Medical Forum - November 2019 - Public Edition by Medical Forum WA

The Care Factor Aged and Palliative Care Mental Health, Frailty, Bones Climate for Change

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November 2019

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EDITORIAL Jan Hallam, Managing Editor

Growing Old, a Tricky Business This is the aged care and palliative care edition and it never ceases to put the team in a reflective mood. At this particular moment in the state’s history, with the highly emotive debate around voluntary assisted dying drawing to a conclusion, how and when we die has never been more discussed. Let’s put that down as an enormous plus. The one big wish is that aged care, in all its myriad forms, similarly comes out of the shadows and becomes an essential community discussion. If we’re lucky, most of us will grow old. While legislation may offer people more say in how they wish to die, governments and business have not done a consistent enough job in giving ageing individuals more say in how they want to live. We have had policies for decades advocating ageing in place. This has led to the rise in consumer directed care – a beautiful piece of paper, if you’re lucky enough to get a package before you are forced to go into residential care or you die. We have seen enormous variability in quality and viability of residential aged care facilities over the same period of time. The Royal Commission into Aged Care Quality and Safety, now ticking over 12 months in the job of peeling back the wallpaper on the horror stories, is just moving into perhaps the most critical of areas – the aged care workforce. I have followed this story almost from the beginning of my time at this desk – since 2012. There have been parliamentary inquiries, taskforces, roundtables, you name it. After all the talk it comes down to quite a simple statement. There are not enough appropriately trained staff in RACFs – and we’re not talking registered nurses or medical professionals (although that is true numerically, at least), it comes down to what is lacking the most – care workers.

citizens rely. Yet care workers are undervalued, often poorly selected, inadequately trained and woefully underpaid – and they leave, after short periods of employment. I am in no position to talk about greedy operators, we’ve all read the stories, but for every one of those operators, there are establishments we know that work exceptionally hard, in very difficult clinical, political and regulatory circumstances to deliver quality care. What’s also apparent is there are no quick fixes. I wrote last year that the royal commission ran the risk of diverting attention, possibly resources as well, to the possible solutions contained in the Aged Care Workforce Strategy Taskforce’s report, A Matter of Care. The chair of that taskforce, Prof John Pollaers, gave the execution of the timeline three years and when implemented, the recommendations would position the industry well for the next four to seven years. Prof Pollaers appeared before the royal commission on October 15 lamenting government inaction on his report. He was also less than impress by his being totally ignored by the departments and the minister. Since his report was tabled there’s been an election, a change of minister, a lack of policy – in any direction – and a royal commission that is spraying the heat around. Screeching headlines about unscrupulous aged care operators takes the heat off government. Prof Pollaers told the commission that he believed government had positioned itself to say workforce issues were industry issues and industry could deal with the unions. The government was using the woefully fragmented system to put up its hands and claim they didn’t know who to listen too. Stalemate. This is an ancient political ruse that has proved successful for directionless policy makers for millennia, but it is a cynical and shameful neglect of the country’s most vulnerable people.

It is on these people, in these vital jobs, do our elderly

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MEDICAL FORUM

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

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CONTENTS OCTOBER 2019

INSIDE 18 Palliative Care a Human Right 24 Depression in the Elderly 26 Science of Living Longer 30 RPH Trauma Symposium

NEWS & VIEWS 1 Editorial: Growing Old, a Tricky Business – Jan Hallam 4 Letters to the Editor:

10 34 38 50

Big Dry is Real – Dr Richard Yin Look to the Science – Dr George Crisp World Can’t Wait – Dr Deborah Field It’s a MDRAP – Mr Tim Shackleton Doctors on Climate Strike Alcohol and Pregnancy Joint Replacement Registry National Health Expenditure

LIFESTYLE 52 Tale of Three Cars – Dr Mike Civil 55 Wine Review: Millbrook – Dr Martin Buck 56 Social Pulse: SJG Subiaco Research Week; Winter Wonderland 58 Competitions

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MEDICAL FORUM

CONTENTS OCTOBER 2019 CLINICALS

5 Colorectal Serrated Neoplasia Dr Michael Armstrong

40 Knee imaging, which test when? Dr Matt Prentice

Encouraging Self-Confidence in the Elderly Dr Daryl Kroschel

Who Benefits from Cannabinoid Therapies Dr Alistair Vickery

Managing Behavioural in Dementia Care Dr Scott Blackwell

Skeletal Regeneration Prof Richard Prince

Frailty – What, Why & How Dr Claire Meyerkort

Solid Tumours Dr Mihitha Ariyapperuma (Ari)

Oral Cancers Dr Amanda Phoon Nguyen

2019

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DO YOU HAVE A PASSION FOR DOCTORS’ HEALTH?

Testosterone Deficiency Ms Melissa Hadley Barrett

AMS in Indigenous Communities By Dr Asha Bowen

AUSTRALASIAN DOCTORS’ H E A LT H C O N F E R E N C E 22-23 NOVEMBER 2019 PE RT H AU ST R ALIA

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

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GUEST COLUMNS

8 A Climate Confession Dr Toby Pearn

12 Why Action is Needed Now Dr Colin Hughes

33 Regulations of Restraints David McMullen

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

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Big dry is real

Look to the science

Dear Editor,

I refer to the letter How different is it? by Colin Smyth (October edition) in response to my September edition letter.

As doctors we act according to the best medical scientific evidence and knowledge available, and, on that basis, we expect others to respect our expertise and advice. So, it is curious that any of us would choose to dismiss the advice of experts from other scientific fields.

Regarding the Bureau of Meteorology (BOM) rainfall data, their State of the Climate 2018 report http://www. bom.gov.au/state-of-the-climate/australiaschanging-climate.shtml highlights the profound drying trend in recent decades across southern Australia and most evident in south-western and south-eastern corners of the country. The long-term trend is pretty clear with rainfall over south-west Western Australia around 20% less than the average from 1900 to 1969 and since 1999, this reduction has increased to around 26%. They also report on the decline in streamflow in Perth with water storage dropping 388GL during 1911-1974 to 134GL from 1975-2017, with a further fall to 47GL during the last six years. I am somewhat surprised then by Dr Smyth's interpretation of the data by the BOM, which clearly was not what they concluded. Instead, BOM highlighted the widespread concerning climatic changes as a result of global warming, which was evident across Australia. As to the opinion of Greenpeace cofounder, Patrick Moore, my preference for scientific opinion on climate change would be with climate scientists reporting to the Intergovernmental Panel on Climate Change, our own Bureau of Meteorology and CSIRO. The science presented clearly speaks to an urgency to rapidly reduce our global emissions if we are to avoid catastrophic climate change impacts. We need to collectively act now if our children are to have a healthy future. Dr Richard Yin WA chair Doctors for the Environment Australia ....................................................................

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4 | NOVEMBER 2019

Particularly when the physics relating to the effects of greenhouse gasses in the atmosphere have been understood for as long as we've known microbes cause infectious diseases.

emissions – that is much more than the US (16%). Clearly, a zero emissions target for Australia will have a significant impact. In addition, Australia is more vulnerable to global warming effects because of our dry climate already prone to extreme conditions. It is therefore in our interest to act to prevent unmanageable climate change. How can we ask other countries to make the necessary reductions if we are not prepared to contribute fairly? A global zero emissions target by 2050, accompanied by a peak in greenhouse emissions ASAP and definitely by 2030, has the best chance of limiting global warming to 1.5C above pre-industrial levels. This is the goal of the Paris Agreement. If this target is met, the agreement will have helped to delay or avoid some of the worst consequences of climate change.

NASA, The Royal Society, Australian Academy of Science, CSIRO and every other major science organsation have easily accessible online resources that clearly explain climate science. There is absolutely no need to refer to Breitbart or nonscientists for explanations of this or any other area of science.

If the world does nothing to address greenhouse gas (GHG) emissions, the 2018 IPCC Assessment quotes global warming to reach ~ 3.5C (global mean) above pre-industrial levels by 2100, with utterly unpalatable consequences for millions of species including humans. This is the legacy we will leave for our children, their children and their grandchildren.

The rapid changes that are now occurring in Earth's previously stable climatic system are altering those conditions on which ecosystems, our agriculture and infrastructure are adapted. Our dependence of these fundamental determinants of health, prosperity and security are threatened and in fact already being compromised.

And yet, Australia’s GHG emissions continue to rise. Currently our emissions are 8% higher than 2005. When the huge LNG projects in WA are fully operational, Australia’s contribution to global GHGs will have tripled to >3%. The carbon emissions from these WA gas projects will dwarf those of the Queensland Adani mine.

That is why this is a health emergency. Dr George Crisp, GP Shenton Park ....................................................................

The world can’t wait Dear Editor, Re: Change Behaviour, Dr Blair (October 2019 edition) states that a zero emissions target for Australia will have zero measurable impact in 100 years. Australia is the 16th largest contributor to GHG (greenhouse gas) emissions (1.3%). If all of the nations that emit the same and less than Australia were grouped together they would account for 30% of global

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

Dr Blair suggests a more practical approach is to reduce the burden of population on the planet by measures including education of women, contraception, adequate nutrition and clean water. These measures have too long a long lead time (many generations) to have any effect on current global warming. We need to reduce emissions in a fraction of that time. Dr Deborah Field, GP, Palmyra ....................................................................

continued on Page 6

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LETTERS TO THE EDITOR

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Major Partner: Clinipath Pathology

By Dr Michael Armstrong, Gastrointestinal Pathologist

Colorectal Serrated Neoplasia The latest edition of the WHO Classification of Tumours of the Digestive System has been released, a decade on from the 4th edition. This review looks at changes in the terminology related to colorectal serrated lesions and polyps.

WHO 2019 5 TH EDITION

WHO 2010 4TH EDITION

Hyperplastic Polyp, Microvesicular Type

Hyperplastic Polyp, Goblet Cell Rich Type

Hyperplastic Polyp, Goblet Cell Rich Type Hyperplastic Polyp, Mucin Poor Type

Sessile Serrated Lesion

Sessile Serrated Adenoma/Polyp

Sessile Serrated Lesion with Dysplasia

Sessile Serrated Adenoma/ Polyp With Dysplasia

Traditional Serrated Adenoma

Serrated Adenoma, Unclassified For the majority of pathologists last century, serrated colorectal polyps were called “hyperplastic polyps”. These were considered to be simple, common, non-concerning lesions. However, in the mid-1990s, it was recognised that a subset of these were probable precursor lesions to colorectal carcinoma and were subsequently relabelled as sessile serrated adenomas or sessile serrated polyps. For various reasons, these synonymous terms have been somewhat controversial and polarising for many clinicians and pathologists. In the new WHO 2019 classification, these have now been reborn as Sessile Serrated Lesions (SSL).

the right colon and are pale, poorly defined, flat, sessile lesions, sometimes covered by a mucus cap. Detection and complete removal can be challenging. Histologically, distinction from HP is based on architecture and includes changes at the crypt base with dilated crypts, horizontal spread along the muscularis mucosae and serrations extending to the crypt base. Current guidelines suggest the minimum diagnostic criterion required is only ONE unequivocally architecturally altered serrated crypt with the above features. Well orientated sections of lesions evaluating the crypt bases are essential in the histologic evaluation of these lesions. Studies have shown there is significant interobserver variation among pathologists in the differentiation of SSL from HP. In biopsies that are superficial or tangentially embedded, it may be impossible to render a specific diagnosis. However, the pathologist may be guided by the anatomical site (proximal = SSL, distal = HP). Sessile Serrated Lesion with Dysplasia (SSLD) It is thought that SSLs progress to carcinoma through a phase of dysplasia. Studies show this may take 10 years or longer, however, there are cases where progression to cancer has been rapid (so called “interval cancers”). Histologically, the dysplastic focus shows a more complex architecture with crowded crypts, complex branching and cribriforming associated with cytologic atypia. Follow-up for patients with SSLD should be at an earlier interval.

About the Author Dr Michael Armstrong is the team lead for Gastrointestinal Pathology. He also retains a consultant position at PathWest as a core member of the specialist GI Pathology team. He is a member of the Australasian Gastrointestinal Pathology Society (AGPS).

Traditional Serrated Adenoma These account for 1% of colorectal polyps and they are usually large polypoid exophytic lesions in the distal colon and rectum, although some may be present in the right colon as flat lesions. These are thought to represent slightly higher-risk lesions and require earlier follow-up. Serrated Adenoma, Unclassified Some serrated polyps with dysplasia are difficult to classify precisely as either SSLD or TSA and are included in this group. Also included in this group is the recently described serrated tubulovillous adenoma. Conclusion Serrated polyps are a diverse group of lesions, some of which are associated with an increased risk of colorectal adenocarcinoma. For detailed management and follow-up information, please refer to the NHMRC clinical practice guidelines for surveillance colonoscopy, March 2019.

Hyperplastic Polyp (HP) These are the most common type of serrated polyp accounting for 30% of all colorectal polyps. Some studies show 25-30% of adults have at least one hyperplastic polyp. These are usually found in the left colon and are small (<5mm). Histologically they exhibit superficial serrated epithelium, funnel shaped crypts and, importantly, no basal crypt changes. These have little or no malignant potential. Sessile Serrated Lesion (previously known as Sessile Serrated Adenoma/ Sessile Serrated Polyp) These account for 5-10% of all colorectal polyps and prevalence is estimated at between 2-15%. These are usually found in

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LETTERS TO THE EDITOR

IMGs and the Rural Workforce

continued from Page 4

It’s an MDRAP Dear Editor, I write in response to the article ‘International Medical Graduates and the Rural Workforce’, which appeared in the October edition of Medical Forum. As Dr Bell notes in the article, prevocational exposure to a specialty is a critical aspect of career decision-making. Stepping into the breach created by the cessation of the Prevocational General Practice Placements Program (PGPPP), the More Doctors for Rural Australia Program (MDRAP) has been developed to provide a non-binding opportunity for pre-vocational doctors to gain that essential exposure to rural general practice in a structured, supported way. Importantly, MDRAP is not a medical training program, rather it is a precursor experience to entry into GP fellowship training. Broadly, MDRAP accommodates three groups of pre-vocational doctors: The largest cohort comprises experienced, non-Fellowed doctors who have been working in general practice. MDRAP incentivises these doctors to work towards Fellowship, while providing a more structured pathway to do so. Doctors on the MDRAP must apply to a college-led training program within two years. The second cohort comprises doctors working primarily in the hospital system or

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other non-GP settings. This cohort may or may not have prior GP experience, but will typically have a good understanding of the Australian health system and knowledge of other aspects of medicine. The final cohort are junior doctors who have experience in the Australian hospital system and are PGY3-5. As Dr Bell notes, doctors can be riskaverse. The absence of prevocational experiential programs for general practice for several years now has meant we have been asking junior doctors to commit to a lifelong career without knowing whether it is the most suitable choice for their professional, lifestyle, financial and family aspirations. MDRAP will provide ‘GPcurious’ junior doctors with exposure to rural general practice and better equip them to make their career choice, before they become settled in the city or are lured into other specialties. We recognise the concern that the junior doctor cohort may be left to fend for themselves in rural communities. As Rural Health West will be responsible in WA for approving doctors to MDRAP and for supporting them and their supervisors, I would like to alleviate this concern. It is in the best interests of the junior doctor, the community, the employing practice and the WA health sector at large, that these doctors have a positive experience in rural general practice during their time on MDRAP. Rural Health West is committed to ensuring this is the case. AHPRA supervisory requirements for doctors with less than six months general practice experience are stringent. Any doctor entering MDRAP with less than six months experience will require Level 1 supervision for the first month of practice, and Level 2 supervision for at least five months.

Readers will recognise that Level 1 supervision is a significant undertaking for any practice or supervisor, but it is critical to ensuring the safety of both patients and the doctor. Additionally, these doctors must consult with their supervisor after any ‘at risk’ presentations for the first six months of their program. In addition to the support of their supervisor, Rural Health West will case manage each doctor on MDRAP, with a particular focus on supporting those with less prior GP experience. Prior to commencement, each of these doctors will participate in a Rural Health West orientation program and will be connected with our medical advisory team, all of whom are highly experienced rural GPs. All doctors with less than six months general practice experience will also be required to complete the Foundation of General Practice modules from either RACGP or ACRRM within the first six months of practice. We will be supporting all doctors on MDRAP to complete these modules. We are excited about this new opportunity to expose doctors to rural general practice and are committed to ensuring MDRAP is conducted in a manner that prioritises the safety of both patients and doctors. We look forward to collaborating with ACRRM, RACGP, WAGPET and WACHS to ensure the program delivers on its intended promise to provide a new mechanism for building the rural workforce, while ensuring the doctors on the program have an experience that encourages them to pursue a career in rural general practice. Tim Shackleton Chief Executive Officer, Rural Health West

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Major Partner: Silver Chain

Encouraging Self-Confidence in the Elderly Dr Daryl Kroschel National Medical Director About the Author: Daryl has diverse clinical experience in Australia and the UK across acute, ambulatory care and General Practice. He is the National Medical Director with Silver Chain Group and is the clinical lead for Integrum Aged Care+.

The term ‘reablement’ is often used as a synonym for rehabilitation. While both include some element of restoring physical function, reablement is broader in context and shorter in duration. It is about an individual learning or relearning the day-to-day skills needed to encourage self-confidence and support independence. Reablement is usually time-limited (approximately six-eight weeks), has a strong focus on psycho-social as well as physical wellbeing, and has a primary goal of enabling people to maximise their capacity to continue to live in their own home. Australian researcher Professor Gill Lewin led one of the few global randomised controlled trials of this approach and published evidence of its long-term cost effectiveness. Yet Australia has been slower to embed this into aged care policy and practice. This is starting to change with aged care policy and procurement now actively advocating for a reablement approach for aged care services. I believe one of the real challenges to reablement being fully embraced in Australia stems from ageism.

is debilitating. Positive self-perceptions of ageing results in increased longevity of more than seven years, and I have challenged my own assumptions. I have also learned that I am not being helpful when I tell patients that I am going to refer them to My Aged Care so they get an aged care package, and someone will clean their house for them and help them shower safely. Instead, I now talk about how I can refer them so someone can come to their home, see how they are managing everyday tasks and work with them to help them maintain their independence. This might mean investigating rails to reduce the risk of falling in the shower, or exercises to help build up the strength in their legs to improve their mobility. Silver Chain has been providing short term, reablement-focussed support to older people for the past 20 years and the results have been extraordinary. It should be general practice and part of all our programs and services.

How many times do we, as clinicians, assume someone is unable to ‘manage’ because of assumptions made based on their age or medical condition? How often have we communicated that to our patients and indirectly affected their own views of their capabilities?

Take for example the case of the man whose mobility, following his six-week hospital stay for bladder stone removal and flu, deteriorated. His goal was to return to his pre-admission level of mobility – that being 200m to the local bus stop using a stick, a seated rest for a few minutes, then the 200m return walk. The man also wanted to be able to water his pot plants which required him to carry a watering can while walking on grass.

Since joining Silver Chain as its National Medical Director, I have learned that ageism

Within four weeks of his reablement phase, this person had achieved his goal with

T (08) 9242 0242

the support of a home exercise program and weekly sessions with Allied Health and Therapy Services. He remained in the program and on discharge could walk three times the distance (ie 1200m) with no seated rest and no walking aid required. He is now enjoying being back in the garden. Or the woman who lost her driver’s licence due to her declining vision and cognition and lacked the confidence to take the bus to meet her friends. As a result, she became socially isolated and depressed. Through the reablement program, she learned the bus routes, purchased a Smart Rider and practised catching a bus with the assistance of a support worker. At the end of the reablement phase, she was confident enough to travel independently and taught her friends to do the same. We, as clinicians, can build confidence or destroy it; we can support our patients to build on their strengths, or reduce them. The aged care system is moving to encourage independence through reablement strategies before older people are referred for ongoing services. While My Aged Care has a long way to go before this is standard practice, as is the case in the UK and New Zealand, we can support its implementation through our own actions. The evidence of better outcomes for older people and taxpayers is compelling; I hope you join me in encouraging this approach with your patients. References on request

W silverchain.org.au

A 6 Sundercombe Street, Osborne Park, WA, 6017 SilverChainGroup

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GUEST COLUMN

A Climate Confession Esperance GP Dr Toby Pearn helped organise the climate march in the town and believes doctors need to advocate loudly on this vital issue. It is easy to blame oil and other fossil fuel companies for the climate crisis, but that is not true. I am to blame. I am a doctor in a small rural town in Western Australia. I have known about global warming since I was at primary school. Even back then, the climate science was robust and easy to understand. But that didn’t stop me taking a gap year between school and medical school, and flying around the world. I flew on holidays to a different corner of the globe most summer holidays. I watched Al Gore’s An Inconvenient Truth in 2006, though I already knew most of the information it contained. I’ve taken my family on holidays to Europe, Canada and Africa, and flew with mates on surf trips to Indonesia. I currently drive a diesel guzzling Mitsubishi Pajero. I have no idea what my carbon footprint has been to date, or what it is. It would be a fallacy to try to calculate it, as I have no idea how far I’ve flown, how many miles I’ve driven or steaks I’ve eaten. Oxfam states the wealthiest 10% are responsible for 50% of the global CO2 emissions. The super-wealthy, the top 0.1%, contribute the most, mostly due to jet travel. According to the global rich list, on an Australian GP income, I am in that top 0.1%. That makes me personally one of the world’s largest consumers of fossil fuels. I also work in healthcare, where CO2 emission is not considered in the slightest, and is estimated to contribute between 3-10% of the national footprint.

I like to think that overall I’m a good person, as is the prevailing human psychological assessment of oneself. So, the idea that it is actually me to blame for the climate crisis is rather confronting.

I have benefited enormously from the proceeds of burning oil, but this has caused the climate to warm and now other people will suffer the consequences. These will include my two children, currently aged seven and nine years old. They will be in the prime of their life when temperatures are predicted to have risen 2-3 degrees Celsius. However, the poorest billion of the world’s population, who have hardly any CO2

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emissions to count between them, will be the hardest hit by rising temperatures and extreme weather events. Thinking about this climate crisis provokes a cocktail of negative emotions. I may have elements of ‘climate anxiety’, a growing mental health phenomenon among those educated in climate science. I have guilt at my own carbon footprint and feel sadness for the world my children will inherit. I have a sense of my own hypocrisy in talking about the need for action, and helplessness in my being unable to fix it. It is easy to understand why so many wealthy educated people still deny the climate crisis is happening, or simply don’t want to talk about it. It is an assault on the positive opinion of oneself. Talking about the climate crisis at a dinner party is as popular as flatulence. Personally, I would love to be able to live a sustainable, carbon neutral life, but I’m nowhere near that yet. I agonise about flying, given jet flight is the largest contribution to climate change per person. It is hard to give up. I am no Greta Thunberg. I have had so many great experiences and memories as a result of flights, and my parents reside in Europe. I rationalise that becoming carbon neutral myself is not going to stop the climate crisis when the rest of the world just carries on burning fossil fuels, business as usual.

finances at my disposal, how can I expect the less wealthy and educated 99.9% of the world’s population do just that? So, am I selfish? I just play by the rules of society around me, as do most of us. As the future Nobel prize winner Greta Thunberg has said, “We can’t save the world by playing by the rules, the rules have to be changed”. The millions of kids marching in the #ClimateStrike know it, with their placards reading “System change, not Climate change” and “Planet over Profit”.

As doctors we need to recognise that the climate crisis is what the World Health Organisation says it is, the greatest threat to health this century, and then act accordingly.

We need to be brutally honest, and talk openly and realistically about this enormous challenge. It is no exaggeration to say the CO2 emissions as a result of our lives and work will cause death and suffering to others in the not too distant future. It really is that simple. It is what the science tells us, and we believe in science, right? We are currently part of the problem, in both our personal and professional lives. We should be part of the solution.

So, if I can’t go carbon neutral, when I’m educated in the climate science and have

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MAJOR PARTNER

Who benefits from cannabinoid therapies? Cannabinoid therapies (medicinal cannabis) were legalised in Australia in 2016.1 Since then, enthusiastic widespread community interest in its use has been coupled with broad scepticism and unwillingness to prescribe amongst clinicians. Almost two thirds of GPs have been asked by patients about using medicinal cannabis.2 Most clinicians admit that their knowledge of cannabinoid therapies is inadequate, and that they have insufficient information to prescribe. This likely stems from there being no formal medical curricular or vocational training for doctors in the use of cannabinoid therapies. In addition, the prescribing bureaucracy, both Federal and State, has been complex and unwieldy. Using the available published evidence, the Commonwealth Health department and relevant state governments have approved specific clinical indications for cannabinoid therapy. The approved and accepted indications for prescribing of cannabinoid therapies in Australia3 include: Chronic non-cancer pain (neuropathic) Cancer indications

Chemotherapy induced nausea and vomiting (CINV)

Cancer pain

Sarcopenia and anorexia Refractory epilepsy (particularly paediatric) Neurological spasticity

Multiple sclerosis

Parkinson’s disease Anorexia and wasting due to chronic illness

For nearly all indications, cannabinoid therapy is seen as acceptable having exhausted all other therapeutic modalities and in Western Australia, prescribers require support from a relevant specialist. Other indications currently under investigation include PTSD, primary insomnia and nocturnal agitation in the elderly. In neuropathic pain, systematic reviews and meta-analysis have demonstrated an opioid-sparing effect with concomitant cannabinoid therapies.4 Co-administration of cannabinoids may enable reduced opioids while maintaining analgesic efficacy,

Referral forms can be downloaded from www.emeraldclinics.com.au

without the same hazardous side effects. Why is this important? In the last 20 years, there has been a precipitous increase in prescribed opioids and subsequent related prescription deaths, Australia more than most.5 To help address this, OTC codeine was up-scheduled to prescription only in early 2018.6 Emerald Clinics comprehensively assess referred patients’ suitability for cannabinoid therapies, with a view to reducing reliance on opioid use for pain relief. This shared-care model involves the patient’s GP and relevant specialty colleagues to continue to coordinate comorbidities and downregulation of opioid medications.

By Dr Alistair Vickery References 1. Medicinal cannabis facts sheet. www.health.gov.au/internet/ministers/ publishing.nsf/Content/546FB9EF48A2D570CA257EE1000B98F2/$File/ Medicinal-cannabis-factsheet.pdf 2. Karanges EA, Suraev A, Elias N, Manocha R, McGregor IS. Knowledge and attitudes of Australian general practitioners towards medicinal cannabis: a crosssectional survey. BMJ open. 2018 Jun 1;8(7):e022101. 3. Medicinal cannabis - guidance documents www.tga.gov.au/medicinalcannabis-guidance-documents 4. Nielsen S, Sabioni P, Trigo JM, Ware MA, Betz-Stablein BD, Murnion B, Lintzeris N, Khor KE, Farrell M, Smith A, Le Foll B. Opioidsparing effect of cannabinoids: a systematic review and meta-analysis. Neuropsychopharmacology. 2017 Aug;42(9):1752. 5. Islam MM, McRae IS, Mazumdar S, Taplin S, McKetin R. Prescription opioid analgesics for pain management in Australia: 20 years of dispensing. Internal medicine journal. 2016 Aug;46(8):955-63. 6. Larance B, Degenhardt L, Peacock A, Gisev N, Mattick R, Colledge S, Campbell G. Pharmaceutical opioid use and harm in Australia: The need for proactive and preventative responses. Drug and alcohol review. 2018 Apr;37:S203-5.

For DIGITAL Referrals see www.emeraldclinics.com.au/uploads/ resources/181213_Emerald_Clinics_Referral_Form.pdf > or order referral pads through info@emeraldclinics.com.au

1300 436 363 For patients referrals or to join our network of specialists, visit our website at:

www.emeraldclinics.com.au

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FEATURE

Critical Mass…Critical Issue Doctors have always advocated for the health of their patients. They are now, in increasing numbers, advocating for action over the mother of all health issues, the survival of the planet.

GP Greg Glazov, Dr Deborah Fields (with sign), Dr Hakan Yaman, Dr Brett Montgomery Dr Jane Ralls (with sign), medical studient Sahron Kaur, Dr Chris Curry and Dr Robin Collins

he School Strike for Climate and the campaigns of the climate group Extinction Rebellion have resonated with the WA health community standing up in greater numbers than ever before.

The Flood the City action in October followed a week-long series of protests around the CBD and outside mining

company headquarters and media outlets. We know some doctors took part in those protests.

Among them were representatives from the WA chapter of the Doctors for the Environment Australia (DEA).

The Climate Strike which took place nationally on September 20 attracted about 300,000 protesters with estimates of the Perth crowd being between 10,000 and 15,000, with marches also taking place in regional and rural centres all over the state.

GP Dr Deborah Field, who has been a member of DEA for about 15 years, has only recently stepped up her activism. She spoke to Medical Forum to explain why. “After the last election, I realised that Australia’s climate inaction was going to continue for another three or four years and I felt that as a mother of two children I couldn’t turn my back on it, for their sake and the sake of their children,” she said. “I've been happily paying my subs and I felt I was doing my bit but now I feel I have to do something personal because to do nothing is unacceptable.” Action beats inaction “I'm now more involved, attending meetings and doing some secretary tasks. I know from my own practice that there are a number of doctors who are really concerned about climate change and the health implications but feel overworked and overwhelmed. There’s a lot of doctors on the cusp of wanting to do something but not knowing what to do.”

From left to right: Sallie Forrest, George Crisp, Deborah Field and Robin Collins (background)

10 | NOVEMBER 2019

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FEATURE “But doing anything is better than doing nothing. We need to generate some hope.” Deborah is heartened by the growing recognition of the health crisis as a result of a rapidly changing climate. With the AMA joining the Royal Australian College of Physicians in developing climate change position statements on the issue, a mainstream swell is starting to occur. “The DEA has been chipping away for a long time, raising awareness, so if the other specialist colleges develop climate change position statements and we all work together, that’s a big medical lobby group that could make something happen in government,” she said. “A study out of Harvard suggests that 75,000 people is the number required at the grassroots level to influence government policy. The climate strike saw 300,000 people take to the streets so that's a great start.” The Climate Strike movement was born from the growing concerns of young people around the world, prominently voiced by Swedish teenager Greta Thunberg who has taken the fight all the way to the UN. September’s strike in Australia and here in Perth was organised by young people and Deborah said it was exceptionally well organised, both starting and finishing on time. “It was colourful with a real feeling of solidarity. There were a lot of adults there supporting the young people and from groups I had never heard of – architects, 'medical mums' – all these groups were coming together,” she said. Youth-led change

Greg Glazov, GP the commitment they made to the Paris Agreement.” “As citizens of the planet, we have to do everything we can with everyone we can to do anything we can, whether that's putting up a poster outside your house, moving to solar power, composting, all those small things.” “But as a health professional I'm going to focus my energies into DEA because there are many here in WA especially, Dr Richard Yin and Dr George Crisp, who've been speaking out for years, and I want to support them.”

“All the speakers at the rally were young people and they were articulate, passionate and well-informed. And they're not asking for much. All they want is for governments to stick to

WA Health has launched a Climate and Health public inquiry which has moved into its public formal hearings

stage before the reporting deadline of March next year. The DEA were among groups such as NMHS, EMHS, CAHS and Telethon Kids to have addressed the inquiry. Groups lined up to address the inquiry are AMA WA, Department of Health and SMHS. Deborah said she put in a submission, the first time she had ever done anything like it. “I put in a personal submission to the WA inquiry into Climate Health Australia and I put in a submission to the EPA, which is reworking its guidelines for greenhouse gas emissions,” she said. “I used the discussion papers with all the quotes and scientific references provided by Conservation Council and DEA. When I read through them, I was horrified and decided to express the depth of my concern as a GP and as a concerned mother.” “Everyone can participate in these processes.” “In my GP practice, we probably see a couple of hundred patients a day and I would love us to gradually make the point to them that we are attempting to be as green as we can get. There might be some non-believers but doctors are respected and people do listen to us.” The WA branch of DEA are holding some of their meetings using video conferencing so people who are unable to attend physically can join the conversation. For more information, contact Dr Richard Yin, DEA WA 0403 028 067.

Curtin Univesity medical students James Leigh and Sharon Kaur

MEDICAL FORUM

NOVEMBER 2019 | 11

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GUEST COLUMN

Why Action Is Needed Now Retired GP Dr Colin Hughes has joined the swelling ranks of doctor climate activists. He explains why. Why would a former College Chair and Head of Public Health risk getting arrested at a climate demonstration? You all know about climate change, but do you really know about global heating? Then you start reading and learning about global heating, but you don’t really feel it… until you do. My epiphany was visiting Coral Bay for the second time around 1998. We had taken the kids up there when we first arrived in WA in 1987. They could snorkel straight off the beach over magnificent coral teeming with tropical fish. But that second visit the coral was dead from massive coral bleaching and the fish gone. And, yes, some of you will say that’s just part of the natural cycle, but then it happened again two years later. Then it happened twice to the Great Barrier Reef, bleaching over half the reef, most of which will not recover. The science says that if the world reaches 2 degrees Celsius of heating then 90% of coral reefs will disappear and with it 30% of the world’s fish stocks. So, the predictions in 1990 were wrong. Arctic ice was predicted to disappear by 2030 but empirical science says that will be in just five years. The planet is heating faster than predicted with 20 of the past 22 years the hottest on record. Irrefutable empirical evidence. Perth has had its hottest winter day and hottest and driest September on record. Carbon has hit 416 ppm, it was only 350ppm at the time of Kyoto summit. The world’s carbon emissions have risen over 50% since Al Gore’s An Inconvenient Truth. And with all of that, the Intergovernmental Panel on Climate Change (IPCC) says we have less than a 50% chance of keeping to our 1.5 degree target by 2030 if we stopped burning coal, oil and gas now. Many scientists would dispute that, saying we have already reached the tipping point with a 10-year lag time for carbon as the seas warm and the big carbon sinks that are the oceans release carbon. That’s not to mention the lack of reflection of the ice caps, the dark seas underneath and the methane escaping from the melting permafrost. The United Nations has accepted its One Health declaration in 2017 recognising the inter-relationship of human health with that of the ecology and environment. David Attenborough warns of the Anthropocene,

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or sixth mass extinction, caused by manmade global heating. But what does this mean?

professional and ethical standpoint, to take personal action to mitigate climate change and improve health and equity.

We are facing societal collapse with most damage inflicted unequally on the poor and marginalised in developing countries. Massive droughts, cyclones and floods will cause mass migration due to food shortages and loss of human habitat, and regional conflict over scant water and resources. Western nations although marginally protected will not be immune.

So, here I am waiting to get arrested. I have written my letters, signed my petitions and attended the rallies. Governments do not listen.

Already Australia is experiencing a 50% decline in agricultural production due to ongoing drought. Climate mitigation will cost trillions of dollars. This means less to spend on pensions, social security and health. Yet somehow the Australian psyche refuses to acknowledge the existential threat to their children and grandchildren. But the kids get it. The medical organisations get it. The AMA, BMA, American MA and colleges including the RACGP and RACP have declared climate emergencies, warning of the health effects including disease and injury from mass climate events such as bushfires, droughts and cyclones. Heat stroke will directly affect those with decreased immunity, especially the elderly, leading to increased deaths from heart disease, respiratory disease and infections. Vector borne diseases will rise exponentially. Climate change is not linear. We are already seeing the rise in mental health problems and suicides caused by the ongoing drought in Australia. But the RACGP goes further. It calls on GPs to protect the health of their patients and future patients. It asks GPs from both a

Yet meaningful and massive social change has happened in the past through nonviolent civil disobedience. Think of the freedom riders in outback NSW; Emily Pankhurst and the suffragettes chaining themselves to the British Parliament with over 1500 arrests; Ghandi’s march to the sea; and the civil rights movement in the US. For me, personally, it was the Moratorium which started with just 60 of us outside the Pan AM building in Melbourne burning our draft cards and getting arrested. It finished with hundreds of thousands of people marching in Australia to change the government and stop the Vietnam War. Some are just terrified at the catastrophic horror and can’t imagine just standing and watching while society collapses, especially as it will affect my children and grandchildren. Some will see it like the RACGP as an ethical responsibility, a civic duty. We belong to a society that has obligations as well as rights. I know what has to be done. Others just want a sense of adventure, put some purpose back into their lives now that they have retired, or in the case of the young, there’s nothing to lose, or just a sense of redemption. I have done my best.

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HAVE YOU HEARD? Obesity by postcode Western Australia is punching under its weight in the latest obesity statistics courtesy of the Mitchell Institute at Victoria University and Australia’s Health Tracker by Area. Perth’s western suburbs have the lowest rates of obese and overweight populations Australia-wide. WA also has to least obese suburb. Looking at the reported data from a socioeconomic perspective, the wealthiest suburbs in Perth have the lowest rates of obesity Australia-wide and some of the poorest suburbs, the highest rates. The least obese suburb in Australia is Nedlands with only 12.8% of the population reportedly obese, Claremont is a close second with 14%. WA’s most obese suburb is Collie with 34.3% and Wheatbelt town of Beverly has 33.8%. The most obese suburb in Australia is Wellington, NSW, at 43.9%. Nationwide, Australians are 31.3% obese, 67% are obese or overweight and 52.7% are inactive or not getting enough exercise.

Causes of deaths

Stroke of good fortune

Continuing on with the data, this time from the Australian Bureau of Statistics (ABS): there were 158,493 registered deaths in Australia in 2018.

A $1 million grant from the Australian Government’s Medical Research Future Fund has been awarded to a 30-strong team of multidisciplinary experts, known as the Australian Stroke Alliance, led by Professors Geoffrey Donnan and Stephen Davis at The University of Melbourne and the Royal Melbourne Hospital (RMH).

The ABS reported ischaemic heart diseases were the leading cause of death, with 17,533. Dementia, including Alzheimer's disease, caused the second most deaths, with 13,963. The report states, cerebrovascular diseases, Cancer of the trachea, bronchus and lung and chronic lower respiratory diseases respectively represent the top five. More than one-third of all registered deaths was caused by the top five leading causes of death. Intentional self-harm (suicide) accounted for 3,046 deaths, and was the leading cause of death for the 15-44 age cohort. Opioids were identified to be responsible for an average of three deaths a day, with the majority being unintentional overdoses. The majority of these involved the use of pharmaceutical opioids and middle-aged males. Of the 1,740 drug-induced deaths, two thirds (1,123) were caused by opioids.

Medevac momentum Eleven of the peak medical colleges in Australia have released a joint statement urging members of the Senate to reject the proposed repeal of the Medivac Legislation. So far more than 130 people requiring medical treatment have come to Australia since it was passed in February 2019. “Every person should have access to necessary and appropriate medical care and, as clinicians, we have a duty to uphold this basic human right,” the statement said.

14 | NOVEMBER 2019

The Australian Stroke Alliance is developing portable brain imaging tools that can be fitted to air and road ambulances, with the objective of transforming access to early pre-hospital treatments and improved stroke outcomes. With upwards of half a million people living with the effects of a stroke in Australia and over 56,000 strokes a year, imaging tools designed for point-of-care diagnosis and emergency stroke treatment could be transformative for patients and first responders, especially those in rural and regional areas without access to imaging equipment.

BMA’s mea culpa The British Medical Association has released the findings from an independent inquiry into sexist behaviour, sexual harassment and bullying within the organisation. The review was commissioned after two female BMA members revealed to the publication GPonline a series of misogynistic events that more broadly represented a culture of sexism. The 32-page report, led by Daphne Romney QC, found there is an ‘old boys’ club’ culture, where some women feel undervalued, overlooked and patronised. Romney made 31 recommendations to eliminate the toxic, discriminatory culture and gender bias within the ranks.

Chair of the BMA Dr Chaand Nagpaul issued an apology, saying: “I have been very clear that sexism and sexual harassment have no place in the BMA and, on behalf of the association, I offer my heartfelt and unreserved apologies to all of those who have been affected by these behaviours.”

Hospital admissions up The AIHW report, Admitted patient care 2017-18, has found hospital admissions are going up at a higher rate than population growth. Admissions between 2013-14 and 2017-18 increased each year by an average of 3.8%, while the population increased on average just 1.6% per annum. There were 11.3 million admissions in 2017-18, a majority of which (60%) occurred in public hospitals. In 2017-18 there was a combined 30.2 million days of patient care, from 2013-14 patient days rose by an average of 2.1% per year. Between 2013-14 and 2017-18, hospital admissions for the 65-74-year cohort increased by an average of 6.3% per annum or 28% overall. Individuals aged 65 and represented 42% of separations and 49% of patient days in 2017-18, despite this age group comprising 15% of the population. With an increasingly ageing population in Australia, this could be an indication of the future.

RPH mental health Royal Perth Hospital has opened the doors to the Mental Health Emergency Centre (MHEC), a new inpatient care facility that has eight ‘low-stimulus’ treatment spaces. It will be staffed with specialised mental health professionals and can

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MEDICAL FORUM

KING OF HEARTS

Congratulations Robert Larbalestier on receiving the Officer of the Order of Australia

He’s a pioneer and a leader. He’s an expert, a teacher and he’s certainly a lifesaver. To us Robert Larbalestier is all those things but he’s also a humble, hardworking cardiothoracic surgeon who typically credits his success to the people who have supported and worked with him during his long and illustrious career. So it’s no surprise to us he’s just received the Officer of the Order of Australia in the Queen’s Birthday Honours list. We’re only surprised it’s taken this long. From all of us at the Mount Hospital, we’d like to congratulate him on this incredible achievement. mounthospital.com.au

MEDICAL FORUM

NOVEMBER 2019 | 15

continued from Page 14 accommodate admitted patients for up to 72 hours. The MHEC is located adjacent to the RPH emergency department. Patients attending the emergency department will be assessed and if they present with acute mental health issues, they will be transferred to the MHEC. This specialised team can also provide outreach support for the ED in the interests of care continuity.

the capability of reversing the disease progression. The research involved using Phylogica’s proprietary drug delivery technology on a ‘retina in a dish’ – a stem cell derived 3D retina replica with retinitis pigmentosa. Phylogica intends to seek validation of these results with animalbased toxicology studies, and eventually human clinical trials.

Nerve regeneration

While VAD legislation is still passing through the WA Parliament, the WA Department of Health is pushing on with its Palliative Care package. It is seeking expressions of interest for two Clinical Leads in the WA Cancer and Palliative Care Network for End-of-Life and Palliative Care.

Another WA based company has reported some positive interim findings. Orthocell, a regenerative cell company located in Murdoch, stated that CelGro, their proprietary collagen scaffold has, along with microsurgery, resulted in 73% of nerve repairs being functionally recovered in affected muscles 12 months after treatment. Preliminary results were from 12 study participants that had 25 nerve transfers.

The department is looking for candidates that “will have influence and networks across the WA health system, and knowledge and experience in the palliative care or end-of-life stream.”

According to the trial lead, Dr Alex O’Beirne, “CelGro facilitates tensionless repair and can prevent regenerating nerves from being compressed or trapped by scar tissue.”

Eyes wide open

With these positive findings, Orthocell is intending to fast-track regulatory approval in the EU, US and Australia.

EOI for clinical leads

Nedlands based biotechnology company, Phylogica, has reported positive findings from its research into treating retinitis pigmentosa, suggesting their proprietary drug delivery technology was more than 90% effective from a solitary dose, with

Aged-care agenda After 20 years of inertia, the Aged Care Quality Standards have been reformed, with the objective of improving

The RACGP WA faculty committee has undergone some changes. The new committee is Chair Dr Sean Stevens, Deputy Chair Dr Mary Wyatt, Deputy Chair Dr Andrew Png, Provost Dr Frank Jones, State Censor Dr Helen Wilcox, Dr Francis Akinyemi, Dr Mariam Bahemia-Gannon, Dr Colleen Bradford, Dr Mike Civil, Dr Russell Fayers, Dr Cameron Gent, Dr Alan Leeb, Dr Lewis Mackinnon, Dr Peter Maguire, Dr Erin O’Donnell-Taylor, Dr Ramya Raman, and Dr Damien Zilm. The Australian Academy of Health and Medical Sciences elected 40 new Fellows into the academy at a meeting held in Perth last month. Professor Tim Davis, was the only WA-based fellow.

transparency for consumers, while ensuring the regulations are clear to providers. Along with the refreshed standards comes a new Charter of Aged Care Rights, which enshrines 14 rights for Australians in care, such as: safe and high-quality care and services; be treated with dignity and respect; live without abuse and neglect.

Nobel hypoxia researchers The Nobel Prize in Physiology or Medicine was jointly awarded to three scientists for their research on how cells sense and adapt to oxygen availability. The three winners are William Kaelin Jr from Harvard University, Sir Peter Ratcliffe from Oxford University and Gregg Semenza from Johns Hopkins University, who also shared a Lasker award from 2016. The discoveries from the Nobel Laureates have assisted in the collective understanding of the most fundamental processes, as they established the foundation of understanding how oxygen levels affect cellular metabolism and physiological function.

Pill testing Medical Forum explored the pros and cons of pill testing in the August edition and just as this edition was going to press, a draft of the NSW Coroner Harriet Grahame's recommendations from an inquest into several music festival-related deaths was leaked to the media. Official findings will be handed down this month but the draft recommends the introduction of pill testing and the elimination of police sniffer dogs and body searches at music festivals in the state. The leaked report has already been met with government resistance with the NSW premier, Gladys Berejiklian, dismissing the recommendations, telling the ABC, "We will not go down that path because we feel very strongly that it sends a wrong message." Advocates of pill testing, say it all about harm reduction rather than taking a prohibition stance. Dr David Caldicott, an emergency doctor and illicit drug researcher told the ABC, "There's an abundance of evidence in support of pill testing, and saturation policing probably makes festivals more dangerous."

16 | NOVEMBER 2019

Tetraplegic walks with exoskeleton Researchers from the Grenoble University Hospital implanted wireless epidural recorders over the upper limb sensorimotor areas of the brain of a 28-year-old tetraplegic man to aid in movement. The man initially cortically controlled a video game avatar to acquire the skills to perform simple tasks before migrating to simulated walking using an exoskeleton. The lead researcher Alim Louis Benabid, told The Guardian, “This isn’t about turning man into machine but about responding to a medical problem. We’re talking about ‘repaired man’, not ‘augmented man’.” The results have been published in The Lancet.

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HAVE YOU HEARD?

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HAVE YOU HEARD? RACGP Fellowship Ceremony The RACGP WA faculty welcomed more than 250 new fellows into the College with four fellows inducted into Advanced Rural General Practice. At the induction afternoon, hosted by Dr Sean Stevens, chair of the WA faculty, 131 new fellows were in attendance. Sean welcomed the national RACGP president, Dr Harry Nespolon, and national RACGP Rural Chair, A/Prof Ayman Shenouda, to Perth. Also present were Dean of the School of Medicine at University of Notre Dame Prof Gervaise Chaney along with WAGPET Chair Dr Damien Zilm and WAGPET CEO Adj/Prof Janice Bell. Sean commended the work of retiring council members Dr Peter Winterton, Dr James Quirke and Dr Cory Lei, who will remain the chair of the new fellows committee.

Sean also paid tribute to Dr Jack Christodulou, the college’s head examiner who died in August. He announced that there would be an annual examiner’s award in Dr Christodulou’s name. 1 Fellowship Ceremony group photo 2 Dr Sean Stevens presents Illawarra Medical Centre, represented by Dr Alan Leeb, the RACGP WA General Practice of the Year 3 RACGP WA GP Registrar of the Year, Dr Sylvia Nicholls, from Granada Medical Practice 4 RACGP WA GP Supervisor of the Year, Dr Derrick Kuan, from Currambine Family Practice and Ocean Keys Family Practice 5 RACGP WA GP of the Year, Dr Lewis Mackinnon, from Skye Medical in Armadale 6 Dr Wence Vahala took off the inaugural Jack Christodulou Examiner Award 7 Dr Colleen Bradford received the Sam Bada Medical Educator Award 8 Edward Gawthorn Award Recipient Dr Jasna Lee 9 Edward Gawthorn Award Recipient Dr Orlaith Reid

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FEATURE

Palliative Care a Human Right Amid the debate of the VAD legislation, palliative care groups found a unique moment to advocate. At a recent conference in Perth it came down to a human right.

he Oceanic Palliative Care Conference in mid-September was held in Perth against a volatile social and political backdrop of the WA Voluntary Assisted Dying (VAD) legislation, which was making its way through the state parliament.

While palliative care physicians and organisations have fought hard to separate palliative care and VAD in the debate, it has also sparked a greater awareness of palliative care and the need for government to resource it more appropriately. Without going into the ‘he saids’, ‘she saids’, or making assumptions on why politicians do and say what they do and say, more cash (and critics will argue too little) has been put on the table. The state budget in May included a $41 million end-of-life choices and palliative care services package. At the time, Palliative Care WA expressed concern as the specific allocation of that money. As the VAD Bill progressed to the Upper House (we went to Press before the final vote), the government announced a further $17.8 million for palliative care projects based on the recommendations of the Joint Select Committee Report on End of Life Choices. The breakdown of that funding is: • $9 million towards an additional 10 inpatient palliative care beds in the northern metropolitan suburbs; • $6.3 million for the expansion of community-based services across both metropolitan and regional

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Western Australia; and • $2.5 million for enhancing rural and regional palliative care services by improving governance. The Premier and Health Minister issued a joint statement that indicated how some of the money would be spent, with the funding of 61 full-time equivalent (FTE) staff to be phased in across regional WA, apparently tripling staff for palliative care support there. “This includes the establishment of new specialist district palliative care teams comprising medical, nursing, allied health

and Aboriginal health workers across all regions. As part of the package, $3 million will enable 24-hour support via the WA Country Health Service telehealth hub to ensure staff, patients and families have access to nursing care for patients who wish to die at home,” the statement said. In progress is a 38-bed residential aged and palliative care facility in Carnarvon, for which $16.6 million has already been allocated. In September the Australian Institute of Health and Welfare (AIHW) reported that in 2017-18, WA had the highest rate of subsidised palliative medicine specialist services in Australia with 762.3 per 100,000 population), more than double

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This table shows what the regions will receive: CURRENT FTE

ADDITIONAL STAFF

TOTAL STAFF AFTER INVESTMENT

4.1

8.35

12.45

8.45

11.45

Kimberley

3.5

9.95

13.45

$4 million

Mid-West and Gascoyne

2.7

10.85

13.55

$4.9 million

Pilbara

1.65

11.80

13.45

$2.5 million

South-West

5.90

16.90

$2.7 million

Wheatbelt

5.3

6.15

11.45

INVESTMENT

REGION

$3.6 million

Goldfields

$3.5 million

Great Southern

$4.4 million

*Final FTE and configuration will be determined as the models of care are established.

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Palliative Care a Human Right the national average rate (354.5). WA also accounted for the highest population rate of palliative medicine case conferences (90.5 per 100,000 population), followed by New South Wales (65.5). So, while there was some local action on palliative care in the political corridors, there was also a lot of global thinking at the Oceanic conference, which presented an Indo-Pacific perspective on issues such as access, ethics and rights. A feature of the conference was a panel discussion on the subject of ‘Palliative care is a human right!’. In the preamble, it stated that the World Health Organization (WHO) had explicitly recognised palliative care under the human right to health. “Worldwide, only about 14% of people who need palliative care receive it, and 80% of the world’s population don’t have access to morphine. The panel will discuss what can be done to improve these statistics and ensure that palliative care is on the agenda for human rights campaigns and that the needs of under-served populations are met.” The panellists included facilitator, Prof Fran Baum, who is the chair of Public Health and Director of the Southgate Institute of Health, Society and Equity at Flinders University; Dr Frank Brennan, PallCare Law and Palliative Care Physician based at Calvary, St George and Sutherland Hospitals in NSW; Liliana De Lima (USA), Executive Director of the International Association of Hospice & Palliative Care (IAHPC); Maria Osman, The Humanitarian Group, Member of WA’s Ministerial Expert Panel on Voluntary Assisted Dying (VAD); Dr Christian Ntizimira (Rwanda), Masters Candidate at Harvard Medical School, Department of Global Health and Social Medicine, City Manager, Kigali, C/Can 2025 at Union for International Cancer Control (UICC) and the former Executive Secretary of the Rwanda Palliative Care and Hospice Organization (RPCHO); and Dr Barbara Daveson, National Manager, Palliative Care Outcomes Collaboration & Senior Research Fellow Australian Health Services Research Institute, University of Wollongong

Is Palliative Care a human right?

suffering. It's an immediate priority.”

Frank Brennan tackled this question.

“We know from PCOC that palliative care needs to be integrated into primary care and social care to address inequitable distribution. PCOC Australia is moving into primary care and residential aged care and working with service partners to look at sustainable, innovative models to drive improved outcomes for patients, residents and their families.”

“Often people see human rights in terms of civil and political rights – the right to free assembly, the right not to be tortured, the right to join a trade union. But in addition to those, there are designated and quite specific economic, social and cultural rights. And among those rights is the right to health.” “As that concept has fleshed out, there are core elements of affordability, acceptability, accessibility and quality of care irrespective of the resources of the signatory countries.” He said that broke down to three key points: • No discrimination in access to health. • Essential medications must be provided. • There needed to be a national policy on pain and palliative care. So, every signatory has a duty to achieve these things. What action needs to be taken to improve access to palliative care? Barbara said it was essential to have national end-of-life care policies or palliative care policies.

“We know from our data that the palliative care provision that does occur is disproportionately allocated in high socioeconomic status areas compared with low ones. The trends show that palliative care service activity occurs more in the major cities than elsewhere. And we know that Aboriginal and Torres Strait Islander people are generally underrepresented in our palliative care service data.” “We need to move to an outcomes-focused agenda because if palliative care is a human right then it is really about achieving the highest attainable standard of care for people. We've got an opportunity now as a sector to raise the bar and embrace an outcomes agenda, moving beyond just a discussion about palliative care availability, which is still extremely important.”

“And we need to ensure that government officials involved in making those policies look at research, knowledge exchange, enhancing and mobilising workforces, sustained and adequate government funding and also a national platform for outcomes such as Palliative Care Outcomes Collaboration (PCOC).”

Access for CALD communities

“We know, that the income of a country is a good indicator for palliative care availability and also quality. There are vast differences internationally between the low-and-middle income countries compared with highincome countries. Pain relief and palliative care services is an absolute immediate priority for those countries. It's the basic minimum.”

“Australia does not have a Human Rights Act. Some states do – Queensland and Victoria – but nationally there is no framework in which we can drop down those policies and procedures that we need to implement.”

“High-income countries which represent 15% of the global population constitute 94% of the global opioid consumption. We know that the majority of children, 98% of them internationally, 15 years or younger, are dying in low-and-middle income countries with serious health-related

Maria Osman addressed this issue from a human rights perspective. “Australia is one of the most culturally diverse countries in the world. We have over 300 ancestries, 300 languages, diverse faiths and diverse religions.

“That makes it an enormous challenge if you are a service provider attempting to meet the nation’s need and an enormous challenge for the service users and their families.” “Leadership is essential as is engagement. The presentation from the Mary Potter Hospice in New Zealand offered the perfect explanation of culturally competent care. And I'd love to transpose that here, because often what happens is that policies and facilities are developed and then there's an afterthought about those who are left out – the vulnerable groups in our community.” “There's a saying from the disability sector, ‘nothing about us, without us’. We need to ensure we have that diversity around

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Palliative Care a Human Right the table when decisions are being made about palliative care and take on board the concept of substantive equality.” Maria called for role models for ethnospecific services because they were all complex communities, so funding for grassroots, community-based groups was essential for these diverse populations. She also called for action on institutionalised racism. “I'm of Somali heritage and I have lived in Australia for 35 years and institutional racism is on the increase. We need to look at how we deliver care to patients from those diverse communities so they feel safe and comfortable in those environments.” The Rwanda Story Christian shared how his country set about re-establishing a health care system after years of war. “To build the health system, we first needed to build the nation. It was imperative for the government to offer leadership, the people had to show resilience and there had to be justice, reconciliation and forgiveness.”

“Those elements are fundamental. So, when approaching the rebuild of the health system, the health minister said that every policy and initiative had to be completely integrated and palliative care was no exception. He told me that there was to be no parallel system.” “So, from the beginning we worked with all partners and colleagues.” “Secondly, we needed to invest in people. We don't have mining, we have coffee and tourism, so a lot of investment has gone into people integrated throughout. So home-based care practitioners and community health workers in palliative care was one of the keys.” International Association of Hospice & Palliative Care Liliana de Lima in her role as executive director of the IAHPC said that access to affordable medicines was one of the core issues for the association. “Our research focuses on access to medicines and the use of opioids and their availability and pricing throughout the world. This is an enormous issue for many

Ethics in palliative care

he Oceanic Palliative Care Conference was held in Perth in September. The biennial conference brings together practitioners from a number of disciplines all seeking to optimise the quality of life of those whose days may be numbered.

A plenary session on Ethical challenges and their impact on palliative care featured a panel comprising a lawyer, two palliative care physicians (from Australia and New Zealand), a consumer advocate and the federal RACGP President. The panel had the perhaps unenviable task of discussing “… voluntary assisted dying and its impact on palliative care, particularly the ethical challenges we will face as individuals, teams and communities in deciding where we will personally and professionally draw the line”. This was set against the background of citizens wanting more control around the timing and manner of their deaths. With Voluntary Assisted Dying legislation winding its way through state parliament, such a discussion could not have been timelier. It would be great to report that the

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issue was resolved but, of course, it was not nor could it be. Some issues teased out included defining terminal illness. Those with non-cancer disease such as COPD where cure or improvement is not expected but the condition is not deemed ‘terminal’ can fall through the cracks. Access to palliative care outside capital cities or major regional centres was discussed. Pilot work in the Riverina district looked at better use of community supports, so that while they may not have four university degrees, were they capable of providing comfort and doing non-medical tasks successfully? RACGP President Dr Harry Nespolon correctly observed that the GP was generally the only person who had prior knowledge of the individual and usually their family as well and how intercurrent issues always ended up back in the GP’s lap. Communication was necessarily vital but not always happening. There was broad agreement that palliative care and assisted dying are not mutually exclusive.

countries. Another focus is education and advocating for palliative care to be adopted into undergraduate health curricula, as well as the creation of specialty programs in countries where there are none. And finally, information dissemination.” “Through IAHPC advocacy palliative care has been included in the Convention of the Rights of Older Persons. It is the only legal binding document right now in the world that mentions palliative care specifically. Currently it's regional, it only covers the Americas but we hope the Human Rights Council will eventually adopt it.” “But all these documents and all these beautiful resolutions and conventions are nothing if they don't benefit the patient. And how do we translate that? Everyone sitting here plays a role. We need everybody on different stages, and with different skills, capabilities and connections to work together. But unless all these efforts get down to the patient level, we're not doing anything. It's just going to be a piece of paper.”

By Jan Hallam

COMMENT today’s ‘evidence-based’ world. Yet not everyone gets the same result with the same treatment and there are remarkably few double blinded placebo control trials in palliative care – funny that! The key take home message was that the journey is about the individual not the care providers and certainly not those making guidelines in ivory towers. This reminded me of a piece by Richard Horton who opined on the clash between public health policies and guidelines and the lived experience of the individual thus “public health science needed to pay more attention to the lived experiences of people in societies”. Horton’s criticism of “on high” decision making got more pointed. The solution then is accepting that there is no one solution. The autonomy of the individual to live and die with dignity and be as free as possible from distress and discomfort must be our aim.

By Dr Joe Kosterich References available on request

The lived experience of the individual has become increasingly disregarded in

NOVEMBER 2019 | 23

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Depression in the Elderly Identifying older people at risk of developing depressive episodes is a key to better treatment, according to Prof Osvaldo Almeida.

nowing what to look for when it comes depression risk factors among older people is critical to understanding the different symptomology, diagnoses and treatments for this cohort. Medical Forum spoke with geriatric psychiatrist Prof Osvaldo Almeida from the University of WA, who specialises in research programs designed to establish and modify risk factors for cognitive decline and depression in later life and to improve the mental health outcomes of older people. Identifying the risk-factors that are causal to depression is key to prevention and intervention. Older people with comorbidities, usually physiological ones, are at higher risk than those without. “They might have ischaemic heart disease, they might have had a stroke or have

chronic pain, arthritis or chronic renal disease. They might have a number of other morbidities that are hindering their ability to function at the optimal level.” Once those individuals are identified, an intervention can be designed to minimise the risk of them developing a full-blown depressive episode. “We have done some work with stroke patients and other groups, such as women who are undergoing a menopausal transition, to see if we can modify the risk to decrease the severity of depressive symptoms,” he said. Beware threshold Osvaldo said people who had threshold symptoms were at greatest risk of poor mental health outcomes. “For example, people who have a mild cognitive impairment, which is a prodromal phase of a full-blown dementia episode, or development of dementia syndrome,” he said.

“We know that about a third of people with mild cognitive impairment will, within a period of one to two years, go on to develop a dementia syndrome thus becoming a target population for interventions designed to try to prevent the onset of dementia. The rationale for depression is the same.” To further complicate identification, some people will present with sub-threshold depressive symptoms. “They won’t have a full-blown depression episode in terms of the number of symptoms they experience. They are not impaired from a functional point of view and are not hindered in their daily lives, but it's sufficient to make their daily function suboptimal.” “Some of those symptoms could be experiencing some mood irritability, or they find it harder to enjoy the usual activities. They might have some of these disruptions in their sleep pattern or they might feel more easily fatigued, but they still are able to function in spite of the symptoms.” “We know that in a period of one year, about 15% of those who have subthreshold depressive symptoms will go on to develop a full-blown depressive episode. That's much larger than in the general population, which is about 1%.” Depression risk table Osvaldo and his colleagues have developed a depression risk table to help GPs with early intervention. The table is similar to the Framingham Rick Score that exists for cardiovascular diseases. “We devised a similar risk score based primarily on lifestyle factors but also the presence of co-morbidities. This helps clinicians and GPs to be better able to advise their patients in a way that may minimise the risk of them developing a depressive episode.” The depression risk table helps GPs to glean a specific understanding of risk factors such as smoking, harmful

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FEATURE or hazardous alcohol use, obesity, the presence of co-morbidities as well as early life-adversity and social support. “There are a number of other factors that are not commonly associated nor usually investigated when assessing for depressive episodes that, in this case, are important. It helps to remind the practitioner that it's worth assessing those and, if possible, trying to modify the risk-factors because they might modulate the risk further down the line,” he said. “In later life, there is a convergence of risk factors. The same risk factors that are relevant for a depressive episode in later life are also relevant for a heart attack or for a fall or stroke. The prevalence of depressive disorders starts increasing once people reach their mid-70s and into their 80s – even more so given social isolation and co-morbidities.” Frailty also plays a part. “As we get older, our ability to correct for loss of physiological capacity decreases because the systems become overwhelmed by trying to fix things that are going wrong and, eventually, there can be a straw that breaks the camel's back. Older people with depression have a clinical outcome that is often associated with how frail they are,” Osvaldo said. Behaviour intervention Mitigating frailty and maintaining functional capacity through behavioural interventions is paramount to ensuring individuals in their mid-70s and older are not susceptible to depression. “Interventions to keep people in this age group active is very important. One of the concepts that people used to have in relation to frailty was that it’s a prodromal phase leading to death: people become sick, they develop complications, which can result in multiple morbidities and they become frail and they lose function, strength and balance. They become prone to falls and then they die,” he said. “However, there's evidence now that you can actually push people out of frailty to recover and regain some level of functional reserve.” Interventions that have been proven helpful with frail people are mostly related to increasing balance, physical activity and socialisation. Frailty is not a variable that can be easily measured, rather it is a convergence of factors that diminish functionality both physiologically and psychologically. “Depression in older people can be part of that syndrome of frailty, and addressing frailty, or that loss of reserve and functional capacity itself, may be helpful.” Behaviour activation, according to Osvaldo, is an ideal intervention for individuals who have lost physical function because it works in a similar way to cognitive

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behavioural therapy, but it focuses primarily on behaviours and not cognitions. Behaviour activation centres on the components of the activity relevant to maintaining good integration, and replacing them with functional substitutions that are positively reinforced. ACF programs “We're currently working on a program of behavioural activation for people living in nursing homes, targeting people with subthreshold depressive symptoms and trying to identify these functional equivalents, things that people are no longer able to do because they are living in residential care,” he said. “We may be able to find other activities that provide similar feedback.” “We are trying to do that in a structured, systematic manner to see if we can improve the mood of people living in residential care facilities, and decrease the extent of major depressive episodes. Depression is a major issue in aged care facilities, which is why we're targeting that particular population.” An important focus of behavioural activation, according to Osvaldo, is to minimise psychologising what older people experience and focus on linking behaviours to experiences, and how the behaviours can be rewarding. “When we use this type of approach, we identify people with sub-threshold depressive symptoms and engage them in a behaviour activation program. Those who engage in such a program will be less likely to develop depressive symptoms.” A benefit of behavioural activation interventions is the simplicity of the therapy. For instance, a GP can implement the intervention and then transition the positive reinforcement aspect of it to care staff and in an aged care facility, or even to family members. Osvaldo emphasised that keeping the interventions, such as behavioural activation simple, structured and manualised is ideal for the training of care staff. “If we want to come up with interventions that can be used and can be sustained in practice, we need to devise things that are practical and simple to use so care staff, with different qualifications or training backgrounds, are able to understand the type of activity, and then deliver the interventions in an effective way,” he said. The role of the GP in the lives of older patients is particularly important, he said. GPs influence “Advice from a person’s GP is very important. If you tell your patient that you think they are drinking a bit too much, and then explain what that might mean to their health, and that help is available it would make a big difference.”

their GP. And, more often than not, they'll have a go at the advice they give. GPs are incredibly powerful. We just sometimes need to encourage people not to neglect those risk factors. So, as part of their assessments, it’s important to review these risk factors on a regular basis so that they can be addressed.” Access to psychological services in aged care facilities in Australia is poor, according to a research paper published in Australian Psychologist by Swinburne PhD student Jennifer Stargatt. “There can be a great deal of grief and loss involved in making that move into residential aged care,” Jennifer said. “Residents are often socially isolated as well. They can experience a loss of independence and autonomy. It's a huge shift to be taken away from what they are comfortable from. It's complex, there are a number of factors that contribute to poor mental health.” At the time of publishing the paper, the Medicare Better Access Scheme did not allow for rebated psychology services to residents of commonwealth supported aged care facilities – the policy has been amended since 2018 – and this lack of access was a factor in the findings from the paper. The paper surveyed senior staff from residential aged care facilities. Normalising depression “We found that access to psychological services was poor. The respondents reported that medication such as antidepressants was the most commonly used treatment for when residents had mental health issues,” she said. “They also offered psychosocial activities such as music and arts. Mental health support was sometimes provided by pastoral care workers, occupational therapists and social workers, but access to psychologists and psychiatrists was a limited.” Another potential issue was the normalisation of depression in later life. “Researchers have looked at attitudes towards depression in late life and they found people tend to think that it's normal and that nothing can be done for older adults when they're depressed because ‘of course, you're depressed, you're old’. There is a normalisation that they can't do much about it, which is simply not true.”

By James Knox

“More often than not, people will listen to

NOVEMBER 2019 | 25

The Science of Living Longer Clinical and political concerns are rightly focused on caring for ageing people. However, we know little of the scientists looking for its cure. Here’s a little of what they’re thinking.

he traditional archetype of ageing goes something like this: the older we get, the more susceptible to degenerative diseases we become, until we face an eventual death. This has been, and is, the established norm. But what if that paradigm is no longer so clear cut? And, what if the process of ageing can be reversed and health-span extended through pharmaceutical interventions?

These are questions that, until recently, were purely hypothetical, or considered too ponderous to ask, but with the evolution of ageing research, some are looking for tangible answers. Medical Forum spoke to some of these researchers to explore some of the detail of their work. While the idea of lifespan extension is difficult to rationalise clinically as there is a dearth of scientific evidence in human trials, there is tangible research that suggests health-span can be increased. Dr Lisa Chakrabarti is associate professor of mitochondrial biology at the University of Nottingham. Lisa’s area of specialty is focused on changes in mitochondrial function as time and the environment exert their effects. Lisa started focusing on ageing research when she was working in the area of neurodegeneration. “At that time, I was very interested in the brain. I was working with a mouse model on Purkinje cell degeneration that develops a neurodegenerative phenotype very early in life, quite soon after development is complete,” she said. The confounding factor “I was trying to compare our findings in this model with human disease and I realised that for many human diseases, ageing is a confounding factor. So, I started to be interested in the distinctions between ageing and diseases of ageing.” Lisa’s research on mitochondria has found what could be the key to extending an individual’s health-span.

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“The work we have done suggests very strongly that if the brain and its mitochondria can be kept optimally nourished with glucose and oxygen, then it stands a better chance of staying healthy for longer. So vascular health and aerobic capacity and diet all have important roles to play in at least delaying the onset of disease,” Lisa said. “Depending on how you are looking at mitochondria (or the tissue they are derived from), it seems that the detrimental effects of the passage of time may start much earlier than we typically consider. At around middle age there appears to be a balance trying to be struck between intrinsic protective and compensatory mechanisms and the breakdown of cellular processes.” According to Lisa, the idea of ageing and why humans have a limited lifespan is a simple concept complicated by numerous processes occurring at the same time, which essentially overloads the body and contributes to dysfunction. However, further research is needed to crystallise which processes are beneficial to an extended health-span and to isolate the biomarkers for dysfunction. “Just because there is no obvious cell loss or dysfunction, it doesn’t mean that the cell isn’t ageing, it may have important compensatory activities unregulated.” Fugue and variations “We still have a long way to go. I think the most methodical way is going to be a thorough characterisation of the ageing process and the variations within it. Then the defining molecular signatures can be targeted to see whether there is an improvement in cellular physiology and function compared with controls,” says Lisa. While it may be possible in the future to extend an individual’s life-span, it could come at a cost. Further health complications and susceptibilities are possible. “The ideal would be that we can extend the health of individuals to measure their life expectancy. Theoretically we could

extend lifespan much further but if that means an extra 20 years of poor quality of life, that in my view isn’t a worthwhile goal in itself, Lisa said. “Also, as we have extended life-span we have seen certain diseases become more prevalent in the population. Significantly extending lifespans further may uncover other classes of disease that you need to live even longer in order for them to develop.” Medical Forum also spoke with biogerontologist Dr Suresh Rattan from the Aarhus University, Denmark. Suresh has been studying the biology of ageing for more than 35 years with a particular focus on the regulation of protein synthesis and turnover, screening and testing potential ageing interventions using natural and synthetic compounds and mild stress-induced hormesis. “The processes of living are the causes of ageing,” Suresh said. “There are no specific genes for the purpose of causing ageing, rather it is the inability and imperfections of the processes of maintenance and repair that leads to ageing, age-related impairments and eventual death. So, ageing is not ‘caused’ by anything. Ageing ‘happens’ because the body cannot prevent its failure.” Repair and maintain Although there are diseases that commonly occur in old age, Suresh takes a holistic view of how to expand individuals’ health span. He says these diseases are, “a consequence of the progressive failure of homeodynamics of maintenance and repair. We need to look for methods and approaches to modulate the whole ageing process – its rate, its extent, its consequences.” In terms of how age-related damage could be offset by clinical interventions, Suresh said: “Regeneration could be possible by damage-specific targeted intervention, such as stimulation of proteasome and autophagy

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FEATURE [mechanisms]. Damage occurrence and accumulation could also be slowed down or prevented, to some extent, by whole body targeted approaches, for example, the way exercise works.” Hormones are crucial chemicals for survival, health and longevity. But the age-related decline in the levels of several hormones can also be a sign of the body’s adaptive changes for survival in the post-reproductive duration. Therefore, unless there are severe deficiencies of one or more hormones leading to clear cut pathologies, hormone supplementation may actually be, at best, useless or, at worst, harmful in terms of counteracting the adaptive survival responses of the ageing body. Suresh discovered kinetin (N6furfuryladenine), a class of plant hormone, could delay the onset of several signs of ageing in human skin. “The cytokinin or kinetin was tested in cell culture in the Hayflick system of cellular ageing with some effects on maintaining health and functionality of normal human cells for a longer period. It has several routes of action via stimulating turnover of damaged proteins, protecting DNA and protein from oxidative damage, and stimulating stress responses to counteract damage accumulation,” explained Suresh. As far as extending an individual’s lifespan with therapeutic interventions, Suresh says this is theoretically possible but we are not there yet.

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The Science of Living Longer Wishing on a star? “If you can find the methods to repair all the damage occurring at any time, or remove all the damaged molecules from every single cell of the body, or totally prevent the occurrence of all molecular damage, then there will be no mechanistic reason left for becoming old and dying,” he said. “We will then be potentially immortal, but still die one day before immortality, either from our own choice or due to the probability/laws of quantum physics and thermodynamics in terms of pure chance/ stochasticity.” British biomedical gerontologist Dr Aubrey de Grey believes it’s perilous to consider ageing as a disease because of the many confounding factors that contribute to the ageing process. Rather he works on the premise that ageing is a succession of molecular and cellular damage that can be reversed. Aubrey is founder of the US-based Strategies for Engineered Negligible Senescence (SENS) Research Foundation and vice president of New Technology Discovery at AgeX Therapeutics. He is something of a maverick in the science world as he believes that regenerative medicine will lead to individuals living longer and healthier lives by rolling back their biological clocks through pharmaceutical interventions targeting agerelated damage. Aubrey became interested in ageing research in his early 20s while working as an artificial intelligence and software engineer in the 1980s. As Aubrey puts it: “The only reason I wasn’t interested sooner was because I mistakenly assumed that other people were, specifically, professional biologists. It was only when I met and married a senior biologist that I gradually understood that biologists were overwhelmingly uninterested in ageing.” Last man standing “So, I eventually decided that my only option was to switch fields and do it myself.” Aubrey’s education in biology was selfguided and he was awarded a PhD in biology from Cambridge University for his book The Mitochondrial Free Radical Theory of Aging. While sceptics will scoff, Aubrey believes it is simply a matter of time before the wider population sees ageing as something to overcome, despite scepticism within the scientific community. “The good news is that the paradigm is already shifting. It took a decade,

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Mitachondria

basically 2002 to 2012, before my idea of comprehensive damage repair was taken on board by the scientific community. That is actually rather quick for such a profound paradigm shift,” he told Medical Forum. “Since then, there has emerged a pretty clear consensus that ageing is, first, a bona fide medical problem that can potentially be solved with medicine, and second, that its most practical solution is through comprehensive damage repair.” “I have concluded, after many frustrating years, that the only way to overcome scepticism is to make progress in the laboratory and the clinic. The pro-ageing trance is a psychological device by which people protect themselves from getting their hopes up. The only real way to get people to see that they no longer need such protection is to show them how close we are to a breakthrough.” Aubrey founded the SENS Research Foundation in 2009 to develop therapies that will repair the various types of damage that drive ageing. So far, the foundation has been conducting clinical trials on mice with encouraging results and are planning to conduct human trials in 2020. According to Aubrey, the therapeutic interventions will be what he describes as “very normal medicine”. “It will be injections, mainly, though the injected material will be extremely complex. It will include various stem cells, engineered

viruses delivering genes; vaccines to activate the immune system in new ways.” Seven ages of man SENS has highlighted seven major classes of cellular and molecular damage that are causal to ageing: Cell loss and tissue atrophy; Cancerous cells; Mitochondrial mutations; Death-resistant cells; Extracellular matrix stiffening; Extracellular aggregates; Intracellular aggregates. For each of these types of age-related damage, SENS suggests there is treatments via rejuvenation biotechnology, although these are either in prototype or still theoretical. The overarching theme behind Aubrey’s work is for humans to reach a longevity escape velocity – a theory that posits that life expectancy is extended longer than the time that is passing. He believes people will be able to choose which biological age they want their body to be and stay at that age semi-permanently. Until clinical trials are approved for SENS to migrate their research from mice to humans, it’s impossible to say what their interventions will actually achieve. What is clear, though, there is a growing number of researchers questing the holy grail of longevity.

By James Knox

NOVEMBER 2019 | 29

Trauma Care: A Maze or Amazing? Some of the world’s leading trauma clinicians are heading to Perth to share and learn how to handle these extreme occurences.

oyal Perth Hospital’s Trauma Service and Paramedics Australasia (WA) have pulled together some fascinating topics and heavy hitters in the field for the 2019 WA State Trauma Symposium to be held in Perth at the end of November.

Head of RPH’s Trauma Service Dr Sudhakar Rao said from a patient’s perspective, trauma care can be both a maze and amazing. “It is important we remember the patient’s difficult journey through the trauma care process. RPH is the state’s only level one trauma service, so it’s vital to keep questioning our service and to look at it from different angles,” he told Medical Forum. “It's easy to become complacent, so we're hoping the symposium will offer us some scientific-based evidence to help us improve our service, while highlighting the things we do well. That is important too. We are the second largest trauma service in the country and have been on the frontier of many initiatives.” “We were the first to have clinical psychologists attached to the trauma

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service for both patients and staff to handle the aftermath of trauma. We are still the only service to have a dedicated trauma ward – very few hospitals have that. But we can always learn from others.” Sudhakar said the trauma service at RPH had grown partly because of its location and partly because of the integration of facilities that made it best able to deal with trauma cases, and not necessarily because WA had more trauma than other states. Organisation is key “We don't have more injuries than other states – for instance New South Wales has about eight trauma hospitals, but not all hospitals get the same volume so can’t deliver certain things. I think WA is just better organised.” One of the keynote speakers at the symposium will be Dr Chris Wakeman, consultant general surgeon from Christchurch Hospital in New Zealand, who will share some of the clinical experiences of the mass shooting that took place in March this year. When asked if RPH and WA could handle such an event, Sudhakar said there were two approaches to such preparedness. “Firstly, is to perform everything we do well on an everyday basis. We get multiple major traumas, sometimes three or four at a time, and we do that every day. So,

if there were a catastrophe with multiple casualties, it’s a matter of ramping up on the day,” he said. Right support “But in order to do that, there must be the framework to do it. And we do run multiple casualty exercises across disciplines and services, including St John ambulance, that can go a whole day.” Sudhakar said as well as government designation, the state trauma service also underwent a rigorous verification process every three years by five specialist colleges – Surgeons, Emergency Physicians, Nursing, Intensive Care and Anaesthetists – for an intense two-day assessment. “RPH is the only hospital in the country that's passed that verification four times in a row. That credentialing is very important,” he said. The symposium will also hear from US trauma specialist, Professor Martin Schreiber, who will be discussing blood use and trauma and the role of stem cells. Sudhakar said RPH was doing a lot of work in this area exploring how they can help with wound healing and tissue regeneration, with hopes that in the future they could help repair spinal cord damage among other tissue damage. ED: The conference will be held at the Duxton Hotel, November 29-December 1.

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Royalties for legends The upcoming RPH trauma symposium will be an opportunity to hear from a world leader in neuro-imaging.

n a coup for the Royal Perth Hospital and University of WA, renowned Belgian radiologist Prof Paul Parizel has been appointed to the newly created David Hartley Chair of Radiology. It’s a role made possible by the royalties from the Endovascular Stentgraft – an innovation developed at RPH by imaging radiographer Mr David Hartley and vascular surgeon Prof Michael Lawrence-Brown 20 years ago. Paul brings a wealth of clinical and administrative experience to Perth. His previous roles include Chairman of Imaging at University of Antwerp and the President of the European Society of Radiology. He has also been involved with several start-ups focused on artificial intelligence and imaging, one of which has more than 50 staff and has just secured 16m Euros in funding. This company is focused on developing software for quantitative analysis of brain data sets from MRI and CT scanners.

When asked why he chose to relocate from Belgium to Perth, Paul explained that the uniqueness of the roles – time shared between clinical and academic duties – was the deciding factor.

“And I think that these artificial intelligence tools are going to be a great aid to help doctors establish accurate diagnosis rapidly, reproducibility and assess patients in a in a more objective way.”

“I had also worked at Royal Perth in 1994 when I was still junior in my career. I was an associate professor and spent a sabbatical here and I was very much impressed by the place, the environment and the professional ethics of the people. And I'm here now 25 years later,” he said.

Paul has an interesting analogy when it comes to AI and imaging.

“It's taken me a quarter of a lifetime to get back, but I still have that same feeling of professional excellence and being among people giving their best with all the means at their disposal.” Paul’s research background is in neuroradiology with dual focuses on cranial cerebral trauma and the implementation of AI techniques in analysing imaging data sets. Paul has been involved in the AI space for the past decade and sees its implementation as the future of imaging. “I know there's a lot of hype around artificial intelligence and there's a lot of stories being told, but there's also a world of possibilities. The field of medicine and especially imaging is changing more rapidly than anybody could ever have imagined,” he said.

“AI is like a GPS unit in a car. It's not replacing the driver, but it will alert the driver to traffic situations. It will help the driver find an alternative way if there has been an accident. I've been driving most of my life without a GPS, but I think it has helped me to be a better and safer driver.” At Antwerp University Hospital, Paul implemented some AI solutions and the outcomes were positive for the doctors involved. “Our registrars were saying that when they were on call in the weekend, the artificial intelligence systems were like somebody watching over their shoulder, they didn't feel alone, which is one of one of the big problems, I think, in hospitals and certainly in trauma units and emergency departments.” “AI software is helping doctors to organise and prioritise their findings, focusing their attention on the images or the data sets they should look at first.”

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Restraints – a New Regulatory Landscape Lawyer David McMullen explores the impacts of the changing regulations around restraints and suggest it will be an evolving space. The Quality of Care Principles within the Aged Care Act 1997 have been amended to minimise the use of restraints. The new principles, which came into effect on July 1, arrived in a climate of adverse media coverage (notably, images on television of residents with dementia being strapped to chairs) and scrutiny from the ongoing Royal Commission into Aged Care Quality and Safety. The use of physical and chemical restraints in residential aged care is a focus area for the Commission. What is a restraint? The new principles attempt to guide decision making on the use of restraints – whether they should be physical or chemical, or used at all. A chemical restraint is a ‘restraint that is, or that involves, the use of medication or a chemical substance for the purpose of influencing a person’s behaviour ...’, whereas a physical restraint is a restraint other than a chemical one. Excluded from both definitions is ‘medication prescribed for the treatment of, or to enable treatment of, a diagnosed mental disorder, a physical illness or a physical condition’. This means a pharmacological agent might be regarded as a chemical restraint in some scenarios, yet not be considered a ‘chemical restraint’ if used to treat a diagnosed mental disorder. Who does this apply to? The Quality of Care Principles apply to approved providers of aged care (that is, government-funded aged care providers regulated under the Aged Care Act). So (for readers who are not aged care providers), the Quality of Care Principles become relevant if you are employed by or contracted to work for an aged care provider. You should expect to be contractually required to act consistently with the obligations of that aged care provider. The following are some key considerations: Decision to restrain When considering physical restraints, alternatives to restraint must be used ‘to the extent possible’. Where a physical restraint is to be applied, the restraint must be the ‘least restrictive form of restraint possible’. A chemical restraint, on the other hand, must not be used unless assessed

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and prescribed by a medical or nurse practitioner. Interestingly, there is no express requirement to consider alternatives, nor a requirement to use the least restrictive form of restraint, as there is with physical restraints. This is presumably in recognition that the prescribing of chemical restraints is a matter for a practitioner’s clinical judgment, rather than being something capable of being governed by prescriptive regulation. A decision to restrain must be documented, with specific requirements depending upon whether a physical or chemical restraint is used. Consent People receiving aged care often have representatives making decisions on their behalf. This can create challenges where difficult decisions such as decisions to restrain are to be made. The Quality of Care Principles attempt to provide some structure: • For physical restraint, informed consent is required except in an emergency. • Before using a chemical restraint, a representative must be informed ‘if it is practicable to do so’. • A representative is to be informed as soon as practicable, if a physical or chemical restraint is used without the necessary consent being obtained, or representative being informed prior. These requirements raise some practical challenges in their implementation. What is the likelihood that a person (or their representative) would consent to the use of physical restraint? What is a practicable means of informing representatives prior to using chemical restraints, particularly

where the use is not just a one-off (i.e. where a drug is to be administered multiple times and/or over an extended period)? Monitoring and duration of use Where a physical restraint is used, it must be only for the ‘minimum time necessary’. The restrained person’s condition, and the necessity of the restraint, must be regularly monitored. When a chemical restraint is used, the restrained person must also be regularly monitored. However, there is no express requirement in the User Rights Principles to limit the duration of a chemical restraint, nor to regularly monitor necessity in the same way as for a physical restraint. The User Rights Principles do not attempt to specify how these types of decisions are to be made. As with the initial decision to use a chemical restraint, the practitioner’s professional judgment remains the guiding factor. Concluding comment Regulatory responses to the use of restraints in aged care may continue to evolve – particularly as the sector moves through a period of heightened scrutiny and reform. Each aged care provider will have their own policies, processes and procedures for compliance with their legal obligations, especially in areas of record keeping and consent. Readers who work in aged care should have an awareness of the new provisions of the User Rights Principles, and be mindful that responses will vary from provider to provider. ED. David McMullen is Special Counsel at Panetta McGrath Lawyers. He focuses on health and ageing and has previously practised law as in-house counsel at a provider of retirement villages, in-home care and aged care services.

NOVEMBER 2019 | 33

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NEWS & VIEWS

Asking the Alcohol Question

The food standards body is moving on with mandatory warning labels for pregnant women and GPs are being urged to talk to their patients.

ews came through earlier this month that the Food Standards Australia and New Zealand (FSANZ) was calling for public comment on the design of mandatory warning labels on alcohol, which would target pregnant women.

Labels have been voluntary since late 2011, now commonwealth, state and New Zealand governments have agreed they should be mandatory. Sectors of the alcohol industry have already flagged resistance.

consumption with their pregnant patients. A survey indicated that 45% of GPs were having such conversations, which leaves 65% silent on the issue. “Health professionals generally, not just GPs, aren't always comfortable asking women about their alcohol use, which is curious given they don't seem too uncomfortable asking them about their other drug use,” Tracey said. “I think that that probably comes back to the broad social and cultural acceptance of alcohol.”

However, the move will be supported by many health practitioners working on minimising the risk of children being born with Fetal Alcohol Spectrum Disorder (FASD).

“However, we know prenatal alcohol exposure interrupts, at some level, the developing baby. What the outcome of that is depends on the woman herself, and it's not just high-risk alcohol users who are exposing their babies to danger.”

For Dr Tracy Reibel, senior research fellow at Telethon Kids Institute, it comes as timely support for the institute’s campaign urging GPs to raise the issue of alcohol

“A pregnant woman may be at a wedding and think a couple of glasses of champagne is not going to hurt. And it may not, but you just don't know the impact of

The label proposed by FSANZ confounding health factors. While on the other hand there are other women who merrily drink through their pregnancies and have perfectly healthy babies.” “There is a diversity of outcomes, but why why would you risk it when it's only nine months of abstinence to ensure a lifelong condition such as FASD is avoided. Telethon Kids has produced materials for GPs to help raise alcohol consumption with their patients. A series of three-minute videos featuring GPs and young mothers discuss the importance of asking (and being asked) the alcohol question.

Should women over 75 years stop or continue screening mammograms?

reastScreen Australia, the national population-based breast cancer screening program, recommends that women aged 50–74 years without any significant breast symptoms attend for free two-yearly screening mammograms. Whilst screening mammography has been shown to be effective in reducing breast cancer mortality in women aged 50-74 years, the

World Health Organisation has found that there is insufficient evidence of benefit to recommend screening in women 74 years and older.1

As the first point of contact for health issues for many Australians, GPs have a key role in communicating the potential benefits and harms (eg. over-diagnosis and over-treatment) of screening mammography to older women. A reasonable approach to optimising the benefits of screening for older women is for GPs to individualise their advice based on comorbidity status and life expectancy. A decision to stop breast cancer screening does not mean abandoning health promotion, but rather refocusing on interventions more likely to be of benefit sooner. 1

Lauby-Secretan B, Scoccianti C, Loomis D, et al. Breast cancer screening—viewpoint of the IARC working group. NEJM 2015

Women may book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50 34 | NOVEMBER 2019

Mar ‘18

Photograph courtesy of BreastScreen Australia

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“We deliberately chose young Caucasian women because the other issue we have here is that people generally confine this problem to alcoholics and Aboriginal people. It is absolutely not the case. A placenta is a placenta and a fetus is a fetus and it doesn't matter whose body it is, it will be affected by exposure to alcohol,” she said. “And this is the motivation behind these videos – to get across to people that it doesn't matter who you are. We can't afford doctors to make assumptions about

who walks into their surgery. A woman wearing a hijab doesn’t mean she doesn't drink, or women who say they rarely drink or never drink.” “It’s still important to have the conversation to reinforce the risks associated with alcohol because we know that people tend to dismiss occasional use, for example, because we tend to think of drinking alcohol as something we do all the time.”

the facts, they will make the decisions themselves, but they do need the information and the advice. Women are confused by the ambiguity of the alcohol messaging and GPs are most likely the first health professional a pregnant woman will approach, so tell her. And then it's up to the woman to decide, but she can't make a decision on something she doesn't know about.”

By Jan Hallam

“Pregnant women want to know everything about their growing baby. If you give them

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Managing behavioural problems in dementia care By Dr Scott Blackwell, GP, Joondanna Behavioural problems, in reality, are often why dementia sufferers come to reside in Residential Aged Care (RAC). It just gets too hard at home. The aim is that the facility provides a better environment for the resident, allowing family to spend quality time with their loved one. An early family meeting is vital to develop good relationships and an opportunity for advanced care planning for the management of whatever lies ahead. Without this, the road can be filled with conflict and the resident’s journey suboptimal. So first build the relationships with family and facility staff. There is always a period of adjustment after admission to RAC. Depression tools such as the Cornell score will often be high, but we need not rush into prescribing antidepressants. It is better to involve family in socialisation and if necessary psychological counselling for those whose dementia is not too advanced. A well-

KEY MESSAGES Involve family from day one Treat secondary causes of behavioural problems Use symptom specific medication and minimise dose managed adjustment period creates a good foundation for the rest of the resident’s life. The next vital tool in managing behavioural problems in dementia is the skill of facility staff. Clinicians will often feel pressured to prescribe tranquillisers, antidepressants, and antipsychotics. Upskilling the staff is a more important intervention. Dementia Services Australia provides on-site staff training. It is not good practice to medicate when other answers can be found. Supporting and educating RAC staff is also a role to which GPs and Nurse Practitioners can contribute while managing difficult residents.

When challenging behaviours develop, look for and correct treatable physical causes such as UTIs, chest infections, pain, and constipation. If treating secondary causes does not resolve the behaviours, then pharmacological intervention can be considered. So, where does medication fit into the management of the difficult behaviours of dementia? Firstly, there is no medication specific to this role. Pain and other secondary causes should be treated on their merits. If there are psychotic symptoms it is reasonable to try antipsychotics. Equally try anxiolytics for anxiety symptoms. With insomnia, explore other symptoms that co-exist as treating these may resolve the issue (e.g. hallucinations, pain). The next step may be low-dose mirtazapine, then other sleep agents. Sodium valproate has no evidence base in trials we are told, but our experience is that it is of value in some cases. In my

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CLINICAL UPDATE

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Accessing Home Care can be confusing To help we’ve created this simple guide Step 1.

ACAT referral. You, the GP, refer them for an ACAT assessment via www.myagedcare.gov.au/health-professionals OR Ask your

experience it helps in the highly agitated who look at you with eyes like flame throwers, the ones who often leave you feeling unsafe. Maybe the trials don't relate to a specific enough cohort, maybe my experience is coincidental, this is the nature of the space we work in. If it is of no benefit in modest doses, then withdraw.

to call us and we will conference call MyAgedCare with them to arrange the referral.

Step 2. Your will be contacted by the ACAT to arrange to visit them and work out the amount of help they may need.

The most significant error we make in medication management is that once behaviours are controlled, we don't follow-up and minimise the doses. We are implored to follow evidence-based guidelines (often from clinicals trial not done in an RAC) in managing challenging behaviour in residents. The problem is that experts who produce guidelines base them on evidence not including all the evidence we face as clinicians. We can be faced with agitated, sometimes paranoid and aggressive residents who are a physical risk to themselves, staff and other residents. The intuitive decision-making skills of the clinicians are under siege as all involved deserve to be considered. Furthermore, there is little or no support from specialist services when crisis peaks. If ED is resorted to, I feel sorry for the clinicians there as they cannot resolve the real issue which revolves around society having marginalised this cohort of people to a place not equipped or staffed to cope with extreme behaviour. The complication of these difficult moments is the fracturing of relationships we have worked hard to develop, as well as traumatised family members, other residents and staff. For the resident it can herald a significant deterioration and sometimes death.

Step 3.

with Department of Human Services (DHS) The can call us on 1300 26 26 26 and we can mail the form to them.

Step 4. 1. ACAT approving their care level. with their income assessment. 2. DHS - this may 3. Home Care Package Assignment take 6 to 12 months.

Step 5. They have 56 days to organise their services.

Step 6. Compare service providers With their in hand – they call their preferred providers to compare services and costs, and hopefully we’re one of them.

Many sad stories have been told to the Royal Commission. Some are bad practice. In others I feel the urge to be protective of the staff, thrown in, out of their depth, to manage behaviours from people no longer responsible for their actions.

Step 7. Select a service provider and sign up

Sadly, I expect that the Royal Commission will deliver more oversight, and regulation but little to improve the current staffing and training deficits. Instead of random visits by a compliance officer that creates chaos, money is better spent on rapid response teams to help in crisis situations.

yourself stuck, call the team at If you or your Amana Living. Leonie and Andrea have helped hundreds of people get their Call us during

Ultimately, each case is different and the intuitive decision-making skills of the clinicians must take in the evidence from the history and examination and investigations, then apply the evidence from trials and seek the best solution for the person in question.

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amanaliving.com.au Author competing interests – nil

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Providing quality care in WA for over 50 years.

NOVEMBER 2019 | 37

Out of Joint...the Statistics

he Australian Orthopaedic Association (AOA) has released its National Joint Replacement Registry 2019 Annual Report for Hip, Knee and Shoulder Arthroplasty. The report draws data from the National Joint Replacement Registry, which was created to improve patient outcomes for joint replacement surgery.

Nationwide figures The report is the 20th produced by the AOA and they have provided analysis of all primary and revision procedures recorded by the registry totalling 1,492,892. Joint specific procedures accounted for 52,052 shoulders; 643,567 hips; 782,600 knees. In 2018, 122,854 procedures were recorded with 64,343 knee replacements, 48,896 hip replacements and 6,892 shoulder replacements, 1664 spinal disk replacements, 671 elbow replacements, 298 ankle replacements and 90 wrist replacements. Public vs private Across the figures there was a unifying theme, more procedures occurred in private hospitals nationally and state-

by-state, with the exception being ACT/ NT, where more procedures took place in public hospitals. The national total hip replacements in private hospitals was 28,806, with WA accounting for 3,491 procedures. Hip replacements in public hospitals totalled 20,090, with 2,007 in WA. For knee replacements in private hospitals the total was 45,018 nationally, and 5,719 procedures in WA. Public hospitals reported 19,325 replacements nationally and 1,702 in WA. Nationwide shoulder replacements totalled 4,815 for private hospitals, with 662 occurring in WA. Public hospitals reported 2,077 shoulder replacements, WA accounted for 256 of the total. New procedures, less revisions As the AOA has a plethora of data stretching back to 1994, they have been able to highlight how the advances in new procedures resulted in less revisions or redo operations. The report analysed revisions of procedures for three different time periods: 1999-2005, 2006-2012 and 2012-2018.

For hip replacements, the least likely time period for revisions was 2013-2018 and the most likely was operations completed between 2006-2012 with the 2006-2012 time period falling in-between. Similar findings were reported for knee replacement procedure revisions, again the report identified that new procedures was causal for less revisions. Procedures steadily growing Hip and knee replacement procedures have steadily increased over time, with hip replacements growing 162.4% from 199495 to 2017-18, knee replacements have increased 381.2% from 1994-95. In 1999-00 there was a total 42,653 hip and knee replacements in both public and private hospitals, compared to 113,239 in 2017-18. The growth in hip and knee replacements is far beyond that of the population growth, between 1999-00 and 2017-18 the Australian population grew 32%.

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Normal ageing or pathology?

I am now

new hearts at Mount Hospital

By Melissa Hadley Barrett, Nurse Practitioner/Sexology, Perth Low testosterone levels without symptoms can be a normal part of ageing. Testing is indicated where a low level would have important consequences for patient management. Restrict screening to symptomatic patients, or those with medical conditions associated with insulin resistance (obesity, type 2 diabetes, and metabolic syndrome and testosterone deficiency (TD) signs and/ or symptoms). TD screening should be considered for men with HIVassociated weight loss, osteoporosis (or height loss, or low trauma fracture), patients using long-term opioids, high alcohol intake or glucocorticoids. Signs and symptoms

KEY MESSAGES

Reduced sexual Testosterone deficiency affects many older men response is common and prominent. Low Screening is appropriate in certain sexual desire and patient groups decreased nocturnal Treatment includes lifestyle and and morning erections testosterone therapy are clearly associated with TD, whereas the association with impaired sex-induced erections is less evident. Other common symptoms include inability to perform vigorous activity, muscle weakness, fatigue, depression and increased body fat. Hot flushes and alterations in cognition and memory are less common. Men with suspected TD should be examined to identify physical signs. Examination may be normal. The most prevalent signs of TD are increased visceral obesity and smaller prostate volume. Decreased muscle mass is less prevalent and difficult to confirm. Not all manifestations need to be evident simultaneously and interindividual variability exists. An erection symptom score sheet can be helpful. Investigating patients with suspected TD starts with a morning (before 8am) total testosterone (TT) test. If low (TT below the laboratory reference range) repeat it with serum LH, FSH, SHBG and calculated free testosterone. At this point the biochemist/ pathologist at the lab will indicate if testing Prolactin is appropriate. Repeat TT, as two test results are required for PBS prescribing. Treatment starts with lifestyle interventions. Weight loss, diet, exercise, cessation of smoking, and reduction of alcohol intake can be effective at improving testosterone levels, as well as having positive effects on lipids, sugars, cardiovascular risk and mental health.

Cardiothoracic Surgeon Practicing at Mount Hospital

Clinical interests include: • All aspects of adult cardiac disease; • Off pump coronary artery bypass grafting; • Thoracic transplantation; • Aortic surgery; • Structural heart disease; • Lung cancer and benign lung disease and • Multi-disciplinary management of complex cardiothoracic disease.

For more information visit: www.mounthospital.com.au or call Mount Hospital on 08 9327 1100.

Symptomatic men with TT lower than 6nmol/L can be treated with testosterone therapy (TTh) under the PBS guidelines. The patient must be treated by a urologist, endocrinologist or a fellow of the Australian Chapter of Sexual Medicine or in consultation with one of these specialists (see PBS guidelines for more details). A trial of TTh in symptomatic men with levels higher than 6nmol/L can be considered based on clinical presentation (if no contraindications), via a private prescription. However, it is important to note that once patients commence testosterone therapy, they are rarely able to cease so careful consideration is required.

Find out why Mount Hospital is winning the hearts and minds of our patients and everything in between. Phone: 08 9327 1100 | www.mounthospital.com.au

Author competing interests - nil relevant disclosures. Questions? Contact the editor

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NOVEMBER 2019 | 39

Knee imaging, which test when? By Dr Matt Prentice, Radiologist In acute trauma, the Ottawa Knee Rules determine if x-rays should be obtained (see Text Box 1). A normal horizontal beam lateral (Fig.1) can reassure fracturing is unlikely. If there is significant arthritis, which is best demonstrated on AP weight bearing x-rays (Fig.2), knee replacement may be more appropriate than arthroscopy, obviating the need for further imaging. For post-surgical cases or fracture follow-up, x-rays screen for complications and confirm fracture healing. MRI gives a gold standard overview of all knee structures. It can enable more rapid return to work or sport through exclusion of a significant injury and triage injured patients for arthroscopy versus conservative management. A twisting or ‘dislocating’ type injury with rapid

The Ottawa Knee Rules – Developed by Dr Ian Stiell A knee x-ray series is only required for knee injury patients with any of the following findings Age 55 or older Isolated tenderness of the patella (no other bony tenderness) Tenderness of the head of the fibula Cannot flex to 90 degrees Unable to bear weight both immediately and in ED for 4 steps.

KEY MESSAGES Plain films: first line in trauma and arthritis MRI: imaging gold standard, especially in suspected cruciate or meniscal injury CT arthrogram: in over 50 year olds, with no significant OA, where MRI not rebateable onset effusion/haemarthrosis suggests a potential ACL tear or patella dislocation. Often difficult to differentiate clinically, MRI can confirm the diagnosis (Fig.4) and frequently reveal and characterise other important intra-articular injuries, such as meniscal tears. In isolation, meniscal tears tend to cause more gradual onset effusion, while displaced meniscal fragments may cause a block to full extension. MRI can also reveal articular cartilage injuries and marrow oedema due to arthritis/stress or insufficiency fractures that are usually occult on other imaging modalities. In children, a rebateable MRI can be obtained irrespective of trauma history, helping exclude a range of important conditions e.g. osteochondritis dissecans (Fig.5) or juvenile arthritis. A Medicare rebate applies for knee MRI scans in adults (16-49 years) following acute

trauma where inability to extend the knee suggests a possible acute meniscal tear or clinical findings suggests acute anterior cruciate ligament tear, and in those under 16 for suspected internal joint derangement. CT has a limited role in acute knee trauma, being primarily used for operative planning of comminuted or intra-articular fractures (Fig.6). CT may reveal an occult fracture if lipo-haemarthrosis on x-ray, but is insensitive to other intra-articular injuries identified on MRI. CT plays a key role in surgical planning for computer or robotassisted TKRs.

Figure 1 Horizontal beam lateral film with lipo-haemarthrosis (white arrow) secondary to tibial plateau fracture (black arrow).

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Figure 2 AP weightbearing films demonstrate severe medial tibiofemoral joint narrowing/OA. Meniscal tearing guaranteed CT arthrograms are not routinely performed if MRI is available, due to their inferior sensitivity for soft tissue pathology and bone marrow oedema, radiation (albeit low dose on modern scanners) and the invasive component to the scan. It is reasonable for detection of meniscal tears as long as adequate contrast coating of the menisci is achieved (problematic in acute trauma with a haemarthrosis). CT arthrogram does have better sensitivity for full thickness fissuring than MRI, so is occasionally requested by orthopaedics for work up of uni-compartmental knee replacement.

Figure 3, axial PD fatsat MRI, demonstrates a Baker’s cyst seen on a prior ultrasound. The cause for excessive joint fluid decompressing from the joint into the cyst and posterior pain is a radial tear of the posterior root of the medial meniscus (green arrows)

Figure 5 Unstable osteochondral lesion at the typical site for Osteochondritis dissecans (black arrow) with internal and surrounding marrow oedema.

Ultrasound is limited to assessment of superficial soft tissues; collateral ligaments, quadriceps and patella tendons, bursae and Baker’s cyst, confirming an effusion or synovitis if inflammatory arthritis is suspected. Author competing interests – the author works for a group providing imaging.

Figure 4, High grade ACL tear with 1 ligament bundle retracted and the other lax (green arrows).

Figure 6 Intra articular comminuted fracture of the tibial plateau involving the articular surface and the tibial eminence.

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Better antibiotic use urgently needed in remote areas By Dr Asha Bowen, Paediatric Infectious Disease Specialist, Wembley Antimicrobial resistance has been a growing issue for many years. Without coordinated strategies to improve antibiotic use and slow progression of resistance, there will be dire consequences for rural and remote Aboriginal communities. Research shows these remote communities have Australia’s highest rates of antibiotic resistance to bacteria like Staphylococcus aureus (golden staph) – around 50 per cent are resistant compared to 15 per cent elsewhere – and according to a Medical Journal of Australia article, it’s due in part to the heavy burden of infectious diseases combined with high rates of necessary antibiotic use to treat these infections – many of which are at high levels due to poverty and other social disparities experienced in remote Australia. As Head of Skin Health at the Wesfarmers Centre of Vaccines and Infectious Diseases based at the Telethon Kids Institute, I led the first antimicrobial stewardship audits in the remote sector in partnership with other researchers and remote health care service

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KEY MESSAGES Antimicrobial resistance is growing and is worse in remote communities Current hospital data understates the problem A coordinated approach is needed to solve this problem providers as part of the HOT NORTH Improving Health Outcomes in the Tropical North research program at Menzies School of Health Research. Previous studies have shown that 50% of Aboriginal children in remote communities have at least six antibiotic prescriptions by their first birthday, for conditions including respiratory tract infections, skin sores and ear infections. Updated, timely, high quality data about how antimicrobials are being used in the most remote parts of Australia is needed to learn how big the problem really is. Current data, mostly gained from hospitalised

patients, is only the tip of the iceberg. We already know that if we can’t slow the spread of antibiotic resistance to deadly pathogens in these remote communities, we will come to a point where there just aren’t any treatment options available to save the lives of people suffering lifethreatening infections. Finding the right balance is incredibly difficult – we don’t want to discourage people from seeking treatment and taking antibiotics when they need them, and we also need to encourage healthcare providers to prescribe the right medications, to the right patients, for the right indication and for the correct duration of time according to evidence-based guidelines. The only way forward is a co-ordinated approach nation-wide, collating information to help us understand the true magnitude of the problem and prompting action to move skills and resources for antibiotic stewardship into the sectors that need it most. This will ensure the necessary

continued on Page 45

NOVEMBER 2019 | 43

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Skeletal regeneration By Dr Richard Prince, Endocrinologist, Perth As you are reading this update, your skeleton is regenerating itself throughout every bone to replace old, micro-fractured bone with new bone formed in sheets with biomechanical properties similar to plywood. This is achieved by specialised multi-nucleate osteoclasts (the only cells in the body that can dissolve hydroxyapatite crystals) using a proton pump similar to the stomach wall. These remove an area of damaged bone as they move across the surface of the honeycomb-like trabecular bone at the ends of long bones and in the vertebrae, or cut out a cylinder of bone in cortical bone. Bone is replaced with layers of osteoid protein secreted by osteoblasts. Once outside the cell the osteoid is infiltrated with hydroxyapatite crystals consisting of calcium, phosphate and water molecules that provide bone rigidity. This happens in all bones to regenerate them, a process taking five to 10 years making the skeleton five to 10 years’ old. This regenerative mechanism does not maintain bone structure after the age of 30 because osteoclastic resorption occurs faster than osteoblastic bone formation due to osteoblast senescence, an active research area connected to other areas of cell senescence research. We have pharmaceuticals available that, in conjunction with lifestyle modification, not only stop progression but can result in skeletal regeneration. The MBS bone density schedule (developed by a committee I chaired back in 1995) lists the conditions predisposing to accelerated bone loss. Age-related bone senescence,

continued from Page 43

AMS for remote areas frameworks are developed and the knowledge about antibiotic resistance in the area is available so that antibiotics are prescribed accordingly. We must also acknowledge antimicrobial resistance can’t be addressed in isolation. The drivers come down to the social determinants of health such as living conditions and access to clean water. The problem is all encompassing and it’s our responsibility to work together to solve it. References available on request Author competing interests – nil

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KEY MESSAGES The skeleton can regenerate itself but loss exceeds this ability after age 30 Osteoporosis is treatable Bone scanning informs treatment exacerbated by ovarian or testicular failure, is the most common. The question is not whether it can be done, but whether it is worth the time and cost to reduce fracture risk. The best way to decide this is by a dual energy bone structure examination (DXA) that, with extra demographic data, provides a reasonably accurate fracture risk over five years. Many use a 10% risk to advise the addition of pharmaceuticals to lifestyle advice. Ideally your bone density provider will provide an easily readable image to correctly identify reference area of spine, hip or forearm and will provide a graph of where the patient

is in relation to the normative data. These graphs act as an important explanatory aid to improve patient compliance and improve risk identification. The usual pharmacological antiosteoclast medication must include calcium and vitamin D to prevent secondary hyperparathyroidism based bone loss. More severe skeletal damage may benefit from osteoblast stimulatory medication in addition to certain antiosteoclast medications. Osteoporosis is an important disease of older patients due to osteoblast senescence as well as younger individuals with disease predisposing to rapid increased bone turnover and associated relative osteoblast senescence. In all categories, it is possible to stop bone loss and if necessary regenerate the skeleton by using the inherent processes developed over our biological evolutionary history. Author competing interests – nil

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Frailty – the what, why & how By Dr Claire Meyerkort, Geriatrician, Nedlands Frailty refers to a state of increased vulnerability and diminished reserve in response to an external stressor, with poor ability to return to baseline. With an ageing population, it is increasing. In a frail individual, an apparently small insult (e.g. new medication, minor illness/surgery) results in a disproportionate change in health; from independent to dependent, mobile to immobile, postural stability to falling, lucid to delirious (Figure 1). Frailty is measured because it is a better predictor of adverse health outcomes than chronological age alone. It is associated with hip fracture, disability, hospitalisation and mortality independent of other health behaviours, pre-existing disability and comorbidity. Poorer postoperative surgical outcomes are also correlated with frailty. How to measure frailty? Previously the ‘eye-ball test’ was used to subjectively identify adults as ‘frail’ or ‘not frail’. Today, two broad approaches are

KEY MESSAGES Frailty is associated with adverse outcomes at an individual and population level. Several validated tools are available to screen and detect frailty. Use an individualised, holistic and multidisciplinary approach to management.

(EFS), and the Clinical Frailty Scale (Table 1). Recognising frailty helps clinicians identify individuals at risk of complications related to the disease and/or intervention being considered. This can guide decision making (e.g. considering an invasive procedure or medication). Frailty, rather than chronological age, can be used to weigh up the advantages and disadvantages of

recognised – a phenotypic and a cumulative deficit model – from which multiple frailty tools have been developed. How to decide which one to use? This depends on the clinical setting and purpose of measuring frailty. Some tools are better suited to research settings, or require a trained administrator, while others can be easily self-completed by the patient or carer. Three tools worth highlighting are the F.R.A.I.L Scale, the Edmonton Frailty Scale

Fig.1 Frailty conceptualised

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CLINICAL UPDATE

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CLINICAL UPDATE Table 1 Assessment tools

Description

F.R.A.I.L Scale

Edmonton Frailty Score

Clinical Frailty Scale

5 item questionnaire that assesses key components of frailty: 1. Fatigue (‘F’) 2. Resistance (‘R’) 3. Ambulation (‘A’) 4. Illnesses (‘I’) 5. Loss (‘L’) of weight (F.R.A.I.L).

9 item questionnaire that assesses these Domains: 1. Functional independence. 6. Social support. 2. General health status. 7. Nutrition 3. Mood 8. Cognition 4. Continence 9. Functional performance. 5. Medications

Pictorial representation of frailty based on clinical judgement, intended to be used after a comprehensive clinical assessment.

Advantages

Patient can self-complete. No special training or equipment required.

Validated for use by non-geriatricians. Physical and non-physical domains assessed.

Predictive of death and institutionalisation if used

Disadvantages

Focus on physical components of frailty.

Patient can’t self-complete.

Less valid if performed by non-trained staff without

treatments, allowing patients and families to make more informed decisions. Identifying a frail individual can lead to consideration about what can be done to optimise their health status. Given frailty is a multidimensional syndrome, management usually involves a multidisciplinary team. Consideration of referral to a geriatricianled team to undertake comprehensive geriatric assessment (CGA) can help to identify and optimise frailty and/or avoid futile interventions based on risk-benefit assessment. Comprehensive geriatric assessment that

with a CGA.

clinical assessment.

leads to therapeutic intervention can optimise the likelihood of improved clinical outcomes, including returning home, minimising cognitive and functional decline and lower hospital mortality. Review polypharmacy and consider deprescribing in frail individuals, who may not live long enough to experience the benefits of certain medications. Consider prescribing an individualised exercise program, as physical activity can improve mobility and functioning among frail older adults. Although specific nutrition interventions have not been established in preventing or treating frailty, diet and nutrition

should be evaluated because higher protein intake has been associated with lower risk of incident frailty. Frailty is associated with alcohol, smoking, and obesity so ongoing attention to these factors is important. References available on request ED: The author acknowledges the input of Dr Charles Inderjeeth in the preparation of this article

Author competing interests – nil

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capitalradiology.com.au 48 | NOVEMBER 2019

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CLINICAL UPDATE

Immunotherapy in solid organ malignancies By Dr Mihitha Ariyapperuma (Ari), Medical Oncologist, Subiaco Chemotherapy has been the mainstay treatment for most solid organ malignancies. The introduction of immunotherapy, which works by potentiating patients own immune system to control cancers, has revolutionised cancer management. A Nobel prize was awarded to two main researches, James P Allison and Tasuku Honjo, for discovering cancer therapy by inhibition of negative immune regulation. Immunotherapy agents have been one of the main treatment modalities in melanomas showing around a 70% response rate with 58% of patients showing more than three years of survival in trials. Immunotherapy has been used in lung cancer for some years, and, more recently, it has expanded into multiple other types of malignancies. In lung cancer with high PDL1(programmed death-ligand 1) expression rate, median progression-free survival is around 10 months on immunotherapy alone compared to six months with chemotherapy.

KEY MESSAGES Immunotherapy is used increasingly in solid organ malignancies. Immunotherapy tends to be more tolerable compared to chemotherapy. Combining chemotherapy with immunotherapy is a trend showing promising results but increasing the probability of side effects.

Common instances where immunotherapy is used in cancer treatment include metastatic non-small cell lung cancers. maintenance treatment of stage III lung cancers following definitive chemoradiotherapy, adjuvant treatment of highrisk melanomas, metastatic melanomas, clear cell renal cell cancers in first-line and second-line settings and oropharyngeal squamous cell cancers. Long-term responses are seen in a considerable proportion of patients

Nivolumab: melanoma, non-small cell lung cancers, head and neck cancers , clear cell renal cell cancers Pembrolizumab: melanoma, non-small cell lung cancers, urothelial cancers Durvalumab: non-small cell lung cancers Atezolizumab: non-small cell lung cancers

PBS Reimbursed Immunotherapy Drugs in Australia (August 2019) Name

Company Target

Indications

Clinical Frailty Scale

Nivolumab

BMS

– Melanoma – NSCLC – RCC – H&N SqCC

1L combination with Ipilimumab or 1/2nd line single agent 2L post failure platinum-doublet chemotherapy 1L combination with Ipilimumab or 2L post TKI 2L post failure platinum-doublet chemotherapy

Pembrolizumab

MSD

PD-1

– Melanoma – NSCLC – Bladder – Hodgkin lymphoma

1L single agent or 2nd line post TKI single agent 1L PD-L1 >50% 2L post failure platinum doublet chemotherapy Refractory disease

Atezolizumab

Roche

PD-L1

– NSCLC

2L post failure platinum-doublet chemotherapy

Avelumab

Pfizer

PD-L1

– Merkel cell

Atezolizumab

Ipilimumab

BMS

CTLA-4

– Melanoma

1L combination with nivolumab or 2nd line post aPD-1

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PD-1 (Programmed cell death protein 1) PD-L1/L2 (programmed death-ligand 1 and 2) CTLA-4 (cytotoxic T-lymphocyte-associated protein 4) TIGIT (T-cell immunoreceptor with Ig and ITIM domains) BTLA (B- and T-lymphocyte attenuator) VISTA (V-domain Ig suppressor of T-cell activation)

Immunotherapy agents currently in common use in Australia for treatment of solid organ malignancies

PD-1

Immunotherapy agents – a key to acronyms

TIM-3 (T-cell immunoglobulin and mucin domain 3) GITR-Glucocorticoid-induced tumour necrosis factor (TNF)-like receptor depending on type of cancer. Trials are under way combining immunotherapy with chemotherapy and there are access programs open in Australia for combined treatments. Examples are combining chemotherapy and immunotherapy in advanced lung cancers and triple negative breast cancers. The expression of PD-L1 receptor levels in cancer tissue has been a predictor for response to immunotherapy. Commonly used immunotherapy agents in clinical practice include PD1 (Programmed cell death protein 1) inhibitors, PD-L1 inhibitors and CTLA-4 (Cytotoxic T-lymphocyte associated protein 4) inhibitors. There are multiple other types of immunomodulatory agents at various stages of development. Immunotherapy is available under PBS for multiple solid organ malignancies including melanoma, lung cancer, renal cell cancer and head and neck squamous cell cancer. The indications for immunotherapy are expanding. Several access programs are currently active in Australia, providing patients free access in different conditions. Side effects seen with immunotherapy are quite different to chemotherapy related side effects. These include hepatitis, colitis, pneumonitis and endocrinopathies. Even though immunotherapy seems to be generally better tolerated than chemotherapy, some of these side effects can be life-threatening so early recognition is vital.

Author competing interests – nil

NOVEMBER 2019 | 49

Oral Cavity Squamous Cell Carcinoma By Dr Amanda Phoon Nguyen, Oral Medicine Specialist, West Leederville, Jandakot & Bunbury Oral cancer is a heterogenous group of conditions encompassing the main subsites of the external lip, oral cavity and oropharynx. With over 657,000 new cases diagnosed annually, it is the sixth most common cancer. In Australia, a decline in the incidence of lip and oral cavity cancer and a rise in the incidence of oropharyngeal cancer has been reported. It is typically a disease of the elderly, occurring during the fifth to eighth decades of life. Considered rare in younger age groups, there have been reports of increasing incidence. Inconsistency exists in the oral cancer literature, with wide variations in definition and description making comparison difficult across studies. A distinction should be made between oral cavity, external lip, nasopharyngeal and oropharyngeal sites, due to different aetiology, prognosis and management.

Oral Cavity Squamous Cell Carcinoma in a 54-year-old male from other oral tissues, including the salivary glands. Oral cavity squamous cell carcinoma (OCSCC) is mostly preceded by lesions termed oral potentially malignant disorders (OPMDs). The most common OPMDs are leukoplakia, erythroplakia, oral submucous fibrosis, actinic cheilitis and oral lichen planus.

The vast majority of oral cancers are of epithelial origin. Cancers may also arise

KEY MESSAGES Five-year survival in oral cancer is approximately 50% for all anatomical sites and stages. The poor prognosis is largely due to its frequent diagnosis at an advanced stage, making early detection vital. View an oral mucosal lesion persisting beyond two weeks with a degree of suspicion.

Despite technological advances, OCSCC survival rates have not improved. Much of the current research aims towards uncovering biomarkers for the disease and therapeutic alternatives. The overall five-year survival rate for oral cancer is approximately 50% for all anatomical sites and stages. Cases which present with regional lymph node infiltration (Stages III and IV) are reported to have a five-year survival rate of 9-41%, compared to the 66-85% survival associated with cases without lymph node involvement (Stages I and II).

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CLINICAL UPDATE

Oral cancer aetiology is multifactorial. Human papillomavirus (HPV) infection, most commonly HPV16 and 18, is implicated especially in oropharyngeal SCC. Alcohol and smoking are major risk factors, with a synergistic effect when used together. Other risk factors for OCSCC include areca nut/betel quid chewing, other smokeless tobacco use, marijuana and qat use, use of alcohol containing mouthwash, poor diet and genetic predisposition. High risk sites for OCSCC include the lateral tongue and floor of mouth. Early presentation of oral cancer is usually asymptomatic. It can appear as an ulcerative, flat, raised or exophytic, red and/ or white lesion. The oral cavity can also be the site of cancer metastasis from other parts of the body, most commonly of breast, kidney and lung. Metastasis may present similarly to primary cancers, or mimic inflammatory or reactive lesions. Author competing interests – nil

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50 | NOVEMBER 2019

non-government sources funded the remaining 31.7%. Of the non-government payers, individuals contributed $30.6b or 16.5%; private health insurers contributed 9% or $16.6b; other sources contributed 6.2% or $11.5b. Primary health care expenses totalled 36.4% or $28.1b of the total expenditure with $10.6b spent on the Pharmaceutical Benefits Scheme, $10.6b on unreferred medical services and $2.2b on other health services. Individual out-of-pocket expenditure equated to $1,578 per person or 2.5% of average annual income, while private health insurers’ expenditure equated to $1,470 a person.

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NOVEMBER 2019 | 51

CAR REVIEW

The Magic Three

he top three best-selling BMWs to WA-based medicos are the 330i, X3 and X5. In a similar vein to an (in)famous TV show, our Editor would like to know which is the better choice. Or is it more about certain specialist colleagues are more likely to choose in a particular way? Perhaps it would be worth naming the prospective Beemers? The X5 would be “Clarkson”, the X3 “May” and the 330i “Hammond”. I’m sure you get my drift.

To build the scenario further, I will be able to drive each of our three ladies over the course of a week and will need to piece together the winning traits and tricks. First the similarities: They are all BMWs, so build quality is outstanding on all three. There is the usual range of electronic wizardry to play with, they all have the same style of gear box. All are automatic, with four different driving modes – comfort, sport, adaptive and eco-pro (whatever that is!) They also all have flappy paddles attached to the steering wheel to allow the driver to select a more manual mode to get better connected to the driving experience. But, with so many different choices on the setting of the automatic box (there are eight forward gears), is there really any need to have those flappy paddles at all?

52 | NOVEMBER 2019

I am sure that BMW will point out how they want to reinforce that driving experience, to those would-be rally car drivers. Those who want to be more in touch with ‘driving’ the car. Back-paddling Having played with the paddles, and tried each of the different settings, personally I don’t think the paddles add enough to the driving experience. Once engaged with one, I soon switched back to the sport mode on the auto box, leaving me to concentrate on when to break, where to hit that apex, how hard to accelerate out of that corner. Leave the changing gear to the oh so smooth gearbox. Having been a rally driver for nearly 20 years, I do enjoy changing gears for the sake of changing gears. There’s a very tactile connection with what the car is doing, but perhaps I’m showing my age here. If I wanted to have that gearbox connection, I’d choose a four, five or even six-manual box, with an H pattern on the floor! I wouldn’t be reaching for a flappy paddle. As mentioned, the electronic wizardry is similar in all three models. There’s excellent on-board navigation, a great sounding hi-fi (media, sorry) and driver assistance aids. True, the X5 and the 330i do sound a little more refined and are a little sharper and

smoother than the X3, but they are still all doing the same job. It’s very neat how the heads-up display will also show you the navigation images. I have been a little cynical of all things “heads-up display”, but I have to admit to being converted! It is so handy to be able to see you speed and the speed limit, just hovering in mid-air above the bonnet. Having a reminder of how much your fine is going to be, if you get caught, would also be a nice add on. One little idiosyncrasy that I had not come across before – if you wear polarised sunglasses, the heads-up display vanishes! Polarising vision You have to twist your head to get a brief glimpse of it. Apparently, it is a ‘thing’ with heads-up displays and not just a BMW trait, but I would have thought those clever boffins would have thought of a way around it. Ok, so you’ve connected your phone, added the proposed destination to the navigation mode and have adjusted the seats, mirrors … now’s the time to drive. The 330i is a classic sedan, and the X3 and X5 are SUVs (Sports Utility Vehicles). The 330i (Hammond’s) is a very competent normal-sized car with oodles of oomph and performance, particularly in sport mode.

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Three Beemers, one man and an open road. Dr Mike Civil was asked to road test the medical profession’s most preferred BMWs.

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The X5 (Clarkson’s) is the big luxurious SUV and the X3 (May’s) its slightly smaller and slightly less luxurious sibling. The 330i would win any performance contest between the three, but a race-track would be the only way to test that, rather than a double demerit long weekend. When walking towards the X5 you just get the impression that this is one big car! Think Prado – a big car. But when you get in, did it just shrink?

continued from Page 54

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NOVEMBER 2019 | 53

CAR REVIEW BACK TO CONTENTS

continued from Page 53

The Magic Three It doesn’t seem possible and is certainly not a feeling I get when jumping in my Prado. The X5, well it’s smaller, I swear! It nails the luxury button and is a real pleasure to drive. I couldn’t believe how nimble it feels, how sporty and how non-big car. Even only having been in the X5 for a few minutes, I felt confident in where I was placing the car and happy to dive into small gaps that I just would not believe from my BMW car yard perception. Then the next surprise, it’s a diesel. If it had not got diesel written next to the gauge, and at other opportunities, I would have never believed it. Diesel magic It doesn’t sound like a diesel, smell like a diesel and certainly doesn’t go like one. This is much nearer to a Le Mans 24-hour race car diesel than my lowly 4WD “go over that field”, type diesel. Very impressed and that is a first. I can’t recall the last time that I would have been so well misled! The X3, while being still very well accomplished, just doesn’t have quite the same level of smoothness and ‘go’ about it. Still a great little (well smaller than an X5) car, but just can’t match its X5 sibling. Of course, there is the small matter of the extra $25,000 that you would need to fork out for the X5 over the X3. The X5 is around the $110,000 mark and the X3 about $84,000. You do get a lot for your extra hard earned. If my lady wife was not looking, I would just go for it, it’s only money, right? The i330 is the ‘cheapy’ of the bunch at $70,000ish. I have one small criticism of the X5. The gear knob looks as if it has come out the top of a crystal-cut glass decanter. It seemed so wrong that I just had to ask our friendly sales rep, why? Apparently, consumer surveys have come out strongly in favour of its but, it was just far too ‘bling’ for me!

So, Clarkson would have loved the ‘power’ of the X5. It’s surefootedness and deceptive nature of the small-large car. May would have preferred the option of having ‘nearly’ all that the X5 has to offer, in the X3, but admittedly at a slightly lower level, and the option of being able to buy a boat to tow behind it! Hammond would have plumped for the 330i, more of a driver’s car, performance to match, electronic wizardry nearly on par with the X5 and again able to spend time counting the spare dollars. Fit for purpose But, perhaps they are matched to particular medical specialities. I can imagine an orthopaedic surgeon running around in the X5, his anaesthetist rocking up in the 330i and perhaps the occasional GP assisting in

NEw SS E aDDRaME N & iously

Prevylands “Ma unding” po C om

surgery, having the X3 – sensible, practical and still a great little car. I must be slowly coming around the idea of what SUVs are all about. My dearly beloved Prado does just seem a bit agricultural in comparison. For me…. if (or when) I am in the market, it would be for a desire to have that little extra luxury, that understated performance, but still be able to tow the rally car if the need arose. It would have to be the X5, but can someone please distract my wife, while I write the cheque… ED The cars for this review were courtesy of Victoria Park BMW dealership, Auto Classic.

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WINE REVIEW

Millbrook Gems Millbrook have had a stellar year with multiple medals and trophies for their wines both within Western Australia and interstate. Winemakers Damian Hutton and Adair Davies have been making some impressive wines from both established as well as some lesser known alternative varieties. Millbrook has never been afraid to adopt emerging varieties such as Viognier as well as Tempranillo and more recently Fiano. Millbrook has been one of my favourites labels and has delivered some impressive European-styled wines. Why buy imported wines when you can travel an hour from Perth and enjoy such rich pickings?

By Dr Martin Buck

2019 Millbrook Fiano Fiano is an Italian variety from southern Italy and Sicily where it was once known as Apianum â&#x20AC;&#x201C; so named because of the large number of bees attracted to the flowers. The Millbrook 2019 Fiano has aromas of lemon, pears and floral hints. An attractive textural palate with lime and honeysuckle flavours. Itâ&#x20AC;&#x2122;s crisp and finishes well. Definitely a wine to drink young while fresh and would be perfect for summer.

Winemaker Damian Hutton

REVIEWER'S

2018 Millbrook Tempranillo

2018 Millbrook Single Vineyard Shiraz My final stop on this European tour is the Rhone Valley where this single vineyard shiraz from the Frankland River is a benchmark cool climate Shiraz. Hues of deep purple and cherry colours are in the glass with aromas of spice, plums and berries. The palate is dense, full of smouldering berries, some earthiness and soft tannins. This is a great example of 30-year-old single vineyard Great Southern Shiraz with plenty of ageing potential.

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Tempranillo is a favourite of mine and Millbrook have been able to source some impressive fruit from the Geographe region. The 2018 Millbrook Tempranillo is a special wine with all the finesse of Rioja but with Western Australian terroir. An amazing deep purple hue in the glass with smoky oak, plum and berry aromas. The palate is jam-filled with intense flavours reminding me of some of the best Rioja wines, a great balance of fruit and subtle French oak tannins. Certainly, this is an amazing wine given its youth and will age well for the next five years. This is a wine for those red wine lovers who have not yet been converted to this Spanish variety.

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Research Week Members of WA’s research community celebrated the opening of St John of God Subiaco Hospital’s annual Research Week. This year’s theme was ‘Putting Patients First’. Researchers from the various fields of study including breast cancer, gynaecological oncology, colorectal oncology, anaesthesia and pain, emergency medicine and neurosurgery were out in force. The hospital CEO Prof Shirley Bowen said research enabled engagement with new technologies, treatments and practices. 1 CIC Cancer Project team: Lesley Millar, Subiaco CEO Prof Shirley Bowen, Prof Christobel Saunders and Niloufer Johansen

2 Gorette De Jesus, Prof Cameron Platell, Dr Eva Denholm 3 Researchers Tracey Lee-Pullen and Dr Melanie McCoy 4 Janet Ferrier, Prof Steve Webb and Dr Ed Litton 5 Dino Cercarelli, CEO SJG Foundation Bianca Pietralla, Meg Croucher and Prof Eli Gabbay 6 Researchers Jen Fraser and Alannah Cooper

SJG Caregiver Ball St John of God Subiaco Hospital recently held its annual ball to thank caregivers for the nurturing they provide to patients and visitors. More than 460 caregivers threw themselves into the theme of ‘Winter Wonderland’ enjoying the evening’s live entertainment and music.

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SOCIAL PULSE Mandurah centre opens

GenesisCare officially opened its new $10m Mandurah Centre for Oncology, Cardiology, Sleep and Respiratory with Mandurah Mayor Rhys Williams doing the honours. It's the first integrated cancer centre in the Peel region. Both public and private patients will be able to access the service, with a large portion of the cost of treatment covered by Medicare rebates. 1 Mayor Rhys Williams and community members learn about the centreâ&#x20AC;&#x2122;s new linear accelerator from senior medical physicist Peter Rampant. 2 Melanie Marsh, Cancer Council WA, left; Dr Eugene Leong, GenesisCare Radiation Oncologist & Director of Clinical Services; Mr Brendon Ball, GM GenesisCare Cardiology, Sleep & Respiratory WA; Mayor Rhys Williams, Mr Michael Davis, GM GenesisCare Oncology WA; Peel elder Mr Harry Nannup, Mandurah centre leader Ms Alison Murray, Centre Leader, and Mr Franklyn Nannup, who performed the Welcome to Country. 3 Franklyn Nannup, Mayor Rhys Williams, Alison Murray and Harry Nannup admire some of the local artwork in the centre.

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Enter Medical Forum's competitions! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link. Movie: Mrs Lowry & Son Beloved British artist L.S. Lowry (Timothy Spall) lived all his life with his overbearing mother Elizabeth (Vanessa Redgrave). Bed-ridden and bitter, Elizabeth actively tried to dissuade her bachelor son from pursuing his artistic ambitions, while never failing to voice her opinion at what a disappointment he was to her. In cinemas, November 28

Choral: Handel’s Messiah Perth Symphonic Chorus’s annual Messiah will feature both exciting young voices and the resonance of experience. Soprano Bonnie de la Hunty returns from her Masters studies at the Royal Academy of Music in London to take a soloist’s chair alongside the well-loved WA mezzo-soprano Fiona Campbell and bass James Clayton. The PSC Messiah will again feature the voices of interested community members who join the chorus at rehearsals and help bring to life this giant of the choral repertoire. PSC director Margaret Pride will lead the chorus, the people’s choir and the Perth Baroque Orchestra (with concertmaster Paul Wright) for this onenight-only performance. Messiah has been stirring hearts and voices for nearly 300 years with rousing choruses such as the iconic Hallelujah, and arias to make your spirits soar – The Trumpet Shall Sound and I Know that My Redeemer Liveth. Perth Concert Hall, December 21, 7.30pm MEDICAL FORUM

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September Winners

Deadly Dust

When strait-laced fire superintendent Jake Carson (John Cena) and his elite team of firefighters come to the rescue of three siblings in the path of an encroaching wildfire, they quickly realise that no amount of training could prepare them for their most challenging job yet – babysitters. Unable to locate the children’s parents, the firefighters discover that kids – much like fires – are wild and unpredictable. In cinemas, January 1

Movie: Like a Boss Best friends Mia and Mel (Tiffany Haddish and Rose Byrne) run their own cosmetics company they’ve built from the ground up. Unfortunately, they’re in over their heads financially, and the prospect of a big buyout offer from a notorious titan of the cosmetics industry Claire Luna (Salma Hayek) proves too tempting to pass up, putting Mel and Mia’s lifelong friendship in jeopardy. In cinemas, January 23

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

Movie: Zombieland – Dr Melanie Chen, Dr Patrick Lai, Dr Julia Charkey-Papp

Movie: Playing with Fire

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We’ve specialised in your profession since 1993. In those 25 years, we’ve learned a great deal about how you work and what you need. This experience has proved invaluable in building flexible solutions to help achieve your goals.

Movie: Jumanji: The Next Level

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Movie: Ride Like A Girl – Dr Catherine Bacon, Dr Elena Monaco, Dr Renuka Alakeson

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September 2019 www.mforum.com.au

Movie: Gemini Man – Dr Susanne Sperber, Dr Aleksandra Vujovic, Dr Luca Crostella Dr Lynette Spooner Theatre: Fully Sikh – E/Prof Max Kamien Music: Durufle’s Requiem – Dr Katherine Ng

In cinemas, December 26

Opera: Macbeth – Dr David Bucens

Wine winner

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The gang is back but the game has changed. Dwayne Johnson and Jack Black lead the team back to Jumanji to rescue one of their own but they find that nothing is as they expected. The players will have to brave parts unknown, from the arid deserts to the snowy mountains, in order to escape the world’s most dangerous game.

Psychiatrist Dr Helen Slattery has won the Schild Estate Doctors Dozen. With their old vines, the Schild Estate team make them wines full of body and flavour.

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