class of drugs known as checkpoint inhibitors leading this change. Checkpoint inhibitors block negative regulators which normally come into play to limit an immune response. Whilst these negative regulators may play a useful role in avoiding potentially damaging autoimmunity, they can also switch off an anti-tumour immune response before it can usefully inhibit tumour growth. Checkpoint blockade ‘takes the brakes off’ immune cells, potentially allowing an effective anti-tumour response to flourish. Unfortunately, only a small proportion of patients experience the dramatic responses

Prof Anna Nowak and Dr Joost Lesterhuis

to single agent immunotherapy which have captured the imagination of the public, the media, and the scientiﬁc community. Increasing the number of responders to checkpoint blockade treatment, and thus long-term cancer survivors, is the goal of the next generation of chemo-immunotherapy clinical trials. Durvalumab is a monoclonal antibody which blocks PD-L1, the inhibitory ligand (binding partner) expressed by both many cancer cells, and some lymphocytes. The upcoming clinical trial, which is likely to be open before the end of the year, combines standard chemotherapy for mesothelioma (cisplatin and pemetrexed) with durvalumab given at three weekly intervals, and continues durvalumab as maintenance treatment once chemotherapy has been completed.

The Australia-wide phase II trial will begin recruiting just over 50 patients soon, and will be focussing on outcomes of tumour response, progression-free survival, and toxicities. Finding a treatment that works is not the only challenge. The high costs of checkpoint blockade, together with potential toxicities, make it particularly important to identify biomarkers and predictors of patient beneﬁt. NCARD, headquartered in Perth, will also be leading the correlative biomarker studies under the guidance of tumour immunologist Dr Joost Lesterhuis. He will be using a number of novel techniques in the hunt for biomarkers which can predict responses to combination treatment.

continued from Page 19

A Gene Approach collected in the UK and in Perth from over 1000 patients further conﬁrmed this. With funding from the NHMRC and the Cancer Council of WA, the teams demonstrated that removal of FGF-9 from mesothelioma tumours stopped its growth in animal models. In addition, antagonists of FGF-9 or its receptors were able to retard the tumour

MEDICAL FORUM

growth in different types of mesothelioma models in mice.

chemotherapeutic treatments. The study will enrol up to 55 patients at SCGH.

These ﬁndings have led to the FRAME trial, a phase II study funded by the NSW Dust Diseases Authority designed to evaluate the clinical effectiveness of a receptor antagonist of FGF-9 in mesothelioma patients that have progressed despite conventional

The FRAME study also provides an opportunity for training new clinician researchers. (Drs Wei-Sen Lam and Sanjeevan Muruganadan, both recipients of the WA Cancer & Palliative Cancer Network Clinical Fellowships, will be involved.)

SEPTEMBER 2016 | 21

Medical Marketplace

The IT Scramble in Health The era of Health IT has arrived and doctors and patients are looking for trustworthy information and useful applications that make life easier. RACGP has invested in Health&. Here's what they are about.

The RACGP has invested in www. Healthand.com in Melbourne, presumably to add value to its Oxygen IT product and thereby satisfy its 32,000 members, many of whom have CPD as the main drawcard of membership. Health& is evolving and taking on partners to provide health information, recalls for preventive health, appointment scheduling and anything that ﬂows from an electronic health record. Services to health consumers will have to be free to encourage uptake. We spoke to Dr Piraveen Pirakalathanan, Chief Medical Ofﬁcer of the website, which already claims 500,000 visitors per month (40% return visits), and 64% of them on mobile devices. He said each visitor stayed about two minutes per visit and viewed 2½ pages, with 89% of visitors from Australia and 40% of these from outside metro areas (based upon postcode). Since its inception in 2014, Heath&’s aim has been to assist consumers better manage their health, and the rural reach has not gone unnoticed. Personal health Piraveen said the database of self-help information choosing commonly searched health conditions, about 400 in all. Pitched

22 | SEPTEMBER 2016

at a reading age of 14, videos and text are created in-house in Melbourne using a team including writers and animators. “We created the information in a way that is engaging and easy to understand for consumers – each topic undergoes medical checks from when it is written up through to various stages of animation, for example, to ensure colours of inhalers are correct.” He said the ﬁnal check comes from their “medical advisory board of nine eminent professors”. Having taken care of credibility, Health& has turned its attention to other things. Top of its agenda is the evolving electronic health record. Health& clearly wants to enter that space.

feed, Health& will need to generate income somehow. “We don’t want it to be a medical website that is heavily into marketing. We want it to be a credible service for consumers to help them manage their health.” Their latest is a free word search engine that uses “natural language”, IBM Watson. It’s still being worked out but it is part of the ‘ask questions’ functionality on the website. Melbourne-based entrepreneur Bob Biddle is the ﬁnancier of the website.

“In April this year we launched a consumer health record, where consumers and their families can store health information, uploaded through users answering questions around lifestyle risk factors, allergies etc.”

“Bob used to work for government, then set up Origin Health Care nursing agency in the 1980s and ’90s and sold it on to Skilled and went on to early retirement. He had this idea of adding value to consumers and started off doing a successful pilot in the US around providing fertility information before coming back to Melbourne.”

Piraveen said a company would soon have them linked to about 300 of the most common wearable devices, outside the FitBit offering evident on their website. You don’t see Google ads as the policy is to avoid advertising. However, with such a big team to

Bob’s developer partner and IVF expert Professor Gab Kovaks is on the Medical Advisory Board of Health&. During the writing of this article the website changed to give greater emphasis to RACGP involvement, credible health information, the personal

MEDICAL FORUM

health record and the one-stop nature of the website. Nothing by accident Piraveen said the personalised health record was no accident. “We are in discussions with the government and are a registered health organisation, which gives us the ability to tap into the MyHealth record. We have the same privileges and responsibilities as a medical centre or hospital to Dr Piraveen Pirakalathanan upload consumer health information. The government doesn't have a good consumer facing website. It has set up the infrastructure to allow private companies to provide functionality to consumers and value-add around it.”

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“We plan to integrate into the MyHealth record so the health information is effortlessly available to consumers when they come to set up in the later part of this year.” “We want to provide some value to health consumers around storing their health information so we have taken the Red Book recommendations and MHMRC Guidelines and created those algorithms that run over the consumer data and provide them with personalised reminders around health prevention.” Skin cancer and bowel cancer are currently on the website. The RACGP is backing their illness prevention screening, using information uploaded by consumers that assist with tailor-made recalls for their doctor. Of course, this relies on consumers uploading accurately and a compliant local GP who is an RACGP member. “The RACGP is an equity owner in the company Health& through its private arm, RACGP Oxygen. Its sole focus is ﬁnding digital solutions they can present to their members to help them in their work. We sit nicely in terms of one of their solutions so they are investing in us and supporting us – we are helping them deliver one of their objectives of primary prevention.” Stay out of politics “They [the College] are held back by their old-school thinking and reservations about not compromising their reputation, which is all understandable, yet they want a company at arm’s length that is on the edge of those boundaries and being innovative and creative. That’s the whole point of setting up RACGP Oxygen”. The RACGP is also based in Melbourne. Piraveen said they do not want to get “political” and like any startup, providing a service that satisﬁes most stakeholders will help them develop. “Obviously the commercial reality will impact on that. We are yet to encounter the political,” Piraveen said. “Most GPs – they quote 98% - are members of the college but, you are right if members do not believe in what the RACGP is doing and are purely there for CPD activities, I think they would still agree to the service we provide to health consumers. Regardless of whether you support the RACGP, at a core level as a doctor, I think you would be supportive of an initiative to support primary prevention in the community.” “Our objective is to help consumer-driven care – we want the consumers to dictate what health professionals do in terms of their health. It still needs to be collaborative. We don’t want to move to a model where consumers order the tests but we want consumers to be better participants in their health. It is what we are advocating.” “We are talking with another organisation [Health Engine, we determined] to build in appointment booking functionality, purely to help consumers.” We queried who was calling the shots at Health Engine, acknowledging it was focused like them on health consumer convenience, but whether convenience would clash at some points with best medical practice. “To be honest we are not quite sure if Telstra Health is a potential competitor or collaborator. We are yet to work out what is happening with that.” Here’s hoping they get it right.

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By Dr Rob McEvoy MEDICAL FORUM

SEPTEMBER 2016 | 23

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MEDICAL FORUM

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SEPTEMBER 2016 | 25

Feature

Fog of Confusion The e-cigarette isn’t going away anytime soon so clearing the air with a frank and robust discussion is vitally important. There’s a lot of highly confusing smoke being blown around the pros and cons of E-Cigarettes (ECs). There are those who see it as a dangerous gateway to cigarette smoking and others who regard it as an effective cessation device with a proven track record. And if you throw in suggestions that Big Tobacco has its finger in the EC pie it really gets interesting! A recently released documentary opens with the statement that ‘one billion lives will be lost this century due to cigarette smoking.’ The film, A Billion Live, doesn’t pull any punches. Its central tenet is that the death toll would be dramatically reduced if the public were made aware of the real EC story. Part of the problem, they suggest, is that some elements of Big Tobacco and governments are putting out flawed research and misinformation to discredit what they term, The Vaping Revolution. It’s no surprise that the tobacco companies are worried by the rapid up-take of ECs – they’re losing customers, profits are falling and shareholders aren’t happy. Some sections of Big Tobacco have seen the writing on the wall and have gone across to the ‘dark side’. They’ve purchased smaller EC companies and are now selling their products. In fact, Philip Morris recently declared that they’re in the process of developing a new range of ‘harm-minimisation’ delivery systems. Nicotine minus the smoke! And the Australian government? Well, it’s probably a good idea to factor tobacco tax revenue into the equation. Proponents of ECs argue that they are highly effective in helping smokers quit, particularly those who are heavily addicted, and even more so with the complementary assistance of GP support, counselling and targeted antismoking therapies. One such individual is former GP Dr Colin Mendelsohn who works as a Tobacco Treatment Specialist in Sydney.

26 | SEPTEMBER 2016

“Smoking is a very powerful addiction. Many people can’t quit using currently available methods and if ECs help some people to stop smoking then I’m all for it. Smoking cessation programs at NHS Clinics in the UK are encouraging patients to use them and I do the same.” “I often prescribe Champix complemented by counselling and the use of electronic cigarettes.” No one is suggesting that ECs are a universal panacea GP Dr Colin Mendelsohn for a death-toll inextricably linked with cigarette smoking. But there’s strong evidence that a vapour-based system of nicotine delivery is a much safer alternative that the combustion system in conventional cigarettes. It was the central argument in Dr Michael Mosely’s recent SBS documentary. Colin feels much the same way. “It’s obviously preferable that people don’t use ECs at all, but better they do that than smoke cigarettes. The Royal College of Physicians in the UK released a report last year that was highly supportive of ECs stating that they are 95% safer than smoking. They factored in an estimation of future risk and also concluded that the harm associated with passive smoke is negligible. The College strongly endorses the use of ECs, as does Public Health England.” At the moment, the sale of electronic, battery-powered aerosol devices delivering a nicotine dose is illegal in WA (Tobacco Products Control Act 2006/Poisons Act 1964). In April 2014 an appeal was lodged in the WA Supreme Court and was unanimously dismissed. The legislation clearly states that items resembling ‘tobacco products, regardless of whether they contain nicotine or not, cannot be sold in WA.’

Consequently, individuals who wish to purchase ECs do so online. And it’s worth pointing out that not all vapour-based systems actually contain nicotine. There are flavours ranging from raspberry and chocolate to pistachio crème, which have themselves come under scientific scrutiny. Claims and counterclaims abound in the EC debate. For every argument that these devices are a ‘gateway’ to cigarette smoking there are others suggesting that effective regulatory frameworks would be easy to implement. The old adage that ‘for every complex problem there’s a simple solution… and it’s always wrong’ fits rather nicely in the EC debate. Given the lives lost to cigarettes it’s a discussion worth having. The ‘truth’, as they say, is out there somewhere..

By Peter McClelland

VAPE FACTS så %#SåCONTAININGåNICOTINEåCANåBEå legally prescribed. så 0ATIENTSåCANåIMPORTåTHREEå åMONTHSå of nicotine for therapeutic purpose. Under Australian law, liquid nicotine is classiﬁed as a Schedule 7 dangerous poison. Under state laws, it is illegal to manufacture, sell or supply an S7poison without a licence or speciﬁc authorisation, although the laws vary from state to state. However, if liquid nicotine is for a therapeutic use, such as to stop smoking or prevent relapse to smoking, there are exemptions and it can be legally accessed with a prescription from a registered Australian medical practitioner as a Schedule 4 drug. See www.tga.gov.au/personal-importationscheme

MEDICAL FORUM

Guest Column

Help or Hindrance? Mr Terry Slevin and Ms Fiona Phillips from Cancer Council WA urge caution in the e-cigarette debate. There’s plenty of vigorous debate about the safety and efficacy of electronic nicotine and non-nicotine delivery systems better known as E-cigarettes (ECs). Unsurprisingly, there are more questions than answers. så !REåE CIGARETTESåAåSAFEåANDåEFFECTIVEåWAYå to help smokers to quit? så !REåTHEYåAåHINDRANCE åADDINGåFUELåTOå"IGå Tobacco’s fire to keep smokers smoking? så 7ILLåTHEYåENCOURAGEåYOUNGåPEOPLEåTOå commence smoking? så 7ILLåTHEYåMARKåTHEåBEGINNINGåOFåTHEåENDåFORå tobacco products? There are some who are openly enthusiastic about the potential benefits of ECs. Many others are far less so. However it seems prudent that while the debate rages on, particularly in the UK, we take a cautious approach. It’s important to be sure that these products are both safe and effective. There is no doubt that, despite the prohibited sale of ECs, smoking rates are falling in Australia. The adult smoking rate in WA in 2002 was 21.6%, thirteen years later it was 12.5%. Increasing tobacco excise, the

introduction of plain packaging and ongoing community education programs are all a factor in the downward trend. It is currently unlawful to sell ECs containing nicotine in any form. Nicotine is a scheduled poison and can only be lawfully sold in the form of legal tobacco products and approved nicotine replacement items. However, laws in WA, SA and Qld also prohibit the sale of non-nicotine ECs due to the fact that they resemble tobacco products. Despite these bans, it doesn’t prevent the online sale and marketing of ECs, with or without nicotine. Some would argue that the uptake of ECs by young people is of growing concern. A recent NSW study showed that approximately 16% of the 18 – 29 year-olds used ECs. While most would agree that ECs are less harmful that cigarettes, the evidence increasingly shows that ECs are far from harmless. There are others who argue that they are counterproductive in the effort to actually quit smoking. On the other hand, some suggest that the EC is a ‘magic

bullet’ despite the fact that there is a paucity of supporting evidence that they are any more effective than unassisted cessation or conventional nicotine replacement therapy. Big Tobacco's investment in the EC market is significant and increasing. The tobacco industry is spending millions developing nicotine delivery products of their own. Significantly, the marketing of ECs is almost identical to the promotion of traditional cigarettes decades ago. Recent research shows that some aspects of EC marketing have the potential to drive former smokers back to cigarettes. There are many viable options for current smokers. There are five different TGA approved and well-researched forms of nicotine replacement therapy widely available. An encouraging word from a GP is an important factor in encouraging smokers to quit the habit. Until ECs have been approved by the TGA as a safe and effective therapy it would seem prudent that the marketing, sale and use of these products remains prohibited.

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SEPTEMBER 2016 | 27

Guest Column

Technology Offers New Way of Seeing Assistive technologies are smoothing the path to meaningful employment for the vision-impaired, says A/Prof Iain Murray from Curtin University. It was a double privilege to receive an Order of Australia in the recent Queen’s Birthday Honours because one of the main reasons I began working with vision-impaired people was linked with my brother’s blindness. He was born blind. Growing up with members of the blind community in the 1970s made me realise that, even with the best intentions, they weren’t really being helped to reach their full potential. The general feeling at the time was that the blind would never attend university or become productively employed. As an electronics engineer I felt strongly that technology might provide some answers. I taught programming at the Association of the Blind (WA) and developed some education products that proved helpful before moving to Curtin University with a research focus on ‘eLearning Modalities for the Vision Impaired’. What we’ve tried to do is develop industry-recognised practical courses that give hands-on experience combined with a good theoretical understanding of the study material. The broader Cisco concept is a blended learning model linking classroom instruction with online curricula and using

You can’t put a price on the independence that comes with further education interactive tools, hands-on activities and assessments providing immediate feedback. And it’s ideally suited for people with vision impairment. The ICT industry often doesn’t require a great deal of mobility and that’s a good thing because orientation and mobility training can be expensive and timeconsuming. It took many trials and modiﬁcations before we commenced delivery to blind students worldwide. Lectures and tutorials, delivered via teleconferencing, are led by an instructor using real equipment with the broader aim of building a community of international peer support. The impacts have been uniformly positive, indeed life-changing for many students. In an overseas context we’re talking about constructive employment for more than 75%

of the students who have taken these courses. And when you put that alongside the chronic under-employment of the vision impaired it’s a move in the right direction. We’re now offering courses ranging from computer network design to ‘How to Cook when you can’t see the Oven’, all offered by volunteer instructors. It’s vitally important to offer vision-impaired people the opportunity to participate in the workforce and utilise their abilities. You can’t put a price on the independence that comes with further education and there’s a positive spin-off in improved physical and mental health. Assistive technologies that enhance the ability of disabled people to contribute and integrate more fully in the community are vitally important. Focused and effective training can, and does, result in improved outcomes. ED: The spin-off from research has been ICT training under the banner of Cisco Academy for the Vision Impaired (CAVI). CAVI is hosted at Guidedogs WA in Victoria Park and there are now students in 15 countries from Sri Lanka to the UK.

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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28 | SEPTEMBER 2016

MEDICAL FORUM

Guest Column

The Digital Dilemma

PIVET MEDICAL CENTRE

Journalist turned medical student Ms Linda Cann explores how the digital age is transforming news.

Rejuvenating Older Eggs

Thomas Jefferson once declared that “were it left to me to decide whether we should have a government without newspapers or newspapers without a government, I should not hesitate to prefer the latter”. That quote was as inspiring to me as a young, idealistic newspaper journalist as Fiona Wood’s story is to me now as a youngish and equally idealistic medical student. While the news media isn’t perfect, many examples showcase the positive impacts of journalists raising awareness of health issues such as smoking or holding the government to account regarding systemic problems. This is Journalism as the Fourth Estate: the guardian watchdog of the people providing checks and balances on the Legislature, the Judiciary and the Police. Such noble vision is manifested most potently in investigative journalism, with its corruption-chemotactic pursuit of the public interest. It can shine a light on public interest issues such as insufficient hospital funding and unfair distribution of health resources. While the digital revolution has generated some benefits, it’s also bringing investigative journalism to its knees. Newspapers provide many opportunities for in-depth reporting, but are suffering declining circulation and advertisers. Online news are struggling to find a business model to sustain general news journalism, let alone investigative reporting. The latter is distinctly time and resource intensive.

Investigative journalism will lose its ability to hold the powerful to account... How can a news organisation justify dedicating months to an investigation that results in the same number of clicks as an article about the weather? Furthermore, the feedback capabilities of the internet have exposed what people actually read and it’s hard for journalists not to become cynical when an average day might see a health reform article in a prominent position on the homepage be blitzed by a gallery of models in bikinis. The internet has exposed the inconvenient truth that investigative reporting in newspapers is largely subsidised by classified ads, the TV magazine and the sports pages. Readers are no longer ‘accidentally’ informed of government health policy while on their way to the celebrity gossip section. The digital era has fragmented audiences, resulting in niche media channels with fewer viewers. This means fewer advertisers, less revenue and a reduced number of journalists. In the past decade there have also been mergers of media organisations with consequent newsroom job losses. In WA, there is one daily newspaper and it recently merged with a major television station. It’s also in the process of swallowing-up the only other newspaper in town. Less news diversity reduces the number of spotlights shining in dark corners. The digital age has obvious consequences for all sectors of society, including health professionals. Questionable government health policy and poor working conditions in hospitals may well fly under the radar with any calls for change ignored by authorities. Social media and search-engine algorithms often serve to reinforce a particular world view through the use of targeted content. No more bumping into serious content on the way to stories about vaccination conspiracies or homeopathic cancer ‘cures’. Thankfully, opportunities do exist. An organisation such as ProPublica, an independent, non-profit investigative newsroom based in Manhattan, has found success in pursuing public interest journalism. But it does need wellfinanced individuals to champion its work.

by Medical Director PROF JOHN YOVICH

SPECIALISTS IN REPRODUCTIVE MEDICINE & GYNAECOLOGICAL SERVICES

... is it feasible? In the human female, only a relatively short period is allocated to an efficient reproductive process. The best data indicates that age range 18 to 34 years works best, providing healthy pregnancies with low aneuploidy rates and offspring with the lowest rates of congenital disorders and the lowest risks for childhood diseases, both physical disorders including cancers as well as mental disorders including autism and schizophrenia. Obstetric complications are elevated at both younger and older ranges but the most concerning data is now emerging for offspring where maternal ages are >40 years (Tarin et al, 2016; Reprod Fert & Develop). Mostly the meta-analysis data shows relative risks (RR) of 1.1 to Robert Casper, Canadian Gynecologist (left) 1.5 (i.e. increased with renowned Stem Cell scientist Evelyn rates of 10-50%; Telfer from Edinburgh and Justin St John, includes most expert on mitochondria, from Australia. childhood cancers, diabetes and autism spectrum) but some conditions are seriously higher at RR 2.0 (testicular cancer, schizophrenia) to RR 4.0 (non-chromosomal cardiac disorders) and even RR 8.0 (male infertility). The ANZARD report 2015 shows that 67,980 autologous IVF procedures were performed during 2013 in Australia & New Zealand, with 27% of the women and 36% of the men aged ≥40 yrs. These data reflect the dramatic social changes evolving in our community with assisted reproductive technology rising to meet the expectations. For abnormalities in offspring the IVF data is reassuring, showing minimal or no contribution over the age factor (Hart & Norman, 2013; Hum Reprod Update). The reproductive scientific community is now focusing on the two main underlying problems –the natural process of oocyte depletion culminating in the menopause; and the associated reduced oocyte quality. Advanced work was covered in various workshops at the recent ESHRE meeting in Helsinki where I participated. One of these presented work from the Ovascience company applying mitochondrial transfer into poor quality oocytes. This associates with emerging but currently controversial knowledge about oocyte “stem cells” that Robert Casper from Toronto has used as his cytoplasmic source in the “Augment treatment”, achieving some remarkable pregnancies in poor prognosis cases. He is bringing this experience to Perth at the FSA meeting.

NOW AT 2 LOCATIONS PERTH & BUNBURY

For ALL appts/queries: T 9422 5400 F 9382 4576 E info@pivet.com.au W www.pivet.com.au

I hope similarly like-minded people exist in Australia because the health sector will always need healthy injections of investigative journalism. MEDICAL FORUM

SEPTEMBER 2016 | 29

ADVERTISING FEATURE

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The treatment involves drying the vagina with swabs and inserting a dry laser probe,

By Dr Jayson Oates FRACS

Suite 1A Arcadia Chambers 1 Roydhouse St SUBIACO WA 6008

30 | SEPTEMBER 2016

which is the most uncomfortable aspect of the procedure, but reported as similar to a pap smear. The laser ďŹ res thousands of laser dots 0.2mm diameter each 1mm apart and maximum penetration of 1mm. The laser vaporizes a microscopic column of the epithelium and creates a thermal injury followed by a regenerative healing process. Because only 6% of tissue is treated in each session, it is recommended that 3 treatments are performed a month apart and current protocol is to provide a follow up treatment on a yearly basis.

References on request.

Tel 9382 4080 www.academyfaceandbody.com.au

MEDICAL FORUM

News & Views

Back to Basics – Inhaler Technique The NAC is promoting better inhaler technique but maybe the problem is poor monitoring of prescribing in the ﬁrst place? The National Asthma Council (NAC) – a Melbourne NFP group comprised of allergists, GPs, pharmacists, and nurses in the know – recently sent a media release urging health professionals to check their patients’ inhaler technique. Why? Because their research showed up to 90% of patients incorrectly use their inhalers for asthma or COPD. Moreover, amongst the 75% of patients who reported their inhaler technique over the last 2-3 years was OK, only 10% were correct when checked. To combat the problem of poor inhaler technique NAC has put this info on their website and launched updated versions of its information paper for health professionals and demonstration videos on inhaler technique for people with asthma or COPD. While few would argue that correcting the inhaler technique of any patient who really needs it could improve lung function, quality of life and asthma control, there are some unanswered questions. Does the 90% “incorrect technique” really refer to those who need the treatment? Maybe there are too many people on inhalers who don’t really need them? One of the key contributors to the NAC information Assoc/Prof Helen Reddel commented. (Helen is an Australian respiratory physician with expertise in inhaler technique and helps oversee the Australian Asthma Handbook.) She said that amongst those studied the evidence was strong (but mentioned one study in which 1,664 patients averaging age 62 years were referred to a chest clinic!). “In these studies there is a strong association between poor technique and poor health outcomes, and as asthma control improves after ﬁxing inhaler technique, it is a

reasonable assumption that most of the patients needed the inhalers.” Fair enough for patients associated with hospitals or needing regular treatment. But she didn’t really answer either of our questions which are likely to refer to patients confined to primary care. Metered dose inhalers (MDIs) are available over the counter these days so it is important for the primary care doctor to know this. These doctors may also want to know if amongst the reported 90% incorrect technique there are faults in technique that have major influences on treatment efficacy? NAC says “poor asthma symptom control is often due to incorrect inhaler technique” but how often? According to NAC literature, about 1 in 10 people are said to have asthma and only 45% of these are “poorly controlled” yet can we assume these people use up most of the estimated $1.2bn spent per annum on asthma healthcare? Dr Reddel points out, “Half of the costs of asthma in Australia is from medications for all patients. See data from AIHW: www.aihw.gov.au/ asthma/expenditure/. We commissioned a wider report on the cost of asthma last year, which is available at www.nationalasthma.org.au” Are current NAC efforts well directed and aimed at decreasing asthma deaths and asthma/COPD hospitalisations for exacerbations? NAC says “incorrect inhaler technique increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD”. There are commercial interests behind asthma treatments and planners wish to avoid (expensive) hospitalisations. One can see how poor inhaler technique will be a popular ‘angle’ amongst those looking to save money (i.e. less unnecessary scripts and hospitalisations). However, faulty technique reflects poorly on the prescribing doctors, whether specialists or GPs, so the onus is on bodies like the NAC to ensure their efforts are correctly targeted. There are 10 different devices featured in the information paper and videos – a daunting task for any doctor to get their head around and anecdotally different devices would be prone to different errors. The updated information includes checklists on each of the 10 respiratory devices available. Advice is to always check (by viewing) the inhaler technique before considering dose escalation or add-on therapy. Health professionals are advised to brush up themselves before handing out advice. NAC suggests one-on-one training in correct inhaler technique, where necessary. To ensure the proper technique continues into the future, reminders are likely needed as most people need reminding within three years. Target groups are as you might expect - young children, older adults, people already SOB and people using more than one type of inhaler. National asthma week is the first week in September. See www. nationalasthma.org.au/living-with-asthma/resources/healthprofessionals

By Dr Rob McEvoy MEDICAL FORUM

SEPTEMBER 2016 | 31

Clinical Update

Keeping COPD patients well – inhalers COPD, affecting 14% of Australians aged over 40 and the fifth leading cause of death, has had eight new inhalers receive TGA approval in the last two years (so much so, you could be forgiven for thinking COPD stood for “Continuously Offering Pulmonary Devices”!). Where do these therapies fit in to the current management plan? The core aims of pharmacotherapy are to treat symptoms and reduce risk of deterioration and exacerbations. A useful tool in assessing current COPD symptomatic severity is the CAT score (www. catestonline.org). When it comes to predicting exacerbations, the best available predictor is still a simple question: Did you experience a period of persistent worsening beyond day-today symptoms in the past year? We now appreciate that a major exacerbation in the course of COPD can have deleterious effects that can last up to a decade. Hence exacerbation prevention is a priority. The latest GOLD classification of COPD severity is multi-faceted with FEV1 no longer the only determinant but rather, frequent exacerbations are another major axis. Role of ICS (inhaled corticosteroids) It is in those patients who have two or more exacerbations in the preceding two years that combined inhaled steroid - long-acting beta2agonist (ICS-LABA) appear to have the most benefit and are recommended. Using this combination, there is clear evidence for reduction of exacerbations, with NNT (number needed to treat) about 15-20 over one year and suggested reduced mortality (TORCH and INSPIRE trials). However there are side-effects including good recent evidence these medication can increase risk of pneumonia (NNH – number needed to harm – about 20 over three years). As an addendum, the risk of pneumonia may not be a class effect, with meta-analysis suggesting higher risks with the fluticasone-salmeterol combination. Hence, the decision to administer ICS needs to be balanced between prevention of exacerbations and side effects.

Contrary to guidelines, about 50% of COPD patients are using ICS in real-life practice, when it would not be recommended. In this light, the WISDOM trial provided valuable information. Patients who withdrew ICS but continued using dual bronchodilators LABA +LAMA (long-acting muscarinic antagonists) did not experience more exacerbations.

Dr Sina Keihani Respiratory & Sleep Disorders Physician Applecross

a mean follow-up of 2.3 years, the risk of mortality did not differ, however, a relatively healthier population was studied (patients with renal failure, cardiac arrhythmia, IHD, severe CCF and coronary heart disease were excluded) - see Table 3. LAMA-LABA combinations

We now have several LAMA-LABA fixed The strongest evidence for a beneficial dose combinations in a single inhaler (see effect of ICS is in COPD patients with below) available for patients who remain frequent exacerbations or with a concurrent symptomatic despite monotherapy. asthma diagnosis, a group described as LAMA-LABA combinations, which have ‘Asthma COPD Overlap Syndrome’ (ACOS). demonstrated improvements in pulmonary The COPD-X guidelines recommend ICSfunction and variable improvements in LABA combinations when FEV1 < 50% symptoms compared with monotherapy predicted AND ≥ 2 exacerbations Table 2: Inhaler Combinations in 12 months. Drug Device Class Some guidelines advocate either scenarios rather Salmeterol+fluticasone (Seretide) Diskus or MDI LABA + ICS than both these Formoterol+budesonide (Symbicort) Turbuhaler or MDI LABA + ICS criteria. Fluticasonesalmeterol Vilanterol+Fluticasone (Breo) Ellipta LABA + ICS (SeretideTM), Vilanterol+Umeclidinium (Anoro) Ellipta LABA + LAMA budesonideformoterol Indacaterol+Glycopyrronium (Ultibro) Breezhaler LABA + LAMA (SymbicortTM) and Tiotropium + olodaterol (Spiolto) Soft mist LABA + LAMA the new fluticasonevilanterol (Breo ElliptaTM 100mcg alone, may also reduce exacerbations and strength NOT 200mcg) have been approved. the potential risk of pneumonia suggested for inhaled glucocorticoids. Change to LAMA/LABA For patients receiving short-acting bronchodilators who have persistent dyspnoea, adding a LABA or LAMA for regular use is recommended. Both have been shown to reduce exacerbation rates (TORCH and UPLIFT trials) with data supporting the notion that the LAMA are more effective than LABA.Tiotropium is available now in a novel soft mist inhaler (RespimatTM). Initial reviews raised concern about a possible increase in mortality however these studies had methodologic concerns. Subsequently, a large RCT (TIOSPIR) trial has provided reassuring data; over 17000 patients with COPD were randomly assigned to RespimatTM or dry powder inhaler - after

In a multicenter trial published last month in the NEJM (FLAME), glycopyrroniumindacaterol was compared with ﬂuticasonesalmeterol in 3362 patients with moderateto-severe COPD, and a history of at least one moderate-severe exacerbation in the previous year. Over the 52 week trial, glycopyrroniumindacaterol reduced the rate of exacerbations (RR 0.9) and was associated with slightly fewer episodes of pneumonia. Further reading: Go to http:// lungfoundation.com.au and click on Healthprofessionals>Guidelines>COPD X Plan Author competing interests: nil relevant disclosures. Questions? Contact the author on 6161 7647.

Table taken from COPD-X Stepwise Management of Stable COPD, Lung Foundation Australia, 2016. This also lists important nonpharmacological interventions and the role of spirometry. Note: S/LAMA = short/long-acting muscarinic antagonists; ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist

32 | SEPTEMBER 2016

MEDICAL FORUM

Clinical Update

Common dubious autoantibody results

By Dr Michael O’Sullivan Immunologist Fiona Stanley Hospital Murdoch

Without careful forethought autoantibody testing can produce results of dubious clinical use, creating anxiety for patient (and doctor). In that scenario, additional testing can be helpful.

Positive ANA (speckled, homogeneous, nucleolar)

High clinical suspicion of ANA-associated rheumatic disease

Low clinical suspicion of ANA-associated rheumatic disease

Anti-nuclear antibodies (ANA) High numbers of requests and poor specificity for disease make the ANA test the most common source of positive results of dubious clinical significance. Beware using the ANA as a screening test for autoimmune disease – a 5% prevalence of positive ANA results in the general population (higher in women and elderly) and the low incidence of systemic autoimmune disease makes it likely any positive result will be an incidental finding, unless patients are carefully selected first.

Test ENA and dsDNA

Negative

In the laboratory, the ANA test is the ‘parent’ test in looking for more speciﬁc autoantibodies that target certain proteins within the nucleus, like antibodies to extractable nuclear antigens (ENA) or double-stranded DNA (dsDNA). In the clinic, screening for ANA-associated diseases such as systemic or drug-induced lupus, Sjogren’s syndrome and scleroderma is best done by history and examination.

Positive

No further investigation

Positive

Consider FBP, C3 & C4, anti-CCP, ESR, immunoglobulins and urinalysis

A positive ANA (even at high titre) with negative ENA and dsDNA is unlikely to indicate ANA-associated rheumatic disease without associated suggestive clinical symptoms. With ongoing clinical suspicion of autoimmune disease, useful supportive tests include full blood picture (for cytopaenias), inﬂammatory markers, complement C3 and C4 (reduced in immune complexmediated disease such as SLE), anti-CCP, serum immunoglobulins (raised in chronic inﬂammatory conditions) and urinalysis.

In this instance, the usefulness of ANA testing increases in patients with symptoms of systemic rheumatic disease such as arthritis, photosensitive or discoid rash, sclerodactyly and Raynaud’s phenomenon, alopecia, or dry eyes and mouth. It is less helpful when only non-speciﬁc symptoms present, such as headache, tiredness and fatigue.

Those with an isolated positive ANA could be monitored clinically with any emerging symptoms prompting re-evaluation.

In patients with low to moderate pre-test probability of ANA-associated rheumatic disease, negative ANA has a high negative predictive value, so it is understandable that a negative result may reassure the patient in this scenario.

Anti-neutrophil cytoplasmic antibodies (ANCA) Although most causes of vasculitis do not show a positive ANCA, the test can be useful for evaluating patients with suspected small vessel vasculitides.

When a positive ANA is detected, testing for ENA and dsDNA antibodies can help.

Negative

The ANCA-associated vasculitides (e.g. Wegener’s granulomatosis, Churg-Strauss syndrome) are rare and the ANCA can still be negative. Patients with ANCA vasculitis generally have a cytoplasmic (cANCA) or perinuclear (pANCA) pattern, and the specific antigen target can be confirmed with testing for antibodies to PR3 (proteinase-3) and MPO (myeloperoxidase) respectively. As with ANA, clinical evaluation is important prior to requesting ANCA (supported by simple investigations like dipstick urinalysis) to reduce the likelihood of dubious positive results. “Atypical” ANCA with negative PR3 and MPO antibodies may be encountered in a range of autoimmune and other inflammatory conditions where its clinical significance is uncertain. Author competing interests: nil relevant disclosures. Questions? Contact the author on 6152 8006.

Keeping COPD patients well – inhalers Table 3: Change to LAMA/LABA Medication

Device

Class

Dose

FEV1 improve

Exacerbation NNT

Indacaterol (Onbrez)

Breezhaler

LABA

OD 75μg

149

Aclidinium (Bretaris)

Genuair

LAMA

BD 400μg

Glycopyrronium (Seebri)

Breezhaler

LAMA

OD 50μg

112

Tiotropium (Spiriva)

Handihaler

LAMA

OD 18μg

90-140

Tiotropium (Respimat)

Soft Mist

LAMA

OD 5μg

119

Umeclidinium (Incruse)

Ellipta

LAMA

OD 62.5μg

MEDICAL FORUM

KEY POINTS så #/0$åPATIENTSåWHOåHAVEå å exacerbations in the preceding 2 years, co-existing asthma and perhaps FEV1 <50%, have most beneﬁts from ICS-LABA. så )#3 ,!"!åCANåINCREASEåRISKåOFå pneumonia så ,!-! ,!"!åCOMBINATIONSåIMPROVEå lung function, symptoms and probably risk of exacerbation more than monotherapy alone.

SEPTEMBER 2016 | 33

perth clinic on a mission As a “mission statement sceptic” I’ve had to keep it quiet but I have always sort of liked Perth Clinic’s previous mission statement which was “We Strive to Provide the Best in Psychiatric Care.” I think that I like it because it is believable. Yeah, I know it’s corny, but it’s true. That’s not to say that they are always perfect but I think that on the whole, Perth Clinic staff live up to this philosophy.

Dr De Felice gives two thumbs up for TMS.

BY DR C NICK DE FELICE Consultant Psychiatrist

34 | SEPTEMBER 2016

As with all things though, change is inevitable and with the growth and success of Perth Clinic as an organisation, its continual aim to provide high quality mental health services for 20 years now intends to continue do so for many years to come. On 1 July 2016, Perth Clinic celebrated its 20th Birthday where the organisation’s signiﬁcant achievements and contributions to mental health were

recognised and acknowledged. In doing so, the management of Perth Clinic announced the introduction of a new mission statement which reﬂects their progression from its initial conception to the robust organisation it is today reﬂecting their successes, commitment and core values. Perth Clinic’s mission statement is now “Empowering You on the Journey to Mental Health Recovery”.

MEDICAL FORUM

ADVERTISING FEATURE

NEW SERVICE - TRANSCRANIAL MAGNETIC STIMULATION In this spirit, Perth Clinic has recently set up a new Transcranial Magnetic Stimulation (TMS) service. This is a new treatment modality in psychiatry, new in the sense that it will become increasingly available as a number of the private hospitals take the step in providing this service. It is certainly not new in the research area. There is now quite an established literature that indicates that TMS is a useful treatment alternative in the management of major depression. There were initial articles that indicated that it was as effective as ECT, but I think the weight of opinion now is that it is not. The only TMS service in WA until this year has been run by Dr Joseph Lee at the Neurosciences Unit attached to Graylands Hospital. In fact, I understand that it was the ﬁrst TMS service in the public sector in Australia. Joseph and his team have many years of experience and if you have ever heard Joseph speaking about TMS, you would have caught his undoubted enthusiasm for the treatment, having seen many people get better. Now that’s not just his anecdotal experience but is backed up by the research that they’ve done at that Unit which shows the effectiveness of the treatment. This adds to the quite substantial body of literature, such that I think it’s now generally accepted that TMS has a place in the treatment of depression. What the results will be in practice outside of dedicated research centres might lead to different conclusions, but at the moment it seems as though TMS is here to stay.

With this in mind, Perth Clinic has launched a TMS service which is now available for your patients. There are a range of different ways that patients can access this, and the step that you need to know is that they need to be referred to one of the psychiatrists accredited to Perth Clinic. On that front, as an older fellow in psychiatry it’s exciting to see the new young psychiatrists come up and start private practice. I am not retiring quite yet, but I am reassured by the competence and enthusiasm of many of the new folk coming through, and as well as that, the ones I’m associated with seem to care about their patients. As there are a number of these young ones just starting out, it might be a little easier for your patients to access a private psychiatrist, either for an outpatient appointment, maybe a more urgent outpatient appointment if that’s what’s needed, or for an acute admission. HOW TO REFER To simplify the process for you, Perth Clinic has an Admissions Manager whom you could ring on 9488 2973 to speak about a referral. This is a trained mental health nurse who will triage the call and will be the best liaison person for you with the psychiatrists at Perth Clinic Medical Suites. Usually, you will be requested to fax your referral also to 9481 4454.

GP EDUCATION AT PERTH CLINIC For the purpose of developing new and maintaining current relationships between Perth Clinic and GPs, Perth Clinic continues to foster the liaison role to enable regular engagement and to provide information regarding services and referral processes. Perth Clinic will also be hosting a series of GP education sessions over the forthcoming year by hosting a dinner club event on a monthly basis for 10-15 GPs. This will provide you with presentations / education sessions from consultant psychiatrists on a variety of specialist subjects. We aim to provide monthly evening sessions with our ﬁrst dinner club on Wednesday 14 September 2016 at 6:00pm to be held on site at 29 Havelock Street West Perth, which will provide you the opportunity to meet our clinical team and view Perth Clinic’s facility. At this session I will be the guest speaker presenting on TMS treatment in psychiatry and developments in ECT. Should you wish to attend this event or register your interest for any upcoming events, please register your interest / attendance with Perth Clinic’s Executive Assistant (Natalie Fazari) on (08) 9488 2980 or email natalief@perthclinic.com.au. Numbers are limited so please RSVP by no later than COB 9 September 2016. I hope you have the experience of Perth Clinic providing the best in psychiatric care and your patients feel empowered during their journey to mental health recovery.

Hospital Address: 29 Havelock Street, West Perth WA 6005 Phone: (08) 9481 4888 Website: www.perthclinic.com.au MEDICAL FORUM

SEPTEMBER 2016 | 35

Close-Up

M ED IC A R E F U N D E D M R I S C A N N E R FOR NOLLAMARA CLINIC

Great news – Your patients can now get a Medicare rebate for GP rebateable MRI scans. They can now get a scan locally AND benefit from a Medicare rebate at the same time. Perth Radiological Clinic is always trying to keep medical imaging locally available and affordable for your patients. For this reason we have chosen to locate our new Medicare funded MRI scanner at our Nollamara Clinic. It’s a “win-win” for you and your patients 2 No need to travel to Joondalup or Subiaco to have access to a Medicare rebate. 2 Why pay completely out of pocket when there is an excellent, much more affordable option? 2 Have the full benefit of PRC’s well recognised excellence in MRI imaging and reporting. 2 Be confident sending your patients to PRC for scanning; the imaging provider of choice for Perth Specialists. 2 Excellent parking at no charge.

www.perthradclinic.com.au 36 | SEPTEMBER 2016

Leaders in Medical Imaging MEDICAL FORUM

Clinical Opinion

Venous leg ulcers Since Egyptian times venous leg ulcers have been treated with compression bandaging. This ‘gold standard’ treatment can be protracted and up to 30% do not heal. Modern wound care now offers negative pressure therapy, however, used alone it fails to address the underlying aetiology of venous hypertension. New research combining both treatments hopes to uncover a better way to treat this common problem.

By Sharon Boxall MN

Some patients present as mixed ulcers, with combined features and an ABI between 0.6 and 0.8. Treatment Venous ulcers heal faster with compression to combat the venous hypertension – graduated compression bandaging with the highest targeted pressure of 40mmHg at the ankle is most commonly used/recommended. This can be achieved using two or four layer bandaging systems (e.g. Coban® or Profore®). Choose a wound dressing based on wound assessment and add a contact layer of zinc paste bandage if your patient has multiple small ulcers or vascular dermatitis. Once the ulcer is healed, reduce the chance of recurrence by encouraging patients to wear compression hosiery and educate them in preventative leg care. Mobility to improve calf muscle pump function should be encouraged. Endovenous or open venous surgery are recommended to remove/obliterate incompetent superﬁcial venous systems. ED. The author, Dr Shirley Jansen and the Heart Research Institute team at QE II campus are currently recruiting patients to a randomised control trial involving negative pressure therapy in the treatment of venous leg ulcers. All patients will receive compression bandaging and half will also receive negative pressure therapy. Patients with a venous leg ulcer can be referred by their GP or direct. Contact the author on 0478 624 556 or Sharon.Boxall@health.wa.gov.au.

What causes venous leg ulcers Ulcers are caused by either a failure of the calf muscle pump (valve failure causing reflux) or immobility where the calf muscles are not used enough, or both. It is important to understand that different joint and neurological problems can prevent normal calf muscle pump function despite normal venous valves e.g. rheumatoid, ankle fusion, stroke, polio etc. Venous hypertension causes leakage of fluid and red cells into the tissues supplied by the capillary bed, resulting in oedema and chronic inflammation. Left untreated, this can progress to vascular dermatitis, haemosiderosis (brown skin staining) and lipodermatosclerosis (thickened, woody indurated tissues). Minor trauma can then lead to venous skin ulcers or they occur spontaneously.

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An estimated 0.3% of adult Australians are affected. Risk increases with age – 3% incidence if over age 60 and 5% if over 80. Diabetes does not cause venous leg ulceration, however, obesity is a risk factor and many Type 2 diabetics are obese. Once a diabetic patient has a venous leg ulcer, healing is likely to be adversely impacted by any hyperglycaemia, neuropathy, and microvascular disease. Other risk factors include previous DVT or major leg injury, female gender and immobility. Diagnosis A typical venous ulcer is shallow, irregularly shaped, situated in the lower third of the leg and associated with an Ankle Brachial Index (ABI) of 0.8 - 1.2 denoting an absence of signiﬁcant arterial disease.

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The leg is typically warm, with evidence of hair and oedema. On the other hand, with an arterial ulcer the leg is usually pale, cool, hairless, the ulcer has a punched-out appearance with a pale or necrotic base, and the ABI is < 0.6. Arterial ulcers usually occur on the foot or malleolar region.

MEDICAL FORUM

SEPTEMBER 2016 | 37

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Clinical Update

Lessons from respiratory case reports

By Dr Michael Prichard Respiratory Physician Mount Hospital

Three cases are presented to illustrate the role of CT thorax in diagnosis and management of clinical presentation with respiratory infection. Most cases of community-acquired pneumonia are relatively straightforward and can be diagnosed conﬁdently using clinical signs and symptoms and a plain chest

x-ray (done to conﬁrm the diagnosis, particularly when cardiac and respiratory problems might coexist, as chest signs may be misleading). CT thorax provides this additional information, compared to plain x-rays, when opacities are thought to be lung infection: distribution

within the lungs (particularly peripheral vs central), complications of infection (e.g. cavitation and bronchiectasis), focal ﬁbrosis, parapneumonic effusion, possible aetiologies (e.g. endobronchial tumour, foreign body) and patterns useful for distinguishing some forms of pneumonia e.g. aspiration, lipoid pneumonia viral and atypical infection.

Case Report 1

Case Report 2

Case Report 3

A 29-year-old non-smoking female who had no history of asthma presented with three episodes of respiratory infection in the two years before referral.

A 50-year-old non-smoking woman had no prior respiratory history.

A 40-year-old male house painter who had never smoked, was a competitive power lifter who had used anabolic steroids for 10 years.

On each occasion she had fever, cough productive of sputum, shortness of breath and malaise. On the ﬁrst and third occasions she had left-sided pleuritic chest pain and a chest x-ray performed during only the second episode of respiratory infection demonstrated left upper zone peribronchial opaciﬁcation consistent with bronchopneumonia. On each occasion she was treated with oral antibiotics. Between episodes of infection she complained of persistent cough. Examination: a well looking woman with normal SaO2 (97%), short inspiratory wheeze in both lungs.

CT octreotate PET scan showing an obstructing, radionucleotide-enhancing lesion in the left upper lobe bronchus (arrow). Octreotate PET scan is more appropriate for carcinoid tumours.

Clinical concern: Recurrent respiratory infection close together is unusual in an otherwise healthy individual. Persistent cough between episodes raised the possibility of localised structural abnormality such as bronchiectasis or endobronchial pathology. CT thorax: demonstrated a round endobronchial lesion left upper lobe (figure). At bronchoscopy she had a round polypoid tumour almost occluding the left upper lobe bronchus (figure). Biopsy confirmed typical carcinoid tumour. Octreotate PET scan demonstrated increased radioisotope uptake in the primary lesion with no obvious metastatic disease. The lesion was completely resected by a radical left upper lobectomy with sleeve resection to preserve the left lower lobe.

MEDICAL FORUM

She developed lethargy, shortness of breath on exertion, a non-productive cough, night sweats and mild malaise a week after returning from a short holiday in Bali. She improved temporarily when treated with three different antibiotics. Investigations: A chest x-ray series over 2-3 months demonstrated migratory airspace opaciﬁcation in both lung ﬁelds. Two CTs of her thorax were performed

HR CT thorax showing groundglass airspace in left lower lobe early in the clinical course, migrating over 2 months, suggestive of COP.

2 months apart with completely different regional opaciﬁcation.. Full blood count was normal (WCC = 13 with no eosinophilia). ESR = 70. Respiratory serology was negative across an extensive panel. Autoantibodies were negative. Bronchoscopy was noncontributory. She responded to an extended course of oral steroids. Diagnosis: cryptogenic organising pneumonia (COP; previously known as steroid sensitive pneumonia). This should be included in the differential diagnosis of peripheral lung inﬁltrates, characteristically in different regions over time (migratory opacities). Although there is often no aetiology, sometimes it is a manifestation of autoimmune disease. Author competing interests: nil relevant. Questions? Contact the author on 9481 2244.

He presented to ED with a 2-3 week history of wheeze, chest tightness, cough productive of sputum, difﬁculty breathing and more recent fever, nausea, sore throat and malaise. He was febrile 38.1°C, PR = 110, RR = 22 and SaO2 = 96% on RA. He had widespread expiratory wheeze and basal crackles. A chest x-ray in ED demonstrated bilateral mid zone ground glass opacities. Creatinine = 147, HB = 165, WCC = 6.0, CRP = 114. He was commenced on IV antibiotics in hospital. Spirometry was markedly impaired: FEV1/FVC = 1.38/2.10 L (predicted = 4.22/5.16 L). Respiratory viral PCR on postnasal aspirate was positive for inﬂuenza B.

CT thorax illustrates pulmonary venous hypertension (green arrow), and interlobular septal thickening (red arrow) in association with groundglass opaciﬁcation (oedema or pneumonitis) and cardiomegaly.

CT thorax was performed the day after admission (because of atypical ground glass opacities and a severe restrictive ventilatory defect); there were areas of ground glass opacification and interlobular septal thickening consistent with pulmonary oedema. He had cardiomegaly. CT thorax was useful in distinguishing between what was thought to be an acute infective process and cardiac decompensation. A cardiologist confirmed pulmonary oedema and mitral regurgitation; echocardiogram demonstrated a dilated heart with severe impairment of LV function. He responded to oseltamivir, IV antibiotics, steroids and antifailure therapy. Diagnosis: acute viral myocarditis and influenza bronchiolitis and pneumonitis, possible anabolic steroid cardiomyopathy.

SEPTEMBER 2016 | 39

Clinical Update

It’s estimated that 1.2 million Australians (5% of the population) have a sleep disorder.1 The most common sleep disorder is Obstructive Sleep Apnoea (OSA), with one in every five adults experiencing sleep disordered breathing.2 Untreated obstructive sleep apnoea has been linked to increased risk of all-cause mortality,1 hypertension, 2, 3 congestive heart failure4 and Type 2 diabetes.5 There is a large body of research demonstrating the high prevalence of sleep apnoea in patients with cardiovascular disease. There is a significant treatment gap for patients with sleep apnoea in Australia and in particular, in Western Australia, where access to services is limited.

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Please note that our sleep studies and full suite of tests including lung function, are reported by and patients seen by one of our two local accessible Sleep Physicians, unlike other providers whom have tests reported interstate.

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> Access to facilities for bilevel studies, vigilance testing, respiratory failure

1. Access Economics, Wake up Australia – The value of Healthy Sleep. 2. Logan et al, Journal of Hypertension 2001. 3. Sjostrom et al, Thorax 2002 4. Einhorn et al, Prevalence and associations of sleep apnoea in a population of adults with Type 2 diabetes mellitus. 5. O’Keeffe & Patterson, Obesity Surgery 2004.

www.genesissleepcare.com.au/wa

MEDICAL FORUM

Clinical Update

Penicillin allergy - what to do next? Penicillin allergy, particularly self-reported historical penicillin-allergy, is common. Avoiding penicillins in these patients often necessitates prescription of second-line antibiotics that can be less effective, contribute to multi-drug resistance, and lead to increased hospitalisations and poorer outcomes. Adverse drug reactions (ADRs) can broadly be classiďŹ ed as Type A (predictable side effects based on known drug pharmacological properties), or Type B (unpredictable â&#x20AC;&#x153;idiosyncraticâ&#x20AC;? adverse reactions). Type B reactions that are immune mediated are called 'drug allergy'. ADRs not entirely explained by either mechanism have been termed â&#x20AC;&#x2DC;intoleranceâ&#x20AC;&#x2122;. Different reactions Immune-mediated drug allergy can be divided into immediate (IgE mediated) reactions 1 to 6 hours after drug administration (ranging from a mild reaction to life-threatening anaphylaxis) and delayed reactions that occur between 1 hour and days later (immune cell mediated; and their clinical presentation varies with the target cells involved) â&#x20AC;&#x201C; see Table 1. The most common culprit for penicillin IgE mediated allergy and severe cutaneous adverse reactions is amoxicillin.

Health professionals typically encounter ADRs to penicillins in two situations: In patients who are currently taking penicillin-based antibiotics and, more commonly, in those who self-report historical "penicillin allergy".

performed six weeks to six months after the reaction. Testing for serum drug speciďŹ c IgE is also useful if performed within six months.

Investigating current penicillin allergy

Seek veriďŹ cation and details from previous medical reports. Testing of serum speciďŹ c IgE is not recommended. Ideally, everybody with a self-reported penicillin allergy should be investigated but this may not be feasible. Referral for drug allergy testing for patients with a historical reaction should therefore be prioritised for patients with likely future need for antibiotic treatment, including the immunocompromised, and those with chronic diseases or multiple antibiotic allergies.

For acute reactions, it is important to make a thorough assessment of the nature and severity of the ADR, especially if warning signs of a severe reaction exist (Table 2). The suspected culprit antibiotic, usually the most recently started, should be ceased. Further complementary testing at the time of the reaction can be helpful. For example, a rise in serum mast cell tryptase during the reaction supports the diagnosis of anaphylaxis; blood eosinophilia and increased liver functions (LFT) may point towards a systemic drug reaction. Skin biopsy (if a rash is present) can help assess the type and severity. To verify or disprove a suspected allergy, it is important to capture sufďŹ cient information (see list). Diagnostic conďŹ rmation of a presumed allergic reaction is not possible during the reaction itself. Skin testing and oral provocation testing are available in drug allergy specialist clinics and should ideally be

Table 1: Allergic immediate and non-immediate reactions Immediate reaction

Non-immediate reaction

Immune mechanism

IgE mediated

T cell mediated

Clinical presentations

Mild to moderate: Urticaria, angioedema, rhino conjunctivitis, gastrointestinal symptoms Severe: Anaphylaxis, bronchospasm, anaphylactic shock

Mild to moderate - Skin only: Delayed urticaria, maculopapular rash, exanthema ďŹ xed drug eruption Severe - with skin involvement: Severe cutaneous reactions (SCAR): Stevens-Johnson syndrome (SJS); toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS); acute generalised pustulosis (AGEP); vasculitis Severe: organ speciďŹ c. Hepatitis, renal failure, pneumonitis, anaemia, neutropenia, thrombocytopenia

Treatment

STOP THE CULPRIT ANTIBIOTIC Mild-moderate: Antihistamines (non-drowsy) Severe: Adrenaline bronchodilators

sĂĽTelethon Kids Institute director Prof Jonathan Carapetis and Dr Tom Snelling were ďŹ nalists in the Australian Museumâ&#x20AC;&#x2122;s Eureka Prize for leadership. sĂĽThe instituteâ&#x20AC;&#x2122;s Prof Carol Bower was a ďŹ nalist in the Premierâ&#x20AC;&#x2122;s Scientist of the Year award and Dr James Fitzpatrick was a

MEDICAL FORUM

By A/Prof Michaela Lucas Immunologist/Allergist QE2 Medical Centre & PMH

Investigating historical â&#x20AC;&#x153;penicillin allergyâ&#x20AC;?

LIST: INFORMATION TO CAPTURE sĂĽ $RUGĂĽANDĂĽDATEĂĽPRESCRIBED sĂĽ $OSE ĂĽROUTE ĂĽFREQUENCYĂĽOFĂĽDRUG sĂĽ 2EASONĂĽFORĂĽPRESCRIPTIONĂĽ E G ĂĽTYPEĂĽ of infection) sĂĽ 2EACTIONĂĽ TYPE ĂĽDURATION MANAGEMENT sĂĽ /THERĂĽMEDICATIONĂĽGIVENĂĽAROUNDĂĽTHEĂĽĂĽ time of reaction

Table 2: Alert signs for severe reactions

STOP THE CULPRIT ANTIBIOTIC Mild-moderate: Anti-histamines (nondrowsy) for pruritus, topical and/or shortcourse of oral corticosteroids Severe: Transfer to specialist care immediately

Signs (do not all have to be present)

Diagnosis

Sudden onset of systemic symptoms (cardiovascular and respiratory)

Anaphylactic shock

Inspiratory dyspnoea, dysphonia, sialorrhoea

Laryngeal oedema Anaphylaxis

Painful skin, atypical target lesions, mucosal erosions (over 2 mucosal sites); skin blisters; Nikolsky sign positive; abnormal FBC and renal function

SJS/TEN

Fever >38.5oC; skin rash involvement Severe non-immediate >50% body surface; centrofacial reaction (e.g. DRESS) oedema; lymphadenopathy (more than 2 Vasculitis sites); abnormal FBC, LFT, renal function and proteinuria, palpable purpura; abnormal renal function; low complement

Author competing interests: no relevant disclosures. Questions? Contact the author michaela.lucas@health.wa.gov.au

ďŹ nalist in the Early Career Scientist of the Year award. sĂĽCockram Construction has won a $20.4 million contract for redevelopment of the Katanning Health Service. sĂĽMr Tim Kelsey has been appointed CEO of the Australian Digital Health Agency. He

was formerly at Telstra Health and prior to that was National Director for Patients and Information in NHS England. sĂĽMercyCare has bought the privately owned Belrose Care Group taking ownership and management of its four aged care facilities at Joondalup, Maddington, Kelmscott and Rockingham.

SEPTEMBER 2016 | 41

Clinical Update

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Fertility, Gynaecology and Endometriosis Treatment Clinic 42 | SEPTEMBER 2016

MEDICAL FORUM

Clinical Update

Spring â&#x20AC;&#x2DC;hay feverâ&#x20AC;&#x2122;

By Dr Colin Somerville Allergist Leeming

This Spring Australians will spend over $220m on over-the-counter medications for hay fever with additional effects on productivity and impacts on other conditions like asthma, sinusitis and otitis media. WA has Australiaâ&#x20AC;&#x2122;s second highest rate of hay fever, affecting 19.7% of the population (with the ACT higher at 21%, and Queensland lower at11.3%).

Montelukast helps some individuals, especially those with associated asthma. If working outdoors, frequent saline lavage helps wash allergen out of the nose. Depot steroids are often prescribed for severe ďŹ&#x201A;ares but repeated use is contraindicated because of the increased risk of aseptic necrosis of the femoral head, osteoporosis and diabetes. Oral steroids are preferred.

Wind pollinated plants cause most hay fever symptoms â&#x20AC;&#x201C; thatâ&#x20AC;&#x2122;s WA grasses, most introduced. Pollens from bee-pollinated plants are too heavy to blow around, so the beautiful ďŹ&#x201A;owering gums, wattles, native ďŹ&#x201A;owers and cape weed that West Australians blame for their symptoms are not the culprits, they just ďŹ&#x201A;ower more obviously in season.

Subcutaneous immunotherapy (SCIT) is usually chosen when conventional therapies are either inadequate or produce unacceptable side effects. Patients should have treatment tailored to their speciďŹ c allergens, 6 to 12 months before the next season. Generally, the patientâ&#x20AC;&#x2122;s general practitioner can safely give all the injections. Off the shelf sublingual or oral immunotherapy is increasingly available but they are formulated for use in Europe and the USA and often will not adequately treat local allergen combinations. One size deďŹ nitely does not ďŹ t all.

Three main temperate grass families are found throughout the world. The Pooideae (e.g. Timothy grass, cultivated Wheat and Rye), the Panicoideae (Cultivated corn, Johnson, Buffalo and Bahai grasses) and the Chlorideae (Couch grass). Most patients will need treatment for all three. The peak period for hay fever symptoms is midOctober to mid-November, when the crops in our Wheatbelt are ďŹ&#x201A;owering and prevailing easterly winds bring huge swathes of pollen across the coastal plain, drowning out any effect from the couch grass in the back garden. Pulling up the lawn wonâ&#x20AC;&#x2122;t help! Most trees ďŹ&#x201A;ower in late winter through early spring. In Perth, a surprising 80% of sufferers show strong responses to olive trees that have a much longer ďŹ&#x201A;owering period. There are quite signiďŹ cant suburban variations in allergenic trees too, depending on â&#x20AC;&#x2DC;tree

MEDICAL FORUM

fashionâ&#x20AC;&#x2122; e.g. Norfolk Pines in Cottesloe, London Planes in the City Centre and Olive trees in the Swan Valley. The Weeping Peppermint, often demonised, is actually quite benign. Asthma is often triggered by these same allergens and indeed acute asthma admissions increase signiďŹ cantly after Spring rains because the moisture ruptures the pollen grains releasing smaller micropolyspora that are more easily inspired into the lower airways. Symptomatic treatment of hay fever with standard doses of â&#x20AC;&#x153;24 hourâ&#x20AC;? antihistamines and intranasal steroids may not be sufďŹ cient for many patients. It is reasonable and safe to take both of these 12 hourly. Initially a 7-day course of decongestant spray used before the nasal steroid may allow better drug penetration.

KEY POINTS sĂĽ $ON TĂĽUNDERESTIMATEĂĽTHEĂĽIMPACTĂĽOFĂĽ hay fever on a patientâ&#x20AC;&#x2122;s QoL. sĂĽ 4HEĂĽMAINĂĽALLERGENSĂĽINĂĽ7!ĂĽAREĂĽ unavoidable grasses. sĂĽ !VOIDĂĽDEPOTĂĽSTEROIDS ĂĽ)FĂĽRESPONSEĂĽ to antihistamines and intranasal steroids is poor, consider personalised immunotherapy. Author competing interests: no relevant disclosures. Questions? Contact the author 9313 5171

SEPTEMBER 2016 | 43

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MEDICAL FORUM

Clinical Updates

Winter: fevers, coughs and runny noses

By Dr Christiane Remke Paediatrician & Paediatric Allergist Nedlands

During winter, fever, coughs, colds and runny noses are common amongst children attending their general practitioner. Apart from identifying the acutely unwell child who needs immediate treatment and possibly referral to hospital, it can be difﬁcult to determine what is ‘normal’ and what could indicate an immune problem.

with antibody deﬁciency. Affected children present often very early in life with opportunistic infections, failure to thrive and/ or chronic diarrhoea. These patients can become very unwell very early in life therefore early specialist referral is important. Phagocytic immune defects (e.g. defects in neutrophils) present with recurrent pyogenic or fungal infections and/or abscesses. Complement disorders should be considered when there is evidence of recurrent infections with Neisseria species.

What is ‘normal’? Children have more infections than adults, especially toddlers. Many of these respiratory, gastro-intestinal and ear infections happen in the ﬁrst two years of life; URTIs occur up to 5-8 times per year in a healthy child under two years. The rate of infections naturally decreases with age as children’s immune systems mature and gain a greater range of immunity to pathogens. From the age of ﬁve, these infections are normally limited to four times per year.

Initial investigations: så &ULLåBLOODåCOUNT åLYMPHOPENIA åCOMMONåINå viral infections, should be transient and not profound; neutropenia can be a marker of phagocytic immune defects så 1UANTITATIVEå)MMUNOGLOBULINSå )G' å)G! å IgM): hypogammaglobulinaemia as marker for humoral immunity så )NmAMMATORYåMARKERS å#20 å%32

Children who have older siblings and/ or attend daycare often have even more frequent acute respiratory infections, as well as children who are exposed to cigarette smoke; up to 12 per year.

så 3KINåSWABS åEARåSWABS åSPUTUMåSAMPLEå for pathogen identiﬁcation Children with early warning signs of immunodeﬁciency, abnormal pathology testing or whose history and/or presentation is confusing or worrying should be referred for specialist assessment.

Healthy children mostly have relatively mild infections and recover completely between episodes, but over winter this can be hard to achieve when a common cold can last up to two weeks and the child attends daycare. Most infections should be of viral origin supported by examination ﬁndings. It is worth counselling parents about the importance of smoke avoidance, the beneﬁcial effects of a healthy diet and the importance of keeping immunisations up-to-date. Discussing the normal rates of childhood infections with concerned parents can be very reassuring to them.

Don’t forget allergies

så !CCOMPANYINGåSYMPTOMSåSUCHåASåCHRONICå diarrhoea, severe refractory eczema

Red ﬂags for immune deﬁciencies

så 5NUSUALålNDINGSåONåEXAMINATION å dysmorphism, absence of lymphoid tissues such as lymph nodes or tonsils

Primary immune deﬁciencies are rare (prevalence about 1 in 1200). As delay in diagnosis is unfortunately common, immune deﬁciencies should be considered in children expressing the following early warning signs:

så 3IGNSåOFåCHRONICåORGANåDAMAGEåSUCHåASå hearing impairment with recurrent ear disease, bronchiectasis or signs of chronic lung disease such as clubbing with chronic respiratory infections

så &REQUENTåINFECTIONSåREQUIRINGåTREATMENT å å 8 ear infections, >1 serious sinus infection , >1 pneumonia per year

så &AILUREåTOåRESPONDåTOåIMMUNISATIONS

så 5NUSUALåTYPESåPFåPATHOGENSåCAUSINGå infections så $EEPåSEATEDåINFECTIONS åRECURRENTå abscesses or septicaemia så )NFECTIONSåNOTåRESPONDINGåTOåANTIBIOTICSåASå expected; persistent thrush, ear discharge or sputum production så &AILUREåTOåTHRIVEåORåLOSSåOFåWEIGHTå 7(/å growth chart) så &AMILYåHISTORYåOFåIMMUNODElCIENCIES å especially in consanguinity

MEDICAL FORUM

If any of these red flags are present, physical examination and a detailed history are most important. Amongst primary immunodeficiencies in children, antibody deficiencies are most common. They often present with frequent and/or prolonged infections of the respiratory system including ears from about three months of age. Common pathogens causing these infections include Pneumococcus, Meningococcus and Haemophilus.

Although infections most commonly cause a constant runny nose and cough in children, aeroallergen sensitivity does not stop over winter. Up to 15% of Australians suffer from allergic rhinitis, which often coexists with asthma and sinus disease, presenting as a recurrent cough, sinusitis or rhinitis. Sensitivity to dust mites, animal dander or mould spores can cause perennial symptoms. Pharmacotherapy and minimisation of aeroallergen exposure can be helpful; specialist referrals should be considered for further assessment and treatment such as immunotherapy. The Australasian Society of Clinical Immunology and Allergy has published e-training courses for health professionals about Immunodeﬁciencies and Allergic Rhinitis (http://www.allergy.org.au/aboutascia/about-ascia-e-training). Author competing interests: No relevant disclosures. Questions? Contact the author on 6389 0786

Cellular immune deﬁciencies are much less common, they mostly occur in combination

SEPTEMBER 2016 | 45

Clinical Update

Sexual function after gynaecological surgery

By Dr Jason Tan Gynaecological Oncologist WA Cancer & Palliative Care Network

Gynaecological surgery can impact on a womanâ&#x20AC;&#x2122;s sexuality, and while many improve in sexual function with the surgical treatment of symptomatic disorders such as menorrhagia and endometriosis1, some women experience a signiďŹ cant decline. In particular, women undergoing surgery for the treatment or prevention of gynaecological cancer may experience high rates of sexual dysfunction (60-80% experience some changes2,3). The most common sexual problems after gynaecological surgery include: vaginal dryness, low libido, sexual discomfort, and orgasm difďŹ culty2,4. Aetiology of sexual issues This is often multifactorial but includes the effects of: sĂĽ 3URGICALĂĽMENOPAUSEĂĽ MITIGATEDĂĽBUTĂĽNOTĂĽ alleviated by HRT5); sĂĽ !DJUVANTĂĽCHEMOTHERAPYĂĽAND ORĂĽ radiotherapy; sĂĽ #HANGEDĂĽSEXUALĂĽANATOMYĂĽ E G ĂĽCLITORALĂĽ removal, vaginal shortening, pelvic nerve damage, hysterectomy); sĂĽ 2ELATIONSHIPĂĽCHANGESĂĽBROUGHTĂĽONĂĽBYĂĽ the cancer diagnosis and associated treatments, all inďŹ&#x201A;uenced by prior relationship and partner satisfaction sĂĽ 0SYCHOLOGICALĂĽEFFECTSĂĽOFĂĽCANCERĂĽDIAGNOSISĂĽ and treatment (e.g focus on survival, body image changes, femininity, depression and psychological stress).

Discussing sexuality Sexual difďŹ culties are common after gynaecological surgery, and despite the majority of patients wanting to discuss this with their doctors, actual discussions are low11. Several barriers to discussion have been suggested, including: fear of causing patient distress; lack of experience and training; uncertainty about initiating

The effect of surgical menopause on sexual function can be dramatic, and these women often beneďŹ t from a referral to a menopause specialist. For a majority of gynaecological cancers, hormone replacement therapy (HRT) or topical vaginal oestrogen can be safely commenced after surgery6. While oestrogen replacement can improve vaginal lubrication and sexual discomfort7, it may not alleviate the vasomotor and sexual menopausal symptoms associated with surgical menopause5. Other pharmaceutical options for the treatment of female sexual dysfunction such as testosterone patches and Flibanserin have limited safety data in women with cancer8,9. However, Lidocaine gel has recently been successful in the treatment of penetrative dyspareunia in women with breast cancer and is a safe treatment option10. Sexual discomfort may beneďŹ t from referral to a womenâ&#x20AC;&#x2122;s health physiotherapist, and counselling from a sexual therapist may help address speciďŹ c sexual concerns for both couples and individuals. Author competing interests: no relevant disclosures. Questions? Contact the author on 9468 5188

46 | SEPTEMBER 2016

Several online training courses are designed to enhance cliniciansâ&#x20AC;&#x2122; skills (Figure 1) and the ExPLISSIT model for sexual communication may assist clinicians to incorporate routine sexuality discussions into their practice.

Fig 1: Resources for clinicians on sexuality issues in women. Resource

Source

Summary

Address

PSGC Learning Modules

Cancer Australia

Learning modules and videos regarding the psychosexual care of women affected by gynaecological cancers.

http://modules.cancerlearning.gov. au/psgc/

Female Sexuality Handbook

Association of Reproductive Health Professionals

Handbook on female sexual health and wellbeing, including conversation starting and referrals.

https://www.arhp.org/publicationsand-resources/clinical-practicetools/handbook-on-female-sexualhealth-and-wellness

For Health Practitioners

American Sexual Health Association

Video and links to guides regarding sexual history taking.

http://www.ashasexualhealth. org/healthcare-providers/sexualhealth/

Australian information

Australian Society of Sexologists

Limited patient information and sexual therapist details

http://societyaustraliansexologists. org.au

Treatment of sexual issues As with the aetiology, treatment is also multifactorial and a multi-disciplinary team approach is optimal.

discussion; insufďŹ cient time; lack of knowledge; and lack of access to treatment resources.

1. Pauls RN. Impact of gynecological surgery on female sexual function. Int J Impot Res 2010; 22(2): 105-14. 2. Tucker PE, Bulsara MK, et al. Prevalence of sexual dysfunction after risk-reducing salpingo-oophorectomy. Gynecol Oncol 2016; 140(1): 95-100. 3. Lindau ST, Abramsohn EM, Matthews AC. A manifesto on the preservation of sexual function in women and girls with cancer. Am J Obstet Gynecol 2015; 213(2): 166-74. 4. Vaidakis D, Panoskaltsis T, Poulakaki N, et al. Female sexuality after female cancer treatment: a clinical issue. Eur J Gynaecol Oncol 2014; 35(6): 635-40. 5. Madalinska JB, van Beurden M, Bleiker EM, et al. The impact of hormone replacement therapy on menopausal symptoms in younger high-risk women after prophylactic salpingo-oophorectomy. J Clin Oncol 2006; 24(22): 3576-82. 6. Singh P, Oehler MK. Hormone replacement after gynaecological cancer. Maturitas 2010; 65(3): 190-7. 7. Tucker PE, Bulsara MK, SalďŹ nger SG, et al. The effects of pre-operative menopausal status and hormone replacement therapy (HRT) on sexuality and quality of life after risk-reducing salpingo-oophorectomy. Maturitas 2016; 85: 42-8. 8. Braunstein GD. Management of female sexual dysfunction in postmenopausal women by testosterone administration: safety issues and controversies. J Sex Med 2007; 4(4 Pt 1): 859-66. 9. Jaspers L, Feys F, Bramer WM, et al. EfďŹ cacy and Safety of Flibanserin for the Treatment of Hypoactive Sexual Desire Disorder in Women: A Systematic Review and Meta-Analysis. JAMA Intern Med 2016. 10. Goetsch MF, Lim JY, Caughey AB. A Practical Solution for Dyspareunia in Breast Cancer Survivors: A Randomized Controlled Trial. J Clin Oncol 2015. 11. Marwick C. Survey Says Patients Expect Little Physician Help on Sex. JAMA 1999; 281(23): 2173-74.

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Feature

m o r f k c Jags Ba

k n i r B e th

Dr John Teasedal

ss e's work in progre

Two Perth surgeons are working on ‘patients’ who won’t complain about a thing but neither will they be paying their bills. Prof Piers Yates and Dr John Teasdale both have a passion for the E-Type Jaguar and their cars are in various stages of restoration. “It’s always been a dream of mine to restore an E-Type. Enzo Ferrari said that they’re the most beautiful car in the world and he knew a thing or two about beautiful cars,” said Piers. “I’ve driven an E-Type before but never owned one and this project has the added beneﬁt of giving me a focus outside work. That’s always a good thing!” “Usually I manage to put in half-a-day on the car on the weekend and I’m pretty happy with that. Although I don’t completely shut-down from my day job, the phone’s still there and it rings constantly.” “It’s a good ﬁt for me. Orthopaedic surgeons are well suited to this sort of thing, taking bits and pieces apart, rebuilding them and making them work again.” There’s quite a lot to be done before the rubber hits the road on a car that began life in the USA. “I found the car midway through 2015

48 | SEPTEMBER 2016

in America and it arrived a week before Christmas. The ones that come from the UK are either rusted-out or too expensive and it’s very difficult to get one at all in Australia. It’s interesting, because around two-thirds of the E-Types were built for the US market and were shipped over there in the 1960s and ’70s.” “From a rebuilding point of view the ones from the States are the best in the world.” “This one was partially disassembled in 1981 and has been off the road since then. I’ve stripped it right down, started ordering new parts and will be putting it back together in a month or so.” “I’m learning as I go along. Now I know how to weld and lead-load, which was what people used before synthetic fillers were around. I’ll be doing all the paint preparation except for the final top coat of opalescent blue because you have to use a paint-booth for that process. The engine rebuild requires a lot of specialist equipment so I’ll be doing all the mechanics apart from that.” The E-Type project will be a family affair in the Yates household and their house, to some extent, will be shaped around the car. “One of the ideas behind this was that the children [eight-year-old twin boys and a 16-year-old daughter] would be actively

st Transforming in

ages

involved and they have been, except for anything involving dangerous chemicals.” “The car will probably take about another year to ﬁnish and we’re meant to be

MEDICAL FORUM

Prof Piers Y ate

s' fa mily proje

ct.

rebuilding our house as well! The E-Type is in a carport now and we’ll end up building the garage around it” It’s fair to say that Dr John Teasdale is no stranger to restoring classic cars. The latest E-Type acquisition completes his Jaguar collection and adds to a DeLorean, some Buicks and a 1949 Triumph Tourer originally owned by a dentist in Northam.

Piers tackles a

welding proje

old Y ou ng a nd

a re involved

“I get a lot of my cars from a dealer in Nevada, USA. The big plus is that they have about two inches of rain a year so there’s very little rust. This car is a 1964 Series 1 3.8 Litre and they were about half-way through restoring it when I bought it.” “They’d done it in a pretty haphazard way and I had to get it completely rewired when it arrived.” It takes some highly specific expertise to work on these cars, skills that are becoming increasingly difficult to find.

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“I’m not all that mechanically minded but there are people around who love working on these classics. Most modern mechanics wouldn’t have a clue about these cars and the Jaguar V12, in particular, is a very difﬁcult car to restore.” “I belong to a few car clubs and, sadly, the really knowledgeable guys are all in their 90s and dying out.” “The value of these cars is appreciating all the time but it’s usually the case that the amount of money you spend on the restoration will be far in excess of the car’s value on the market. At the moment, cars similar to this one are fetching around $140,000.” “I’ve got one of each in the series so that’s it for E-Types as far as I’m concerned. A lot of people buy cars like these to restore in their retirement and then end up dying before the car’s ﬁnished.” “I’m still working and very much alive!”

By Peter McClelland

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SEPTEMBER 2016 | 49

A committe

e is a group that keeps minutes and loses hours .

- Milton Ber

The following jokes were evaluated by 55 London School of Economics undergraduates aS the world’s 10 most funniest jokes. Judge for yourself. 1. Snail With A 'Tude A guy is sitting at home when he hears a knock at the door. He opens the door and sees a snail on the porch. He picks up the snail and throws it as far as he can. Three years later there’s a knock on the door. He opens it and sees the same snail. The snail says: ‘What the hell was that all about?’ 2. Three Wishes Three guys stranded on a desert island find a magic lantern containing a genie, who grants them each one wish. The first guy wishes he was off the island and back home. The second guy wishes the same. The third guy says: ‘I’m lonely. I wish my friends were back here.’ 3. Fever Pitch It’s the World Cup Final, and a man makes his way to his seat right next to the pitch. He sits down, noticing that the seat next to him is empty. He leans over and asks his neighbour if someone will be sitting there. ‘No,’ says the neighbour. ‘The seat is empty.’ ‘This is incredible,’ said the man. ‘Who in their right mind would have a seat like this for the Final and not use it?’ The neighbour says, ‘Well actually the seat belongs to me. I was supposed to come with my wife, but she passed away. This is the first World Cup Final we haven’t been to together since we got married.’ ‘Oh, I’m so sorry to hear that. That’s terrible….But couldn’t you find someone else, a friend, relative or even a neighbour to take her seat?’ The man shakes his head. ‘No,’ he says. ‘They’re all at the funeral.’ 4. Early Bird A guy shows up late for work. The boss yells, ‘You should’ve been here at 8.30!’ He replies. ‘Why? What happened at 8.30?’ 5. Circle of Life Sid and Irv are business partners. They make a deal that whichever one dies first will contact the living one from the afterlife. So Irv dies. Sid doesn’t hear from him for about a year and concludes there’s no afterlife. Then one day he gets a call. It’s Irv. ‘So there is an afterlife! What’s it like?’ Sid asks. ‘Well, I sleep very late. I get up, have a big breakfast. Then I have sex, lots of sex. Then I go back to sleep, but I get up for lunch, have a big lunch. Have some more sex, take a nap. Huge dinner. More sex. Go to sleep and wake up the next day.’ ‘Oh, my God,’ says Sid. ‘So that’s what heaven is like?’ ‘Oh no,’ says Irv. ‘I’m not in heaven. I’m a bear in Yellowstone Park.’ 6. Coffee Break? A guy dies and is sent to hell. Satan meets him, shows him doors to three rooms, and says he must choose one to spend eternity in. In the first room, people are standing in dirt up to their necks. The guy says, ‘No, let me see the next room.’ In the second room, people are standing in dirt

50 | SEPTEMBER 2016

up to their noses. Guy says no again. Finally Satan opens the third room. People are standing with dirt up to their knees, drinking coffee and eating pastries. The guy says, ‘I pick this room.’ Satan says 'Okay' and starts to leave, and the guy wades in and starts pouring some coffee. On the way out Satan yells, ‘OK, coffee break’s over. Everyone back on your heads!’ 7. Kid Vs Barber A young boy enters a barber shop and the barber whispers to his customer. ‘This is the dumbest kid in the world. Watch while I prove it you.’ The barber puts a dollar bill in one hand and two quarters in the other, then calls the boy over and asks, ‘Which do you want, son?’ The boy takes the quarters and leaves. ‘What did I tell you?’ said the barber. ‘That kid never learns!’ Later, when the customer leaves, he sees the same young boy coming out of the ice cream store. ‘Hey, son! May I ask you a question? Why did you take the quarters instead of the dollar bill?’ The boy licked his cone and replied, ‘Because the day I take the dollar, the game is over!’ 8. One in a Million China has a population of a billion people. That means even if you’re a one in a million kind of person, there are still a thousand others exactly like you. 9. Friends Forever? Two campers are walking through the woods when a huge brown bear suddenly appears in the clearing about 50 metres in front of them. The bear sees the campers and begins to head toward them. The ﬁrst guy drops his backpack, digs out a pair of sneakers, and frantically begins to put them on. The second guy says, ‘What are you doing? Sneakers won’t help you outrun that bear.’ ‘I don’t need to outrun the bear,’ the ﬁrst guy says. ‘I just need to outrun you.’ 10. Value for Money A guy meets a sex worker in a bar. She says, ‘This is your lucky night. I’ve got a special game for you. I’ll do absolutely anything you want for $300 as long as you can say it in three words.’ The guy replies, ‘Hey, why not?’ He pulls his wallet out of his pocket and lays $300 on the bar, and says slowly. ‘Paint…my…house.’

MEDICAL FORUM

Wine Review

Gem on our Doorstep Tasting these wines from Upper Reach is a salient reminder what the Swan Valley can do. With the obsession we have with the (wonderful) wines produced in the South West of our state, it is easy to overlook the quality we can ﬁnd on the doorstep of Perth. And Upper Reach certainly shows that level of quality.

By Dr Craig Drummond Master of Wine

Derek and Laura Pearse purchased 4ha of vines at Baskerville in the upper reaches of the Swan Valley and established Upper Reach Wines in 1996. Derek, pictured below, came from a wheat farming family in Wubin and so was well equipped to develop the property. (I have always believed that if you want to know how to do something, ask a farmer.) Later, working at a wine shop in London, Derek discovered two momentous things – his passion for wine and meeting Laura. He had to start from scratch to get the vineyard in order, learning viticulture and then winemaking. There was some input from local legend, Dorham Mann, but essentially Derek is a true example of the 'self-made man'. Today Upper Reach ﬁts the deﬁnition of a genuine 'wine estate' with grape production and winemaking [including bottling and packaging] all taking place on the property. Added to this is an award-winning restaurant and great wine-tasting facilities onsite and it is well worth a visit.

1. Upper Reach 2016 Verdelho This Portuguese variety has an identity with our Swan Valley. It’s seldom seen as a straight varietal except at a few locations, the Swan being one of the best and this wine a good example. It’s fruity with tropical fruit aromas and flavours of lime cordial and a touch of honeysuckle. Shows typical textural fruit weight with an unctuous edge. Enjoyable now, though ‘the Valley’ variety has a record for ageing, so put some away for a few years. (RRP $20) 2. Upper Reach 2014 Reserve Chardonnay Aromas show good fruit/oak integration. The flavours show stonefruit and nashi pear with a creamy, textural, layered mouthfeel. It has balance and avoids the overripe flavours often seen in warm-climate chardonnays. A nice wine. (RRP $32) 3. Upper Reach 2013 Petit Verdot This variety is traditionally a Bordeaux blender but with its punchy tannins can, as this wine shows, make a good varietal wine. It is a late ripener (later even than cab sav) making it well suited to the Swan Valley climate. Scents of violets and plum are restrained but gradually open in the glass, leading to black plum and mulberry flavours. Nice balance. The firm, dusty, drying tannins and acidity will give longevity for 10-12 years. (RRP $45)

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4. Upper Reach 2013 Cabernet Sauvignon This is a great wine. The fruit is 50/50 Swan Valley/Great SouthernFrankland. Matured in quality French oak, the nose is a fascinating mix of primary cabernet fruit and slightly oxidative secondary fruit characters that need a little 'breathing'. The palate is of rich ripe blackberry, sweetly fruited with nice oak integration. All-in-all an intense, yet subtle wine. Very alluring. (RRP $30) 5. Upper Reach 2013 Shiraz I love the aromas here. There’s a complex mixture of white pepper and redcurrant. It’s perfumed, for me, is reminiscent of Côte Rôtie in the Rhône Valley. It leads to a rich, ripe succulent palate of spicy redcurrant and raspberry. It has great oak ﬂavours with grippy tannins and a clean acid ﬁnish. This wine is warm, welcoming and generous and will go for 12-15 years. (RRP $38)

.. or online at

www.medicalhub.com.au

REVIEWER'S

PICK

Wine Question: Which Upper Reach wine reminds the reviewer of Cote Rotie?

Email Please send more information on Upper Reach's offers for Medical Forum readers.

Answer: ...................................................

Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, September 30, 2016. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

MEDICAL FORUM

SEPTEMBER 2016 | 51

Opera

Pitch Perfect for Pearl Fishers e Sa m Rob

In the entire world of opera, the tenorbaritone duet from Bizet’s The Pearl Fishers is perhaps the most recognisable and certainly the most loved. It’s been the showpiece for the likes of Enrico Caruso and Guiseppe de Luca, Jussi Borling and Robert Merrill, Roberto Alanga and Bryn Terfel. It’s a jewel that makes audiences swoon and singing stars to be confirmed in the firmament. WA Opera will be introducing a new duo when its production of the opera opens at His Majesty’s Theatre from October 25. And proudly, it’s West Australian grown. Baritone Sam Roberts-Smith and tenor John Longmuir as Zurga and Nadir will duel in song for the love of the priestess Leila, a role being sung by WA-raised Emma Matthews, one of the world’s top sopranos. Artistic director Brad Cohen is a scholar of Bizet and of this work in particular. He has reportedly created a lot of magic with the orchestration and Sam Roberts-Smith is, for one, eager to touchdown on the Maj’s mainstage. The young baritone, who was educated at Hale and took up singing after sustaining a sporting injury at school, told Medical Forum he was excited but a little nervous of the task at hand. “It’s a famous duet and it’s everyone’s favourite, so no pressure! But the opera is full beautiful music.” It is also a homecoming of sorts as Sam finds himself bouncing between bases in Sydney and Perth, but mostly, it seems, sitting on aeroplanes and overseas rehearsal rooms and theatres.

52 | SEPTEMBER 2016

His singing journey is an extraordinary one and a testament to his talent and determination to be the singer he dreams to be, and it begins where so many talented young people’s story starts – WAAPA. “I trained as a baritone, I completed my degree as a baritone and when I graduated, Opera Australia offered me a place on their Young Artists Program for four years. The rub was they asked if could join the program as a tenor. I had been experimenting privately in my singing lessons with some of the tenor repertoire and I did have access to the top range of my voice but I had always sung baritone roles and quite successfully in competition.” “The upshot was I accepted the position with OA. I so badly wanted to be in the program but it was challenging to say the least. I felt like I was on a tightrope every day, fronting audiences at the Sydney Opera House, singing in a voice type that wasn’t really me.” “After two years I decided that instead of being a tenor and living with that constant pressure, I would work to be one of the best baritones around. I felt completely capable of doing that, so why not sooner than later. It was a leap of faith and a scary thought to go out on my own but I was conﬁdent in my ability so I left.” It seems the Universe agreed with him and within weeks he took out third and the audience-voted Best Performance Award at the Paris Opera Awards in 2014 as a baritone and made the ﬁnals of the Opera Foundation NY competition. But Sam wasn’t taking anything for granted. If there were an advertisement with the word sing in the title, he applied for it.

rts-Smith

As he was about to go on stage in Paris, one of his ﬁshing lines, the classical crossover boy band, Ten Tenors, asked him to audition. “I didn’t think much of my chances when I sent the email, especially as I was a baritone. I heard there was a vacancy coming up so I hurriedly shot an audition video in the bathroom and sent it off next day. I didn’t think anything would come of it and comforted myself that I was very much into mainstage opera and not crossover.” “When I returned from Paris, I got an email from the Ten Tenors telling me I was in – without an audition.” So between world tours with the Ten Tenors and maintstage opera gigs here and in Europe, Sam is living the busy life of a freelance singer. “I believe it’s important to be proactive about life in general. Freelancing is tricky because it’s hard to see around corners. But I have a great agent in Kathryn Morrison, who has amazing stable of singers – Teddy Tahu Rhodes, Greta Bradman, Yvonne Kenny, Cheryl Barker among them. It’s great to be in that environment.” “But I’m a big believer in not waiting for things to happen. I don’t like wasting time worrying about things because it doesn’t help. I’m fortunate to have had these opportunities. I’ve got to make sure I make the most of them.

By Jan Hallam ED: Just as we were going to press news arrived that Sam had won the prestigious Deutsche Oper Berlin Award, giving him an 11-month performing contract.

MEDICAL FORUM

Entering Medical Forum’s competitions is easy!

Competitions

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).

Movie: Inferno The latest instalment of Dan Brown’s Robert Langdon series, which began with The DaVinci Code, sees the famous symbologist (played by Tom Hanks) on a trail of clues tied to Renaissance poet Dante Alighieri’s famous poem. A picturesque race across Europe with a beautiful young woman guaranteed. In cinemas, October 13

Movie: The Magniﬁcent 7 A modern reworking of the John Sturges 1960 classic Western sees Denzel Washington and Ethan Hawke lead the posse into the sleepy town of Rose Creek, which is under the deadly control of industrialist Bartholomew Bogue (Peter Sarsgaard). It was great 56 years ago and could be great again. In cinemas, September 29

Movie: The Girl on the Train Emily Blunt stars in this psychological thriller based on Paula Hawkins' best-selling novel. Newly divorced Rachel spends her daily commute fantasising about the seemingly perfect couple who live in a house that her train passes every day, until one morning she sees something shocking.

FEATURE

COMP Movie: Café Society The latest ﬁlm from Woody Allen is a tribute to the gilded age of Hollywood of the 1930s with a cast that includes Jesse Eisenberg, Kristen Stewart, Steve Carell, Parker Posey and Blake Lively. An ingénue (Eisenberg) from New York heads to Hollywood to work for his agent uncle (Carell) where he meets and is seduced by the women and the lifestyle. In Cinemas October 20

In Cinemas October 6

Movie: Julieta Spanish director Pedro Almodóvar introduces his audience to Julieta, a 55-year-old teacher who writes a letter of confession to her daughter, Antía, who left home at 18 and hasn’t been in contact with her mother in 12 years. It’s a moving ﬁlm of guilt, abandonment and consequences. In Cinemas October 13

Opera: The Pearl Fishers Bizet’s beautiful opera is about loyalty and friendship between two young men with the love of the same woman the prize. Stage great Michael Gow directs while Artistic Director Brad Cohen’s mastery of this opera can be heard in the glorious music.

Doctors Dozen Winner Zonte’s Footstep is one of Dr Alan Bryant’s favourite wineries so our July competition was a real bonus for the Mt Lawley - based podiatric surgeon. Alan came to pick up his wine on his son-in-law’s birthday and it was on the cards that a bottle would be opened to celebrate.

His Majesty’s Theatre, October 25, 27, 29 & November 1, 3, 5

Winners from the July issue Movie – Absolutely Fabulous: Dr Amy Gates, Dr Susanne Sperber, Dr Wen Loong Yeow, Dr Christopher Lam, Dr Kathrine Ng, Dr Lynette Spooner, Dr Jason Chin, Dr Rob Hendry, Dr Karen Prosser, Dr Catherine Keating

Growing Healthy Men

Movie – Free State of Jones: Mr Ray Barnes, Mrs Maggie Juengling, Dr Mandy Croft, Ms Leanne Reed, Dr Neda Namdar, Dr Ian Walpole, Dr Robert Weedon, Dr Geoff Mullins, Dr Brett Baird, Dr Dereck Scurry

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SEPTEMBER 2016 | 53

Cabaret

l e a ich

M & e l o C Goes g n i h t y n A

Adelaide-born cabaret star Michael Grifﬁths is heading to Perth for a tribute to the life and music of the great Cole Porter. He has collaborated with acclaimed pianist and author Anna Goldsworthy for a show that brings insight into one of the 20th century’s great musical talents. Michael was in Edinburgh for a cabaret season when Medical Forum contacted him. MF: You have been garnering pretty impressive reviews for Cole. What are you bringing to this material that has ignited audiences? MG: A love of the material and a fascination for the man. His life was so extraordinary that my writer Anna Goldsworthy didn’t have to make a single detail up. Rather we explore the songs that shed some light on his character and weave through stories of his life that we imagine inspired his lyrics. MF: You have been the architect of most of your own shows in the past, what has this collaboration with Anna Goldsworthy been like? MG: Joyful! We were mates at high school back in the 1980s and crossed paths again a few years ago when we both coincidentally had moved back to our hometown of Adelaide. She’s a concert pianist in her own right and so has the perfect sensibility and sensitivity for the project. We are both very proud of it. MF: Does this show shed new insights into Cole’s life and work? MG: Only if you are not well acquainted with his story already. The movie De-Lovely does

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a good job of setting the scene but I feel our show goes further in terms of a character study. I'm constantly talking to people who tell me they don’t know any Cole Porter tunes until I mention Anything Goes, Night and Day, I’ve Got You Under My Skin and then people quickly realise his songs transcend his own fame. MF: What inspires you about the cabaret genre? MG: The storytelling, the immediacy and the intimacy. There’s something delightfully exposing about cabaret where there’s no scenery or costume changes to hide behind. I also love the connection with an audience it allows – both as a performer and an audience member. MF: What is your favourite Porter song? MG: Night and Day is hard to beat but my favourite to sing in the show is Love For Sale. Cole was often quoted as saying it was his favourite too! It has all the ingredients of a perfect Porter tune – major and minor, sitting side by side, romance, sex and melancholy. MF: The ABC documentary, Sperm Donor Anonymous, was a powerful call for changes around donor anonymity and the rights of the donor child to know their biological origins. How has knowing who your biological father was changed the way you feel about yourself? MG: Finding out that his folks were also pianists and his grandparents were travelling musical theatre performers with J.C. Williamson all around Australia was a delight. It gives me greater belief in what I do and a greater understanding of who I am.

MF: A lot of medical students in the past were sperm donors, some of them reading this magazine right now, what would you like to say to them regarding the issue of donor child rights? MG: Connecting with my sperm donor was about putting an end to secrecy and the unknown. It was very difficult finding out as an adult that my father wasn’t my biological father and I struggled with a feeling of not knowing where I came from. I would have been happy with a single meeting if that was meant to be. We first met just over a year ago. As it turns out we feel very connected and maintain a friendship that I treasure. I also was thrilled to discover I have two half brothers and we are all part of each other’s lives now. I think fear of the unknown is what keeps some sperm donors afraid to be open to connection. I can only speak from my own experience and it has been nothing but positive on both sides.

By Jan Hallam

WIN! Michael Grifﬁths will be performing Cole at Downstairs at the Maj from September 29 to October 1 starting at 7.30pm. For you chance to win a double ticket, please email competitions@medicalhub.com.au with the words Cole Porter in the subject line.

MEDICAL FORUM