Medical Forum 08/15 Public Edition by Medical Forum WA

It’s hard to make a case against the expertise of Avant

Dr Brien Hennessy Avant WA member

This year, many doctors like you will face a medico-legal

including lawyers, medical advisors, claims managers and

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local state experts, it’s hard to make a case against the

could have a massive impact on your career.

expertise of Avant.

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0466 539 530 or 08 6189 5706 james.francis-hayes@avant.org.au *IMPORTANT: Professional indemnity insurance products are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, ﬁnancial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms, conditions, and exclusions that apply, please read and consider the policy wording and PDS, which is available at www.avant.org.au or by contacting us on 1800 128 268.

Editorial

Transparency and Health Professionals The behaviours of people brought to account by Royal Commissions is clearly evident these days through internet video - very ordinary people behaving badly, cloistered away and deliberately hidden from view for too long. The various enquiries into stolen generations, child abuse, sport drug cheats, ďŹ nancial planners, etc. have taught us that people in positions of power must earn any trust and come up squeaky clean after closer scrutiny. Otherwise, it may be safer to assume they have something to hide. The world is changing. Attempts to stiďŹ&#x201A;e dissent and â&#x20AC;&#x2DC;weather the stormâ&#x20AC;&#x2122; are passĂŠ. They just lead to premature resignations, redundancies, suicides, or such like because protagonists who hold the majority view want meaningful change now, and have the means to pursue things to a conclusion. Independent media has an important role in shining light on issues important to your average Joe Bloggs. For Medical Forum, this means issues important to the profession. Even good people in the profession who struggle with adopting transparency, require this tick of approval. We take the positive view that our profession has its altruists, people on pedestals and quiet achievers. However, an all-cards-on-the-table approach should be adopted to avoid any perceptions that there are those capable of abusing power and inďŹ&#x201A;uence. The profession can decide and Medical Forumâ&#x20AC;&#x2122;s role is to canvas important discussion points. Healthâ&#x20AC;&#x2122;s political edge is growing as money gets tight, so an independent watching brief is not to be taken lightly. AGPAL In the last edition, we looked at both the lack of response and the corporate governance of this organisation and its so-called governing bodies. Two delayed letters of response are published in this edition (see p4). We can only suggest you read carefully and consider your position â&#x20AC;&#x201C; we donâ&#x20AC;&#x2122;t know if the alternative group do it any better. sĂĽ ĂĽOFĂĽ'0SĂĽTHINKĂĽITĂĽISĂĽIMPORTANTĂĽ @VERY ĂĽ ĂĽORĂĽ@SLIGHTLY ĂĽ ĂĽ THEYĂĽKNOWĂĽHOWĂĽTHEĂĽACCREDITATIONĂĽFEESĂĽPAIDĂĽTOĂĽ!'0!,ĂĽAREĂĽUSED

FOI because it was not considered in the public interest and disclosure would be unreasonable, due to a likely adverse effect on his lawful business affairs. GP Representation '0ĂĽADVOCACYĂĽISĂĽAĂĽCURRENTĂĽISSUE ĂĽ7EĂĽWELCOMEĂĽMOREĂĽTRANSPARENCYĂĽONĂĽ members amongst representative groups. sĂĽ 4HEĂĽ2!#'0ĂĽREPORTEDLYĂĽHASĂĽ ĂĽ'0ĂĽMEMBERSĂĽ!USTRALIA WIDE ĂĽ For what purpose? sĂĽ 4HEĂĽFEDERALĂĽ!-! ĂĽASĂĽOFĂĽ-AYĂĽ ĂĽHADĂĽ ĂĽ'0ĂĽlNANCIALĂĽ MEMBERSĂĽACROSSĂĽ!USTRALIAĂĽ ORĂĽ ĂĽOFĂĽ'0SĂĽREGISTEREDĂĽWITHĂĽ !(02! ĂĽANDĂĽ ĂĽNON '0ĂĽlNANCIALĂĽMEMBERS ĂĽĂĽ sĂĽ %ACHĂĽYEAR ĂĽLEGISLATIONĂĽREQUIRESĂĽTHATĂĽTHEĂĽ!-!ĂĽ7!ĂĽMEMBERSHIPĂĽ TOTAL ĂĽASĂĽATĂĽ*ANUARYĂĽ ST ĂĽISĂĽPROVIDEDĂĽTOĂĽTHEĂĽ7!ĂĽ)NDUSTRIALĂĽ2ELATIONSĂĽ #OMMISSION ĂĽ!SĂĽATĂĽ ĂĽ*ANUARYĂĽ ĂĽTHISĂĽWASĂĽ ĂĽ lNANCIALĂĽORĂĽ NOT ĂĽNOTĂĽSTATED ĂĽABOUTĂĽ ĂĽOFĂĽDOCTORSĂĽREGISTEREDĂĽINĂĽ7! ĂĽ sĂĽ 4HEĂĽONLYĂĽREFERENCEĂĽTOĂĽ a breakdown of WA membership numbers we COULDĂĽlNDĂĽWASĂĽINĂĽAĂĽ ĂĽ edition of Medicus, which SAIDĂĽhMOREĂĽTHANĂĽ ĂĽOFĂĽTHEĂĽ practising profession in WA (in all categories)â&#x20AC;? were AMA members. Contact Details for You Medical Forum WA â&#x20AC;&#x201C; editor@mforum.com.au AMA WA â&#x20AC;&#x201C; mail@amawa.com.au 2!#'0ĂĽ7!ĂĽnĂĽWA RACGP ORG AU !'0!,ĂĽ ĂĽINFO AGPAL COM AU !(02!ĂĽ ĂĽ ĂĽ ĂĽ

Dr Rob McEvoy

e-Poll

AHPRA + Medical Board 4HESEĂĽlGURESĂĽAREĂĽFROMĂĽVARIOUSĂĽDOCTORĂĽE 0OLLSĂĽREPORTEDĂĽINĂĽMedical Forum, and are taken at face value. The medical editor is still waiting for an â&#x20AC;&#x153;escalatedâ&#x20AC;? response from the Medical Board to a request SUBMITTEDĂĽVIAĂĽTHEIRĂĽWEBSITEĂĽONĂĽ-AYĂĽ sĂĽ ĂĽOFĂĽDOCTORSĂĽSAIDĂĽBOTHĂĽ!(02!ĂĽANDĂĽTHEĂĽ-EDICALĂĽ"OARDĂĽ showed an unacceptable level of impartiality when handling a COMPLAINTĂĽAGAINSTĂĽAĂĽDOCTORĂĽ ĂĽSATISlED ĂĽ ĂĽWEREĂĽUNCERTAIN sĂĽ ĂĽOFĂĽDOCTORSĂĽSAIDĂĽ-EDICALĂĽ!SSESSMENTĂĽ0ANELĂĽDOCTORSĂĽCOULDĂĽLACKĂĽ IMPARTIALITYĂĽTOĂĽAĂĽSERIOUSĂĽEXTENTĂĽ ĂĽDISAGREED ĂĽ ĂĽWEREĂĽUNCERTAIN sĂĽ ĂĽBELIEVEĂĽTHEĂĽIDENTITIESĂĽOFĂĽOTHERĂĽDOCTORSĂĽWHOĂĽAREĂĽASKEDĂĽTOĂĽ report on or investigate doctors should be revealed prior to their APPOINTMENTĂĽ ĂĽSAIDĂĽNO ĂĽ ĂĽWEREĂĽUNCERTAIN sĂĽ ĂĽOFĂĽ'0SĂĽBELIEVEĂĽ!(02!ĂĽANDĂĽTHEĂĽ-EDICALĂĽ"OARDĂĽDOĂĽNOTĂĽUSEĂĽĂĽ INCOMEĂĽFROMĂĽDOCTORS ĂĽREGISTRATIONĂĽFEESĂĽWISELYĂĽ ĂĽSAIDĂĽTHEYĂĽDO ĂĽ ĂĽWEREĂĽUNCERTAIN sĂĽ ĂĽOFĂĽDOCTORSĂĽSAIDĂĽFAILEDĂĽACTIONSĂĽBYĂĽ!(02!ĂĽANDĂĽTHEĂĽ-EDICALĂĽ Board should be independently scrutinised. For example, in ONEĂĽCASEĂĽTHEĂĽ-EDICALĂĽ"OARDĂĽLOSTĂĽINĂĽ ĂĽWEĂĽLEARNTĂĽUNDERĂĽAĂĽ&/)ĂĽ APPLICATION ĂĽTHATĂĽ ĂĽWASĂĽPAIDĂĽTOĂĽ0ROFĂĽ"ERNARDĂĽ0EARN 2OWEĂĽFORĂĽPREPARINGĂĽAĂĽ ĂĽPAGEĂĽREPORTĂĽASĂĽANĂĽEXPERTĂĽWITNESS ĂĽ4HEĂĽ additional cost of his appearance in court was not given under

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Mr Glenn Bradbury (0403 282 510) advertising@mforum.com.au

MEDICAL FORUM

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

GP e-Poll â&#x20AC;&#x201C; see pages 18 and 36 for more results. How important is it to know what use AGPAL puts the accreditation fees it collects from general practices to? 66%

Very important Slightly important Take it or leave it Not important at all Hardly important Uncertain

Do you believe the Medical Board and AHPRA use their income from doctorsâ&#x20AC;&#x2122; registration fees wisely? 47%

No Uncertain Yes

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

AUGUST 2015 | 1

Contents

August 2015 10

FEATURES 10 Family Violence 16 Trailblazer: Dr James Fitzpatrick 25 Autism & Music 36 E 0OLLåOFå'0å/PINION

LIFESTYLE 38 Funny Side Humour 39 Theatre: Writing to the Brink 40 !UGUSTå#OMPETITIONSå å*UNEå0RIZEWINNNERS 41 7INEå2EVIEW å3TEPåBYå3TEPåWITHå:ONTE S Dr Louis Papaelias

42 NEWS & VIEWS 1 Editorial: Transparency Among 4

(EALTHå0ROFESSIONALS ,ETTERS 4ELEHEALTHå#HAMPIONSå Babies at Bentley !'0!,å'OVERNANCE .03å3CRIPTå$ATAå-INING

Dr Michael Watson Dr Greg Caddy Mr Mark Metherell Dr Sheilagh Cronin Dr Bill Chapman

,ORDSåOFå4HEå$ANCE Ms Jan Hallam

3ATIRE å2IDINGåTHEå7AVESå Ms Wendy Wardell

3EEå0AGEå å

Response: NPS -EDICALå"OARDå2ESPONSIVENESS Dr Patrick Hanrahan 4ESTOSTERONEå0RESCRIBINGå"ITES Anonymous

Response: Dr David Millar

8 14 18

Prof Tim Welborn Money for Nothin’? Dr Colin Hughes #URIOUSå#ONVERSATIONS åDr Peter Melvill-Smith

Have You Heard? Almost Mission Impossible Mr Peter McClelland

/LDERå)NPATIENTSå#ANå&ALLå,ESSå

MAJOR SPONSORS 2 | AUGUST 2015

MEDICAL FORUM

Clinical Contributors

Dr Luigi Dโ Orsogna Exercise and Heart $ISEASEรฅINรฅ#HILDHOOD

Prof Graeme Suthers 2USTYรฅ'ENES

Dr David Roberts Origins of Attachment 0ARENTING

Dr Kunal Thacker Eosinophilic Oesophagitis INรฅ#HILDREN

Dr Colin Whitewood (IPรฅ0ROBLEMSรฅINรฅ#HILDREN

Dr Christiane Remke Introduction of Solids for Infants

Dr Aveni Haynes 7HYรฅISรฅ#HILDHOODรฅ4YPEรฅ รฅ $IABETESรฅ)NCREASING

Dr Senq Lee +IDSรฅ'ETรฅ!RTHRITISรฅ4OO

Guest Columnists

Ms Rosie Batty '0Sรฅ4ACKLINGรฅ&AMILYรฅ6IOLENCE

Ms Janina Faulkner A Motherโ s Eyes

Dr Nathan Gibson Mental Health Act #OMINGรฅ3OON

Dr Alan Campbell PhD (OWรฅTOรฅ0REVENTรฅ&AMILYรฅ Violence?

PMH Stormy Rebirth 'ODรฅKNOWSรฅALLรฅTHEรฅPOLITICSรฅBEHINDรฅITรฅBUTรฅ*OHNรฅ(OLLAND รฅSOLDรฅBYรฅ,EIGHTONรฅ (OLDINGSรฅTOรฅ#HINAรฅ#OMMUNICATIONSรฅ#ONSTRUCTIONรฅ#OMPANY รฅREPORTEDLYรฅOWESรฅ SUBCONTRACTORSรฅMILLIONSรฅASรฅPARTรฅOFรฅTHEรฅ BILLIONรฅBUILDรฅOFรฅ0ERTHรฅ#HILDREN Sรฅ Hospital at the QEII precinct. Subcontractors doing the outside faรงade and internal ๏ฌ ooring are involved. The suicide of the managing director of a ceilings subcontractor, reported in The West, who was awaiting $2m payment from John (OLLAND รฅHASรฅBROUGHTรฅDELAYEDรฅPAYMENTSรฅINTOรฅTHEรฅPOLITICALรฅSPOTLIGHT รฅ#ERTAINLY รฅ THEรฅCONSTRUCTIONรฅISรฅAรฅHUGEรฅENDEAVOURรฅWITHรฅTHEรฅCOMPLETIONรฅDATEรฅGIVENรฅASรฅ รฅ by the government website. However, things are far from ๏ฌ nished according to CONTRACTORSรฅINVOLVEDรฅWITHรฅTHEรฅ รฅBEDรฅHOSPITAL รฅWITHรฅSOMEรฅSUGGESTINGรฅLATEรฅ รฅ is a more realistic commissioning date. At present, the relatively complete outside faรงade is covering much to do inside (see photos).

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), Michele Kosky AM (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Mike Ledger (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM AUGUST 2015 | 3

Letters to the Editor

Telehealth champions

Babies at Bentley

$EARĂĽ%DITOR

To the best of our knowledge there is a commitment to retaining Bentley maternity services for another year, thereafter to be reviewed.

As a telehealth advocate the Medical Forum article interested me (Where to Telemedicine, July edition). The consistent theme is that Telehealth is emerging despite government assistance rather than as a result of it. The opportunities telehealth presents to reduce costs, improve efďŹ ciencies and most of all provide high quality health care for disadvantaged Australians is being delayed because of a paucity of effective government assistance. In collaboration with some outstanding private and not for proďŹ t organisations we have proven the beneďŹ ts of telehealth to the elderly in aged care facilities and to children with ear disease in remote communities. Hard work has overcome all the technical and clinical obstacles to delivering high quality health care â&#x20AC;&#x201C; chronic disease models of care with collaboration between primary care CLINICIANSĂĽANDĂĽSPECIALISTS ĂĽ$ESPITEĂĽTHIS ĂĽPOORĂĽ funding makes them non-viable for private/ not for proďŹ t clinicians and organisations. Enormous ďŹ nancial beneďŹ ts reaped by the federal and state governments are not being returned to the clinicians involved. One example replaced an ENT specialist ďŹ&#x201A;own to remote communities in the Kimberley with telehealth consultations. High quality video conferencing can now be delivered via satellite internet and the bandwidth can be purchased hourly, making it cost-effective. The net saving of this example was thousands of dollars but the federal and state government do not fund the additional band-width to make this work.

2ECENTĂĽMEDIAĂĽCOVERAGEĂĽHASĂĽSUGGESTEDĂĽ imminent closure of the Bentley Hospital Maternity Unit. This has resulted recently in LESSĂĽREFERRALSĂĽFROMĂĽLOCALĂĽ'0S ĂĽ (OWEVER ĂĽSHOULDĂĽ"ENTLEYĂĽCLOSE ĂĽTHEĂĽEXTRAĂĽ ĂĽ maternity patients would overwhelm KEMH and Armadale Hospitals. As well, the new maternity unit at Fiona Stanley does not have the capacity to deal with this load (due to high risk referrals and patients from Kaleeyaâ&#x20AC;&#x2122;s closure). Bentley continues to provide a maternity service for low risk patients with midwife and general practitioner deliveries, specialist obstetrician involvement, epidurals and seven day caesarean and anaesthetic cover. Antenatal care is provided at the hospital and where necessary by bulkbilling general practitioners. 2EFERRALSĂĽATĂĽAROUNDĂĽ ĂĽWEEKSĂĽGESTATIONĂĽAREĂĽ WELCOMEDĂĽFROMĂĽ'0S Dr Greg Caddy, GP Obstetrician, Mead Medical, Kalamunda ED. Bentley Health Campus does 1,100 deliveries a year. Dr Aseel Alkiaat (O&G specialist and Head of Dept), is backed by GP Obstetricians who are accredited to do caesarians (except *) â&#x20AC;&#x201C; Dr Alison Philpott, Dr Julia Marcello, Dr Ann Lewis, Dr Karvi Soma, Dr Tom Matthews, Dr Meng Foo, Dr Stuart Prosser, Dr Greg Caddy* â&#x20AC;&#x201C; and O&G specialists Dr Vincent Lee, Dr Gordon Das, and Dr Jacques Pretorius.

'OVERNMENTSĂĽNEEDĂĽTOĂĽRECOGNISEĂĽTHEĂĽTELEHEALTHĂĽ champions that already exist and fund their successes, not pour money into new COMMERCIALĂĽVENTURESĂĽ LIKEĂĽTHEĂĽ0#%(2 ĂĽTHATĂĽAREĂĽ likely to fail at great cost to all.

........................................................................

Dr Michael Watson, Public Health Physician

Thanks for seeking our views [How Transparent is AGPAL? July edition].

........................................................................

We have no comment to make on the matter.

!'0!,ĂĽGOVERNANCE $EARĂĽ%DITOR

Mr Mark Metherell, Communications Director, Consumers Health Forum of Australia ACT ED. The CHF is listed as one of the governing bodies of AGPAL.

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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.

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 reďŹ&#x201A;ect 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.

$EARĂĽ%DITOR

I am responding on BEHALFĂĽOFĂĽ2$!! ĂĽASĂĽTHEĂĽ 2$!!ĂĽNOMINEEĂĽONĂĽTHEĂĽ "OARDĂĽOFĂĽ!'0!,ĂĽSINCEĂĽ The members of the Board are put forward by THEĂĽMEMBERSĂĽOFĂĽ!'0!, ĂĽ the tenure is usually three years with the ability to renominate if that is authorised by the member organisation. I believe most of the Board are members OFĂĽTHEĂĽ!)#$ĂĽANDĂĽ3TEVEĂĽ;#%/ĂĽOFĂĽ!'0!,=ĂĽISĂĽAĂĽ &!)#$ĂĽANDĂĽASĂĽAĂĽ"OARDĂĽ)ĂĽBELIEVEĂĽAREĂĽSTANDARDSĂĽ of governance are high and in accordance with best practice. The remuneration is very modest and is only paid on attendance at meetings. We are acutely aware of the costs of general PRACTICEĂĽANDĂĽ!'0!,ĂĽISĂĽRUNĂĽVERYĂĽEFlCIENTLYĂĽTOĂĽKEEPĂĽ costs to a minimum. The Health Engine initiative is a way of giving back to our loyal clients (i.e. '0S ĂĽANDĂĽITĂĽISĂĽOBVIOUSLYĂĽAĂĽHELPĂĽTOĂĽPATIENTS Dr Sheilagh Cronin, Cloncurry, Queensland ED. We responded to Dr Croninâ&#x20AC;&#x2122;s invitation to phone her. She suggested that accreditation and the PIP payments that ďŹ&#x201A;owed from it were good for general practices. She said the AGPAL board had four face-to-face meetings each year. She had never looked at her proďŹ le on HealthEngine. We pointed out it said she consulted at Montville and Cloncurry in Queensland. At Montville Medical Centre, HealthEngine said she â&#x20AC;&#x153;unfortunatelyâ&#x20AC;? did not list appointments with them and offered up ďŹ ve practices that did within 23.5 km, including one that was bulkbilling and open 7 days (and had 12 favourable patient reviews, including one that mentioned HealthEngine). Dr Cronin said she had sold the Montville practice three years ago and had not consulted there since July 2014.

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.03ĂĽSCRIPTĂĽDATAĂĽMINING $EARĂĽ%DITOR

2% ĂĽ-EDICINE)NSIGHTĂĽnĂĽTHISĂĽGOVERNMENTĂĽFUNDEDĂĽ agency is unilaterally collecting data from practices. It is paying practice principals to join their PRACTICEĂĽDATAĂĽTOĂĽTHEIRĂĽPROGRAMĂĽ RUNĂĽBYĂĽ.03 ĂĽ so it must be good!), which it accesses via the practice server after hours to download noncontinued on Page 6

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 indemniďŹ es 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.

Advertisers are responsible for ensuring that

4 | AUGUST 2015

MEDICAL FORUM

AUGUST 2015 | 5

Letters to the Editor continued from Page 4 identiďŹ able clinical data regarding prescribing and diagnoses. Individual doctors in the practice cannot opt out of this, so their clinical practice data is going off site to a third party. There is no patient consent. When I advised I did not consent to this, the email response from MedicneInsight said: â&#x20AC;&#x153;Dear Dr Chapman We will ensure your record is updated in our system. As per your practice agreements with MedicineInsight, we are collecting data from your practices on the consent of your practice principal and practice manager. I have attached agreements from [Medical Practice A] and [Medical Practice B]. Individual GPs are invited to consent to link GP information with non-identiďŹ able clinical data to produce customised practice reports. If consent is not provided by GPs (i.e. you in this instance), customisation of reports will not occur and data will be provided at an aggregated practice level within your practice reports. Your decision to not consent to MedicineInsight will not preclude you from participating in NPS quality improvement activities, including MediceInsight practice meetings. Additionally, at no stage will information that could identify participating practices or consenting GPs be released to any third party or used in publications resulting from research using MedicineInsight data.â&#x20AC;? I am worried that this data is collected on my clinical practise without my consent or that of my patients. The quality of data would be very interesting, as it is my experience that very few doctors actually put a â&#x20AC;&#x153;reason for prescribingâ&#x20AC;? with each script, or keep a â&#x20AC;&#x153;reason for visitâ&#x20AC;?. Is this truly a safe altruistic collection of data? 7HYĂĽAREĂĽ.03ĂĽPAYINGĂĽTHEĂĽPRACTICESĂĽFORĂĽACCESSĂĽ to their server after hours? Why isnâ&#x20AC;&#x2122;t this program a requirement for accreditation? )TĂĽISĂĽMYĂĽEXPERIENCEĂĽOVERĂĽTHEĂĽYEARSĂĽTHATĂĽTHEĂĽ.03ĂĽ ANDĂĽ()#ĂĽAREĂĽREALLYĂĽALLĂĽABOUTĂĽlSCALĂĽOUTGOINGS ĂĽ not medical outcomes.

What will be next? Will they look at consultation times and match the billing? 0ERHAPSĂĽ)ĂĽAMĂĽJUSTĂĽAĂĽDINOSAUR Dr Bill Chapman, General Practitioner .................................................

.03ĂĽ2%30/.3% -EDICINE)NSIGHTĂĽISĂĽANĂĽINITIATIVEĂĽOFĂĽ.03ĂĽ MedicineWise, an independent, not-for-proďŹ t organisation that receives funding from the !USTRALIANĂĽ'OVERNMENT ĂĽ.03ĂĽ-EDICINE7ISEĂĽ improves quality use of medicines by identifying problems with the way medicines are used in practice, and developing evidencebased programs and interventions to support better decision making and improved health outcomes for Australians. It is not a government agency. MedicineInsight is a unique dataset as it is longitudinal and follows the patient journey from diagnosis through to treatment outcomes in primary care. It provides one of the most comprehensive pictures of general practice healthcare at a local and national level. 0ARTICIPATINGĂĽGENERALĂĽPRACTICESĂĽAREĂĽOFFEREDĂĽ clear insights into their prescribing and clinical activity and receive tailored reports that show comparisons with other participating PRACTICESĂĽANDĂĽBESTĂĽPRACTICEĂĽGUIDELINES ĂĽ.03ĂĽ MedicineWise also offers whole-of-practice meetings to discuss the feedback and quality improvement initiatives. 0RIVACYĂĽANDĂĽSECURITYĂĽOFĂĽTHEĂĽDATAĂĽISĂĽPARAMOUNT ĂĽ All data is collected ethically, legally, securely and conďŹ dentially, and all patient information is de-identiďŹ ed and encrypted prior to the DATAĂĽBEINGĂĽSECURELYĂĽTRANSFERREDĂĽTOĂĽ.03ĂĽ MedicineWise. )NDIVIDUALĂĽ'0SĂĽCANĂĽOPTĂĽOUTĂĽBUTĂĽTHISĂĽPREVENTSĂĽ customised clinical reports back to the PRACTICE ĂĽ0ATIENTĂĽOPT OUTĂĽISĂĽMANAGEDĂĽ independently by practices. 0RACTICESĂĽTHATĂĽSIGNĂĽUPĂĽTOĂĽ-EDICINE)NSIGHTĂĽAREĂĽ not paid for their data; there is a nominal sign up payment to cover practice costs associated with installation and administration.

ED. Currently, 515 Australian practices are enrolled in MedicineInsight (and have the required Best Practice or Medical Director software). The practice principal can give permission for data collection, without the consent or knowledge of a contract GP (who if aware of the arrangement can opt out of being identiďŹ able in the data set). NPS pays the practice principal $1,000 for data access. NPS MedicineWise reports to government on the use of particular medicines or classes of medicines (e.g. the most recent report was on seven antibiotics â&#x20AC;&#x201C; including patterns of drug utilisation, patient cohort proďŹ le, prescribing of repeats plus dose and duration, and differences between PBS/Repat and private prescriptions). The program is not directly endorsed by the RACGP. MedicineInsight says it is for â&#x20AC;&#x153;all Australiansâ&#x20AC;? See www.medicineinsight.org.au or phone 1300 721 726.

........................................................................

Testosterone prescribing bites $EARĂĽ%DITOR

2% ĂĽ4ESTOSTERONEĂĽ PRESCRIBINGĂĽANDĂĽ424ĂĽ CUTBACKSĂĽ *ULYĂĽ Surely the common sense approach to most adult males with a borderline testosterone level in whom serious organic causes are excluded is not a â&#x20AC;&#x153;therapeutic trialâ&#x20AC;? of testosterone replacement, but rather a combination of: sĂĽ 2EGULARĂĽSTRENGTHĂĽTRAININGĂĽ INCLUDINGĂĽ compound barbell exercises such as squatting, deadlifting etc. on a progressive regime). sĂĽ !ĂĽSMALLĂĽAMOUNTĂĽOFĂĽSHORTĂĽ())4ĂĽTYPEĂĽCARDIOĂĽ training (sprinting, Tabata intervals of burpees and similar). sĂĽ %LIMINATEĂĽALCOHOL ĂĽSERIOUSLYĂĽREDUCEĂĽSUGAR ĂĽ Eat more protein, eat more ďŹ bre, eat more â&#x20AC;&#x153;good fatâ&#x20AC;?, take ďŹ sh oil supplementation. sĂĽ ,OSEĂĽFAT ĂĽGAINĂĽMUSCLEĂĽ ĂĽTHEĂĽABOVEĂĽSHOULDĂĽ take care of this. sĂĽ %NSUREĂĽADEQUATEĂĽSLEEPĂĽ HRSĂĽ sĂĽ 2EASSESSĂĽAFTERĂĽ ĂĽMONTHSĂĽOFĂĽRELIGIOUSĂĽ adherence to these lifestyle changes. Most of this has at least some scientiďŹ c support, and makes sense for a whole heap of reasons beyond testosterone levels. Anonymous [via www.medicalhub.com.au]

WA Medical Board responsiveness $EARĂĽ%DITOR

Six months ago I WROTEĂĽTOĂĽTHEĂĽ0ROFESSORĂĽ -ICHAEL ĂĽ#HAIRĂĽOFĂĽTHEĂĽ Medical Board of WA ABOUTĂĽTHEĂĽWAYĂĽ!(02!ĂĽHADĂĽHANDLEDĂĽAĂĽCLEARLYĂĽ vexatious, and ultimately dismissed, complaint about a colleague. He did not reply. !TĂĽTHEĂĽ$OCTOR SĂĽ$RUMĂĽMEETINGĂĽINĂĽ-AY ĂĽ 0ROFESSORĂĽ-ICHAELĂĽTOOKĂĽMYĂĽCOLLEAGUE SĂĽHANDSĂĽ in his and assured them that yes, now he would reply. He has not replied.

................................................. !ĂĽMONTHĂĽAGOĂĽTHEĂĽ-$!ĂĽLAWYERĂĽWROTEĂĽTOĂĽ0ROFĂĽ Michael about this issue - to date there has been no reply.

!54(/2ĂĽ 2%30/.3%

I then read in the June issue of Medical Forum THATĂĽ0ROFESSORĂĽ-ICHAELĂĽBELIEVEDĂĽTHEĂĽSYSTEMĂĽ should be â&#x20AC;&#x153;..accessible, responsive and timelyâ&#x20AC;?.

Thank you for inviting me to respond. ĂĽ 4HEĂĽSUBSETĂĽOFĂĽMENĂĽ discussed in the article are those who suffer from a chronological decline in their testosterone levels, late onset hypogonadism i.e. they have no identiďŹ able organic cause, including visceral obesity. 2. Best for patients with low/borderline testosterone levels and visceral obesity

0ROFESSORĂĽ-ICHAELĂĽHADĂĽALWAYSĂĽSEEMEDĂĽTOĂĽ me a very decent man, and so I thought he would not mind a telephone call regarding the apparent difďŹ culty he has responding to written communication. !FTERĂĽCONSIDERABLEĂĽDIFlCULTY ĂĽTHROUGHĂĽ!(02!ĂĽ)ĂĽ LEARNEDĂĽHOWĂĽTOĂĽCONTACTĂĽ0ROFESSORĂĽ-ICHAEL ĂĽ(EĂĽ only accepts written communication. Dr Paddy Hanrahan, South Perth

continued on Page 8

6 | AUGUST 2015

MEDICAL FORUM

Major Sponsor: Western Cardiology

Exercise and Heart Disease in Childhood

%S -VJHJ % 0STPHOB MBBS, DRCOG, FRACP

About the author Children with heart disease should be encouraged to exercise regularly and participate in sport by parents, educators and health professionals. If there is any doubt regarding the level or intensity, advice from the attending paediatric cardiologist should be sought.

General principles The health beneďŹ ts of exercise are universally recognised and accepted, with regular exercise and sports improving physical wellbeing as well as producing psychological and social beneďŹ ts. Encouraging children and teenagers to be more physically active and less sedentary has become a major public health issue in First World countries. These beneďŹ ts also apply to children with heart disease. However, often they are restricted through the misconception of parents, carers and health professionals who perceive signiďŹ cant risk from exercise. 2ECENTĂĽPUBLICATIONSĂĽCONlRMĂĽTHATĂĽVIRTUALLYĂĽALLĂĽ children with heart disease, including those who had surgical or transcatheter intervention, can participate in regular physical activity and leisure sport. Fortunately, most can play any competitive sports without restriction. Some may need sport to be tailored from high to low intensity with varying degrees of dynamic and static components depending on the type of heart disease, clinical status and formal testing. Avoiding exercise is only applicable to VERYĂĽFEWĂĽ SEEĂĽ,ISTĂĽ

Exercise and heart surgery #HILDRENĂĽRECOVERINGĂĽFROMĂĽACUTEĂĽMYOCARDIALĂĽ or pericardial inďŹ&#x201A;ammation, including cardiac surgery, should avoid exercise until the INmAMMATIONĂĽHASĂĽABATED ĂĽ0OST SURGERY ĂĽ children are usually advised to avoid exercise for the ďŹ rst two weeks and gradually increase activity thereafter â&#x20AC;&#x201C; regular exercise and noncontact sport by six weeks for most. It is safe to participate in unrestricted contact sport from three months after surgery. However, toddlers often break the rules and it is not uncommon to see a toddler running out

of the cardiac ward within a week of operation despite the best effort of adults to restrain them! Further post-surgery restriction at home of young toddlers is almost impossible â&#x20AC;&#x201C; perhaps testimony to the rapid recovery and resilience of young hearts. Those who have severe outďŹ&#x201A;ow obstruction, right or left, should avoid exercise until the obstruction is relieved to at least moderate in degree. Avoidance of exercise is also warranted prior to surgery for severe aortic dilatation. Whilst restricted exercise is recommended FORĂĽSOMEĂĽCARDIACĂĽCONDITIONSĂĽ SEEĂĽ,ISTĂĽ ĂĽ even some regular physical activity for these affected children is important, adjusted to each childâ&#x20AC;&#x2122;s clinical status and exercise

List 1: Avoid Exercise sĂĽ )MMEDIATEĂĽPOSTĂĽCARDIACĂĽSURGERY ďŹ rst two weeks sĂĽ !CUTEĂĽMYOCARDIALĂĽORĂĽPERICARDIALĂĽ inďŹ&#x201A;ammatory disease sĂĽ 3EVEREĂĽLEFTĂĽORĂĽRIGHTĂĽOUTmOWĂĽOBSTRUCTION sĂĽ 3EVEREĂĽAORTICĂĽDILATATION

List 2: Restrict Exercise sĂĽ ĂĽTOĂĽ ĂĽWEEKSĂĽPOSTĂĽCARDIACĂĽSURGERY sĂĽ #ARDIOMYOPATHY ĂĽHYPERTROPHIC ĂĽDILATED ĂĽ restrictive, left non-compaction sĂĽ #YANOTICĂĽHEARTĂĽDISEASE ĂĽINCLUDINGĂĽ Eisenmenger Syndrome sĂĽ 0RIMARYĂĽPULMONARYĂĽHYPERTENSION sĂĽ #ONNECTIVEĂĽTISSUEĂĽDISORDERSĂĽASSOCIATEDĂĽ with aortic dilatation e.g. Marfan Syndrome, %HLERSĂĽ$ANLOSĂĽ3YNDROME ĂĽ,OEYSĂĽ$IETZĂĽ Syndrome sĂĽ )NHERITEDĂĽARRHYTHMOGENICĂĽCONDITIONSĂĽE G ĂĽ ,ONGĂĽ14ĂĽ3YNDROME ĂĽ"RUGADAĂĽ3YNDROME ĂĽ #ATECHOLAMINERGICĂĽPOLYMORPHICĂĽVENTRICULARĂĽ tachycardia

Luigi Dâ&#x20AC;&#x2122;Orsogna trained in Paediatrics at the Childrenâ&#x20AC;&#x2122;s Hospital in Vancouver, Canada and Princess Margaret Hospital in WA. Thereafter, he completed a fellowship in Paediatric Cardiology at the Childrenâ&#x20AC;&#x2122;s Hospital in Boston and Harvard Medical School. He is director of the Fetal Cardiology Service in the Maternal Fetal Medicine Unit at KEMH for Women, and his private practice covers all aspects of general Paediatric Cardiology.

response. As well, some children after congenital heart disease â&#x20AC;&#x153;repairâ&#x20AC;? have limited exercise capacity; particularly with univentricular heart surgery (Fontan procedure) and biventricular heart surgery where cardiac lesions such as pulmonary incompetence and pulmonary artery stenosis remain after Tetralogy of Fallot repair. &ORMALĂĽEXERCISEĂĽTESTINGĂĽUSINGĂĽSTRESSĂĽ%#'ĂĽANDĂĽ exercise cardiopulmonary testing are helpful for monitoring, guidance and the design of cardiac rehabilitation for these children with unrepaired and â&#x20AC;&#x153;repairedâ&#x20AC;? heart disease. Often these children are on anti-coagulation medications such as warfarin or have implantable pacemakers but this should not stop them from participating in competitive sports, even non-intentional contact sports like basketball and ďŹ eld hockey. References (1) Longmuir PE et al. Promotion of physical activity for children and adults with congenital heart disease. Circulation. 2013;127: 2147-2159. (2) Takken T et al. Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease. Eur J Cardiovasc Prev Rehabil. 2012; 19: 1034-1065 (3) Rhodes J et al. Exercise testing and training in children with congenital heart disease. Circulation. 2010;122: 1957-1967.

Visit www.westerncardiology.com.au 17 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services

Main Rooms: St John of God Hospital, Suite 324/25 McCourt Street, Subiaco 6008 5FM t $PVOUSZ 'SFF $BMM Urban Branches: Applecross, Balcatta, Duncraig, East Victoria Park, Joondalup & Midland Regional: Bunbury, Busselton, Geraldton, Kalgoorlie, Mandurah & Northam

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Letters to the Editor continued from Page 6 would certainly be a structured weight loss program, including cardio exercise, dietary measures (including those suggested), and/or consider bariatric surgery. Where POSSIBLEĂĽTHISĂĽWOULDĂĽBEĂĽSUSTAINEDĂĽFORĂĽ ĂĽ months before contemplating testosterone replacement therapy. When late onset hypogonadism is the primary cause of their visceral adiposity, and not a consequence, such endeavours will have little effect on their androgen proďŹ le and clinical state. ĂĽ !SĂĽDISCUSSED ĂĽTHEĂĽCLINICALĂĽPICTUREĂĽOFĂĽ hypogonadism includes, low energy levels, apathy, poor sleep and a reduced capacity to build muscle mass with exercise. These men often suffer from a variety of physical ailments that limits the types of exercise they can perform. A â&#x20AC;&#x2DC;religious adherenceâ&#x20AC;&#x2122; to your prescriptive program would not be practical. 4. It is important to appreciate that we are not treating â&#x20AC;&#x2DC;T levelsâ&#x20AC;&#x2122;. We are treating a patient who has low/borderline testosterone levels and (after taking a detailed history) a strong clinical picture of testosterone deďŹ ciency that is causing them and their family signiďŹ cant distress. ĂĽ !ĂĽTHREEĂĽMONTHĂĽTRIALĂĽOFĂĽTESTOSTERONEĂĽ replacement, in appropriate patients, is based on strong clinical evidence and is endorsed by the premiere medical organisations, including urologists, endocrinologist and sexual health physicians. When successful, the changes to these patientâ&#x20AC;&#x2122;s health and quality of life is dramatic. I hope these comments clarify my personal views on late onset hypogonadism. Dr Dave Millar, Sexual Health Physician, Nedlands ................................................. $EARĂĽ%DITOR

The guidelines and comments are timely and helpful. But I write to clarify the clinical deďŹ nitions of male hypogonadism, because there are common reversible causes of low testosterone levels.

Primary male hypogonadism is characterised BYĂĽLOWĂĽCALCULATEDĂĽFREEĂĽTESTOSTERONEĂĽ #&4 ĂĽ WITHĂĽHIGHĂĽ,(ĂĽ &3( ĂĽLEVELS ĂĽ4HEĂĽCAUSESĂĽ include neoplastic, traumatic, postinďŹ&#x201A;ammatory (mumps) conditions of the testes, undescended testicles, also Klinefelterâ&#x20AC;&#x2122;s Syndrome (XXY chromosome). Usually lifelong testosterone therapy is indicated. In secondary male hypogonadism there are LOWĂĽTESTOSTERONEĂĽ #&4 ĂĽLEVELSĂĽWITHĂĽNORMALĂĽ ORĂĽLOWĂĽ,(ĂĽ &3( ĂĽLEVELSĂĽRESULTINGĂĽFROMĂĽ hypothalamic-pituitary disease or dysfunction. #AUSESĂĽINCLUDEĂĽRAREĂĽPITUITARYĂĽDISEASESĂĽSUCHĂĽ as prolactinoma, and genetic conditions such as Kallmanâ&#x20AC;&#x2122;s Syndrome. Much more common causes are haemochromatosis, severe obesity, and sleep apnoea. These are potentially reversible and patients should be advised of the treatment options. Note also that over-treatment can lead to long TERMĂĽSUPPRESSIONĂĽOFĂĽ,(ĂĽ &3( ĂĽPOLYCYTHAEMIA ĂĽ and can accelerate the background risk of prostate cancer, and these risks can be monitored by the prescribing doctor.

Mr W just needs some repeats but canâ&#x20AC;&#x2122;t stop worrying about his boy on Ice. Actually due for diabetic review so needs work up but priority is alcohol and drug counselling and showing him useful websites. Then offered speciďŹ c HEALTHĂĽADVICEĂĽREĂĽQUITTINGĂĽSMOKING ĂĽ ĂĽMINUTES -RĂĽ0ĂĽCOMESĂĽFORĂĽAĂĽSECONDĂĽOPINIONĂĽABOUTĂĽHISĂĽ#4ĂĽ scan showing a major condition that requires careful explanation and specialist referral. Also needed to review of his care plan that has been charged but not actually actioned by another clinic (multiple co-existing medical PROBLEMS ĂĽ ĂĽMINUTES ĂĽ 4HISĂĽISĂĽJUSTĂĽTYPICALĂĽnĂĽAĂĽ'0ĂĽWHOSEĂĽPATIENTSĂĽ are getting older and more complicated yet we have to work under a Medicare payment system that rewards those doctors who can GETĂĽPATIENTSĂĽINĂĽANDĂĽOUTĂĽINĂĽLESSĂĽTHANĂĽ ĂĽMINUTES ĂĽ Itâ&#x20AC;&#x2122;s time for a fair deal for patient rebates. Dr Colin Hughes, Midland Family Practice

Prof Tim Welborn, Endocrinologist UWA ........................................................................

Money for nothinâ&#x20AC;&#x2122;?

We welcome your letters and leads for stories.

$EARĂĽ%DITOR

Ms J a new patient asking for a letter for HomesWest; two screaming children under ďŹ ve in tow. An extensive history plus some general advice on toddler control and how to use time out. The HomesWest CERTIlCATE ĂĽ ĂĽMINUTES ĂĽ Next, Mrs T waiting for life saving surgery; a death in the close family and a government employer is refusing to let her take some of HERĂĽ ĂĽ ĂĽWEEKSĂĽANNUALĂĽLEAVEĂĽFORĂĽ@OPERATIONALĂĽ reasonsâ&#x20AC;&#x2122;. Assessment of her depression rating, grief counselling and general social work, plus CERTIlCATE ĂĽ ĂĽMINUTES ĂĽ

0LEASEĂĽKEEPĂĽTHEMĂĽSHORT ĂĽ UNDERĂĽ ĂĽWORDSĂĽPREFERRED Email: editor@mforum.com.au (include full address and phone NUMBER ĂĽBYĂĽTHEĂĽ THĂĽOFĂĽEACHĂĽMONTH ĂĽ ,ETTERSĂĽMAYĂĽBEĂĽEDITEDĂĽFORĂĽLEGALĂĽ issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.

Curious Conversations

Mind, Body and Soul Multi-instrumentalist, psychiatrist and sports lover Dr Peter Melvill-Smith is a passionate believer in the mystery of both music and the human condition. The most inspirational medico Iâ&#x20AC;&#x2122;ve ever met isâ&#x20AC;Ś Steven Stahl, the neuropsychopharmacologist from the USA. Heâ&#x20AC;&#x2122;s revolutionised education in his ďŹ eld with a combination of brilliant academic work and wonderful creative ďŹ&#x201A;air. If I could change one thing in the public mental health system it would beâ&#x20AC;Ś to increase the visible presence of clinical psychiatrists. One ORĂĽTWOĂĽONĂĽTHEĂĽ-ENTALĂĽ(EALTHĂĽ#OMMISSIONĂĽANDĂĽAĂĽPANELĂĽMEMBERĂĽONĂĽTHEĂĽ #OUNCILĂĽOFĂĽ/FlCIALĂĽ6ISITORSĂĽWOULDĂĽBEĂĽAĂĽGOODĂĽSTART

8 | AUGUST 2015

If I could step into the shoes of someone else for a year Iâ&#x20AC;&#x2122;d beâ&#x20AC;Ś "RUCEĂĽ#OCKBURN ĂĽTHEĂĽ#ANADIANĂĽMUSICIANĂĽANDĂĽHUMANISTĂĽPAR EXCELLENCE ĂĽ Heâ&#x20AC;&#x2122;s a talented lyricist and guitarist and his music is inspiring. My biggest regret isâ&#x20AC;Ś not having studied Sports Medicine because MYĂĽINITIALĂĽAIMĂĽWASĂĽTOĂĽPRACTISEĂĽASĂĽAĂĽ3PORTSĂĽ0SYCHIATRIST My next overseas holiday will be toâ&#x20AC;ŚĂĽ$UBLIN ĂĽ) LLĂĽBEĂĽATTENDINGĂĽANĂĽ international conference on depression and taking a small side-trip to see family and visit my forefatherâ&#x20AC;&#x2122;s stamping ground in Scotland.

MEDICAL FORUM

By Prof Graeme Suthers, PhD FRACP FRCPA, Director of Genetics, Sonic Healthcare (Australia)

Major Sponsor: Clinipath Pathology

Rusty Genes Please pause for a moment (by all means, sip your coffee) while I take you back to your moment of conception. The fertilised egg that was you contained two copies of the entire genetic code. You will BEĂĽFAMILIARĂĽWITHĂĽTHEĂĽICONICĂĽHELICALĂĽ$.!ĂĽTHATĂĽ represents the encoded genetic information. What is less widely appreciated is the length OFĂĽTHISĂĽ$.! ĂĽ!TĂĽCONCEPTION ĂĽTHEREĂĽWEREĂĽTWOĂĽ LINEARĂĽMETRESĂĽOFĂĽ$.!ĂĽINĂĽTHEĂĽFERTILISEDĂĽCELL ĂĽ4HATĂĽ IS ĂĽYOUĂĽAREĂĽASĂĽTALLĂĽASĂĽTHEĂĽLENGTHĂĽOFĂĽ$.!ĂĽINĂĽAĂĽ single human cell. This simple observation leads to consequences that are both staggering and relevant in healthcare. 4HEĂĽ$.!ĂĽINĂĽAĂĽSINGLEĂĽCELLĂĽMUSTĂĽBEĂĽCOPIEDĂĽ before the cell divides. This occurs in a tiny space and is repeated billions of times, so it is not surprising that errors occur. The error rate ISĂĽSTAGGERINGLYĂĽLOWĂĽ per nucleotide) but, GIVENĂĽTHEĂĽLENGTHĂĽOFĂĽYOURĂĽ$.! ĂĽTHISĂĽAMOUNTSĂĽTOĂĽ SIXĂĽNEWĂĽ$.!ĂĽSEQUENCEĂĽERRORSĂĽGENERATEDĂĽATĂĽ every cell division. At an early stage in development, a new mutation may compromise an entire lineage of cells. By the end of the ďŹ rst week of DEVELOPMENT ĂĽAPPROXIMATELYĂĽ ĂĽOFĂĽEMBRYOSĂĽ will have major chromosome abnormalities. These abnormalities occurred either in the formation of the sperm or egg, or, more commonly, reďŹ&#x201A;ect new mutations which occurred after conception. The great majority of these chromosomally abnormal embryos are so functionally compromised that they are lost by spontaneous miscarriage, often before a woman is aware she is pregnant. These new mutations, whether they be abnormalities in chromosome number, or mutations in individual genes, contribute to the burden of congenital malformations identiďŹ ed at birth or within the ďŹ rst few years of postnatal life. An adult human consists of approximately ĂĽTRILLIONĂĽCELLSĂĽCONTAINING ĂĽINĂĽTOTAL ĂĽ ĂĽTRILLIONĂĽ METRESĂĽOFĂĽ$.!ĂĽI E ĂĽYOUĂĽCONTAINĂĽAPPROXIMATELYĂĽ ĂĽLIGHT DAYSĂĽOFĂĽ$.! ĂĽ)TĂĽISĂĽIMPORTANTĂĽTOĂĽNOTEĂĽTHISĂĽ INCREDIBLEĂĽLENGTHĂĽOFĂĽ$.!ĂĽISĂĽNOTĂĽAĂĽHOMOGENEOUSĂĽ strand, like a piece of string, but is a highly ordered sequence of nucleotides. As noted above, it is impossible to create a highly structured strand this long without creating errors. Furthermore, it is impossible to sustain the integrity of the genetic code over this extraordinary distance. Even if further cell divisions did not occur, the sheer length of our

Part of the DNA from a single cell

entire genetic code dictates that the sequence must become corrupt over time. The Second ,AWĂĽOFĂĽ4HERMODYNAMICSĂĽDESCRIBESĂĽAĂĽ fundamental property of energy and matter: energy must be expended to maintain order. The amount of energy required to maintain the precise order of nucleotides along a length of ĂĽLIGHT DAYSĂĽISĂĽMIND BOGGLING The net effect is that the integrity of your genetic code has been corroding since the moment of your conception. Your genetic code may have been compromised by genetic errors already present in the egg or sperm from which you developed; this is the basis of heritable predisposition to disease. But even if you had perfect genes at conception, fundamental physical forces dictate that your genetic code becomes â&#x20AC;&#x2DC;rustyâ&#x20AC;&#x2122; throughout your lifetime. Two consequences arise from the development of genetic rust. First, the accumulation of genetic errors (particularly in MITOCHONDRIALĂĽ$.! ĂĽEVENTUALLYĂĽCOMPROMISESĂĽ cell function. If sufďŹ cient cells within an organ have compromised function, we recognise this clinically as age-related organ failure. Second, genetic errors in a single cell can disrupt the control of cell division and result in that cell growing out of control i.e. cancer. From this genetic perspective, issues of infertility, miscarriage, malformations, cancer, organ failure, and ultimately mortality, can all be attributed to the single underlying

mechanism of rusting genes. The signiďŹ cance of these genetic processes, both heritable and acquired, is reshaping our understanding of the biological basis of disease and the investigations that can inform our clinical decisions. Throw in a good dash of technological advances, and we have a revolution in pathology that is providing us with unprecedented information. 'ENETICĂĽTESTINGĂĽISĂĽCHANGINGĂĽTHEĂĽFACEĂĽOF modern pathology. Sonic Healthcare laboratories across Australia, INCLUDINGĂĽ#LINIPATHĂĽ0ATHOLOGY ĂĽOFFERĂĽAĂĽGROWINGĂĽ range of genetic tests that include international laboratories. Our comprehensive website includes information on the purpose, utilisation, and cost of each genetic test. It also provides information for patients, and links to other resources for patients and doctors. Many clinicians feel overwhelmed by the sheer volume and complexity of genetic tests now on offer. The website has been designed as a useful starting point for your queries, and those of your patients, about medical genetic tests and how to use them. I recommend the website, www.sonicgenetics.com.au, to assist you identify what tests are available and relevant to your patients. (OW SĂĽTHEĂĽCOFFEE ĂĽ'ONEĂĽCOLD

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www.clinipathpathology.com.au MEDICAL FORUM

AUGUST 2015 | 9

Feature

Standing up to Family Terrorism Family violence is on the national agenda thanks to Rosie Battyâ&#x20AC;&#x2122;s outspoken activism but it will take the whole community to make it history. On January 26, there was a major breakthrough in the campaign against family violence. Rosie Batty, who just a year earlier had witnessed her ex-husband murder their son after cricket training, was named Australian of the Year. It brought the issue of family violence out of the shadow into the glare of national attention, particularly when THEĂĽ0RIMEĂĽ-INISTERĂĽ Tony Abbott made it the lead item on the agenda of Aprilâ&#x20AC;&#x2122;s Rosie Batty, #/!'ĂĽMEETING ĂĽ Australian of the Year Unfortunately the '34ĂĽCARVE UPĂĽ gazumped it for the headlines, and then along

came the Budget and terrorism and the issue slipped back. !GAINĂĽ2OSIEĂĽ"ATTYĂĽSTOODĂĽUP ĂĽ&RONTINGĂĽTHEĂĽ .ATIONALĂĽ0RESSĂĽ#LUBĂĽINĂĽ*UNE ĂĽSHEĂĽTOLDĂĽTHEĂĽMEDIAĂĽ gathered that the government needed to pay family violence the same amount of attention as terrorism and accused the nationâ&#x20AC;&#x2122;s leaders of not taking strong enough leadership on the issue. â&#x20AC;&#x153;On one hand [theyâ&#x20AC;&#x2122;re] giving voice to support but on other hand there is a lack of funding and CUTSĂĽTOĂĽESSENTIALĂĽFRONTLINEĂĽSERVICES ĂĽ,ET SĂĽSTARTĂĽ calling family violence terrorism and then maybe we can start to see funding ďŹ&#x201A;owing to this area.â&#x20AC;? Family violence is a gender issue She also boldly spoke out saying family violence was a â&#x20AC;&#x153;gender issueâ&#x20AC;? and should be addressed at its core. Women and children were predominately the victims and the victim shaming among the community needed to stop.

Family Violence Snapshot: How Bad Is It? )NĂĽ7!ĂĽ$URINGĂĽ ĂĽTHEREĂĽWERE sĂĽ ĂĽREPORTEDĂĽDOMESTICĂĽASSAULTS ĂĽTHEĂĽMOSTĂĽ common reported offence against a person E G ĂĽCWĂĽ ĂĽNON DOMESTICĂĽASSAULTS ĂĽOFĂĽ WHICHĂĽ ĂĽOCCURREDĂĽINĂĽTHEĂĽMETROĂĽAREA sĂĽ POLICEĂĽRESPONSESĂĽTOĂĽOVERĂĽ ĂĽ ĂĽCALLSĂĽ for assistance for family violence related INCIDENTSĂĽ AĂĽ ĂĽINCREASEĂĽONĂĽ ĂĽANDĂĽ ĂĽ of all reported cases). sĂĽ ĂĽINSTANCESĂĽOFĂĽREPORTEDĂĽTHREATENINGĂĽ behaviour, domestic and otherwise. sĂĽ POLICEĂĽPREFERREDĂĽCHARGESĂĽFORĂĽABOUTĂĽ ĂĽ offences related to family violence.

sĂĽ !BOUTĂĽ ĂĽVIOLENCEĂĽRESTRAININGĂĽORDERSĂĽ 62/S ĂĽ served by police on behalf of the courts. sĂĽ /VERĂĽ ĂĽ ĂĽPOLICEĂĽORDERSĂĽISSUEDĂĽTOĂĽPROTECTĂĽ victims and place restrictions on perpetrators. sĂĽ ĂĽCHILDRENĂĽAGEDĂĽUPĂĽTOĂĽ ĂĽYEARSĂĽWEREĂĽ RECEIVINGĂĽCHILDĂĽPROTECTIONĂĽSERVICESĂĽ ĂĽ either investigation of a notiďŹ cation, on a care and protection order, or being in out-of-home CAREĂĽ ĂĽWITHĂĽAĂĽRELATIVE KINSHIPĂĽCARER sĂĽ )NĂĽ ĂĽ ĂĽ ĂĽFATALITIESĂĽWEREĂĽRECORDEDĂĽASĂĽAĂĽ RESULTĂĽOFĂĽFAMILYĂĽVIOLENCE ĂĽINĂĽ ĂĽ ĂĽ ĂĽFATALITIES ĂĽ ANDĂĽSOĂĽFARĂĽINĂĽ ĂĽ ĂĽ ĂĽFATALITIESĂĽDUEĂĽTOĂĽ&6 Sources: WA Police and AIHW Child protection Australia Report 2012-13

Ms Batty said the opinions of young people in relation to violence and masculinity were also concerning and a concerted effort needed to change those as well. ,ONGTIME #%/ĂĽOFĂĽTHEĂĽ 7OMEN SĂĽ#OUNCILĂĽ FORĂĽ$OMESTICĂĽ Family Violence Services WA Angela Hartwig couldnâ&#x20AC;&#x2122;t agree with her more. In her 20 years at the centre she has seen Ms Angela Hartwig the community response to domestic and family violence wax and wane. â&#x20AC;&#x153;Over the years initiatives have been implemented that give some sort of promise that the system is responding to victims but often they are made to feel the violence was a result of a ďŹ&#x201A;aw in their own character,â&#x20AC;? she said. â&#x20AC;&#x153;That cohort then starts presenting at medical

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In the Pipeline sĂĽ 4HEĂĽ,AWĂĽ2EFORMĂĽ#OMMISSIONĂĽHADĂĽRECOMMENDEDĂĽ ĂĽLEGALĂĽ CHANGESĂĽAROUNDĂĽFAMILYĂĽVIOLENCE ĂĽ ĂĽOFĂĽWHICHĂĽRELATEDĂĽTOĂĽNEWĂĽ separate restraining orders for family and domestic violence victims. sĂĽ .EWĂĽ&AMILYĂĽ6IOLENCEĂĽ2ESTRAININGĂĽ/RDERSĂĽWILLĂĽMODERNISEĂĽTHEĂĽ deďŹ nition of family violence, away from proof of abuse to behaviour intended to intimidate, coerce or control. sĂĽ -AGISTRATEĂĽDISCRETIONĂĽINĂĽISSUINGĂĽAĂĽ&62/ĂĽWILLĂĽBEĂĽREMOVEDĂĽ and courts must adopt a risk management approach by CONSIDERINGĂĽ7!ĂĽ0OLICE ĂĽANDĂĽ'OVTĂĽ!GENCYĂĽINFORMATIONĂĽANDĂĽ perhaps ordering mandatory counselling. sĂĽ &ROMĂĽ*ULYĂĽ ĂĽCOURTSĂĽWILLĂĽREARRANGEĂĽCASEĂĽLISTINGSĂĽSOĂĽTHATĂĽ &62/ĂĽBREACHESĂĽANDĂĽSERIOUSĂĽASSAULTĂĽMATTERSĂĽAREĂĽHEARDĂĽONĂĽ one designated day to ensure the victim support and other specialists are available. (Family violence courts did not reduce reoffending.) sĂĽ !TĂĽTHEĂĽ"ARNDIMALGUĂĽCOURTĂĽINĂĽ'ERALDTON ĂĽINVOLVINGĂĽ!BORIGINALĂĽ community members in specialised court responses to family violence was a crucial part of their model. practices. They think thereâ&#x20AC;&#x2122;s something wrong with themselves and are pathologised as such and end up with a mental health diagnosis.â&#x20AC;? Prof Donna Chung from #URTINĂĽ5NIVERSITYĂĽ told Medical Forum she had been investigating this in a study of ĂĽWOMENĂĽWHOĂĽ had left violent relationships. While the results are yet Prof Donna Chung to be published, $ONNAĂĽSAIDĂĽTHATĂĽ early evaluation pointed to most of these women being perfectly well-adjusted prior to their violent relationship, dispelling the longheld myth that â&#x20AC;&#x2DC;a certain type of woman went for a certain type of manâ&#x20AC;&#x2122;. Long-term impacts of violence What was indisputable was the lasting impact of these relationships on their lives and the lives of

their children, which impacted on their options for housing, work and social development. â&#x20AC;&#x153;The study explores womenâ&#x20AC;&#x2122;s lives before, during and after their involvement in these relationships and most are pushed away from social activities such as sport, friendships, social groups. The stats show these activities falling away to NOTHING vĂĽ$ONNAĂĽSAID Angela said that while the reporting system had improved for women and there were positive initiatives to keep women in the family home, resources could not keep up with the demand. h2EFUGESĂĽWILLĂĽALWAYSĂĽBEĂĽNEEDEDĂĽASĂĽANĂĽINTEGRALĂĽ part to crisis response.â&#x20AC;? If family violence were to receive the same sort of funding as the governmentâ&#x20AC;&#x2122;s response to terrorism, Angela would have a few projects sheâ&#x20AC;&#x2122;d like to see funded immediately. The Safe at Home program has been an option FORĂĽSOMEĂĽWOMEN ĂĽBUTĂĽNOTĂĽALL ĂĽSINCEĂĽ ĂĽWHICHĂĽ allows women and children to stay in their own home. If the woman has equity in her home and is able to maintain tenancy, then she and

the children stay and get case management support form Safe at Home team for up to a year. Six sites are funded in WA and Angela would like to see a lot more of those rolled out across the state. â&#x20AC;&#x153;There should be greater investment in perpetrator intervention programs, so that men who breach an order are able to obtain support and knowledge to ďŹ rstly diffuse reactive revenge motivated violence and secondly to DISCOVERĂĽWHATĂĽITĂĽMEANSĂĽTOĂĽBREACHĂĽAĂĽ62/ ĂĽ)TĂĽ gives these men a chance to get some help.â&#x20AC;? â&#x20AC;&#x153;A small study is being conducted ACCOMMODATINGĂĽ ĂĽMENĂĽnĂĽWEĂĽNEEDĂĽAĂĽFOURĂĽ more of those centres so that more intensive work can be done with these men who want to change their use of violence.â&#x20AC;? â&#x20AC;&#x153;And there needs to be some strong, sustained programs in schools which teach gender equality and healthy relationships that are embedded in curriculum. We need to be emulating the â&#x20AC;&#x2DC;no smokingâ&#x20AC;&#x2122; and â&#x20AC;&#x2DC;drink/driveâ&#x20AC;&#x2122; campaigns which have demonstrated real behaviour change.â&#x20AC;? â&#x20AC;&#x153;Australia needs a national bipartisan program to reduce violence against women and children. 7EĂĽDON TĂĽWANTĂĽTOĂĽWAITĂĽ ĂĽYEARSĂĽTOĂĽSEEĂĽAĂĽFEWĂĽ initiatives roll out.â&#x20AC;? Contacts 7!ĂĽ0OLICEĂĽENCOURAGEĂĽDOCTORSĂĽTOĂĽPROMOTE reporting incidents to police. Support agencies include: sĂĽ Crisis Care UnitĂĽnĂĽ ĂĽ ĂĽ sĂĽ Sexual Assault Resource Centre â&#x20AC;&#x201C; ĂĽ ĂĽ sĂĽ Family HelplineĂĽnĂĽ ĂĽ ĂĽ sĂĽ -ensline AustraliaĂĽnĂĽ ĂĽ ĂĽ sĂĽ Womenâ&#x20AC;&#x2122;s Domestic Violence nĂĽ ĂĽ sĂĽ Menâ&#x20AC;&#x2122;s Domestic Helpline â&#x20AC;&#x201C; ĂĽ ĂĽ ĂĽORĂĽ ĂĽ sĂĽ Kids HelplineĂĽnĂĽ ĂĽ ĂĽ

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Incisions

GPs Tackling Family Violence Rosie Batty wants us all to take family violence personally and make a difference, for which she speaks some home truths. Australiaâ&#x20AC;&#x2122;s rates of family violence are shocking and hard to comprehend with one in three women and one in four children affected by family violence. Family violence can happen to anybody. No matter how nice your house is, how intelligent you are. )TĂĽISĂĽINEVITABLEĂĽTHATĂĽ'0SĂĽWORKINGĂĽINĂĽ!USTRALIAĂĽ will have patients who are impacted by family VIOLENCE ĂĽ7OMENĂĽANDĂĽCHILDRENĂĽVISITĂĽTHEIRĂĽ'0ĂĽ REGULARLYĂĽWITHĂĽHEALTHĂĽCONCERNSĂĽANDĂĽ'0SĂĽCANĂĽ help identify family violence and ensure victims are referred to the specialised help they need. I recently gave a patientâ&#x20AC;&#x2122;s perspective to a GROUPĂĽOFĂĽ'0SĂĽWHENĂĽ)ĂĽSPOKEĂĽATĂĽTHEĂĽ2!#'0ĂĽ 7OMENĂĽINĂĽ'ENERALĂĽ0RACTICEĂĽ#OMMITTEE SĂĽ family violence conference in Melbourne. I told THEĂĽGATHEREDĂĽ'0SĂĽABOUTĂĽHOWĂĽITĂĽFEELSĂĽWAITINGĂĽ in a busy practice room knowing you have reached a point where you need extra help. ,IKEĂĽMOSTĂĽPEOPLEĂĽWHOĂĽAREĂĽVICTIMSĂĽOFĂĽFAMILYĂĽ VIOLENCE ĂĽ)ĂĽDIDN TĂĽPRESENTĂĽTOĂĽMYĂĽ'0ĂĽANDĂĽSAY ĂĽ â&#x20AC;&#x2DC;Iâ&#x20AC;&#x2122;m in a violent relationship, help meâ&#x20AC;&#x2122;. In my case, I presented to my doctor with signiďŹ cant anxiety. I had reached a point where I couldnâ&#x20AC;&#x2122;t

Itâ&#x20AC;&#x2122;s important for GPs to remember that the safety of their patients must come ďŹ rst

get out of my pyjamas, ďŹ nish an email or prioritise the tasks that were important I visited my doctor only a few weeks after ,UKE SĂĽFATHERĂĽHADĂĽPHYSICALLYĂĽASSAULTEDĂĽMEĂĽ for the ďŹ rst time. This was the ďŹ rst time I was seriously concerned for my physical safety and I called the police and waited a long time for them to come. I was still trying to cope with this incident when I visited my doctor who was very understanding and also very concerned. -YĂĽ'0ĂĽHELPEDĂĽMEĂĽUNDERSTANDĂĽTHATĂĽ)ĂĽNEEDEDĂĽ medication for the anxiety, medication I am still on because it helps me manage my condition. 4HISĂĽAPPOINTMENTĂĽWITHĂĽMYĂĽ'0ĂĽWASĂĽTHEĂĽlRSTĂĽ time I was able to admit I needed extra help to cope with my anxiety and the assurances from

my doctor helped me to accept that getting help was OK. Victims of family violence can present in complex situations with complex problems that are not always easily linked back to VIOLENCE ĂĽ)T SĂĽIMPORTANTĂĽFORĂĽ'0SĂĽTOĂĽREMEMBERĂĽ that the safety of their patients must come lRST ĂĽ'0SĂĽNEEDĂĽTOĂĽCONSIDERĂĽIFĂĽTHEIRĂĽPATIENTSĂĽAREĂĽ at risk and link them to specialised services that can provide the care they need. /NĂĽWHATĂĽWOULDĂĽHAVEĂĽBEENĂĽ,UKE SĂĽ THĂĽ birthday, on June 20 this year I launched the Never Alone campaign to push for changes that will reduce Australiaâ&#x20AC;&#x2122;s shockingly high rates of family violence. We want to empower women, give children a voice and hold perpetrators accountable. ED. Further reading Never Along campaign: www.neveralone.com.au RACGPâ&#x20AC;&#x2122;s resource for GPs: Abuse and violence: working with our patients in general practice, 4th edition, (the White book) go to: www.racgp.org.au/ your-practice/guidelines/whitebook/

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AUGUST 2015 | 13

Have You Heard?

The gall to change

Buttons and homeless reports

$RĂĽ,EONĂĽ!DAMSĂĽATĂĽ#HARLIESĂĽHASĂĽFOUNDĂĽINĂĽ ĂĽ NON ALCOHOLICĂĽFATTYĂĽLIVERĂĽDISEASEĂĽ .!&,$ ĂĽ patients that venesection offered no beneďŹ ts. Fat in the liver, liver injury, insulin resistance, and quality-of-life didnâ&#x20AC;&#x2122;t improve with regular venesection, which is likely to be abandoned in THEĂĽONEĂĽTHIRDĂĽOFĂĽPATIENTSĂĽWITHĂĽ.!&,$ĂĽANDĂĽRAISEDĂĽ levels of iron in their blood. Venesection was thought to improve insulin resistance and the progression of liver injury in these patients.

Button batteries in many common household items including remote controls, calculators, bathroom scales, car keys, etc pose a threat to kids, especially children under ďŹ ve. Stuck in the throat, the batteries are said to react with saliva and burn through the oesophagus in as little ASĂĽTWOĂĽHOURS ĂĽ-EANWHILE ĂĽTHEĂĽ#OMMISSIONERĂĽ FORĂĽ#HILDRENĂĽANDĂĽ9OUNGĂĽ0EOPLEĂĽINĂĽ7!ĂĽHASĂĽJUSTĂĽ released their Literature Review â&#x20AC;&#x201C; Children who are Homeless ĂĽDONEĂĽBYĂĽ1LDĂĽ5NI ĂĽ4HEĂĽ2EVIEWĂĽISĂĽ great reading, outlines gaps in knowledge and includes summaries of important past research (see www.ccyp.wa.gov.au under â&#x20AC;&#x153;reportsâ&#x20AC;?).

Practice nurses will deliver 4HEĂĽ(ON ĂĽ3USSANĂĽ,EYĂĽHASĂĽALLOCATEDĂĽ MĂĽ OVERĂĽTHREEĂĽYEARSĂĽTOĂĽ!0.!ĂĽSOĂĽITĂĽCANĂĽDELIVERĂĽTHEĂĽ .URSINGĂĽINĂĽ0RIMARYĂĽ(EALTHĂĽ#AREĂĽ0ROGRAM ĂĽ!0.!ĂĽ 0RESIDENTĂĽ+ARENĂĽ"OOTHĂĽSAIDĂĽNURSESĂĽWEREĂĽATĂĽ the forefront of the primary health care system and could combat rising costs and demands â&#x20AC;&#x201C; mainly chronic disease and ageing with a strong focus on rural and remote communities and those with the greatest health needs.

RACGP appears cashed up

Dr Leon Adams

2EMEMBERĂĽTHEĂĽDAYSĂĽWHENĂĽTHEĂĽ2!#'0ĂĽWASĂĽ in deep water ďŹ nancially? Things seem to be buzzing along nicely now and the collegeâ&#x20AC;&#x2122;s visible ďŹ nancial reporting is beyond statutory REQUIREMENTS ĂĽ!CCORDINGĂĽTOĂĽTHEĂĽ ĂĽ!NNUALĂĽ 2EPORT ĂĽREVENUEĂĽTHATĂĽYEARĂĽFROMĂĽ-EMBERSHIP ĂĽ 1)ĂĽ ĂĽ#0$ĂĽ&EESĂĽINCREASEDĂĽBYĂĽABOUTĂĽ MĂĽFROMĂĽ THEĂĽPREVIOUSĂĽYEARĂĽTOĂĽ M ĂĽ4HEĂĽCOLLEGE SĂĽ core business increased too, with revenue INCREASEDĂĽBYĂĽABOUTĂĽ MĂĽTOĂĽ MĂĽFORĂĽ%DUCATION ĂĽ

#OURSEĂĽ2EGISTRATIONĂĽ ĂĽ/THERĂĽ&EES ĂĽ)NCOMEĂĽFROMĂĽ 2ESEARCHĂĽ ĂĽ/THERĂĽ'RANTSĂĽANDĂĽ$ONATIONSĂĽWASĂĽ DOWNĂĽABOUTĂĽ MĂĽTOĂĽ M

WAâ&#x20AC;&#x2122;s GP training support Health Minister Kim Hames says government WILLĂĽFUNDĂĽTHEĂĽ#OMMUNITYĂĽ2ESIDENCYĂĽ0ROGRAM ĂĽ WITHĂĽ ĂĽORĂĽMOREĂĽ2-/SĂĽTOĂĽUNDERTAKEĂĽCOMMUNITYĂĽ PLACEMENTSĂĽINĂĽ ĂĽ CONTRACTSĂĽTOĂĽBEĂĽPUTĂĽ to tender). State Health spent $4.2m on it last year. The aim is to improve training pathways to general practice and importantly, to rural general practice and Aboriginal health to take OVERĂĽFROMĂĽTHEĂĽFEDERALLYĂĽFUNDEDĂĽ0REVOCATIONALĂĽ 'ENERALĂĽ0RACTICEĂĽ0LACEMENTSĂĽ0ROGRAMĂĽ CEASEDĂĽ ENDĂĽOFĂĽ

RHD disgrace amongst Aboriginal kids 0ROFĂĽ*ONATHONĂĽ#ARAPETISĂĽFROMĂĽTHEĂĽ4ELETHONĂĽ +IDSĂĽ)NSTITUTEĂĽCHAIRSĂĽ7! SĂĽ2HEUMATICĂĽ(EARTĂĽ $ISEASEĂĽCLINICALĂĽADVISORYĂĽGROUP ĂĽANDĂĽHASĂĽ SAIDĂĽ2($ĂĽINĂĽ!BORIGINALĂĽCOMMUNITIESĂĽISĂĽAĂĽBADĂĽ SIGN ĂĽ.OW ĂĽ2($ĂĽHASĂĽBEENĂĽMADEĂĽAĂĽNOTIlABLEĂĽ disease (it joins acute rheumatic fever), which it is hoped will improve data and therefore TARGETEDĂĽINTERVENTIONS ĂĽ2ECURRINGĂĽEPISODESĂĽOFĂĽ !2&ĂĽCANĂĽCOMPOUNDĂĽHEARTĂĽDAMAGEĂĽANDĂĽTHISĂĽ Strep initiated problem is almost exclusive to Aboriginal communities in remote areas.

Telemedicine predictions Just as we published our review of Telemedicine and ďŹ&#x201A;agged Telstraâ&#x20AC;&#x2122;s foray into THISĂĽAREA ĂĽ4ELSTRAĂĽ(EALTH SĂĽ2EADY#AREĂĽSERVICEĂĽ was ofďŹ cially launched. An assistant works out from a call if a doctor is needed, gets the

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'0ĂĽTOĂĽRINGĂĽBACKĂĽ FROMĂĽ!LEXANDRIAĂĽINĂĽ3YDNEY ĂĽ SOĂĽhPATIENTSĂĽCANĂĽTALKĂĽWITHĂĽAĂĽ'0ĂĽUSINGĂĽPHONEĂĽ or video, upload images of their condition and receive comprehensive care.â&#x20AC;? And so on. 4HEIRĂĽ#LINICALĂĽ!DVISORYĂĽ0ANELĂĽCONSISTSĂĽOFĂĽPASTĂĽ 0RESIDENTSĂĽOFĂĽTHEĂĽ2!#'0 ĂĽ!#22-ĂĽANDĂĽTHEĂĽ #OLLEGEĂĽFORĂĽ%MERGENCYĂĽ-EDICINE ĂĽ#OVER -OREĂĽ 'ROUP ĂĽWHICHĂĽPROVIDESĂĽTRAVELĂĽINSURANCEĂĽANDĂĽ medical assistance to travellers, has signed on WITHĂĽ2EADY#ARE

Doctors, now dentists &ROMĂĽ*ULYĂĽ ĂĽTHEĂĽ!USTRALIANĂĽ$ENTALĂĽ)NDUSTRYĂĽ Association has taken on a new code of practice designed to ensure treatment decisions are based on sound clinical evidence, not driven by incentives or other inďŹ&#x201A;uences. The ethical conduct of all parties and the quality use of therapeutic products are mentioned. The dentists will be more in line with government initiatives to align the codes affecting medicines and medical devices.

WA rural workforce snapshot 2URALĂĽ(EALTHĂĽ7EST SĂĽREPORTĂĽFinding My Place DETAILSĂĽTHEĂĽRURALĂĽ'0ĂĽWORKFORCE ĂĽBOTHĂĽANECDOTALLYĂĽ and with facts. Things you may not know is the NUMBERĂĽOFĂĽ'0ĂĽREGISTRARSĂĽ TRAINEES ĂĽMAKEĂĽ ĂĽ OFĂĽTHEĂĽRURALĂĽ'0ĂĽWORKFORCE ĂĽ)NTERNATIONALĂĽ-EDICALĂĽ 'RADUATESĂĽCONTINUEĂĽTOĂĽMAKEĂĽUPĂĽ ĂĽANDĂĽ WA has the highest proportion of solo general PRACTITIONERSĂĽNATIONALLYĂĽ ĂĽ)NĂĽ ĂĽ ĂĽ doctors joined the permanent workforce from THEIRĂĽ'0ĂĽTRAININGĂĽPROGRAM ĂĽREPRESENTINGĂĽ ĂĽOFĂĽ all new arrivals, doctors employed for more than ĂĽYEARSĂĽINCREASEDĂĽBYĂĽ ĂĽWITHĂĽDOCTORSĂĽSTAYINGĂĽ LONGERĂĽTHANĂĽ ĂĽYEARSĂĽINCREASEDĂĽTOĂĽ

Health needs rescuing? Itâ&#x20AC;&#x2122;s happening outside medicine tool. Government is looking for researchers and industry to boost the commercial returns from research, and for universities and industry to collaborate more. The Australian Research Council has given 21 research grants worth $8.3m to WA to promote industry-university linkages (of $294m in grants applied for nationally, only $87m was approved, and an additional $153m has been pledged by industry). Healthâ&#x20AC;&#x2122;s priority areas include more efďŹ ciency, indigenous health, and self-care that uses mobile apps, remote monitoring and online access.

We take care of you â&#x20AC;Ś so you can take care of others Rural Health West has been recruiting GPs to country WA for over 25 years. If you want to practise interesting and challenging medicine, contact us today. T 08 6389 4500 E recruit@ruralhealthwest.com.au W www.ruralhealthwest.com.au

MEDICAL FORUM

AUGUST 2015 | 15

Trailblazer

A Journey of a Lifetime When paediatrician Dr James Fitzpatrick went to Fitzroy Crossing in 2008, town sobriety was a struggle. Now the focus is on making FASD SD history history. y. In September 2013, Medical Forum spoke to June Oscar, one of the women elders who led the campaign in the Fitzroy Valley to restrict the sale of full-strength alcohol ďŹ ve years earlier. Back then she recounted with pride how the restrictions had transformed her community but Fetal Alcohol Spectrum Disorder (FASD) was now the great challenge before them.

Dr James Fitzpatrick

Itâ&#x20AC;&#x2122;s a challenge they do not face ALONE ĂĽ$RĂĽ*AMESĂĽ Fitzpatrick, architect of the ,ILILWANĂĽ3TUDY ĂĽ has developed tools to diagnose &!3$ĂĽINĂĽTHEĂĽVALLEYĂĽ and helped the community ďŹ nd ways to prevent and treat the condition.

Itâ&#x20AC;&#x2122;s been a powerful experience for the 40-yearold, who is attached to Telethon Kids Institute. â&#x20AC;&#x153;The change has come from within the community. They put their hands up and said we have a big problem here; our kidsâ&#x20AC;&#x2122; future and the continuation of our culture are at risk,â&#x20AC;? he said. â&#x20AC;&#x153;The community leaders were courageous and clever enough to say we can do most of it ourselves â&#x20AC;&#x201C; we can get community support AGAINSTĂĽ&!3$ĂĽUSINGĂĽOURĂĽOWNĂĽORGANISATIONSĂĽ such as the womenâ&#x20AC;&#x2122;s centre and the Aboriginal Medical Service to run activities but we need research partners and agents of change to partner us.â&#x20AC;? His commitment to the people of Fitzroy #ROSSINGĂĽWASĂĽBORNĂĽOFĂĽHISĂĽRURALĂĽROOTSĂĽ HEĂĽWASĂĽ born in Bathurst, NSW), a year in the army, and a medical career in the West. Responding to rural kids

James with one of his charges, Tristan

means they can accommodate their needs better. Itâ&#x20AC;&#x2122;s hoped the long-term cycle of mental health, alcohol abuse and contact with the justice system will reduce two to fourfold with early intervention and supportive family environments.â&#x20AC;? â&#x20AC;&#x153;Stimulating behaviour change through improved regulation and executive functioning is in the school-based Alert program across EIGHTĂĽSCHOOLSĂĽINĂĽTHEĂĽ+IMBERLEY ĂĽ#HILD ĂĽPARENT ĂĽ and teacher all have strategies to deal with behaviour working largely with sensory strategies. None of them is rocket science but they help.â&#x20AC;? â&#x20AC;&#x153;Working around memory impairment with stepby-step visual routines help children to carry out their daily tasks. Sometimes these visual cues need to go into adolescence and adulthood.â&#x20AC;?

At UWA, he joined the rural health club 30).20(%8ĂĽWHEREĂĽHEĂĽURGEDĂĽTHEĂĽGROUPĂĽTOĂĽ change its focus towards community service WITHĂĽCHILDREN SĂĽWELFAREĂĽCENTRAL ĂĽ)NĂĽ ĂĽHEĂĽ ORGANISEDĂĽTHEĂĽ#ARNARVONĂĽ#HILDREN SĂĽ&ESTIVAL ĂĽTOĂĽ build community and reduce racial tension in THEĂĽTOWNĂĽnĂĽTHISĂĽWASĂĽRECOGNISEDĂĽWITHĂĽTHEĂĽ ĂĽ Young Australian of the Year award.

(EĂĽSAIDĂĽDRUGSĂĽDON TĂĽWORKĂĽINĂĽ&!3$ĂĽBUTĂĽSOMEĂĽ SLEEPĂĽDISTURBANCE ĂĽSEVEREĂĽBEHAVIOURS ĂĽ!$($ĂĽ may respond. Approach to therapy needs to be individualised.

But his focus is on the here and now.

â&#x20AC;&#x153;I know anecdotally that young women are pressuring each other not to drink particularly INĂĽPREGNANCY ĂĽ&!3$ĂĽHASĂĽALLOWEDĂĽTHEĂĽCOMMUNITYĂĽ to talk about alcohol, which takes the blame and shame off everyone. Their message to each other is â&#x20AC;&#x2DC;We need to settle down for our children and the continuity of our cultureâ&#x20AC;&#x2122;. There has been a change in the social norms.â&#x20AC;?

h4OĂĽMAKEĂĽ&!3$ĂĽHISTORYĂĽWEĂĽWANTĂĽTOĂĽDRIVEĂĽDOWNĂĽ DRINKINGĂĽINĂĽPREGNANCYĂĽTOĂĽBELOWĂĽ ĂĽBYĂĽ ĂĽANDĂĽ the community is well on the way to do that.â&#x20AC;? â&#x20AC;&#x153;We are also mindful of the children already AFFECTEDĂĽBYĂĽ&!3$ĂĽANDĂĽHOWĂĽITĂĽIMPACTSĂĽONĂĽTHEIRĂĽ lives both at home and school. These families need support to understand the strengths and LIMITATIONSĂĽOFĂĽ&!3$ AFFECTEDĂĽCHILDREN ĂĽWHICHĂĽ

16 | AUGUST 2015

Alcohol tackled head-on 4HEĂĽ,ILILWANĂĽSTUDYĂĽHASĂĽSTRENGTHENEDĂĽTHEĂĽ&ITZROYĂĽ communityâ&#x20AC;&#x2122;s resolve to control drinking.

h)NĂĽ ĂĽ ĂĽOFĂĽWOMENĂĽWEREĂĽDRINKINGĂĽINĂĽTHEĂĽlRSTĂĽ TRIMESTER ĂĽINĂĽ ĂĽITĂĽHASĂĽREDUCEDĂĽTOĂĽ ĂĽ4HISĂĽISĂĽ

real change which empowers the community to WORKĂĽTOWARDSĂĽTHATĂĽ ĂĽBYĂĽ ĂĽGOAL v The lesson of the Fitzroy Valley is that ambitious goals can be met when everyone works cohesively â&#x20AC;&#x201C; a model that is being followed in other communities. He said communities just need to be aware of the problem and be willing to do something about it. h$ELEGATESĂĽFROMĂĽCOMMUNITIESĂĽOFĂĽTHEĂĽ7ESTERNĂĽ $ESERTĂĽHAVEĂĽTRAVELLEDĂĽTOĂĽ&ITZROYĂĽTOĂĽTALKĂĽTOĂĽ*UNEĂĽ /SCAR ĂĽ-AUREENĂĽ#ARTERĂĽANDĂĽ%MILYĂĽ#ARTERĂĽANDĂĽ that peer-to-peer support is most powerful. 7HENĂĽ(ALLSĂĽ#REEKĂĽWORKEDĂĽTHROUGHĂĽALCOHOLĂĽ restrictions, they received enormous support from Fitzroy. Now ďŹ ve years on, there has been AĂĽ ĂĽDECREASEĂĽINĂĽALCOHOL RELATEDĂĽHOSPITALĂĽ admissions and police activity.â&#x20AC;? Proving restrictions work â&#x20AC;&#x153;What we can do as researchers is generate data to support the need for restrictions by SHOWINGĂĽTHEIRĂĽEFFECTIVENESS ĂĽ)NĂĽ ĂĽSALESĂĽOFĂĽ pure alcohol from one takeaway outlet alone in &ITZROYĂĽ#ROSSINGĂĽWASĂĽ ĂĽLITRESĂĽORĂĽ ĂĽ CANSĂĽOFĂĽFULL STRENGTHĂĽBEERĂĽINĂĽAĂĽTOWNĂĽOFĂĽ ĂĽ people. Six months post-restrictions and that SALESĂĽRATEĂĽHADĂĽDROPPEDĂĽBYĂĽ v â&#x20AC;&#x153;Just imagine the beneďŹ ts of that seismic change in chronic alcohol sales.â&#x20AC;? 3OMEĂĽ&ITZROYĂĽDRINKERSĂĽSHOWEDĂĽUPĂĽINĂĽ%$SĂĽINĂĽ $ERBY ĂĽ7YNDHAMĂĽANDĂĽ(ALLSĂĽ#REEK ĂĽBUTĂĽTHEĂĽ increases were modest, according to James. BeneďŹ ts far outweighed these ill-effects, however. continued on Page 32

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AUGUST 2015 | 17

Feature

Almost Mission Impossible They are the face of medicine and all things to all people â&#x20AC;&#x201C; three GPs give their reďŹ&#x201A;ections while our e-Poll results provide an interesting backdrop. Itâ&#x20AC;&#x2122;s still the best job in the world for Midland '0 ĂĽDr Nicholas Stanley-Cary, but the weight of responsibility for making unpopular DECISIONS ĂĽLIKEĂĽDOINGĂĽ#ENTRELINK SĂĽDIRTYĂĽWORK ĂĽ can leave a bad taste.

â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve got better things to do, such as looking after people who are sick.â&#x20AC;? â&#x20AC;&#x153;Having said that, itâ&#x20AC;&#x2122;s a wonderful privilege to do this job and I love the fact that people trust us. The trick for me is to take lots of holidays, go running, SKIINGĂĽANDĂĽSITĂĽINĂĽTHEĂĽSAUNAĂĽWITHĂĽMYĂĽ"EATTYĂĽ0ARKĂĽMATES vĂĽ Dr Jeff VelingĂĽISĂĽAĂĽ#HURCHLANDSĂĽ'0ĂĽWHOĂĽSAYSĂĽ the social context of what they do is growing.

h$ELIVERINGĂĽAĂĽDISAPPOINTINGĂĽASSESSMENTĂĽ REGARDINGĂĽAĂĽ#ENTRELINKĂĽBENElTĂĽCANĂĽGENERATEĂĽAĂĽ bit of tension and it also has the potential to slightly depreciate a meaningful professional exchange. Youâ&#x20AC;&#x2122;re supposedly the patientâ&#x20AC;&#x2122;s Dr Nicholas advocate, yet you have to say â&#x20AC;&#x2DC;sorry, you can Stanley-Cary go to the toilet by yourself and you can walk up the stairsâ&#x20AC;&#x2122; and sometimes they think youâ&#x20AC;&#x2122;re a bit of a meanie.â&#x20AC;? h4HEY REĂĽSITTINGĂĽTHEREĂĽTHINKINGĂĽ@WELL ĂĽWHOSEĂĽSIDEĂĽAREĂĽYOUĂĽON ĂĽ!SĂĽAĂĽ'0ĂĽ youâ&#x20AC;&#x2122;re placed in a position where you have to tell them that what theyâ&#x20AC;&#x2122;re ASKINGĂĽFORĂĽISĂĽQUITEĂĽINAPPROPRIATE ĂĽ#ENTRELINKĂĽSAYĂĽTHEY VEĂĽGOTĂĽAĂĽDUTYĂĽOFĂĽCAREĂĽ to tell people that these beneďŹ ts exist.â&#x20AC;? â&#x20AC;&#x153;It does get a bit stressful at times, particularly when assessing a personâ&#x20AC;&#x2122;s capacity to drive, and it would be nice if there were a few more ďŹ lters in place before some of these issues turn up at the surgery. A lot of departments, it would seem, are saying take this form to a doctor and theyâ&#x20AC;&#x2122;ll sort it out.â&#x20AC;?

What GPs Do Best

e-Poll

ĂĽ'0SĂĽGAVEĂĽTHEIRĂĽVIEWSĂĽONĂĽIMPORTANTĂĽTASKSĂĽTHEYĂĽUNDERTAKE by answering this question: Some say the family doctor, during his/her normal work, is crucial to personally ďŹ xing or preventing certain problems. Please tick any situations you think this applies to. M+F

Screening for certain disorders

Quit smoking

0ARENTINGĂĽPROBLEMS

71%

57%

Management of disability

0APERWORKĂĽFORĂĽHEALTHĂĽBENElTS E G ĂĽ#ENTRELINK ĂĽ

49%

60%

$OMESTICĂĽVIOLENCEĂĽnĂĽVICTIM

-EDICAREĂĽ#AREĂĽ0LANS

$RIVINGĂĽSAFELY

51%

39%

Work disputes

23%

34%

$OMESTICĂĽVIOLENCEĂĽnĂĽPERPETRATOR

2ADICALISATIONĂĽOFĂĽRELIGIOUSĂĽZEALOTS

Uncertain

None of these choices

* Indicates the percentage of females and males who chose this answer â&#x20AC;&#x201C; major discordance between the sexes are highlighted.

â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t take many new patients these days, particularly those who want to be bulk-billed, because they often come along with multiple problems. Some might say thatâ&#x20AC;&#x2122;s not entirely fair but weâ&#x20AC;&#x2122;ve only got so much time we can give to patients.â&#x20AC;? â&#x20AC;&#x153;At this point in my career I tend not to see new patients from the outer suburbs. They also present with complex issues because THEIRĂĽLOCALĂĽ'0ĂĽHASN TĂĽWANTEDĂĽTO ĂĽORĂĽCOULDN T ĂĽ sort out their problems. A new patient from the outer suburbs relys on public transport, which often means missed appointments and further stress on time management.â&#x20AC;? Dr Jeff Veling

â&#x20AC;&#x153;I recently saw a lady who lives on her own with no family backup and little social support. She wanted me to write a letter to Homes West asking them not to do inspections on her home and restrain neighbours from harassing her. I prefer to do medicine, not sorting out social problems that are often insurmountable and time-consuming.â&#x20AC;? Jeff feels changes in the aged care sector will add another layer of complexity. â&#x20AC;&#x153;The government is putting the onus on us to provide additional services and, from July, people will need to apply for the funding for their own care rather than a package supplied to them by aged care organisations. Inevitably, a lot of this is going to fall back on us.â&#x20AC;? â&#x20AC;&#x153;And itâ&#x20AC;&#x2122;s important to remember that as we age so do our patients and THEIRĂĽREQUIREMENTS ĂĽEVERYTHINGĂĽFROMĂĽTAXIĂĽVOUCHERSĂĽTOĂĽ!#2/$ĂĽSTICKERSĂĽANDĂĽ #ENTRELINKĂĽQUERIES ĂĽBECOMEĂĽMOREĂĽCHALLENGING ĂĽ9OU LLĂĽGETĂĽCOMMENTSĂĽSUCHĂĽ as â&#x20AC;&#x2DC;my friend gets her physiotherapy for free, so why canâ&#x20AC;&#x2122;t I?â&#x20AC;&#x2122; All this can be very difďŹ cult and itâ&#x20AC;&#x2122;s getting worse.â&#x20AC;? Unlike her city colleagues, .ARROGINĂĽ'0ĂĽDr Mariet Job is feeling no pain. The bush is a foreign country, they do things differently there. â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t feel too much pressure regarding raised expectations because I set very clear BOUNDARIES ĂĽ) MĂĽ$UTCH ĂĽ)ĂĽCALLĂĽ a spade a spade and country people are a bit different. Theyâ&#x20AC;&#x2122;re pragmatic, they live close to the land and they know the drill â&#x20AC;&#x201C; youâ&#x20AC;&#x2122;re born, you live, you die.â&#x20AC;?

Dr Mariet Job

â&#x20AC;&#x153;I had one guy who wanted a medical certiďŹ cate because he was worried about ďŹ&#x201A;ying his aeroplane with a self-diagnosed collapsed lung. I sent him STRAIGHTĂĽTOĂĽ%$ĂĽTOĂĽGETĂĽAĂĽDRAINĂĽPUTĂĽIN v â&#x20AC;&#x153;In any case, there are ways around these things. If I think someoneâ&#x20AC;&#x2122;s a bit marginal driving a car Iâ&#x20AC;&#x2122;ll arrange for an occupational therapy assessment.â&#x20AC;? â&#x20AC;&#x153;In Holland these sorts of things are done by a doctor whoâ&#x20AC;&#x2122;s not THEĂĽPATIENT SĂĽ'0 ĂĽ)TĂĽMAKESĂĽITĂĽSOĂĽMUCHĂĽNICERĂĽANDĂĽTHERE SĂĽNOĂĽNEEDĂĽFORĂĽ arguments.â&#x20AC;?

By Mr Peter McClelland 18 | AUGUST 2015

MEDICAL FORUM

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MEDICAL FORUM 0IEHIVW MR 1IHMGEP -QEKMRK

Guest Column

A Motherâ&#x20AC;&#x2122;s Eyes Janina Faulkner, President of SANDS WA, reďŹ&#x201A;ects on the moment she learnt her child had died and reminds us how much doctors inďŹ&#x201A;uence things. For every bereaved parent it is a tragically unique event accompanied by a multitude of different reactions â&#x20AC;&#x201C; grief, shock, confusion and anger. Common to all is the fact that their subsequent care will have a huge impact on their long-term wellbeing.. )ĂĽWASĂĽ ĂĽYEARS OF AGEĂĽANDĂĽINĂĽMYĂĽ STĂĽWEEKĂĽ of pregnancy with my ďŹ rst baby when I found myself sitting in front of my obstetrician. Heâ&#x20AC;&#x2122;d just ďŹ nished telling me that the ultrasound Iâ&#x20AC;&#x2122;d had earlier that morning conďŹ rmed there was no heartbeat and that my baby had â&#x20AC;&#x2DC;died in utero.â&#x20AC;&#x2122; The rest was a blur, but I do remember the words â&#x20AC;&#x2DC;go home, you will probably go into labour spontaneously. If you donâ&#x20AC;&#x2122;t, Iâ&#x20AC;&#x2122;ll see you in a weekâ&#x20AC;&#x2122;s time.â&#x20AC;&#x2122;

The doctor hadnâ&#x20AC;&#x2122;t given me any information but, to be honest, I hadnâ&#x20AC;&#x2122;t thought to ask. It was only after I got home that I thought of a million questions.

then, the one thing I do know from supporting others is that understanding, sensitivity and warmth from a medical team can make a big difference.

A work colleague had experienced perinatal loss and was involved with a group called 3!.$3 ĂĽ;%$ ĂĽ4HISĂĽISĂĽNOĂĽLONGERĂĽANĂĽACRONYMĂĽ but rather a â&#x20AC;&#x2DC;taglineâ&#x20AC;&#x2122; for miscarriage, stillbirth and neonatal death support.] So I got in touch with them and they became my lifeline during this difďŹ cult time and throughout my two subsequent pregnancies.

Some helpful hints? sĂĽ "EĂĽGENTLEĂĽANDĂĽPATIENT ĂĽ0ARENTSĂĽWILLĂĽOFTENĂĽASKĂĽ the same questions over and over again. It will help them if they feel comfortable being able to ask the â&#x20AC;&#x2DC;pettiestâ&#x20AC;&#x2122; of questions. sĂĽ "EĂĽAWAREĂĽOFĂĽTHEIRĂĽEMOTIONALĂĽNEEDS ĂĽ,ISTENĂĽ to what theyâ&#x20AC;&#x2122;re saying and give them permission to grieve. sĂĽ 4RYĂĽTOĂĽUSEĂĽPLAIN ĂĽSIMPLEĂĽ%NGLISHĂĽWITHĂĽMINIMALĂĽ medical jargon. sĂĽ 'IVEĂĽPARENTSĂĽASĂĽMUCHĂĽTIMEĂĽASĂĽPOSSIBLE with their baby; many regret they didnâ&#x20AC;&#x2122;t spend longer. sĂĽ %NCOURAGEĂĽTHEMĂĽTOĂĽCREATEĂĽMEMORIESĂĽnĂĽ photographs, a lock of hair, a hand/ foot print. sĂĽ ,ETĂĽPARENTSĂĽKNOWĂĽABOUTĂĽ3!.$3ĂĽANDĂĽOTHERĂĽ support services.

Three decades later I still donâ&#x20AC;&#x2122;t have an answer for why my son died but I have learnt to accept it. Although my loss was quite a long time ago, and the medical profession has changed since

My son, Keith was born three weeks later. The obstetrician and the scan were correct, there was no heartbeat. I really liked this doctor. He was kind, professional and obviously knew his stuff but, naturally enough, I needed a lot of emotional support. I left his ofďŹ ce wondering what to do, how I was going to get through all this and who I could I talk to?

He was kind, professional and obviously knew his stuff but, naturally enough, I needed a lot of emotional support.

ED. SANDS Contacts: 24hr National Support Line 1300 072 637; www.sands.org.au; and SANDS WA 0424340115 E: supportwa@sands.org.au

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Image re-produced with permission from BreastScreen Australia

MEDICAL FORUM

AUGUST 2015 | 21

Guest Column

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Prof John Yovich

ESHRE 2015 â&#x20AC;Ś continuing to advance the frontiers in Reproductive Medicine The annual meeting of the European Society for Human Reproduction and Embryology was held in Lisbon in June this year and continues to showcase a vast array of ideas which will impact on Australia and New Zealand.

Chief Psychiatrist Dr Nathan Gibson has helpful advice for anyone preparing for the November launch of the new long-awaited Mental Health Act.

Clinical Professor John Yovich

The meeting was held at the International Lisbon Fair which easily accommodated the more than 10,000 delegates attending workshops, plenary sessions, industry symposia and 6 parallel sessions along with extensive trade displays over 5 days. This conference venue was set in a new city to the north on the river Tagus which embraced tourist attractions, a vast multilayered shopping mall, huge concert hall and a cable car connecting the Vasco da Gama Tower to a modern Oceanarium and nearby Living Science Centre. Numerous high-rise hotels in the area provided 15,000 high-class rooms. Those of us who stayed in Lisbon old city had numerous transport options including bus, train, metro, trams and even boat ferries and gondolas in the cable car. Whilst the Europeans could not understand why Australiaâ&#x20AC;&#x2122;s earlier preeminent position in Reproductive Medicine had slipped away so dramatically, they paid respect to our Lisbonâ&#x20AC;&#x2122;s monument to the Portuguese Explorers philosophy of who left their inďŹ&#x201A;uence in so many parts of the single embryo world including South-east Asia transfers and were following $XVWUDOLDÂˇV OHDG EXW DSSO\LQJ PRUH VFLHQWLĂ&#x20AC;F UDWLRQDOLVDWLRQ ZLWK respect to embryo selection. Many IVF clinics had moved to universal pre-implantation genetic screening of embryos to detect both chromosomal aneuploidies and genetic anomalies and the technologies had rapidly advanced to meet this advanced trend. PIVET has initiated a debate on this issue which is currently being expressed in the pages of the journal Human Reproduction, but one senses the European views, particularly from Spain, will prevail.

NOW AT 2 LOCATIONS PERTH & BUNBURY

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

22 | AUGUST 2015

Mental Health Act Coming Soon

As announced by the Minister for Mental Health, November 30 is the big day â&#x20AC;&#x201C; the Mental Health Act WA 2014 (MHA 2014) is due to commence. What does this mean for medical practitioners in WA? &IRSTLY ĂĽDON TĂĽPANIC ĂĽ-ENTALĂĽ(EALTHĂĽ!CTĂĽ7!ĂĽ ĂĽ -(!ĂĽ ĂĽISĂĽSTILLĂĽTHEĂĽ RELEVANTĂĽLAWĂĽUNTILĂĽ.OVEMBERĂĽ 0RACTICALLY ĂĽ-(!ĂĽ ĂĽMEANSĂĽGREATERĂĽRIGHTSĂĽFORĂĽPATIENTS ĂĽGREATERĂĽSTATUSĂĽ for families in mental healthcare and increased accountability processes for clinicians. The ďŹ rst two sound good, and the third sounds like more work for already overworked clinicians. Any new mental health legislation invariably brings increased accountability. The challenge will be to develop IT processes in WA that streamline the mental health forms, notiďŹ cations and reporting for clinicians - itâ&#x20AC;&#x2122;s a critical issue, and one which will, in part, deďŹ ne the successful implementation of the MHA. 4HEĂĽBIGGESTĂĽVARIATIONĂĽFROMĂĽ-(!ĂĽ ĂĽ TOĂĽTHEĂĽNEWĂĽ-(!ĂĽ ĂĽISĂĽTHEĂĽCHANGEĂĽTOĂĽ referral and involuntary criteria â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s now a capacity-basedĂĽ!CT ĂĽ#APACITY BASEDĂĽ legislation (WA is second in Australia, after Tasmania) deďŹ nes a marked shift in how we see restrictive care. An individual must lack capacity to consent, among other existing criteria, before the MHA can be invoked. There is a well-deďŹ ned set of capacity criteria SPECIlEDĂĽINĂĽTHEĂĽ-(!ĂĽ ĂĽANDĂĽTHISĂĽWILLĂĽ be a major focus of training.

MHA 2014 means greater rights for patients, greater status for families in mental healthcare and increased accountability for clinicians.

Who needs to know? ,ARGEĂĽNUMBERSĂĽOFĂĽDOCTORSĂĽANDĂĽOTHERĂĽCLINICIANSĂĽWORKINGĂĽINĂĽ-ENTALĂĽ (EALTH ĂĽ%MERGENCYĂĽ$EPARTMENTS ĂĽINĂĽTHEĂĽ2&$3 ĂĽANDĂĽACROSSĂĽSEVERALĂĽ sectors around WA will all need training suitable to their needs; several thousand professionals, which is no mean feat for the implementation team. Training will be through a mixture of online e-learning packages and a multitude of face-to-face opportunities across the state, available ESSENTIALLYĂĽINĂĽTHEĂĽTHREEĂĽMONTHSĂĽRUNNINGĂĽUPĂĽTOĂĽ-(!ĂĽ ĂĽCOMMENCEMENT ĂĽ 4HEĂĽ#LINICIANS ĂĽ0RACTICEĂĽ'UIDEĂĽTOĂĽTHEĂĽ-(!ĂĽ ĂĽHASĂĽBEENĂĽLAUNCHEDĂĽONĂĽ THEĂĽ7!ĂĽ#HIEFĂĽ0SYCHIATRIST SĂĽWEBSITEĂĽ WWW CHIEFPSYCHIATRIST WA GOV AU ĂĽSEEĂĽ h-ENTALĂĽ(EALTHĂĽ!CTĂĽANDĂĽ2EGULATIONSv ĂĽnĂĽNOWĂĽAVAILABLEĂĽTOĂĽALLĂĽCLINICIANSĂĽANDĂĽ the public. What about General Practitioners? -OSTĂĽ'0SĂĽRARELYĂĽUSEĂĽ-(!ĂĽFORMSĂĽnĂĽITĂĽMIGHTĂĽONLYĂĽBEĂĽONCEĂĽINĂĽ ĂĽYEARS ĂĽ3OĂĽ HOWĂĽDOĂĽWEĂĽINFORM EDUCATEĂĽ'0S ĂĽANDĂĽHOWĂĽDOĂĽTHEYĂĽREMEMBERĂĽWHATĂĽTHEYĂĽ HEARDĂĽ ĂĽYEARSĂĽAGO ĂĽ!ĂĽ'0ĂĽINFORMATIONĂĽROLLOUTĂĽISĂĽPLANNEDĂĽTHROUGHĂĽ a range of usual channels, including access to online training, easily digestible written overviews and brief face-to-face training. But if you forget and need urgent guidance then â&#x20AC;&#x153;just INĂĽTIMEvĂĽADVICEĂĽISĂĽONĂĽTHEĂĽ#HIEFĂĽ0SYCHIATRIST SĂĽWEBSITEĂĽ WWW chiefpsychiatrist.wa.gov.au). For those who want to (you know who you are), you can DOWNLOADĂĽ-(!ĂĽ ĂĽFROMĂĽWWW AUSTLII EDU AUĂĽANDĂĽHAVEĂĽSOMEĂĽ light bedtime reading â&#x20AC;&#x201C; all 402 pages!

MEDICAL FORUM

Clinical Opinion

Origins of attachment parenting

Medical Audiology Services

Hear the best you can! By Dr David Roberts, Paediatrician, Joondalup

Progressive and Late-Onset Hearing Loss In Children Timely management of hearing loss leads to better speech, language and learning outcomes for children. The current WA Newborn Hearing Screening Program covers all public and private maternity services across the state.

Prescriptions on how to raise children have a long history; from the Pentateuch and Plato, through Locke and Rousseau, to the 20th century. The most recent popular movement is Attachment Parenting. Examples of this are known as positive, non-aversive, ethical, nurture or â&#x20AC;&#x2DC;helicopterâ&#x20AC;&#x2122; parenting, as well as concerted cultivation, emotional coaching, and the circle of security.

Andre Wedekind

Some background !TTACHMENTĂĽ4HEORY ĂĽUPONĂĽWHICHĂĽ!TTACHMENTĂĽ0ARENTINGĂĽISĂĽBASED ĂĽWASĂĽlRSTĂĽ PROPOSEDĂĽBYĂĽ"RITISHĂĽPSYCHIATRISTĂĽ*OHNĂĽ"OWLBYĂĽPOSTĂĽ77)) ĂĽ,IKEĂĽ%RIKSON SĂĽ theory, it proposes that psychosocial development in humans occurs in stages. Bowlby sought to explain the origins of signiďŹ cant mental and behavioural problems in adolescence and adulthood, as the result of a disordered early childhood infant-mother relationship. He proposed that the childâ&#x20AC;&#x2122;s ďŹ rst stage is to bond to the caregiver, usually mother, not merely with affection, but attachment. The caregiver, in being reliable and responsive to needs, instils a sense of safety and security, an expectation of always being readily accessible, and conďŹ dence in secure attachment. Otherwise, healthy psychosocial development is at risk. American psychologist Mary Ainsworth extended Bowlbyâ&#x20AC;&#x2122;s concepts, devising a method of categorising security of attachment in infants, â&#x20AC;&#x2DC;The Strange Situationâ&#x20AC;&#x2122;. Its validity and reliability are not universally accepted. Using The Strange Situation, she and others found disordered attachment not only in mothers and babies presenting clinically with problems, but also in mother-infant â&#x20AC;&#x2DC;dyadsâ&#x20AC;&#x2122; randomly drawn from the population, and with unexpected frequency. Bowlbyâ&#x20AC;&#x2122;s idea that attachment disorders were a cause of mental ill health was then generalised; attachment disorders were seen as the major cause. Not so simple The many studies supporting this view have been criticised. This is for methodological ďŹ&#x201A;aws related to poor study design and ďŹ&#x201A;aws inherent in the paradigm of psychology research, which examines psychological constructs rather than observable reality (behaviourism excepted). Attachment theorists counter that their critics have the good fortune to work in more objective ďŹ elds. The evidence gap between Attachment Theory and clinical practice I E ĂĽ!TTACHMENTĂĽ0ARENTING ĂĽISĂĽALSOĂĽWIDE ĂĽ&ORĂĽPSYCHOLOGISTS ĂĽTHEĂĽTHEORYĂĽ suggests most causes of child behavioural problems are attachment related. Therefore parents should work with therapists to restructure their parenting style and practice, their internal working models of parenting. 4HISĂĽISĂĽAĂĽVARIATIONĂĽOFĂĽCOGNITIVEĂĽBEHAVIOURALĂĽTHERAPY ĂĽ0ARENTSĂĽAREĂĽINSTRUCTEDĂĽ TOĂĽBEĂĽ@SUPPORTIVE ĂĽANDĂĽRISKĂĽHARMINGĂĽTHEIRĂĽCHILDĂĽIFĂĽTHEYĂĽSAY ĂĽh.Ov ĂĽ0ARENTSĂĽ are often upset by the implication, but comply. A second consequence is drawn from the modern fashion of advocacy. Attachment Theory supports preventative mental health programs on the care of children SUCHĂĽASĂĽ4HEĂĽ#IRCLEĂĽOFĂĽ3ECURITYĂĽANDĂĽTHEĂĽ 0OSITIVEĂĽ0ARENTINGĂĽ0ROGRAMME ĂĽ,OCALLY ĂĽTHEĂĽ $ISABILITYĂĽ3ERVICESĂĽ#OMMISSION SĂĽ#ODEĂĽ FORĂĽTHEĂĽ%LIMINATIONĂĽOFĂĽ2ESTRICTIVEĂĽ 0RACTICESĂĽISĂĽANOTHERĂĽEXAMPLE ĂĽ Unfortunately, like breast-feeding advocates, zealotry is the rule rather than the exception. Author competing interests: no relevant disclosures. Questions? Please contact the author 9300 3002

MEDICAL FORUM

M.Aud.,M.Clin.Aud., BHSc (Physio)

Dr Vesna Maric AuD.,M.Aud.S.A.,M.Clin. Aud.,BSc.(Hons)

While such programs identify hearing loss in newborns, many children remain at risk of a permanent hearing loss developing in infancy and early childhood. Knowledge of the risk factors for late onset and progressive hearing loss is vital, along with continued vigilance in screening, monitoring and referrals. Rates of permanent hearing loss increase during childhood, meaning that some auditory dysfunctions develop (or worsen) only after routine newborn hearing screening is passed. Hereditary factors, infection, trauma and teratogens are among the leading causes.

An audiological evaluation is needed if any of the following risk factors are identiďŹ ed: Caregiver concern regarding hearing, speech, language or developmental delay Family history of permanent childhood hearing loss NICU stay more than 5 days Ototoxic medications Hyperbilirubinemia requiring exchange transfusion In utero infections (e.g. CMV, Herpes, Rubella, Syphillis, Toxoplasmosis) Craniofacial anomalies (involvement of pinna, ear canals, ear tags and pits) Temporal bone anomalies Physical ďŹ ndings associated with a syndrome Meningitis Head trauma requiring hospitalisation Neuro-degenerative disorders In young children, detecting hearing losses through observation is problematic, especially if the problem is mild or ďŹ&#x201A;uctuating. Immediate referral for comprehensive audiological testing is needed if any problems are suspected. Audiologists use a combination of electrophysiological and developmentally-appropriate behavioural tests to test hearing at any age and developmental level. Strict monitoring protocols may be required thereafter. It is important to remember that conductive hearing loss associated with otitis media remains the most common childhood hearing problem and can cause social, developmental and learning delays comparable to those observed through permanent hearing loss.

51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au

AUGUST 2015 | 23

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fertilitynorth.com.au 24 | AUGUST 2015

MEDICAL FORUM

Feature

The Wheels of the Bus... A teddy bear called Cyril and concert pianist David Helfgott have both made the lives of children with autism a little easier. Clinical psychologist Jeremy Marriott used every ounce of his resourcefulness and his long list of friends to make his study into anxiety in children with severe autism work successfully, starting with Cyril and David. Theyâ&#x20AC;&#x2122;re the poster boys for his PhD research into music as a disrupter of selfinjurious behaviour in these children. â&#x20AC;&#x153;The research uses a simulated school bus because a school bus was a more logical setting. If music were to be helpful listening to on the way to school it might get them there calmer. That could only be good for them, their teachers and their parents.â&#x20AC;? 4HEĂĽ#URTINĂĽ5NIVERSITYĂĽLECTURER SĂĽPREVIOUSĂĽWORKĂĽ in disability services shaped the structure of the study â&#x20AC;&#x201C; useful but with scientiďŹ c rigor. Thus begun a complex process, which started by MEETINGĂĽ$AVIDĂĽ(ELFGOTTĂĽWHOSEĂĽOWNĂĽSTRUGGLESĂĽ with mental illness formed the basis of the Academy Award winning ďŹ lm, Shine. h$AVIDĂĽISĂĽHUGELYĂĽGIFTEDĂĽANDĂĽVERYĂĽPHILANTHROPICĂĽ ANDĂĽHEĂĽANDĂĽHISĂĽWIFE ĂĽ'ILLIAN ĂĽAREĂĽPARTICULARLYĂĽ keen to help those who have challenges in their lives. He selected six pieces of music that he thought would have a calming effect and would meet the guidelines of Hooper and COLLEAGUESĂĽESTABLISHEDĂĽINĂĽ v

Pianist David Helfgott with Jeremy Marriott. Left: Jeremy hams it up in readiness for saliva sample collection.

over four consecutive weeks, with and without Beethovenâ&#x20AC;&#x2122;s input, with the accompanying saliva samples.

He selected music by Mozart, Beethoven and Brahms in three forms â&#x20AC;&#x201C; sonata, rondo and theme with variations, which he played and recorded. â&#x20AC;&#x153;I took the six pieces and created two-minute segments and built an online survey, deidentifying the pieces. The survey was then sent to service and support groups here, in the US, and in the UK and interested people WEREĂĽINVITEDĂĽTOĂĽTAKEĂĽPART ĂĽ0ARENTSĂĽRATEDĂĽHOWĂĽ calming the pieces were for their child. We came out with the second movement of the "EETHOVENĂĽSONATAĂĽ.OĂĽ ĂĽ/PĂĽ ĂĽ COMMONLYĂĽ KNOWNĂĽASĂĽTHEĂĽ0ATHETIQUE v Setting it up in readiness While waiting for his survey results, Jeremy started riding the special school bus from Mt (AWTHORNĂĽTOĂĽTHEĂĽ3IRĂĽ$AVIDĂĽ"RANDĂĽ#ENTREĂĽTOĂĽ plan the scene for his controlled trial. â&#x20AC;&#x153;I wanted the research to be translational, so I wanted to replicate the school bus interior as realistically as possible.â&#x20AC;? He recorded the sound of the bus with the HELPĂĽOFĂĽ#URTINĂĽSOUNDĂĽEXPERTĂĽ$ALEĂĽ4OWNER ĂĽANDĂĽ ďŹ lmed to project realistic images. He then went to West Van Quip, which retro-ďŹ t vans for wheelchairs, to ďŹ t a pair of bus seats designed by an engineer friend and built by his welder COUSIN ĂĽ4HEĂĽ#URTINĂĽ#HEMISTRYĂĽ$EPARTMENTĂĽ offered him the use of the perfect room, and his school bus simulator was ready for his randomised control trial.

MEDICAL FORUM

Jeremy needed to record biomarkers, so FUNDINGĂĽFROMĂĽTHEĂĽ3TATEĂĽ#HILDĂĽ$EVELOPMENTĂĽ #ENTREĂĽALLOWEDĂĽHIMĂĽTOĂĽBUYĂĽSWABS ĂĽTUBESĂĽANDĂĽ reagents for saliva samples, while friends in Health Sciences showed him how to take the samples and analyse them. 4WOĂĽGROUPSĂĽOFĂĽ ĂĽBOYSĂĽWITHĂĽSEVEREĂĽAUTISMĂĽ were chosen and one by one they came to the bus simulator. They sat in the bus seat, their seat belt was clipped in and the ďŹ rst saliva sample was taken. Those who had the music â&#x20AC;&#x2DC;bus rideâ&#x20AC;&#x2122; had another sample taken DIRECTLYĂĽAFTERĂĽANDĂĽTHENĂĽAGAINĂĽAFTERĂĽ ĂĽ ĂĽAND 20 minutes. â&#x20AC;&#x153;The kids couldnâ&#x20AC;&#x2122;t have breakfast beforehand, so it was difďŹ cult for some, but others quite liked it because they couldnâ&#x20AC;&#x2122;t clean their teeth either. After the trial, it was mufďŹ n and a drink COURTESYĂĽOFĂĽTHEĂĽ#URTINĂĽCAFĂ&#x17D; v Saliva shows anxiety drop â&#x20AC;&#x153;The saliva analysis showed that the kids who participated in the music group had signiďŹ cantly lower amylase and cortisol levels than the non-music group. Music did calm these children, which led to the third phase.â&#x20AC;? Three school-aged boys, known as Master Wednesday, Master Thursday and Master Friday all demonstrate confronting selfinjurious behaviours. They visited the simulator

4HISĂĽISĂĽWHEREĂĽ#YRILĂĽTHEĂĽ4EDDYĂĽ"EARĂĽCOMESĂĽIN ĂĽ #YRIL ĂĽNAMEDĂĽAFTERĂĽONEĂĽOFĂĽ*EREMY SĂĽBIOMEDĂĽ SUPERVISORSĂĽ! 0ROFĂĽ#YRILĂĽ-AMOTTE ĂĽWOREĂĽ special glasses ďŹ tted with a small camera to record the boysâ&#x20AC;&#x2122; behaviour. The results in study three were fascinating and, in Master Fridayâ&#x20AC;&#x2122;s case, revolutionary. Master Friday has a mouth reďŹ&#x201A;ex where he has to be chewing on something all the time, which has impacted on his jaw development and displaced teeth. â&#x20AC;&#x153;His activity prior to the music was high FREQUENCYĂĽnĂĽOVERĂĽ ĂĽONĂĽMYĂĽRECORDSĂĽnĂĽBUTĂĽ when the music started he was transďŹ xed; he focused on the sound, he stopped self-injuring and his biomarkers all dropped. I thought, THAT SĂĽMYĂĽ0H$ĂĽRIGHTĂĽTHERE v The other two boys were ear blockers and had ear infections as a result. While their results were interesting, they werenâ&#x20AC;&#x2122;t quite as remarkable as Master Friday. â&#x20AC;&#x153;I know from my clinical work how big an issue anxiety is for people with autism right along the spectrum and the everyday world is not geared up to accommodate them. If we can get an idea of what their baseline anxiety is, we can make a difference.â&#x20AC;?

By Ms Jan Hallam

AUGUST 2015 | 25

26 | AUGUST 2015

MEDICAL FORUM

AUGUST 2015 | 27

Geneaâ&#x20AC;&#x2122;s GeneSyte prenatal test provides reliable, comprehensive answers about the health of a developing foetus. The test represents a major advancement in prenatal testing, providing accurate answers about foetal chromosomal healthâ&#x20AC;&#x201D;without the risks associated with invasive procedures, such as amniocentesis or chorionic villus sampling (CVS). Performed as early as 10 weeks gestation, [OL [LZ[ KLTVUZ[YH[LZ Z\WLYI ZLUZP[P]P[` HUK ZWLJPĂ&#x201E;JP[` MVY [OL TVZ[ WYL]HSLU[ [YPZVTPLZ GeneSyte can also detect sex chromosome aneuploidies in singleton pregnanciesâ&#x20AC;&#x201D;at no extra charge. I !:9:>:8D * '@=91= >D90=:81

I **+ 7591217?1= >D90=:81

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I *++ -/:.> >D90=:81

I :1?-7 >1C ** := *+ K-50> 59 =5>6 >?=-?5G/-?5:9 :2 * 759610 05>:=01=> >@/4 -> 418:;4575-

Test performance in most common sex aneuploidies1 N

Sensitivity

95% CI H

:WLJPĂ&#x201E;JP[`

INTENDED USE:

95% CI

Accuracy

95% CI

'45> >/=119593 ?1>? 5> 59?19010 2:= ;-?519?> -? B116> := 3=1-?1= 31>?-?5:9 B5?4 >59371?:9 := ?B59 ;=139-9/51> B4: 811? -9D :2 ?41 2:77:B593 /=5?1=5- I 0A-9/10 8-?1=9-7 -31 * D1-=> 2:= >59371?:9 -90 * D1-=> 2:= ?B59 ;=139-9/51> -? 0175A1=D I $:>5?5A1 >1=@8 >/=119

Source: Verinata Health Inc. (2012). MX â&#x20AC;&#x201C; Monosomy X (Turner syndrome) â&#x20AC;&#x201C; XXX, XXY, XYY: Limited data of these more rare aneuploides preclude performance calculations.

I .9:=8-7 @7?=->:@90 I 5>?:=D >@331>?5A1 :2 59/=1->10 =5>6 2:= ' ' := ' := >1C /4=:8:>:81 -91@;7:50D

What will the results say?

Expansion into twin pregnancies.

I ;:>5?5A1 =1>@7? 5905/-?1> ?4-? :91 :2 ?41 /4=:8:>:8-7 /:905?5:9> 59/7@010 59 ?41 >/=119593 ;-917 4-> .119 01?1/?10 $=139-9/51> ?4-? -=1 ;:>5?5A1 2:= -91@;7:50D B577 .1 /71-=7D 5019?5G10 59 ?41 =1>@7?> 2:= 1C-8;71 F'45> ;=139-9/D 4-> >/=11910 -> - '=5>:8D !-71 18-71 :1?@>J

%1/19?7D ?41 ;=19-?-7 ?1>? 4-> .119 1C;-9010 ?: 59/7@01 ?41 :;?5:9 ?: ?1>? 2:= ' ' -90 ' 59 .:?4 8:9:ED3:?5/ -90 05ED3:?5/ ?B59 ;=139-9/51> ?1>? 2:= ?41 ;=1>19/1 :2 ?41 + /4=:8:>:81 /-9 .1 :=01=10 2:= ?B59> -> B177

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

An easy, non-invasive blood test delivering the answers you seek in just days. 191&D?1 5> 1->D ?: :=01= -90 9110> :97D - >58;71 .7::0 >-8;71 &58;7D /:8;71?1 191- > $=19-?-7 %1<@1>? :=8 -90 -0A5>1 D:@= ;-?519? ?: -??190 - 191- /:771/?5:9 /19?=1K59 )1>?1=9 @>?=-75- ?41 /:771/?5:9 /19?=1 5> :77DB::0 1=?575?D 19?=1K2:= ?415= .7::0 ?1>? ->D ?: =1-0 =1;:=?> -=1 -A-57-.71 B5?459 B:=6593 0-D> 2=:8 >-8;71 =1/15;?

A Genea Prenatal Request Form is available from www.hollywoodivf.com/doctorsinformation/useful-forms.aspx

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MEDICAL FORUM

Clinical Update

Eosinophilic oesophagitis in children Eosinophilic Oesophagitis (EoE) is a relatively new disease causing signiďŹ cant upper gastrointestinal morbidity in children. Diagnosis is based on symptoms of oesophageal dysfunction associated with at least 15-eosinophils/high power ďŹ eld in an oesophageal biopsy specimen, as well as exclusion of other causes of oesophageal eosinophilia. %O%ĂĽINCIDENCEĂĽOFĂĽABOUTĂĽ ĂĽNEWĂĽCASEĂĽPERĂĽ ĂĽ per year is thought to be an underestimate, with a steady rise in incidence over the last decade. In ĂĽAĂĽ FOLDĂĽRISEĂĽINĂĽPREVALENCEĂĽOFĂĽBIOPSYĂĽPROVENĂĽ %O%ĂĽOVERĂĽTHEĂĽPRECEDINGĂĽ ĂĽYEARS ĂĽPARALLELEDĂĽTHEĂĽ rise in allergies for children of Western Australia. How children present #HILDRENĂĽPRESENTĂĽWITHĂĽVARIABLEĂĽSYMPTOMSĂĽTHATĂĽ are usually age-dependent (compared to adults where dysphagia is universal). sĂĽ )NFANTSĂĽANDĂĽTODDLERSĂĽAREĂĽMOREĂĽLIKELYĂĽTOĂĽ present with difďŹ culty feeding, manifest as gagging, choking, refusal of certain foods (mainly solids) and vomiting. sĂĽ 9OUNGERĂĽCHILDRENĂĽEXPERIENCEĂĽVOMITING ĂĽ regurgitation, water brash and decreased appetite. sĂĽ $YSPHAGIAĂĽANDĂĽFOODĂĽBOLUSĂĽIMPACTIONĂĽISĂĽNOTĂĽ commonly seen until adolescence.

MEDICAL FORUM

By Dr Kunal Thacker, Paediatric Gastroenterologist & Hepatologist

Facts: Eosinophilic Oesophagitis

2ISKĂĽOFĂĽCOMPLICATIONSĂĽ OESOPHAGEALĂĽSTRICTURE ĂĽ increases with duration of untreated disease.

sĂĽ !ĂĽCLINICALĂĽENTITYĂĽMADEĂĽMOREĂĽIMPORTANTĂĽBY a rise in incidence. sĂĽ !ĂĽHIGHĂĽINDEXĂĽOFĂĽSUSPICIONĂĽHELPSĂĽWITHĂĽEARLYĂĽ diagnosis. sĂĽ 'ASTROSCOPYĂĽANDĂĽRANDOMĂĽOESOPHAGEALĂĽ biopsies from at least two segments (proximal and distal) are required to conďŹ rm the diagnosis. sĂĽ #OMPLICATIONSĂĽCANĂĽENSUEĂĽWITHOUTĂĽTREATMENTĂĽ (either topical steroids or long term avoidance of the offending dietary allergens).

'ASTROSCOPYĂĽANDĂĽBIOPSIESĂĽREMAINĂĽTHEĂĽONLYĂĽ tests to conďŹ rm the diagnosis. Macroscopic appearance in younger children is inďŹ&#x201A;ammatory (loss of vascularity, linear furrowing and white exudate), whereas older children and adolescents may demonstrate additional ďŹ brotic features (trachealisation, crepe-paper oesophagus and strictures). A proportion of children may have normal looking oesophageal mucosa at endoscopy but diagnosis is made on histology. Treatments

#HILDRENĂĽWITHĂĽ%O%ĂĽAREĂĽUSUALLYĂĽSLOWĂĽEATERS ĂĽ avoid certain meats, cut meat in small pieces and consume a lot of water with their meals. There is higher rate of atopy (asthma, eczema, hay fever and allergies) in these children. #HILDRENĂĽWITHĂĽSOMEĂĽOTHERĂĽMEDICALĂĽDISORDERSĂĽ are known to be at increased risk of EoE e.g. TRACHEOESOPHAGEALĂĽlSTULA ĂĽ$OWNĂĽSYNDROME ĂĽ heart defects and connective tissue disorders. Diagnostic dilemmas Symptoms of EoE overlap with gastroesophaGEALĂĽREmUXĂĽDISEASEĂĽ '%2$ ĂĽ4HEREĂĽCANĂĽBEĂĽSIGNIlcant delay in diagnosis from onset of symptoms; MOREĂĽTHANĂĽTHEĂĽDOCUMENTEDĂĽDELAYĂĽOFĂĽMOREĂĽTHANĂĽ ĂĽ years in adults and even more in children.

Topical corticosteroids and dietary elimination is the mainstay of treatment for children with EoE. Other treatments such as antihistamines, mast cell stabilizers and biologic therapies are not for routine use. A six-food elimination diet has been superior to an elimination diet based on skin prick tests, in both children and adults. New pharmacological modalities including biologic therapy are being explored as a result of improved understanding of pathophysiology. Author competing interests: none relevant. Questions? Contact the author please on 9310 8778.

AUGUST 2015 | 29

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Clinical Opinion

How to prevent family violence? Early education of boys about gender equality and non-violent behaviour management may help stem domestic violence, says Dr Alan Campbell, PhD.

Thereâ&#x20AC;&#x2122;s a new name for the Stateâ&#x20AC;&#x2122;s leading Ophthalmic Day Hospital.

Media attention on the impact of family and domestic violence (FDV) has raised awareness of this problem. Decisive and effective interventions are needed to address the damaging effects of family violence on children, their parents and the community. &$6ĂĽISĂĽCOMPLEX ĂĽ7HILEĂĽITĂĽINCLUDESĂĽPHYSICALĂĽACTSĂĽOFĂĽVIOLENCE ĂĽCURRENTĂĽ Australian deďŹ nitions are broader and encompass acts such as emotional, psychological and ďŹ nancial abuse, social isolation and sexual assault. !ĂĽMAJORĂĽPARTĂĽOFĂĽ&$6ĂĽISĂĽTHEĂĽPERPETRATOR SĂĽABILITYĂĽTOĂĽINSTILĂĽFEARĂĽINĂĽTHEĂĽVICTIMĂĽ and children, through use of words, gestures and behaviours calculated to control and intimidate someone else. Fear also involves the exercise of power over that person. Because men are in more powerful positions THANĂĽWOMEN ĂĽMOSTĂĽPERPETRATORSĂĽOFĂĽ&$6ĂĽAREĂĽMEN ĂĽ Services have therefore focused both on protecting women and their children, and on approaches to change the behaviours of men. #URTINĂĽ5NIVERSITYĂĽISĂĽRESEARCHINGĂĽWHATĂĽAPPROACHESĂĽAREĂĽAVAILABLEĂĽANDĂĽWHETHERĂĽ THEYĂĽEFFECTIVELYĂĽSTOPĂĽMENĂĽFROMĂĽPERPETRATINGĂĽ&$6 ĂĽ0REVIOUSĂĽSTUDIESĂĽHAVEĂĽ found that group programs for men are successful in the short-term but methodological ďŹ&#x201A;aws raise doubts about long-term outcomes. Using comparison groups creates a dilemma. Many studies do not use them as withholding service to a man can be considered unethical. Those that do, often look to program dropouts to study the differences between those who stay and those who go. Some studies have used recidivism rates but these rely on police reports or reports from the victims themselves, the reliability of which has been questioned. Behavioural programs are also more reactive than proactive, targeting MENĂĽWHOĂĽHAVEĂĽBEENĂĽVIOLENT ĂĽ2EACHINGĂĽMALESĂĽATĂĽANĂĽEARLIERĂĽSTAGEĂĽINĂĽTHEIRĂĽ lives, before they begin to use violence, would reďŹ&#x201A;ect a more proactive APPROACHĂĽTOWARDSĂĽPREVENTINGĂĽ&$6 ĂĽ Early education in schools, focusing on respect, equality between the genders, non-violent ways of managing negative experiences, communication, and relationship building and maintenance, may help young males to reject violent behaviours in the future. A broad sex education curriculum that also challenges bullying, inappropriate sexualised behaviours and the use of power will also CONTRIBUTEĂĽTOĂĽTHEĂĽPREVENTIONĂĽOFĂĽFUTUREĂĽ&$6

In recognition of our expanded service area (the entire metropolitan area), our international-standard specialisation (â&#x20AC;&#x2DC;Eyeâ&#x20AC;&#x2122; surgery) and our substantially increased scale (weâ&#x20AC;&#x2122;re a leading Western Australian day hospital), the Eye Surgery Foundationâ&#x20AC;&#x2122;s name has changed to Perth Eye Hospital. As the Perth Eye Hospital we continue to offer an unmatched team of world-class surgeons and support professionals. All with access to state-of-the-science technology and systems. We remain as passionate about providing patient care and comfort as we have been since our inception in 1987.

References on request ED: The author is a lecturer at Curtin Uniâ&#x20AC;&#x2122;s School of Occupational Therapy and Social Work.

To see everything we offer, simply visit pertheyehospital.com.au or call 9216 7900.

The RACGP has its Whitebook on Abuse & Violence at www.racgp.org.au/yourpractice/guidelines/whitebook/. At 152 pages (fully downloadable and searchable as a pdf), it is not light reading but it contains mostly everything about abuse and violence in both common and uncommon situations. It includes what to look for, assessment tools, what patients want, society attitudes, and resources for each State. Chapters of particular interest are Violence & the Law, Dealing With Perpetrators in Clinical Practice, Safety & Risk Assessment, and Young People & Bullying. Whether â&#x20AC;&#x153;medicalisingâ&#x20AC;? domestic violence is a step in the right direction is debatable but this document is great for improving vigilance and awareness amongst both female and male doctors.

42 Ord Street West Perth 6005

MEDICAL FORUM

AUGUST 2015 | 31

Clinical Update

Hip problems in children Hip problems in paediatric patients not infrequently present with thigh or knee pain (mediated by the obturator nerve), perhaps with no associated hip or groin symptoms. Transient synovitis of the hip (aka: Irritable Hip Syndrome) is one of the commonest childhood hip disorders affecting approximately two per ĂĽCHILDRENĂĽANNUALLY ĂĽ)TĂĽTENDSĂĽTOĂĽAFFECTĂĽCHILDRENĂĽ INĂĽEARLYĂĽPRIMARYĂĽSCHOOLĂĽ n ĂĽYEARĂĽOLDS ĂĽANDĂĽCANĂĽ clinically resemble several other conditions. These can be divided into infections (septic arthritis or osteomyelitis, pyomyositis, appendicitis or abdominal /pelvic abscess), inďŹ&#x201A;ammation (juvenile idiopathic arthritis and chronic recurrent multifocal osteomyelitis), MECHANICALĂĽCONDITIONSĂĽ 0ERTHESĂĽDISEASE ĂĽ slipped upper femoral epiphysis, and femoral stress fracture) and neoplastic disorders (osteoid osteoma, leukaemia, solid tumours, and pigmented vilonodular synovitis). In young children, the differentiation between transient synovitis and septic arthritis is time critical due to the potentially catastrophic consequences of delayed treatment of an infection. Unfortunately, there is no one investigation or

By Dr Colin Whitewood, Orthopaedic Surgeon, Nedlands

Hip Hints in Children sĂĽ +NEEĂĽORĂĽTHIGHĂĽPAINĂĽCANĂĽRELATEĂĽTOĂĽHIPĂĽPROBLEMS sĂĽ 4RANSIENTĂĽHIPĂĽSYNOVITISĂĽISĂĽMOSTĂĽCOMMONĂĽANDĂĽ can mimic other problems. sĂĽ %32 ĂĽ7##ĂĽ ĂĽNONĂĽWEIGHTĂĽ bearing, fever together predict infection. sĂĽ #AREFULĂĽEXAMINATION ĂĽHISTORYĂĽANDĂĽPERHAPSĂĽ hip x-rays aid in diagnosis. blood test that can distinguish between the two conditions. Kocher et al investigated this ISSUEĂĽ ĂĽANDĂĽEXAMINEDĂĽTHEĂĽIMPORTANCEĂĽ of a history of fever, non-weight bearing, an %32ĂĽOFĂĽATĂĽLEASTĂĽ ĂĽMM HR ĂĽANDĂĽAĂĽWHITEĂĽCELLĂĽ COUNTĂĽOFĂĽMOREĂĽTHANĂĽ ĂĽTHEĂĽPROBABILITYĂĽ FORĂĽSEPTICĂĽARTHRITISĂĽWASĂĽ ĂĽIFĂĽTHREEĂĽOFĂĽTHESEĂĽ VARIABLESĂĽWEREĂĽPRESENTĂĽANDĂĽWASĂĽOVERĂĽ ĂĽIFĂĽ all four predictors were present. The authors recommended careful observation without aspiration if none of the four independent predictors are present. Legg-Calve-Perthes disease (or avascular necrosis) is much less common than transient SYNOVITIS ĂĽ4HEĂĽSYMPTOMSĂĽOFĂĽ0ERTHESĂĽCANĂĽBEĂĽHIGHLYĂĽ variable, episodic and some children can be

completely symptom-free and unaware of a hip condition. This male dominated condition takes about ďŹ ve years to proceed from the initial vascular insult to the ďŹ nal remodelling of the femoral head and a good result can usually be predicted in the younger children (less than six years of age at diagnosis) and in those children who maintain good range of motion in all directions. An obese adolescent with a limp has a slipped upper femoral epiphysis (SUFE) until proven otherwise. With the epidemic of childhood obesity in the western world, there has been an increase in the incidence of SUFE along with it being seen more in preadolescent children. When seeing an overweight teenager who complains of knee pain, remember to check the hips! The lack of internal rotation in ďŹ&#x201A;exion is usually a giveaway, but all these children SHOULDĂĽHAVEĂĽX RAYSĂĽPERFORMED ĂĽINSISTINGĂĽONĂĽ!0ĂĽ and lateral views (usually more obvious on the lateral views). Author competing interests: no relevant disclosures. Questions? Contact the author 9389 3800

A Journey of a Lifetime continued from Page 16 â&#x20AC;&#x153;Fitzroy perceived it had a problem, it was like a burglary, so they put a lock on their door. This approach has had a knock-on effect with a growing number of communities considering similar restrictions. It speaks volumes to the importance of a regional approach.â&#x20AC;? #LINICALLY ĂĽ*AMESĂĽSAIDĂĽTHEREĂĽWASĂĽAĂĽHUGEĂĽGAPĂĽINĂĽ DIAGNOSTICĂĽCAPACITYĂĽFORĂĽ&!3$ â&#x20AC;&#x153;Until recently we didnâ&#x20AC;&#x2122;t have diagnostic guidelines but our group and Sydney University have developed a diagnostic tool, which is currently being trialled. It will increase the capacity of child development services and

PAEDIATRICIANSĂĽTOĂĽLOOKĂĽFORĂĽ&!3$ĂĽANDĂĽACTUALLYĂĽ diagnose it.â&#x20AC;?

neurological impairment of others with no known cause, may be alcohol exposure.â&#x20AC;?

Diagnosis is crucial

4HEĂĽ!USTRALIANĂĽ0AEDIATRICĂĽ3URVEILLANCEĂĽ5NITĂĽ ĂĽGIVESĂĽ&!3$ĂĽPREVALENCEĂĽASĂĽ

â&#x20AC;&#x153;Being able to link, at an individual level, [alcohol] exposure and brain damage is a powerful driver of prevention for the mother of that child. It also raises visibility in the COMMUNITY ĂĽ2IGHTĂĽNOWĂĽIT SĂĽINVISIBLE v (EĂĽSAIDĂĽTHEIRĂĽGROUPĂĽISĂĽWORKINGĂĽWITHĂĽTHEĂĽ.$)3ĂĽONĂĽ interventions for children and young adults with &!3$ĂĽTOĂĽlNDĂĽWHATĂĽWORKSĂĽANDĂĽWHATĂĽNEEDSĂĽTOĂĽBEĂĽ done differently. The assessment they do has four components: sĂĽ !LCOHOLĂĽEXPOSUREĂĽINĂĽPREGNANCYĂĽ QUANTIlED sĂĽ !SSESSĂĽGROWTH ĂĽWHICHĂĽMAYĂĽBEĂĽRELATEDĂĽTOĂĽ alcohol use in pregnancy. sĂĽ &ACIALĂĽFEATURES sĂĽ #OMPLEXĂĽCENTRALĂĽNERVOUSĂĽSYSTEMĂĽ assessment. For small children, paediatric assessment; and school-aged children assessments by psychologist, speech therapist, OT and paediatrician. â&#x20AC;&#x153;We assess where the strengths and weakness of the individual lie and if the neurological weaknesses are signiďŹ cant enough to classify as neural-development impairment, it would be CALLEDĂĽ&!3$ v

Paediatrician James with Hudson

32 | AUGUST 2015

â&#x20AC;&#x153;We donâ&#x20AC;&#x2122;t want to over-diagnose this problem because there are a lot of people exposed to alcohol during pregnancy who are doing ďŹ ne, or are not signiďŹ cantly impaired. However,

h)NĂĽTHEĂĽ53 ĂĽTHEĂĽlGUREĂĽISĂĽBETWEENĂĽ ĂĽ which makes it the most common cause of preventable neural-development impairment,â&#x20AC;? James adds. h)NĂĽ!USTRALIA ĂĽ&!3$ĂĽDOESN TĂĽTRIGGERĂĽDISABILITYĂĽ FUNDINGĂĽWHEREASĂĽAUTISMĂĽ; ĂĽOFĂĽ!USTRALIANS ĂĽ !"3ĂĽ =ĂĽDOES ĂĽ!ND ĂĽUNLIKEĂĽAUTISM ĂĽ&!3$ĂĽ has a stigma, so physicians are often more uncomfortable making a diagnosis. But we NEEDĂĽTOĂĽREMEMBER ĂĽ&!3$ĂĽISĂĽ ĂĽPREVENTABLE v â&#x20AC;&#x153;Our job as doctors is to encourage the best health outcomes for our clients and there is no time of life more critical than in pregnancy and early childhood. To make our jobs easier, there needs to be a simple, united and strong voice on the importance of no alcohol during pregnancy.â&#x20AC;? â&#x20AC;&#x153;If we complicate the discussion, if we start debating what a standard drink is or how many glasses, we not only confuse the public, we also confuse ourselves. There is no generic â&#x20AC;&#x2DC;safeâ&#x20AC;&#x2122; amount, so take ambiguity out of the discussion. We as doctors need to counsel every single person with this consistent and strong message. It is as simple and as difďŹ cult as that.â&#x20AC;?

By Ms Jan Hallam

MEDICAL FORUM

REGENERATE LUMBAR DISC

First & Exclusive PRP Stem Cell Specialist Centre in WA

PREVENT DISC DEGENERATION

Pre Injury Control MRI

Post Injury MRI

57M with many years of low back pain. He had numerous cortisone injections, facet rhizotomy over several years.

Following a twisting injury he

Figure 1: T2 weighted MRI images, sagittal (top image) and axial (lower image) of the lumbar spine few years before current injury are the control images of this report.

show complex longitudinal and

The yellow arrows show the intact annulus fibrosus ligament pre injury.

Post Rx MRI at 3 months

suffered foot drop and sciatica. Figure 2: Sagittal (top) and axial (lower) T2 weighted MRI images radial tears (red arrows) of the L3/4 disc posterior annulus fibrosus ligament (broken yellow lines in lower image). Reduced signal of central disc nucleus in the top image compared to 4 years ago (figure 1 top image) is due to loss of hydration. However disc height is preserved over this time.

Dr Arockia rockia Doss

Post Rx, his foot drop resolved over 2 months. He stopped regular pain medications. No deterioration at 18 months follow up. Figure 3: Sagittal (top) and axial (lower) post percutaneous repair under CT guidance with autologous orthobiologics. The posterior annulus tear has resolved (yellow arrows) to pre injury status of control images in Figure 1. Preserved disc height suggests containment of the central nucleus pulposus due to integrity of a repaired annulus fibrosus.

Figure 4: MRI after IV gadolinium corresponding to images in Figure 3, there is enhancement due to neotissue (yellow arrows). Black arrow in fig 4a outlines the native annulus margin as it abuts the spinal canal. Compare bottom row images in figures 2, 3 with 4 (red and yellow arrows respectively) to assess post treatment neotissue that replaces the annulus tear defect.

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Suite 3, 55 Hampden Road Nedlands nds WA 6009 P 6389 9 2776 F 6389 2778

info@imageguidedtherapyclinic.com

MEDICAL FORUM

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AUGUST 2015 | 33

Clinical Update

Introduction of solids for infants Introducing solids is difďŹ cult for most parents, especially with the rising prevalence of food allergies in children. Those with a family history of allergy and children with severe atopic eczema are at higher risk but many without predisposing factors also develop food allergies. 0REVIOUSĂĽINTERNATIONALĂĽRECOMMENDATIONSĂĽ advised delayed introduction of highly allergenic foods in infants at high risk for allergic disease to prevent future allergy: cowâ&#x20AC;&#x2122;s milk until age one; egg until two; and peanuts, tree nuts, and ďŹ sh until three. This has proven to be ineffective, with the incidence and prevalence of food allergy and allergic diseases in general increasing substantially.

By Dr Christiane Remke, Paediatric Allergist, Nedlands.

Some research suggests that delayed introduction of foods beyond six months may even lead to an increased risk of food allergy, as shown for the introduction of wheat and egg. New data suggests the early introduction of the highly allergenic foods may reduce the risk of food allergy.

Current recommendations

Key Messages sĂĽ &OODĂĽALLERGIESĂĽAREĂĽCOMMONĂĽEVENĂĽINĂĽBABIESĂĽ without any risk factors sĂĽ 3OLIDSĂĽCANĂĽBEĂĽINTRODUCEDĂĽINTOĂĽAĂĽBABY SĂĽDIETĂĽ FROMĂĽ ĂĽMONTHSĂĽOFĂĽAGE sĂĽ .EWĂĽEVIDENCEĂĽSUGGESTSĂĽTHATĂĽEARLYĂĽ introduction of solids for babies may help to prevent food allergies sĂĽ #AREFULĂĽSTRATEGIESĂĽAREĂĽNEEDEDĂĽFORĂĽINFANTSĂĽATĂĽ high risk of food allergies to avoid adverse reactions sĂĽ &INDĂĽ)NFANTĂĽ&EEDINGĂĽADVICEĂĽONĂĽWWW ALLERGY ORG AU

Australian, North-American and European Allergy Associations all conclude that there is no current evidence to suggest that delaying

Why is childhood type 1 diabetes increasing? Type 1 diabetes, characterised by insulin deďŹ ciency secondary to autoimmune destruction of the pancreatic beta-cells, is one of the commonest childhood chronic conditions. Together with the daily challenges of blood glucose monitoring and insulin therapy, the disease brings with it signiďŹ cant long term complications and a large number of demands on patients and families. The cause remains unknown. Both genetic and environmental factors are thought to play AĂĽROLE ĂĽ3INCEĂĽTHEĂĽMID S ĂĽTHEĂĽINCIDENCEĂĽOFĂĽ CHILDHOODĂĽTYPEĂĽ ĂĽDIABETESĂĽHASĂĽBEENĂĽINCREASINGĂĽ BYĂĽANĂĽAVERAGEĂĽOFĂĽ ĂĽAĂĽYEARĂĽINĂĽMANYĂĽ%UROPEANĂĽ populations and Western Australia. This increase is too rapid to be accounted for population genetic changes, which strongly suggests environmental factors associated with modernisation and urbanisation. Nature and nurture Environmental factors implicated in childhood TYPEĂĽ ĂĽDIABETESĂĽAETIOLOGYĂĽINCLUDE ĂĽ

34 | AUGUST 2015

Strategies to support families of high risk infants need to be discussed before introducing solids. This includes recognition and treatment of any adverse reactions as well as instructions about how to introduce foods.

New thinking

Exclusive breast-feeding is recommended for all infants till at least four to six months of age. Then complementary foods can be introduced according to European, American and Australian Allergy societies, however the WHO recommends EXCLUSIVEĂĽBREASTFEEDINGĂĽFORĂĽ ĂĽMONTHS ĂĽ Feeding solids before four months of age may increase the chances of the development of food allergies or eczema.

2ESULTSĂĽFROMĂĽTHEĂĽ,%!0ĂĽ ,EARNINGĂĽABOUTĂĽ0EANUTĂĽ Allergy) study showed early introduction of peanuts signiďŹ cantly decreased the frequency of the development of peanut allergy among high risk children.

the introduction of solid foods beyond four to six months of age will prevent food allergies, eczema or other allergic disease. There is no need to avoid introducing complementary foods as long as the baby is developmentally ready to start solids. This also includes â&#x20AC;&#x153;allergenic foodsâ&#x20AC;? such as egg, cowâ&#x20AC;&#x2122;s milk, peanut, tree nuts, ďŹ sh or shellďŹ sh.

Infants with an existing food allergy might be at higher risk for other food allergies, and caution is needed when advancing the diet. SigniďŹ cant adverse reactions can occur even on the ďŹ rst few exposures. Thus feeding recommendations for infants without existing allergies might be different from those suggested for children with an established food allergy. Highly allergenic foods are best ďŹ rst introduced at home rather than at day-care. Minimal exposure and then gradually increasing amounts can be a useful tool for parents. For infants showing adverse reactions or at high risk of developing them, an assessment by an allergist is recommended to assess risk and facilitate safe introduction of solid food. Author competing interests: no relevant disclosures. Questions? Contact the author on 6389 0786

Dr Aveni Haynes, Research Fellow, Department of Diabetes & Endocrinology, PMH

sĂĽ VIRUSĂĽINFECTIONSĂĽ ENTEROVIRUSĂĽANDĂĽROTAVIRUSĂĽINĂĽ particular), sĂĽ VITAMINĂĽ$ĂĽDElCIENCY ĂĽ sĂĽ EXPOSUREĂĽTOĂĽCEREALSĂĽBEFOREĂĽFOURĂĽMONTHSĂĽANDĂĽ after six months of age, sĂĽ REDUCEDĂĽEXPOSUREĂĽTOĂĽMICROBIALĂĽINFECTIONSĂĽINĂĽ early life (the â&#x20AC;&#x153;hygiene hypothesisâ&#x20AC;?), sĂĽ RAPIDĂĽEARLYĂĽWEIGHTĂĽGAINĂĽANDĂĽOBESITYĂĽ THEĂĽSO called â&#x20AC;&#x153;accelerator hypothesisâ&#x20AC;?), sĂĽ EXPOSUREĂĽTOĂĽSTRESS ĂĽANDĂĽ sĂĽ CHANGESĂĽINĂĽTHEĂĽINFANTĂĽGUTĂĽMICROBIOME ĂĽ 0ERINATALĂĽFACTORSĂĽASSOCIATEDĂĽWITHĂĽANĂĽINCREASEDĂĽ risk include: sĂĽ BIRTHĂĽBYĂĽ#AESAREANĂĽSECTION ĂĽ sĂĽ OLDERĂĽMATERNALĂĽAGE ĂĽ sĂĽ PREMATUREĂĽGESTATIONALĂĽAGE ĂĽAND sĂĽ HIGHERĂĽINFANTĂĽBIRTHĂĽWEIGHTĂĽANDĂĽBIRTHĂĽORDER ĂĽ How such factors act to increase the incidence remains unclear. Are different factors or genetic and environmental factors combining to initiate autoimmunity and the disease process, progress the disease, and

triggering its presentation? Understanding the COMPLEXITYĂĽOFĂĽTYPEĂĽ ĂĽDIABETESĂĽISĂĽEVOLVINGĂĽANDĂĽ explains why ďŹ nding answers remains elusive. &URTHERMORE ĂĽTYPEĂĽ ĂĽDIABETESĂĽISĂĽAĂĽ heterogeneous disease, with multiple phenotypes, and therefore, likely multiple causal pathways. With this in mind, results from longitudinal birth cohort studies such as THEĂĽMULTINATIONALĂĽ4%$$9ĂĽ 4HEĂĽ%NVIRONMENTALĂĽ $ETERMINANTSĂĽOFĂĽ$IABETESĂĽINĂĽTHEĂĽ9OUNG ĂĽ ANDĂĽ!USTRALIA WIDEĂĽ%.$)!ĂĽ %NVIRONMENTALĂĽ $ETERMINANTSĂĽOFĂĽ)SLETĂĽ!UTOIMMUNITY ĂĽSTUDIES ĂĽ which aim to elucidate the natural history and PATHOGENESISĂĽOFĂĽCHILDHOODĂĽTYPEĂĽ ĂĽDIABETES ĂĽ are eagerly awaited. The ultimate aim is to prevent it. References available on request

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

MEDICAL FORUM

Australiaâ&#x20AC;&#x2122;s First AAGL Centre of Excellence in Minimally Invasive Gynaecology WA GynaeScope, along with Joondalup Private Hospital, has become Australiaâ&#x20AC;&#x2122;s ďŹ rst designated â&#x20AC;&#x153;Centre of Excellence in Minimally Invasive Gynaecologyâ&#x20AC;?

Launched in early 2010, the Center of Excellence in Minimally Invasive Gynecology (COEMIG) designation was initially offered only to surgeons in the US. In mid-2011, COEMIG expanded to include surgeons, hospitals and ambulatory surgery centres around the world that provide minimally invasive gynecologic surgical care. 4HEĂĽ#/%-)'ĂĽPROGRAMĂĽDELIVERSĂĽONĂĽTHEĂĽ!MERICANĂĽ!SSOCIATIONĂĽOFĂĽ'YNAECOLOGICALĂĽ,APAROSCOPISTS ĂĽCOMMITMENTĂĽTOĂĽADVANCEĂĽTHEĂĽ ADOPTIONĂĽOFĂĽMINIMALLYĂĽINVASIVEĂĽGYNAECOLOGYĂĽWORLDWIDE ĂĽ4HEĂĽOFlCIALĂĽDESIGNATIONĂĽAWARDEDĂĽTOĂĽPARTICIPANTSĂĽISĂĽh#ENTERĂĽOFĂĽ%XCELLENCEĂĽINĂĽ -INIMALLYĂĽ)NVASIVEĂĽ'YNECOLOGYv ĂĽ ,EADINGĂĽTHISĂĽACCREDITATIONĂĽAREĂĽTHEĂĽFOUNDERSĂĽOFĂĽ7!ĂĽ'YNAE3COPE ĂĽGYNAECOLOGICALĂĽLAPAROSCOPICĂĽSURGEONSĂĽ3ANTANUĂĽ"ARUAHĂĽANDĂĽ'IANĂĽ 5RBANI ĂĽ7!ĂĽ'YNAE3COPEĂĽ www.wagynaescope.com.au ĂĽWASĂĽFOUNDEDĂĽINĂĽ ĂĽWITHĂĽTHEĂĽAIMĂĽOFĂĽPROVIDINGĂĽEXCELLENTĂĽCAREĂĽTOĂĽPATIENTSĂĽWITHĂĽ gynaecological needs and promoting minimally invasive gynaecological surgery. Minimally invasive gynaecology has several advantages over the traditional approach, including better visualisation of anatomy, a shorter hospital stay, less post-operative pain, quicker recovery and fewer post-operative wound problems. 7!ĂĽ'YNAE3COPEĂĽCARRIESĂĽOUTĂĽMOREĂĽTHANĂĽ ĂĽMINIMALLYĂĽINVASIVEĂĽPROCEDURESĂĽEVERYĂĽYEAR ĂĽ4HESEĂĽPROCEDURESĂĽRANGEĂĽFROMĂĽSTRAIGHTFORWARDĂĽ procedures such as endometrial ablation to the more complex operations such as laparoscopic total hysterectomy, laparoscopic myomectomy and laparoscopic resection of severe cases of endometriosis. 7!ĂĽ'YNAE3COPEĂĽ$IRECTORĂĽOFĂĽ-INIMALLYĂĽ)NVASIVEĂĽ3URGERY ĂĽ$RĂĽ3ANTANUĂĽ"ARUAH ĂĽSAIDĂĽTHATĂĽEARNINGĂĽTHEĂĽ#ENTREĂĽOFĂĽ%XCELLENCEĂĽDESIGNATIONĂĽ ESTABLISHEDĂĽ7!ĂĽ'YNAE3COPEĂĽANDĂĽ*OONDALUPĂĽ0RIVATEĂĽ(OSPITALĂĽASĂĽCONSISTENTĂĽPROVIDERSĂĽOFĂĽSAFEĂĽANDĂĽHIGH QUALITYĂĽCARE -ANAGERĂĽOFĂĽ!CCREDITATIONĂĽANDĂĽ%DUCATION ĂĽANDĂĽTHEĂĽ3ENIORĂĽ3ITEĂĽ)NSPECTORĂĽATĂĽTHEĂĽ53ĂĽBASEDĂĽ3URGICALĂĽ2EVIEWĂĽ#ORPORATION ĂĽ4ERESAĂĽ ,EATH ĂĽSAIDĂĽDOCTORSĂĽ3ANTANUĂĽ"ARUAHĂĽANDĂĽ'IANĂĽ5RBANI ĂĽANDĂĽTHEIRĂĽTEAMĂĽATĂĽ*OONDALUPĂĽ0RIVATEĂĽ(OSPITAL ĂĽPROVEDĂĽTOĂĽBEĂĽhKNOWLEDGEABLE ĂĽ professional and dedicated to providing excellent care to their minimally invasive gynaecologic surgery patientsâ&#x20AC;?. h!ĂĽCULTUREĂĽOFĂĽEXCELLENCEĂĽWASĂĽEVIDENTĂĽINĂĽALLĂĽLEVELSĂĽOFĂĽTHEĂĽPROGRAMĂĽANDĂĽTHEIRĂĽACHIEVEMENTĂĽASĂĽTHEĂĽlRSTĂĽ#ENTREĂĽOFĂĽ%XCELLENCEĂĽINĂĽ-INIMALLYĂĽ )NVASIVEĂĽ'YNECOLOGYĂĽINĂĽ!USTRALIAĂĽISĂĽWELLĂĽDESERVED vĂĽ-SĂĽ,EATHĂĽSAID WaGynaescope media release

Joondalup Private Hospital Suite 23, Level 2 Specialist Medical Centre (East), Shenton Avenue Joondalup WA 6027

Tel: (08) 6406 1801 Fax: (08) 6406 1802 www.wagynaescope.com.au

CENTRE OF EXCELLENCE IN MINIMAL INVASIVE GYNAECOLOGICAL SURGERY MEDICAL FORUM

AUGUST 2015 | 35

e-Poll

WA GPs A Pot Pourri of Issues !ROUNDĂĽ ĂĽ'0SĂĽ NEARLYĂĽTWOĂĽTHIRDSĂĽMALE ĂĽ responded within a week to give us this editions E 0OLL ĂĽ7E VEĂĽREVISEDĂĽTHEĂĽLAYOUTĂĽSOĂĽIT SĂĽEASIERĂĽTOĂĽ give your opinion on a mobile device. Thanks to everyone who took part or looked us over. J.O. was the random winner of our wine prize. Medical Politics From what you know so far, will the new Curtin Medical School in WA be good for general practice? 64%

No Yes Uncertain

ED. Close on two thirds of GPs do not share the view that the new Curtin Medical School will boost general practice, so proponents have some convincing to do. Unfavourable comments were along the lines: sĂĽ -ONEYĂĽBETTERĂĽSPENTĂĽONĂĽEXPANDINGĂĽJUNIORĂĽDOCTORĂĽ training places. sĂĽ #URTINĂĽWILLĂĽDUMBĂĽDOWNĂĽMEDICALĂĽEDUCATION ĂĽ accepting those who do not qualify for UWA or Notre Dame etc â&#x20AC;&#x201C; their brochure says so. sĂĽ -OREĂĽMEDICALĂĽSTUDENTSĂĽWILLĂĽNOTĂĽEQUATEĂĽTOĂĽMOREĂĽ rural GPs â&#x20AC;&#x201C; instead, what about a rural GP training college or a mandatory 12 months in rural practice for early graduates, specialist trainees included.

sĂĽ 7EĂĽNEEDĂĽPOSTĂĽGRADUATEĂĽTRAININGĂĽPLACESĂĽINĂĽGENERALĂĽ practice not more medical schools. sĂĽ )TĂĽISĂĽHIGHLYĂĽUNLIKELYĂĽTHATĂĽVERYĂĽYOUNGĂĽURBANĂĽGRADUATESĂĽ will work in the country â&#x20AC;&#x201C; instead, spend the money on supporting the IMGs who have very little support. sĂĽ 7HOSEĂĽVOTESĂĽAREĂĽBEINGĂĽBOUGHTĂĽBYĂĽ#URTINĂĽ-EDICALĂĽ School? Will GPs be expected to take up the slack of teaching placements? If they are spending so much on this, why are they cutting back in so many other areas of primary care? Am I going to be shut out of admitting to Midland Hospital because it will be tertiary and GP skills not wanted?

Testosterone Prescribing What do you believe is the main purpose for recently changing PBS criteria for testosterone prescribing?

To prevent potentially harmful overprescribing To reduce costs to government Uncertain To improve beneďŹ ts from testosterone use

M+F

60%

31%

34%

45%

ED. Twice e as many women think (with more certainty) that men are overprescribed testosterone, as think recent PBS changes are designed to save government money. Men think the reversel.

Helicopter Parenting In your work, how often do you see parenting that you consider too restrictive and detrimental to the child involved? Never

2ARELY

Occasionally

42%

Often

Very Often

Uncertain

$OESN TĂĽ!PPLY

ED. Interestingly perhaps, there were no signiďŹ cant gender difference in responses to this question â&#x20AC;&#x201C; one in ďŹ ve GPs think kids should be allowed to â&#x20AC;&#x2DC;harden upâ&#x20AC;&#x2122;.

continued opposite page

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36 | AUGUST 2015

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MEDICAL FORUM

Clinical Update

Kids get arthritis too Juvenile Idiopathic Arthritis (JIA) is an autoimmune inďŹ&#x201A;ammatory disease encompassing a heterogeneous group of clinical entities â&#x20AC;&#x201C; all are children or adolescents under 16 years with symptoms for more than six weeks (about 1-4 per 1000 children). Management varies with each patient because clinical subtypes vary widely. Some JIA patients continue to have arthritis into ADULTHOOD ĂĽ$ELAYĂĽINĂĽDIAGNOSISĂĽANDĂĽTREATMENTĂĽ can sometimes lead to delayed growth, joint damage, limb asymmetry, dysfunction and disability â&#x20AC;&#x201C; conversely, early recognition and management can optimise outcomes. 0ATIENTSĂĽUSUALLYĂĽPRESENTĂĽWITHĂĽJOINTĂĽPAIN ĂĽSWELLING ĂĽ heat and erythema, with reduction in range of motion and morning stiffness. Sometimes patients with Systemic JIA (â&#x20AC;&#x153;Stillâ&#x20AC;&#x2122;s diseaseâ&#x20AC;?) can

By Dr Senq Lee, Paediatric Rheumatologist, Shenton Park

develop fever and rash as part of their systemic illness. Arthritis usually causes dysfunction â&#x20AC;&#x201C; kids are unable to play sports, and periods off school affect academic achievement.

sĂĽ /THERĂĽSIGNSĂĽOFĂĽAUTOIMMUNEĂĽDISEASEĂĽnĂĽ e.g. rash, persistent fevers, psoriasis, nail pitting, alopecia, muscle weakness, hepatosplenomegaly

In young children, itâ&#x20AC;&#x2122;s often difďŹ cult to obtain a clear history and thorough examination, hence looking for clinical clues are warranted. The â&#x20AC;&#x153;red ďŹ&#x201A;agsâ&#x20AC;? in history and examination include:

â&#x20AC;&#x153;Mimicsâ&#x20AC;? to JIA that may present with arthritis or arthralgia:

sĂĽ $IFlCULTIESĂĽWITHĂĽDAILYĂĽACTIVITIES PLAY SPORTS schooling sĂĽ $EVELOPMENTALĂĽDELAYĂĽORĂĽREGRESSION sĂĽ 0ERSISTENTĂĽ ĂĽCHRONICĂĽPAIN sĂĽ 7EIGHTĂĽLOSS sĂĽ .OCTURNALĂĽPAIN sĂĽ 'ROWTHĂĽDELAY sĂĽ 5NUSUAL ASYMMETRICĂĽORĂĽANTALGICĂĽGAIT sĂĽ ,IMBĂĽASYMMETRY sĂĽ 4-*ĂĽPAINĂĽ ĂĽASYMMETRY

Table: Investigations in JIA &"0

Hb for haemolytic anaemia, iron deďŹ ciency anaemia, anaemia of chronic illness; platelets raised DURINGĂĽINmAMMATIONĂĽORĂĽLOWĂĽFORĂĽ)40 3,% ĂĽ7##ĂĽANDĂĽlLMSĂĽTOĂĽSCREENĂĽFORĂĽHAEMATOLOGICĂĽMALIGNANCY

5%# ĂĽ,&4

Baseline check and to ensure normal renal/liver function.

#20 ĂĽ%32

InďŹ&#x201A;ammatory markers can be normal or elevated in patients with JIA.

ANA

JIA: ANA positive patients develop uveitis more often, hence have more frequent eye CHECKS ĂĽ)FĂĽPOSITIVE ĂĽANTI DS$.! ĂĽ%.!ĂĽANDĂĽ# ĂĽSCREENĂĽFORĂĽOTHERĂĽAUTOIMMUNEĂĽDISEASESĂĽ E G ĂĽ 3,% ĂĽTHATĂĽCANĂĽCAUSEĂĽARTHRITIS

0OLYARTICULARĂĽ*)!ĂĽ2&ĂĽPOSITIVEĂĽPATIENTSĂĽTENDĂĽTOĂĽHAVEĂĽAGGRESSIVEĂĽDISEASEĂĽWITHĂĽFEATURESĂĽSIMILARĂĽTOĂĽ adult rheumatoid arthritis and are usually treated more aggressively.

(,! "

Found in normal healthy population but also associated with diseases like psoriatic JIA and enthesitis-related arthritis.

8 RAYĂĽ ĂĽ Ultrasound

Screen for alternative aetiologies for joint pain; screen for inďŹ&#x201A;ammation/synovitis/effusion.

e-Poll

sĂĽ /THERĂĽAUTOIMMUNE INmAMMATORYĂĽCAUSES ĂĽ 3,% ĂĽJUVENILEĂĽDERMATOMYOSITIS ĂĽCHRONICĂĽ recurrent multifocal osteomyelitis; vasculitis; arthritis that accompanies inďŹ&#x201A;ammatory BOWELĂĽDISEASE ĂĽANDĂĽ#&ĂĽARTHROPATHY sĂĽ -ALIGNANCY sĂĽ )NFECTIONĂĽ E G ĂĽOSTEOMYELITIS

reactive arthritis). Other factors such as growth, development, puberty, and adolescent issues must also be ADDRESSED ĂĽ+IDSĂĽWITHĂĽ*)!ĂĽHAVEĂĽUPĂĽTOĂĽAĂĽ ĂĽ chance of developing uveitis, so patients are often referred for uveitis screening; and those with it often require more aggressive therapy. First line investigations are detailed in the TABLE ĂĽ#URRENTLYĂĽWEĂĽDOĂĽNOTĂĽTESTĂĽFORĂĽANTI ##0 ĂĽASĂĽ we are unsure of its clinical relevance in JIA. Fortunately JIA is very treatable generally with anti-inďŹ&#x201A;ammatory medications. This may include non-steroidal anti-inďŹ&#x201A;ammatories .3!)$S ĂĽORĂĽCORTICOSTEROIDSĂĽ ORALLY ĂĽ)6ĂĽORĂĽINTRA articular steroid injections). Some patients who have severe or recurrent arthritis may need more specialised drugs such as methotrexate or biologic medications. References available on request

Author competing interests: no relevant disclosures. Questions â&#x20AC;&#x201C; contact the author on 9380 9484.

WA GPs - A Pot Pourri of Issues

continued from Page 36

Other comment

Caution for Key Opinion Leaders Doctors are asked to declare any competing interests when presenting on an aspect of health care. Does the number of competing interests declared affect how much you take at â&#x20AC;&#x2DC;face valueâ&#x20AC;&#x2122; any comments the doctor makes? Maybe

31%

Yes

29%

Uncertain

$OESN TĂĽAPPLY

ED. About 60% GPs, especially females, are wary of the competing interests of speakers. Something for Medicines Australia and the ACCC to consider?

MEDICAL FORUM

2ESPONDENTSĂĽWEREĂĽINVITEDĂĽTOĂĽLETĂĽLOOSEĂĽONĂĽ whatever they considered relevant â&#x20AC;&#x201C; here are some edited responses. sĂĽ Dr Techniques. Iâ&#x20AC;&#x2122;ve seen a lack of many physical techniques in examination, to ascertain health problems. sĂĽ Care Plans. '0SĂĽHAVEĂĽBEENĂĽFORCEDĂĽ INTOĂĽCONDUCTINGĂĽ#AREĂĽ0LANSĂĽASĂĽAĂĽWAYĂĽOFĂĽ generating income. The patient is forced into them to access Allied Health Services at reduced cost. For the patient who cannot afford even a reduced fee there ISĂĽNOĂĽBENElTĂĽATĂĽALLĂĽTOĂĽHAVINGĂĽAĂĽ#AREĂĽ0LAN ĂĽ )ĂĽAMĂĽNOTĂĽATĂĽALLĂĽCONVINCEDĂĽTHATĂĽ#AREĂĽ0LANSĂĽ are a better way of managing or preventing health problems. sĂĽ Testosterone prescribing â&#x20AC;&#x201C; the lack of a â&#x20AC;&#x153;grandfather clauseâ&#x20AC;? is a big problem: I have PATIENTSĂĽWHO VEĂĽBEENĂĽTREATEDĂĽFORĂĽOVERĂĽ ĂĽ years and a change in practice makes the original test results unavailable; itâ&#x20AC;&#x2122;s taken an

enormous amount of time to trawl through old paper ďŹ les when TT was initiated at my practice; all to collate evidence for their new endocrinologist/old urologist. I see men who already purchase their TT overseas and/or on-line. I suspect many will reduce followup/medical supervision, with consequent DETRIMENTALĂĽEFFECTS ĂĽ#ANBERRAĂĽDECISION making at its worst. sĂĽ Medical Board. We pay large fees to the medical board which is adversarial to doctors! I think Medicare levy should pay that fee rather than me support the role the board is doing now. sĂĽ Representation. The biggest problem is not having a cohesive body representing '0SĂĽINTERESTSĂĽTHATĂĽHASĂĽTHEĂĽTEETHĂĽANDĂĽTHEĂĽ b****s to stand up to these ridiculous 'OVERNMENTĂĽDICTATES ĂĽLIKEĂĽTESTOSTERONEĂĽ prescribing.

AUGUST 2015 | 37

A soldier who survived mustard gas and pepper spray is now a seasoned veteran. I stayed up all night to see where the sun went. Then it dawned on me. The girl said she recognised me from the vegetarian club, but I never met herbivore.

A SCRIPT FOR LIFE

Iâ&#x20AC;&#x2122;m reading a book about anti-gravity. I canâ&#x20AC;&#x2122;t put it down.

The patient went to his doctor for a check-up, and the doctor wrote out a prescription for him in his usual illegible writing. The patient put it in his pocket but he forgot to have it ďŹ lled. Every morning for two years, he showed it to the conductor as a train pass. Twice, it got him into the movies, once into the football, and once into the symphony concert. He got a raise at work by showing it as a note from the boss. One day, he mislaid it. His daughter picked it up, played it on the piano, and won a scholarship to a conservatorium of music.

APHORISMS â&#x20AC;&#x201C; LACONIC EXPRESSIONS OF WISE OR CLEVER OBSERVATIONS

HIP â&#x20AC;&#x2DC;Nâ&#x20AC;&#x2122; HAPPENING Who is the coolest man in the hospital? The ultra sound guy.

SPORTS ALERT A man goes for a run, as he is running he sees a tennis ball on the road, so he picks it up and puts it in his shorts pocket and carries on running. As he approaches a set of trafďŹ c lights, a lady shouts, â&#x20AC;&#x2DC;whatâ&#x20AC;&#x2122;s that in your pocket?â&#x20AC;&#x2122; The runner replies, â&#x20AC;&#x2DC;itâ&#x20AC;&#x2122;s a tennis ballâ&#x20AC;&#x2122;. The lady replies, â&#x20AC;&#x2DC;you poor bastard I had tennis elbow onceâ&#x20AC;&#x2122;.

sĂĽ -ONEYĂĽWILLĂĽBUYĂĽAĂĽlNEĂĽDOGĂĽBUTĂĽONLYĂĽKINDNESSĂĽWILLĂĽMAKEĂĽ him wag his tail. sĂĽ 3EATĂĽBELTSĂĽAREĂĽNOTĂĽASĂĽCONlNINGĂĽASĂĽWHEELCHAIRS sĂĽ !ĂĽGOODĂĽTIMEĂĽTOĂĽKEEPĂĽYOURĂĽMOUTHĂĽ shut is when youâ&#x20AC;&#x2122;re in deep water. sĂĽ (OWĂĽCOMEĂĽITĂĽTAKESĂĽSOĂĽLITTLEĂĽTIMEĂĽFORĂĽ a child afraid of the dark to become a teenager who wants to stay out all night? sĂĽ 3TROKEĂĽAĂĽCATĂĽANDĂĽYOUĂĽWILLĂĽHAVEĂĽAĂĽ permanent job. sĂĽ .OĂĽONEĂĽEVERĂĽSAYSĂĽh)T SĂĽONLYĂĽAĂĽGAMEvĂĽWHENĂĽTHEIRĂĽTEAMĂĽISĂĽWINNING ĂĽ sĂĽ $OĂĽYOUĂĽREALIZEĂĽTHAT ĂĽINĂĽABOUTĂĽ ĂĽYEARS ĂĽWE LLĂĽHAVEĂĽTHOUSANDSĂĽOFĂĽOLDĂĽ ladies running around with tattoos? sĂĽ 0OLITICIANSĂĽANDĂĽNAPPIESĂĽSHOULDĂĽBEĂĽCHANGEDĂĽOFTEN ĂĽANDĂĽFORĂĽTHE same reason.

A LESSON IN LIFE, IN PLAIN ENGLISH 0EOPLEĂĽSAYĂĽTHEREĂĽISĂĽNOĂĽDIFFERENCEĂĽBETWEENĂĽTHEĂĽWORDSĂĽ#/-0,%4%ĂĽANDĂĽ &).)3(%$ "UTĂĽTHEREĂĽIS ĂĽ7HENĂĽYOUĂĽMARRYĂĽTHEĂĽRIGHTĂĽONE ĂĽYOUĂĽAREĂĽ#/-0,%4%

GIVE THE MAN GAS

!NDĂĽWHENĂĽYOUĂĽMARRYĂĽTHEĂĽWRONGĂĽONE ĂĽYOUĂĽAREĂĽ&).)3(%$

A man speaks frantically into the phone, â&#x20AC;&#x153;My wife is pregnant, and her contractions are only two minutes apart!â&#x20AC;?

And when the right one catches you with the wrong one, you are... #/-0,%4%,9ĂĽ&).)3(%$

â&#x20AC;&#x153;Is this her ďŹ rst child?â&#x20AC;? the doctor queries. â&#x20AC;&#x153;No, you idiot!â&#x20AC;? the man shouts. â&#x20AC;&#x153;This is her husband!â&#x20AC;?

THE HEAT IS ON A surgical patient wakes up after the operation to ďŹ nd herself in a room with all the blinds drawn. â&#x20AC;&#x153;Why are all the blinds closed?â&#x20AC;? she asked her doctor. â&#x20AC;&#x153;Well,â&#x20AC;? the surgeon responded, â&#x20AC;&#x153;Theyâ&#x20AC;&#x2122;re ďŹ ghting a huge ďŹ re across the street, and we didnâ&#x20AC;&#x2122;t want you to wake up and think the operation had failed.â&#x20AC;?

GOING NUTS A man visits his aunt in the nursing home. It turns out that she is taking a nap, so he just sits down in a chair in her room, ďŹ&#x201A;ips through a few magazines, and munches on some peanuts sitting in a bowl on the table. Eventually, the aunt wakes up, and her nephew realises heâ&#x20AC;&#x2122;s absentmindedly ďŹ nished the entire bowl of peanuts! â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m so sorry, auntie, Iâ&#x20AC;&#x2122;ve eaten all of your peanuts!â&#x20AC;? â&#x20AC;&#x153;Thatâ&#x20AC;&#x2122;s okay, dearie,â&#x20AC;? the aunt replied. â&#x20AC;&#x153;After Iâ&#x20AC;&#x2122;ve sucked the chocolate off, I donâ&#x20AC;&#x2122;t care for them anyway.â&#x20AC;?

PUN-OGRAPHY:

WHATâ&#x20AC;&#x2122;S A PARAPROSDOKIAN? sĂĽ )ĂĽWANTĂĽTOĂĽDIEĂĽPEACEFULLYĂĽINĂĽMYĂĽSLEEP ĂĽLIKEĂĽMYĂĽGRANDFATHER ĂĽ.OTĂĽ screaming and yelling like the passengers in his car. sĂĽ 'OINGĂĽTOĂĽCHURCHĂĽDOESN TĂĽMAKEĂĽYOUĂĽAĂĽ#HRISTIANĂĽANYĂĽMOREĂĽTHANĂĽ standing in a garage makes you a car. sĂĽ ,IGHTĂĽTRAVELSĂĽFASTERĂĽTHANĂĽSOUND ĂĽ4HISĂĽISĂĽWHYĂĽSOMEĂĽPEOPLEĂĽAPPEARĂĽ bright until you hear them speak. sĂĽ 7ARĂĽDOESĂĽNOTĂĽDETERMINEĂĽWHOĂĽISĂĽRIGHTĂĽ ĂĽONLYĂĽWHOĂĽISĂĽLEFT sĂĽ 4OĂĽSTEALĂĽIDEASĂĽFROMĂĽONEĂĽPERSONĂĽISĂĽPLAGIARISM ĂĽ4OĂĽSTEALĂĽFROMĂĽMANYĂĽISĂĽ research. sĂĽ !ĂĽBUSĂĽSTATIONĂĽISĂĽWHEREĂĽAĂĽBUSĂĽSTOPS ĂĽ!ĂĽTRAINĂĽSTATIONĂĽISĂĽWHEREĂĽAĂĽTRAINĂĽ stops. On my desk, I have a work station. sĂĽ $OLPHINSĂĽAREĂĽSOĂĽSMARTĂĽTHAT ĂĽWITHINĂĽAĂĽFEWĂĽWEEKSĂĽOFĂĽCAPTIVITY ĂĽTHEYĂĽCANĂĽ train people to stand at the very edge of the pool and feed them ďŹ sh. sĂĽ 7OMENĂĽWILLĂĽNEVERĂĽBEĂĽEQUALĂĽTOĂĽMENĂĽUNTILĂĽTHEYĂĽCANĂĽWALKĂĽDOWNĂĽTHEĂĽSTREETĂĽ with a bald head and a beer-gut, and still think theyâ&#x20AC;&#x2122;re sexy.

IT MADNESS sĂĽ Tech support: How can I help you? sĂĽ Customer: Hi, I canâ&#x20AC;&#x2122;t print. Every time I try, ITĂĽSAYSĂĽ@#AN TĂĽlNDĂĽPRINTER ĂĽ) VEĂĽEVENĂĽLIFTEDĂĽTHEĂĽ printer and placed it in front of the monitor, but the computer still says he canâ&#x20AC;&#x2122;t ďŹ nd it... sĂĽ Tech support: Whatâ&#x20AC;&#x2122;s on your monitor now, maâ&#x20AC;&#x2122;am? sĂĽ Customer: A teddy bear my boyfriend bought for me at Woolies.

I tried to catch some fog. I mist. When chemists die, they barium. *OKESĂĽABOUTĂĽ'ERMANĂĽSAUSAGEĂĽAREĂĽTHEĂĽWURST

38 | AUGUST 2015

MEDICAL FORUM

Theatre

Writing to the Brinkâ&#x20AC;Ś Mystery, sex and intrigue are the dramatic partners in Hannie Raysonâ&#x20AC;&#x2122;s new play, Extinction.

Itâ&#x20AC;&#x2122;s a precarious career, playwriting, but for Hannie Rayson it has been her constant livelihood for nearly 40 years. In that time, sheâ&#x20AC;&#x2122;s written 14 plays, numerous TV shows, ďŹ lm (including the successful Australian movie, Hotel Sorrento, based on her play) and, when Medical Forum caught up with her, she was about to settle down to work on a new commission from the Melbourne Theatre Company after the publicity hurly burly of the launch of her memoir, Hello Beautiful. Her latest play, Extinction, will receive its world PREMIEREĂĽINĂĽ0ERTHĂĽBYĂĽ"LACKĂĽ3WANĂĽ3TATEĂĽ4HEATREĂĽ #OMPANYĂĽ NEXTĂĽ MONTHĂĽ UNDERĂĽ THEĂĽ DIRECTIONĂĽ OFĂĽ Stuart Halusz. h0LAYSĂĽ AREĂĽ THEĂĽ WAYĂĽ )ĂĽ COMMUNICATEĂĽ WITHĂĽ THEĂĽ world. I tell stories in dialogue rather than prose and they lead me down interesting tracks. Being a writer is a passport to adventures and Extinction was a real doozy for me,â&#x20AC;? she said. Extinction begins on a dark night when a man runs down a tiger quoll, which until that moment was believed to be extinct. He jumps out of his car, wraps the quoll in a towel and heads to a wildlife rescue centre and a week later shows up at a ďŹ ctional university and puts $2m on the table to aid the search for more tiger quolls. â&#x20AC;&#x153;While Iâ&#x20AC;&#x2122;m a committed conservationist, Iâ&#x20AC;&#x2122;d given up on writing on environmental issues because by necessity it would be didactic. Itâ&#x20AC;&#x2122;s what I call corridor theatre, where you arrive at the beginning and can see where youâ&#x20AC;&#x2122;ll end

MEDICAL FORUM

UP ĂĽ0EOPLEĂĽDON TĂĽWANTĂĽTOĂĽSITĂĽINĂĽAĂĽTHEATREĂĽFORĂĽTWOĂĽ hours knowing how the play will end.â&#x20AC;? â&#x20AC;&#x153;Then I came across a group of conservations ATĂĽ#APEĂĽ/TWAYĂĽINĂĽ6ICTORIAĂĽWHOĂĽWEREĂĽSEARCHINGĂĽ for tiger quolls, which were proliďŹ c when I was a girl but up until recently were thought to be extinct because their hadnâ&#x20AC;&#x2122;t been a proper SIGHTINGĂĽINĂĽ ĂĽYEARS ĂĽ*USTĂĽASĂĽ)ĂĽPRESSEDĂĽSENDĂĽONĂĽ the second draft of the play, which was getting AĂĽ READINGĂĽ ATĂĽ THEĂĽ -ANHATTANĂĽ 4HEATREĂĽ #LUBĂĽ INĂĽ New York, I heard news on the radio saying that there had been a full sighting of a tiger quoll.â&#x20AC;? â&#x20AC;&#x153;The stars were lining up. Now they have found four.â&#x20AC;? The eco mystery is given some political intrigue by the injection of research dollars from the owner of the local coal mine. â&#x20AC;&#x153;Who gets into bed with who, literally and ďŹ guratively, made this project really interesting â&#x20AC;Ś among other things it asks the fraught question, â&#x20AC;&#x2DC;Where does research money come from?â&#x20AC;&#x2122;. Since writing Life After George, which explores the corporatisation of universities, Iâ&#x20AC;&#x2122;ve been interested in how groups maintain their independence from the funding source.â&#x20AC;? â&#x20AC;&#x153;There is also the question of ecological rationalism, which I was introduced to in the writing of Extinction. One of the characters is a statistician who develops an index that mathematically indicates when an endangered species is not worth saving in relation to the investment of the conservation dollar. I was

Myles Pollard and Ha nna h Day. Pictures: Robert Frith stunned to learn that such an index exits. It was developed by a mob in Adelaide and is being EXAMINEDĂĽBYĂĽAĂĽTEAMĂĽATĂĽ*AMESĂĽ#OOKĂĽ5NIVERSITYĂĽ in Townsville.â&#x20AC;? â&#x20AC;&#x153;Sometimes I look around in my urban area of Fitzroy and think, â&#x20AC;&#x2DC;who cares, why am I banging the drum for this stuffâ&#x20AC;&#x2122;. But you know making decisions like that is about life and death. What does it do to us as a society to see our record for mammal extinction? What does that do to our souls? I guess thatâ&#x20AC;&#x2122;s the human heart of the drama.â&#x20AC;?

By Ms Jan Hallam

AUGUST 2015 | 39

Competitions

Entering Medical Forumâ&#x20AC;&#x2122;s competitions is easy!

Simply visit www.medicalhub.com.au and click on the â&#x20AC;&#x2DC;Competitionsâ&#x20AC;&#x2122; link (below the magazine cover on the left).

FEATURE

COMP

Movie: Me, Earl and the Dying Girl 7INNERĂĽOFĂĽTHEĂĽ'RANDĂĽ*URYĂĽ0RIZEĂĽTHEĂĽ ĂĽ3UNDANCEĂĽ &ILMĂĽ&ESTIVAL ĂĽTHISĂĽSTORYĂĽFOLLOWSĂĽ'REG ĂĽAĂĽTEENĂĽWHOĂĽ avoids meaningful relationships but with his only friend Earl, makes short ďŹ lms. But life changes when 'REG SĂĽMOTHERĂĽASKSĂĽHIMĂĽTOĂĽSPENDĂĽTIMEĂĽWITHĂĽ2ACHEL ĂĽ a girl in his class who is diagnosed with cancer. In Cinemas, September 3

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Movie: Pixels Aliens misinterpret video-feeds of classic arcade games as a declaration of war and launch an attack on Earth, using the games ASĂĽWARĂĽSTRATEGY ĂĽ4HEĂĽ0RESIDENTĂĽCALLSĂĽONĂĽHISĂĽCHILDHOODĂĽBESTĂĽFRIEND ĂĽ SĂĽVIDEOĂĽGAMEĂĽCHAMPIONĂĽ3AMĂĽ"RENNERĂĽ !DAMĂĽ3ANDLER ĂĽNOWĂĽ a home theatre installer, to lead a team of old-school arcaders to defeat the aliens and save the planet. In Cinemas, September 10

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Doctors Dozen Winner There are some subtle and beautifully crafted reds in the Smallwater Estate Doctorâ&#x20AC;&#x2122;s Dozen and that suits neurologist, Dr Nerissa Jordan just ďŹ ne. The screw-caps will be squeaking quite soon because Nerissaâ&#x20AC;&#x2122;s birthday rolls around in early July and son, Miles will be turning the grand-old age of one on the 22nd August. Happy Birthday x 2!!

Winners from the June issue Movie â&#x20AC;&#x201C; Scandinavian Film Festival: Dr Colin Stewart, Dr Michael Armstrong, Dr Helen Potter, Mr Vincenza Frisina, Ms Gabrielle Tallman, Dr Angelo Carbone, Dr Kym Connor, Dr Pam Quattermass, Dr Dorothy Graham, Dr Helen Mead

An adaptation of Bill Brysonâ&#x20AC;&#x2122;s bestselling memoir OFĂĽTHEĂĽSAMEĂĽNAME ĂĽ2OBERTĂĽ2EDFORDĂĽASĂĽ"RYSONĂĽHITSĂĽ the Appalachian trail with old buddy and recovering alcoholic Stephen Katz (Nick Nolte). As the men set off into the wilderness ful of bears and bad weather the fun begins.

)NĂĽTHISĂĽNEXTĂĽCHAPTERĂĽOFĂĽ-AZEĂĽ2UNNER ĂĽ4HOMASĂĽ ANDĂĽHISĂĽFELLOWĂĽ'LADERSĂĽSEARCHĂĽFORĂĽCLUESĂĽABOUTĂĽTHEĂĽ mysterious and powerful organization known as 7#+$ ĂĽ4EAMINGĂĽUPĂĽWITHĂĽRESISTANCEĂĽlGHTERS ĂĽTHEĂĽ 'LADERSĂĽTAKEĂĽONĂĽ7#+$ SĂĽVASTLYĂĽSUPERIORĂĽFORCESĂĽANDĂĽ uncover its shocking plans for them all. In Cinemas, September 17

Theatre: Extinction 4HEĂĽWORLDĂĽPREMIEREĂĽOFĂĽ(ANNIEĂĽ2AYSON SĂĽNEWĂĽPLAY ĂĽ Extinction, pivots on the accidental death of an endangered tiger quoll and event that unravels the personal and ethical dilemmas of research. Andy is a vet committed to protecting the environment; his girlfriend is a conservation biologist who undertakes RESEARCHĂĽPAIDĂĽFORĂĽBYĂĽTHEĂĽ#%/ĂĽOFĂĽAĂĽMININGĂĽCOMPANY Heath Ledger Theatre, September 19-Oct 4; Medical Forum performance, September 19

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Movie â&#x20AC;&#x201C; Paper Towns: Dr Max Traub, Dr Braad Sowman, Ms Andea Piesse, Dr Simon Machlin, Dr Elizabeth Sinclair, Dr Michael Hung, Dr Wendy Sexton, Dr Monica Keel, Dr Sarah Harris, Dr Sarat Rangaiah

Musical Theatre: Lord of the Dance Irish dance entrepreneur Michael Flatley brings his new show Dangerous GamesĂĽTOĂĽ0ERTHĂĽWITHĂĽAĂĽ stunning cast of young Irish dancers and musicians. A battle of good versus evil is played out on stage with ďŹ&#x201A;ashing taps and wild leaps with not too many guesses as to who triumphs. Crown Theatre, September 15-20; Medical Forum performance, September 15

Movie â&#x20AC;&#x201C; Madame Bovary: Dr George Carter, Dr Max Kamien, Dr Davis Storer, Dr Sue Bant, Dr Andre Chong, Dr Bibiana Tie, Dr Donna Mak, Ms Joanne Marks, Dr Eric Khong, Dr Jenny Fay Theatre â&#x20AC;&#x201C; Dirty Dancing: Dr Catherine Bacon, Dr Jane Weeks Kids Theatre â&#x20AC;&#x201C; The Gruffaloâ&#x20AC;&#x2122;s Child: Dr Astrid Valentine

40 | AUGUST 2015

MEDICAL FORUM

Wine Review

Step by Step with Zonteâ&#x20AC;&#x2122;s

:ONTE SĂĽ&OOTSTEPSĂĽISĂĽAĂĽRELATIVEĂĽNEWĂĽBRANDĂĽTHATĂĽ BEGANĂĽ INĂĽ ĂĽ ASĂĽ AĂĽ POOLINGĂĽ OFĂĽ AĂĽ NUMBERĂĽ OFĂĽ South Australiaâ&#x20AC;&#x2122;s experienced wine industry players. The intention was to offer a broader range of wine styles than what each individual was capable of doing.

By Dr Louis Papaelias

The viniďŹ cation has been the responsibility of Ben 2IGGS ĂĽAĂĽHIGHLYĂĽEXPERIENCEDĂĽANDĂĽACCOMPLISHEDĂĽ winemaker. He was one of Australiaâ&#x20AC;&#x2122;s earliest ďŹ&#x201A;ying winemakers working two vintages a year in the southern and northern hemispheres involving Napa Valley, the south of France, Marches, Abruzzo,

0UGLIA ĂĽ4USCANYĂĽANDĂĽ'REECE ĂĽ"ASEDĂĽINĂĽ-C,ARENĂĽ 6ALE ĂĽ:ONTE SĂĽ&OOTSTEPSĂĽALSOĂĽDRAWSĂĽONĂĽFRUITĂĽFROMĂĽ #LAREĂĽANDĂĽTHEĂĽ!DELAIDEĂĽ(ILLS ĂĽ"AROSSA ĂĽ#OONAWARRAĂĽ ANDĂĽ,ANGHORNEĂĽ#REEK ĂĽ4OĂĽQUOTEĂĽ*AMESĂĽ(ALLIDAY ĂĽ â&#x20AC;&#x153;The wine quality is as good as the prices are MODEST vĂĽ4HEĂĽNAMEĂĽDERIVESĂĽFROMĂĽAĂĽ THĂĽ#ENTURYĂĽ :ANTEĂĽCURRANTĂĽVINEYARDĂĽASĂĽNEWĂĽPLANTINGSĂĽFOLLOWĂĽTHEĂĽ original footstep of the pre-existing currant vines. The winemaking is expert and accomplished showing diversity and ďŹ&#x201A;air. All the wines tasted are LISTEDĂĽONĂĽTHEĂĽWEBSITEĂĽATĂĽ ĂĽFORĂĽTHEĂĽREDSĂĽANDĂĽUNDERĂĽ ĂĽFORĂĽTHEĂĽWHITEĂĽANDĂĽ2OSE ĂĽ4HEYĂĽREPRESENTĂĽVERYĂĽ good value for the excellent quality on offer.

1. Doctoressa Di Lago -ADEĂĽFROMĂĽ ĂĽ0INOTĂĽ'RIGIOĂĽGROWNĂĽINĂĽTHEĂĽ!DELAIDEĂĽ(ILLS ĂĽTHISĂĽISĂĽAĂĽVIBRANTĂĽ and fresh drop. Smelling of ďŹ ne ripe pears it has a generous mouthfeel with a crisp ďŹ&#x201A;avoursome ďŹ nish Awarded a gold medal at this yearâ&#x20AC;&#x2122;s 2OYALĂĽ3YDNEYĂĽ7INEĂĽ3HOW ĂĽITĂĽISĂĽLOVELYĂĽTOĂĽDRINKĂĽNOWĂĽANDĂĽPERFECTĂĽWITHĂĽFOOD ĂĽ 2ECOMMENDED

4. Chocolate Factory -ADEĂĽINĂĽ ĂĽFROMĂĽ-C,ARENĂĽ6ALEĂĽSHIRAZ ĂĽNOTĂĽSURPRISINGLYĂĽGIVENĂĽTHEĂĽNAMEĂĽ it has aromas of cocoa and spice with full-ďŹ&#x201A;avoured rich chocolatey fruit and balanced tannin. It is a generous companion at table for foods BASEDĂĽONĂĽMEAT ĂĽMUSHROOMĂĽORĂĽCHEESE ĂĽ!ĂĽTRUE TO TYPEĂĽ-C,ARENĂĽ6ALEĂĽREDĂĽ thatâ&#x20AC;&#x2122;s very satisfying on a cold winter night.

2. Scarlet Ladybird 4HISĂĽ ĂĽ2OSEĂĽISĂĽMADEĂĽFROMĂĽUNGRAFTEDĂĽVINESĂĽGROWNĂĽATĂĽAĂĽSINGLEĂĽSITEĂĽONĂĽ 3OUTHĂĽ!USTRALIA SĂĽ&LEURIEUĂĽ0ENINSULA ĂĽ)TĂĽHASĂĽATTRACTIVEĂĽPINKĂĽCOLOURĂĽWITHĂĽAĂĽ FRAGRANTĂĽHINTĂĽOFĂĽSPICE ĂĽ'OODĂĽDEPTHĂĽOFĂĽmAVOURĂĽWITHĂĽSAVOURYĂĽFRUIT ĂĽ)T SĂĽVERYĂĽ ENJOYABLEĂĽNOWĂĽANDĂĽWILLĂĽPLEASEĂĽMANY ĂĽ2ECOMMENDED

5. Lake Doctor 4HEĂĽADDITIONĂĽOFĂĽAĂĽSMALLĂĽAMOUNTĂĽOFĂĽVIOGNIERĂĽTOĂĽTHISĂĽ ĂĽ,ANGHORNEĂĽ#REEKĂĽ shiraz brings a notable lift in aromatics to the full cocoa richness of the WINE ĂĽ'OODĂĽBALANCEĂĽANDĂĽSUPPLEĂĽmAVOURS ĂĽ4HEREĂĽAREĂĽSAVOURYĂĽlNEĂĽTANNINSĂĽ and a clean ďŹ nish. A wine of class and substance.

3. Canto Di Lago 4HISĂĽISĂĽAĂĽ ĂĽBLENDĂĽOFĂĽ3ANGIOVESEĂĽANDĂĽ"ARBERAĂĽGROWNĂĽNEARĂĽ,AKEĂĽ !LEXANDRINAĂĽINĂĽTHEĂĽ,ANGHORNEĂĽ#REEKĂĽDISTRICT ĂĽ#HIANTIĂĽLOVERSĂĽWILLĂĽRECOGNISEĂĽ the delicious combination of fruit and savoury ďŹ&#x201A;avours offered by this wine. Its agreeable tannins allow for attractive drinking and especially so IFĂĽACCOMPANYINGĂĽGOODĂĽ-EDITERRANEANĂĽSTYLEĂĽFOOD ĂĽ2ECOMMENDED

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MEDICAL FORUM

AUGUST 2015 | 41

Dance

-ICHAELĂĽANDĂĽ-ARIEĂĽ$UFFYĂĽ0ASKĂĽAREĂĽTHEĂĽ choreographers with the day-to-day c w whip cracking going to Marie. But itâ&#x20AC;&#x2122;s c clear that all the dancers get a thrill when Michael pulls on the taps. w

Irish dancing master Michael Flatleyâ&#x20AC;&#x2122;s ďŹ&#x201A;ashing feet, his record-busting 35 taps s a second and his on- and off-stage charisma have all contributed to a legend that we collectively call Lord of the Dance.

â&#x20AC;&#x153;I incredible for us to step on stage â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s WITHĂĽ-ICHAELĂĽ&LATLEY ĂĽ/VERĂĽTHEĂĽ ĂĽYEARS ĂĽ W Iâ&#x20AC;&#x2122;ve danced with him a number of times Iâ&#x20AC;&#x2122;v bu but you can see the thrill on the faces of the new guys when he enters.â&#x20AC;? th

Flatley still occasionally pulls on the dance e shoes but the he has a big business to run THESEĂĽDAYSĂĽAND ĂĽATĂĽ ĂĽHISĂĽBODYĂĽISĂĽSTARTINGĂĽ to tell him things his mind probably doesnâ&#x20AC;&#x2122;t want to hear. He has indicated that he will retire from the stage at the end of the year BUTĂĽUNFORTUNATELYĂĽ0ERTHĂĽWON TĂĽSEEĂĽHIMĂĽPERform when he brings the latest incarnation of the show, Lord of the Dance Dangerous Games ĂĽTOĂĽTHEĂĽ#ROWNĂĽINĂĽ3EPTEMBER 4HEĂĽ NEWĂĽ @,ORD ĂĽ ISĂĽ *AMESĂĽ +EEGANĂĽ ANDĂĽ when he spoke to Medical Forum on the EVEĂĽOFĂĽTHEĂĽ!USTRALIANĂĽTOURĂĽHEĂĽSAIDĂĽAFTERĂĽ ĂĽ years with the company, he still had to pinch himself that he has landed such a wonderful role.

Ja James is eyeing a long career.

Irish dancing phenomenon that is Lord began in 1997 and today it is a huge tourof the Dance ing operation.

James was born in Manchester in the UK, which is not unusual among Irish dancers. FlatLEY ĂĽ HIMSELF ĂĽ WASĂĽ BORNĂĽ INĂĽ #HICAGOĂĽ SUCHĂĽ ISĂĽ THEĂĽ reach of the Irish diaspora and the commitment to keep Irish culture alive in far-ďŹ&#x201A;ung lands. He started dancing at the age of four and while he enjoyed it, he also loved football. He was PRETTYĂĽmASHĂĽATĂĽTHATĂĽASĂĽWELL ĂĽ!TĂĽ ĂĽHEĂĽWASĂĽINĂĽTHEĂĽ ACADEMYĂĽ ATĂĽ "LACKBURNĂĽ 2OVERSĂĽ HAVINGĂĽ BEENĂĽ scouted by Manchester United and considering life as a professional footballer.

42 | AUGUST 2015

hh-ICHAELĂĽWASĂĽ ĂĽWHENĂĽHEĂĽBEGANĂĽLord of the Dance, and Iâ&#x20AC;&#x2122;m not very injury prone, so touch wood, Iâ&#x20AC;&#x2122;ll be around for a while. Th The company looks after us really well with top physios and training and nutriwit tion regimes to prolong our careers.â&#x20AC;?

â&#x20AC;&#x153;The decision was taken out of my hands when I broke my leg. A year out of football was career-ending but not for dancing,â&#x20AC;? he said !TĂĽ ĂĽHEĂĽISĂĽAĂĽVETERANĂĽOFĂĽ&LATLEY SĂĽDANCEĂĽTROUPE h7HENĂĽ)ĂĽSTARTEDĂĽASĂĽAĂĽ ĂĽYEARĂĽOLD ĂĽ)ĂĽWASĂĽDANCINGĂĽ with Michael and a lot of the original cast, so I was schooled by the best. When I took the lead in the tour of South Africa in 2004, it was QUITEĂĽ AĂĽ PRIVILEGE ĂĽ *USTĂĽ ĂĽ YEARSĂĽ EARLIERĂĽ )ĂĽ WASĂĽ AĂĽ kid watching Michael perform in my hometown of Manchester.â&#x20AC;?

Wit the current tour taking in South AfWith RICA RICA ĂĽ !USTRALIA ĂĽ .EWĂĽ :EALAND ĂĽ 3INGAPOREĂĽ and Italy, thereâ&#x20AC;&#x2122;s a lot of dancing and wor world to see with an Irish bar in every town. â&#x20AC;&#x153;Without a doubt, we see an Irish bar as often ASĂĽ WEĂĽ SEEĂĽ AĂĽ -C$ONALDS ĂĽ 4HEĂĽ )RISHĂĽ AREĂĽ EVERYwhere.â&#x20AC;?

By Ms Jan Hallam

MEDICAL FORUM

Laugh Lines

Riding the Waves

By Wendy Wardell

Now that kids arenâ&#x20AC;&#x2122;t leaving home until roughly early middle-age, have childhood ailments evolved accordingly? I had assumed that travel-sickness was something â&#x20AC;&#x2DC;grown out ofâ&#x20AC;&#x2122; by puberty unless youâ&#x20AC;&#x2122;re foolish enough to have anything to do with boats. I now realise that there are some who are physiologically unsuited to leaving the sofa at any age. Holidays with my daughter invariably include the sort of travel experiences that bring dividends for local pharmacists and lingering odours for unfortunate upholstery. There are no countries weâ&#x20AC;&#x2122;ve visited that havenâ&#x20AC;&#x2122;t seen the local cuisine returned with emphasis to its pavements. No hire cars delivered back to their point of origin without a piquancy to their atmosphere that even a forest of pine tree-shaped air fresheners could dent. 3IANA SĂĽNOWĂĽ ĂĽANDĂĽSOĂĽFARĂĽHASĂĽBEENĂĽTAKENĂĽFROMĂĽ one aircraft by wheelchair, having swooned on top of a passing ďŹ&#x201A;ight attendant. She has barfed into bags in the airspace above most countries YOUĂĽCANĂĽNAME ĂĽANDĂĽINĂĽTUNNELSĂĽBELOWĂĽ,ONDON SĂĽ RIVERĂĽ 4HAMES ĂĽ 4HEĂĽ MAJESTICĂĽ BEAUTYĂĽ OFĂĽ THEĂĽ .:ĂĽ countryside has echoed to sounds that would make Orcs retreat in fear and revulsion. There MAYĂĽBEĂĽAĂĽCALL UPĂĽCOMINGĂĽFROMĂĽ0ETERĂĽ*ACKSON Ever the optimist, I thought she would grow out of it and that a cease-ďŹ re would eventually be called between her semi-circular canals and her digestive system. Wrong. The ďŹ rst sign is often a common cold. Iâ&#x20AC;&#x2122;m certain that for us, they are a suitcase-borne virus as colds are an inevitable part of travel preparations and bode ill. On the morning of our last trip, Siana awoke with a cold, and in the usual groggy fashion of a teenager for whom a good nightâ&#x20AC;&#x2122;s sleep would, in other species be considered hibernation, headed to the kitchen, ďŹ lled a bowl with cereal and stuck her face in it. Attempting to medicate her in preparation for the ďŹ&#x201A;ight was my ďŹ rst mistake. The effect of COMBININGĂĽ #ODRALĂĽ ANDĂĽ TRAVELĂĽ SICKNESSĂĽ TABLETSĂĽ with juice and sugar was much like adding baking soda to vinegar. Siana went pale and ventured outside to get fresh air, resulting in the petunias being liberally crop-dusted with second hand orange juice and crunchy nut cornďŹ&#x201A;akes. We hadnâ&#x20AC;&#x2122;t even started travelling. With the reassurance that it was at least â&#x20AC;&#x2DC;out of her systemâ&#x20AC;&#x2122;, we set off for the airport, having been offered a lift by a kindly elderly neighbour, Alan. While I sat in the front making polite

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conversation with him, murmurings from the back seat informed me that all was not well. I quickly retrieved, emptied and passed back a small plastic bag from my handbag. This was rapidly reďŹ lled accompanied by a full symphony of guttural sound effects as peristaltic waves slammed into reverse gear. However, our drivERĂĽWASĂĽCLEARLYĂĽDEAFĂĽTOĂĽ3IANA SĂĽ6OMITORIUMĂĽINĂĽ#ĂĽ minor, as our conversation continued on its chipper path without deviation or interruption. This created a surreal state of affairs, as to me ITĂĽ SOUNDEDĂĽ LIKEĂĽ !LIENĂĽ VSĂĽ 0REDATORĂĽ WASĂĽ BEINGĂĽ re-enacted in the back seat. I was loathe to draw Alanâ&#x20AC;&#x2122;s attention to Sianaâ&#x20AC;&#x2122;s digestive dilemma, as he had already nearly driven straight through a red light even when his full attention was on the road. I feared that his concern for the rear upholstery in his new car could quickly prove terminal for all three of us.

By the time we boarded the plane Sianaâ&#x20AC;&#x2122;s condition had stabilised. At least until the engines were switched on. Barely had we achieved cruising altitude when the ďŹ&#x201A;ight attendants experienced a sudden ďŹ&#x201A;urry of demand from people in the seats adjacent to ours to please be moved to the rows behind the screaming babies. Apparently in space no one can hear you SCREAM ĂĽ BUTĂĽ ATĂĽ ĂĽ FEETĂĽ THEYĂĽ CANĂĽ DElNITELYĂĽ hear you barf.

The back seat chorus abated but relief was short-lived as I was quietly informed that the bag was leaking. A ďŹ le protector sleeve was all I could ďŹ nd by way of reinforcement and as I handed it back, the airport hove into view. As we ďŹ&#x201A;ed into the terminal with the additional liquid hand luggage, I thanked our kindly neighbour profusely and prayed that the small souvenir of the experience remaining on the back seat would also escape his attention.

AUGUST 2015 | 43

Older inpatients can fall less The elderly falling on hard hospital ďŹ&#x201A;oor tiles is largely preventable and private health funds donâ&#x20AC;&#x2122;t want a bar of it.

Inpatient falls cost hospitals. But falls that injure can be reduced 40% in those over 60 with personalised patient education combined with staff training that includes patient feedback. Thatâ&#x20AC;&#x2122;s the conclusion of a study published in the Lancet under geriatrician Dr Nick Waldron (WA Health) and Dr Anne-Marie Hill (NDU). Across eight WA hospital rehab units, the rate OFĂĽ FALLSĂĽ AMONGĂĽ ĂĽ OLDERĂĽ INPATIENTSĂĽ DURINGĂĽ ANĂĽ AVERAGEĂĽ DAYĂĽ STAYĂĽ DROPPEDĂĽ FROMĂĽ FROMĂĽ ĂĽ TOĂĽ ĂĽFALLSĂĽPERĂĽ ĂĽPATIENTĂĽDAYS ĂĽ 0ATIENTSĂĽWEREĂĽASKEDĂĽTOĂĽSETĂĽPERSONALĂĽGOALSĂĽSUCHĂĽ as ring the call bell for assistance, wait for help from staff and use prescribed walking aids. Interestingly, although those with higher mini mental state scores were only targeted (shown a

Geriatrician Dr Nicholas Waldron, patient Joan Klimaitis and senior physiotherapist Wuan-Chin Lee.

$6$ ĂĽGIVENĂĽAĂĽWORKBOOK ĂĽANDĂĽ ĂĽSESSIONSĂĽFROMĂĽ a trained physiotherapist), all patients on the ward beneďŹ ted from the intervention, including dementia patients who didnâ&#x20AC;&#x2122;t receive the education. This was put down to increased staff vigilance and response to patient feedback (e.g. keeping a patientâ&#x20AC;&#x2122;s mobility aid within reach). In the past, lowering bed heights and installing bed alarms have been unsuccessful and patient education programs had been shown to only beneďŹ t patients with normal cognition. An estimated $4 saving comes from every dollar INVESTEDĂĽINĂĽTHEĂĽINITIATIVEĂĽ ORĂĽ ĂĽLESSĂĽFALLSĂĽDURINGĂĽ THEĂĽ WEEKĂĽSTUDY ĂĽWHICHĂĽEQUATESĂĽTO ĂĽ ĂĽ saving to the government health system). Falls are the most common adverse events in HOSPITALSĂĽ n ĂĽ OFĂĽ ALLĂĽ INCIDENTĂĽ REPORTS ĂĽ WITHĂĽ

ABOUTĂĽ ĂĽ OFĂĽ INPATIENTĂĽ FALLSĂĽ CAUSINGĂĽ PHYSICALĂĽ injuries, and non-injurious falls raising costs through increased stay in hospital. In private sector hospitals, health funds are trying to negotiate contracts with private hospitals where they do not pay for avoidable adverse events, like falls in hospital and surgical mistakes, said to add $42 m to Medibankâ&#x20AC;&#x2122;s hospital BILLSĂĽ ALONEĂĽ INĂĽ ĂĽ -EDIBANKĂĽ HASĂĽ JUSTĂĽ FAILEDĂĽ TOĂĽ NEGOTIATEĂĽSUCHĂĽAĂĽDEALĂĽWITHĂĽ#ALVARYĂĽ(OSPITALĂĽOVERĂĽ EAST ĂĽ 7ITHĂĽ BILLIONĂĽ PAIDĂĽ OUTĂĽ TOĂĽ PRIVATEĂĽ HEALTHĂĽ funds via government rebates last year, the funds are under considerable cost pressures. 4HEĂĽ #ONSUMERSĂĽ (EALTHĂĽ &ORUMĂĽ HASĂĽ CALLEDĂĽ FORĂĽ AĂĽ national enquiry into the private health fund industry.

By Dr Rob McEvoy

â&#x20AC;&#x153;Money for Medicine â&#x20AC;&#x201C; $licing the Cakeâ&#x20AC;? Donâ&#x20AC;&#x2122;t miss the next Doctors Drum breakfast for 2015 The breakfast takes its own course but maybe these things will crop up; ĂĽ sĂĽ Is there waste and where? ĂĽ sĂĽ Who decides and are they up to it? ĂĽ sĂĽ Who isnâ&#x20AC;&#x2122;t getting their fair share? ĂĽ sĂĽ #ANĂĽWEĂĽMAKEĂĽITĂĽWORKĂĽFOR our patients? Thursday 10 September 7.15-8.50am A Free Breakfast at 2ENDEZVOUSĂĽ3CARBOROUGH -ODERATORĂĽISĂĽ2USSELLĂĽ7OOLF

A serious moment during the last Doctors Drum

h)ĂĽTHOUGHTĂĽTHEĂĽDISCUSSIONĂĽWASĂĽEXCELLENT ĂĽ'REATĂĽTOĂĽGETĂĽSOMEĂĽINSIGHTĂĽFROMĂĽTHEĂĽPOLITICIANS ĂĽ7ELLĂĽDONE vĂĽ Dr Cliff Neppe, Duncraig â&#x20AC;&#x153;A very enjoyable breakfast and a welcome break from work. I enjoyed meeting new people and SPECIALISTSĂĽ)ĂĽHAVEĂĽREFERREDĂĽTOĂĽBUTĂĽNEVERĂĽMET ĂĽ4HEĂĽPANELĂĽWEREĂĽVERYĂĽIMPRESSIVEĂĽANDĂĽ2USSELLĂĽ7OOLFĂĽWASĂĽ GREAT ĂĽ)TĂĽWASĂĽVERYĂĽUSEFULĂĽFORĂĽTHEĂĽ'0SĂĽTOĂĽVENTĂĽTHEIRĂĽFRUSTRATIONS v Dr Rimi Roper, Mt Lawley

Limited numbers, reserve your place now at www.doctorsdrum.com.au 44 | AUGUST 2015

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medical forum FOR LEASE

MURDOCH New Wexford Medical Centre o 4U +PIO PG (PE )PTQJUBM 2 brand new medical consulting rooms available: t TRN BOE TRN t DBS CBZ QFS UFOBODZ Lease one or both rooms. 'PS GVSUIFS EFUBJMT DPOUBDU +BNFT 5FI Universal Realty 0421 999 889 KBNFT!VOJWFSTBMSFBMUZ DPN BV KELMSCOTT Room available for lease now "MCBOZ )XZ Reception staff, phone/fax/internet all inclusive Suitable for medical specialist or allied health service Contact Jo on 9390 8555 Or reception@akmd.com.au SUBIACO / WEST LEEDERVILLE Sessional consulting room available. Can be used on weekly, fortnightly, monthly basis. &YDFMMFOU MPDBUJPO o DBS CBZ BWBJMBCMF Newly fitted out medical suite. -PWFMZ FOWJSPONFOU o GSFTI BOE NPEFSO 'SJFOEMZ IJHIMZ FYQFSJFODFE SFDFQUJPO TUBGG Online Medicare claims / Inpatient billing available. For further information please phone: 0457 723 945

NEDLANDS Hollywood Medical Centre Suite 36 , 85 Monash Ave -Available for lease now -86 sq. metres -Fully fitted -1 car bay Contact Irene: 0409 688 339 or email irene.tay8@gmail.com MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: gcford56@gmail.com BULLCREEK Specialist consulting room available at a very busy practice. For long-term or short-term use. Perfect for any professional. Furnished. Newly renovated. Contact Karuna 9332 0488 or admin_pm@bullcreekmedical.com WEST PERTH For lease at 51 Colin Street Medical Consulting Suite is now available for lease. Colin Street Day Hospital is situated on floor below. Furnished medical consulting suite includes:t TRN t DPOTVMUJOH TVJUFT t 5SFBUNFOU SPPN t 3FDFQUJPO 8BJUJOH SPPN t ,JUDIFOFUUF t 4UPSBHF SPPNT Y t VOEFSDPWFS DBS CBZT t #JDZDMF BOE TIPXFS GBDJMJUJFT JO CVJMEJOH Contact Marie Sheehan on 0411 738 809 Email: marie@csds.com.au

SHOALWATER Sessional and/or permanent rooms available at our brand new Shoalwater Medical Centre. Opening 1st September 2015 Fully furnished and fitted out ideal for medical specialists and allied health practitioners. Full secretarial support if required. Fully equipped treatment room and procedure areas available. Experienced and friendly nursing and admin team. Located near both the Waikiki Private Hospital and Rockingham hospital. Please phone Rebecca on 08 9498 1099 or Email manager@sevilledrivemedical.com

MURDOCH Wexford Medical Rooms for lease 1MFBTF DPOUBDU BQUSBO!KPJOUTXFTU DPN BV NEDLANDS Hollywood Medical Centre - 2 Sessional Suites. Secretarial support available. Phone: 0414 780 751

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RESIDENTIAL FOR LEASE

PSYCHIATRISTS INVITED

WELLARD House Accommodation to Rent .BMF PXOFS OPO TNPLFS o QSPGFTTJPOBM seeking non-smoking working professional or couple to rent in newly built house. -BSHF N Y N #FESPPN QBSUMZ GVSOJTIFE room with built in robes. Own bathroom with separate toilet and vanity. 4FQBSBUF GSPOU 57 SPPN 0GGJDF GPS PXO VTF Discuss laundry / kitchen/ food BSSBOHFNFOUT o PQFO QMBO MJWJOH EJOJOH Ducted reverse cycle air-conditioning throughout house. Double lock up garage with some storage available. Secure. Approx 15mins drive to Fiona Stanley Hospital. 5 minute drive to shops and train station. TJOHMF PS DPVQMF QFS XFFL JODMVTJWF PG JOUFSOBM CJMMT JODMVEJOH /#/ JOUFSOFU BDDFTT 5FSNT NBZCF OFHPUJBCMF Available now. &NBJM 5JN BU UJN!FNQZSFBO XB FEV BV Mb: 0447 698 467

Are you intending to start Private Practice? 5IJT JT B TIFFS XBML JO Part time, sessional or full time - all enquiries welcome. Furnished consulting rooms with secretarial support: "OOPJT 3PBE #JCSB -BLF 8" $VSSFOUMZ 1TZDIJBUSJTU B 1TZDIPMPHJTU work here Clinic is open 5 days a week EBZ QIBSNBDZ BOE (1 TVSHFSZ JT OFYU EPPS 5 minute drive to St John of God 'JPOB 4UBOMFZ You are welcome to visit us or Phone Navneet 9414 7860 www.blsc.net.au

FOR LEASE OR SALE MURDOCH An attractive suite at SJOG Murdoch. 5IJT GVMMZ TFMG DPOUBJOFE TVJUF JT TR metres and has a reception area, kitchen, and consulting room. 5IF SFOU JT POP QMVT PVUHPJOHT QB For Sale $510 000 negotiable Please contact 0407 192 227

FOR SALE MANDURAH Solo GP practice for sale, real estate included. Would suit procedural GP with Obstetrics and Gynaecology interest. Can suit husband and wife team. Phone 0408 241 674

INTERSTATE POSITION SYDNEY Campsie a busy inner west suburb of Sydney a city of cultural diversity. 100% of billings for the first 3 months and temporary accommodation provided. -PPLJOH GPS 73 (1T XJUI VOSFTUSJDUFE QSPWJEFS number on a part-time or full time basis. With all Allied Health Services and RN support. Prefer Chinese speaking but not necessary. $POUBDU %S #FO "OH 0426 271 168 or bhc2008@hotmail.com

Do you need a website or a refresh? Contact Thinking Hats UPEBZ BOE XF DBO IFMQ hats@thinkinghats.net.au

RURAL POSITIONS VACANT ALBANY t 4U $MBSF T JT B OFX GBNJMZ QSBDUJDF based in Albany t 4NBMM GSJFOEMZ QSBDUJDF t 'VMM UJNF OVSTJOH BOE administration support t 1BUIPMPHZ PO TJUF t 'VMM PS QBSU UJNF (1 XBOUFE UP KPJO PVS UFBN t 4QFDJBM JOUFSFTU JO TLJO XPVME CF JEFBM t $VSSFOUMZ OP %84 VOMFTT XJMMJOH UP XPSL in afterhours period t (1T OPU SFRVJSJOH TVQFSWJTJPO SFRVJSFE Please contact Practice Manager, Helen Williams: 08 9841 8102 Email: helen@stclare.com.au 0S TFOE ZPVS $7 UISPVHI BOE XF XJMM HFU back to you.

URBAN POSITIONS VACANT COMO Want variety in your work? Special interest opportunities at the Well Men Centre in Como. 1BSU UJNF (1 T GPS PVS 1FSUI .PMF $MJOJD Skin Cancer Screening Service and for our Holistic Health Management Programme. Call 9474 4262 or Email: wellmen@optusnet.com.au WEMBLEY DOWNS 0QQPSUVOJUZ UP KPJO PVS QSJWBUFMZ owned practice. 1SJWBUF #JMMJOH Flexible hours On site pathology Fully computerised All Correspondence in confidence Email: Diane pmgr@ovmc.com.au ASCOT 1BSU 5JNF 73 (1 SFRVJSFE GPS PVS XFMM established Accredited Privately Owned Friendly Family Practice in Redcliffe. We are fully computerised, using #FTU 1SBDUJDF TPGUXBSF Nurse is support available. Non DWS area. 1MFBTF DBMM o 9332 5556

SEPTEMBER 2015 - next deadline 12md Friday 14th August â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

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WANNEROO 73 (1 3FRVJSFE 'VMM 5JNF 1BSU 5JNF i(1 8&45 iSFRVJSFT GVMM UJNF 73 (1T to work in our state-of-the-art medical DFOUSF XJUI DPOTVMU SPPNT XIJDI JT opening in June 2015. 'VMMZ DPNQVUFSJTFE XJUI #FTU 1SBDUJDF full time Nurse and onsite Pathology, allied health and pharmacy. 7JTJU XXX HQXFTU DPN BV GP owned and great remuneration for foundation doctors. Contact Dr Kiran Puttappa on 0401 815 587 or send cvs to kiranpkumar@hotmail.com NEDLANDS 73 (1 MPPLJOH GPS TFTTJPOT PS 15 Next to UWA in busy shopping centre Fully accredited Mixed billing Contact Suzanne at 9389 8964 Email: nedlandsdoctor@yahoo.com.au

SORRENTO ' 5 PS 1 5 (1 GPS CVTZ 4PSSFOUP Medical Centre, Normal/after hours available , we are like family, OVSTF BMMJFE TFSWJDFT PO CPBSE SFNVOFSBUJPO Please call Dr Sam 0439 952 979

MANDURAH Modern Medical Clinics team is looking for new doctors to assist with our expansion plans. Mandurah is currently recognised as an area of need and district work shortage but this will not last for long. If you would be interested in moving to the paradise of Mandurah in the next few ZFBST UP KPJO PVS UFBN please contact Steve or Carol for a confidential discussion mail@modernmedicalclinics.com.au CANNINGTON Southside Medical Service is an accredited practice located in Cannington area. We are a family practice and offer mixed billings. 8F IBWF QPTJUJPOT GPS B (1 UP KPJO PUIFS (1 T DVSSFOUMZ XPSLJOH It is a well-positioned practice, close to the Carousel Shopping Centre. Phone: 9451 3488 or Email: reception@southsidemedical.com.au GREENWOOD Greenwood/Kingsley Family Practice 5IF MBOETDBQF PG HFOFSBM QSBDUJDF JT changing, and it is changing forever. Are you feeling demoralised by the recent Federal government proposal on changes to Medicare? Do you feel that you have to keep bulk billing in order to retain patients? *U EPFTO U IBWF UP CF UIJT XBZ Come and speak to us and see the different ways in which we operate our general QSBDUJDF #F QBSU PG UIF HBNF DIBOHFS Our practice is located north of the river. Sorry we are not DWS. Please contact shenychao@hotmail.com or 0402 201 311 for a strictly confidential discussion.

WILLETTON (1 73 SFRVJSFE MPOH UFSN Full time or Part time FBSOJOHT Contact: 0412 346 146 ampmdoctors@westnet.com.au

HELENA VALLEY

JOONDALUP CANDLEWOOD MEDICAL CENTRE (1 SFRVJSFE UP KPJO PVS GSJFOEMZ UFBN GPS B busy computerised practice in Joondalup. 7FSZ BUUSBDUJWF SFNVOFSBUJPO Privately owned. AGPAL accredited general practice. Contact John Wong P: 08 9300 0999 M: 0414 981 888 E: cmc1@iinet.net.au

General Practitioner '5 15 73 GPS QSJWBUFMZ PXOFE HFOFSBM QSBDUJDF JO 4DPUU 4USFFU )FMFOB 7BMMFZ 5IF XFMM FTUBCMJTIFE DMJOJD JT GVMMZ accredited and computerized with full time RN support. 60-65% billings + pip incentives. Mixed billings. Please contact: pmanager@hvmc.com.au or call 9255 1161

CURRAMBINE Mole and Skin Cancer Clinic is looking GPS BO FYQFSJFODFE '5 PS 15 73 EPDUPS New Purpose built clinic with Great facilities, Non-Corporate, NOR, Accredited Practice - Onsite Nurse - Rates Negotiable #FTU 1SBDUJDF TPGUXBSF Email your resume to shentonavenuemedical@outlook.com

CANNING VALE $BOOJOH 7BMF %84 SFRVJSFT GVMM QBSU UJNF PS MPDVN 73 (1 VSHFOUMZ 3BUFT OFHPUJBCMF Privately owned practice - fully computerised, huge consulting rooms, spacious treatment room with RN, and on-site pathology with other health alliances in the complex. Phone: Julie 9456 1900 &NBJM KQIZP!OJDIPMTPONFEJDBM DPN BV

HAMILTON HILL A female GP required for a clinic in a DWS and AON area 5 minutes drive from Fremantle. 3 Doctor GP Practice. Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 PS 4FOE $7 UP eric@hamiltonhillfamilypractice.com.au

DUNCRAIG & OSBORNE CITY Duncraig Medical Centre Osborne City Medical Centre 3FRVJSF B GFNBMF (1 o XPVME be fully booked day 1. Flexible Mon to Fri hours. (after hours optional) Excellent remuneration. Modern, predominantly private billing practice. Fully computerised. Please contact Michael on 0403 927 934

BEECHBORO 1 5 PS ' 5 (1 SFRVJSFE UP KPJO MPOH established busy medical practice in #FFDICPSP Privately owned, 8 doctor practice with full nursing support. %84 BOE FBHFS UP SFQMBDF SFDFOU (1 T departure back to Europe. Mixed billing. Generous terms. Confidential enquiries to manager@altonemed.com.au

BUTLER Connolly Drive Medical Centre 73 (1 SFRVJSFE GPS UIJT WFSZ OFX TUBUF of the art, fully computerised, absolutely paperless, spacious medical centre. Fully equipped procedure rooms and casualty, well-furnished consult rooms, pathology, allied health, RN support. Abundant patients, DWS, non-corporate. Generous remuneration. Confidential enquiries Dr Ken Jones on (08) 9562 2599 5JOB NBOBHFS PO 9562 2500 Email: ken@cdmedical.com.au

MADELEY 73 /PO 73 (FOFSBM .FEJDBM Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new non DPSQPSBUF QSBDUJDF XJUI GFNBMF NBMF General Practitioners. Sessions and leave negotiable, salary is compiled from billings rather than takings. 6Q UP PG CJMMJOHT QBJE EFQFOEBOU PO experience). Please contact Jacky on 0488 500 153 or & NBJM UP KBDLZ TUFWFO!MJWF DP VL EASTERN SUBURBS #SBOE OFX (1 QSBDUJDF MPPLJOH GPS 73 (1 with fellow to start ASAP. Good remuneration and excellent team to help you build your patient base quickly in a high demand area. Location eastern suburbs of Perth, DWS 15-20 min from the city . Contact 0401 625 712 or email Waliadr@hotmail.com CHURCHLANDS Herdsman Medical Centre in Churchlands SFRVJSFT B 1BSU UJNF 73 BOE '3"$(1 qualified GP. We are a friendly western suburbs practice. o TFTTJPOT QFS XFFL SFRVJSFE 1 Saturday morning per month. Practice culture is quality care and we QSJWBUF CJMM BMM QBUJFOUT FYDFQU BU %PDUPS T discretion. Computerised, well-staffed, practice nurse. 1MFBTF GPSXBSE $7 XJUI SFGFSFODFT to Ms Dianne Swift by email practicemanager@herdsmanmedical.com.au

WILLETTON Herald Ave Family Practice We are looking for a suitable full time or QBSU UJNF 73 (1 UP KPJO PVS GSJFOEMZ UFBN We are a small, non-corporate practice, fully computerised and accredited, with registered nurse support. *G ZPV XPVME MJLF UP KPJO VT Email: hafp@eftel.net.au or call 9259 5559 www.heraldavefamprac.com.au

Are you looking for doctors for your medical practice? "VTUSBMJBO .FEJDBM 7JTBT JT PXOFE BOE run by 2 Practice Managers based in WA, who have over 20 years experience of the UK and Australian healthcare systems. We currently have a number of doctors who are looking for positions in Australia. We are able to assist practices with all paperwork involved including the migration process (if required). Please visit our website www.australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or Andrea on 0401 371 341.

YANCHEP North of River (DWS Area) &YQFSJFODFE '5 (1 SFRVJSFE #VTZ DPNQVUFSJTFE QSBDUJDF Nurse and Admin support &BSO VQ UP PG CJMMJOHT Flexible hours /PO 73 XFMDPNF UP BQQMZ &ORVJSJFT UP 1IJM QIJM CD!HNBJM DPN

KALAMUNDA & FORRESTFIELD Mead Medical was awarded the RACGP (FOFSBM 1SBDUJDF PG UIF :FBS BOE has been servicing patients in the area for 60 years. We currently have a vacancy for a 73 (1 QPTJUJPO GPS B NPOUI DPOUSBDU with a view to extension, for our well established, friendly practices in Kalamunda and Forrestfield. t 5IF QSBDUJDF IBT B XFMM FTUBCMJTIFE patient base, and offers an exciting opportunity for an enthusiastic QSBDUJUJPOFS UP KPJO PVS QSBDUJDF t 1SJWBUF CJMMJOH QSBDUJDF JODMVEJOH pensioners and HCC) t 4VQQPSU PG 1SBDUJDF /VSTFT BOE PO TJUF pathology and pharmacy. t 6OJRVF NFOUPSJOH PQQPSUVOJUJFT available, and excellent support staff and facilities Please email Jann Doherty JDoherty@meadmedical.com.au for further information and position description. JOONDANNA 8F BSF TFFLJOH B 73 (1 UP KPJO PVS GSJFOEMZ team on a part-time or full-time basis. New, state of the art medical centre. Flexible hours and billing. Percentage negotiable. Fully-computerised. Nursing support for CDMP. Please call Wesley on 0414 287 537 for further details.

SEPTEMBER 2015 - next deadline 12md Friday 14th August â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum CLAREMONT 5IF 8BML JO (1 QSBDUJDF MPDBUFE JO the trendy suburb of Claremont. 80% of billings. Looking for GPs for Saturdays and Sundays (DWS) Fully computerised with on-site pathology and RN support. Located in a modern complex with access to the gym and pool. For further information please contact Dr Ang on 9472 9306 or Email: info@thewalkingp.com.au WBDBODJFT NBZ CF BWBJMBCMF GPS 73 (1T on weekday PM sessions). GOSNELLS Ashburton Surgery. Established 2002. 73 (1 OFFEFE QBSU UJNF Ethical patient oriented practice Fully Accredited. Private billing. PG CJMMJOHT Fully equipped with nurse support. Email: angiesurgery@gmail.com or call Angie 0422 496 594

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology and Allied services on site. Privately owned. Generous remuneration. 1MFBTF DBMM %S 5BLMB 0439 952 979

SHOALWATER ' 5 73 (1 SFRVJSFE GPS PVS CSBOE OFX medical centre located in Shoalwater (DWS), opening 1.9.15. Offering modern surrounds and fully computerised clinical software. We are a friendly, privately owned and run centre. A full complement of nursing staff/ admin team as well as onsite allied health/specialists and pathology. Remuneration negotiable. Please phone Rebecca on 08 9498 1099 PS &NBJM $7 UP manager@sevilledrivemedical.com

Myaree Medical Centre seeks a full-time 73 (1 GPS PVS NPEFSO FYQBOEJOH TPVUI PG the river practice. We are a private billing, non-corporate practice servicing a predominantly younger demographic. Our surgey is a modern, well equipped, purpose built facility. Our doctors have a special interest in skin cancer medicine as well as mainstream general practice. Excellent remuneration. Weekdays only, no after hours. Fully computerised, onsite pathology. All applications considered. Confidential enquiries to Julia reception1@myareemedicalcentre.com.au or 9317 8882

At IPN, weâ&#x20AC;&#x2122;re looking after you We take care of running the medical practice so you can focus on your patients and enjoy a greater work-life balance. I.T. Resources

Financial Services

Practice Management

Nursing Support

To view videos of Doctors sharing their own personal experiences partnering with IPN, visit: www.ipn.com.au/testimonials 1800 IPN DOC (1800 476 362)

enquiries@ipn.com.au

SEPTEMBER 2015 - next deadline 12md Friday 14th August â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au

medical forum

GP Opportunities - WA

EXMOUTH-Ningaloo reef

Concerned with the rising practice costs? Worried about the Medicare schedule freeze? As a result of IPN’s expanding network, there are currently a number of exciting opportunities for Doctors and practices looking at their future prospects.

Brand new premises available for entrepreneurial GP. Be the ﬁrst private GP in town, with opportunity to focus on occupational and dive medicals.

IPN’s Business Development Manager, Craig Coombs will be in Perth from the 2 - 9 September. Call today to schedule a discussion to discover how IPN can look after you. For all conﬁdential enquiries, please contact Craig Coombs: 0427 744 097 craig.coombs@ipn.com.au

Contact draburkett@live.com

With IPN, we’re looking after you.

ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? As WA’s only specialised medical business broker we have helped many buyers ﬁnd medical practices that match their experience.

GPs Wanted – Belvidere Health Centre (Belmont, 39 Belvidere Street) Ŕ Ŕ Ŕ Ŕ Ŕ

GPs Wanted – GP After Hours Clinics in Belmont, Armadale and Rockingham

You won’t have to go through the onerous process of trying to ﬁnd someone interested in selling. You’ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision. We’ll take care of all the bits and pieces and you’ll beneﬁt from our experience to ensure a smooth transition.

To ﬁnd a practice that meets your needs, call:

Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au

(FOFSPVT IPVSMZ SBUFT 'MFYJCMF XPSLJOH IPVST $MJOJDBM BOE OVSTJOH TUBŢ TVQQPSU .PEFSO XFMM FRVJQQFE GBDJMJUJFT 'VMMZ DPNQVUFSJTFE

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(FOFSPVT IPVSMZ SBUFT .PEFSO XFMM FRVJQQFE GBDJMJUJFT 'VMMZ DPNQVUFSJ[FE BOE BDDSFEJUFE DMJOJDT 1SJWBUF BOE #VML #JMMJOH PQUJPOT $MFSJDBM BOE OVSTJOH TUBŢ TVQQPSU For more information contact Rod Redmond at 08 9458 0505 or r.redmond@archehealth.com.au

Lease - $6,000 per month plus outgoings

SEPTEMBER 2015 - next deadline 12md Friday 14th August – Tel 9203 5222 or jasmine@mforum.com.au

medical forum

GP Opportunities - WA

Female VR GP for Sessional Work *( ).Ĺ&#x2014; '/#Ĺ&#x2014;Ä&#x2020;Ĺ&#x2014; ($'4Ĺ&#x2014; -1$ .Ĺ&#x2014;$.Ĺ&#x2014;. &$)"Ĺ&#x2014; Ĺ&#x2014;! ( ' Ĺ&#x2014; Ĺ&#x2014; Ĺ&#x2014;2$/#Ĺ&#x2014; )Ĺ&#x2014;$)/ - ./Ĺ&#x2014;$)Ĺ&#x2014;2*( )Ä&#x17D;.Ĺ&#x2014;. 30 'Ĺ&#x2014; ) Ĺ&#x2014;- +-* 0 /$1 Ĺ&#x2014; # '/#Ĺ&#x2014;!*-Ĺ&#x2014;. ..$*) 'Ĺ&#x2014;2*-&Ĺ&#x2014;$)Ĺ&#x2014;$/.Ĺ&#x2014; $ 'Ĺ&#x2014;Ä&#x2020;Ĺ&#x2014; '/#Ĺ&#x2014; -1$ Ĺ&#x2014; '* / Ĺ&#x2014;$)Ĺ&#x2014; **) '0+Ĺ&#x2014; ) Ĺ&#x2014; *-/# -$ " Ăż Ä&#x2026;Ĺ&#x2014; ..$*).Ĺ&#x2014;) "*/$ ' Ĺ&#x2014; ) Ĺ&#x2014;! ($'4Ĺ&#x2014;!-$ ) '4Ăż Ä&#x2026;Ĺ&#x2014; ** Ĺ&#x2014;- (0) - /$*)Ăż Ä&#x2026;Ĺ&#x2014; ' -4Ĺ&#x2014;. -$Ăą $)"Ăż Ä&#x2026;Ĺ&#x2014; 0-. Ĺ&#x2014; ) Ĺ&#x2014;

Ĺ&#x2014; Ĺ&#x2014;.0++*-/Ăż Ä&#x2026;Ĺ&#x2014; - $/ Ĺ&#x2014;. -1$ Ăż Contact Barbara BarclayÄ&#x20AC;Ĺ&#x2014; - ' 4Ä˘2#!.Ăż*-"Ăż 0Ĺ&#x2014; Womens Health & Family Services,Ĺ&#x2014; Ĺ&#x2014; *3Ĺ&#x2014;ĂˇĂśÄ&#x20AC;Ĺ&#x2014; *-/# -$ " Ä&#x20AC;Ĺ&#x2014; Ĺ&#x2014;ĂťĂ˝ĂťĂşÄ&#x20AC;Ĺ&#x2014; 'Ĺ&#x2014;Ă´Ă˝Ĺ&#x2014;6330 5400Ĺ&#x2014; 3Ĺ&#x2014;Ă´Ă˝Ĺ&#x2014;6330 5499

/,, (.&3 " - *)-#.#)(- 0 #& & ), ) .),- #( ." )&&)1#(! (., - /,# ( 3 ( , & , .# #($ ,, # & (., (( ,)) /* , &#(# . , )/,- ,' &# # & (., . , )/,- IPN offers: 4 &#(# & -)0 , #!(.3 4 ** &#(! 5( ( # & #( (.#0 4 ) ,( 1 && +/#** &#(# 4 /**),. ,)' 2* ,# ( -. For all conďŹ dential enquiries, please contact Lucy Barker:

&/ 3 ,% , #*( )' / With IPN, weâ&#x20AC;&#x2122;re looking after you.

Venosan Diabetic Socks HEALTH WATCH CLINICS MELVILLE / JANDAKOT / COTTESLOE )FBMUI 8BUDI $MJOJDT SFRVJSFT B 15 '5 73 (1 GPS XPSL BU FBDI PG JUT DMJOJDT )FBMUI 8BUDI $MJOJDT BSF BDDSFEJUFE GVMMZ DPNQVUFSJTFE QSBDUJDFT XJUI BO JOUFSFTUJOH NJY PG HFOFSBM QSBDUJDF BOE PDDVQBUJPOBM IFBMUI )FBMUI 8BUDI JT BTTPDJBUFE XJUI B +BOEBLPU CBTFE BJS BNCVMBODF GPS UIPTF XJUI BO JOUFSFTU JO TPNF BJS BNCVMBODF XPSL PS SFQBUSJBUJPO XPSL

See: www.healthwatchclinics.com.au www.medicalair.com.au Enquiries to: sherri@healthwatchclinics.com.au or (08) 9383 3435

Produced right here in Western Australia! Full Colour Personalise ed Practice Newsletter -RLQ RYHU VDWLVÂżHG PHGLFDO SUDFWLFHV DFURVV $XVWUDOLD ZKR SURYLGH Health News DV D YDOXDEOH SDWLHQW VHUYLFH LQ WKHLU SUDFWLFH ,W DVVLVWV ZLWK DFFUHGLWDWLRQ DQG ZH GR DOO WKH ZRUN IRU \RX 9HU\ UHDVRQDEO\ SULFHG DQG D Free Trial Offer IRU WKRVH VWDUWLQJ RXW 6LPSO\ SKRQH -HQQ\ on 9203 5599.

The Magic of Silver for Sensitive Feet No Compression Silver Ion Therapy Contains the antimicrobial silver yarn ShieldexÂŽ which enhances a balanced foot climate. Tested and proven in controlling over twelve types of bacterial and fungal infections common on the feet and legs. t

Silver yarn - is permanent and cannot be washed out of the socks.

Keeps feet cooler in the summer and warmer in the winter

Comfort for The Patient t

Soft-Spun Cotton - Ultra soft cotton

Fully cushioned foot and fully cushioned sock

Comfortable for arthritic patients

Your WA Consultant â&#x20AC;&#x201C; Jenny Heyden Tel 9203 5544 or Mob 0403 350 810

SEPTEMBER 2015 - next deadline 12md Friday 14th August â&#x20AC;&#x201C; Tel 9203 5222 or jasmine@mforum.com.au