Medical Forum 09/14 Public Edition by Medical Forum WA

Health Rescue t Future for Private Hospital Insurance? t Hospital CEOs Stanford & Mott t Without Antibiotics t COPD; Asthma; Sleep; OM; Mesothelioma; Cough

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Contents

September 2014 16

FEATURES

LIFESTYLE

13 16 19 31

Private Health Insurance: A Case Study Dr Michael Stanford: Balancing Act Hollywood Expands Rethinking Tertiary Respiratory Services World Without Antibiotics

45 47 48 49

NEWS & VIEWS 3 4

4 10 20 22 24 30 32 41

Editorial: Specialist Fees Letters: Midwives and CS Rates – Dr Sara Bayes Consumer VBAC Support – Ms Asha Barber Vaccination Concerns – Ms Sarah Parker Curious Conversations – Prof Steve Stick Have You Heard? COPD Community Management Lung Blueprint Needs Action What are e-Cigarettes? Indigenous Quit Support Latest Medical Gadgetry Beneath the Drapes

MAJOR SPONSORS medicalforum

Goldfields Arts and Medicine Cape Grace Wines Dr Louis Papaelias Travel: New Norcia Camino Dr Donna Mak Pianist Stephen Hough Competitions Funny SIde

EVENTS 46 48

GPCE Perth Doctors Drum

iss Don’t M rum ’s D Doctor 8 Page 4

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

INDEPENDENT ADVISORY PANEL for Medical Forum Michele Kosky AM Consumer Advocate Mike Ledger Orthopaedic Surgeon Stephan Millett Ethicist Kenji So Gastroenterologist Alistair Vickery General Practitioner: Academic Olga Ward General Practitioner: Procedural

ISSN: 1837–2783

John Alvarez Cardiothoracic Surgeon Peter Bray Vascular Surgeon Joe Cardaci Nuclear & General Medicine Chris Etherton-Beer Geriatrician & Clinical Pharmacologist Philip Green General Practitioner: Rural Mark Hands Cardiologist

ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510)

Clinical Contributors

MEDICAL FORUM MAGAZINE 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

We ask Clinical Contributors to provide a phone number should a doctor wish to clarify a management issue.

EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

SHARON 30 MS LAGAN

Journalist Mr Peter McClelland journalist@mforum.com.au

Spirometry – Quality Measurement

MARK 34 DR EVERARD Childhood Asthma

MICHAEL 35 DR WERTHEIM Allergic Eye Disease

MICHAEL 37 DR PRICHARD Respiratory Pitfalls

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reﬂect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemniﬁes the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

DR SINA KEIHANI DR BILL MUSK 39 Assessing 40 Update: Sleep Apnoea

Mesothelioma

DR GEORGE SIM 41 Otitis Media and Antibiotics

NOLAN 42 DR MCDONNELL AFE Demands Respect

Guest Columnists DR GEOFF HEE 43 Throat Clearing

DR DANIEL FATOVICH Skepticism is Good Medicine

SUZANNE 27 DR ROBINSON Cut with Care

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN Thinking Hats

MORAG 27 MS SMITH Medicolegal Q&A: Test Reports

DR MIKE CIVIL 28 e-Health and General Practice

PENNY 29 DR WILSON Twitter – Not Just for Celebrities

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Editorial By Dr Rob McEvoy Medical Editor

Health insurers, to maintain customer services, must cut costs or perish. With few options and little time, they sense that health consumers are questioning the value of private health insurance, due to rising premiums and gap payments. Specialists providing services in private hospitals generate considerable cost. The elephant in the room is money. In this monthâ&#x20AC;&#x2122;s magazine we tested the waters as a â&#x20AC;&#x2DC;virtual consumerâ&#x20AC;&#x2122; (see P13). No wonder consumers are pulling their hair out. No wonder GPs are uncertain about how to modify referral patterns. It is â&#x20AC;&#x2DC;once bitten, twice shyâ&#x20AC;&#x2122; for health consumers (and even for those working in the industry). While some consumers hold on to the notion of medicine as a vocation, most are simply searching for competence and service at a fair price. Private hospitals are a good illustration of how difficult this is. Not even insurers can explain why specialist fees vary 400% for the same procedure in the same hospital. Consumers face uncertain gap payouts despite â&#x20AC;&#x153;top hospital coverâ&#x20AC;?. Insurer payouts for private hospital work are relatively lavish compared to Medicare rebates but are hidden from consumers by direct billing between hospitals and insurers or clinicians and insurers if they are â&#x20AC;&#x2DC;no-gapâ&#x20AC;&#x2122; or â&#x20AC;&#x2DC;known-gapâ&#x20AC;&#x2122; providers. Many private specialists are aware of the financial pain to consumers, try and accommodate them, and even though they see themselves as clinicians not business people, are willing to make prices known. These are price-sensitive times. GPs have been under cost pressures for years, without private insurers to assist them. Private hospitals wish to attract those specialists who are most cost-effective for them (those with higher turnover skills in anaesthetics, surgical procedures and obstetrics) and for their insured consumers (those specialists who provide no-gap services). Government subsidises private sector health care in two ways â&#x20AC;&#x201C; Medicare payments for private hospital services and the 30% consumer rebate for private health insurance (means tested of late). One essential argument to maintain the subsidies (now 35cents in the dollar) is the relief it provides the overburdened public system (92 cents in the dollar). However, the government has no control over spending in the private sector and medicalforum

Private Insurers are Crunching the Numbers if consumers feel this is too much or at the expense of funding public services, politicians will sit up and take heed.

.C BOE B GVSUIFS BT ,OPXO (BQ .C BOE IBT BHSFFNFOUT XJUI private hospitals.

Specialists we spoke to in private hospital practice regarded the AMA Schedule of fees, viewed as a benchmark of the professionâ&#x20AC;&#x2122;s sentiment, as asking too much of health consumers. Others do not, often benchmarking against the AMA rebate for their most common procedure.

t *O QVCMJD IPTQJUBMT VOEFS UIF "." negotiated Industrial Agreement, full-time medical practitioners can forgo any income from limited private practice, in return for an additional $75,000-$101,000 each year, depending on whether you are a GP or consultant.

Private Hospitals

Direct billing of insurer Case Mix

Provide best equipment Consulting rooms Hospital staffing

Physio OT Pharmacy Dietitian

Health Consumer Specialists

Teaching Research

Health Funds

No Gap products AMA scheduled fees

? GPs

Q ED: More on this topic on P13 and P27.

Doctors will increasingly be asked their opinions on some colleaguesâ&#x20AC;&#x2122; behaviour, which will not be easy. Here are some facts: t Ä&#x2021;F "#4 SFQPSU TBZT PG people aged 15 or more have private health insurance, almost all with both hospital and extras cover. Those in poor health, living in rural areas, or with higher levels of socioeconomic disadvantage were less likely to insure. t PG QFPQMF BHFE PS NPSF TFF B medical specialist (private or public) per year â&#x20AC;&#x201C; 38.7% 2-3 times and 28% four or more times. Those with a long-term health condition are twice as likely to visit but 8.3% delay that visit due to cost (compared to 5% for GPs, and 18% for dentists). t )#' IBT PG UIF 8" NBSLFU (Medibank 20.8%), returns a 13.1% profit on total revenue (Mb 4.7%), changes 1.7% of members each year (Mb 1%), covers 94.4% of hospital charges in WA (Mb 91.4%), provides 82% of medical services as No Gap in WA

t Ä&#x2021;F SFDFOU UI "OOVBM )FBMUI *OTVSBODF Summit focused on â&#x20AC;&#x153;preventative health to reduce costs and focus on chronic disease managementâ&#x20AC;?. Health insurers largely pay out on downstream interventions by specialists in private hospitals, so they realise upstream investment in GPs has to be cost-effective, overall. t Ä&#x2021;F OVNCFS PG EPDUPST HSBEVBUJOH IBT doubled but those choosing General Practice has dropped (45% to 38%; 2011). There are various reasons for this; one is that specialists JO "VTUSBMJB FBSO NPSF UIBO (1T GPS UIF same hours worked. As we went to press there was a Senate Committee on out-of-pocket costs in the health sector and the RACS president went public decrying extortionate surgeon fees as exploitative and unethical, and a breach of the Collegeâ&#x20AC;&#x2122;s Code of Conduct. Improved disclosure of fees was one answer. O

Letters to the Editor

Midwives respond to high CS rates Dear Editor, In response to the article Caesarean Rates in WA [August edition], the caesarean section (CS) rate in WA is the third highest in the country. In the recently released WA perinatal statistics report (Western Australiaâ&#x20AC;&#x2122;s Mothers and Babies, 2011, Hutchinson & Joyce, 2014), public maternity servicesâ&#x20AC;&#x2122; CS rates (excluding those of the 4UBUF UFSUJBSZ NBUFSOJUZ TFSWJDF ,JOH Edward Memorial Hospital) average out at 25% across all-risk women while the private TFDUPS SFQPSUT GJHVSFT PG CFUXFFO BOE 57% for a largely well, healthy clientele. The scientific evidence against non-medically essential CS is now overwhelming. The care context itself, then, seems to largely explain the CS rate. Among other factors in private sector health care (such as the extremely high cost to private providers of both indemnity insurance premiums and service visiting rights) is the way in which for-profit maternity care is conducted. In this system, consultant obstetricians working in a single operator business model typically take on a caseload of 40 or more women per month each. Clearly, for an obstetrician to be able to manage a caseload of that size it is not possible for all of the women they manage to labour and give birth spontaneously; high rates of intervention, including CS, therefore become necessary to control the workload. Encouragingly, a way of rebalancing the CS rate is at hand: as Dr Janet Hornbuckle

noted, [August edition], the research examining midwifery-led maternity care repeatedly associates it with a range of improved maternal and neonatal outcomes, including a much lower caesarean section rate than occurs in medically-led systems. It is also evident that this model, when medical referral and collaboration are available for women who need it, also confers no risk to mothers or babies. In contrast to the private obstetric approach, midwives working in this model each take a caseload of no more than four women per month. This provides for women to be supported to work towards a birth mode that is best for them as the individual who must live with the physical, psychological and emotional legacy of that choice and experience for the rest of their lives. Midwifery models of care are increasing exponentially in WA and across Australia, and we look forward to the day when our CS rates are reduced as a result. References on request Dr Sara Bayes, on behalf of the Executive Committee, Australian College of Midwives, WA Branch Inc

Consumer group urges VBAC support Dear Editor, Despite the view commonly expressed that women are â&#x20AC;&#x2DC;askingâ&#x20AC;&#x2122; for caesareans out of convenience in defence of the current caesarean rate, evidence points towards lack of choice for women, especially those birthing in the Private Sector and a lack of

genuine support for VBAC (Vaginal Birth after Caesarean) as the main drivers of the current caesarean rate in WA. Birthrites, a consumer group which supports women after a caesarean birth, believes that women are â&#x20AC;&#x2DC;groomedâ&#x20AC;&#x2122; for a caesarean from early on in pregnancy. The following passage from a birth story is a commonly raised at Birthrites support meetings: â&#x20AC;&#x153;My first few appointments with the obstetrician were fine â&#x20AC;&#x201C; quick check-ups. All was well and I was feeling good. As the birth came closer it was time to discuss birth plans. I was a little taken back to be asked if I would like an elective caesarean as I had thought that caesareans were for emergencies. I was also asked if I would like to be induced a week or so early.â&#x20AC;? Birthrites agrees with the comment by a GP in your e-Poll [August issue] who stated: â&#x20AC;&#x2DC;The caesarean rate in the private sector is inappropriately high, and in conducting informed consent of patients regarding elective caesarean, inadequate information about the risks is commonly givenâ&#x20AC;&#x2122;. Part of the increase could be the increasing numbers of women (most of whom are low risk) who obstetricians see, with numbers SFQPSUFE UP CF VQ UP XPNFO B NPOUI WA has the highest rate of caesarean with no labour, which is confirmed by the complaints we receive from women who believe they are being groomed for elective caesareans even before their â&#x20AC;&#x2DC;due dateâ&#x20AC;&#x2122; approaches. Birthrites has been working towards having current information available to every birthing woman at the first point of GP contact that explains all of the birthing choices available in WA, their intervention rates and their benefits. Continued on P6

Curious Conversations

Take a Deep Breath A gold medal run down a snow-covered mountain is on the wish list for PMH Head of Respiratory Medicine, Dr Steve Stick. My strongest memory of childhood isâ&#x20AC;Ś my grandfather discussing the British Empire. Bert grew up in a poor, working-class area and was a staunch unionist. I remember him describing a day when the Royal Family visited the East End of London. â&#x20AC;&#x153;There they were in all their finery, riding in fancy carriages, and there we were waving our Union Jacks with the arse hanging out of our shorts.â&#x20AC;?

One of my most satisfying moments in medicine wasâ&#x20AC;Ś going to bed after 72 hours straight looking after a nursery full of very premature infants. My last meal would beâ&#x20AC;Śa large slab of rich fruit cake without the need for insulin! ,OPXJOH UIJT XPVME CF NZ MBTU NFBM B DIVOL of my favourite food minus medication would be a wonderful and defiant gesture.

If I could win one event at the next Winter Olympicsâ&#x20AC;Śit would be the Menâ&#x20AC;&#x2122;s Downhill JO 1ZFPOHDIBOH 4PVUI ,PSFB JO 5P XJO UIF HPME NFEBM BU UIF BHF PG XPVME have to be record, particularly factoring in my conspicuous lack of talent. The first thing Iâ&#x20AC;&#x2122;ll do when I retire isâ&#x20AC;Ścheck my emails. O medicalforum

Letters to the Editor Continued from P4 We invite any doctors who is able to provide information, support or advice to our campaign, or would like information posters or pamphlets for their office to contact birthrites at convenor@birthrites. org. Ms Asha Barber, Birthrites Convenor

Parents wary on vaccination Dear Editor, Early this year the Immunisation Alliance of WA ran the â&#x20AC;&#x153;I Immuniseâ&#x20AC;? campaign in the Greater Fremantle area, targeting alternative-lifestyle parents to promote a pro-immunisation sentiment. We are still working on the results of an associated evaluation of the campaign, but a few things are starting to become apparent. Over half of all respondents had concerns BCPVU JNNVOJTBUJPO "MNPTU PG UIFTF respondents did not believe vaccines to be safe or effective. Regardless of their EPVCUT PG SFTQPOEFOUT DPOUJOVFE with vaccinating their children. In order to combat these doubts, respondents access various sources of information, but the trust in each source is different. Almost 50% of respondents told us they use the Internet to get more information on vaccination, but only 15% of people trusted the information they found. Many people found the pro-vaccination sites too scientific and data driven, and then found the antivaccination sites too emotive and with little factual basis. In both cases, the respondents believed the sites to be biased towards their specific agendas. Family and friends are consulted by 70% of

respondents, and 90% of people trust these sources. This can be worrying in light of the variable knowledge and education, but does also present opportunities for similar campaigns, with potential target groups other than parents of young children. This underlines the communal nature of vaccination, highlighting how personal networks are a crucial aspect of support and education. The Alliance is about to launch an educational book targeted at four-year-old children. We are delighted to offer Beat The Bugs for free. Medical centres can request a kit which will include posters, book marks, and stickers for children once they have had a vaccination. If you would like to know more, or order some for your centre, visit www.immunisationalliance.org.au. Ms Sarah Parker, Project Officer, Immunisation Alliance of WA

Star

Joke

From the Editor Readers have asked about Major Sponsorsâ&#x20AC;Ś Major Sponsors of Medical Forum magazine work within the WA medical community. Each feels the need to offer something extra to the medical profession. We value their distinctive contribution to this reputable industry publication. Medical Forum was founded over 20 years ago by two people working within the profession, and the improved quality and readership of the publication since then speaks volumes for all involved. Independence, dedicated WA focus, and ethical behaviour are the cornerstones of the publicationâ&#x20AC;&#x2122;s success. Major sponsorships are offered on that basis.

Whoâ&#x20AC;&#x2122;s Responsible? Three engineering students were gathered together discussing the possible designers of the human body. One said, â&#x20AC;&#x153;It was a mechanical engineer. Just look at all the joints.â&#x20AC;? Another said, â&#x20AC;&#x153;No, it was an electrical engineer. The nervous systems has many thousands of electrical connections.â&#x20AC;? The last said, â&#x20AC;&#x153;Actually it was a civil engineer. Who else would run a toxic waste pipeline through a recreational area?â&#x20AC;?

We welcome your letters. Please keep them short. Email to editor@mforum.com.au (include full address and phone number) by the 10th of each month. You can also leave a message at www.medicalhub.com.au. Letters may be edited for legal issues, space or clarity.

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Incisions

Skepticism is Good Medicine It is important the profession questions research and understands how bias inﬂuences conventional wisdom, says Prof Daniel Fatovich. Why most published research findings are false, is the most downloaded paper in the history of PLoS Medicine (see www. plosmedicine.org/). Its author, Prof John Ioannidis, is a doctor, epidemiologist and maths prodigy, and one of the world’s foremost experts on the credibility of medical research. He has proven mathematically that most published research findings are false. Claimed research findings are likely to simply represent accurate measure of the prevailing bias; i.e. researchers find results they want to find and conveniently ignore what they don’t want to see. In simple terms: believing is seeing. Ioannidis explicitly states: “what matters is the totality of the evidence.” Some consider that meta-analysis is the pinnacle of medical evidence. However, at the 2013 7th International Conference on Peer Review and Biomedical Publication, Ioannidis reported the results of his team’s meta-analysis of 85,000 meta-analyses. This showed that only one had a big effect that was highly significant. Ioannidis concludes that “we have to learn to live with small effects”. This highlights the fragility of the data used to construct our medical knowledge. Ioannidis illustrated this theme with another study done by his team. They randomly selected 50 ingredients from a cookbook and then searched PubMed to examine which ingredients were linked to a higher or lower

risk of cancer. The answer was 40. Yet these individual results would have been widely promoted in the media. Richard Smith, a former editor of the BMJ writes that “the public may be smarter than the scientists in discounting and ignoring these reports”. The reason why so many studies are wrong is because of bias and random error. This, therefore, highlights the importance of replication of study results to ensure that the effects are genuine. And even when replication confirms a study result, the true magnitude is typically smaller than originally claimed. Medical reversal is where a new superior trial contradicts current clinical practice.1 Many medical reversals involve a clinical practice that is based upon our incomplete or flawed understanding of pathophysiology. Hence, it is self-evident that doctors have been using medications or procedures in vain and causing harm. Yet these have been advocated in clinical guidelines.2,3 Studies now indicate that about half of established practices are reversed. But reversals rarely seem to garner the same fanfare as a positive study. So we need to constantly challenge our medical thinking. Yet when some brave clinicians try to do this, the research is frequently labeled as unethical. There are many examples where doctors refused to enrol patients in studies because they considered it unethical. When the study

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is completed, it reaches the exact opposite conclusion to what was expected and practised. These medical reversals remind us that replication of results by independent researchers is an essential step in progressing our knowledge, together with healthy debate and elimination of bias. A single study isn’t enough. Foy and Filippone argue that intervention bias (the doctor’s bias to intervene with drugs, tests or procedures, when not intervening would be a reasonable alternative) has serious consequences: “to guard against it, we should always remain skeptical, insist on rigorous experimentation and reporting of trials with hard endpoints, and be unafraid to protest the widespread utilization of interventions that do not pass this test.”4 References: 1. Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA 2012; 307(1): 37-8. 2. Fatovich DM. Medical reversal: What are you doing wrong for your patient today? Emerg Med Australas 2013; 25(1): 1-3. 3. Lenzer J. Why we can’t trust clinical guidelines. BMJ 2013; 346: f3830. 4. Foy AJ, Filippone EJ. The case for intervention bias in the practice of medicine. Yale J Biol Med 2013; 86(2): 27180. O

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Have You Heard?

O Barriers to self-management Asthma management is still the hot potato it was back in 2011 when we looked at the role of community pharmacies and the introduction of the HDWA Asthma Action Plan card. Research back then showed that pharmacies were not referring patients appropriately and patients and GPs were not using the cards distributed by pharmacies. Fast forward and UWA Pharmacy PhD candidate Ms ,JN 8BULJOT JT NJEXBZ UISPVHI FWBMVBUJOH those programs and asthma management in community pharmacy to find out what can be done better. She told Medical Forum her focus groups with asthma patients, GPs, practice nurses, pharmacists, pharmacy assistants and asthma educators were an eye-opener. There were more barriers to leap than the Grand National. The development of diagnostic tools BOE HVJEFMJOFT JT OPU FOPVHI "T ,JN TBZT there is more to be done than â&#x20AC;&#x2DC;hereâ&#x20AC;&#x2122;s the tool and guidelines, get on with it. We need to look more specifically at the barriers to best practice.â&#x20AC;&#x2122; A vital key is collaboration.

O Asthma still a killer The Australian Institute of Health and Welfareâ&#x20AC;&#x2122;s (AIHW) report last month showed the death rate from asthma had fallen by almost 70%, but it was still relatively high on an international scale â&#x20AC;&#x201C; there were 378 deaths in 2011. The same year, COPD was the underlying cause PG EFBUIT PG QFPQMF BHFE BOE PWFS "T ,JN 8BULJOT SFTFBSDI JT Ä&#x2022;OEJOH TFF BCPWF asthma sufferers fail to take their condition seriously and often wait too long to seek treatment. NPS MedicineWise, spruiking its e-Audit to GPs, claims patients with a current written asthma action plan have around 40% fewer hospital admissions. It adds, however, that only 18% of those diagnosed with asthma have an action plan written by a doctor. Combine that with the report in the Australian Asthma Handbook 2014, which reckons that up to 90% of Australians with asthma donâ&#x20AC;&#x2122;t use their inhaler correctly, the picture is not pretty. O COPD rehab services This month we are looking at COPD rehab from the perspective of both health professionals and consumers [see P20-21]. Hospital run clinics are much like community programs but may have more equipment and see more patients at cardiovascular risk (pulmonary H/T, cardiac problems, and IPF). A move to activity based funding (ABF) may exclude referrals from GPs or private respiratory physician. Community Programs are run by Community Physiotherapy Services (CPS) for less severe/complex patients. They are located at Healthridge, Beechboro, Leederville, North Lake and Rockingham. However, ongoing funding is uncertain. Some were to be run by Medicare Locals but their future is uncertain. Hospital-based programs are at SCGH, Swan Districts Hospital, RPH, Bentley, Armadale, Fremantle and 3PDLJOHIBN &BTZ #SFBUIFST O Where next for MA Code at ACCC?

The deadline for submissions on whether the ACCC should authorise the new edition of MAâ&#x20AC;&#x2122;s Code of Conduct has closed and support has been anything but overwhelming. There were 47 submissions, 40 against acceptance of v18 of the Code because: not enough transparency; too slow to move; no tangible public benefit in changes; no single source tracking that amalgamated sponsorship for particular providers; no disclosure of sponsorship of research and clinical trials; not disclosing sponsored individuals was unethical; MA ignored work of its own Transparency Working Group; not happy with use of starter packs; health organisations not

part of disclosure; those non-compliant with disclosure can still receive benefit; erosion of professional integrity; should include nonprescription items; and sponsorships below a threshold are not accumulative when it comes to declaration. Submissions came from 28 individuals as well as Choice, RANZCP, Consumers Health Forum, Pharmacy Guild, Pharmaceutical Society, Society of Hospital Pharmacists, Medicines Australia, Cancer Voices Australia, SA Medicines Advisory Committee and RACGP. A notable â&#x20AC;&#x2DC;yesâ&#x20AC;&#x2122; tick for the proposed Code came from the federal AMA, which said there was no evidence that disclosures helped health consumers; and most practitioners would comply because when companies asked doctors for â&#x20AC;&#x153;usual disclosureâ&#x20AC;? this would scare them off. Also amongst the seven submissions endorsing the code in its DVSSFOU GPSN XFSF (4, "VTUSBMJBO 1SBDUJDF Nurses Association, Pfizer, and MSD.

O Birth defects sober A close look at the WA Register of Developmental Anomalies since 1980 is sobering. For every 1000 children born in WA, about 45 will have birth defects (more males; multiple pregnancies) â&#x20AC;&#x201C; among them, about 18 will have musculoskeletal (e.g. hip dysplasia) problems; 10 urogenital (e.g. hypospadias), 1 neural tube (e.g. hydrocephalus), and 1 Down syndrome. Down syndrome rates have slowly increased since 1980 and for every child born with this chromosomal abnormality today, about four pregnancies are terminated. Amongst stillbirths and neonatal deaths, birth defects affect 8.1% and 27.7%, respectively, while fetal anomaly were the reason for UFSNJOBUJOH PG QSFHOBODJFT "CPVU B quarter of cases have more than one defect. On top of this, cerebral palsy birth prevalence rates are about 2.3 per 1000 live births, with most children having mild motor impairment and just under half having intellectual disability. O Funding cracks PCWA It was born from the ashes of the WA GP Network and it had hoped to become a hub for the many organisations that constitute primary care. Primary Care WA had 37 groups involved and the membership included NGOs, Medicare Locals and consumer groups. However, in March, after 18 months of trying and failing to secure steady funding, the board decided to wind up PCWA, a process which chairman Dan Minchin says is almost complete. Any surplus funds, which he says will be minimal, will be distributed to â&#x20AC;&#x2DC;a like-minded organisationâ&#x20AC;&#x2122; in accordance with the PCWA constitution. O medicalforum

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medicalforum

Medical Marketplace

Private Hospital Cover – A Consumer View The health consumer is piggy in the middle when it comes to private health insurance and deregulated specialist fees. We follow one woman’s journey through the system. Private health insurance is undergoing a major shake-up. Everyone is in for a slice of the action. SJGHC and HBF are both big players in the WA marketplace, and they are also not-for-profits, which changes the shape of things. Pity, then the consumers, many of whom feel vulnerable to increasing premiums, who face uncertain refunds and growing gap payments. Something has to give. Here, we look at one health consumer’s trip through the system as an illustration of how things are.

two offer up quotes to specific MBS item numbers when told the person at the end of the phone is a doctor. Non-disclosure makes informed financial consent very difficult for the referring GP dealing with any patient facing out-of-pocket expenses. The three specialists work out of different private hospitals, depending on the day admitted, with different anaesthetists and pathology providers. None is registered with HBF to provide ‘no-gap’ services, with one withdrawing from that relationship in the past two years.

CASE REPORT

Pathology

A young woman with health insurance is told she requires a cone biopsy ASAP for precancerous changes, following a colposcopy and biopsy in the public system. She struggles to pay $410 a month family cover for “GapSaver” health insurance from HBF because she had experienced two previous episodes of private hospital care costing about $1000 each in gap payments, which had come as a surprise as she thought she was fully covered on top hospital cover. Her understanding is that

HBF simply puts aside the extra she pays under “GapSaver” (about $100 per month), in effect a saving plan, to pay any extra gap beyond insurance benefits. She noted that specialist consultation gaps largely disappear if care occurs while an ‘inpatient’ but fails to understand why there should be a difference.

The specialists Three specialists are recommended. Two are reticent to quote on exact inpatient costs until the patient is seen. Reluctantly,

Amongst the three pathology providers involved, two say they will not charge the patient a gap, and one of these has special arrangements with two private hospitals whereby private health funds are billed direct on behalf of the patient. The third says that under a special arrangement with HBF, the patient will pay a $40 gap per hospital stay, no matter the operation performed or the pathology tests performed. Other patients have their gap payments Continued on P14

Q Standford

smithcoffey

medicalforum

Feature

The St John of God Brand The health industry built around private hospitals is fascinating, and so is the community’s relationship with religious owners. As group CEO at St John of God Health Care (SJGHC), Dr Michael Stanford directly oversees the running of 14 hospitals, part of 75 not-forprofit Catholic hospitals that share information, do benchmarking on clinical matters and provide buying power. He finds better co-operation here than in either public or private sector hospitals, having worked in all three sectors. He has just signed another fiveyear contract and is busy positioning SJGHC as a top player in the industry. One reality now is that he has to keep specialist doctors happy, particularly surgeons, anaesthetists and obstetricians, to make it all profitable. Yet the community is told hospitals can be a drain on health resources and more of the insured ageing population are experiencing gap payments on specialist services. Is there a dilemma there? “We definitely want people who go into our hospitals to be well looked after so they don’t bounce back. Unless we, government, funds and doctors look at a way of having a more sustainable model it is all going to fall over – something that minimises the number of people who need hospital. It’s in everyone’s best interests to do that,” he said. A couple of health funds have been criticised for hooking up programs and GPs to reduce hospitalisations. Michael isn’t closed to that idea. “HBF would almost certainly like to know enough about its members to try and look after them so they don’t need hospital care. Until a member goes into hospital they don’t know if you have diabetes or are morbidly obese. I suspect that the PCEHR, and information sharing is in everyone’s best interests if we do it the right way.” The pressure is really on health funds to save or face a consumer backlash against rising premiums. “We are in negotiations with the health funds about not funding ‘dysquality’. Here’s an example, I think we will find health funds will not fund ‘never events’, things like wrong site surgery that should never happen. That will be incentive for us to fix quality things.” “Consumers will be more assertive too. Every time they go to their specialist they will have researched things online. They will be more demanding of what we provide them. We are sure that the equivalent of Trip Advisor will come in where doctors and hospitals, like it or not, will get reviews medicalforum

of their performance. Consumers will look more at what other consumers think, before they look at the spin hospitals or doctors put out. Technology will help them do that.” “Doctors attitudes and approach to how they provide services will also change. Prices will come under more scrutiny and they will have to be more publicly available. Health funds say about 50% of the total insured population in Australia earn under $50,000. For a lot of retired people that’s what they hang on to and we see a lot of that. It surprises me, the notion that it’s only the well-heeled who are health fund members.” “Premium rises are a big issue for health funds and if their finances fall over it is going to make it hard for doctors and hospitals, and that’s why it’s in their interests to work with funds to try and optimise things for all parties.” And so he is quick to defend what SJG hospitals do with their earnings, which does not include squirreling it away for the Church. “St John of God Healthcare is an incorporated association within WA. We are required to keep all our money within our Association and we have about $300m of bank borrowings – the redevelopment at Murdoch, we have just bought Mercy Mt Lawley Hospital, and are building Midland.” “We are deemed by the Commonwealth Government to be a charitable institution and keeping all the money within the health system is why the State and Commonwealth Governments give us the tick. They could change the ruling on that. We adhere to Church teaching and try to add a lot of community benefit, increasing our research budget this year to $4.6m, just over half at Subiaco; we will spend about $20m on social outreach; and we are lining up to do more on education of junior medical staff and others.” How whole-of-community benefit stacks up is important for any registered charity, particularly a religious one with declining congregations and a 25% endorsement at the latest Census. Michael says in WA SJGHC takes and trains nursing students from Murdoch, Curtin, Notre Dame and ECU, and no university has an exclusive agreement with them. “Unless the community sees us as worthy of being considered a charity, a really good corporate citizen that does extra stuff compared to a for-profit, we would lose community support. That’s a very

significant obligation for us. We think we have to get the community to trust us. They may not love us but over time they will respect us. At Midland if we don’t succeed then we don’t deserve to have the contract.” Satisfying their Catholic owners is also important, which is part reason why he and about 80 others have done the Graduate Certificate in Leadership and Catholic Culture. O

By Dr Rob McEvoy 13

Continued from P13

Private Hospital Cover â&#x20AC;&#x201C; A Consumer View capped at $450 ($300 for pensioners) if not covered by Medicare. All refuse to quote on the histopathology, even when a level of complexity is indicated by a particular MBS item number. In each case, the pathology provider gets a fixed percentage above the MBS from HBF.

in the public system, but freelanced privately on his â&#x20AC;&#x2DC;days off â&#x20AC;&#x2122;. This is common practice.

Hospital Both HBF and one private hospital confirm that day theatre costs are 100% covered by health insurance. The patient says she paid a gap to the hospital last time she was admitted on top hospital cover.

Anaesthetist A private anaesthetist group says the only way to find out about anaesthetic costs before surgery is to present the surgeonâ&#x20AC;&#x2122;s item number list to the anaesthetist, ask for a quote, and then return to the surgeon if you are unhappy with any out-of-pocket costs. It is up to the patient to then ask the surgeon to review their use of anaesthetist! One anaesthetist we tracked worked primarily in the public system, collected the salary increase in return for forgoing private work

Insurer Medicare pays any surgeon or hospital 75% of the scheduled fee, with private health funds picking up the rest, to varying degrees. All but HBF allow the surgeon to charge up to $500 directly from the patient and send the account for the balance to the private health fund. Where the surgeon and/or anaesthetist agree to charge the insurerâ&#x20AC;&#x2122;s benchmarked fees (usually set below the AMAâ&#x20AC;&#x2122;s schedule), they are registered with the

MBS Item

Medicare pays 75% Sched Fee

Initial Consult

104

Cone Biopsy

Hysteroscopy

Description

Anaesthetist

Pathology

HBF top-up pays

AMA Schedule Fee

72.75**

Nil

+405.85

+143.45

insurance fund as a â&#x20AC;&#x2DC;no-gapâ&#x20AC;&#x2122; provider. Where the provider agrees to become a â&#x20AC;&#x2DC;known gapâ&#x20AC;&#x2122; provider, they charge an agreed private gap that is never more than 10% above the benchmark fee, but if they stray above the agreed fee, the consumer will lose all but the 25% Medicare refund. The specialist can optin or opt-out of this case-by-case. Looking at the table (below) for this case, three things are particularly notable: 1) HBFâ&#x20AC;&#x2122;s top-up payment brings specialist payment very close to the AMA schedule fee, 2) Anaesthetists seem to be getting a 100300% top-up from the private health fund, and 3) Variations between these surgeonâ&#x20AC;&#x2122;s fees vary little when funds tell us 400% variations occur. O By Dr Rob McEvoy

Surgeon1 Charges

Surgeon2 Charges

Surgeon3 Charges

Minimum Gap Paid by insured patient

250.00

255.00

280.00

$177-207

800.00

950.00

$0-380

240.00

215.00

305.00

$28-93

219.00

Unknown

23023#

29.70

Unknown

20940

+153.20

292.00

Unknown

72825

135.20

Nil

430.00

$0-40

Amounts in this row are 50% of the full fee, because that is how charges for a secondary procedure are calculated. ** Because the initial consult is in the specialistâ&#x20AC;&#x2122;s rooms, this fee is given as 85% of the scheduled fee, for which health insurance is prevented from paying anything. # This item number adds a further two anaesthetic â&#x20AC;&#x2DC;unitsâ&#x20AC;&#x2122; anticipating the procedure takes just over 30 minutes.

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Feature

Interview: Peter Mott The relatively new CEO of Hollywood Private Hospital has moved across from the NFP sector, for a career change. Are health consumers in good hands? Peter Mott and Hollywood Hospital appear to have a lot to offer each other. He brings extensive hospital management experience and an attitude that fits the Ramsay ethos, while the hospitalâ&#x20AC;&#x2122;s expansion offers him a challenge. â&#x20AC;&#x153;As CEO, I probably spend a third of my time on my in-tray and email, a third with people, and my aspiration is to give strategy the final third. When you are running an organisation with a significant annual turnover, you make sure you have good processes so you donâ&#x20AC;&#x2122;t mess up,â&#x20AC;? he said. After 10 years at St John of God Murdoch, his transition to Ramsay 18 months ago came not long before the death of Paul Ramsay, the founder of the now publicly listed company that recently BDRVJSFE TNBMM IPTQJUBMT in France. Its footprint in WA â&#x20AC;&#x201C; Joondalup, Hollywood, Peel, Attadale and Glengarry hospitals â&#x20AC;&#x201C; is set to grow with expansion at Hollywood that will make it the biggest private hospital in WA. His predecessor and boss, ,FWJO $BTT 3ZBMM JT CBTFE BU Hollywood Hospital but now oversees WA and SA, as well as an Indonesian and Malaysian joint venture. The pair go back a MPOH XBZ ,FWJO SBO "SNBEBMF )PTQJUBM PWFS 20 years ago when Peter ran Swan Districts and they often talked about working together one day. One dilemma for Peter is how to maintain his hands-on management style as the hospital grows? The hospital appears to have room to burn for expansion â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s on 10ha alongside tertiary public hospitals in Nedlands â&#x20AC;&#x201C; having EPVCMFE JO TJ[F UP CFET TJODF 3BNTBZ UPPL over from DVA in 1994. â&#x20AC;&#x153;Bureaucracy can be a function of size. We need to find a way, as we grow, to maintain Hollywoodâ&#x20AC;&#x2122;s â&#x20AC;&#x2DC;special feelâ&#x20AC;&#x2122;,â&#x20AC;? he said.

Paul Ramsayâ&#x20AC;&#x2122;s legacy â&#x20AC;&#x153;Paul Ramsay talked about the philosophy of people caring for people, which was the number one thing for him. Donâ&#x20AC;&#x2122;t put on the table anything you wouldnâ&#x20AC;&#x2122;t accept for yourself; the principle of respect for other people.â&#x20AC;? 16

Q Peter Mottâ&#x20AC;&#x2122;s pride and joy on his ofďŹ ce wall is a mock-up of him on the cover of Tracks surďŹ ng magazine, given to him by his mates on his 50th birthday.

â&#x20AC;&#x153;I havenâ&#x20AC;&#x2122;t found the transition difficult because St John of God takes its stewardship seriously, as does Ramsay. The opportunity to be part of the Ramsay group, given its size, reputation and growth opportunities on this campus, was too good an opportunity to pass up,â&#x20AC;? he said. The DVA patient numbers are dwindling but veterans are important and still have â&#x20AC;&#x2DC;ownershipâ&#x20AC;&#x2122; (wards are named after Victoria Cross recipients). â&#x20AC;&#x153;We are the only Perth private hospital with an acute inpatient mental health service â&#x20AC;&#x201C; it opened in 1997 and recently grew from 40 to 70 beds. From a business point of view it is vibrant and well regarded by GPs who refer to it. From a society point of view I think mental health illness will overwhelm us as a community in the next 5-10 years.â&#x20AC;?

Hands-on management Peter tries to keep a strong connection with the pointy end of caring for people. Promoting the right attitudes is paramount

HJWFO UIF IPTQJUBM DBSFT GPS people a year â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s a bit clichĂŠd but â&#x20AC;&#x2DC;teamworkâ&#x20AC;&#x2122; is the key, a lesson learnt when Peter began his first job at Osborne Park Hospital in stores. He discovered the knock-on effect if he messed up. â&#x20AC;&#x153;Hospitals are all about teamwork, and it doesnâ&#x20AC;&#x2122;t matter what your role is, it is important. A key role of mine is to develop strong relationships with doctors and the executive team.â&#x20AC;? â&#x20AC;&#x153;Management sets expectations. Mostly, when you want to move someone on it is not about competence, it might be attitude or commitment. We make it clear from day one itâ&#x20AC;&#x2122;s about values, which go all the way through the organisation. We have a low tolerance for people who deviate from them. It relies on having a good bunch of middle managers to make it work.â&#x20AC;? â&#x20AC;&#x153;For example, a nurse manager on the ward is responsible for 30 beds and good patient care, being a good leader to their staff, working within financial parameters â&#x20AC;&#x201C; they are big roles. We have a rigorous selection process and donâ&#x20AC;&#x2122;t have problems filling vacancies when we have them, which says a fair bit about our reputation.â&#x20AC;?

Life outside work

Married with two daughters, one studying nursing at Notre Dame, Peter credits exercise for keeping him on top of his game. â&#x20AC;&#x153;If I donâ&#x20AC;&#x2122;t exercise I donâ&#x20AC;&#x2122;t feel sharp â&#x20AC;&#x201C; I used to run every day but my knees and lower back gave me strife so I go to the gym every other day and run twice a week.â&#x20AC;? Outside work, he Chairs AIM WA and was past Chairman of Lifeline WA, both roles giving him an opportunity to influence areas he is passionate about. His pride and joy on his office wall is a mockup of him on the cover of Tracks surfing magazine, given to him by his mates on his 50th birthday. â&#x20AC;&#x153;I hang around with a bunch of mates Iâ&#x20AC;&#x2122;ve known for a very long time and they keep me grounded. We go surfing or drink a bit of wine together every six weeks or so, and have a road trip once a year. You get no b.s. from these guys.â&#x20AC;? O

By Dr Rob McEvoy medicalforum

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medicalforum

Feature

Rethinking Tertiary Respiratory Services New drugs and monitoring devices, better self-care and ambulatory care can be seen as â&#x20AC;&#x2DC;change facilitatorsâ&#x20AC;&#x2122; for respiratory care. What else? $MJO " 1SPG 1FUFS ,FOEBMM NBZ TPPO CF preaching to the converted if respiratory health management remains under pressure to be more efficient and make good use of limited resources. As a respiratory physician within the tertiary public system, he believes changes he has promoted for years will assist the public system to cope with financial pressures. He has lobbied and received a favourable response.

Such â&#x20AC;&#x153;case managersâ&#x20AC;?, which includes nurses with special training, can not only assess acute exacerbations but also do a six monthly check on people on home oxygen, to compare their saturation with targets, and assess key symptoms, to note if they are retaining CO2. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s about making a decision without dragging the patients into hospital clinics all the time. We are not talking rocket science here, it is pretty basic stuff and these are experienced people.â&#x20AC;?

Outreach services Planners with Fiona Stanley Hospital talk of a â&#x20AC;&#x2DC;hub and spokeâ&#x20AC;&#x2122; arrangement, where each specialist has a central and peripheral hospital appointment. He agrees, and carries the idea further. A mobile respiratory service under his guidance, which includes a mobile lung function lab, has regularly visited Narrogin (15 years), Albany (five years) and Bunbury (nine years). â&#x20AC;&#x153;There are individuals doing really good things. RPH takes nephrology to Esperance. The paediatricians go all over the place. There are a lot of specialist outreach services funded through the Commonwealth Government. There is a sleep service in Albany,â&#x20AC;? he pointed out, before adding that our sparse population makes things uniquely difficult. â&#x20AC;&#x153;The hardest place to deliver health care is outer metropolitan areas â&#x20AC;&#x201C; Joondalup, Swan, Armadale, Rockingham and Mandurah â&#x20AC;&#x201C; where the smaller hospitals are. Doctors wonâ&#x20AC;&#x2122;t live there, so it is hard to get specialist help in peripheral areas where the most disadvantage lies and where the most chronic disease occurs.â&#x20AC;?

Rethink tertiary hospital care He draws on his long experience in respiratory medicine. â&#x20AC;&#x153;Doctors have entrenched security and comfort that only allows them to work in a tertiary hospital. If you go through tertiary hospitals today you would find patients that need to be in a general hospital bed, not here, because these places are vastly expensive to run.â&#x20AC;? â&#x20AC;&#x153;By a significant margin we are the most expensive State in Australia â&#x20AC;&#x201C; bar the Northern Territory â&#x20AC;&#x201C; for health care delivery per head of population. Some say this is because we are such a big State but I think it is because we have too many tertiary beds.â&#x20AC;? â&#x20AC;&#x153;The expense includes enormous outpatients at tertiary hospitals, where some review visits medicalforum

,FFQJOH QBUJFOUT PVU PG IPTQJUBM OFFET appropriate linkages, geared to local capacity.

Q Dr Peter Kendall is HoD Respiratory Medicine, Fremantle Hospital, a Clinical Lead with the Health Networks Branch, HDWA, and Medical Adviser on Clinical Governance with SMAHS

could be replaced by more active consultant review and discharge.â&#x20AC;? â&#x20AC;&#x153;There is no need necessarily to come back â&#x20AC;&#x201C; make a proper diagnosis, get things measured properly, give the GP a good management plan and all of sudden GPs are handling things quite well. In my Department [Fremantle Hospital], upwards of 45% of outpatient appointments are for new patients.â&#x20AC;? He says that if tertiary hospital respiratory services apply their skills properly, the average length of hospital stay should go up, while the yearly bed days come down. â&#x20AC;&#x153;In South Metropolitan Health, the bed days have come down in a straight line over the last decade â&#x20AC;&#x201C; in this hospital [Fremantle], from 3300 to 1300 bed days a year, a huge reduction. It has bottomed out in the last few years because I suspect we are managing things better in the community. I believe it is also due to good diagnosis and outpatient management in our clinics.â&#x20AC;?

Management in the community He says targeted respiratory patients as those in the â&#x20AC;&#x153;grey zoneâ&#x20AC;?, those who are between obvious ventilatory failure and mild bronchitis cared for at home. â&#x20AC;&#x153;We can supply ways to look after those people in their homes. A health professional of some sort can have direct links with the patient â&#x20AC;&#x201C; see them at home and make a decision based on oxygen levels [saturation probes], their chronic CO2 state [bicarb results], and bedside signs of flapping tremor, bounding pulse, warm feet, etc about whether they need to go to hospital.â&#x20AC;?

â&#x20AC;&#x153;At best it would be a community based nurse, local GP and a hospital specialist. It might also include a physiotherapist, say for someone with bronchiectasis. The nurse would be trained up in COPD management.â&#x20AC;? Once people were open to the model, he said, it was not difficult to train people, BOE XJUI BCPVU PO IPNF PYZHFO across metropolitan Perth, not a big task either. He envisaged about three centres in metropolitan Perth overseeing this, with contracts for â&#x20AC;&#x2DC;hospital in the homeâ&#x20AC;&#x2122; linked to a tertiary hospital.

Whereâ&#x20AC;&#x2122;s the prevention? He feels a strong focus on tertiary care can send the wrong message. â&#x20AC;&#x153;There is a relative lack of resources in preventative medicine versus interventional medicine. For example, nicotine addiction can be defined as a chronic disease, rather than wait for another disease to develop. We still spend about 80% of the health budget in the last two years of peopleâ&#x20AC;&#x2122;s lives, which is just wrong.â&#x20AC;? â&#x20AC;&#x153;It seems we are waiting for people to get established disease before treating them as chronic disease. When we last looked there were 45 anti-smoking programs in the ,JNCFSMFZ UIBU MBDLFE DPPSEJOBUJPO BDSPTT the group, and it just seemed to me we were losing the opportunity to do things.â&#x20AC;? He pointed to successful workplace Quit programs that have languished without ongoing funding. His philosophy is to stay in the system to effect change, and while marvellous things happen in WA (e.g. more outreach amongst younger specialists), a generational change is needed. Community expectations are now very high, he noted. O

By Dr Rob McEvoy

Pulmonary Rehab

COPD Health Professionals By Nola Cecins and Sue Jenkins, Physiotherapists, SCGH, Lung Institute of WA & Community Physiotherapy Services

Pulmonary rehabilitation aims to reduce dyspnoea and fatigue, increase exercise capacity and daily physical activity, improve quality of life and reduce health care burden in people with chronic lung disease. Programs include supervised exercise training and information on disease management, and are usually conducted in a group setting.

How does it work? Exertional dyspnoea is common in people with chronic lung disease â&#x20AC;&#x201C; particularly COPD. To avoid this distressing symptom, people with chronic lung disease avoid physical activity. This leads to a downward spiral of progressive inactivity, muscular and cardiovascular deconditioning, depression and poor quality of life. Exercise training is the component of pulmonary rehabilitation with the strongest evidence for benefit. Lower limb endurance training, for example, walking at an adequate intensity, induces physiological changes in the muscles. This improves their oxidative capacity, reduces lactate build-up during exercise and leads to a decrease in ventilation

and dyspnoea. Symptomatic benefits and psychological benefits accrue as individuals become more confident to undertake physical activity. This in turn reduces social isolation, anxiety and depression and improves quality of life. People with COPD who have higher levels of physical activity have fewer hospitalisations for exacerbations and a decrease in respiratory and all-cause mortality.

Phases of Pulmonary Rehabilitation Phase 1: Inpatient hospital or home-based rehabilitation during or immediately after an exacerbation. Phase 2: Programs are based in hospital outpatient departments (for those with complex medical problems or requiring supplemental oxygen) or in communitybased non-medical facilities; over 8 weeks, two supervised sessions a week of exercise training and self-management education; plus a home exercise program 2 or 3 days each week. Phase 3: A weekly group-based program that aims to maintain the benefits from Phase 2 and trouble-shoot ongoing problems; hospital or community based.

Programs in WA are mostly run by physiotherapists with access to other health professions (e.g. respiratory nurse, dietitian) where indicated and available.

Which patients benefit? People with chronic lung disease who are limited by breathlessness are likely to benefit. Improvements can occur in mild to severe disease, across a spectrum of respiratory conditions â&#x20AC;&#x201C; COPD, asthma, bronchiectasis, interstitial lung disease, lung cancer and chest wall deformities. Those not suitable have comorbidities that would compromise their safety or ability to exercise (e.g. unstable cardiovascular disease, uncontrolled diabetes) or if they are unmotivated to attend. Pulmonary rehabilitation that encourages regular physical activity can help improve quality of life, reduce symptoms, enhance functional ability and reduce the healthcare burden. O Further Reading Jenkins, S. (2010) State of the Art: How to set up a pulmonary rehabilitation program. Respirology 15: 1157-1173. References on request

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COPD Consumers Pulmonary rehab helps but the funding roulette is making the community program more difďŹ cult. Taking a deep breath is top of the list for three participants in the SCGH â&#x20AC;&#x2DC;Easy Breathersâ&#x20AC;&#x2122; program. Their â&#x20AC;&#x2DC;patient experienceâ&#x20AC;&#x2122; has embraced positive steps, setbacks and periodic exacerbations but they all stress the importance of a good doctor/patient relationship and easy access to structured rehab in a community setting. It was a sobering NPNFOU GPS ZFBS old Hilary Monton when she realised that cutting out cigarettes wasnâ&#x20AC;&#x2122;t going to ameliorate the effects Q Hilary Monton of her emphysema. Nonetheless, a combination of physical exercise, surgery and a willingness to confront her condition is paying dividends. â&#x20AC;&#x153;I was a heavy smoker. It began in my mid20s and I wouldâ&#x20AC;&#x2122;ve smoked under water if that were possible. I became quite unwell and breathless in 1994, stopped smoking soon afterwards and thought Iâ&#x20AC;&#x2122;d be fine. I wasnâ&#x20AC;&#x2122;t.

The damage was done.â&#x20AC;? â&#x20AC;&#x153;That was the catalyst for going along to see Sue Jenkins and Nola Cecins at Easy Breathers. From there I went to a community-based exercise program at Joondalup but funding was withdrawn so I transferred to Quinns Rock, close to where I live. I found that quite depressing because I didnâ&#x20AC;&#x2122;t see myself as an old woman shuffling around with a disease.â&#x20AC;? â&#x20AC;&#x153;So I stopped exercising and that wasnâ&#x20AC;&#x2122;t a good idea. After going to see a specialist in early 2013, I ended up doing about 40 round trips from Quinns Rock to attend Easy Breathers. Iâ&#x20AC;&#x2122;m currently in a community program at Heathridge after funding was also axed at Joondalup. That prompted NF UP XSJUF UP UIF )FBMUI .JOJTUFS ,JN Hames about the lack of rehab classes in the northern corridor.â&#x20AC;? â&#x20AC;&#x153;He replied advising me of the one-on-one sessions at the Health Campus but the group setting is so much better.â&#x20AC;? Mid-way through last year, Hilary decided to proceed with lung volume reduction surgery. The damage due to smoking was

Q Community-based Pulmonary Rehabilitation at a local recreation centre

confined to the top third of her lungs but her spirometry readings were heading in the wrong direction. â&#x20AC;&#x153;They did one side at a time, the right in mid-June 2013 and the left four months later. It was done using keyhole surgery, I left hospital on a Sunday and went shopping on Tuesday. Iâ&#x20AC;&#x2122;m a public patient and itâ&#x20AC;&#x2122;s been a good experience. The rehab has been fantastic and integral with the whole process of increasing my strength and lung capacity. Iâ&#x20AC;&#x2122;m able to take a deep breath and thatâ&#x20AC;&#x2122;s something I havenâ&#x20AC;&#x2122;t been able to do for a long time. Iâ&#x20AC;&#x2122;m just so grateful.â&#x20AC;? â&#x20AC;&#x153;The one thing I would like to say is that a patient is much more than just a cough. Once I went along with something quite different and the GP said, â&#x20AC;&#x2DC;Hilary, I couldnâ&#x20AC;&#x2122;t see past your emphysema.â&#x20AC;&#x2122; I knew it was time to change doctors.â&#x20AC;? In October last year Denise Wright, 75, was diagnosed with pulmonary fibrosis. She knows her

Q Denise Wright

Continued on P22

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If you are looking for a change â&#x20AC;Ś â&#x20AC;Ś WEâ&#x20AC;&#x2122;LL FIND YOUR PERFECT FIT T 08 6389 4500 E recruit@ruralhealthwest.com.au | W www.ruralhealthwest.com.au medicalforum

News & Views

Lung Blueprint Needs Action Nowhere is the crossover between private, public, GP, specialist, nurse and pharmacy evident than in chronic respiratory disease. The 2013 Chronic Lung Conditions Model of Care, developed by the Health Department, sits hierarchically above the Asthma, COPD and Cystic Fibrosis Models of Care and provides a blueprint for consumer and carer-focussed health services (see www.healthnetworks.health. wa.gov.au/network/respiratory.cfm). In reality, people are doing the best with what they have and some leaders are trying to change the way we do things, to become more patient-focused and efficient. For cash-strapped governments, this translates into cost effectiveness. ,FZ SFDPNNFOEBUJPOT PG UIF .PEFM JODMVEF t 5BDLMJOH SJTL GBDUPST F H TNPLJOH and populations (e.g. those in prisons, with mental health issues, from low socioeconomic backgrounds, culturally and linguistically disconnected, and pregnant women). t &BSMZ EJBHOPTJT UISPVHI JODSFBTFE BDDFTT to services in community settings. t #FUUFS NBOBHFNFOU UISPVHI UIF VTF PG action or self-management plans, expanded community-based smoking cessation programs, pulmonary rehabilitation programs and case management/care plans. t &EVDBUJPO PG DPOTVNFST BOE DBSFST BOE training for health professionals, including evidence-based guidelines and protocols that build skills.

t *OUFHSBUFE SFGFSSBM QBUIXBZT BDSPTT boundaries to ensure a holistic multidisciplinary service delivery. t *OGPSNBUJPO DPNNVOJDBUJPO UFDIOPMPHZ (ICT) to enable multi-disciplinary care and facilitate appropriate data exchange that includes external providers (including Telehealth). Creating efficiencies include Action Plans, which try to engage both patients and carers, and enlisting new providers. We have previously critiqued the Asthma Action Plan, which enlists the support of community pharmacists (providing OTC short-acting beta agonists) and consumers (through their wallet-sized Action Plan, partly completed by their GP). There is now a similar COPD Action Plan. The wallet-sized card was produced along with patient health information sheets to be handed out by GPs, hospital and community providers. Current treatments and emergency plans are the focus of the cards (which can be ordered online). Upskilling health providers includes the COPD online course module for nurses, which we presume is free in the public system but costs $250 elsewhere, and is provided through the Lung Foundation. We reviewed the equivalent asthma course in more detail mid-2012 and present the COPD course, in a nutshell, here (see box right).

www.lungfoundation.com.au t -BVODIFE .BSDI VQEBUFE "QSJM t 5XP TUSFBNT FBDI XJUI MFBSOJOH NPEVMFT o OVSTFT JODMVEFT QIZTJPMPHZ QIBSNBDPUIFSBQZ BOE TQJSPNFUSZ BOE QIBSNBDZ JODMVEFT SPMF PG QIBSNBDJTU TDSFFOJOH JO UIF DPNNVOJUZ QIBSNBDZ BOE QMBOOJOH B $01% TFSWJDF $BO CPPLNBSL ZPVS QMBDF BOE DPNQMFUF PWFS UJNF *OUFSBDUJWF BOE JODMVEFT DBTF TUVEJFT DBSF QMBOT BOE UIF .#4 BOE EPXOMPBEBCMF BTTFTTNFOU UPPMT BOE QBUJFOU IBOEPVUT t 5JNF DPNNJUNFOU IPVST UP DPNQMFUF SFDPNNFOEFE UXP NPOUIT 5IFSF JT BTTFTTNFOU PG LOPXMFEHF BU UIF FOE PG FBDI NPEVMF XIJDI UFOET UP CVJME LOPXMFEHF PO UIF MBTU "DDFTT JT QSPWJEFE GPS NPOUIT TP OVSTFT DBO DPOUJOVF UP VTF UIJT BT B QSPGFTTJPOBM SFTPVSDF BOE UP EPXOMPBE SFTPVSDFT BT UIFZ SFRVJSF t 5IF OVSTFT DPVSTF JT BJNFE BU BMM OVSTJOH HSPVQT 4P GBS BCPVU FOSPMNFOUT XJUI BCPVU IBMG TUBSUFE BOE KVTU PWFS IBMG PG UIFTF GJOJTIFE #SFBLEPXO 3/T &/T BMMJFE IFBMUI SFTQJSBUPSZ OVSTF TQFDJBMJTUT GSPN HFOFSBM QSBDUJDF DPNNVOJUZ IFBMUI DFOUSF QVCMJD IPTQJUBM OPO HPWFSONFOU PSHBOJTBUJPO QSJWBUF IPTQJUBM "1/" BOE "$/ BDDSFEJUFE t $PTU JODM (45 #VML CPPLJOH EJTDPVOUT TFF IUUQ MVOHGPVOEBUJPO DPN BV IFBMUI QSPGFTTJPOBMT USBJOJOH BOE FEVDBUJPO DPQE OVSTF USBJOJOH POMJOF

t 0UIFS SFMBUFE POMJOF DPVSTFT PGGFSFE P -VOHT JO "DUJPO )FBSU 'BJMVSF 5SBJOJOH P -VOHT JO "DUJPO DPNQSFIFOTJWF USBJOJOH GPS FYFSDJTF QSPGFTTJPOBMT

P 1VMNPOBSZ 3FIBCJMJUBUJPO 5SBJOJOH 0OMJOF P .FTPUIFMJPNB Contact: Judy Powell, COPD National Program, Lung Foundation Australia. M: 0458 505 206 E: judy@lungfoundation.com.au

Continued from P21

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condition will worsen but at her age a lung transplant is not an option. â&#x20AC;&#x153;It all started in 2003. I was having trouble breathing and my doctor thought I had an asthmatic condition. Iâ&#x20AC;&#x2122;ve had the same GP for 18 years and she knew I wasnâ&#x20AC;&#x2122;t getting any better and so did I.â&#x20AC;? â&#x20AC;&#x153;The only medication Iâ&#x20AC;&#x2122;m on is Seretide but every day is pretty tough. Iâ&#x20AC;&#x2122;m no longer able to go swimming, dancing or play the piano and I really miss those things. Iâ&#x20AC;&#x2122;m attached to oxygen 24/7 and thereâ&#x20AC;&#x2122;s a trail of tubing through the house. Iâ&#x20AC;&#x2122;m constantly tripping over it and I suppose broken bones will be the next thing Iâ&#x20AC;&#x2122;ll have to deal with.â&#x20AC;? â&#x20AC;&#x153;I began to feel very ill in early 2013 and I ended up admitting myself to hospital. That led to the connection with Easy Breathers. I canâ&#x20AC;&#x2122;t speak highly enough of the program, the classes educate us and and itâ&#x20AC;&#x2122;s a wonderful team approach.â&#x20AC;? O

By Mr Peter McClelland 22

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News & Views

Whatâ&#x20AC;&#x2122;s this Vapour Caper? E-Cigarettes and â&#x20AC;&#x2DC;vapingâ&#x20AC;&#x2122; have become the latest passion of Gen Y but will it be just a passing fad or a possible health crisis? The health consequences

The Klanger Aerotank costs $US40 and is an e-cigarette containing a small battery, which converts liquid into a mist or vapour. They have been banned in Perth since mid-April after a Supreme Court ruling of a case brought on by the WA Health Department. And the decision had nothing to do with nicotine. Vincent van Heerden, who lost the case, was the proprietor of online business Heavenly Vapours (now defunct). He would have been disappointed to hear Judge Prichard find that any product that mimicked a â&#x20AC;&#x2DC;hand to mouth actionâ&#x20AC;&#x2122; resulting in the expulsion of vapour contravenes the Tobacco Products Control "DU And hereâ&#x20AC;&#x2122;s the sub-clause that sank van Heerden: A person must not sell any food, toy or other product â&#x20AC;Ś designed to resemble a tobacco product or a package, effectively making WA the first jurisdiction in the world to ban the sale of e-cigarettes.

Whatâ&#x20AC;&#x2122;s in them? The barrels of these battery-powered devices contain â&#x20AC;&#x2DC;eJuiceâ&#x20AC;&#x2122; and the liquid comes in every colour of the rainbow. The cartridges all contain propellants and, after that, it becomes a lot more interesting. An online look reveals a multiplicity of choices from Totally Bananas and Blueberry Blast to blends containing tobacco-based and/or synthetic nicotine. The vials of eJuice come in varying strengths with a mid-range nicotine baseline of 12mg/100ml. A standard pack costs around $30 and consists of 3x30ml bottles; one bottle of eJuice is roughly equivalent to a carton of cigarettes. Local users can purchase â&#x20AC;&#x2DC;personal amountsâ&#x20AC;&#x2122; (a somewhat slippery category) of the real thing only from overseas online websites because nicotine is classified as a â&#x20AC;&#x2DC;dangerous poisonâ&#x20AC;&#x2122; in Australia. And, as such, it can only be sold under licence in the form of cigarettes.

What do they look like? The design of the â&#x20AC;&#x2DC;tankâ&#x20AC;&#x2122;, which comes in increasingly elaborate shapes and sizes, is becoming an art form. Devotees, known as â&#x20AC;&#x2DC;Vapersâ&#x20AC;&#x2122;, can spend thousands of dollars on bespoke, hand-crafted models. There are even â&#x20AC;&#x2DC;tanksâ&#x20AC;&#x2122; that look like a cigarette, right down to an artificial glowing tip. The Piston Steampunk will set you back $US700.

Gen Y devotees One Gen Y, who epitomises the e-cigarette demographic is 33-year-old Nomi Ananda. â&#x20AC;&#x153;I know several people whoâ&#x20AC;&#x2122;ve gone from nicotine e-cigarettes to eJuice vaping and continue with the latter because they enjoy the flavours and the â&#x20AC;&#x2DC;hand-to-mouthâ&#x20AC;&#x2122; sensation. As with many quitting techniques itâ&#x20AC;&#x2122;s a case of tapering the nicotine intake,â&#x20AC;? said Nomi. â&#x20AC;&#x153;Vaping has changed my life for the better. I no longer smoke cigarettes, my sense of taste has returned and my smokerâ&#x20AC;&#x2122;s cough has gone.â&#x20AC;?

Big Tobacco There are vastly different economies of scale. The global e-cigarette market is currently worth around $US3b, a minnow compared with a world-wide tobacco market of $US800b. The latter, and highly lucrative sector (excluding China), is dominated by five major players according to online discussion site The Conversation. And all have established a stake in this new and burgeoning market through strategic buyouts of independent e-cigarette companies.

â&#x20AC;&#x153;Theyâ&#x20AC;&#x2122;re dodgy products,â&#x20AC;? said Prof Mike Daube. â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s no quality control and we know nothing about the long-term consequences. Youâ&#x20AC;&#x2122;d be mad to touch the flavoured variety. You just donâ&#x20AC;&#x2122;t know where theyâ&#x20AC;&#x2122;ve been.â&#x20AC;? â&#x20AC;&#x153;In any case, theyâ&#x20AC;&#x2122;re the Mickey Mouse end of the market. The big issue is nicotine e-cigarettes. Itâ&#x20AC;&#x2122;s a huge business overseas with predictable vested interests. These products have nothing to do with cessation. Itâ&#x20AC;&#x2122;s all about promoting and normalising smoking behaviour.â&#x20AC;? A recent episode of the ABC TVâ&#x20AC;&#x2122;s Fact Checker program (8 August 2014) noted that the current proportion of smokers in Australia is down to 13%, one of the lowest in the Western world. However, thereâ&#x20AC;&#x2122;s plenty of anecdotal evidence that suggests the number of people using e-cigarettes is rising, particularly amongst hipster GenYs.

Vaping as a quitting device? â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s too soon to tell, either way,â&#x20AC;? stated Executive Director of Public Health, Prof Tarum Weeramanthri, on Fact Checker. â&#x20AC;&#x153;There may be isolated instances of cessation but it seems more likely that people will continue smoking both forms.â&#x20AC;? However, not all agree. In a recent edition of the Medical Observer (13 August 2014) Professor Wayne Hall, Director of the Centre for Youth Substance Abuse Research University of Queensland, stated that banning e-cigarettes is an â&#x20AC;&#x2DC;incoherent form of risk regulationâ&#x20AC;&#x2122;. What impact this will have on e-cigarettes and their WA devotees is debateable. It seems likely that the status quo will remain relatively undisturbed, online sales will continue to boom and the local ramifications of the Prichard judgement will disappear in a puff of smoke unless the anti-tobacco lobby ratchets up the pressure.O

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Guest Column

Cut With Care Is rationing the answer to the health cost funding challenge? A/Prof Suzanne Robinson says whatever path, action is needed.

here has been much discussion recently about the sustainability of the Australian healthcare system and agreement in most camps that reform is needed. Recent budget proposals to introduce co-payments for GP visits are seen by some as the beginning of the end for Medicare and universal health coverage in Australia.

Whilst evidence suggests that co-payments will do little to curb inefficiency or help with any equity issues, it does bring the rationing debate to the fore – should we ration public spending on health? There may be agreement on the need for reform but less agreement on the measures needed. Health is complex and political service cuts or a move to raise tax to pay for increased demand are not vote winners. So what are the options facing politicians and decision makers in health?

Increase efficiency Work has been undertaken around disinvesting in ineffective treatments and using approaches such as LEAN to make services more efficient (ie eliminate waste). However, this will not bear sufficient fruit to close the supply-demand gap. Reform tends to focus on supply activity rather than demand management, which relates to focusing on individual behaviour and the wider social determinates of health. Evidence suggests that services outside of healthcare (including education, public health and self-care) can do much more to change behaviour and prevent chronic health than the current focus on illness and high-cost hospital services. However, often services that focus on these social determinates are the first to face cuts when the rationing axe falls.

Explicit priority setting This focus requires a political will to engage with consumers around what should and should not be included in the Medicare insurance bag. Governments and funders are reluctant to engage in such dialogues, however the alternatives include: increased spending; long waiting lists for treatment or an over reliance on ‘bedside’ rationing. International attempts at priority setting have tended to focus on the margins and low-hanging fruit rather than in areas of core spend often because of the hindrance of longstanding structures and organisational relationships. Effective priority setting requires an evidence-based design process that involves clinicians and effective leaders from across the system working in a more integrated way. Making and implementing tough rationing decisions requires a certain set of leadership skills that include being able to mobilise support and operate political ‘astuteness’. One thing’s for sure, we can’t continue to fund the increasing demand for health care without an increase in tax or a reduction in some services. However, there are options including a more evidence-based focus to setting priorities and a mature discussion with consumers about what we need to do collectively to provide more efficient and equitable high quality health services. The time is right to start the debate.

Q&A Medicolegal

“A patient of mine failed to re-attend an appointment to review test results, which I discovered were abnormal, what should I do? Is timing important?”

Errors in notifying patients of clinically significant test results can have a severe effect on a patient’s prognosis and expose you to the risk of a claim for damages or a complaint to the Australian Health Practitioner Regulation Agency (AHPRA).

One study 1 in the United States found that the rate of failing to inform or to document informing patients of clinically significant test results was in the order of 7.1%.

Response by Morag Smith, Senior Solicitor, Avant Mutual Group Limited

Here in Australia, case law suggests that you have a legal duty to take reasonable steps to inform the patient of the abnormal result and recommend ongoing treatment or referral to a specialist. This duty applies, even if you have asked the patient to contact the rooms, or to make another appointment to discuss the results, because most patients assume you will contact them if an abnormality is detected and think that ‘no news is good news’. What is deemed ‘reasonable,’ depends on the clinical significance of the result. A result is considered ‘clinically significant’ if the patient is likely to suffer harm if follow-up does not occur. If the risk of harm to the patient is serious, there is an increased onus on you, and your practice, to take steps to contact the patient. If you conclude that a result is clinically significant but not serious, then a phone call is adequate. This, of course, requires a proactive practice management system to check that you have the correct contact details. This should be done each time the patient attends the practice. If the first phone call is unsuccessful, consider two or three phone calls at different times of the day. For more serious conditions, you should also send a letter to the last known address, or a letter by person-person registered mail explaining why follow-up is required. Timing of follow-up is crucial if the patient’s welfare is at risk or if a delay in treatment could have an adverse effect on their prognosis. In a circumstance where the patient’s immediate welfare is at risk and your attempts to contact the patient have failed, it may be reasonable to enlist the assistance of the police to help locate the person. Each attempt to contact the patient should be documented in the patient’s medical record. When documenting phone calls include the date and time of the call, the name of the person who made the call, and a summary of any message left. If a letter is sent by registered mail, make a note of this in the patient record. (1) Frequency of failure to inform patients of clinically significant outpatient test results. Casalino et al. Arch Intern Med 2009;169(12): 1123-1129 O ED. Commentators suggest that if a patient co-payment comes in, for those normally bulk-billed, there will be more non-attendances for review of test results, especially if normal results are anticipated. We thought readers would like to know their legal responsibilities.

References on request. O

ED: Suzanne is Director of Health Policy and Management at the Curtin University School of Public Health

medicalforum

Guest Column

e-Health and General Practice General Practitioner Dr Mike Civil sees how computers aid medical practice, if we can ﬁnd time to use them to their full potential.

lectronically speaking, it is positives all the way… BUT it is not having the electronic wizardry that is important, it is ensuring we use it effectively and fully. There is an awful lot we can do with electronic gadgets in our surgeries now. As a techno enthusiast, I do not believe it would be better to return to the ‘good old days’. Let’s consider the range of things now available. Nearly all GPs have a computer on their desktop. We do scripts, pathology requests, referral letters and write patient notes electronically. We do ECGs and spirometry in our surgeries, uploaded to our clinical software and attached to the patient’s file; ECGs have interpretive software and even if we disagree with the diagnosis being offered, at least we are prompted to consider a differential that we may have missed. (Reception staff don’t have to cut little squares of paper, stick them to a sheet of A4 and then scan them into the system…or was it just our practice that did this?).

‘Learning to use it properly’ is the phrase that really captures it all. Do we really use installed systems effectively and well? I think not.

Sterilisation records that include instrument tracking, and data loggers for vaccine fridges, can be dutifully recorded in our computer systems. I have not even mentioned the accounting software that makes finances so much easier…once we learned how to use it properly. “Learning to use it properly” is the phrase that really captures it all. Do we really use installed systems effectively and well? I think not. Initially, it takes time to learn how to use the bits we need daily, without remembering all the fancy bits that the software company rep enthusiastically showed us.

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Using coding, such as our chronic disease registers, is a classic example. With coded conditions, we can then find patients whose diseases need to be followed more closely. We can make better use of the GP Management Plans because we can follow patients and set reminders, recalls and prompts. There are support tools such as the PEN Clinical Support Tools that can prompt us when patients have not had appropriate monitoring for their medical problems. The PCEHR shifted our focus – to get electronic systems up to speed. We used telehealth before changes to the MBS changed the emphasis for those working in outer metro areas. Distractions or further tools to aid healthcare? Regardless of your view, the PCEHR highlights the enormous scope of e-systems that we can use. But at the end of the day, electronic systems mean we can offer better care if we use them properly and never forget the importance of the patient sitting next to us. O

CANNIN G LIVINGS VALE/ TON

Call Ashley Hicks on 0410 192 668 for further details medicalforum

Guest Column

Twitter – Not Just for Celebrities GP Dr Penny Wilson urges doctors to reclaim social media from the clutches of pop culture and start connecting to a world of engagement and information.

magine accessing a smorgasbord of high quality, free, relevant medical education as and when needed. Imagine discovering game changing research before it’s even published, or listen in on any conference in the world from your own home. Imagine a place where academics, public health experts, doctors from all specialties, nurses and other health practitioners could all share their perspectives on important health topics. Imagine surrounding yourself with inspiring people challenging to you to become the best doctor you could be. This is all possible through social media. I was sceptical at first. Sure, I used Facebook to keep in touch with friends and family, but I was adamant that I wouldn’t follow the Twitter herd and I would have laughed at the suggestion that tweeting would be good for my work. After grudgingly signing up to Twitter for a conference, I started following a bunch of really interesting people, discovered FOAMed (free open access medical

A few examples:

It’s hard for people who’ve never experienced it to appreciate how rewarding social media and FOAMed can be. Sadly, conservative policies from AHPRA, our professional bodies and MDOs scare people away.

t * IBE B EJďDVMU DMJOJDBM RVFTUJPO BCPVU congenital long QT syndrome which I posted on Twitter and within a couple of hours was discussing it with a Sydney professor who heads the paediatric genetic cardiology research team.

You do need to remember that everything is public so maintaining patient confidentiality and avoiding professional faux-pas is both important – and easy. Just don’t say anything that you wouldn’t be happy to see printed, or overheard in a crowded elevator.

t * WF BUUFOEFE POMJOF JOUFSOBUJPOBM 5XJUUFS journal clubs, participated in fun medical radiology and ECG quizzes and watched some fantastic instructional videos for medical procedures.

Online information also needs critical appraisal just as from any other source. The best FOAMed is well referenced and undergoes the ultimate form of peer review in the form of critiques from the online medical community.

education) and became part of a wonderful online community. A new world of powerful tools opened up connecting particularly us in rural, remote, solo or small group practices.

t * WF MFBSOU FNFSHFODZ SFUSJFWBM BOE DSJUJDBM care principles that will be vital in the remote hospital setting. t * XFOU UP UIF 4PDJBM .FEJB BOE $SJUJDBM Care (SMACC) conference on the Gold Coast this year and it felt like a reunion of old friends I just hadn’t met yet. t * IBWF GPVOE GBOUBTUJD NFOUPST PO 5XJUUFS from different parts of Australia.

I encourage everyone to give it a go. The more you put in, the more you get out, and the real benefits come from engaging with others and it may just change the way you practice medicine for the better. O ED: For more on FOAMed see http:// lifeinthefastlane.com/foam

“Our vision was to build a world-leading service in implantable hearing devices. We have done just that, and our patients beneﬁt the most.” Professor Marcus Atlas, ESIA Director speaking at the 13th International Conference on Cochlear Implants and Other Implantable Auditory Technologies, Munich, Germany, June 2014.

There’s one outcome that each referring GP and ENT specialist demands: The best possible results for your patient, regardless of their age, the complexity of their condition or the severity of their hearing loss. The team at the ESIA Hearing Implant Centre has a track record in delivering the best outcomes for our patients. As a part of the Ear Science Institute Australia, a comprehensive centre of excellence for hearing health, we’re able to bring the best of research and experience into our clinic.

What’s more, we have the resources and top-level skills to provide your patient with initial assessments and ongoing post-implant rehabilitation and monitoring, for life. To learn more about our team, and our outstanding record of success, you’re invited to visit hearingimplantcentre.org.au or call us on 6380 4944.

www.hearingimplantcentre.org.au

+Hʋɠ ʙLȯɏ Wɛ ʃȱɏ ʓʅɸɗ medicalforum

CLINICAL UPDATE

Spirometry â&#x20AC;&#x201C; a quality measurement S

pirometry can be an excellent tool to help diagnose and monitor respiratory disease. For example, the patient who presents with unexplained acute or chronic breathlessness, cough, or someone exposed to injurious agents who may go on to develop respiratory disease. A trained practice nurse can be responsible for accurate spirometry.

Choosing a spirometer Amongst many types of spirometers, some are better than others. Devices should meet well defined internationally recognised standards(1) and if accompanying software is loaded onto a laptop it can make a big difference for the user. Look for the ability to: t 4IPX SFBM UJNF EJTQMBZ PG FBDI FGGPSU t 7JFX BMM FGGPSUT OPU KVTU UIF CFTU UISFF PS worse â&#x20AC;&#x201C; one!) t 0WFSSJEF BOZ BVUPNBUFE TPGUXBSF UP FBTJMZ select and deselect efforts t *ODMVEF SFDFOUMZ QVCMJTIFE QSFEJDUFE WBMVF sets t *ODMVEF -PXFS -JNJU PG /PSNBM JO SFQPSUT not just percent predicted t "MMPX FOUSZ PG PQFSBUPS DPNNFOUT PO the quality of patient effort and relevant medications t 5VSO PGG BVUPNBUFE SFQPSUJOH

By Sharon Lagan, Respiratory Scientist, Dept of Pulmonary Physiology & Sleep Medicine SCGH

Remember to ask about ongoing consumable costs such as disposable sensors and, most importantly, try before you buy! Comprehensive advice can be found in the ANZSRS Spirometry Buyers Guide at http:// anzsrs.org.au/index.php/regular-features/ links.

Quality assurance Calibration Checks: the unknown element Spirometers use flow devices that can alter. International standards(1) say you should: t $IFDL BDDVSBDZ PO UIF EBZ PG VTF XJUI a 3L Calibration syringe (Time required: 3 minutes a day) t &TUBCMJTI POF PS UXP TUBGG NFNCFST BT biological controls. Repeatable results on your staff, confirms reliable patient results. (Time required: 3-5 minutes, once a week) Infection control: beyond universal precautions, things to consider are: t 6TF PG TJOHMF QBUJFOU TFOTPST PS mouthpieces with bacterial filters to prevent cross contamination t 6TF PG EJTQPTBCMF TQBDFST BOE OPTF QFHT (these should not be washed and reused). t 3FHVMBS DMFBOJOH BOE UIPSPVHI ESZJOH of flow senor according to manufacturerâ&#x20AC;&#x2122;s instructions t 4VSGBDF DMFBOJOH XJUI B EFUFSHFOU XJQF PS suchlike between patients

How to streamline spirometry in your practice t #F SFBMJTUJD BCPVU UIF UJNF SFRVJSFE GPS reliable testing. A minimum of 3 acceptable and repeatable efforts are required, which VTVBMMZ UBLFT BU MFBTU BUUFNQUT PO UIF GJSTU visit so allow up to 15 minutes. t "DDVSBUF IFJHIU XJUIJO B DN OP TIPFT is essential for predicted values. Allow a few minutes for this. t 6TF UIF XBJU UJNFT FGGFDUJWFMZ F H QPTU bronchodilator 10 minutes) or place the patient in the waiting area. t "MMPX NJOVUFT UP QFSGPSN QPTU bronchodilator spirometry t 3FWJFX SFTVMUT PO TDSFFO PS QSJOU GPS interpretation by the doctor Expect that a naĂŻve patient will be in the practice for 30-40 minutes, but probably less for subsequent visits. *Reference: (1) ATS/ERS Task Force: Standardisation of lung function testing at https://www.thoracic.org/statements/ resources/pfet/PFT2.pdf. O Competing interests declaration: Nil relevant. The author can be contacted on Tel 9346 2888

Helping Indigenous to Quit Recruitment and management of participants in two distant locations; appropriate training of the indigenous researchers; staff absences and shortages; and maintaining organisation commitment were some of the challenges.

Prof Julia Maley of the Rural Clinical School in Broome has handed in her findings from the Be Our Ally Beat Smoking #0"#4 TUVEZ JO UIF ,JNCFSMFZ and despite promising results, still awaits the verdict from the city decision-makers.

The essential ingredient was flexibility to adapt the intervention to local settings and circumstances, and taking sufficient time to allow this to occur.

The study was conducted last year to pilot an intervention that would support Indigenous smokers to quit. Smoking is a serious health problem for all the community but its hold in some indigenous communities, where the Quit programs have not had the same impact, is critical (see below). BOABS sought to give program participants intensive support to quit with regular support sessions led by a trained Aboriginal smoking prevention officer plus open support groups. It ran at two sites â&#x20AC;&#x201C; Derby Aboriginal Health Service and the Ord Valley Aboriginal Health 4FSWJDF XJUI QBSUJDJQBOUT o XIFSF were enrolled in the usual care group at the centres and 58 were assigned to the outreach group. There was a good follow-up rate, with 88% of participants reporting on their smoking 30

Indigenous Smokers Q Picture: AAP

status at the end of the study with 11% of the outreach group having quit smoking at 12 months â&#x20AC;&#x201C; more than twice the quit rate of the group who received usual clinic care. Perhaps equally important, BOABS gave researchers insight into conducting outreach programs in a community setting â&#x20AC;&#x201C; the things that work and the significant issues that need to be overcome.

t "CPSJHJOBM BOE 5PSSFT 4USBJU *TMBOEFST BHFE ZFBST TNPLF t PG *OEJHFOPVT BEVMUT TNPLF DJHBSFUUFT JO TPNF OPSUIFSO DPNNVOJUJFT t PG "CPSJHJOBM EFBUIT DBO CF BUUSJCVUFE UP B TNPLJOH SFMBUFE JMMOFTT t BSF VOBXBSF PG 2VJU BJET t PG "CPSJHJOBM QSJTPOFST TNPLF 4PVSDF XXX DSFBUJWFTQJSJUT JOGP

medicalforum

Feature

A World Without Antibiotics! Doctors are in the ďŹ ring line as resistance renders drugs useless to ďŹ ght common bacterial infections and makes fresh discoveries uneconomical. Antibiotics are a diminishing resource. The professionâ&#x20AC;&#x2122;s boost that started with penicillinâ&#x20AC;&#x2122;s discovery in 1928 is now waning due to the overuse and misuse of antibiotics. Yet doctors are pulled in all directions â&#x20AC;&#x201C; consumers wanting immediate results, legal risk minimisation by prescribing for rare possibilities, uncertainty in clinical diagnosis, overservicing accusations if everyone is tested, and prescribing, which can be the backbone of the private doctorâ&#x20AC;&#x2122;s income. Inaction means that antibiotic resistance has become a whole-of-community issue, no longer in the hands of the profession alone.

are worse) or the community. In 2011, non-typhoidal Salmonella resistance to fluoroquinolones was 11% in China and 33% in PNG.

return to inappropriate antibiotic use if left alone. Mind you, audits and available guidelines make this approach more feasible in hospitals, compared to community care.

Which infections?

What happens in the community

Resistance impacts on common infections like UTIs, pneumonia, blood infections, wound or surgical site infections, and meningitis.

*O "VTUSBMJB BCPVU QFPQMF EJF FBDI week from infection. That number is predicted to double by 2030 and, without antibiotics, direct deaths from infection of the young and elderly are likely. There will be more amputations, chemotherapy and immunosuppression will become risky. Procedures we take for granted, such as hip replacements, simple cannulas and catheters, will risk infection. An example of misuse: antibiotic prescribing for â&#x20AC;&#x153;acute bronchitisâ&#x20AC;? is about 71% when evidence, guidelines, quality measures and educational efforts say it should be zero. Worries about missing pneumonia, and ignoring harms (diarrhoea, gut-ache, rash and thrush) are no longer in the debate that calls for antibiotic stewardship at the primary care level.

Drug companies seem uninterested in discovering new antibiotics that become ineffective within a few years due to emergent resistance. Hence, there have been no new antibiotics of note in the pipeline since the 1980s. There are still opportunities for returns though. Resistant bugs in our food have been put down to prophylactic antibiotic overuse in animal husbandry to increase yields.

The global village Antibiotic resistance is probably underreported worldwide. Surveillance is often lacking in countries with high disease rates, for example, reliable resistance data for gonorrhoea to mark how much resistant gonococci have spread. In Australia, Neisseria gonorrhoeae is resistant to third-generation cephalosporins. Such failed treatments of last resort have now been reported by 10 countries â&#x20AC;&#x201C; the fear is gonorrhoea will soon become untreatable as no vaccines or new drugs are in development. Resistant bugs are also more easily spread as â&#x20AC;&#x2DC;carriersâ&#x20AC;&#x2122; visit from overseas. Visitors, from the Indian subcontinent for instance, are landing with vancomycin resistant E Coli (VRE) in their bowel making spread to susceptible patients a problem if they attend hospital. World-wide, there is resistance to antimicrobials used to treat TB, HIV, malaria, and influenza. Extensively drugresistant tuberculosis (XDR-TB) has been identified in 92 countries. E. coli resistance to fluoroquinolones varies JO *OEJB GSPN EFQFOEJOH PO UIF UZQF of infection (e.g. UTI or lower respiratory infection), region of India, and whether the sample is taken in hospital (where things medicalforum

Methicillin resistant Staph aureus (MRSA) has gone from being a hospital-acquired infection to community-based. While Australia has MRSA rate of around 30%, this compares favourably to the Philippines .POHPMJB 1/( Cambodia (55%) and Japan (53%) â&#x20AC;&#x201C; all 2011 figures. Studies show inferior outcomes where infections are caused by certain resistant CBDUFSJB *OGFDUJPOT XJUI SFTJTUBOU & DPMJ , pneumonae, or S. aureus increase all-cause mortality, while resistance to third generation DFQIBMPTQPSJOT & DPMJ PS , QOFVNPOBF PS MRSA, in particular, cause fatal infections.

What happens in hospitals Hospitals face escalating costs: forced to isolate-nurse carrier patients; shut down affected wards; and provide longer bed stays for those infected. This is already happening in Perth. We know about 40% of hospital in-patients receive antibiotics, and nearly half of those are said to be unnecessary or sub-optimal. Hospital doctors also fear blame or litigation if potent antibiotic options are not used. The judicious use of antibiotics is not valued much. Hospital-based â&#x20AC;&#x2DC;antimicrobial stewardship programsâ&#x20AC;&#x2122; can alter behaviour and reduce inappropriate prescribing but doctors quickly

It is not hard for community doctors to envisage escalating health costs and consequences such as infertility, chronic UTIs, and poor pregnancy outcomes when antibiotics lose their effect. Changing human behaviour is not working. Will prohibition? Diagnosing the need for, and prescribing, antibiotics may be handed to only an infectious diseases physician. Different doctors prescribe antibiotics differently, without impacting on cure rates. The difference varies very little for each doctor over time. This says a lot. What professional and organisational structures will we be allowed to support the careful use of antibiotics, particularly potent, broad-spectrum antibiotics that are our only defence against highly resistant bugs, without fear of reprisal if things go wrong? Further reading Animal antibiotics: http://whqlibdoc.who.int/ publications/2012/9789241503181_eng.pdf WHO summary: www.who.int/mediacentre/ factsheets/fs194/en/ Low antibiotic resistance in ACFs: www. biomedcentral.com/1471-2318/14/30 NPS: Symptomatic management pad; NPS Health News and Evidence (duration of antibiotic therapy; vaccination and antibiotic resistance); NPS Direct: Top five key messages: www.nps.org.au/health-professionals O

By Dr Rob McEvoy 31

News & Views

Medical Technology Some bright ideas were on display in the Trade Exhibit at the recent GPCE in Perth. Here’s a small sample.

Foreign body removal For those who struggle getting things out of kids’ noses or ears, this US invention might please. It’s a Bionex product (see www.bionixmed.com) brought to the Oz market by NL-Tec Pty Ltd (Tel 08 9259 5100, www.nl-tec.com.au). The basic unit consists of a small sealed, reusable light source (life span of about 50 ear curettages) that sits on the end of disposable fibre-optic forceps. This improves visibility remarkably, aided by a magnification lens. The forceps action is very touch-sensitive. A box of 10 forceps, with one light source and one magnification lens costs $134.80 (ex freight & GST). They have other product ideas for ear curettage and syringing.

radial artery and the device has been TGA approved. Each BPro unit costs about $5000 so Real Health is providing these to select practices which pre-pay for 10 overnight b.p. reports (at $80 each). The practice charges on top for the service.

CPD Courses The list is growing and many are online, either offering prereading for modules or more. mdBriefCase, a Canadian offshoot, was offering free accredited online activities that qualified for category 1 and 2 CPD points. (see www.mdbriefcase.com.au). Some rural placements require prior training in emergency medicine. For this, there are various providers, including the RACGP and CynergexGroup which were both at the GPCE. In fact, the Medical Emergency or Remote Emergency Courses are offered as companion courses to attendees because face-to-face is required. Both qualify for various CPD points though you need an acronym expert to keep up with it! Costs vary. See www.racgp.org.au/ education/courses/cemp/ and www.cynergexgroup.com.au

Coming to a tearoom near you

White coat hypertension? There are a growing number of selfmonitoring devices that are becoming more portable and user-friendly thanks to technological advances. Real Health International (see www.realhealthint.com, Paul Long 0404 472 012) has brought out a watch-like unit that reports on ambulatory blood pressure, based on 15-minute recordings. Readings are sent to a web portal via a Smartphone App where patient and doctor can view them. Readings are collected through direct pressure interaction with the 32

Medical Media was the brainchild of "BSPO 4LMBWPT XIP FTUBCMJTIFE BCPVU promotional posters in the backrooms of doctor’s surgeries. A later sell-out to Australian Doctor and conversion to wallmounted tablets, means all sorts of people who want the attention of doctors and practice staff can now gain some visual access. This includes rotated messages from OzDoc (news), pharma companies (prescription products), NFPs (health campaigns), Government (announcements), and suchlike. Using wifi, the tablets can be updated remotely. Apparently there are about PVU UIFSF GSFF UP QSBDUJDFT BOE XF HVFTT keeping the tablets away from personal use (photos of the kids) is the biggest challenge. Healthscope has them in their practices. medicalforum

News & Views Kiwis ahead of the game? While most of us are sick of hearing about the PCEHR’s lack of progress, Medtech Global was flying the flag for its equivalent at GPCE, the web-based ManageMyHealth, launched in 2012. It is only available to Medtech32 clinical and practice management software users – comprising 85% of the NZ GP market, so this product dovetails nicely. Medtech32 also has a relatively strong practice presence in WA. If GP and patient agree, the practice gives the patient a secure login to a web portal that also links to them on the practice software, so that test results, requests for scripts (not eScripts as such), booking of appointments, recalls and even secure emails can travel between the two (securely, using SSL technology). It is marketed as good for chronic disease management and patient participation. Shared health summaries, eReferrals, event summaries, and population health clinical audit tools are in there somewhere – it’s all about useful integration of data. The patient’s pages on the website can be used to store other health-related information – news, community forums, calendar and wellness initiatives. The web server is in Melbourne where BDM’s Ms Navina Bilimoria can BOTXFS RVFTUJPOT OCJMJNPSJB! medtechglobal.com) – he didn’t respond to our request for website access. O

Best Practices Since 2002, WA based Medifit has helped hundreds of healthcare providers across Australia create their dream practices. Medifit are medical design and construction specialists. Our experience and efficiency combine to provide a level of service and quality of outcome that is second to none in this space. From initial design concepts, through construction, fitout and beyond, we will deliver the practice you want, in the timeframe and budget you need, without the stress. If you’re thinking of building or refurbishing a practice, contact us today for a no obligation consultation. Your patients won’t be the only ones smiling.

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medicalforum

CLINICAL OPINION

Childhood asthma – going in circles By Winthrop Prof Mark Everard, Paediatric Respiratory Medicine, School of Paediatrics & Child Health UWA

nlike adults with chronic diseases, children with respiratory problems do not (or cannot) articulate how these impact on their quality of life. In a Brisbane study, 15% of children referred to a respiratory clinic with persistent bacterial bronchitis had seen a doctor 20 or more times in the previous year. These are the children with the more tenacious mothers – others give up, feeling dismissed as ‘neurotic’ or frustrated by the failed trials of treatments.

Impacts on child and family can be profound. Night time cough may not wake the child but poor quality of sleep can adversely affect behaviour and daytime functioning. Mothers lose sleep, which adds to the stress of not knowing what is wrong with their child; their frustration builds when the doctor says ‘just another virus’ and ‘don’t worry about it, the chest is clear’; and a relatively well looking child reinforces the doctor’s perception of an ‘over anxious mother’. The management of asthma and related respiratory conditions is about doing simple things well. This involves ensuring correct diagnosis, providing clear explanation, prescribing appropriate therapy, and ensuring the patient uses a device effectively if prescribed inhaled therapy.

Learning from history? About 25 years ago, paediatric respiratory clinics were very straight forward. Preschool and early school age children were referred with recurrent respiratory illness, after multiple courses of antibiotics, with the question, ‘Do they have immunodeficiency’? Back then, prescribing low dose inhaled corticosteroids (ICS) often transformed their lives and parents thought we were wonderful. Doctors in primary care also adopted this approach, in part due to ‘opinion leaders’ who highlighted high levels of under diagnosis and told us ‘wheezy bronchitis’ and asthma were in effect the same and should be treated as ‘asthma’. The message was reinforced by pharmaceutical companies anxious to sell their wares. A decade later we change our view on ‘wheezy bronchitis’. We know the musical sound of ‘wheeze’ results from flow limitation, largely due to bronchospasm. In ‘wheezy bronchitis’, airways secretions and mucosal oedema brought on by viral bronchitis limits flow in the small airways of some pre-school children; ‘wheezy bronchitis’

we renamed the more politically correct (though vague and unhelpful) ‘early transient wheeze’ or ‘viral wheeze’. We are now in danger of going full circle with statements like, “You cannot diagnose asthma under the age of five”, which is likely to return us from over diagnosis to under diagnosis.

Common sense in diagnosis Without wishing to sound like someone ‘teaching grandmother to suck eggs’, it is important to realise that most misdiagnosis occurs because a presumptive diagnosis is not confirmed. While suspicions are raised by the history and maybe clinical signs, a patient should only be categorised as definite asthma when there is a clear and unequivocal response to therapy. Occasionally this is based on a >15% increase in FEV1 with a beta-agonist or a dramatic and rapid response to a beta-agonist when acutely short of breath and wheezy. More commonly it is a dramatic response within six weeks of introducing ICS – the parents’ lives are transformed by them having a ‘new child’ (beyond normal childhood fluctuations of coughing a bit less or waking less). In a child with ‘difficult asthma’, where symptoms persist despite moderate to high doses of ICS, one of three things is usually happening:

1. wrong diagnosis, 2. they have asthma and something else is causing asthma-like symptoms (e.g. persistent bacterial bronchitis or dysfunctional breathing) 3. they are not taking treatment effectively, either missing doses and/or not using a device correctly Hence, the approach is, what is the evidence this child has asthma? If evidence of asthma is clear cut, is there anything else going on? If not, can they and are they taking their inhalers properly? Teaching effective use of inhalers helps but those who choose to ignore advice or who have poor adherence can make this difficult. In wheezy preschool children, distinguishing between the minority with asthma (i.e. will benefit from regular therapy) and the majority with recurrent ‘wheezy bronchitis’ can be a challenge. Assessing a response to a trial of therapy for sufficiently troublesome symptoms is essential if we are to avoid over diagnosis (useless preventer therapy) or under diagnosis (denying asthmatic children effective treatment).

Diagnostic dilemmas – chronic cough One condition that may be misdiagnosed as asthma, or co-exist with asthma, is persistent bacterial bronchitis, particularly in preschool children (although it may occur at any age). ,FZ GFBUVSFT BSF B QFSTJTUFOU HFOFSBMMZ XFU cough, particularly on waking, and shortness of breath on exercise that is really due to the severity of coughing bouts. The variable cough generally does not fully resolve as it does after viral infections; distinguishing it from mild to moderate asthma can be difficult. Recurrent or persistent respiratory symptoms are common, especially amongst preschool children, so attempting to distinguish between frequent respiratory tract infections (no specific therapy), asthma (treatable), or conditions like whooping cough, bacterial bronchitis, airways structural problem, or dysfunctional breathing can be challenging but rewarding if you get it right. O Author competing interests: No relevant disclosures. Reader questions can be directed to the author on Tel 0478 487 630.

medicalforum

CLINICAL UPDATE

Allergic eye disease

By Dr Michael Wertheim, Ophthalmologist

lthough allergic eye disease (AED) can be frustrating and difficult to treat, it helps to simplify it into three main groups. There is usually a family or personal history of atopy and the cardinal symptom of all subtypes of AED is itching.

Seasonal and perennial allergy Seasonal allergy at specific times of the year usually links to a particular seasonal allergen such as grass pollens or mould spores. Perennial allergy is often due to partly avoidable allergens such as house dust mite or indoor pets. Seasonal allergy tends to be more severe than perennial allergy, often when outdoors and the wind is blowing. The eyes tend to be red with swollen conjunctiva (chemosis).

Vernal keratoconjunctivitis 7FSOBM LFSBUPDPOKVODUJWJUJT 7,$ JT VTVBMMZ seen in male children below the age of 10. It tends to be seasonal (but can be perennial), chronic, recurring and bilateral in nature. The disease tends to last 2-10 years and usually resolves after puberty. Around 75% of patients have a history of eczema or asthma. The hallmarks of the disease are lesions at the limbus (Trantas dots â&#x20AC;&#x201C; see Fig. 1), giant subtarsal papillae and corneal ulcers (shield ulcers). The eyelids very rarely CFDPNF JOWPMWFE JO 7,$

present up until age 50 or so, it rarely presents before puberty. Often perennial in nature, chronic rubbing of the eyes can increase susceptibility to keratoconus, cataract and retinal detachment. Affected patients are also more prone to develop blepharitis and Herpes simplex keratitis. The disease can have severe direct complications that include corneal neovascularisation and scarring of the conjunctiva (sympblepharon â&#x20AC;&#x201C; see Fig. 2), so early aggressive treatment is advised to prevent these complications.

Treatment options For AED these range from conservative management to immunosuppression. The former starts with cold compresses and simple lubricants, but most patients will need more focussed treatment such as a mast cell stabiliser olopatadine drops (Patanol, prescription only) or ketotifen drops (Zaditen, over the counter). If mast cell stabilisers (QID for 2 weeks) have good therapeutic results then BD and OD thereafter should keep disease under control. Topical antihistamines and NSAID drops may also be used. For more severe cases, topical steroid and, at times, subtarsal steroid injection may be indicated. Nasal steroid sprays are an excellent adjunct. Beware oral antihistamines though: they can dry the eyes and exacerbate the allergic eye symptoms. O

Q Fig 1. A classic sign of VKC are Trantas dots at the superior limbus. These areas are made up of clumps of degenerated eosinophils

Q Fig 2. Symblepharon is severe scarring between tarsal and bulbar conjunctiva. This scarring can effect the position of the eyelid by contraction and shortening of the fornices. This may lead to corneal exposure and poor lid position

Atopic keratoconjunctivitis Atopic keratoconjunctivis typically affects young adult males and although it may

Declaration: Perth Eye Centre P/L, managing the Eye Surgery Foundation, supports this clinical update through an independent educational grant to Medical Forum. Author â&#x20AC;&#x201C; no competing interests

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CLINICAL UPDATE

A few pitfalls in respiratory medicine P

atterns of referral for complex problems and unresolved diagnostic dilemmas have changed. Improved education, more effective medication and better management plans have had their effect. Most asthma is now managed in general practice because of a good response to combined inhaled steroid and LABA therapy and readily available education and support. COPD is moving in the same direction, while more frequent comorbidities and higher mortality make misdiagnosis more important. What can go wrong with either?

Beware COPD diagnosis on CXR alone COPD is best defined by symptoms and spirometry. Chest x-rays can be misdiagnosed as “COPD” or “emphysema” because of 1) over-penetrated films (darker) – a technical problem, or 2) reported hyperinflation – on x-rays it is defined by the right hemidiaphragm (in the midclavicular line), being at or below the seventh rib anteriorly; asthma, chronic bronchiolitis or congenitally large lungs may produce a similar appearance.

Q Fig 2. Normal chest x-ray.

FEV1 reading to suggest obstructive changes; and early termination of expiratory effort can reduce the FVC to look like a restrictive picture. Poorly maintained and calibrated equipment can produce erroneous results. There are excellent online resources to assist with office spirometry. Additional measurement of static lung volumes and transfer factor improves diagnostic accuracy (e.g. distinguishing airflow limitation due to emphysema, chronic bronchitis, asthma or bronchiolitis) but known limitations, such as a wide normal range, also require clinical and radiological data consideration.

Interpreting dyspnoea

Peak flow is widely used but is often unreliable because it is very effort-dependent and does not discriminate between obstructive and restrictive lung disease. Peak flow is useful for frequent monitoring, for example in occupational asthma.

Dyspnoea due to respiratory impairment is always worse on exertion – severity is measured by the level of exercise intolerance, and walking distance is a good guide. Physical deconditioning (with or without obesity, lower lumbar arthritis or obstructive sleep apnoea) can cause exertional dyspnoea, but this entity is a diagnosis of exclusion. Psychogenic breathlessness usually presents at rest, often improved by exertion; there may be overt hyperventilation or frequent deep sighing breaths. This is a diagnosis of exclusion because this pattern of dyspnoea may occur in mild asthma, bronchiectasis and in subacute or chronic pulmonary embolism – always appropriately investigate the anxious breathless patient! Nocturnal dyspnoea may be a manifestation of cardiac failure, asthma, advanced COPD and sleep disordered breathing (OSA).

Spirometry interpretation

Interpreting chronic cough

Spirometry is mostly used for distinguishing between normal, obstructive and restrictive lung disease. Spirometry is useful for COPD case finding (e.g. screening current and ex-smokers), important for early diagnosis and better management outcomes. However, spirometry involves techniques that the patient needs to be coached on. Poorly performed spirometry can be misleading: submaximal expiratory effort may drop the

For chronic cough (i.e. three weeks or more), think of an airway infection syndrome (pertussis or other atypical pathogens; post viral bronchial irritability), an inflammatory airway disease (e.g. asthma), rhinosinusitis with postnasal discharge (throat clearing cough), gastro-oesophageal reflux, or bronchiectasis. Chronic bronchiolitis suggests itself if there

Q Fig 1: Shows borderline hyperinflation.

Peak flow limitations

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By Dr Michael Prichard, Respiratory Physician, Mount Hospital. is associated inhalational injury, autoimmune disease or otherwise unexplained impairment of spirometry despite normal chest x-ray. Beware the chronic cough with normal chest x-ray. Central airway and mediastinal lesions, retrocardiac lesions, bronchiectasis and bronchiolitis may all be missed on a plain chest x-ray. Gastro-oesophageal reflux may be silent (asymptomatic) in one third of cases, or be suspected by the presence of a hiatus hernia on chest x-ray. CT thorax addresses all of these concerns but ask for a high resolution scan (1-3 mm thick slices) as 10 mm CT slices often fail to detect localised or more subtle bronchiectasis. Expiratory films are useful for detecting bronchiolitis.

Tips for respiratory examinations Wheeze during chest examination. If airway disease is suspected but there is no wheeze on quiet breathing, try forced exhalation; prolonged forced expiratory time with wheeze may be the only clinical sign of airway disease. Not all wheeze is asthma – a fixed (monophonic) wheeze in an asymmetric location is suggestive of central airway obstruction (possible cancer in adults). Breath sounds during examination. These are generally reduced (not the same as reduced air entry) in emphysema. Basal crackles may indicate: left heart failure; interstitial lung disease (may only be present laterally in the midaxillary line), some cases of bronchiolitis and bronchiectasis (coarser crackles).

Miscellaneous COPD is common and frequent exacerbations are a poor prognostic sign. Most exacerbations are due to airway infection but can include environmental exposures, gastro-oesophageal reflux and thromboembolic disease. Inhaled steroids and LABA reduce exacerbation frequency, however the former probably predispose to pneumonia. Accurate clinical diagnosis of pneumonia in the presence of COPD is next to impossible without a chest x-ray (unless it is classical lobar consolidation). Most lung cancers present too late, as symptoms secondary to lung cancer are usually associated with proximal or distant metastasis. There are well-defined risk factors for lung cancer. At risk patients should be screened using low-dose CT thorax (not chest x-ray); criteria for screening include: age >55 years, current or ex-smokers >30 pack years, and no past history of lung cancer. O

Author competing interests: No relevant disclosures. Reader questions can be directed to the author on Tel 9481 2244.

Medical Audiology Services

Hear the best you can!

Evolution of the Modern Cochlear Implant By Dr Dayse Tavora Viera & Dr Vesna Maric

The first commercially available cochlear implant (CI), a single-channel device, was implanted in over 1000 adults between 1972 and mid-1980s. From 1980, candidacy included children over 2 years of age. Meanwhile, multielectrode cochlear implants were being developed simultaneously by three different groups worldwide; Graham Clark’s group at Melbourne University, the UCSF group in the USA and the Holchmairs in Austria. These later became commercialised as Cochlear Corporation’s Nucleus device, the Advanced Bionics’ Clarion and the Med-El system, respectively. The first multi-electrode system was implanted by the Melbourne University group in 1984. The frequencyspecific information it provided marked a significant step towards improved speech understanding. Additional advances in early diagnosis, refinement of surgical techniques and speech processing strategies led to cochlear implants becoming the therapeutic choice for bilateral profound hearing loss. The early success in post-lingually deafened adults and congenitally deaf children drove broadening of selection criteria. Soon, those with residual hearing were implanted successfully, and candidacy extended to include patients with moderate to severe bilateral hearing loss. With this, the potential benefits of hearing aid use in the contralateral ear became the focus, and evidence mounted towards superior results of such ‘bimodal’ hearing relative to CI alone. Importantly, the findings revealed that compatibility between acoustic hearing and electric hearing is possible*. Pushing the candidacy criteria even further, patients with good low frequency hearing and a profound high frequency hearing loss in the same ear became the research focus.

Picture 1. Combined acoustic and electrical stimulation. Image courtesy of Cochlear Limited

Combined electrical and acoustic systems were developed incorporating cochlear implant technology (for high frequency information) and hearing aid technology (for low frequency information) in one instrument, as shown in Picture 1. During early 2000s, multiple studies reported beneﬁts of the combined input over CI use alone or hearing aid use alone*.

Most recently, attention has expanded to cochlear implantation for single-sided deafness. While selection criteria for these patients are still under investigation, several studies have shown that electrical stimulation can be integrated with normal hearing in the contralateral ear and that there is beneﬁt for tinnitus relief and speech understanding*. In Australia, CIs were approved as a treatment for unilateral deafness in late 2013. The current processors are small, lightweight and water resistant. The latest design is a single unit which many users prefer for comfort and aesthetics (see Picture 2). Processors boast high speed, background noise management and connectivity, while modern electrode arrays and surgical techniques allow increasing preservation of residual hearing. Novel internal magnet designs have improved MRI compatibility. *References available on request

Picture 2. Rondo – single unit processor. Image courtesy of Med-El

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

CLINICAL UPDATE

Tests to assess sleep apnoea

By Dr Sina Keihani, Respiratory and Sleep Disorders Physician, Leeming.

bstructive Sleep Apnoea (OSA) is undiagnosed in up to 75% of sufferers. There has recently been a huge growth of groups beyond the relatively small specialised services and traditional sleep labs. To assist health professionals, the Australian Sleep Association (ASA) has now published excellent guidelines for Sleep Studies and CPAP delivery. Accurate assessment of OSA severity is critical because severity correlates closely with risk of future sequelae, including coronary artery disease, stroke and mortality, as well as predicting success with therapies.

Working out pre-test probability of significant OSA is important. Validated tools simplify this process when there is clinical doubt (e.g. OSA-50 or Belin Qn). Assessment also seeks to identify modifiable risk factors, co-existing sleep problems, patient preference for testing and prospective therapies.

Sleep testing Level 1 (attended lab) studies are the reference standard. Advantages include video recording, verification of patient and head posture, real time signal integrity check, and CO2 monitoring. Testing can be used to monitor therapy. Level 2 (portable polysomnographs) are reimbursed once a year by Medicare provided: 7 or more channel recording; prior need established by a qualified Sleep Physician; in someone deemed high risk of significant OSA; and as a part of a comprehensive pathway (usually infers Sleep Physician review). Set-up by a qualified technician assists success; reported failure rate is 7-10% and the Apnoea Hypopnoea Index (AHI) may be underestimated by about 10%. Unsuitable patients are those with neuropsychological impairments, inappropriate home environment, suspected hypoventilation or other co-existing sleep disorders, and other discretionary situations e.g. suspected central sleep apnoea or pure â&#x20AC;&#x2DC;mouth breathersâ&#x20AC;&#x2122;. Limited channel recording (portable, 2-3 signals) lack critical information such as time asleep and often use the manufacturerâ&#x20AC;&#x2122;s automated processing to derive the AHI rather than manual assessment. Accuracy is uncertain, hence these tests are not useful at ruling out OSA (false negative) but an obviously positive test is not usually false.

Using expertise Basic studies can be offered through community groups with variable training and expertise, often with direct links to CPAP sales. If the program is not patient-focused there is a danger here of poor adherence and a lost opportunity. The ASA recommends against clinicians being engaged in the diagnosis of OSA while deriving income from the business of CPAP provision, and vice versa. It is important to differentiate OSA from the syndrome. An estimated 25% of patients with OSA on test actually require specific therapy. Furthermore, there are no uniform accepted criteria for severity scoring of sleep studies hence being familiar with the particular labâ&#x20AC;&#x2122;s index is an important consideration (e.g. AHI or Respiratory Distress Index). Primary care involvement and direct testing accessibility brings key challenges. Assessment ultimately aims to identify those with treatmentrequiring OSA syndrome. Because clinical interpretation and context is vital, knowledge, expertise and adequate specialist support is the key to a successful model of care. Author competing interests: No relevant disclosures. For any clarification, contact author on Tel 6161 7647

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PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Prof John Yovich

&KDQFH RI SUHJQDQF\ UHĂ HFWHG E\ HPEU\R TXDOLW\ â&#x20AC;Ś up to a point? The past decade has seen vastly improved results in IVF, mainly as a consequence of improved laboratory conditions including better culture media systems enabling development through to the day-5 blastocyst stage. Rising implantation rates have now enabled a focus on SET â&#x20AC;&#x201C; single embryo transfers; Australia being the world leaders in this endeavour reducing multiple pregnancy rates to under 10% (compared to 30% in the USA and 20% in the UK and Europe). At PIVET current rates are under 5% whilst maintaining pregnancy rates in the top quartile. Applying the Gardner scoring system for blastocysts shows that the highest grades i.e. 4AA and 5AA, implant at 50-70% rates, the higher levels dependent upon optimal luteal support schedules. At the recent ESHRE meeting in Munich, it appears even higher implantation rates can be achieved by genetic screening of embryos to exclude A Day-5 Blastocyst with Gardner score 4AA aneuploidies which, indicating high quality rating of trophectoderm inner cell mass with full blastocoele cavity like Trisomies 21, 18 & and but not yet hatching 13 and Monosomy X, can be present even in top-scoring embryos. Whilst PGS on Day-3 embryos using FISH technology for 6-8 FKURPRVRPHV SURYHG QRQ EHQHĂ&#x20AC;FLDO WKH FXUUHQW GHEDWH FHQWUHV on Day-5 embryo biopsy with full chromosomal screening using array platforms such as CGH or the more sophisticated SNP array. The technology is moving forward rapidly with next generation massively parallel DNA sequencing. This can now be undertaken with relatively inexpensive desktop instruments such as VeriSeq which can detect even small chromosomal deletions. None-the-less, it appears that embryo quality assessment covers at best 80% of the implantation story and there remains a need for further research concerning the important issue of endometrial receptivity â&#x20AC;&#x201C; both subtle uterine anomalies as well as endometrial synchrony factors may require correction.

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CLINICAL UPDATE

Update: Mesothelioma

By Dr AW (Bill) Musk, Respiratory Physician, Clin/Prof of Medicine and Population Health, UWA. Tel 0409 003 252

estern Australia is currently experiencing, what is hoped to be the peak in incidence of malignant mesothelioma in the community (see graph). Because this cancer currently has a median survival time of less than a year from the time of diagnosis and no available treatment results in complete remission, the attending doctor has a major role in supporting affected patients and their families.

Mesothelioma only appears to develop in response to inhaling asbestos fibres (except for erionite rock fibres in Turkish caves) or very occasionally in response to radiation. There is no level of exposure below which there is no risk and risk of disease increases exponentially after the first 10-15 years following first exposure to asbestos.

The social context Asbestos use in WA was extensive. The current epidemic is a result of the long latent period of this disease â&#x20AC;&#x201C; Wittenoom TIVU EPXO OFBSMZ ZFBST BHP BOE industrial asbestos use has been banned. Removal of asbestos from public buildings has been progressively undertaken but domestic premises containing asbestos persist and legislation covering safe removal and disposal is difficult to enforce. The first wave of mesothelioma cases in the state, attributed to â&#x20AC;&#x2DC;blue asbestosâ&#x20AC;&#x2122; mining and transport from Wittenoom, is tending to decline. The second wave is flattening out and consists of people exposed as carpenters, electricians, plumbers, or suchlike. However, the third wave of people exposed to asbestos distributed around the community continues to increase. Unusual exposures, such as removing carpet underfelt that contains asbestos or the use of hessian bags recycled from Wittenoom to carry superphosphate, have been identified as sources. Any activity that may involve asbestos exposure should be investigated for compensation purposes.

Epidemiology The risk of developing mesothelioma from asbestos exposure increases exponentially for 30-40 years (after the first 10-15 years) but then flattens and may decline, possibly due to clearance of fibres from the lungs and/or the death of more susceptible patients. No gender bias is seen, after considering the greater opportunity of men to have been exposed at work or with DIY. Close follow-up since the early 1970s of Wittenoom workers (miners, millers etc) and township residents relates purely to 40

Q WA Mesothelioma Register

crocidolite (blue asbestos) rather than to mixed asbestos types found elsewhere in industry. The Mesothelioma Registry Committee of the WA Cancer Registry documents the exposure characteristics of all cases, which helps us understand the epidemiology in WA.

Management

Data from Wittenoom indicate a familial predisposition to mesothelioma; the risk of first degree relatives of cases is doubled after allowing for degree of asbestos exposure. This observation has prompted ongoing efforts to understand the molecular genetics of this disease.

Survival studies of mesothelioma cases in WA indicate that age, sex and pathological subtype (epithelioid, sarcomatoid or biphasic) are related to prognosis. The epithelioid type has a longer survival than the sarcomatoid variety (with the biphasic type being intermediate), with median survival times of between 9-10 months and NPOUIT SFTQFDUJWFMZ :PVOHFS QFPQMF fair better than older people and females fare better than males. â&#x20AC;&#x153;Performance statusâ&#x20AC;? is an important determinant. There has been only modest improvement over the decades. Because only about half of cases respond partially to chemotherapy, it usually makes sense to wait for symptoms of the disease to commence, so that any patient who responds may experience improvement in wellbeing. And if there is no response, the patient has at least had a period without toxicity or disabling disease effects, during which time they can do things they want to, such as travel. This is a very individual decision and needs to be taken by the patient with the full information and consultation with family etc. as well as with medical advisors.

Smoking is not related to risk of mesothelioma. Diet may be related, given the observed lower risk of all types of cancer in people on a vegetarian diet. However, vitamin A supplements showed no protective benefit, either as beta carotene or retinol (study by the School of Population Health, UWA). No other protective agents have been identified.

Diagnosis Diagnosis can be less invasive, less expensive and more timely using advanced cytological examination of pleural fluid or fine needle biopsies (validated in WA). In some patients, this avoids the need for larger tissue specimens from pleuroscopic or surgical biopsy. The low dose CT program for earlier detection of lung cancer (a disease more likely to be â&#x20AC;&#x2DC;curableâ&#x20AC;&#x2122;), is specifically not for early detection of mesothelioma. (In fact, there is no demonstrated survival benefit from early diagnosis and initiation of chemotherapy etc., although early diagnosis does allow compensation issues to get under way!)

Multidisciplinary management of mesothelioma improves its clinical course â&#x20AC;&#x201C; respiratory clinicians (diagnosis and initial management), oncologists (chemotherapy and palliative radiotherapy), and palliative care experts (symptom relief).

Helpful support and advice, including compensation issues, may be obtained from the Asbestos Diseases Society in Osborne Park (Tel 9344 4077). O

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CLINICAL UPDATE

Otitis media â&#x20AC;&#x201C; does it need an antibiotic? O

titis media (OM), one of the most common reasons for GP visits in childhood, arises mainly due to immature eustachian tube function in children. The three types are; acute otitis media (AOM), otitis media with effusion (OME) and chronic suppurative otitis media (CSOM)

Accurate diagnosis is the key AOM is a middle ear infection causing otalgia, otorrhoea and possibly pyrexia. OME is a non-purulent collection of mucinous or serous fluid in the middle ear characterised by hearing loss but rarely otalgia and usually follows recurrent episodes of AOM. CSOM is persistent or recurrent ear infections resulting from tympanic membrane perforation. Examination via pneumatic otoscopy should include noting the colour, position, mobility and any perforation of the tympanic membrane. Adjunct tests may include tympanometry and audiometry. Antibiotic use in OM is controversial due to

By Dr George Sim, Paediatric ENT Surgeon, Murdoch ENT.

issues with costs and microbial resistance. Accurate diagnosis of the type of OM determines the role of antibiotic treatment.

Management Treatment of AOM in a child with no pyrexia is observation with adequate analgesia for 48 hours. Systemic antibiotics are recommended if symptoms persist for more than 48 hours or if fever above 39oC develops. Amoxycillin (90mg/kg/day) is the antibiotic of choice if the person is not allergic. Risk factors for AOM (parental smoking, pacifier use, daycare attendance) should also be assessed with parents. Three episodes in six months or four in 12 months should trigger an ENT referral. OME needs to be distinguished from AOM. Studies show limited long-term benefits from antibiotics, antihistamines, and intranasal and systemic steroids. Any child with OME for more than three months or with hearing, speech or learning issues should be referred to an ENT surgeon. Treatment is insertion of grommets and possibly adenoidectomy.

CSOM is managed initially with 0.5% Betadineâ&#x201E;˘ ear toilet and topical fluoroquinolone drops e.g. Ciloxanâ&#x201E;˘. It is important to ensure the patient does not have a cholesteatoma. Systemic antibiotics are usually used in patients with suspected complications of CSOM such as lateral sinus thrombosis, meningitis or cerebral abscess. Uncomplicated CSOM requires ENT referral for a myringoplasty. References available on request

SUMMARY OF MANAGEMENT Acute Otitis Media (AOM) t 1BJO SFMJFG POMZ GPS IST JG OP QZSFYJB t "OUJCJPUJDT BNPYJDJMMJO VOMFTT BMMFSHJD JG OPU TFUUMJOH PS QZSFYJB P$ t &/5 SFGFSSBM GPS SFDVSSFOU "0. Otitis Media with Effusion (OME) t .BOBHF DIJME XJUI OP SJTLT CZ XBUDIGVM XBJUJOH t -JNJUFE SPMF GPS BOUJCJPUJDT BOUJIJTUBNJOFT BOE TUFSPJE TQSBZT t 1FSTJTUFOU 0.& BOE TZNQUPNBUJD DIJME SFRVJSFT &/5 SFGFSSBM Chronic Suppurative Otitis Media (CSOM) t %SZ FBS QSFDBVUJPOT t #FUBEJOF FBS UPJMFU BOE GMVPSPRVJOPMPOF ESPQT t &/5 SFGFSSBM GPS NZSJOHPQMBTUZ

Declaration: competing interests - nil relevant disclosures. Please direct questions to author on Tel 6332 6868

Q Acute otitis media

Q Otitis media with effusion

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CLINICAL OPINION

Amniotic ďŹ&#x201A;uid embolism demands our respect By Clin A/Prof Nolan McDonnell, Obstetric Anaesthetist, Lead Investigator, AFE Study, Australasian Maternity Outcomes Surveillance System.

mniotic Fluid Embolism (AFE) is one of the most feared complications of pregnancy because it can seemingly strike down otherwise healthy women at random and, in the space of a few minutes, turn what was otherwise an unremarkable pregnancy into a catastrophe. Despite advances in modern medicine, AFE remains a leading cause of maternal mortality in developed countries and we still fail to fully understand the condition.

Incidence and outcomes It is a testament to the high quality obstetric care that a condition that was once a â&#x20AC;&#x153;minorâ&#x20AC;? contributor to mortality statistics now dominates, and in the case of Australia and New Zealand, leads the causes of maternal mortality. Currently, AFE is thought to complicate BCPVU QSFHOBODJFT JO "VTUSBMBTJB with a mortality of between 10-40%. It most commonly presents either at delivery, or within the first few hours afterwards but it can occur at any gestation, particularly if there is any uterine manipulation or trauma.

Whilst AFE was once almost inevitably fatal, the decreased mortality now is most likely due to improved knowledge of the condition (such that less severe cases are reported) and advances in resuscitation and ICU care.

Presentation and management AFE can present in a wide variety of ways, from sudden maternal cardiac arrest through to a relatively mild subclinical entity. Premonitory symptoms are common â&#x20AC;&#x201C; such as feeling short of breath and difficult breathing â&#x20AC;&#x201C; as are coagulation abnormalities that can develop incredibly rapidly. Management follows the principles of basic and advanced life support with special considerations given for the pregnant or recently pregnant state and the potential for significant deterioration. Immediate delivery of the neonate may significantly improve the maternal condition.

Unanswered questions Why AFE actually occurs is unclear. There is no reliable animal model of AFE and it would appear that the presence of amniotic fluid in the maternal circulation is relatively

common, yet for some reason in some women it triggers the syndrome. Because we rely primarily on a clinical diagnosis (i.e. there is no diagnostic test), accuracy in diagnosis of AFE is an issue. What can be done to reduce or improve outcomes from AFE? The risk factors for AFE are not readily modifiable (e.g. multiple gestations, fetal macrosomia, augmentation of labour) and the emphasis at the moment is on improving access to high quality maternal resuscitation.

The future ,FZ MFBQT JO PVS LOPXMFEHF PG "'& BSF MJLFMZ to come from a better understanding of the patho-physiological processes that trigger and sustain the condition. With the lack of an animal model to replicate AFE, this information comes from the publication of case reports, especially those that offer unique insights by the use of relatively modern (for anaesthetists and intensivists) technology such as echocardiography and through the notification and reporting of cases through registries such as AMOSS. O

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There is a large body of research demonstrating the high prevalence of sleep apnoea in patients with cardiovascular disease. There is a significant treatment gap for patients with sleep apnoea in Australia and in particular, in Western Australia, where access to services is limited. Provision of sleep diagnostic and treatment services in Shenton House through our SleepCare clinic provides greater access to these services in the growing Joondalup area. Our dedicated local team of sleep professionals have access to the full range of diagnostic and therapy options. We offer timely, accurate diagnostic and treatment studies, sleep physician consulting and ongoing OSA therapy management.

SleepCare Shenton House now offers a 3 bed overnight sleep service Monday to Friday and has currently no wait list.

Sleep Physician consulting Ongoing OSA therapy management

t. 9400 9886 f. 9400 9626 e. jscr-reception@genesiscare.com.au 57 Shenton Ave, Joondalup opposite Joondalup Health Campus

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CLINICAL UPDATE

Throat clearing: annoyance or pointer? Throat clearing is a common symptom. It is often erroneously attributed to a “postnasal drip”. Patients are frequently treated empirically for allergy or sinusitis with perhaps some responding temporarily to the placebo effect.

degrees and the vocal cords lose their “tendinous” white appearance (see Fig 3). There is often no more mucus identified on examination but the inflamed mucosa is irritated and mimics a sense of mucus in the region.

be mucogenic in sensitive individuals. A systematic one month trial of abstinence can help identify the causative agent with reintroduction to see if symptoms recur, to confirm it. The patient can then decide if it is worthwhile excluding it from their diet long term. Mucinous saliva helps lubricate the mucosal contact points during the swallowing process. Thickened, dry mucus can create a sense of irritation in the larynx and can be a sign of inadequate fluid intake or an anticholinergic side effect of prescription medication. Rarely does it herald autoimmune sialadenitis (Sjogren’s Disease).

Q Fig 3. Reflux laryngitis

Post-nasal drip

More detailed history taking will often elicit

Q Fig 1. Normal larynx

Q Fig 2. Pyriform fossa tumour

other symptoms such as hoarseness, mild discomfort, reflux or cough. “Red flags” for cancer include pain, dysphagia, weight loss, blood stained pharyngeal secretions or true haemoptysis; especially in patients who smoke. Whilst most patients can be reassured, those at high risk or with persistent symptoms require further assessment to exclude serious pathology.

Larygopharyngeal reflux An extension of gastro-oesophageal reflux, the larynx is often inflamed to varying

Patients clear their throat, trying (unsuccessfully) to rid themselves of the irritation. Hence the repetitive attempts which often occur subconsciously. Reflux laryngitis does not always respond to acid suppression alone and may require dietary and lifestyle modifications as well. It can often take some weeks of treatment for the laryngeal inflammation to subside and symptoms to improve. An alginate may be helpful as an adjunct as it creates a gel precipitate, which acts as a “raft” barrier to reflux. In refractory cases, adding a pro-kinetic agent and a H2 antagonist may be helpful. A barium swallow gives some functional information of oesophageal motility. Occasionally a pharyngeal pouch or hiatus hernia is identified. Frank reflux may also be elicited during a “water siphon” test. An Upper GI endoscopy is a reasonable alternative.

Mucosal allergy or dryness Some foods, like dairy, wheat or eggs can

Antimicrobial Stewardship. Their work to reduce surgical site infection by using topical decolonisation rather than oral antibiotic prophylaxis was recognised. X Prof Harvey Coates and Prof Gunesh Rajan have won a research award for their tissue engineered tympanic membrane at the Garnett Passe and Rodney Williams Memorial Foundation ‘Frontiers’ meeting. X Dermatologists Clin A/Prof Carl Vinciullo and Dr Harvey Smith received the national 2014 Award for Excellence in Innovative Clinical Practice for medicalforum

By Dr Geoffrey Hee, ENT Surgeon, Nedlands.

X Dr Allan Pelkowitz has been appointed regional coordinator for medical services at St John of God Health Care Group’s Perth northern hospitals. He will continue as medical director of SJG Midland Public and Private Hospitals and will assist with integration of services at the SJG Mt Lawley (previously Mercy). X Ms Heather McRobb, of Eaton Medical Centre and Australind Medical Centre is the 2014 AAPM Practice Manager of the Year WA.

True post-nasal drip is less common than one might expect. Mucus in the laryngeal region is often incorrectly assumed to arise from the postnasal space. Topical nasal steroids can be helpful if there are other symptoms of allergic rhinitis. Occasionally adenoiditis is identified on fibre-optic examination and antibiotics are required. Chronic rhinosinusitis will usually have other associated symptoms such as nasal obstruction and mucopurulent nasal discharge. Occasionally, tonsillar hypertrophy or an elongated uvula can irritate the pharynx and contribute to throat clearing. This is usually easily identified on clinical examination but other more common causes need to be considered before entertaining surgical treatment. O Author competing interests: nil relevant disclosures. The author can answer reader queries on Tel 9386 9418

X The research team from UWA’s Optical + Biomedical Engineering Laboratory, in collaboration with clinicians from RPH and SCGH are finalists in this years WA Innovator of the Year awards for developing the world’s smallest microscope. The microscope can fit into a needle and is capable of detecting cancer cells. XAmity Health, based in Albany, has been awarded a $342,000 contract to QSPWJEF B ,JET )FBMUI -JOL QSPHSBN GPS disadvantaged children and families in the Eastern Wheatbelt.

Arts and Health

Q Western Desert Kidney Health Project choir. Photo: Matt Scurfield.

From Little Things

Big Things Grow

Goldfieldss Paediatrician Paeddiatrician Dr Christ Christine tine Jeffries Jeffries-Stokes Stokes has seen the power of the arts to heal – both body and soul. Now she’s preparing the evidence. For 20 years, since her work with Fiona Stanley and the Telethon Kids Institute took her to the Goldﬁelds to engage with the community to improve maternal and infant outcomes, Dr Christine Jeffries-Stokes has seen how the arts can cut through where facts, ﬁgures and good intentions could not. /FYU NPOUI ,BMHPPSMJF #PVMEFS XJMM IBWF UIF OBUJPOBM BOE JOUFSOBUJPOBM TQPUMJHIU PO JU XIFO UIF GPVS EBZ CJFOOJBM "VTUSBMJB 4VNNJU "SUT &EHFT PS UIF ACVTI CJFO OBMF BT JU JT BMTP LOPXO LJDLT PGG )FSF $ISJTUJOF XJMM EFMJWFS UIF GJOEJOHT PG UIF UISFF ZFBS 8FTUFSO %FTFSU ,JEOFZ )FBMUI QSPKFDU XIJDI BNPOH TPNF QPTJUJWF IFBMUI OFXT IBT VOFBSUIFE TPNF TFSJPVT DSFBUJWF UBMFOU i*U T CFFO BO FOPSNPVT QSPKFDU UP FYBNJOF UIF SFDFQUPST UP EJBCFUFT BOE SFOBM EJT FBTF JO QSFEPNJOBOUMZ "CPSJHJOBM UPXOT BOE DPNNVOJUJFT JO UIF (PMEGJFMET 8F WF TDSFFOFE UIF IFBMUI PWFS QFPQMF BOE IBWF SFUVSOFE FBDI ZFBS GPS UISFF ZFBST UP EP GPMMPX VQ TDSFFOJOHT w &BDI WJTJU XBT BDDPNQBOJFE CZ BO BSUT FOHBHFNFOU UP FOIBODF UIF IFBMUI NFTTBH FT BOE UIF SFTVMUT BSF FODPVSBHJOH i5IF GJSTU ZFBS XBT UFBDIJOH FTQFDJBMMZ DIJMESFO UP SFDPHOJTF UIF SFDFQUPST GPS EJB CFUFT BOE LJEOFZ EJTFBTF 5IF QSFWFOUJPO NFTTBHF XBT CBTJDBMMZ UP FBU XFMM o ESJOL XBUFS BOE FBU OBUVSBM GPPET OBUJWF BOJNBM NFBU BOE GSVJU BOE WFHFUBCMFT w

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Australia Summit: Arts & Edges, Kalgoorlie– Boulder October 16-19

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By Ms Jan Hallam

www.westerndesertkidney.org.au

medicalforum

Wine Review

GraceElegance Wines of

2012 Cape Grace Chenin Blanc "UUSBDUJWF USPQJDBM GSVJU OVBODFT BOE QMFBTBOUMZ ESZ XJUI B SFGSFTIJOHMZ DSJTQ GJOJTI 5IJT JT B TFSJPVT BDDPNQBOJNFOU UP GPPE BOE OPU UP CF DPOGVTFE XJUI PUIFS TXFFUJTI XJOFT PGUFO MBCFMMFE BT MBUF QJDLFE DIFOJO 5IFSF JT BCVOEBODF PG GMBWPVS BOE BDJEJUZ IFSF UIBU XJMM LFFQ JU GSFTI GPS B GFX ZFBST " WBSJFUZ UIBU * CFMJFWF EFTFSWFT HSFBUFS SFDPHOJUJPO

By Dr Louis Papaelias

2011 Cape Grace Chardonnay

This monthâ&#x20AC;&#x2122;s featured wines come straight from the heart of the Margaret River wine region. The Cape Grace vines were planted on 7ha of Wilyabrup gravelly soil in 1996. Owners Robert and Karen Karri-Davies like to point out that Dr Tom Cullity had originally wanted to establish his Vasse Felix vineyard on that same patch of land. Why he didnâ&#x20AC;&#x2122;t, I donâ&#x20AC;&#x2122;t know. Perhaps one of our readers can help here!

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2012 Cape Grace Cabernet Shiraz "UUSBDUJWF ESJOLJOH SJHIU OPX 5IJT XJOF CBMBODFT UIF SFGJOFNFOU PG UIF $BCFSOFU HSBQF BOE UIF NPVUI GJMMJOH TQJDF PG 4IJSB[ 0BL JT VOPCUSVTJWF

2012 Cape Grace Shiraz

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WIN a Doctor's Dozen! Wine Question: Which Cape Grace wine is hand-plunged and basket-pressed? Answer:

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

ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, September 30, 2014. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

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Please send more information on Cape Graceâ&#x20AC;&#x2122;s offers for Medical Forum readers.

Eductaion s monstrate Barker de Robert Grohs e n li u a P Dr ker Dr RPH intern Q J Sp e a chnique to r! suturing te stomary pig trotte cu using the

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Q Renal physician Dr Mark Thomas answers post-lecture questions from UWA medical student Justin Sykes.

Q The interactive session on diabetes care, presented by interstate Drs Leow and Audehm, took delegates through scenarios whereby PBS preconditions for prescribing various diabetic drugs were explained, including apparent contradictions in PBS listings. Q Learning new skin flap procedures: Dr Kavalkumar Patel (Merriwa).

Q Dr Graham Farquhar (Leeming) finds fresh coffee to kick-start his day

medicalforum

Travel

An atheist pilgrimâ&#x20AC;&#x2122;s progress

Q The walkers in front of the Travelling Monk sculpture, Chittering Valley. Photo: Tony Stefanoff.

A couple of times a year, walkers and â&#x20AC;&#x2DC;pilgrimsâ&#x20AC;&#x2122; alike join the Camino Salvado, from the steps of St Josephâ&#x20AC;&#x2122;s Church, Subiaco, to the New Norcia monastery. Dr Donna Bing-Ying Mak writes of the experience.

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medicalforum

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By Dr Donna Bing-Ying Mak

Music UK concert pianist Stephen Hough explores new and interesting ways to spread the musical word. Photography (c) Sim Canetty-Clarke

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By Ms Jan Hallam