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Ageing Well The WA Cannabis Story Telestroke & Rural Equity End-of-Life Choices Care for the Elderly

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EDITORIAL

Why Everyone Needs Sunshine Transparency. Who wants it? Who needs it? Shining a light on the ‘what’ and ‘how’ of what the profession does is a powerful thing. Why? With such transparency comes accountability. Mind you, those with the torch need to know what they are looking at. For example, health consumers want transparency on their health costs but attracted to how things look and feel when it comes to clinical acumen. Maybe that explains in part our profession’s apparent disinterest in transparency. Lack of time and diversity of clinical opinion could be other factors. However, disinterest is easily interpreted as something to hide. Health consumers are flat out thinking of one instance where greater transparency has been a negative. And yet they see examples where it has been a positive. Modern transparency includes: the new Medicines Australia Code and doctor disclosures; web annual reports of doctor organisations with financials (AMA WA seems absent); the voluntary MTAA Code; and web reporting by some private hospitals. We can debate whether transparency should be extended. For example, under the pharmaceutical Code, research funding is not covered. It should be, to shine light on doctor-pharmaceutical company relationships. Health consumers want to know, if research findings are published, who financed the work? Or if research findings are not published, was the doctor involved receiving benefits to conduct research? The profession should lead the debate on health consumer access to marketing around the PBS listing of a drug. Promotional money often becomes available before that listing and during the life of the patent. For script-only items, doctors are heavily involved. Key opinion leaders (KOLs) tell other doctors about the benefits of the drug. Doctors, who face a deluge of medical knowledge, are happy with the filtered information pharma companies offer. Lack of transparency does not equal corruption but it does make it easier for corrupt practices to take hold. When good policies and guidelines are not followed, the door is open to corruption. Good management and leadership can be preventative as can looking after whistleblowers.

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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

Medical Forum feels strongly about this, which is why the last Doctors Drum had the theme ‘Transparency – Clear as Mud?’ to help define where the profession is heading. The next topic, ‘Future Medicine – the Change Game?’ attempts to keep this conversation going using important expert panellists (March 29, 2018). We are not alone. Perhaps the 82 medical publications in Australia are members of COPE (Committee On Publication Ethics) because they have concerns about the ethics of how advances in medicine are reported (see https:// publicationethics.org/about). We know that different medical organisations are clamouring to be heard. Social media may not be their answer. ‘Likes’ or mentions on social media may measure popularity or engage politicians who attempt to put out fires. Is this how health decisions are best made? What level of transparency should we expect from public officers? A key test for identifying conflicts of interest is whether an impartial observer can reasonably question if personal factors inappropriately influence the way an individual carries out their work. These conflicts of interest may be real, perceived, or potential and may be financial or non-financial. Doctors are no different to ‘public officers’ because they deal direct with the public. To those driven by income, the medical profession must seem like a sea of possibilities. For those driven by patient care, the possibilities are just as endless but the pull may be in the opposite direction. Sunshine on these things in this edition…. Appreciate the impact that philanthropy has on later careers. The medical cannabis story in WA is fascinating and evolving – THC content, retro-research, and the opinion of WA corporate players tells us a lot. Let’s hope the pollies listen to doctors and get it right on end-of-life decisions in WA (the Victorian’s are going through it right now). I found the Guest Columns on diabetes education, and protecting the elderly from greed, falls and stroke helpful. Let’s hope you find the clinicals updates on Eyes, Decision-Making, CLL, Parkinson’s, Grief and Infected Joint Replacements a bit different, as I did.

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

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

NOVEMBER 2017 | 1

CONTENTS NOVEMber 2017

12 FEATURES 12 Spotlight: Greta Bradman 14 The WA Cannabis Story 21 Telestroke and Equity 28 Leg up for Madagascar: Dr Li-On Lam NEWS & VIEWS 1 Editorial: Why Everyone Needs Sunshine

6 7 10 25 26 27 44

Dr Rob McEvoy Letters to the Editor Mental Health is Suffering Dr Jane Ralls Funding for Cancer Research Board of the Cancer Research Trust Have You Heard? Beneath the Drapes Life After the Prize End-Of-Life Inquiry Diabetes and DESMOND Aged Care and HIV Move Well

21 Lifestyle 47 Travel: Walk the Flinders Ranges

Dr Lin Arias 48 Inspired Adventures Dr George Crisp 50 My Local: Fibber McGees 50 Potato and Pickled Fennel Salad 50 Wine Winner: Dr Megan Pilkington 51 Wine Review: Lion Mill Dr Louis Papaelias 52 Funny Side 53 Social Pulse: SJG Subiaco Ball 54 Messiah 55 Rescue from Pompeii 56 Competitions

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clinicals

Myopia: Nature or Nurture? Prof David Mackey

Blindness and Ageing; AMD Q&A Dr Jane Khan

‘Who’ First, ‘What’ Second Dr Sam Restifo

Chronic Lymphocytic Leukaemia Dr Gavin Cull

Advanced Therapies for Parkinson’s Dr Barry Vieira

Infection After Joint Replacement Dr Markus Kuster

Frailty and Decision-Making Dr Charles Inderjeeth

Grief in the Elderly Dr Monique O’Connor

guest columns

Targeting Preventable Visual Loss Dr Fred Chen

Protecting the Elderly from Greed Ms Deidre Timms

Getting Up from a Fall Dr Elissa Burton

Virtual Reality in Aged Care Dr Anne Furness

Christmas 2017 G r ee t i n g s F e at u r e

Share the spirit of the season Contact Jenny Heyden E jen@mforum.com.au P 9203 5222

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician) MEDICAL FORUM NOVEMBER 2017 | 3

LETTERS To THE EDITOR Mental health is suffering

skilled therapist who can provide continuity of care. Most patients I see have already been through a basic CBT approach and are in need of a deeper level of healing.

Dear Editor, As a GP who specialises in mental health, I have been closely following developments with WAPHA for options to treat people with financial disadvantage. It is heartening to see a collaborative approach and an acknowledgement of the importance of a sense of place in providing local services. While there can be no doubt the intentions are good, I am disappointed by what is developing, and the evident very poor resources available. For my patients attending my practice in Woodlands, there are two tiers of treatment available. For ‘Mild to Moderate’ presentations, patients with a pension or health care card can access a free, brief online CBT program with telephone backup, or four face-to-face sessions with a psychologist, which can be extended to six sessions in extreme circumstances. This will be useful for first presentations of psychologically naive patients to commence their journey, but is otherwise a very superficial short-term approach. For ‘Severe and Complex’ presentations, patients can access a Mental Health Nurse Case Manager if their illness is severe, and/ or they are using multiple service providers. This is available to those in severe financial need including those who may not have a card (e.g. those who are experiencing domestic violence) which is great. It is either telephone provision or face-to-face, with a review of ongoing need at three months. We are left wheeling and dealing with private psychologists for bulk billing as no psychological therapist is provided by WAPHA. Poor mental health is often the consequence of layers of trauma, and the most crucial part of healing is an enduring relationship with a

I find it really sad that I can help those with financial means through Better Access and private psychologists, but those without means, who are often a lot more traumatised, are dependent on the kindness of an experienced psychologist to bulk bill, or can only access poorer care. I have a number of patients with severe depression, PTSD or severe emotional dysregulation who I have seen heal and grow amazingly under the care of a good therapist and regular stabilising sessions with myself. Frequently I see people able to return to the workforce, and grow in confidence in their parenting, making a huge difference to the health of the next generation. Surely this is money worth spending? Dr Jane Ralls, GP, Woodlands ........................................................................

Funding for cancer research Dear Editor, There is no doubt that greater focus is justified on cancers that are less common and those with poor treatment outcomes, as we make inroads into the cancers that affect larger numbers of people (Research Where Needed Most, October). Research that improves our understanding of the basic biological functioning of cancer cells is likely to be of benefit when it comes to dealing with common cancers and less common cancers. Traditional funding of health research supports personnel, projects, equipment and infrastructure. But which is most effective and likely to generate major breakthroughs? In early 2017, the board of the Cancer Research Trust (CRT) asked that question to a roundtable workshop of leading cancer researchers in WA. There was no consistency in the responses. At best, the group concluded a need for a portfolio of different funding programs.

So the CRT offered a challenge, a blue sky approach to research funding. It would offer up to $1 million a year for five years, potentially renewable, with researchers telling us what was needed to make a seachange in cancer research and translation. Researchers had to involve multiple partner institutions and add new money equivalent to at least 30% of the request from the Trust. A successful application could potentially receive almost $12 million over nine years, providing stability and long-term support. The Trust anticipated that its support would be leveraged with state funds through the new Medical Research Fund, the WA Cancer Council (that generously offered some of the new matching money), Commonwealth funding from NHMRC and the $20 billion Medical Research Future Fund (MRFF). Fifteen applications were reviewed by highly respected cancer experts from out of the state. Two proposals were selected, total funding, $17.5 million. The first, led by Professor Alistair Forrest, involves isolating individual cells from different cancers to develop a molecular atlas of genes that are turned on and off. This information will be used for later diagnosis and development of new treatment strategies, including cancers with poor treatment outcomes. The second successful proposal, led by Professor Christobel Saunders, will improve the lives of those diagnosed with cancer to assess outcomes that are important to patients, deficits in care pathways, and trial new interventions. It is exciting that two such different programs of research could emerge from one competition. This approach demonstrates the need for flexibility by funding agencies, providing support that is long-term, with high quality peer review. It obviates the necessity of making multiple applications to different agencies for the full resource required to mount a high quality research program that ultimately will benefit those in greatest need, the end user and patient. The Board of the Cancer Research Trust

The significant problems we face cannot be solved at the same level of thinking we were at when we created them. Albert Einstein (1879-1955)

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

4 | NOVEMBER 2017

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

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

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HAVE YOU HEARD?

The submissions are in and hearings are completed in the Senate inquiry into transvaginal mesh implants and the report is due on November 30. It was a tragic stream of suffering women that fronted the hearings in Perth, Melbourne, Sydney and the ACT. There were also compassionate doctors trying to be part of a resolution that can help these patients and patients in the future. Murdoch specialist Dr Michelle Atherton, who researched painstakingly to determine how many women are affected and what to do about it, contributed on an individual basis and also had input into the RANZCOG submission. She and colleagues also met women from the Mesh Support Group – recognising their very real health dilemmas. Both submissions are worth following up on the senate inquiry website. Michelle told senators she intended to visit the US in order to learn more from Dr Veronikis in St Louis, “who is probably the most experienced mesh removal urogynaecologist internationally. Whilst we in Australia are able to remove mesh, there will be things to be learned from his vast experience.” In the meantime, among RANZCOG’s nine-point suggestions was the establishment of mesh registry and a better tracking of MBS items numbers to determine the exact number of women who have mesh implants and those with complications. It also recommended that transvaginal mesh should not be used as the primary surgical treatment for pelvic organ prolapse.

RACGP's serious money The RACGP Annual Report 2016-17 has just been released. The college as of July 1 this year had 35,259 members, of which 19,749 are fellows (and the rest are students, doctors-in-training and ‘other’). Against the $62.78m income (up from $57m last financial year), the big ticket expenses were $31.77m employee benefits and on-costs (no mention of the number of employees), $4.24m ITrelated costs (down from the previous year), $4.95m advertising and media (down from previous year), $3.88m GP sessional and sitting payments and $3.51m conference and meeting costs. The RACGP had $32.37m cash on hand on July 1, 2017, and $42.46m in non-current assets and from its statement of revenue from operating activities made (in total $62.78m) includes, $30.61m in membership, QI&CPD fees; $22.88m in

education, course registration and other fees; $3.91m in research and other grants and donations; but only $1.99m in sponsorship and advertising.

WA diabetes breakthrough Groundbreaking work on a rare type of diabetes in young people (under 35) – caused by a single genetic mutation early in life – has launched Prof Tim Davis and his team from UWA, FSH and University of Exeter into the MJA last month. The team’s research into monogenic diabetes in the young (MODY) and how it is distinguished from other types of diabetes garnered praise as it is said to help with early interventions of appropriate therapies, prognosis and family screening. The results come from a longitudinal observational study of 1668 people with diabetes in Fremantle. Their risk of MODY was assessed with the UK risk prediction model, which has been validated for patients with European ethnic backgrounds but is largely untested in non-European populations. Data suggests that about one in 280 Australians diagnosed with diabetes has a monogenic form of the disorder; most have a European ethnic background. “Twelve of 148 young participants with a European ethnic background (8%) were identified likely to have MODY; four had a glucokinase gene mutation,” Tim said. “Thirteen of 45 from a non-European ethnic background (28 per cent) were identified as likely to have MODY, but none had a relevant mutation.

GPs – help is at hand A collaboration between Rural Health West and the WA Primary Health Alliance has produced a one-stop-shop for all things general practice with a new statewise support service, Practice Assist. The service is free for all WA GPs and builds on the existing practice supports from both organisations with a choice of online, telephone and face-to-face services. There are not too many areas Practice Assist doesn’t venture with help offered on practice management and business support to accreditation, digital health and health pathways.CEO of Rural Health West Tim Shackleton told Medical Forum while his organisation had developed a great service with a good reputation, Rural Health West staff was stretched thin when it came to visiting practices face-to-face.

Heard over lunch… Australian Hearing is once again packing the picnic and heading to medical practices across WA to spread the message among GPs about its hearing health and government-funded services, particularly for seniors, veterans, indigenous Australians and children up to the age of 26 years. Topics covered for seniors include signs of hearing loss and health impacts, government subsidies and patient eligibility, the referral process and location of screening clinics. Australian Hearing now has regular clinics at 37 medical practices in metropolitan and regional locations for self-or doctor-referred patients. It takes 15 minutes for the hearing check. It’s a service easily provided at a GP surgery – before a pharmacy steps in an offers the same thing! To arrange an in-house presentation call 131 797 and talk to the Centre Manager. www.hearing.com.au/category/about-hearing/healthprofessionals/

6 | NOVEMBER 2017

The partnership meant PHN liaison staff in the regions could help spread the net wider to more rural GPs. WAPHA CEO Learne Durrington felt the centralised information and resource hub would be a huge boon for GPs. “Most enquiries can be dealt with on the spot, either via the website or a phone call, freeing up practice visits for requests that need more time and more support,” she said. Help Desk 1800 2 277 478, www.practiceassist.com.au

App to help carers According to the media release, Palliative Care Australia is set to develop an app to help people with a life-limiting illness, thanks to a $50,000 grant from the nib foundation. It’s not ready yet, but with National Carers Week (16-22 October) has come the announcement to brighten the lives of Australia’s 2.8 million carers who provide an estimated $1.1 billion of unpaid care every week. PCA CEO Liz Callaghan said, “Our app will enable the primary carer of a person who is sick to share their specific needs. It may be providing a meal, walking the dog or running an errand for them. It may also be providing care for the sick person while their primary carer attends a meeting, a child’s sporting event or takes a break”. These carers have depleted wellbeing, and feelings of isolation with lack of time to maintain personal, physical and mental health. We hope to test drive the App in our next edition.

WA spotlight on abuse Following on the heels of the national inquiry into elder abuse, an upper house select committee has been established by the WA Parliament to look into the local issues. It is inviting submissions to be delivered by 4pm, November 17, 2017 addressing these specific issues: definition and prevalence of elder abuse; what forms it takes, identify risk factors; legislative frameworks and agency and police responses among others. For information email: eld@parliament.wa.gov.au

Who and why of mistakes As part of our link with the WHO, Australia wants to reduce medication errors by 50% within five years. Mistakes are costing the world an estimated US$42 billion annually – with people in low-income countries disproportionately affected. In Oz, between 2-3% of all hospital admissions are medication-related, that’s at least 230,000 admissions annually costing about $1.2 billion. The Australian Commission on Safety and Quality in Health Care is facilitating the campaign launch for the Western Pacific region. Besides Australia, nations represented at the WHO meeting in Brisbane include China, Japan, the US, Malaysia, the Philippines, South Korea, Singapore, New Zealand and France. Commission CEO Adj/ Prof Debora Picone pointed to polypharmacy, medications with a narrow therapeutic range, and patients passed between clinicians as higher risk situations. While Australia worries about such things as the elderly, medication charts in ACFs and medication safety programs in hospitals, you have to wonder why “low-income countries are disproportionately affected”.

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Clearing path on mesh worries

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• Prof Peter Eastwood, head of UWA’s Centre for Sleep Science was awarded $640,210 in NMHRC grants for research into diagnosis and treatments for sleep disorders, particularly in young adults. Prof Trevor Mori from UWA’s Medical School received the same amount to investigate the mechanisms and preventative strategies to alleviate the burden of cardiovascular disease. Prof Graeme Hankey was awarded a $577,188 Practitioner Fellowship to run clinical trials into the treatment and prevention of stroke. • At Curtin University, epidemiologist Prof Christopher Reid, from the School of Public Health, was awarded a $774,540 NHMRC Research Fellowship for work on CVD and chronic disease in the community.

The face tells the story Back in October 2014, we interviewed the then head of Curtin University’s School of Pharmacy, Prof Jeff Hughes, because we heard of interesting research going on there using facial recognition technology to help detect pain in non-verbal patients. The cohort directly in the sights was dementia sufferers. It was the work of Jeff and a PhD student Mustafa Atee and it was plain to see that if this worked, it would be a terrific boon for an ageing population. At the time, the pair was in sensitive negotiations for development funding, then commercialisation talks so they requested no fanfare. Well the trumpets are out now, a company has been formed, ePAT in which both men are involved, and the app has been developed, TGA approved and taken up by Dementia Services Australia (a partnership led by aged care provider Hammond Care). The new app is called PainChek™, and it has a Class 1 Medical Device licence that has TGA and CE mark (Europe Economic Area) regulatory clearance. It uses AI and smartphone technology to visually analyse facial expressions, assess pain levels in real time and update medical records in the cloud. It is expected to be rolled out nationally next year to initially 150 consultants but international markets are also keen. ePAT intends to introduce a specialised app for children’s pain over the next 12 months.

BY THE NUMBERS

$170.4 billion Is the total national health expenditure in Australian 2015-16 • $114.6 billion (67.3%) of this total was funded by governments • The Commonwealth contributed $70.2 billion (42.2% of overall spending) up from $66.2 billion (41%) in 2014-15 • Spending by non-government funders (individuals and private health funds) fell in 2015-16 to $55.8 billion (32.7% of total spending down from 33.1% the previous year. This is the first time that the non-government spend has fallen since 2011-12. • Growth in health spending has slowed rising by 3.6% in 2015-16 below the 10-year average of 4.7% In WA: •

The total Australian government health expenditure was $6.75 billion

• Mr Michael Hogan has been appointed the CEO of St John of God Midland Public Hospital, replacing Mr Glen Power. He was formerly the hospital’s Deputy CEO and has been Acting CEO since August. • Dr Eva Denholm has been appointed the Director of Medical Services at St John of God Subiaco Hospital. She was previously Director of Clinical Services at Fremantle Hospital and the Medical Co-Director at Osborne Park Hospital. • SCGH neurologist and multiple sclerosis clinician and researcher at the Perron Institute, Prof William (Bill) Carroll has been elected President of the World Federation of Neurology (WFN). He takes up the presidency on January 1. • Deidre Timms is the new Chief Executive of Advocare. She was previously head of Silver Chain’s home and community care division. • Avita Medical has signed a $30.5m expansion to its US government contract to further fund its ReCell device trials. • The former commissioner of the WA Department of Corrective Services, Mr James McMahon, has been appointed to the board of St John of God Health Care. • The director of clinical services at the Women and Newborn Health Service, Dr Sayanta Jana, will take up the role of Director of Medical Services at St John of God Midland Public and Private Hospitals in January replacing Dr Alan Pelkowitz.

• The total state and local government health expenditure was $5.85 billion • The total non-government health expenditure was $6.35 billion Source: AIHW Health Expenditure Australia 2015-16

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INCISIONS

Clinician-academic ophthalmologist Dr Fred Chen looks at what is evolving in WA to reduce avoidable visual loss. Lofty goals for 2020 (just over two years away) include a world without nuclear weapons and sustainable food security for all. Are we ready for Vision 2020’s goal of reducing avoidable vision impairment by 25%? Let’s start with the numbers. In 2000, an estimated 431,100 Australian had vision impairment (<6/12). The 2016 National Eye Health Survey projected 453,000 Australians are living with reduced vision: 97% are defined as visually impaired (6/12 to 6/60) and 3% as blind (< 6/60); 60% of visual impairments were due to uncorrected refractive error (not having access to glasses); 15% due to cataract; and 10% due to age-related macular degeneration (AMD). Surprisingly, 65-75% of blindness is caused by AMD, with prevalence increasing with age. Can we do more to reduce cataract-related vision impairment? Around 200,000 cataract surgeries are performed in Australia per year. Success rates for cataract extraction is now almost 99%. As such, the minute incremental gain in outcome from more advanced but expensive surgical technology becomes a debate for the perfectionist or the privileged. What about reducing vision impairment and blindness from AMD? Dr Jane Khan highlights the looming crisis of AMD in this edition (Page 34) Clinical Update. The introduction of drugs that inhibit the vascular endothelial growth factor (e.g. ranibizumab (Lucentis) and

AMD evolves from the early to late stage over 2-3 decades…. Access to treatment for wet AMD is improving in Western Australia. aflibercept (Eylea) has changed the treatment of wet AMD. Lucentis was listed by the PBS for this purpose in 2007 whilst Eylea received approval in 2013. Injections of these drugs increased from 30,000 in 2007-08 to 300,000 in 2015-16 and recently cost the country $434m a year (with numbers on the rise). AMD evolves from the early to late stage over 2-3 decades. The wet form of late AMD is only one of many facets of the disease. Access to treatment for wet AMD is improving in Western Australia. All three major teaching hospitals offer an injection service but capacity is limited due to the strain placed on other areas of ophthalmic service delivery. The Lions Outback Vision Van provides a bridging injection service to patients in remote areas, minimising their need to travel to Perth every four weeks for treatment. In addition there are now a dozen retinal subspecialists who support general ophthalmologists in managing the more unusual AMD cases.

Dry AMD lesions such as atrophy also cause vision loss. Recent phase II trials of drugs that inhibit complement factors D (lampalizumab) and C3 (APL-2) have shown a reduction in atrophy growth rate by up to 30%. Alas, these treatments are also monthly injections into the eye, so eye injections will be with us in 2020 and beyond. Ongoing research needs to be a priority. With treatments on the horizon for both wet and dry AMD, we can reduce the impact of the most common cause of blindness in Australia and perhaps achieve the goals of Vision 2020.

CURIOUS CONVERSATIONS

From Farm to Body Reticulation Life is a team effort for vascular surgeon, Dr Peter Bray. I love my specialty because… my patients are fantastic! Most are aware that lifestyle choices have contributed to their health issues and we tackle those problems as a team. Vascular surgery is challenging, exacting and ‘immediate’, plus I get to use all sorts of exciting new technology. My second career choice would have been… a farmer, believe it or not! I grew up on farms, an orchard, horse stud and vineyard in that order. I love that feeling of being physically tired at the end of a hard day. I used to enjoy working with reticulation pipes, so maybe that’s why I chose vascular surgery? My parents gave me a strong sense of… purpose. My mother and Yugoslav grandparents raised me to have a strong sense of loyalty,

8 | NOVEMBER 2017

respect and empathy. We came from humble backgrounds with large extended families. We weren’t spoilt by material things and the importance of hard work and community were ingrained. I think my wife is wonderful because… she complements me perfectly. I’d be lost without Louise. We’ve been together since I was as an intern and she has great empathy with the stresses of medicine. It takes a special kind of person to put up with a surgeon! She’s a highly intelligent woman and an amazing mum to our two boys. The book I’m reading now is… Ready Player One. It’s got ’80s music, computer games and lots of future tech. The movie is coming out soon so I’ll have to read the book again. Unfortunately, like most surgeons, it’s a long time between books!

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Targeting Preventable Visual Loss

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* The NovaSure® procedure is performed by a gynaecologist. The average treatment time is 90 seconds, and the entire procedure typically takes less than 5 minutes to complete. 2 References: 1. National Women’s Health Resource Center (United States). Survey of women who experience heavy menstrual bleeding. Data on file, 2005. Based on women aged 30-50 years. 2. NovaSure® Instructions for Use. Bedford, MA: Hologic, Inc. 3. Cooper J, et al. A randomized multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia. J Am Gynecol Laparosc. 2002;9:418-428. 4. Gallinat A. An Impedance-Controlled System for Endometrial Ablation: Five-Year Follow-up of 107 Patients. J Reprod Med. 2007;52(6):467-472. ADS-01814-AUS-EN REV.001. © 2017 Hologic, Inc. All rights reserved. Hologic, NovaSure and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States and/or other countries. This information is not intended as a product solicitation or promotion where such activities are prohibited. Because Hologic materials are distributed through websites, eBroadcasts and tradeshows, it is not always possible to control where such materials appear. Hologic (Australia) Pty Ltd, Level 4, 2-4 Lyon Park Rd, Macquarie Park NSW 2113. Tel. +61 2 9888 8000. ABN 95 079 821 275.

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A village in KwaZulu Natal

Charters’ Lessons Fresh, 20 Years On Plunging into the deep end of medicine as winner of the inaugural Alan Charters Prize gave endocrinologist Dr David Henley insight he still draws on. A lot has changed in the two decades since Dr David Henley won the inaugural Alan Charters Prize. He now has young twins, a girl and a boy, and a busy professional career as an endocrinologist. David looks back fondly on his trip to South Africa and would encourage every medical student to step out of the Perth ‘bubble’. “It was part of my elective in 1997 and I did the Prize presentation early the following year. It was a great night! You can sit back and see all the other countries that your fellow students have visited. It was an amazing trip and I was so lucky to have the opportunity.” Dr David Henley

“I went to KwaZuluNatal, which was both challenging and interesting. You’re certainly seeing a lot of problems such as rare and infectious diseases that you don’t see in Perth.”

we were certainly thrown in at the deep end. At one point I was in charge of my own ward.”

career with a good lifestyle because it’s pretty much outpatient based.”

Daunting as that may have been, it’s worth noting that David was a mature-age medical student with a previous career in the medical sector.

“Nonetheless, I’ve always been drawn to medical aid work in developing countries and that was a big part of choosing it as a student elective. I did a PhD after graduating and then my endocrinology training. Having had a comparatively late start to medicine, I thought it would be a good idea to get my specialty out of the way as soon as I could.”

“I had a life before medicine as a radiographer and I’d done a lot of travelling, including an exchange with a hospital in Vancouver in 1991. I was actually there when I decided that medicine was a more attractive option. There was no real continuity of care in radiography and it began to feel a bit like one procedure after another.” “There was a lot more I wanted to do.” “During my medical training I was fortunate to be able to earn a decent salary by working as a radiographer and the long university holidays made travelling pretty appealing. So I’d seen a fair bit of the world before I went to South Africa.” For David, there wasn’t a great deal of soul-searching when it came to choosing a specialty.

Student to Registrar

Instant empathy

“I was based at Mseleni, a former mission hospital that was funded, rather poorly at the time, by the government. As medical students

“I did a term as a resident in endocrinology and absolutely loved it! It was really just applied physiology, which I find fascinating. It’s a great

10 | NOVEMBER 2017

“In the ‘pre-twins’ era I volunteered for Australian Doctors for Africa but now, with young children, my wings are well and truly clipped. I went to places such as Somaliland where the focus was on teaching just as much as seeing patients and doing ward rounds. There is more to it than just going in, doing emergency medicine and leaving.” “We wanted to leave something that endured, such as an enhancement of skills and ongoing education.” “I think every young medical student should give the Alan Charters Prize a go. It’s a great concept and, even if that’s not the way you see your career heading, it’s a wonderful learning experience in both life and medicine.”

By Peter McClelland

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spotlight

Not even a health scare could stop Greta Bradman from singing and sharing stories to brighten lives and connect those who listen. What would you do if you lost function of a body part essential to the high performance required in your career? It is a common question as we age but when someone is in their prime and staring down the possibility of the slate being wiped, how do you absorb that? It was just such a moment for 35-year-old soprano Greta Bradman last year when her doctor called time on the conservative watching brief of her branchial cleft fistula and surgery was recommended. “It ran the length of my neck and it was starting to change and become even more abnormal so I had to have it taken out. The surgery impacted on the nerves that control the voice and I couldn’t talk properly for three months after. I didn’t think I’d sing again,” she told Medical Forum. “I did have that ‘wow’ moment but then I started thinking, what would I miss the most if I couldn’t sing. I had just finished a tour for my album Heroes. I sang all around the country in churches and halls and after every concert I’d go into the foyer and have a good natter with the audience.” Music reaches out “People were full of stories about what the music I had just sung had evoked in them – memories of growing up, loss of a loved one, the joyful moments in life. It was wonderful and it made me stop and think how lucky I was to be connected with people who trusted me with their stories and that was thanks to music.” “That’s what I would miss the most, the conversations that music creates, not necessarily the music itself.” Well lucky for her and her audience, the crystal bel canto voice is not only intact, she has also found another way to communicate – as a radio broadcaster on ABC Classic FM. It was Mental Health Week when we caught up with Greta and her own experiences of depression and bullying (shared with the world on Australian Story) her psychology studies (she is a provisional psychologist)

and the restorative power of music and human connection were very much on her mind. “We need to tell more of our stories because I think in the world we live in the storytellers are the changemakers. No matter where those storytellers come from, we have to be prepared to listen to the good and the bad.” Musicmakers have been storytellers for millennia and have created connections not only through time but generations and circumstance. And that is what excites Greta the most about her life in the arts. Connecting the generations “One piece of music can be heard by everyone – a six-year-old to an 86-year-old – and they will have an emotional connection to the music. It can play a helpful role for the elderly in breaking down isolation and drawing on memory for dementia sufferers. It’s as if music works in the part of the brain that never fails.” One of Greta’s guests on her radio program was celebrated composer Nigel Westlake, who in his Requiem for Eli showed how music rescued him from the deep grief he was in when his son, Eli, was murdered in 2010. Known popularly for his soundtrack to Babe, Nigel muscularly demonstrated that music could also do some heavy mental health lifting. Greta continues to perform and will be in Perth with three of her dearest friends, Lisa McCune, David Hobson and Teddy Tahu Rhodes, in a show with WASO called From Broadway to La Scala. It is the second time they have brought the show to Perth. The joy it gave then and the joy the four performers got out of it meant an encore was inevitable. “I’d never met Lisa but after the Australian Story aired, she rang and offered support and an ear any time I needed. The arts and show business can be hard work but it is also such a joy working with people with such big hearts. And when you’re on stage with people who absolutely support each other magic can happen.” Creating energy, excitement and happiness in a concert hall takes a special personality but Greta thinks audiences expect it these days. “The days of a going to concert like this without audience engagement have gone. People want a story and to be a part of that story and that’s what the show’s creatives, Vanessa Scammell and Tyrone Parke, have done. As performers we want to bring that out for the audience, for ourselves and for each other, as well as having a laugh and enjoying the music along the way.”

By Jan Hallam

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Hail the Changemakers

Left Blank Intentionally

FEATURE

Western Australia is emerging as a key state in the development of a viable medicinal cannabis industry in Australia. Cultivation licences have been issued to at least two WA companies that Medical Forum has ascertained, even though the Office of Drug Control (ODC) declined to name the recipients of the eight licences issued so far. One company is ready to plant its first crop locally and the other has entered into an agreement with Tasmanian Alkaloids (which grows 6% of the world’s legal opiate crop) to cultivate and manufacture in Tasmania with future potential to expand into growing in WA. Security of assets is strict and mandatory. With TGA approval, local medicinal cannabis could be available by June 2018, if not before. To date, the ODC has issued four manufacturing licences, nationally. However, a further licence to manufacture is required from the TGA, which can only be granted for an existing facility. Tasmanian Alkaloids holds one of these rare licences. Hard work, less fun Then there’s the business side of things. After an influx of players and the initial flurry of ASX listings, the reality of entering a highly regulated, big capital investment market has lost some of its shine for less-committed groups. Australia is highly unlikely to head down the US route of cannabis cafes and a ‘recreational’ market, so young guns looking to be in the vanguard of a cool green brigade for local legalisation will be disappointed. What is being established is a strongly regulated medical model. There are also private companies who are taking a steady-as-she-goes approach to see how the market develops before going down the public listing route. So while it is crowded now, the cannabis market is expected to distil into a core of participants with serious medical and pharmaceutical intentions. Of course, there is the question of demand. It’s a hard thing to quantify because local medicinal cannabis products are only now filtering onto the market. Much of the demand

14 | NOVEMBER 2017

has been met in the grey to black areas of the market. Last year, before legislation was passed, Deloittes Access Economics prepared a cost-modelling report for the ODC and Department of Health. It used data collected by the University of Sydney, in partnership with MGC Pharmaceuticals, which put expected patient numbers across three medical conditions – HIV/AIDS, Multiple Sclerosis and Epilepsy – would be about 30,400 a year. In addition it was estimated there would be demand for 995,827 treatment sessions a year among cancer patients (actual patient numbers were not known). Anecdotally, consumer demand in Australia is strong – at least strong enough to achieve legislative change. However, access to the product is putting the brakes on demand for two main reasons – restricted supply, which is set to improve rapidly over the next 12 months, and reluctance of the medical profession to prescribe, which is expected to take longer to turn around. We explore these issues with some of WA’s strategic players in the corporate, scientific and regulatory areas. The Regulators Legislation to allow the cultivation, production, manufacture and prescription of medicinal cannabis took effect on October 30, 2016 with both federal and state governments having a hand in regulating every step of the process. Medicinal cannabis containing tetrahydrocannabinol (THC), the psychoactive element of the 104 cannabinoids present in the plant, became a controlled drug (Schedule 8) of the Poisons Standard on November 1, 2016. (Preparations with 2% or less of other cannabinoids are listed as Schedule 4.) The ODC is tasked with regulating to prevent diversion and illicit use, and controls licences and permits to cultivate, produce, manufacture and import. The TGA issues permits and actively monitors and assesses the quality, safety and efficacy

of medicines before entry onto the Australian Register of Therapeutic Goods (ARTG). It also provides access to those medicines which have not been approved for use, which the TGA says will probably be the major route for patient access to medicinal cannabis products over the next few years. Access to medicinal cannabis in Australia is available through the Authorised Prescriber Scheme and the Special Access Scheme. There has been a low response from practitioners to qualify for the Authorised Prescriber Scheme, which is no great surprise as the process is onerous. Among the hoops and hurdles, a practitioner must gain the approval of a specialty college or a human research ethics committee.

CANNABIS Myth Busting • Recreational use of cannabis will not be legalised in the foreseeable future • Medicinal cannabis is not smoked; it is an oil extract • Schedule 8 medicinal cannabis contains THC in lower levels than illegal cannabis stock • Schedule 4 medicinal cannabis contains < 2% THC and does not require state approval to be prescribed • The Department of Health will not permit the importat of medicinal cannabis without US Drug Enforcement Agency approval • All Australian cultivation of medical cannabis will be strictly monitored and growers must ensure security provisions to prevent ‘diversion’ for unregulated use Where the colleges stand The Royal Australian College of GPs has a position statement that calls for more research on the efficacy and safety of medical cannabis products and goes further by saying these products must be approved or registered through the TGA before they can be prescribed. That will take time.

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Inside WA’s Medical Cannabis Story

FEATURE The Royal Australian College of Physicians does not have a public statement on its website though it has participated in state inquiries and has made it plain its position won’t be hurried but it must be consulted “considering our members’ expertise managing the medical conditions involved”. An ethics committee process is seen as too unwieldy and too slow. So, at least for now, until more practitioners become authorised prescribers, the most common route will be the Special Access Scheme (SAS). Under the SAS, health practitioners can access unapproved therapeutic goods through notification or application pathways. This is not as straightforward as it seems. A notification pathway is for patients who are likely to die without early treatment, so it is expected most doctors will follow an application pathway. State gets in the act A practitioner must get state approval on a patient-by-patient basis from an expert assessment panel. Medical Forum contacted the Chief Pharmacist, Mr Neil Keen, to explain the state process. He said the panel was appointed in December 2016 and, as of September 13, 2017, five patients had been approved to use medicinal cannabis. The panel comprises 13 medical specialists from the public and private sector with expertise in pain medicine, addiction medicine, oncology, paediatric neurology, adult neurology, public health, palliative care, psychiatry, immunology, toxicology and pharmacology. The panel would only review applications for Schedule 8 medicinal cannabis. “At present the notification pathway for medicinal cannabis includes multiple sclerosis. For other indications, approval to prescribe is via an authorisation pathway. As research evidence accumulates it is expected that additional indications will be added to the notification pathway,” he said. “The process is modelled on the one in place for opioids, stimulants and opioid substitution therapy. These processes apply whether or not the medicine has been registered for use in Australia by the TGA.” Too much red tape? We asked Neil if state intervention was necessary given the oversight of the ODC and the TGA. He said the WA process for cannabis-based products was consistent with the well-established controls that apply to all Schedule 8 medicines. “It is independent of, and has a different function to, the Commonwealth approval processes for unregistered medicines. Statebased approvals are part of Medicines and Poisons regulations aimed at public health protection regarding drugs with high potential for dependence and abuse. The prescribing of any Schedule 8 medicine is subject to additional restrictions in WA and all S8 dispensing is observed through a prescription monitoring program.” MEDICAL FORUM

The WA Players AusCann Dr Mal Washer, who as a former Member of the House of Representatives led the debate on drug policy reform that ironically included legalising cannabis, is chairman of ASX-Listed AusCann. His daughter, businesswoman Elaine Darby, is the CEO and together they lead a very Western Australian team of business and science heads. The company has ODC licences to cultivate and manufacture cannabinoid medicines and while it is waiting on TGA permits to produce medicines and move ahead with building its Elaine Darby own facilities in WA, AusCann has recently partnered with Tasmanian Alkaloids to grow and manufacture its products. Until those become available, Elaine said it was importing and rebranding medicines from its Canadian partner, Canopy Growth Corp. It also has gone into partnership with licensed Chilean medicinal cannabis grower, JV DayaCann, and produced its first crop in May.

systematic review of all the clinical studies involving medicinal cannabis and, when combined, the results showed strong evidence for the use of cannabinoids in the treatment of chronic pain in adults and spasticity symptoms for MS patients and chemo-induced nausea,” she said. “The Canadian Pain Society has recommended cannabinoids as third line treatments for neuropathic pain, just behind opiates, and there are a lot of Canadian doctors lobbying for cannabinoids as a preference, particularly for neuropathic pain, because opiates don’t tend to work as well in that area.” The cannabis product in the spotlight is an oil, which is swallowed. Elaine said that AusCann was moving to soft-gel capsules, which was an easier mode of delivery. “It all looks very different to the illicit stereotype, but those images of adverse effects of illicit cannabis use still pervade and persuade. The reality of medicinal cannabis is that is has a much lower level of THC and people don’t develop a tolerance to its analgesic effects, so dosages don’t have to increase. The analgesic effects kick in long before anything else.”

Canopy Growth produces, on licence, the Dutch-developed Bedrocan. Canopy and AusCann agreed two years ago that for an 11% share of AusCann, the WA company could access Canopy’s intellectual property and expertise, which included everything from plant genetics to the right medicinal formulations. “No patient has used an AusCann product yet. We have applications in with the TGA and as soon as we get that clearance, we will apply to the WA panel,” Elaine said. If Elaine had one wish, it would be able to call the product anything but cannabis. Illicit stigma lingers "Unfortunately the name does come with a stigma. If we could approach doctors and say we have this particular compound and this is some of the data of what it can do, I think the medical community would be excited and embrace it, particularly when we can show some of the emerging evidence of the opiate sparing effects of cannabinoids,” she said “While there is a need for regulation and oversight, the multi-layers are off-putting for some specialists who feel they are being second guessed. No doctor we’ve been interacting with is doing this on a whim. They are educated and are making informed decisions.” Elaine said 70% of patients in Canada who were prescribed medicinal cannabis were taking it for chronic pain. She believes, over time, this will be the case in Australia as well. “There have been a number of randomised placebo trials in the area of chronic pain, but only with small patient numbers. The US Academy of Science was tasked with a

“There has been a lot of hype about medicinal cannabis in this country and there’s no question that the potential market in Australia is significant. The highly regulated environment will leave only serious companies intent on producing medicines for patients who will benefit from them. There are Australian patient groups keen to have their doctors advise them about whether these medicines are suitable for them or not. The Australian government is keen to have this happen as well.” Getting confidence of doctors “However, unless doctors are willing to prescribe these substances and go through the approval processes, nothing will happen. Our biggest challenge, as an industry, is to educate our medical community about cannabinoid medicines to get them to a place where they are comfortable to prescribe them for particular patients.” “In Canada, doctors began prescribing, under

continued on Page 16

NOVEMBER 2017 | 15

FEATURE continued from Page 15 their current model, in 2014 for about 7000 patients. Now that figure has grown to over 170,000. Doctors needed to see how it works with key opinion leaders showing the way in order to be comfortable. The Canadian doctors are the pioneers in the space. They had no one to turn to for issues like formulation or dosage or contraindications. We can learn from this experience.”

Little Green Pharma Fleta Solomon is the managing director of a private company of 20 shareholders headquartered in Perth. The medical advisory team is headed by Dr Joe Kosterich and Prof Neale Fong. Fleta told Medical Forum that Little Green Pharma (LG Pharma) was approaching the local market a little differently. “We wanted to establish facilities and build a story to ensure the Fleta Solomon appropriate demand for medicinal cannabis and compliance were in place before expanding,” she said. “Potentially we might look at the listed space down the track but it is easier at this stage to stay a private company without the complications of going public. The Government is learning, we’re all learning.”

Fleta said LG Pharma had been issued a licence for cultivation and it had just received a permit to grow. “We have teamed up with a manufacturer (who cannot be named for security reasons) and we will look to get a Research and Development licence soon.” Fleta believes the multiple layers of regulation will ultimately give Australian medicinal cannabis the edge over its international competitors, which enjoy less stringent oversight by their respective governments. “The process is complicated but it needs to be and is the best thing for the Australian patient because the locally produced product will be high quality, effective and affordable. People can be reassured by that. We’re hoping regulations will relax a little for doctors so it is easier for them to prescribe and patients to benefit.”

Cultivating and Manufacturing Costs • Broadacre cultivation: to meet projected demand per annum is $75/sqm or $888 per kilogram dried flowers (total annual cost, $10.6m) • Greenhouse cultivation: $1108/sqm, $1539 per kilogram of dried flowers (total annual cost, $20.5m) • Indoor cultivation: $2291/sqm or $1909 per kilogram of dried flowers (total annual cost, $41.8m) • Manufacturing by carrier oil extraction, total cost $1.04m a year; by solvent extraction, $1.1m; by super or sub-critical CO2 extraction $0.85m; Light hydrocarbon extraction, $0.58m Source: Deloitte Access Economics

Poised for action Fleta said that once the permit to grow was issued, LG Pharma would be a few months away from product stage. “We have a unique patented technology that can optimise bio-availability allowing a comparable clinical effect at a lower dose of cannabinoids. Amongst the range, we are hoping to produce a Schedule 4 (less than 2% THC) medicinal cannabis product which is simpler for doctors to prescribe.” “Our products are indicated for epilepsy, MS, chronic pain, palliative care and chemo-induced nausea. Discussions are

also underway with local and international researchers to examine the effect of medicinal cannabis on general cognitive deficit in dementia and PTSD.” In her engagement with the WA medical profession, Fleta said she found many doctors to be cautious, yet open and wanting to know more information. “If I had to guess, I would estimate about 10% of doctors are supportive of the use of medicinal cannabis, 10-20% who are set against it and the rest sit in the middle and are open to see what happens. Once a few of the

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FEATURE specialists and GPs start prescribing, it will flow on,” she said. While the Australian market is cautious, its potential is big. Regulations cooling the process “Everyone in the space believes they know where it’s going and that it is worthwhile commercially. It will improve people’s lives. Current regulations are slowing things down. Based on the existing infrastructure and regulations it will be slower than what has been proposed.” “It would be overly optimistic to think that 30,000 people will benefit from medicinal cannabis straight away. Currently, there are only about 100 people receiving local product across Australia and a small number of authorised prescribers.” “The problem I see is one of education. How do interested people even know who can prescribe when there is no website or community site where people can go to for that information? The Canadians struggled with that initially too, so we should learn from that in advance.” “We are progressing, even though it may seem to be painstakingly slow. When doctors are comfortable prescribing the product and the patients are benefiting, demand will be strong and then we can start looking at other conditions medicinal cannabis may help. Research overseas has been very promising but we do need local research going forward.” While the domestic market is just at the

starting blocks, local medicinal cannabis companies no doubt have an eye on export markets down the track. “Overseas growers look at Australia and almost laugh at the stringent regulations in place here but I think that’s a huge benefit because if anybody has a licence to cultivate and produce medicinal cannabis in Australia, that product will be seen as top quality overseas. And that’s thanks to government regulations.”

The US National Academy of Science’s review of medicinal cannabis trials, which Stewart describes as almost a Cochrane review, came out with positive evaluations for its use for chronic pain, MS spasticity and chemoinduced nausea. “It also concluded there was reasonable and anecdotal data around insomnia, eczema and autism but more evidence was required. So that’s where Zelda decided to focus its research and define clinical trials in those areas,” he said.

Zelda Therapeutics This ASX-listed company emerged in 2016 from a reverse takeover of Gleneagle Gold, though Zelda has been around for more than a decade prior. The three major shareholders, according to the ASX, is former Gleneagle Gold miner Wayne Loxton, Jason Peterson, CEO and partner of CPS Capital, a corporate finance and stockbroking firm, and Gemelli Nominees, the private company of Harry Karelis, a founder and chairman of Zelda and board member of AusCann. Medical Forum spoke to co-founder and director Dr Stewart Washer (son of Mal), who was a stem cell researcher before becoming increasingly involved in medicinal cannabis. He is focused on establishing and supporting sound research projects here and overseas to establish how and what conditions medicinal cannabis can help because he knows firsthand that if there is not enough evidence to satisfy the medical profession, Australian doctors will be loathe to prescribe it for their patients.

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Stewart Washer

Research kicks off in WA “We are undertaking an insomnia trial in WA later this year with Dr Peter Eastwood and his team.” [Dr Eastwood is Senior Research Fellow at the West Australian Sleep Disorders Research Institute and at the School of Human Movement, at UWA. He is also Adjunct Associate Professor at the School of Physiotherapy at Curtin University.] “We are also conducting clinical trials for insomnia in Chile. Their researchers have a lot of experience with medicinal cannabis and there is a very good regulatory and clinical trial system there along with experienced practitioners. An eczema trial using a topical formulation and an autism trial will also be conducted there.” continued on Page 19

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FEATURE continued from Page 17

GOVERNMENT OVERSIGHT at a glance

Zelda is also partnering pre-clinical cancer research in Spain with Prof Manual Guzman and Prof Cristina Sanchez from the University of Complutense, who are on the trail of cannabinoids and their potential to affect the growth of tumours, initially focusing on breast cancer.

• 8 licences to cultivate and produce cannabis have been issued

“There is a great deal of anecdotal data from the US on cannabis having a positive effect in cancer, but this is enough evidence to design and conduct some proper studies. That’s why we’ve gone pre-clinical on this to an animal model because we really have to define what works and what doesn’t before we move to a clinical trial,” Stewart said.

Source: Office of Drug Control

“Professors Guzman and Sanchez found cannabis formulations appeared to work against triple negative breast cancer, which is out of bounds for Herceptin or hormone treatments. Guzman and Sanchez saw a different mechanism of actions in the cannabinoids, which work on cancer cells while leaving the healthy ones alone, so it is exciting research.”

• 5 research licences have been issued • 4 manufacturing licences have been issued to produce S8 & S4 cannabis product • As of September 13, 2017 5 patients have been approved for S8 medicinal cannabis Source: WA Chief Pharmacist Mr Neil Keen

South East Asia and Europe for being their preferred supplier of medically validated, quality medicinal cannabis down the track.” Supporting clinical confidence However, Australian doctors need to feel that same level of confidence. “Clinicians are trained in new drug classes all the time and just because it has the word 'cannabis' in it, we shouldn’t be scared of this class of drug either. We have to look at it scientifically and medically, he said. “I support any clinician who has studied the data on medicinal cannabis and decides to say to their patient, this is not for you because… But no clinician should say to a patient this is not for you because I know nothing about it. That’s malpractice. If you don’t know, refer to someone who does.” “Clinicians are very good in Australia and are generally fast to adopt new medical techniques. Once they get over the stigma of cannabis and look at the decent data and the side-effect profiles, it will be a useful drug to prescribe,” Stewart said.

By Jan Hallam

Telethon Kids involvement “We are also establishing research projects here in WA. We are partnering with Telethon Kids Institute for cell line studies in animal models for brain cancer later this year.” “And one of the world’s leading researchers into pancreatic cancer, Prof Marco Falasco, has come with his research team to Curtin University from Italy. He will also be investigating cannabis formulations for pancreatic cancer. There is a lot of exciting work to be done.”

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One of the obstacles facing the acceptance of medicinal cannabis is, unlike modern pharmaceuticals, the cart has largely gone before the horse when it comes to medicinal cannabis use and research. People have been using cannabis medicinally for millennia up until the 1930s when it was banned in the US. Eli Lilly, Parke-Davis (now owned by Pfizer) and Squibb (Bristol-Myers Squibb) all had cannabis-based products until the 1930s. In the 1990s, there was the new-wave of ‘compassionate’ use in the California followed by approval for its medical use in Canada in 2001. Now Australia, in 2016, has joined in. Stewart described the interest in cannabinoid research, in part, as retrofitting, or showing evidence for current use, which is being facilitated by doctors who see the benefit-risk ratio as too high to ignore. However, research is also expanding into new medical territories that if found effective could change the pharmaceutical landscape considerably.

Hunting down receptors Prof Raphael Mechoulam at the Hebrew University in Jerusalem is undertaking studies to locate and identify a group of endogenous cannabinoid receptors in the mammalian brain. He’s found the receptors for THC, CBD CB1 – 100 more to go! “This is a whole new field of medicine that is opening up. While that work is going on, we must ensure that this complex green gloop we are growing and manufacturing is the same time every time. We have to ensure our manufacturing is standardised before we even bother doing tests and that’s what the Australian industry is doing.” “Australia has federal control for medicinal use, and recreational use is banned with little likelihood of it being lifted. It’s very cut-and-dried here. I think that gives us a massive advantage in sceptical markets such as MEDICAL FORUM

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FEATURE BACK TO CONTENTS

Telestroke Building Treatment Equity? The transformative developments in treatment of acute ischaemic stroke have clinicians wide-eyed. Now the challenge is to share the miracles with rural Australians. Those at the sharp edge of stroke treatment around the world are hailing the technique of endovascular clot retrieval (ECR), or endovascular thrombectomy as a game-changer for a select group of patients with acute ischaemic stroke due to large vessel occlusion. Some have dubbed it the Lazarus phenomenon because some stroke sufferers are seemingly ‘brought back from the dead’ – or at least from a life of permanent and major disability. Alongside thrombolysis, ECR has given an extra spring in the step of stroke units everywhere – but there’s the rub. Everywhere is, in reality, only within a workable ‘retrieval’ distance from a multidisciplinary stroke unit capable of doing this complex but minimally invasive surgery. In WA, there are two such units – a 24/7 seven-day a week team at Sir Charles Gairdner Hospital and a five-day a week team at Fiona Stanley Hospital. St John of God Midland has a stroke service but does not do ECR. In the August 2017 edition of Stroke, a journal of the American Heart Association, three Melbourne stroke interventionists discussed equity, access and standards of endovascular thrombectomy in their state of Victoria, which has been in the vanguard of stroke treatment in Australia. Prof Stephen Davis, A/Prof Bruce Campbell and Prof Geoffrey Donnan wrote that these procedures required teams of highly trained health professionals where “clearly, procedural volume and complexity correlate with efficacy and safety.” Stroke workforce issues They went on to acknowledge there was a shortage of neurointerventionists. “Given the need for speedy recanalisation of large artery occlusion and the current workforce problems, we agree that training of a significant proportion of stroke physicians to undertake interventional work should be priority.” So, while those who live in the metropolitan areas of Australia can enjoy 21st century medicine, what happens to those who don’t? This is a particularly fraught question for WA, which has vast areas to cover with little or no chance of fulfilling the desired “procedural volume and complexity to correlate with efficacy and safety”. This is where telehealth medicine is playing an important role. Dr Andrew Wesseldine, who is Stroke Director of WA Department of Health’s Telestroke, said the service had been evolving over the past 3½ years and with the growth of WACHS telemedicine network and the establishment of the acute teams at SCGH and FSH,

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WACHS Telestroke Program Manager Stephanie Waters and Stroke Director Dr Andrew Wesseldine

Telestroke was having a positive impact on the lives of rural patients. “Stroke is still an uncommon condition presenting to rural EDs and the field has seen extraordinary developments in acute treatment over the past decade, which make it very challenging for people who are not experts to manage these situations,” Andrew told Medical Forum. “It’s not possible to have a SCGH or a FSH stroke unit in Geraldton or Albany, but we can bring the stroke doctor to the patient. The key has been communication that is contemporaneous, accurate, useful and delivered as often as possible by a stroke clinician to help the rural doctor or nurse with the care, decision-making and treatment strategies of their stroke patient. That’s at the heart of the Telestroke concept.”

Teleheath builds bridges “Teleheath will be a bridge for future delivery of thrombolysis for a rural patient. It’s certainly been used in Victoria in that regard.” Andrew said the landmark paper from the Netherlands on endovascular thrombectomy, MR CLEAN, in late 2014, which successfully trialled retrieval of clots in the large vessel in the brain via the femoral artery, had been part of treatment in WA at the Neurological Intervention and Imaging Service of WA (NIISwa) for some time. It has had ramifications for rural stroke patients as well. However, he stressed that the procedure was not suitable for every stroke patient. “We screen eight to treat one, so there are a lot who are not eligible, but that’s the nature continued on Page 22

NOVEMBER 2017 | 21

FEATURE continued from Page 21

Telestroke Building Treatment Equity of stroke. It is a heterogeneous condition which is why it’s so challenging. However, for those who are treated, the number needed to achieve a good outcome is only 2.8. This is one of the most cost-effective treatments in medicine,” he said. “Each week, we are retrieving these kinds of acute stroke patients from all around the state with the assistance of our great RFDS and St John Ambulance. WA has a dedicated core of stroke carers, nurses, ED physicians, medicos and I’m not saying these words lightly. These are incredible people.” “They are all pulling into gear on an event that might occur in say Broome once a month. But if they pull into gear on the right patient, we are talking an absolutely remarkable outcome.” Andrew said it was remarkable to consider the number of people involved in the Telestroke process. Meet the team “You’re talking about the nurse or doctor who calls from the ED, then you have the retrieval services, ambulance, RFDS or both, the cath lab nurses at Charlies who come in at two in the morning and the specialist neurointerventionist and all the people in

between – the registrars, consultants on the ground.” The effect of the endovascular treatment was demonstrated recently with the treatment of a 16-year-old boy from Manjimup, whose CT scans were assessed via Telestroke and he was flown to Perth, paralysed down one side and unable to speak. He walked and talked his way out of hospital 48 hours later. “It is not just the skill of those involved. It’s the fact everyone in the care of the individual was communicating effectively about an uncommon problem with a treatment that could only be delivered in a metropolitan hospital because of the scarcity of people with the necessary skills.” “We are very lucky, with a population of our size, to have two multidisciplinary units. Victoria has two. So there’s been a remarkable change in stroke care in WA and for those of us who have been around doing stroke medicine for 20 years or more, it is just transformative.” Andrew said that underpinning these developments was Telestroke as a tool to educate, train, assist and, build communication networks. “Everything about the project is about the

patient, and I am really proud of that. When we compare ourselves nationally we are punching well above our weight.” Counting the seconds “The key to this is to work on the systems to keep learning and getting better. Right now it is not a system you can activate from a GP’s surgery. Patients, particularly if they are hundreds of kilometres away need a CT scan for diagnosis. In rural Victoria, CT scanners have been put into ambulances to aid in a speedy diagnosis.” “Telestroke continues to drive skills capacity in regional areas. We have been doing a lot of work in EDs and with the Emergency Telehealth Service so we can become a cohesive communication network.” “But if you are talking time on the stroke clock, this has only happened at a minute to midnight. These systems of care are currently being shaped and put into practice all around the world and we have had to do the same thing. We are very lucky to have groups like WACHS and a supportive Director General and people in between who support this for WA patients.” Andrew said that time is of the essence in stroke medicine and it differs patient to

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FEATURE care teams, time. “However, in any world we live in, stroke prevention is the most important thing. We want to stop strokes from occurring by treating blood pressure, high cholesterol, diabetes and sleep apnoea. We want to get people with Atrial Fibrillation on to the right drugs. With all the amazing things happening in the treatment of strokes, it’s important to never lose sight of the absolute critical nature of primary care and that interface with the patient.” Telestroke is a fine example of technology being used to help teams separated by vast distances to pull together for their patients and Andrew is encouraged by the willingness of everyone in stroke care to be involved.

A telestroke consulation in progress

patient as to what the treatment options may be. “The initial time window was six hours but recent studies have suggested that selected patients outside of that window may benefit but there is not rule book to determine who they are.” Support around the clock “What we have said to rural doctors, if you have a stroke patient that is acute, in other

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words within the past 12 hours, Telestroke can help determine the treatment pathway. What has become clear is the necessity of consultant support 24/7. There are a number of states that don’t have this coordinated service but we don’t apologise for putting WA stroke patients in the centre of the conversation.” Currently international trials are underway for neuroprotective drugs which could potentially buy the stroke patient and the

“There are new things happening all the time and national networks are growing to share knowledge but for everyone involved who know what a stroke means to a person’s life, it’s motivation enough.” On October 21 and 22, the DoH sponsored a stroke symposium for rural clinicians to meet metropolitan stroke specialists and to go through training scenarios. Andrew said he hoped this would be an annual event and another step in expanding stroke services for those in rural areas. “It’s so important for rural doctors and nurses to feel comfortable asking questions of the stroke team. Questions are critical to good patient care.”

Jan Hallam

NOVEMBER 2017 | 23

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WA End-of-Life Inquiry Begins At the end of August, the WA parliament voted to establish a joint select committee to hold an ‘Inquiry into the need for laws in Western Australia to allow citizens to make informed decisions regarding their own end-of-life choices.’ This follows moves in the Victorian parliament which passed legislation in the lower house last month. The committee of eight will be chaired by Labor MLA Amber-Jade Sanderson. Also on the committee are Nationals MLC and deputy chair Colin Holt, Greens MLC Robin Chapple, (who failed in his bid to have private member’s end-of-life Bill passed in the last Parliament), Liberal MLC Nick Goiran, Labor MLA Simon Millman, Labor MLC Dr Sally Talbot PhD, Labor MLA Reece Whitby and Liberal MLA John McGrath. Its terms of reference include: • Assess the practices currently being utilised within the medical community to assist a person to exercise their preferences for the way they want to manage their end of life when experiencing chronic and/or terminal illnesses, including the role of palliative care; • Review the current framework of legislation, proposed legislation and other relevant reports and materials in other Australian States and Territories and overseas jurisdictions; • Consider what type of legislative change may be required, including an examination of any federal laws that may impact such legislation; and • Examine the role of Advanced Health Directives, Enduring Power of Attorney and Enduring Power of Guardianship laws and the implications for individuals covered

by these instruments in any proposed legislation. Parliament has requested that the committee report to both Houses by August 23, 2018. Public submissions were due to close on October 23, but a series of public forums will be scheduled for later this year and early next year. Community ready for debate Amber-Jade Sanderson, who sponsored the Bill, told Medical Forum that she believed the debate regarding end-of-life choices had evolved significantly in the WA community. “While we have seen a number of Private Members Bills in WA and around the country, it’s clear that this type of process is doomed to fail because there is not genuine community engagement, despite the good intentions of the individuals involved.” This inquiry is an opportunity to engage and gauge the community’s opinion on this divisive yet important issue. “Personally, I’m sympathetic but also very open-minded about how laws could possibly work and what the potential dangers are and that is what the committee needs to explore,” she said. “There are differing opinions on the committee and I think that is very healthy, so we should get a really robust and useful report from this process.” “I’m a seasoned political campaigner with 17 years’ experience of doorknocking and this issue has never come up except at this past election and it took me by surprise. In fact I had a volunteer with me and I was prepping him about issues that would likely crop up and he asked about voluntary euthanasia and I told him it had never happened.”

“At the first door, we were asked our policy on this very issue and it continued over and over throughout the campaign. Of course NSW and Victoria are further through the process and it’s in people’s minds. And I think there is a very strong push in the community for people to have a broader range of choices to manage their end of life.” The March election campaign also featured a dedicated end-of-life choices candidate in GP Dr Alida Lancee in the-then Premier Colin Barnett’s seat of Cottelsoe, and staunch pro-choice advocate Clive Deverill, who was terminally ill at the time, ended his own life on election day in protest to the lack of action in this area. Doctors views vital Amber-Jade said it was imperative the inquiry hears from members of the medical profession for the report to be a useful document. “We know anecdotally that some medical professionals are engaging in assisted dying without a legal framework. We also know there is a deep commitment to and investment in palliative care so we want to hear from all health professionals but in particularly doctors who work in that space and their views on how they saw legislation working to protect them as well as patients’ families and friends.” She said the committee wanted proceedings to be as open as possible but some may request in-camera hearings if they felt they would be open to prosecution. “Unless people request privacy, we intend to be as open and make information readily available to the public.”

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NOVEMBER 2017 | 25

GUEST COLUMN

Diabetes Self-Management Education Recent UWA graduate Dr Samantha White writes about her invaluable experiences with Diabetes WA and their group management program DESMOND. Type 2 Diabetes Mellitus presents an increasing population health burden both in Australia and globally so it’s imperative health professionals work together to find solutions to better engage patients and improve health outcomes. Patient-centred and holistic care is the widely accepted modern approach to providing good patient care in Australia, and as a graduating medical student from the University of WA, I have been lucky to experience this in action with my involvement with Diabetes WA. My service learning project was part of my medical degree and I spent two years with Diabetes WA conducting an evaluation of the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) program, as well as participating in diabetes educator training and observing group education sessions. I gained a wealth of knowledge about diabetes and education strategies, and gained new perspectives about the patient experience of chronic illness. This has shaped my understanding of how patients engage with their chronic disease and the health care system. Adequate diabetes management and glycaemic control and reducing adverse complications (e.g. cardiovascular disease, diabetic nephropathy) requires significant lifestyle modifications by the patient, including improved diet and physical activity, and adaptation to other health-related behaviours such as adherence to medication regimens and engagement with health services. A comprehensive and patient-centred approach to diabetes education, where the patient is the expert of their own disease and accepts responsibility for the daily selfmanagement required in diabetes, promotes patient empowerment and engagement. Group work works Diabetes self-management education programs, such as DESMOND, take an interactive and collaborative approach to patient education, teaching the fundamentals of diabetes and the self-care behaviours required for good glycaemic control, while also helping patients to improve their problem-solving skills to help them navigate the daily challenges of diabetes care. Technical skills training is not included in DESMOND but diabetes educators do teach these specific skills to individual patients. Diabetes WA does offer additional programs such as MeterSmart, ShopSmart and FeetSmart to impart specific information related to various aspects of diabetes management in a group setting. The RACGP guidelines recommend GPs

26 | NOVEMBER 2017

Diabetes educator with a group on the DESMOND program

to facilitate referrals to structured diabetes education at diagnosis, thereby integrating education with clinical management in the primary care setting. Regular (annual) review is also recommended. The findings from my service-learning project suggest that patient knowledge and goal-setting behaviours gained through formal education wanes after six-months, so more regular follow-up and education may be warranted. GPs are trusted by patients to coordinate their care and help them achieve the best possible health outcomes and being involved at all stages of a patient’s health care journey by delivering diagnosis, monitoring progress, planning interventions, treating complications, and providing longitudinal care and support. Need for ongoing learning So there is potential for diabetes education to be better integrated into routine care and to be better supported by GPs. Identifying key stages of change for a diabetic patient (i.e. at diagnosis, new complication, new medication) as indicators for referral to diabetes education, and recognising the role for group-based self-management education, is a useful intervention which can hopefully lead to increased referral rates to diabetes self-management education and greater integration of education into routine clinical care. A multidisciplinary ‘primary care support’ focus group has recently been formed in

an effort to understand and remove the disconnection between community GPs and the National Diabetes Services Scheme (NDSS) services. Many GPs are not aware that diabetes education programs are free for patients through the NDSS. Currently in the community we rely heavily on the one-on-one GP consults and diabetes educator services. Group self-management education strategies have been shown to be as effective as one-on-one diabetes education in regards to health behaviour changes important for good diabetes care, however, these programs are often overlooked. DESMOND is quality controlled and monitored, delivering the same program (content, structure and philosophies) across all centres. By better integrating these services into primary care, we can look forward to significant changes in the way patients with diabetes engage with their chronic illness and health care services, and improve their long-term health outcomes. References available on request ED: Diabetes WA is running GP and Practice Focus Groups in November to help better understand the needs of primary care providers and how Diabetes WA services can be better embedded into general practice. You will be remunerated for your time and light refreshments served. Contact Jesse Elliot, phone 9436 6259 or Jesse.Elliot@diabeteswa.com.au

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news & views

Growing Old with HIV People with HIV are living healthy active lives thanks to antiretroviral therapy but attention is turning to their needs as they age. The Australian Society of HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) and Brightwater WA conducted a pilot training program to help carers in aged care settings meet the needs of a growing number of elderly people who are HIV positive. The pilot was funded by the WA Department of Health and the report was launched in Perth last month by Ita Buttrose, a former chair of the AIDS Council of Australia. Medical Forum spoke to ASHM Senior Project Officer Karen Seager, one of the architects of the training program, which has now been accredited and will be delivered by RTOs nationally. “All the participants agreed the course was relevant and it gave them a better understanding of HIV, which they could apply in the workplace. And being a pilot, there was useful feedback,” she said. As part of the training, ASHM held workshops where speakers with a lived experience of HIV expressed their concerns, despite being relatively young, of how their health issues would be accepted in the aged care setting.

“There is a growing number of people with HIV over the age of 55 and that number will increase so it’s important that care workers in aged settings are trained to support their HIV clients.” “Myths perpetuate around HIV and the At the WA launch: Karen Seager, left, Lisa Bastian (WA DoH), David Kernohan and Lisa Tomney (WA AIDS Council), Ita Buttrose, Uncle Ben program is designed Taylor, Claire Italiano (ASHM board member), Wendy and Stephen Walker to bust those myths. No one is going to get sick by providing Manager of WA Health’s Sexual Health and services to people with HIV. Because of Blood-borne Virus Program Lisa Bastian better-tolerated antiretroviral therapy, HIV said the innovative program would provide is now considered a chronic condition that aged-care workers with the knowledge and can be easily managed with adherence to skills they require to manage HIV-related medication,” Karen said. social and physical health needs of residents, in an environment free from stigma and While the pilot was conducted in discrimination. Brightwater’s aged care facilities, Karen said that consumer-directed care meant services The course, which is currently a separate would also be delivered in the community and module for professional development, is this program was tailored to help carers in all anticipated to be incorporated into certificate training courses across the country. settings.

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FEATURE BACK TO CONTENTS

Having a laugh with happy village children

Healed mid-foot amputation stump for Madura foot (clinically combined bacterial and fungal infection).

Bone tumour of humerus (likely malignant transformation – no histopathology facilities)

Always Ready for the Unexpected Orthopaedic surgeon Dr Li-On Lam has visited Madagascar for the Perth-based charity Australian Doctors for Africa seven times. He writes here how he always learns something new. Madagascar. The name conjures up images of exotic animals, intrepid travel, and an island of bounty and beauty. The real situation is that its charm is more often found in simplicity and its appeal in a lean elegance born out of an uncomplicated life. Although the size of its population approximates Australia’s, it has fewer than 10 buildings of more than 10 storeys. Moreover, it ranks in the top 10 poorest countries in the world, with more than two-thirds of its population earning less than $US1 a day. Australian Doctors for Africa (ADFA) has been involved in Madagascar since 2006. As one of those doctors, I have had the good fortune of making seven trips to the town of Tulear where healthcare challenges are not only due to poverty, corruption, and the lack of infrastructure, but also to the people’s suspicion of the health system and reliance on traditional healers. Recognising this, ADFA has undertaken programs to develop infrastructure which challenges those misconceptions as well as treat patients directly. Examples of some of the organisation’s work includes building a toilet block for a hospital, using the skills

28 | NOVEMBER 2017

of an anthropology graduate in setting up a culturally sensitive club foot program, and assisting in equipping surgical theatres. Teams have involved gastroenterologists, urologists, nurses, anaesthetists, physiotherapists, and orthopaedic surgeons. Local radio announces when the team is arriving. Most patients are from the vicinity but some travel from afar, undertaking journeys by taxi-bus over many hours or even days. It is a bit of a lottery in terms of presentations, but over the years our interpreters have become quasi triage officers and now have a good understanding of what we can treat (which makes for more efficient consulting). One year, our first patient was carried up the steps to the clinic by his friends with a bleeding, macerated above-knee amputation stump. We ended up shortening and revising this. I have performed a number of amputations for various infective and traumatic conditions in Tulear. We try and see children and those with acute injuries first thereby building up a surgical waitlist. We operate in one of the local hospitals where equipment is basic but over the years we have brought over instruments and implants. Every case has to be carefully planned

for as there is nothing sterile waiting on a shelf. Instead, everything from a knife blade to the closing sutures has to be sterilised and available. This is something I learnt the hard way having chosen the wrong size screwdriver and we waited scrubbed while the correct one was sterilised. Over the years, we have treated a variety of conditions. Neglected trauma and infections are common. We have treated gunshot injuries, non-unions, corrected deformities and excised bone tumours. Due to the basic conditions in theatre, relatively simple cases can be difficult – tourniquets are inflated with a bicycle pump and clamped; suction is weak (and non-existent in the earlier years); and I remember buying a file from the marketplace for one case. We turn patients away if we cannot perform their surgery safely or lack materials but it is good to ‘MacGyver’ some operations and think outside the square. The people are very grateful for any help. All this could not happen without the efforts of a team who do everything from administration to packing containers. We trust we work in a manner that reflects this effort and respects the generous donations of so many. MEDICAL FORUM

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Protecting the Elderly from Greed Raising the profile of elderly people’s rights is essential to ensure they have both choice and control in their lives, says Advocare’s CEO Diedre Timms. Everyone agrees that older Australians deserve to be treated with dignity and respect. They’re also entitled to enjoy choice and control over the services they receive from aged care providers. Ideally, every individual should be confident of receiving high quality care but if they do have concerns it’s reassuring to know that they can receive assistance from organisations such as Advocare. Our trained advocates provide free, confidential support to reach a resolution with service providers and we can also act with or on behalf of the older person if required. There have been some complex recent changes in home care arrangements and this has caused confusion for some older people and family members. Advocare can help with information and advice on both residential and home care support. We also have an Elder Abuse Help Line, which is a confidential service for any person experiencing elder abuse. We receive about 50 calls a month and, sadly, that figure is considered to be just the tip of the iceberg. Elder abuse is one of the most pressing social issues facing older Australians at the moment.

It even has a name – Early Inheritance Syndrome. Sadly, some family members are all too keen to get their hands on their elderly parents’ assets. Elder abuse takes many forms. It can range from psychological intimidation, social alienation and financial demands to physical harm and intentional neglect. It’s estimated that about 10% of older people experience abuse but, naturally enough, many are reluctant to ask for help due to fear of reprisal. A big part of our work is helping people to manage family relationships, and some of those are difficult. Elder abuse is perpetrated by family members, often adult children stealing money from their parents or systematically stripping assets. More recently this has become a disturbingly common scenario due to the increasing cost of living.

It even has a name – Early Inheritance Syndrome. Sadly, some family members are all too keen to get their hands on their elderly parents’ assets. There’s a false sense of entitlement playing out here. They’re not prepared to wait until their parents die, rather they devise ways for their parents to either ‘gift’ them money or arrange for a transfer of assets that often borders on the illegal. Advocare has an important role to play in education across the full spectrum of aged care and the community health sectors. It’s crucially important that the rights of older people and appropriate, effective strategies to minimise elder abuse are widely disseminated. Our services are delivered across WA and we’d encourage everyone needing advice to get in touch with us. ED: Advocare is at The Perron Centre, Suite 4/ 61 Kitchener Ave, Victoria Park 9479 7566; 1800 655 566 (Country) WA Elder Abuse Helpline: 1300 724 769; email@advocare.org.au; www.advocare.org.au

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Fertility, Gynaecology and Endometriosis Treatment Clinic 30 | NOVEMBER 2017

MEDICAL FORUM

guest column BACK TO CONTENTS

Getting Up from a Fall A few well-chosen words of advice can be highly effective in reducing the number and severity of falls in the elderly, suggests Curtin University’s Dr Elissa Burton. It’s a disturbing fact that one in three people over the age of 65 suffers a fall every year. And that likelihood increases if a person suffers from illnesses such as Dementia, Parkinson’s or requires the services of a home-care agency. Thankfully, many of those falls don’t result in serious injury but therein lays the problem because some within this cohort don’t tell anyone they’ve had a mishap. They’re frightened of the consequences, they’re embarrassed and they don’t want to go into a care facility. There could be any number of underlying reasons for the fall such as loss of balance, reduced strength, polypharmacy, problems with prescription glasses or incorrect footwear. Or it might be something as simple as tripping on a mat in poor lighting. Once the reasons are determined the older person can receive strategies to minimise, or hopefully avoid, falls in the future. Falls are the leading cause of injury-related hospitalisation for older people in Australia and this group has more injury-related deaths due to falls than motor vehicle fatalities.

I often hear people say, ‘the reason he fell is because he’s old’ yet research has shown that falling is not necessarily a natural progression of ageing. I often hear people say, ‘the reason he fell is because he’s old’ yet research has shown that falling is not necessarily a natural progression of ageing. Some people will reach a ripe old age and never experience a fall. One of the less well-known issues within the spectrum of falls prevention is an older person’s inability to get up by themselves. Many will seek assistance from their spouse, family, neighbours or friends but for some they are forced to call an ambulance simply to help them up and into a chair. This is known in the industry as ‘lift-assist’ and it costs UK health services millions of pounds a year with the figure estimated to rise to £118.9m by 2030.

There’s no reason to doubt that the same trend is occurring here in Australia. A recent study at Curtin University found 30% of home-care clients who had fallen over a 12-month period had called an ambulance to help them up off the floor. And not one of those needed a transfer for further medical attention. Those most likely to have used ‘lift-assist’ were in worse health than the previous year, suffered from arthritis or stroke or had memory problems. They also needed help with their everyday activities, were taking multiple medications and used an emergency alarm system. There’s a lot that can be done to help patients who have had a fall or are in a ‘high risk’ category. It may be something as simple as referring them to a falls specialist or physiotherapist to boost their confidence and give them some preventative strategies. References available on request

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NOVEMBER 2017 | 31

guest column

Role of Virtual Home Visit Embracing the latest technology is a boon for both residents and students in the aged care sector, says Curtin University’s Dr Anne Furness. It’s no secret that the 65+ age demographic will increase rapidly over the next half-century. In fact, there are projections that we will see a 200% increase by 2061. We know that many of these people will prefer to remain in their own homes as long as possible and that means we’ll have to make sure that our aged care students are well trained to deliver home-based services. Given that, it’s a little disconcerting to find that many students in the allied-health sector don’t even see themselves working in aged care. Consequently, they’re not overly motivated to focus on this area of their studies. And that’s a worry because the reality is that many of them will be employed in just those roles. The preferred learning style of the younger generation involves utilising the latest simulation technology to depict real-life working environment situations. It’s a spin-off from their world of computers, tablets and smartphones and that’s not such a bad thing because we all know that clinical placements are both expensive and increasingly hard to find in allied health practicums.

Virtual reality home visits like this are helping students to identify potential risks for the elderly.

One of the most critical areas within aged care is fall prevention. It causes a significant number of serious and costly injuries that impact on patient quality of life. Researchers at Curtin University have developed a ‘Virtual Home Visit (VHV)’ app that’s designed to give students a ‘real experience’ of the processes and protocols involved in conducting a home visit while addressing this particular area. The computer game requires a student to interact with the client, the client’s partner and their teaching supervisor during the home visit. The principal aim is to gather information to determine risks, hazards and appropriate responses in order that effective and timely supports can be put in place to enable the client to remain at home. The VHV provides the learner with a ‘real-time’ learning experience. It can be accessed via a smartphone, a tablet and/or a laptop computer and can easily be delivered to large numbers of students anywhere, anytime. One of the big pluses is that a student can practise the sequences as many times as they wish, with or without a supervisor hovering over them in cyber-space. The entire VHV experience is cost-effective and can be modified to adapt to different learning outcomes. There’s little doubt that more health science courses will develop virtual training tools and we’ll see a lot of benefits from this technology. And that all adds up to improved quality of care for the patient at a reduced cost.

32 | NOVEMBER 2017

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CLINICAL OPINION BACK TO CONTENTS

Myopia: Nature or Nurture?

By Prof David Mackey Professor of Ophthalmology UWA

Are you myopic either because your parents were myopic or because they sent you off to uni where you studied too much indoors? The debate of whether myopia is genetic or environmental has existed since the astronomer Kepler proposed his own myopia was due to all the near work and study he did.

It is not just genes

For example, Stickler syndrome (most often caused by mutations in collagen 2) is characterised by most carriers of the mutation being highly myopic and disease transmission is as an autosomal dominant condition.

We surveyed Chinese medical students doing a term in Western Australia and noted that 95% were myopic and when asked how many spent an hour outside a day (or seven hours a week) not one student raised their hand. (Even Fremantle prisoners in solitary confinement had one hour outside a day!)

Most myopia that develops in high school or university is not as clear cut and is considered a complex genetic disease with interaction between multiple genes and environment. The role of twin studies A good way to sort genes from environment when it comes to causing a condition is to conduct a twin study. A classic twin study compares the correlation of identical twin pairs with the correlation on non-identical twin pairs. If the identical twins are more alike than the non-identical twins it suggests genes are the predominant influence. If the identical and non-identical twins have similar correlations then it suggests that the environment is the main influence. Meta-analysis of twin studies for myopia and measurements associated with myopia indicated there was a high >80% genetic contribution to myopia. Researchers around the world collaborated in the international consortium for refractive error and myopia (CREAM) and in 2013 published the first analysis of data on almost 50,000 people to identify 26 genes associated with myopia.

This is evident from the epidemic of myopia in the cities of East Asia where over 90% of children leaving school are now wearing glasses! A lack of time outdoors appears to be the major contributor.

In fact the large amount of time West Australians spend outside seems to protect us from myopia. Researchers at the Lions Eye Institute found only 23% of 20-year-olds in the WA pregnancy cohort, Raine Eye Health Study, were myopic. But spending time outside carries other risks. When we analysed myopia in the baby boomers of the Busselton Healthy Ageing Study, we found that people who had skin cancer were half as likely to be myopic as those without any skin cancers, 11.9% compared with 21.6%. It appears that some of the myopia genes identified may interact with the environmental

The consortium members had spent decades meticulously examining thousands of subjects and conducting DNA analyses. Years of political negotiations between the international groups were required to convince researchers to hand over all their data, followed by months of data harmonisation and statistical analyses on supercomputers.

MEDICAL FORUM

At present there are few proven interventions to prevent the progression of myopia. At the Lions Eye Institute we have just started a randomised controlled trial of low dose atropine eye drops to determine whether these may slow the progression of myopia in children aged 6-16 years. Children who have myopia of -1.5 diopters or more in each eye and a myopic progression of -0.5 diopter or more over the previous 12 months will be eligible for free eye drops for the duration of the trial. ED. Parents wishing to learn more about the study can contact myopia@lei.org.au

Introducing

These genes highlight the importance of vision and retinal signalling as well as eye growth in the development of myopia and open up new potential forms of treatment.

The same day the list of genes became available to the CREAM researchers, the direct-to-consumer DNA testing company 23andme had analysed their very crude data of “do you wear glasses” and identified dozens of genes. The race to publish our data before this American company, meant a manuscript (with over 100 authors) was completed in three weeks.

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CLINICAL UPDATE

Age-related macular degeneration (AMD) remains one of the leading causes of blindness. Available treatment for one type of AMD (choroidal neovascularization or ‘wet AMD’) has been a breakthrough in recent years but wet AMD only accounts for one third of end-stage blinding disease. How common is it? AMD causes about two thirds of new cases of blindness in those over 50 years i.e. about 590,000 Australians have AMD (early AMD affects 460,000 and late stage AMD affects 135,000). Some take home figures:

in six genes account for about 75% of AMD (no single gene alone is responsible). • Report sudden or recent changes in vision. If macular changes have already occurred, using an Amsler grid to selfreport further changes may enable earlier detection rather than solely using a Snellen acuity chart; in particular, fluid build-up under the macula will cause increasing distortion of straight lines. Reading vision is also affected early in wet AMD. • Refer for urgent macular assessment if either visual acuity drops or the Amsler grid distorts suddenly; Optical Coherence Tomography confirms leakage of fluid under the macula.

• Proportion of over 50 with any AMD – 9% (one in 11) • Proportion of over 65 with any AMD – 18% (one in 6)

We now know that detecting wet AMD early gives a better response to treatment – timely intravitreal anti-VEGF can have impressive results and restore almost normal vision in some patients. How can we detect wet AMD promptly? Unfortunately, ignored or unnoticed symptoms can allow time for scarring so that vision can be stabilised but it remains impaired. The message for patients is: • Have eyes checked regularly – particularly if there is a strong family history as having a first-degree relative affected with AMD increases risk 5-10 fold — polymorphisms

34 | NOVEMBER 2017

• Consider supplements in those who have already lost vision in one eye or who have significant AMD changes at the macula. • Everyone should stop smoking – as the strongest modifiable risk factor (which includes passive smoking). Stopping smoking, even in older age-groups, shows a reduction in risk.

Key POINTs • AMD is the commonest cause of blindness in those over 50 in Australia • Diet and lifestyle changes, and AREDS supplements may prevent vision loss Amsler grid with central distortion.

• Anti-VEGF is an effective treatment for most cases of neovascular AMD • Early diagnosis and referral reduces visual loss in neovascular (wet) AMD.

What treatment can we offer?

In 1989, the amino acid sequence of “vascular endothelial growth factor” (VEGF) was mapped. Thereafter, genetically engineered antibodies to this molecule were used to retard cancer growth. Case-reports then appeared retarding growth of abnormal blood vessels in the eye which lead to the first marketed intravitreal agent for wet AMD in 2006 (ranubizumab).

Current prevention advice:

References available on request

Disability due to AMD can mean progressive loss of central vision. This affects reading, cooking, driving and remaining active and mobile. Independent living is very difficult, with resultant depression and emotional distress. Affected patients show lower Quality of Well-being and Profile of Mood scores, similar to patients with COPD or AIDS.

Until about 10 years ago, the ophthalmologist broke the bad news and directed patients to the Blind Association - wet AMD could cause loss of vision in weeks or even overnight (if they had a sudden bleed).

based on the AREDS formula are available online or from pharmacies and they all contain vitamins C, E and zinc. The studies did not show benefit in those with early AMD so recommending these supplements tends to be reserved for wet AMD or geographic atrophy in one eye or the later stages of dry AMD (large soft drusen and pigment changes) in either eye.

• Maintain a healthy diet (high in antioxidants) and address cardiovascular risk factors.

• Proportion of over 85 with any AMD – 47% (one in 2)

This points to a serious problem given the increasing elderly population.

Dr Jane Khan Ophthalmologist Mosman Park

What can be done about Dry AMD? No treatments are available as yet for the atrophic form of disease (Geographic atrophy or Late Dry AMD). Despite the success of wet AMD treatment, AMD is still responsible for around 2/3 of new cases of blindness in people aged over 50.

• Patient education and screening will assist prompt diagnosis. Author competing interests: nil relevant disclosures. Questions? Contact the author on info@westerneye.com.au

Are there modifiable risk-factors? The strongest modifiable risk factor for end stage AMD (both dry and wet) is smoking. Persistent smokers have 4.5 times the risk of non-smokers of developing wet MD and may develop disease up to 10 years earlier than non-smokers. Other risk factors that may contribute include poor cardiovascular health, poor diet and even passive smoking. Sunlight exposure has not been a consistent association but the theory is that increased oxidative triggers may override the protective mechanisms in the macula. The AREDS trial 1 and 2 showed about 25% reduced rate of progression of advanced MD. The AREDS dietary supplements are aimed at providing antioxidants as well as essential amino acids (however, the addition of fish-oil fatty acids in the AREDS 2 trial did not confer additional benefit). Different supplements

MEDICAL FORUM

BACK TO CONTENTS

AMD – blindness in an ageing population

CLINICAL UPDATE

Patient Q&A for AMD Q. Will I go blind? Macular degeneration affects central vision, which means detailed vision increasingly deteriorates but most people retain reasonable peripheral vision for getting around. Q. Will new glasses help?

Cottesloe Medical Centre is pleased to welcome

Dr Deb Cohen-Jones

Sometimes, especially if they are not up-to-date so maximising full visual potential can help as can increasing the magnification in reading glasses early on. Q. Is macular degeneration genetic? Genes play a large role in risk, particularly in those with a first degree relative (sibling, mother, father) who has macular degeneration. However, it does not mean you will definitely develop disease; other factors, some as yet unknown, add together to increase the risk. Q. What can I do to make it better — diet? Exercise? Vitamins? There is good evidence that some antioxidant vitamins slow the progress of the disease if it is fairly advanced already – your ophthalmologist or optometrist can tell you if you fit in this category. Diet rich in antioxidants (green leafy vegetables and highly coloured vegetables such as capsicum) and diet rich in fish also seem to be protective. Stopping smoking, even in the elderly, can reduce risk. Q. I have been diagnosed with drusen, does this mean I have macular degeneration? There are slightly different types of drusen and most people over the age of 50 will have some small drusen so don't panic. However, larger and more widespread drusen changes might mean you have early stages of disease. Q. I love reading. Will I make my macular degeneration worse by continuing to read? Using your eyesight doesn’t make any difference, so carry on reading! Q. Can 'using' my eyes cause further damage? 'Resting' your eyes doesn’t help – so continue as normal. Q. Can you get macular degeneration in both eyes? The problem is related to ageing, genes and the environment so both eyes can be affected. Q. Does cataract surgery increase the risk of macular disease progression? This is controversial. There appears to be evidence both for and against cataract surgery having an effect on AMD. However if your vision is deteriorating significantly mainly because of cataract it makes sense to proceed with surgery. Delaying cataract surgery may cause further deterioration in eyesight and could increase your risk of making the surgery more complicated due to the cataract becoming increasingly dense. If you are at risk of AMD discuss the risk or benefit of cataract surgery in your case with your ophthalmologist. Q. I have noticed changes to my vision when using the Amsler grid, what should I do? If these changes have developed fairly quickly (days or weeks) you should seek prompt review (within a week) by an ophthalmologist or optometrist and have your macula examined. Early detection of wet AMD (blood vessels growing and leaking under the retina) can mean a much better outcome with prompt treatment.

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CLINICAL UPDATE BACK TO CONTENTS

‘Who’ first, and ‘what’ second Disagreements about treatment are commonplace in clinical settings and may involve patients, family members, clinicians and others. They are more likely found in aged care and mental health settings where persons other than the patient may feel they ought to be centrally involved in treatment decisions. As treatment options are manyfold and can range from symptomatic to heroic in scope, it is not surprising that disagreements frequently arise - how such dissent is addressed varies. Sometimes it involves a competition of opinions shaped by sources ranging from reports in the popular media through to professional ‘treatment guidelines’ (which of themselves can be interpreted as ‘options, ‘suggestions’ or ‘rules’). That such ‘guidelines’ can’t and don’t take into account subjective or contextual personal aspects, such as religious or cultural values, is usually merely overlooked. An unproductive debate might become seemingly more enlightened and promise direction around what might be in the

Dr Sam Restifo Psychiatrist Midland

person’s ‘best interest’. Unfortunately, this doesn’t actually help at all. Why not? If for a moment we were to consider a unicorn, any of us would be able describe this creature in considerable detail, down to whether the horn has a spiral shape or not. Though the unicorn doesn’t exist, we nevertheless all have a clear picture of it. Thus, it is difficult for us to accept that there is actually no identifiable option as ‘the person’s best interest’. Why? Because what is ‘best’ depends on the person that is asked, whose answer will be informed by their life experiences, personal values and cultural or religious beliefs. However, from the mention in the preceding paragraph about ‘who is asked’, we have a clue on how to progress in resolving such impasses about treatment. The question, from both an ethical and legal perspective, is not ‘what is best’ but ‘who decides’. This brings us to the matter of capacity to make an informed decision. Put simply, if the patient is considered to have retained decisional capacity, then only he or she

by Medical Director Prof John Yovich

In caring for patients, the right answers invite the right questions, in the right order.

will be in a position to decide what is ‘best’. If the person is deemed not to have capacity, the next task will be to identify the substitute decision maker. If there is dissent on capacity, or in the case of incapacity on who the substitute decision maker should be, then the matter gets referred to the State Administrative Tribunal for adjudication. It is surprising how often debates about treatment get bogged down: not because the right answer is in dispute, but because the wrong question was asked. ‘Who’ is the first question and ‘what’ comes second (with apologies to Abbott and Costello). Author competing interests: nil relevant. Questions? Contact the author sam.restifo@health.wa.gov.au

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Recent reports in Nature describe an experiment involving human sperm (from a Recent BBC report from Francis Crick Institute in London man carrying a of Dr Kathy Niakan injecting CRISPR-Cas9 for gene dominant gene editing of pronuclear-stage zygote (reported in Nature). for Hypertrophic Cardiomyopathy) was injected into human eggs donated for research, along with transcription nucleotide CRISPR attached to the Cas9 nuclease to cut both DNA strands of the target gene OCT4. This knockout would prevent the embryo forming a normal blastocyst unless a replacement gene was inserted or the corresponding gene from the oocyte was copied over; such was the case in this experiment where 72% of the embryos were disease-free. This type of research is being actively pursued in Oregon in the USA, South Korea, China and the Francis Crick Institute in the UK where specific legislation enables research on embryos up to 14 days.

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CLINICAL UPDATE BACK TO CONTENTS

What’s new in chronic lymphocytic leukaemia Chronic lymphocytic leukaemia (CLL), the most common adult leukaemia, has an annual incidence of 4-5/100,000 (i.e. about 100 new cases per year in WA). As patients with CLL may live for many years, the prevalence is higher and CLL is therefore frequently encountered. The majority of patients are diagnosed after the finding of lymphocytosis on a blood count, while others can present with bone marrow failure or lymphadenopathy and splenomegaly.

does not automatically trigger treatment – some patients with counts over 100,000 may not require immediate treatment.

Our better understanding of the pathophysiology of the malignant CLL cell has led to new, targeted therapies that represent a paradigm shift in management (see below). Firstly, the CLL cell shows constitutive activation of the B-cell receptor signalling pathway which leads to cellular proliferation. Secondly, CLL cells have markedly increased levels of BCL-2 which is a potent suppressor of programmed cell death via apoptosis.

• Systemic symptoms (e.g. fever, sweats, weight loss) due to the CLL

take home POINTs • Chemo-immunotherapy produces long remissions as initial treatment for CLL. The FCR regimen may cure a subset of patients. • The recent development of targeted drugs has dramatically improved the outlook for patients with relapsed and refractory CLL. • As experience with these drugs increases it is conceivable that “chemotherapy free” treatment occurs for some patients with CLL.

The well-established guidelines for initiating treatment in CLL include: • Progressive bone marrow failure (anaemia, neutropenia or thrombocytopenia) • Massive or progressive lymphadenopathy • Massive or progressive splenomegaly • Rapidly progressive lymphocytosis

Frontline treatment of CLL Initial treatment consists of chemoimmunotherapy (CIT), which is a combination of cytotoxic chemotherapy drugs given with a monoclonal antibody targeting the CD20 molecule on the surface of the CLL cell. Patients up to the age of 65-70 with few co-morbidities (“go-go” patients) are treated with a combination of fludarabine, cyclophosphamide and rituximab (FCR regimen). This highly effective combination puts most patients into complete remission and, on average, no further treatment is required for seven years. Older patients and/or those with significant co-morbidities (“slow-go” patients) receive the less intensive combination of oral chlorambucil with obinutuzumab, a new antiCD20 monoclonal antibody. This regimen is also very effective and most patients do not require further treatment for four years.

By Dr Gavin Cull Head of Haematology SCGH

Intervention in CLL is evolving with more options to consider than ever before.

Can CLL be cured? Traditional thinking of CLL as an incurable disease has been challenged recently. Long term follow-up of several studies using FCR has shown a sub-group of patients, mainly those who have a mutated immunoglogulin variable chain gene, with durable remissions extending beyond 10 years. While further follow-up is required, it is likely many of the patients in this sub-group are cured. New treatment options In the last five years, drugs that target proteins in key pathways in the pathogenesis of CLL have come into clinical practice. The first class of drugs inhibit critical proteins in the B-cell receptor (BCR) signalling pathway (see Fig 1). Ibrutinib irreversibly inhibits Bruton’s tyrosine kinase (BTK), downregulates BCR signalling and results in death of the CLL cell. The drug is highly active and can induce sustained responses in patients who are refractory to all other therapy, including those with the aggressive form of CLL with deletion of chromosome 17p. Idelalisib inhibits PI3-kinase and, when administered together with rituximab, induces responses in otherwise refractory patients. Both of these drugs are in tablet form and continued on Page 41

So, in simple terms, the CLL cells grow too quickly and don’t die when they should, resulting in their accumulation in blood, bone marrow and lymph nodes. What is monoclonal B-cell lymphocytosis (MBL)? CLL is diagnosed by flow cytometry with the finding of more than 5x109/L clonal B-cells in the peripheral blood with a characteristic immunophenotype (co-expression of CD19 and CD5). When the clonal B-cells are < 5x109/L, the diagnosis is MBL and these patients progress to CLL at rate of approximately 1-2% per year. When to start treatment? For every patient with newly diagnosed CLL two questions need to be addressed: 1. Do they require treatment? 2. If yes, what is the best treatment for them? As some patients may remain stable for many years without intervention, treatment is reserved for complications or symptoms related to the CLL. A high lymphocyte count MEDICAL FORUM

Figure 1. (A) Ibrutinib and idelalisib block key proteins in the B-cell receptor signalling pathway and inhibit growth and proliferation of CLL cells. (B) Venetoclax blocks the over-expressed BCL-2 in CLL and triggers death by aptoptosis. (Idelalisib is PBS-listed for relapsed CLL. Ibrutinib will be PBSlisted for relapsed CLL from December 1, 2017. Venetoclax is TGA-approved but not PBS-listed.)

NOVEMBER 2017 | 39

MRI | CT | PET | Ultrasound | X-Ray | NucMed | Dental

Envision. At the forefront of technology. 2014 Envision is the first site in the Southern Hemisphere to acquire the Siemens Force CT - capable of ultimate speed scanning at the lowest dose. Siemens awards Envision as having the lowest average radiation dose in the world one year later.

2015 Envision acquires the top-of-the-range Siemens 3T Skyra MRI. The first and still the only private practice in WA offering its optimal imaging quality and wide bore design.

2017 Envision is proud to introduce the first continuous motion Siemens PET-CT in WA a new era in oncological imaging. Scans are easily and quickly customised for each patient to allow superior resolution resulting in greater accuracy, lower radiation dose and reduced scan time for the patient - the end of stop and go.

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CLINICAL UPDATE BACK TO CONTENTS

Advanced therapies for Parkinson’s Disease We increasingly find that Parkinson’s disease begins as a gut based condition with evidence of alpha-synuclein in the colon, vagus nerve and the nasocilliary area. Currently alpha-synuclein protein in Parkinson’s disease appears to be a prion-like entity and spreads throughout the neurological system especially via the gastroenterological system and vagus nerve. This leads to gastric emptying issues and variable delivery of the Levodopa and dopamine agonists and hence contributes to the emerging but inevitable motor fluctuations.

Using the Levodopa-Carbidopa gel, requires a specialised Parkinson’s team approach with an involvement in a Parkinson’s Centre, a gastroenterologist trained in this jejunostomy tube insertion and radiology to assist with the initial nasal trial and then for these services to co-ordinate and follow the patient. Currently this is available at Osborne Park Hospital/Joondalup and WANRI/Sir Charles Gairdner Hospitals.

Research shows that taking Levodopa orally provides peaks and troughs leading to altered firing of the basal ganglia cells and this along with changes in glutamate is another mechanism that leads to motor fluctuation as the disease progresses. In the elderly population, deep brain stimulation (DBS) has limitations given that cognitive issues become more prevalent in Parkinson’s disease as the person ages. With better knowledge of how we introduce medications such as Levodopa and dopamine agonists, we have successfully delayed the onset of major motor fluctuations. Unfortunately, they will occur leading to consideration of alternative advanced therapies (based on different drug delivery) in Parkinson’s disease. Subcutaneous Apomorphine (one of the oldest dopamine agonists) has a rapid absorption and a short half-life. Pumps have led to improved control, as it bypasses the stomach. An initial Apomorphine up-titration and challenge can be done as an inpatient or in the clinic. The main drawbacks for this therapy has been assistance with setup and the pump plus local subcutaneous skin issues and the neuropsychiatric side effects or aggravation of dyskinesia. Another recently listed therapy available is Levodopa/Carbidopa gel (Duodopa) which is delivered via a jejunal percutaneous infusion after an initial nasojejunal trial with uptitration, currently as an inpatient. This therapy (developed in 1988) provides constant plasma Levodopa levels and has the ability to avoid peaks and troughs. Trials are being done in the utilisation of this gel in an outpatient setting for uptitration or even going directly to the percutaneous tube without an in-hospital stay. These treatments have limitations related mostly to developing cognitive issues in elderly patients with advanced Parkinson’s disease along with the person’s home circumstances and the need for carer input in the setup of both pumps.

MEDICAL FORUM

By Dr Barry Vieira Geriatrician Osborne Park & Joondalup

About 75,000 Australians (870 per 100,000 over 50) already live with Parkinson’s disease, the second most common neurodegenerative condition after dementia.

control disorder in Parkinson’s disease. This device uses an accelerometer to identify the movement changes and to provide an average (over a six-day logged period) and has proven far more accurate than patient diaries. It can lead to reduced admissions to monitor and assess movement disorder in the advanced patients. Patient acceptance of this device has been excellent. They find the alarm system useful for medication compliance and it allows us to identify those motor fluctuations that would best be served by discussions of advanced therapies including DBS. The Parkinson’s disease centres in Perth attached to Aged Care services have specialised Parkinson’s nurses available to help with drug titration in the community and assist with identifying and supporting advanced therapies. We also have video conferencing (Telehealth) for country patients to help support them and their doctors.

Five-day print out of watch parameters showing bradykinesia.

Selection of patients with Parkinson’s disease suitable for these advanced therapies is important and criteria are used to help identify patients with moderate to severe motor fluctuations and poor quality of life. A recent Australian development for monitoring has been the Parkinson’s KinetiGraph. This is a wrist worn watch device which assesses bradykinesia and dyskinesia in relationship to medication timing as well as providing a fluctuation score, tremor score, and information on sleep and even impulse

Key POINTs • Advanced therapies that deliver the drugs differently by avoiding gastric emptying is useful. • Anosmia, abnormal R.E.M. sleep, constipation, restless legs, essential tremor and late onset depression/ anxiety can be a prodrome of Parkinson's. Author competing interests: nil relevant disclosures. Questions? Contact the author on barry.vieira@health.wa.gov.au

continued from Page 39

Chronic lymphocytic leukaemia tolerated well by most patients, though they have some unique side-effects.

which can grow rapidly and they should take adequate sun protection measures.

Venetoclax is a selective and potent inhibitor of BCL-2 (Fig 1) which induces rapid reduction of disease burden in CLL and a high overall response rate. Like the BCR-signalling inhibitors, it is active in patients where chemotherapy is no longer working and those with the aggressive 17p deletion form of CLL.

Annual vaccination against influenza is important and pneumococcal vaccination should be kept up to date. Live vaccines should be avoided.

A few tips for patients with CLL Patients with CLL are prone to skin cancers

Author competing interests:Nil relevant disclosures. Questions? Contact the author on gavin.cull@health.wa.gov.au

NOVEMBER 2017 | 41

PSMA PET-CT for Suspected Prostate Cancer and Recurrence Oceanic Molecular, at the Hollywood Medical Centre, is the only private provider of PSMA PET-CT in Western Australia • 68Ga PSMA is a new highly sensitive imaging marker for prostate cancer. • PSMA PET-CT can identify lesions suspicious for prostate cancer when the level of prostate specific antigen is very low. • Detecting recurrence early may significantly influence clinical management. • Treatment and survival after recurrence depends on many factors including early detection

Appointments are available weekly. For further information please contact Ms Julie Crouch 0403 537 113

42 | NOVEMBER 2017

MEDICAL FORUM

CLINICAL UPDATE BACK TO CONTENTS

Infection after Total Joint Replacement Peri prosthetic joint infection (PJI) has decreased from 4% incidence in the 1980s to around 1% for total knee replacement and 0.6% for total hip replacement now. Maintaining a low infection rate and managing patients with a PJI requires a multidisciplinary approach involving the general practitioner, infectious disease specialists, microbiologists, anaesthetist, allied health, and orthopaedic surgeons.

Infection after total joint ED replacement is devastating and expensive. Prevention starts preoperatively and is made more important by emerging antibiotic resistance.

The CRP is a good indicator (CRP should return to normal values within three weeks post-surgery) while ESR has no diagnostic utility within 6-8 weeks postoperatively.

Contributory comorbidities. Diabetes is an independent risk factor – a moderately elevated HbA1c increases the risk two to four-fold. Ideally, patients with poorly controlled diabetes should be delayed, optimised and monitored until the Hb1Ac remains below 7%. Unfortunately, a small proportion of patients (10% in a recent study) do not reach this goal. Morbid obesity (BMI > 40) and PJI are strongly correlated with up to nine times higher risk in these patients after total knee or total hip replacement. Adding diabetes to morbid obesity increases the infection rate another seven-fold – so the indications for total joint replacement in morbidly obese patients with diabetes must be carefully evaluated and discussed. Smoking has a negative effect on PJI and should be ceased 6 to 8 weeks preoperatively. In one study, participation in a preoperative smoking cessation programme reduced the postoperative complications and there were no wound related complications. During total knee and hip replacement haemoglobin (Hb) drops by about 30g/L to 40 g/L irrespective of the approach. A patient with a preoperative Hb of 110 or less might need blood transfusions which has been linked to an increased risk for PJI. Preoperative anaemia should be investigated and treated. Rheumatoid patients often take disease modifying anti-rheumatic drugs (DMARD) or biologic agents. The American College of Rheumatology and the American Association of Hip and Knee Surgeons published guidelines (August 2017) as to the preoperative use of these drugs: DMARD such as methotrexate should be continued; biologics should be discontinued prior to surgery, the operation done at the end of the dosing cycle, and medication resumed about two weeks postoperatively. Recent studies strongly suggest that multiple hip injections and injections within three months of surgery increase the infection risk. Therefore, it is prudent to avoid multiple cortisone injections into the hip joint and delay surgery to at least 6 to 12 weeks after an injection.

MEDICAL FORUM

By Dr Markus Kuster Orthopaedic Surgeon West Perth

The best results for early infections occur if the debridement is performed within three weeks of the primary arthroplasty, the bacterium is known and it is sensitive to antibiotics. Patients with prolonged wound ooze or doubtful wounds need to be seen early by the primary surgeon before starting antibiotics. Chronic joint infection

Antibiotic impregnated hip spacer in situ during two-stage revision for periprosthetic infection.

How to diagnose Acute infections after total joint replacement can often (>60 %) be cured with a thorough debridement, liner exchange and antibiotics. Arthroscopic debridement has generally no role in these cases.

This diagnosis is difficult and treatment often involves a major revision. These patients often have a stiff, unhappy joint with some swelling and unspecific findings. Current recommendations are to measure CRP and ESR whenever there is a chronic painful TKA/ THA. If both are normal, infection is excluded in 90% of cases. Unfortunately, 10% of low grade infections (Staph epidermidis, proprionebacterium acne) can have normal values. Remain highly suspicious in some cases. continued on Page 45

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To refer please call 93014437, fax 93014438, email bookings@wcendo.com.au and for further information visit our website www.westcoastendoscopy.com.au.

NOVEMBER 2017 | 43

CLINICAL UPDATE

Dr Charles Inderjeeth Rheumatologist and Geriatrician Subiaco

Frailty (once termed ‘failure to thrive’) is increased vulnerability and diminished reserve in response to an external stressor, with a poor ability to return to baseline physical, functional and cognitive status. In accommodating frailty, it is important to discuss with patients and family/carers risks vs. benefits of each intervention, how essential interventions are and the alternatives. Clinicians must consider patient’s expectations in terms of prognosis and quality of life.

to reduce stroke or cardiovascular risk to the detriment of haemorrhagic complications; aggressive drug management of pain (polypharmacy) with significant adverse cognitive or falls outcomes.

Clinicians who identify frailty can optimise patient management, prior to intervention, and avoid symptom progression. The mantra ‘do no harm’ is highly relevant – adverse outcomes may outweigh treatment benefits.

Mapping out frailty

Examples of real concerns include: optimising hypertension to the detriment of falls and fracture risk; optimising antiplatelet therapy Table 1: Frailty phenotype (described by Fried et al) 1. Unintentional weight loss 2. Self-reported exhaustion 3. Weakness (grip strength) 4. Slow walking speed 5. Low physical activity

Evidence based treatments (based on younger, more fit populations) are often not validated in older people with multiple comorbidities. The risk-benefit or number needed to harm is usually unknown or may be detrimental. There are three ways of identifying frailty. One involves a cumulative deficit model – a validated example is the Edmonton Frail Scale (EFS; see www.nscphealth.co.uk/ edmontonscale-pdf), which is both easy to administer and brief (about five minutes). Second is a phenotypic model described by Fried et al based on five easily assessed criteria (see Table 1). Thirdly is the subjective global opinion of the clinician. Frailty can be divided into three groups, pre-frail, frail and severely frail. In pre-frail, preventative strategies aim to reduce physical, functional and cognitive decline – effective interventions include exercise programs, falls risk management, and optimising medical management (reduce polypharmacy and nonessential interventions).

Elderly patients have higher ED morbidity, more perioperative complications and longer length of hospital stay. Frailty (rather than age) may be a better predictor of adverse outcomes.

In those considered frail, referral to a geriatric service may optimise treatment outcomes – interventions that work include multidisciplinary care, an elder friendly environment, and facilitated exercise programmes. Geriatric Evaluation and Medical Management (GEM) is an effective co-management model that improves outcomes, that includes a focus on the “geriatric giants” (falls, delirium, dementia and continence). This model is cost effective and improves quality of care in patients with a poor quality of life. In the severely frail, first determine if treatment is really essential and will improve quality of life. Realism is important to avoid unnecessary and futile treatments offering only short term benefit. The aim is to improve quality (life to years) rather than quantity (years to life). Author competing interests : nil relevant disclosures. Questions? Contact the author Charles.Inderjeeth@health.wa.gov.au

Keep on Keeping on The guided and monitored Move Well program run by exercise physiologist Stephanie Kwan at UWA’s Exercise and Performance Centre (EPC) targets fall prevention, mobility and cardiovascular fitness in older people. It’s all about staying fit and active. “The program is designed for people in the 60-80+ age group who want to maintain or improve their current fitness level. If you take just one area, such as a falls, the consequences of a mishap for an older person can be horrendous.” “The EPC offers a diverse range of activities, everything from high intensity exercise to Pilates to aquatic programs. There’s a pretty even gender split, probably sitting at about 60/40 women to men.”

or a treadmill and then we might go to some higher intensity activity like interval training. Research has shown that even within the older age-groups short bursts of intense exercise can be beneficial.” “Then we’ll have a standard circuit-style format with five or six different stations that focus on core strength and balance. And we always try to mix the session up by having something a bit out of the ordinary, such as boxing.” The team at EPC liaise with doctors to vary and modify an exercise regime to fit in with preexisting medical conditions, Stephanie said.

Stephanie describes a typical Move Well session:

“Some participants come to the class at the suggestion of their GP and we always provide assessments and feedback to the relevant doctor. The ultimate aim is to get older people up and moving so they can keep living active lives. A lot of them have grandchildren and are also heavily involved in community programs.”

“We’ll start with some warm-up exercises on cardio-equipment such as a rowing machine

“The social benefits of groups such as these can’t be underestimated. Many of the

44 | NOVEMBER 2017

participants will go for a coffee after a Move Well session. It’s as much about meaningful social interaction as it is about maintaining physical fitness.” ED: www.sseh.uwa.edu

MEDICAL FORUM

BACK TO CONTENTS

How frailty influences decision making

CLINICAL UPDATE BACK TO CONTENTS

Grief onset in the elderly Grief abounds in old age but when is it abnormal? Normal grief following bereavement is usually healed by support from family and friends and the passage of time, and does not require medical intervention. It is important not to medicalise what is a normal human experience. However, bereavement has significant morbidity and pathological grief may be overlooked, often by virtue of reluctance of the sufferer to seek treatment. Treatable complicated grief is more common in elderly women, whilst bereaved men are at elevated risk of suicide.

type of loss. The manifestations can be emotional, cognitive, physical, social, cultural or spiritual. Grief is particularly challenging in the elderly because of a tendency to multiple losses and bereavements, and their own approaching mortality.

Grief is a complex phenomenon (see Table). The presentation varies both with time and

For most people, acute grief becomes ‘integrated’ over months; there evolves

Given their vulnerability, recently bereaved elderly patients who present for whatever reason benefit from assessment of their social support, ability to cope with grief, suicidality, substance use and functional ability. This enables known risks to be identified and managed, and if there is poor coping, referral for bereavement counselling.

Table Grief timing

Characteristics

Management

Acute Grief Weeks to months

Normal condition Disbelief, numbness Yearning, sorrow Anxiety Preoccupation with the deceased Negative emotions (guilt, blame, anger, shame) Positive emotions present Avoidance of reminders of the deceased Tearfulness Insomnia Cognitive difficulty Functional difficulty Social withdrawal, loneliness Physical complaints

Mobilise social support Promote healthy coping Assess risks Treat co-morbidity Bereavement counselling if risks present

Integrated Grief Months - onward

Acceptance of reality of the death Adapting to life without the deceased Comforting memories Meaningful connection with the deceased Transient surges of acute grief

Normal – no treatment required

Complicated Grief Years

Persistent acute grief symptoms Functional impairment

Treatment required

By Dr Monique O’Connor Psychiatrist Perth

KEY POINTS 1. Grief is common in the elderly 2. Bereavement is a major life stressor and can bring on physical and mental illness 3. Assess the bereaved for coping and risk factors (suicidality, substance misuse) 4. The trajectory of grief needs monitoring and treatment when complicated

an acceptance of the death and healthy adaptation to life without the deceased. Without integration, complicated grief follows; identifiable as persisting acute grief symptoms that interfere with daily activities at least a year after the death. Complicated grief is more likely with: • sudden or traumatic deaths, • a history of mental illness, • substance abuse, • lower socio-economic status, or • adversity in childhood. In the elderly, risk increases when the bereaved is a ‘care-giver spouse’ of a deceased dementia patient and in those with poor social supports. Complicated grief requires differentiation from major depression, anxiety, PTSD and substance abuse, which can all be precipitated by bereavement and require usual treatments. These illnesses often go hand-in-hand with complicated grief. ‘Complicated grief therapy’ is a brief psychotherapy that facilitates integration of grief. It is effective in about three-quarters of older adults. Author competing interests : nil relevant

continued from Page 43

Infection after Total Joint Replacement The next step is aspiration of joint fluid with analysis of cells, and microbiological culture. This might have to be repeated as the test sensitivity is only about 80%, and there should be no antibiotics for at least two weeks before the aspiration. The alpha defensin test of the synovial fluid has been promising, with a high sensitivity and no influence from antibiotics in use. Management The management of an infected THA/ MEDICAL FORUM

TKA often involves difficult revisions and is best managed by a multidisciplinary team (infectious disease specialists, physicians and revision orthopaedic surgeons). Seeking a second opinion is useful.

• removal of the implant, insertion of a temporary spacer and re-implantation later (a two stage revision); and

Management options for infected joints include:

References available on request

• debridement, antibiotics, and implant retention; • removal of implant and implantation of new prosthesis in one stage;

• salvage procedures (e.g. arthrodesis or amputation).

Author competing interests : nil relevant disclosures. Questions? Contact the author on 9212 4200

NOVEMBER 2017 | 45

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46 | NOVEMBER 2017

MEDICAL FORUM

TRAVEL

Trails Are Made for Walking Trekkers who need a new compass point, check out this cheeky walk to SA’s beautiful Flinders Ranges, writes Dr Lin Arias. Many of us outdoorsy people in Perth have explored the wonders of WA: from the Kimberly in the north to the Porongorups in the south and the many trails in between. Well I recently went for a delightful week’s adventuring east of the WA-SA border and a new world opened up. The trip was to the Flinders Ranges with a small Perth company called, fittingly, Inspiration Outdoors. Family owned and run, they offer supported trips throughout Australia to some of our most beautiful wilderness areas. We had informative, delightful guides; vehicular transport, comfortable accommodation, delicious meals AND plunger coffee in the morning. All you need to do is pack your personal items, favourite hiking gear, your daypack…and go! The Flinders Ranges are perhaps best known for the formation called Wilpena Pound, a huge area enclosed by angular cliffs. Formed by a syncline, it is a sacred site to the Adnyamathanha people. Ikara, they call it, meaning meeting place. In addition to wonderful hiking, the walks within the Ranges offer views of magnificent rock paintings, ruins from bygone pastoral days, wildflowers and wildlife, especially emus, kangaroos and a huge variety of birdlife. The famous long-distance hiking path, the Heyson Trail, starts north of the Ranges and runs 1200km south to Jervis Bay. It is named after the painter, Hans Heysen,

MEDICAL FORUM

whose paintings brought the arid beauty of the Australian bush, including the Flinders Ranges, to the attention of the city folk. We started in Adelaide and headed north, stopping in Melrose, the oldest town in the Flinders Ranges. It is in the shadow of Mt Remarkable and has a lovely old pub that serves substantial food at good prices and offers a roaring fire in a stone fireplace for you to warm up with your glass of shiraz. We did some short walks before getting to our main base, Rawnsley station. A perfect place to explore the Ranges, it is situated an easy drive south of the Wilpena Pound Visitor Centre and offers wonderful views of sunsets and of the Rawnsley Bluff formation. For the next four days we roamed the Ranges, hiking into the Pound or taking trails that gave us wonderful views into the Pound and the arid countryside beyond. We finished our hiking adventure by walking the last 18km out to Parachilna Gorge, the northernmost point of the Heyson Trail. While it was sad to leave the park, we had more fun ahead: the delicious grub (try the feral grill) and atmosphere of the gastro pub, the Prairie Hotel, in Parachilna for dinner plus the delightful winsome sunrise the next day. Add in an early morning stroll around the interesting sculptures in the tiny town the next day before heading off to the Clare Valley for lunch and wine tasting on our return to Adelaide, it was a trip to remember.

NOVEMBER 2017 | 47

Travel

Boots on a Mission Being a medical officer and a tour guide in some of the world’s most rugged but beautiful places can be an exercise in diplomacy. Getting away from it all in East Africa as a Tour Leader/Medical Guide sounds like a wonderful break from the daily grind. But it can be a little more complex than merely putting one foot in front of the other. Ask Shenton Park GP Dr George Crisp.

“Some of these walks are quite physically demanding but usually it’s the mental challenge that’s the biggest hurdle. You’ll often have people who’ve never camped outdoors, let alone on a cold mountain with a bunch of strangers. It does push some people right to the limit.”

George participated in the Leukaemia Foundation’s Kilimanjaro Challenge 2017, which raised $160,000 to provide support for people with blood cancer.

“The company that runs the trips, Inspired Adventures, is a registered NFP and it’s a pretty lean operation with low overheads to keep administration costs down. They do a good job raising funds for a number of different charities. Each person on the trip has to raise a specific amount, and in the case of the Kilimanjaro trek it was $7000 per person.”

“One of the biggest problems is when people don’t get on too well. That can destabilise the dynamics of the whole group. We’ll often have a wide range of ages and political opinions so the potential for friction is always there,” he said. “But, when it comes down to it, everyone is there to get to the top of the mountain and that usually dissolves any major differences pretty quickly. Thankfully, this last trip to Mt Kilimanjaro went smoothly. There’s a charity fundraising aspect to these trips, and that helps.”

48 | NOVEMBER 2017

“We had 16 team members on this one, so it all adds up.” This wasn’t George’s first medico-tour guide role. It’s a team effort “I’ve done two trips to Kilimanjaro, a few smaller ones to Sumatra and one very challenging, full-on adventure in the Hindukush. It would all add up to about a dozen, I guess. And I’ve got a trip to Tibet pencilled in for next year. They don’t always take a doctor, but they do need some form of leader on the ground. On this last one I went as both tour leader and doctor.”

people and when you’ve finished for the day there’s plenty of opportunities to have a beer with them. But the priority is to look after the group so you don’t get a lot of time to do other things.” “But I’ll often end up treating the guides, giving them medicine and looking after them.” In the case of a serious medical issue there’s a fairly unconventional way of getting someone to a treatment centre. “The guides are pretty nifty at getting people off the mountain. They’ve got this flat-topped contraption that looks like a wheel-barrow with a wheel in the middle and handles on all four corners. The patient is strapped on while lying in their sleeping bag, a porter grabs each handle and they literally run down the mountain.” “There are designated helipads, but it’s usually faster to use the mobile stretcher.” Safety first Some of the destinations are in areas with porous borders and a degree of political instability.

“Relying on local services can be a bit hairy.”

“Safety and security are generally pretty good, but you do need to take some precautions. The local guides will let you know if an area is unsafe and you need to stick together. I haven’t seen any obvious security concerns where we go.”

“There’s a fair amount of interaction with the locals, all the guides and porters are local

“But things can change quickly. I was in Uganda a few years ago and some of

MEDICAL FORUM

TRAVEL

Exhibition & Sale

‘Quacks to Quinine’ November 18th – December 9th

Over 300 rare and original lithographs from 1650 to 1950.

Dr George Crisp takes the job of tour leader to far-flung places very seriously.

the travel alerts were a little concerning. These days, sadly, almost everywhere is potentially a bit tricky and you can run into trouble in any big city.” And for any doctors out there who may feel the need to get away from patients and reconnect with nature, George provides the following advice. “It’s best to get in touch with Inspired Adventures who are based in Sydney. Most of the people they recruit as team leaders have been expedition members before, so they’ve already seen how they operate. Going on a trip with them is a great way to see how they run the show.” “They pay your airfares and on-ground costs, but I’m not too concerned if I have to spend a few dollars here and there. I’ll often use the trip as an opportunity to upgrade my camping kit, perhaps a new sleeping bag and a good jacket.” It’s a complete break from the work routine, says George. And the benefits continue long after you’ve put your hiking boots back in the cupboard. Clearing the head “Going off to climb a mountain is a really good holiday for me. I know some people like to go and lie on a beach but that doesn’t suit me at all. There’s a meditative aspect to trekking. When you’re there, you don’t think of anything else, especially work. Every ounce of mental and physical effort is focused on getting to the top.”

Exhibition & Sale

‘Quacks to Quinine’ November 18th – December 9th

Over 300 rare and original lithographs from 1650 to 1950.

“And you sleep so well while you’re there, and that extends long after you return home. I think we’re made to walk, not sit at a desk. It’s just amazing how all your aches and pains disappear.” “The high points of this trip were the amazing sunrises, wonderful vistas of landscape and light. It’s also a great feeling when you get the entire group to the summit. You’ve come there to do something and you’ve done it. It gives you a great sense of achievement.”

By Peter McClelland

TROWBRIDGE GALLERY www.trowbridgegallery.com.au

52F Old Theatre Lane, Bayview Terrace, Claremont WA 6010 sales@trowbridgegallery.com.au P (08) 9384 4814 | F (08) 9385 1537 A N T I Q U E M A P S | P R I N T S | G LO B E S | F R A M I N G

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NOVEMBER 2017 | 49

Fibber McGee's Irish Pub & Steakhouse

MY LOCAL

711 Newcastle St, Leederville Ph 0459 922 008 www.fibbermcgees.com.au This classic Irish Pub and Steakhouse is just terrific! It’s been sitting in the heart of Leederville for nearly 20 years and its combination of wonderful food, leather banquettes, starched white tablecloths and napkins marks it as a classic GastroPub. Some of the highlights? Irish Soda Bread, Mrs Beeton’s 1861 Shepherd’s Pie, its hearty Guinness Pie and a truly superb Beer Battered Fish and Chips, are just s sample. Fibber’s make the best chips in town! And the Sticky Date pudding with Butterscotch Sauce is totally yummy. The produce is super fresh, they have their own organic farm and they dry-age their own steaks. Fibber’s is fully licensed, with a good and reasonably priced wine list and open seven days a week. And yes, they do have Guinness on tap along with a range of beers and cider. You need to book!

Pickled Fennel Salad Ingredients 500g baby potatoes, skin on 200g streaky bacon, diced ¼ cup extra virgin olive oil ¼ cup Lemon juice Mixed salad leaves (including radicchio) & fresh herbs (including flatleaf parsley) (about 4-5 cups) 1 thinly sliced orange, seeds, pith and white skin removed 100g goat’s cheese 1 quantity of pickled fennel For Pickled Fennel 2 small fennel bulbs, fronds and stalks removed and cut into thin wedges 2 tsp fine salt 1 tbsp water 400ml apple cider vinegar 100g raw sugar ½ tsp each of fennel seeds, caraway seeds and peppercorns Salt

METHOD For pickled fennel, mix fennel with 2 tsp fine salt and 1 tbsp water, and set aside for 10 minutes. Bring vinegar, sugar, spices, 100ml water and a large pinch of salt to a simmer in a saucepan over medium heat. Add fennel, stir to combine and remove from heat. Transfer to a large sterilised jar, seal, stand until cooled, then refrigerate for 2-3 days. If you make extra, it will keep in the fridge for a month. For the salad: Cover potatoes with cook in salted water until just tender. Heat a heavy based frypan over medium-high heat, add a little olive oil and cook bacon until crisp. Transfer to a plate with a slotted spoon. Reserve pan fat and cool briefly before adding lemon juice and olive oil to make a dressing. Whisk to combine, and season to taste. Thickly slice potatoes (with or without skin), then combine in a bowl with leaves, herbs, orange slices and bacon. Add pickled fennel to taste and transfer to a platter. Dot goat’s curd over salad, drizzle on the dressing, and serve. Perfect with fish.

Wine

Winner

50 | NOVEMBER 2017

Running half-marathons and enjoying a glass of wine are not such strange bedfellows according to Onslow Family Practice GP, Dr Megan Pilkington, who this month took home a carton of acclaimed Millbrook and Deep Woods wines. Megan, who enjoys both pinot noir and chardonnay, will soon be charging through the Barossa Valley in her running shoes on the way to a winery visit or two.

MEDICAL FORUM

WINE review

Lion Mill a Roaring Success In 1890, Richard Honey, a South Australian timber merchant who owned Lion Timber Yards in Adelaide, purchased from the Union Bank the property known as White’s Mill in the Perth Hills near what is now Mt Helena. With the goldrush in full swing there was money to be made in milling jarrah, much needed for the expanding colony’s public works and infrastructure projects. The township of Lion Mill was declared in March 1899. Robert Bunning’s Perth Jarrah Mills bought the mill site, now Lion Mill, in 1905. It remained the Bunnings’ main WA mill until its closure in 1923. After the timber was felled, small mixed agricultural and horticultural enterprises flourished and were sustained by the dependable water supply of the Darling Scarp. The current site of Lion Mill wines was purchased in 1996 and planted in 1999.

By Dr Louis Papaelias

According to Dr John Gladstones (Viticulture and Environment, 1992), the elevation of sites on the Darling Scarp and their accessibility to cooling sea breezes allows for a ripening of fruit of up to 2-3 weeks later than on the adjoining Swan Valley floor. He was of the opinion that the climate closely resembles that of the Douro Valley in Portugal making it suitable for full-flavoured table wines and for the production of quality fortifieds. It appears that that Lion Mill has taken heed of what Dr Gladstones has said because there is a substantial planting of varieties well suited to warmer climates – tempranillo, durif and zinfandel (Primitivo). There are wines made from the Bordeaux, Burgundy cultivars, chardonnay and cabernet sauvignon, but, in my opinion, they were less convincing on tasting than those aforementioned. All wines tasted reflected careful and skilful winemaking and viticultural practice.

1. Lion Mill Blanc de Blancs 2015 Made in the traditional method from chardonnay grapes this had a pleasant yeasty fruity nose with fine bubble and a full rich palate. Clean finish. A good aperitif and food wine. 2. Lion Mill Sparkling Shiraz 2014 Full effervescence on pouring and a very attractive, richly flavoured shiraz with bubbles. Crisp and lively. 3. Lion Mill Tempranillo 2014 The noble grape of Spain has here produced an appealing medium-bodied wine of intense colour and savoury red fruit aromas. Soft dry tannins balance an agreeably fruity palate Very nice drinking now. 4. Lion Mill Durif 2016 Deep purple in colour with red black fruit mulberry aromas, it has intense flavour with more noticeable tannin yet a soft and balanced finish. This wine will age well though is balanced enough to be enjoyable right now. Quite moreish.

Lion Mill Zinfandel (Primitivo) 2011 Deep purple-black colour and an aroma of spicy super-ripe plums and prunes. Rich sweet fruit, full-bodied palate and a step-up in intensity. There is a persistence of flavours on the finish. At six years of age, it is still very youthful and promises to age for many more years. Lovely.

5. Lion Mill Cabernet Shiraz 2012 Deep intense colour, aristocratic cassis and plum aromas; fruity and full bodied with firmer tannins. It has the potential to age. A very good wine.

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NOVEMBER 2017 | 51

Too smart for his own good

Short and Clean

She has a point

• What did one orphan say to the other?

A first grade teacher was having trouble with one of her students. One day she asked Johnny what his problem was and he replied, “I’m too smart for the first grade. My sister is in the third grade and I’m smarter than her too.” The teacher took him to the principal’s office and explained the situation to the principal who told her that he would Johnny a test and if he failed to answer one question he would have to go back to the first grade and be quiet.

A woman was seated next to a little girl on an airplane when the woman turned to her and said. “Let’s talk. I’ve heard that flights go quicker if you strike up a conversation with your fellow passengers.”

The teacher and Johnny both agreed.’ Principal: What is 3 x 3?

“Robin, get in the Batmobile.”

• What did the Buddhist ask the hot dog vendor?

“Make me one with everything.”

• The Buddhist gives him a fifty and the vendor pockets it. The Buddhist asks for change and the vendor replies, “Change comes from within.” • And God said to John, “Come forth and you shall be granted eternal life.” But John came fifth and won a toaster. • How do you make holy water?

Put it in a pot and boil the hell out of it.

Johnny: Nine Principal: 6 x 6 Johnny: 36

The little girl, who had just opened her book, closed it slowly and said to the woman, “What would you like to talk about?” “Oh, I don’t know,” said the women, “how about nuclear power?” “OK,” said the little girl. “That could be an interesting topic but let me ask you a question first. A horse, a cow, and a deer all eat grass, the same stuff. Yet the deer excretes little pellets, while a cow turns out a flat patty and a horse produces clumps of dried grass. Why do you suppose that is?” The woman thinks about it and finally says. “I have no idea.”

And so it went on like this. The principal asked him every question a third grader should know. Finally after about an hour he told the teacher “I see no reason Johnny can’t go to the third grade.”

To which the little girl replies, “Do you really feel qualified to discuss nuclear power when you don’t know shit?”

A girls best friend

The teacher asked if she could ask him some questions. Both the principal and Johnny agreed. Teacher: What does a cow have four of that I only has two of?

A sophisticated woman was on a plane arriving from Switzerland. She found herself seated next to a priest whom she asked” “Excuse me Father, could I ask a favour?”

Johnny: Legs

“Of course, my child, what can I do for you?”

Teacher: What do you have in your pants that I don’t have?

“Here is the problem. I bought myself a new sophisticated hair remover gadget for which I paid an enormous sum of money. I have really gone over the declaration limits and I am worried that they will confiscate it at customs. Do you think you could hide it under your cassock?”

The principal gasps but before he can stop him from answering, Johnny says “pockets”. Teacher: What does a dog do that a man steps into? Johnny: Pants

• Why did Star Wars episodes 4, 5, and 6 come before 1, 2, and 3?

Teacher: What starts with F and ends in K and means a lot of excitement?

Johnny: Firetruck The principal breaths a big sigh of relief and says. “Put Johnny in the fifth grade, I got the last four questions wrong myself.”

Because in charge of scheduling, Yoda was.

• If you are ever attacked by a gang of clowns, go for the juggler. • Sometimes I tuck my knees into my chest and lean forward. That’s just how I roll.

“Of course, I could, my child, but you must realise that I cannot lie.” “You have such an honest face, Father, I am sure they will not ask you any questions,” and gave him the gadget. The aircraft arrived at its destination. When the priest presented himself to Customs he was asked, “Father, do you have anything to declare?” “From the top of my head to my sash, I have nothing to declare, my son,” he replied.

Age is something that doesn't matter, unless you are a cheese. - Luis Bunuel

Finding this reply strange, the customs officer asked, “And from the sash down, what do you have?” The priest replied, “I have there a marvellous little instrument destined for use by women but which has never been used.” Breaking out in laughter, the Customs officer said, “Go ahead Father. Next!”

52 | NOVEMBER 2017

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SOCIAL PULSE SJG Subiaco Hospital Research Week

The hospitalâ&#x20AC;&#x2122;s annual Research Week kicked off with a social event which brought researchers, administrators and visiting academics together before the serious work of the seminars and presentations began on a range of topics from life after cancer to the latest bench and bedside trials. 1. Director of Finance at SJGSH Colin Young, Executive Officer of SJGHC Ethics Committee Gorette De Jesus and C/Prof Simon Dimmitt 2. Diane and Theodore Kailis and SJGSH CEO Prof Shirley Bowen 3. SJGSH Director Gynaecological Cancer Research Group Dr Paul Cohen, visiting Queensland psychiatrist Prof Jane Turner and SJGSH Research Management Committee Chair Prof Steve Webb 4. Researchers Tim Miller Andrew Mews and SJGSH Director Colorectal Cancer Research Group Prof Cameron Platell

SJGSH Annual Ball

Staff of St John of God Subiaco Hospital were elegantly decked out for a night of oldschool chic for the Havana-themed annual ball at Crown Perth. 1. Drs Sean Fennessy, Caoimhe McGarvey, Kate Laird, Phil Craven, Billy Storan, Linda Vu, Andrew Jones, Phil McEntee and Jess Khouri 2. SJGSH CEO Shirley Bowen; SJGHC WA Hospitals Executive Director John Fogarty and Clair Buers 3. SJGSH GP Education Director Dr Erin Horsley and Aaron Barwood 4. Dr Stuart Salfinger, Dr Jade Acton, Dr Andrew Dean and Corrie Dean

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NOVEMBER 2017 | 53

Christmas Music

UWACS Keeps Singing The University of WA Choral Society has been singing its heart out for 85 years which is pretty impressive as the university itself is only 105 – such was the dedication of the university’s founding mothers and fathers to give voice to that august learning institution. UWACS also continues to play a significant role in WA’s music calendar with several concerts a year, most recently a requiem double-header of Rossini and Mozart in August. Now the choir’s musical director Christopher van Tuinen is gearing the group up for its 2017 finale of Handel’s Messiah on December 20 – that great theatrical musical masterpiece that has become synonymous with Christmas. “UWACS is a long-running successful community based ensemble in the very best sense of that. We have a lot of choristers from all over Perth who are passionate music lovers and choral musicians who just want to keep singing,” Chris told Medical Forum.

“There is a great sense of tradition among the choristers – some have been with the choir for nearly 40 years. A few of them love to remind me when they have sung a piece before that they sang it with ‘Sir Frank”!” The “Sir Frank” was, of course, Sir Frank Callaway, the father of music at UWA and who led UWACS for 27 years. “I quite like that. I feel my job as music director is to preserve the longstanding enthusiastic traditions of the choir,” Chris said. “That tradition is relevant to Messiah. This is 250-year-old piece of music and we keep performing it because every time it is sung and played you come up with something different and it becomes new again. Genuine masterpieces from the likes of Handel, Bach and Verdi, live in the here and now through live performances.” “Recordings are lovely and they are a great resource for choirs but it is only by coming to a live performance do you get the full impact

Christopher van Tuinen

and power of a work like the Messiah.” The power of a 60-strong choir, four soloists and an orchestral ensemble is not to be underestimated. “People need to be constantly reminded of that power. For regular concertgoers, that’s a lot of the appeal. For those who haven’t been don’t understand quite how powerful they can be. It is an unamplified amount of sound that is equivalent to a rock concert,” Chris said. “I have spent a lot of time in the Sydney Opera House orchestra pit where the sound could reach 120dB, which is like standing next to a jet engine. It is quite thrilling for performers and audience alike.” Regular UWACS soloists Katya Webb, Courtney Pitman, Kris Bowtell will take their positions out front for Messiah while Chris will conduct in the beautiful Winthrop Hall on Sunday, December 17, at 7pm. “The performance starts at 7pm when light will still be coming through the beautiful rose windows – it’s heavenly and suitably theatrical for one of classical music’s most experienced opera composers.” PSC’s Messiah Perth Symphonic Chorus brings its annual Messiah to the Perth Concert Hall on December 4 at 4pm. The performance, under the baton of PSC director Dr Margaret Pride, will feature soloists Teddy Tahu Rhodes, Miriam Allan, Deborah Humble and Andrew Goodwin. The Chorus numbers will swell with the inclusion of the members of the PSC Christmas Choir who will rise to sing in four choruses during the performance.

By Jan Hallam

Book

Review

A Confederacy of Dunces

(John Kennedy Toole, Louisiana University Press) This is a quirky, strange, hilarious and sad novel set in the steamy, southern American city of New Orleans. And it has an even sadder back-story. Its young author, John Kennedy Toole finished the book when he was 27 years-old and sent it to a number of different publishers. Every one of them rejected it, and Toole committed suicide four years later. A decade after his death, mainly due to the efforts of his mother, it was published to critical acclaim. Following the bumbling, stumbling, slothful main character, Ignatius J. Reilly across the pages will make you laugh out loud – a lot! It’s a masterpiece of comic fiction, a great book-club novel and everyone should read it!

54 | NOVEMBER 2017

MEDICAL FORUM

SEA RESCUE

Escape from Pompeii When you walk into the Pompeii exhibition at the WA Maritime Museum in Fremantle you’ll see a huge image of Mount Vesuvius spewing out volcanic ash and chunks of blackened stones. Seven rescue ships sail into the Bay of Naples towards the doomed cities of Pompeii and Herculaneum. It’s a totally new way of looking at this cataclysmic event, says curator Dr Moya Smith. “I did a traditional degree in archaeology at Sydney University many years ago with a focus on Mediterranean and Middle Eastern studies. After that I spent a year or so digging in England and Jordan. The latter was interesting but I felt it would probably be a good idea to move somewhere a little safer.” “So I retrained in pre-European Australian archaeology, moved to WA and did a lot of work around Esperance and up in Broome. I usually managed to avoid winter completely!” “Everywhere you looked there were material objects from the past, and that’s wonderful but it’s only a small part of the whole picture. I became much more excited about trying to understand human stories and how people lived within a landscape.” “Archaeology isn’t just the ‘stuff’ left behind. For me, it’s much more the way people live their lives, the decisions they make and the questions that are thrown up regarding human behaviour. Those are the sort of ‘hooks’ that link archaeology with interactions between people within a social environment.” A written record of the eruption of Mount Vesuvius in 79 AD was famously recorded by Pliny the Younger, whose uncle was

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the captain of the rescue fleet. The latter’s helmsman became concerned about the volcanic ash raining down on the ships and contemplated turning back. Pliny’s uncle refused, saying ‘Fortune stands by the courageous!”. These are archaeology’s ‘human moments’, suggests Moya. “Pompeii is a much picked-over site with those tragic and intriguing casts of people and their animals frozen in time by ash and lava. But this exhibition takes a different approach with its focus on the maritime rescue attempt. It’s a lovely device to use the image of the six ships sailing towards the erupting volcano combined with Pliny’s written account.” “We need to remember that after the Roman Navy defeated the Carthaginians in 221BC they gained complete ascendancy in the Mediterranean.” “This had a huge impact in so many different ways. One of the most significant was the fact that the coastline was now safe for Roman ships, which resulted in a massive increase in trade and a crosscultural exchange of ideas right across the Mediterranean.” “It’s a completely different lens on this period of Roman history and it reframes this story in a wonderfully new way.” It’s all about communication and presenting material in creative ways, says Moya. “We’ve tried to convey a narrative thread in this exhibition that illuminates the objects on display. People of different backgrounds and ages will come to see Escape from Pompeii and we have to be mindful of that fact.” “The exhibition designers have created a real ‘Wow’ moment when people first walk

Dr Moya Smith

in the door and see the erupting volcano. It’s as if they were sitting in one of the ships!” “And that’s one of the good things about having this exhibition at the Maritime Museum. It’s a fabulous location overlooking the water and the perfect ‘space’ for telling this amazing story.” “We’ve sourced material from all over the world and we hope it excites everyone who comes along.”

By Peter McClelland ED: Escape from Pompeii: The Untold Roman Rescue is on at the WA Maritime Museum September 22-February 4 2018.

NOVEMBER 2017 | 55

Competitions

FEATURE

COMP

Entering Medical Forum's competitions is easy! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter. Movie: Only the Brave Based on the true story of the Granite Mountain Hotshots, this film explores the fear, adventure and danger of fighting forest wildfires through the eyes of this elite group of firefighters. Top cast with Jeff Bridges, Josh Brolin, Andie MacDowell and Jennifer Connelly Miles. In cinemas, from November 30

Movie: The Star

Event: Santa’s Magical Kingdom A visit to this special festive wonderland will crank up the kids’ Christmas excitement meters with a chance to rub shoulders with the old man in red and deposit an early Christmas order with the Santa Post. A 25-minute full-throttle Circus Spectacular will set the scene and then the youngsters can fully explore the gingerbread decorating, sand art activity and walkthrough Snow Land with a special treat for every child. Amusement rides will get the adrenaline pumping including Australia’s Sky Flyer, a carousel, Sizzler Ride, bumper cars, Inflatable Land and junior roller coaster. Crown Pyramid, December 1-23; MF family pass, Friday December 1, 6pm

It’s beginning to look a lot like Christmas, folks. A cute animated film tells the Christmas story in the footsteps of a little donkey named Bo who embarks on an adventure with Ruth the sheep and Dave the dove. Throw in three wisecracking camels and there are smiles all the way to Bethlehem. In cinemas, from November 30

Music: From Broadway to La Scala The awesome singing foursome – David Hobson, Teddy Tahu Rhodes, Lisa McCune and Greta Bradman – are back after their 2015 sellout show. Expect more greatest hits from the musical theatre and opera repertoire with WASO under the direction of Vanessa Scammel. Perth Concert Hall, Saturday December 9, 7.30pm

Event: Escape From Pompeii: The Untold Roman Rescue It’s a new and fascinating way to look at an event that rocked the world way back in 79 AD when the eruption of Mt Vesuvius killed thousands and destroyed cities within hours. The WA Museum has brought the story of the ancient Roman navy rescue to the Fremantle Maritime Museum.

Winners from September Kids Theatre – Horrible Harriet: Dr Glenda Khoo Music – Love Songs: Dr David Young

Taking

Plunge

Improving Breathing Dollars and Sense Blood on Track

Theatre – I Am My Own Wife: Dr Karen Moller

Movie – Blade Runner 2049: Dr Lee Jackson, Dr Mohan Jayasundera, Dr Lisa Surman, Dr Dian Harun, Dr Peter Louie, Dr Michael Leung, Dr Colin Lau, Dr Andre Chong Major Sponsor

Movie – Final Portrait: Dr David Jameson, Dr Simon Turner, Dr George Carter, Dr Donna Mak, Dr Bibiana Tie, Dr Donald Reid, Dr Maxwell Weedon, Dr John Williams, Dr Katherine Ng, Dr Patrick Lai Movie – Home Again: Dr Jennifer Martins, Dr Christina Wang, Mrs Vihara Yates, Dr Sally Price, Dr Jo Keaney, Do Joanne Marks, Dr Max Traub, Dr Alarna Boothroyd, Dr Mireille Hardie, Dr Simon Machlin

56 | NOVEMBER 2017

WA Maritime Museum, now until February 4

Coping with Fear

September 2017 www.mforum.com.au

Music: UWACS Messiah The evergreen Messiah oratorio by Handel is in the safe hands of Chris van Tuinen and the University of WA Choral Society who bring this stirring and brilliant music to life – once again. Feel the power! Winthrop Hall, UWA, Sunday December 17, 7pm

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