Medical Forum – April 2022 – Public Edition

Saving hearts

Cardiovascular Health | Myocarditis, atrial fibrillation, TAVI, CVD dental risk, 3D valve printing

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Dr Fiona Langdon Obstetrician and gynaecologist, WA

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Cathy O’Leary | Editor

Two hearts shift focus

It’s difficult to bump COVID off the front page but the death of two revered Australian cricketers did just that a few weeks ago.

Perhaps we were all so sick of the doom and gloom of lockdowns, closed borders and coffee prices tipped to hit $7 that we were all keen to relive the career highlights of the larger-than-life cricketing pair.

Even people who think cricket is as interesting as watching grass grow (yes, guilty) were happy to indulge the pages and pages of reminiscing and images of Warne looking every inch a celebrity.

It was a reminder that all our usual chronic health problems are still ticking over while the global focus is on one virus.

But the fact that both Marsh and Warne died from suspected heart attacks also resonated.

It was a reminder that all our usual chronic health problems are still ticking over while the global focus is on one virus.

A headline about heart disease doesn’t have the same punch as one about the mounting COVID toll, but a 52-year-old sports star dying of a heart attack managed to push COVID off the start of news bulletins, at least for a few days.

And speculation that perhaps Warne’s earlier COVID infection might have played a role in his death, although unproven, has nevertheless added impetus to ongoing research into the long-term impact of COVID on the heart.

This month we look at some of these so-called long-tail effects, and not just in people with preexisting risk factors.

And just to remind ourselves of the how far heart research and technology have come, we hear from a Perth cardiothoracic surgeon whose job involves saving hearts and lives.

Our cover: Professor Robert Larbalestier.

Picture: Tony McDonough

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MEDICAL FORUM | CARDIOVASCUL AR HEALTH

APRIL 2022 | 1

CONTENTS | APRIL 2022 – CARDIOVASCULAR HEALTH

Inside this issue 16 26

12

20

FEATURES

IN THE NEWS

LIFESTYLE

12 Cover story:

1

62 Doctor of laughs will see

Dr Robert Larbalestier

16 Health insurance:

Editorial: Two hearts shift focus – Cathy O’Leary

4 News & Views 6 In brief 10 Opinion: Counting the

Mind the gap

20 Rural docs – growing our own

26 COVID and the heart

you now

65 Wine review: Cullen Wines – Dr Craig Drummond

66 Sean Tinnion – Soundtrack for life

cost of COVID

30 PCH tackles rare diseases 47 Taking nothing for granted

of the matter

– Dr Joe Kosterich

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WINNING WAYS Dr Greg Smith of the Seacrest Medical Centre won our February doctors dozen wine from Fermoy Estate.

And the lucky winners of a double pass to the Alliance Francaise French Film Festival were Drs Paul Kwei, Mark Strahan, Peter Brockhoff, Catherine Civil and Andrew Christophers.

This month, we have a dozen bottles from WA’s iconic Cullen wines up for grabs. Read Dr Craig Drummond’s review and his top wine pick on page 65.

We also have a double pass to see Dr Jason Leong, performing at the Perth Comedy Festival, on Friday May 6 at the Astor Theatre.

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Management of cardiovascular concerns during pandemic Dr Sudha PottumarthyBoddu

LAAO in atrial fibrillation

By Dr Richard Clugston

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Clinical value of 3D printing in CVD Prof Zhonghua Sun

COVID impact on vascular disease Dr Robert Ma

Myocarditis in the time of COVID Dr Steve Gordon

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Dental and cardiovascular health Dr Amanda Phoon Nguyen

Diet and cardiovascular health Jo Beer

Lipoprotein(a) for cardiovascular risk assessment Dr Michael Page

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We know it hurts Dr Bruce Powell

Doctors don’t get sick, right?

Dr David Oldham

Living with COVID is not that easy Rachel Seeley

Getting down to business, COVID smart Jayden Rogers

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NEWS & VIEWS

Walk right in A new walk-in mental health centre has opened its doors in the eastern suburbs.

The Midland Head to Health adult mental health centre is for people seeking help for mild-to-moderate mental health concerns, including stress and anxiety.

It provides a new approach in the mental health system and removes some of the traditional barriers for people seeking support by offering a free, community-based walk-in service available from 10am to 8pm every day of the year.

Midland Head to Health is part of a Federal Government initiative to trial a number of adult mental health centres to improve access to these services for people whose condition may be too complex for many existing primary care services but does not meet the criteria for acute services.

Project hits milestone WA’s first children’s hospice has moved a step closer, with Cancer Council WA chipping in $6 million towards the project which is being coordinated through the Perth Children's Hospital Foundation.

The funding is thanks to a generous bequest from Joan Street and her 4 | APRIL 2022

No referral or appointment is required, and it will provide a safe environment for LGBTIQ+ people, Aboriginal and Torres Strait Islander people and those from diverse cultural backgrounds.

brother John Street, who included a gift in his will for the specific purpose of investing in palliative care hospice facilities.

The hospice will provide palliative out-of-home respite care and support for children aged up to 18 years and their families.

The estimated construction cost is $25.5 million and this latest donation takes the total funding secured by the foundation to more than $23 million.

A $4 million Lotterywest grant has

previously been secured to help with the construction and the State Government has committed $3.2 million for planning and an increase to the current service capacity of the WA Paediatric Palliative Care Service. It is also providing Crown land in Swanbourne for the project.

The PCH Foundation will provide funding for the construction, fitout and ongoing non-operational costs of the hospice, while the Child continued on Page 6

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Management of cardiovascular concerns during the pandemic SARS-CoV-2, known as COVID-19, brought the world to a screeching halt nearly two and a half years ago.

The emergent global collaboration resulted in enhanced understanding of the disease, fast-paced production of molecular and antibody-based assays to assist in management and finally, 10 different vaccines (Emergency Use Listing, WHO) to enable prevention.

Despite this, resumption of normalcy has been staggered with rapid emergence of a series of SARS-CoV-2 variants, currently Omicron, which has rendered some molecular assays ineffective and brought the efficacy of the vaccines into question. The unprecedented COVID-19 vaccine mandate, with mass vaccination worldwide for everyone five years or older, has brought to light previously unrecognised vaccine-related adverse events.

By Dr Sudha Pottumarthy-Boddu MBBS FRCPA D(ABMM) Dr Sudha Pottumarthy-Boddu has a distinguished career in microbiology with extensive experience in the US New Zealand and Australia. Sudha is a Diplomate of the American Board of Medical Microbiology, and a member of both the Antimicrobial Stewardship Committees and Infection Prevention and Control Committees at multiple St John of God hospitals in WA. While primarily a respiratory infection, there is a bi-directional interaction between COVID-19 and the cardiovascular system, with the development of myocardial injury, arrhythmias, acute coronary venous syndrome (ACS) and venous thromboembolism with COVID-19 infection.

The life-threatening cardiovascular events noted with COVID-19 infection is in contrast to mild, self-limiting myocarditis/pericarditis associated with COVID-19 vaccine.

According to US Centers for Disease Control and Prevention, the incidence rates of myocarditis/pericarditis are ~12.6 cases per million doses of second-dose mRNA vaccines among 12-39 years of age, with a strong male predominance and occurs within days of vaccination.

Noting that the mortality from COVID-19 infection remains high (0.1 to 1 per 100,000 for the 12-29-year age group), the risk-benefit ratio is overwhelmingly in favour of the COVID-19 vaccination.

As our experience with the virus evolves, how does this knowledge impact our management of patients presenting with cardiovascular concerns?

Cardiologists are seeing many people who, along with their GPs, have concerns that chest pain after COVID vaccination represents a myo/ Dr Michael Davis, Cardiologist pericarditis, raising questions about having booster vaccinations.

Few of the many I have seen have a clear cardiac cause.

Typical pericarditic pain is central anterior, pleuritic and exacerbated by lying flat and responds to anti-inflammatory agents. Usually after mRNA rather than other vaccines, the pain (and dyspnea, palpitation) comes on 1-5 days after (more commonly second dose) vaccination.

The diagnosis is confirmed by ECG, high sensitivity troponin, and possibly echocardiography.

ATAGI states that ‘further doses of an mRNA COVID-19 vaccine can be given to people who have been investigated for pericarditis but who had normal ECG, troponin and inflammatory markers, and who have been symptom-free for at least six weeks.

Recently, we have seen a significant increase in patients seeking screening for cardiovascular disease.

Dr Rajesh Kanna, Cardologist, With so much information about the recognised but rare side effects of COVID-19 vaccines on the cardiovascular system, patients are asking a lot of questions, which is translating to higher numbers of GP referrals and presentations to ED of young people having chest pain and palpitations after vaccine administration. This has led to increased demand for ECG, pathology and imaging.

But we have seen that the risk with COVID vaccines is very low, even amongst patients with symptoms.

We haven’t seen many patients during or post-COVID infection yet. We are hopeful that due to our current high vaccination rate, we will see a lower incidence of cardiac complications from the virus.

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Prominent WA barrister and solicitor Rob McKenzie has been appointed to the board of the Perron Institute for Neurological and Translational Science.

His experience spans a wide range of industries including financial services, health, science, technology and education.

Down the road, QC Wayne Martin has stepped down as chair of Harry Perkins Institute after three years. Taking the helm is John Barrington, co-founder of artificial intelligence company Artrya, which is developing ways to improve the diagnosis of coronary heart disease.

Pharmaceutical company Zelira has announced plans to buy Health House International, a global distributor of medicinal cannabis products.

HBF has signed an agreement with Terry White Chemmart to provide pharmacy-based health services for its members outside of WA, where it already has a deal with Pharmacy 777.

HBF says it is part of a national expansion plan.

In other moves at HBF, Diane Smith-Gander will succeed Tony Crawford as chair of the not-forprofit private health insurer. Ms Smith-Gander has been on the HBF board since May 2020 and was most recently chair of Safe Work Australia.

St John of God Health Care has appointed Paul Dyer as its new CEO at SJOG Midland Public and Private Hospitals. His appointment takes effect from May 9, taking over from Michael Hogan who is moving back to his home state of Victoria. Mr Dyer is currently CEO of SJOG Mt Lawley Hospital.

6 | APRIL 2022

NEWS & VIEWS

continued from Page 4 and Adolescent Health Service will be responsible for governance, management and operational clinical and support services funding.

Safe and found WA Police and Medic Alert Australia have created a new Australian-first missing person initiative, Safe & Found, which is now being rolled out in WA to keep vulnerable people like the elderly safe and reduce pressure on families, carers and front-line workers.

Safe & Found uses unique member personal information and behavioural characteristics to

support police in locating people quickly and reuniting them with families in the event they go missing.

Demand is expected to increase with growing dementia rates.

The program has already helped in several successful searches in WA and there is now a focus on promoting it to health professionals so they can advise their patients about the resource. Details are at www.safeandfound.org.au

Ringing ears As many as half a million Australians suffer from constant tinnitus, with farmers, automotive workers, transport drivers, construction continued on Page 8

Melanoma scare for cancer chief When Cancer Council WA CEO Ashley Reid grew up in Perth in the 1970s, a slick of zinc cream across his nose was the extent of his skin cancer protection.

Ironically just as a new national skin campaign was being launched by the council last summer, Mr Reid was diagnosed with an earlystage melanoma after he noticed a suspicious mole on his right calf.

Mr Reid said hearing the words ‘you have cancer’ came as an enormous shock.

“As CEO of Cancer Council WA, I talk about cancer and statistics every day,” he said.

“I talk about WA and Queensland having the highest rates of skin cancer in the world and how skin cancer (melanoma, basal cell carcinoma and squamous cell carcinoma combined) is the most common cancer type, and the most costly to treat.”

Just before Christmas he underwent urgent surgery which involved an incision in his right calf down to the muscle, requiring 14 stitches.

He then faced an anxious wait until he was reassured that doctors had all the margins and the cancer had not spread.

“Back in the 1930s and ’40s, a cancer diagnosis was often fatal,” Mr Reid said. “But we’ve seen huge gains in survival rates especially for melanoma as a result of increased symptom awareness, early detection and improvements in treatment all through huge investments in research.”

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continued from Page 6 workers and other trades people at the greatest risk, Curtin-led research has found. The study, published in the Medical Journal of Australia, examined the prevalence of tinnitus among 5000 adult workers across the country.

Lead author and audiologist Kate Lewkowski from Curtin’s School of Population Health said the survey results indicated one-quarter of the Australian workforce suffered from tinnitus, including half a million who live with it constantly.

Working men aged 55 to 64 years were most likely to suffer from the condition. At-risk transport workers included mobile plant operators, as well as taxi, delivery, truck, tanker, bus, rail and forklift drivers.

Access to care in focus Cancer researcher and director of the Harry Perkins Institute, Professor Peter Leedman, has supported

a call for a national network of comprehensive cancer centres, where research, cancer trials and holistic patient care are combined to drive better patient outcomes.

A national network of specialised cancer centres is being considered in the development of the Federal Government’s Australian Cancer Plan and was recently discussed at a meeting of the leaders of cancer centres across Australia.

Professor Leedman said a comprehensive cancer centre in WA would help overcome the disparity that exists between patient outcomes in different regions and between different types of cancers.

“Evidence shows that comprehensive cancer centres such as Victoria’s Peter MacCallum Cancer Centre can overcome disparity and deliver better outcomes for

patients as well as provide them with a much better cancer journey.

“While Australia has some of the best survival rates in the world, with five-year survival for all cancers at 69%, patients in regional and rural Australia had a 7% higher cancer mortality compared with those in metropolitan centres.

“We need a plan that addresses some of the disparities in cancer outcomes caused by our geography.”

Correction: Medical Forum inadvertently published an out-ofdate advertisement on behalf of ChestRad in our March issue, which showed a Calcium Score price of $75. The correct price is $95.

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Research sheds light on hearing loss When baby Charlotte’s cochlear implants were turned on for the first time, her mum said her face lit up with wonder.

Charlotte has been part of a Perth Children’s Hospital hearing loss study into cytomegalovirus, a virus linked to childhood hearing loss.

Lacy Swan believes her decision to allow her newborn baby to have a simple saliva swab for research into the virus was crucial in giving them an early diagnosis of profound hearing loss and access to support.

Charlotte started off with tiny hearing aids at eight weeks old and had cochlear implants fitted when she was nine months old.

After Charlotte’s saliva swab, a follow-up urine test determined that she was positive for CMV, the most common infectious cause of hearing loss in children. For a small number of babies born with CMV infection, life-long hearing loss is known to occur.

8 | APRIL 2022

The WA-first, two-year hearing loss study is now at the halfway point. Researchers want to find out how common CMV is in infants with hearing loss in WA, to track the hearing loss and see whether early diagnosis improves care and ultimately hearing, speech and language development.

Parents of babies born in WA who are aged less than 21 days and don’t pass their newborn hearing screen can enrol. CMV testing must be carried out within the first 21 days of birth to determine if the virus was acquired in utero or after birth.

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NEWS & VIEWS

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Caution advised over heart screening tests Dr Jane Deacon - Manager, Medico-legal Advisory Services, MDA National

Ms H was a 43 year old woman, mother of two young children, and a successful business executive and she was invited by her employer to undergo a ‘cardiac health assessment’ in March 2019.

The ‘cardiac health assessment’ consisted of a coronary artery calcium score and CT coronary angiogram.

Ms H had no history of cardiac problems but was encouraged by her workplace to undergo the assessment. Dr T was the radiologist in attendance on the day Ms H attended the radiology practice for the procedures, and was the only doctor on site. Unfortunately, Ms H suffered a severe allergic reaction when the Omnipaque dye was administered intravenously.

Resuscitation was commenced on site, an ambulance called and Ms H was taken to hospital, but she died about a week later without regaining consciousness.

The cause of death was multisystem organ failure and hypoxic/ischaemic encephalopathy due to anaphylactic reaction to CT contrast medium.

The scan report showed that Ms H had a calcium score of 0 and normal coronary angiogram.

Ms H’s death was the subject of a coronial inquest 1. Ms H’s family requested the inquest, noting that a number of factual issues required investigation and that there were important public health implications, ‘including the process of company employees being tested, the failure to be seen by a doctor prior to an invasive test and the management of her anaphylactic reaction’.

The Inquest Outcome The inquest lasted over two weeks, involving sixteen witnesses and six expert witnesses.

most suitable or whether there should have been a preliminary assessment by a medical practitioner.

The radiology request forms were affixed with Dr S’s electronic signature, although he had never seen or spoken to the people undergoing the tests, and he considered his role was to receive the results and have a discussion with the participants about their results.

The coroner considered that Ms H had not fully given her consent as she did not know the true nature of the procedure, and possible alternate pathways, and had not discussed the procedures with either the referring doctor, or the radiologist.

Ahpra notifications The referring doctor, Dr S, was referred to Ahpra. The coroner was critical that Dr S had allowed his signature to be used for referrals for patients he had not reviewed, and that Dr S failed to apply ethical standards as he considered himself to hold a lesser obligation to persons who he considered to be ‘clients’ or ‘candidates’ rather than ‘patients’.

The radiologist, Dr T, was also referred to Ahpra, with the coroner finding that the CT scan was performed on the basis of a referral with insufficient clinical detail, and that Dr T failed to recognise and manage Ms H’s anaphylaxis appropriately.

Recommendations Extensive recommendations were made by the coroner with many relating to improving the recognition and management of severe contrast reactions and anaphylaxis.

Other recommendations include that: The Royal Australian and New Zealand College of Radiologists (RANZCR) prepare a joint position statement with the Cardiac Society of Australia and New Zealand regarding when ‘screening’ is an acceptable indicator for a CT angiogram or other invasive cardiac tests.

The coroner found that the impetus for the ‘cardiac health assessment’ program had arisen from the best of intentions after a worker for Ms H’s employer had suffered but survived a cardiac arrest. Following this, the managing director wanted to give his staff the opportunity to have ‘the best private medical assessment program for heart health’ at the company’s cost, and he asked one of his managers to develop a suitable program.

RANZCR update its standards and guidelines regarding both clinical requests and consent procedures to address the increasing prevalence of ‘screening’ requests, and to ensure that imaging procedures are not performed for ‘screening’ when lower-risk alternatives might achieve the same end.

The coroner investigated the complex arrangements of business entities and individuals involved in the development and implementation of the ‘cardiac health assessment’ program.

the Royal Australian College of General Practitioners (RACGP) and the Australasian Faculty of Occupational & Environmental Medicine (AFOEM) prepare a joint position statement on the appropriateness of a practitioner authorising, or otherwise allowing, their signature to be used in referring individuals (whether ‘patients’, ‘clients’ or ‘candidates’) for tests when neither the patient, nor any information specific to the patient, has been reviewed.

The coroner determined that Ms H died as a result of substandard clinical judgement from doctors at the beginning and end of this program, combined with a misalignment of incentives amongst the various business entities that facilitated the process. The inquest heard evidence about an industry putting profits over patients.

The ‘cardiac health assessment’ program had been developed without obtaining formal and considered medical advice on the risks of the tests, or whether these two tests were the

1

www.coronerscourt.vic.gov.au/sites/default/files/2021-11/2019%202336%20Hickey%20-%20Form%2037.pdf

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Counting the COVID cost Dr Colin Hughes considers the paradox of successful public health measures.

As we learn to live with COVID, there is much criticism of the extreme public health measures such as lockdowns and their overall cost to society.

The Australian Government spent $337 billion in COVID stimulus, a lot of it wasted, leaving our children with a mountain of debt.

There was the $40 billion from JobKeeper given to small and large companies that made a profit.

The $20 billion spent on COVID supplements to low-income pensioners and jobseekers on the other hand was 100% spent in the community and for the first time lifted so many out of poverty.

How much was wasted on the privatisation of COVID testing or an ineffectual privatised vaccine rollout particularly to the most vulnerable in aged care and NDIS instead of through State-based public health, GPs and pharmacists?

In public health we call this opportunity cost. How much better to spend these billions of dollars on preventative strategies like clean air, clean water, diet and exercise that would save lives from heart and lung disease, mental illness and cancer?

Was the previous strategy all wrong? Could we have just let it rip from the start? Are we ready to let our dearest grandparents die from a preventable disease? Was our public health response over the top and unnecessary?

Only in WA did Mark McGowan actually listen and act on public health advice. Outside China, it is perhaps the one place in the world that a zero COVID policy has been implemented with the economic benefit of an estimated $5 billion surplus by keeping our society, mining, regional tourism and business open and flourishing including hosting the AFL grand final and staging the only live performance of the Messiah in front of a full audience at Perth Concert Hall anywhere in the world in 2020.

He did this by measures including strict quarantine, mask and vaccines mandates.

NSW and the Federal Government chose to cherry pick public health advice. They refused for months to acknowledge that COVID could be airborne spread. Therefore, they refused to provide free N95 masks and implement better clean air strategies in quarantine and more

Individually we must take personal responsibility to not spread the virus to the most vulnerable.

10 | APRIL 2022

importantly all public buildings especially schools.

If we are to live with COVID we must have HEPA filters, CO2 monitors, and externally vented air conditioners preferably with solar power. Masks must be encouraged by changing the focus from mandates to “do it to protect your loved ones at home, your mates at work and all those vulnerable strangers who are more at risk from COVID”.

Individually we must take personal responsibility to not spread the virus to the most vulnerable. My medical colleagues in the UK use their free RATs before visiting any home especially those of the elderly. They use them before getting on a flight and when they are on holiday before flying home. So far none of them have contracted COVID. COVID is not the flu, and we haven’t started to see the waiting lists for treating long COVID. A new variant is just around the corner.

Let’s learn from our mistakes and actually listen to the real public health messages. That means quarantine, N95 masks in public places, free RATS, physical distancing (don’t hug or shake hands), washing hands, QR codes and social distancing with limits on venues and the 2 sqm rule.

As to lockdowns, even they must still be on the table in situations such as regional hospitals being unable to cope.

ED: Dr Colin Hughes, is a retired GP and former Head of Public Health and former chair of RACGP WA.

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APRIL 2022 | 11

Surgery for the strong-hearted Dr Robert Larbalestier has dedicated his life to looking after people’s hearts and lungs, but as he tells Ara Jansen, we also have to look after ourselves.

When you ask Dr Robert Larbalestier why he’s a cardiothoracic surgeon, the answer is simple. He likes helping people. He likes making a difference in their lives. In a practical sense, he says it’s something he really enjoys.

“I really do enjoy seeing people get better,” Robert says. “People who come in for heart surgery and transplants – that’s a big problem. They are looking down the barrel and you can make a big difference to them and not just in the surgical procedure. People who have not really looked after themselves, you can have a strong influence in them making changes to live a healthier lifestyle.

“One of the things I get great joy from is getting an email or a card from someone 10, 15 years later, letting me know it’s an anniversary of the surgery and they’re doing well, or they’ve seen a grandchild get married. I really get a kick out of hearing that.

I’ve got half a dozen albums of cards from the last eight years, when I decided to start keeping them.”

Robert did his medical degree at Sydney University, finished his cardiothoracic training in Perth and completed his post graduate education with a cardiothoracic fellowship at Boston’s Brigham and Women’s Hospital and Boston Children’s Hospital. He returned to Australia for a specialist position at St Vincent’s Hospital in Sydney. He “married a Perth girl” along the way and together they have two sons and a daughter, the eldest who was born in Boston.

Robert moved to Perth with his family for a job in the early 1990s and was instrumental in establishing the WA Heart & Lung Transplant Service in 1994 and sits on the board of the WA Heart & Lung Transplant Foundation, the West Australian Transplant Advisory Committee and the Heart & Lung Research Institute WA. He was named an Officer of the Order of Australia in 2019.

He’s currently director of cardiothoracic surgery and transplantation at Fiona Stanley Hospital, operates at Mount Hospital and is an adjunct professor at Murdoch Veterinary School.

Heart pioneer Robert did the first heart transplant for the WA Heart & Lung Transplant Service in 1995 and its first lung transplant in 2005. It was a game-changer. The service meant adults no longer had to go to the eastern states to wait for life-saving surgery, and that remains so today. Children under 16 years or 40kg still travel to The Royal Children’s Hospital in Melbourne, the current paediatric transplant centre in the country.

“With a small but dedicated team, we’ve now performed more than 400 transplants – about 210 hearts and 200 lung procedures,” says Robert. “We do about 550 heart operations and 30 transplants at Fiona Stanley Hospital each year.”

The specialist says one of the greatest joys of his job is working with a small, dedicated team who come from a variety of disciplines to create a transplant team. He says an ability to work smoothly and efficiently together is vital to achieve quality outcomes.

“I feel very lucky that I work with the best of the best with great anaesthetists, intensivists, perfusionists, theatre nurses and so many other staff who contribute to successful outcomes in difficult patients.”

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COVER STORY

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COVER STORY

Long and difficult operations, heart transplants can run from four to eight hours and lung transplants can run from five to 10 hours.

“People think it’s all about the hands and you can teach anyone to play the violin, but some people are prepared to do more work. They do more work and it makes them better.

Great musicians also have that feel for music and are intuitive with it. Surgery is a bit the same. You can teach people the skill and that’s OK when everything is working well. The art of surgery is really how you handle all the variations and how you deal with the unexpected and when things are not going well.

“For example, there are different nuances and different tissue tensions and strengths and different body integrity in a 25-year-old compared to a 70-year-old. Assessing the whole aspect of their strength and the impact of the surgery beforehand, these are the sorts of things which make the difference between being a ‘Surgeon 101’ and being able to get an excellent result in complex and marginal patients. That’s hard to teach.

I think clearly part of it is experience but part of it is innate. continued on Page 15 Picture: Tony McDonough

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APRIL 2022 | 13

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Surgery for the strong-hearted continued from Page 13 “I’m very fortunate with what I do and have great people around me.

There’s a lot in the decision-making process where we must have robust debate. The path to getting the best outcome is not necessarily absolutely clear, so you need a team of people who can debate its way to the best outcome for the patient.”

Creating an A-team Already “blossoming and growing”, one of Robert’s big aims for his work at Fiona Stanley is to facilitate an environment where the hospital is a recognised centre for teaching and training and has a strong academic profile in cardiothoracic surgery.

Born on Melbourne’s Mornington Peninsula, Robert grew up on the waves at Cronulla, south of Sydney.

It was the heart of working-class Sydney and expectations weren’t about university. At about 13 his parents moved across Sydney and Robert ended up going to St Ignatius College.

“It was very different,” he remembers. “In my class in Cronulla there were probably only a few who expected to make it to uni and half of them left in Year 10. Now the expectation was that there were only a few people who didn’t go to uni. About seven in my year went to medical school. That new environment at St Ignatius certainly affected my decision-making and medicine became an option.”

Coming from a non-medical family, Robert didn’t really know what he wanted to do. What he did know was he didn’t want an office job but thought medicine was pretty practical and useful.

“My final years of medicine changed my view of the world dramatically and I was drawn to surgery. I enjoyed orthopaedics and then got into cardiothoracic and it was those people who really influenced me and influenced how I saw my career. They had a lot do to with my career pathway.

“You need mentors who help you along the path and that’s central in terms of your career development.

If you like the people and they like you, it makes chasing that pathway a lot easier.”

Role models He counts his parents on his list of role models because of the sacrifices they made for him to get a solid education. His mother worked from the age of 16 until she was 74. Both insisted on a strong work ethic and worked hard themselves.

When Robert turned 14, his mother drove him around the local area so he could go into every office and ask for a part-time job.

“They taught me the value of money and hard work. My mum, in particular, taught me that you have to stick it out and put one foot in front of the other, and you will get there. She was a very generous person and very self-sacrificing, but not dramatic about it. She put everyone else’s interests first and was always there to help.”

Now 65, Robert admits he probably likes wine too much but unapologetically loves live performance – everything from the opera and theatre to Midnight Oil or Crowded House.

Being a cardiothoracic surgeon requires him to be in good shape to handle long hours in the operating theatre. Luckily, he’s a lifelong fan of activity. He likes to hike and has done a leg of the Bibbulmun Track and during the northern hemisphere winter you’ll often find him on a ski slope. A former water

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

polo player and surfer, he keeps up his fitness by swimming and gets in the water three or four times a week.

For the last three years he’s been part of the North Cott Pod Squad – those social swimmers who hit the beach early each morning.

He’s done the Rotto Swim twice in a team, various ocean swims and the half Ironman at Busselton four times as part of a team.

“Like I tell my juniors, you have to look after your physical and mental health if you are going to do this sort of surgery. When I take holidays, I usually do something active – I’ve swum in Komodo, Indonesia, and Crete, been on walking holidays in France and Italy and cycling trips in Morocco and Japan.”

Equally, he does have to be careful.

The last time Robert rode a bike he came off it and the last time he played water polo his thumb got a bit of a belting. For less precarious pursuits, he likes a good jigsaw puzzle (9000 pieces anyone?), enjoys cooking, reading and most of all, time with his family.

“I like a challenge. I’ve always got to have something to train and aim for.

In terms of surgery, I like to always be evolving and we continue to do cutting-edge stuff in our program.

If I don’t, it’s time to give up.”

This year he’s heading to Antarctica on an exploration trip with some snorkeling and will be diving in the Abrolhos.

APRIL 2022 | 15

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FEATURE

A planned overhaul of payments to doctors by WA’s biggest health insurer could see winners and losers, as Cathy O’Leary explains.

Looming changes to what HBF pays specialists is dividing the medical profession, and not surprisingly the battlelines are based on whether doctors will get less or more for their services.

HBF recently unveiled to members and providers plans to scrap its historical and problematic Known Gap arrangements from July 1, arguing it is confusing and unfair.

Under the scheme used by about 400 specialists, they have the option to bill in three ways, including opting into a No Gap arrangement where the fees charged do not exceed the fee specified in HBF’s Known Gap Schedule, so patients have no out-of-pocket costs.

They can also opt into a Known Gap arrangement by choosing to charge fees that do not go over the Full Cover Schedule fee, which means the account will be paid up to the Known Gap Schedule fee. Patients then pay the difference between the Known Gap Schedule and the Full Cover Schedule.

Doctors can also opt out altogether and charge a fee that is more than the Full Cover Schedule fee, and the patient pays the difference between the Medical Benefits Scheme fee and the specialist’s fee.

As well as planning to discontinue the Known Gap Scheme, HBF is also ditching an excluded items list which currently allows a doctor who is nogap provider to charge a gap for procedures on that list.

HBF, which has about 50% share of the health insurance market in WA, has told its members that from July 1 they face potentially higher out-of-pocket costs if they use specialists who are not signed up as full cover providers.

It is also launching a new website and provider search tool so that patients can more easily find its full cover specialists.

16 | APRIL 2022

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FEATURE HBF’s director of medical services, Dr Daniel Heredia, told Medical Forum the Known Gap arrangements confused patients – even down to sounding like “no gap”.

“With the No Gap Cover, if you sign up to that, and a member goes to see that doctor, they have absolute certainty that their procedure or service, with a small list of exceptions, is going to be fully covered and they’ll have no gap.”

“With the Known Gap, the doctor can choose to bill in one of three ways – they could choose to have no gap; or they could choose to have a known gap which is a fixed amount up to an upper limit that we set; or they can choose to opt out completely and charge whatever gap they want.

“And those three different scenarios can be done on a patientby-patient basis. And the difference could be a known gap of a few hundred dollars, or they could say, based on x,y,z, I’m going to charge a $3000 or $4000 gap, and that’s for that same procedure, so it’s entirely their discretion.”

Dr Heredia said HBF received a lot of feedback from members over the years who said they didn’t understand why they had a quote with a $4000 gap.

“And the problem is that by the time you go and see a specialist, it’s too late, people don’t feel comfortable to then query it or ask for a second opinion,” he said.

“Interestingly we also get feedback from doctors who say our Known Gap Scheme is unfair because they’ve done the right thing by signing up as a full cover specialist – and in exchange for that we pay them more, but we also cap how much they get paid – but the person in the room next to them is on the Known Gap Scheme and they can charge whatever they want and we still pay them.

“So even doctors find that the scheme doesn’t make sense.”

Dr Heredia said one of the reasons for scrapping the Known Gap Scheme was to make fees more transparent. Gap payments were a major source of angst, with people complaining that they paid thousands of dollars for insurance yet when they went to use it, they had to pay a gap.

Being a no-gap provider from an administrator point of view was much easier because doctors did not have to collect money in their office or deal with bad debt.

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Doctors have been given three months to decide on the Full Cover arrangements, or to go it alone, which would mean that from July 1 any services provided to their HBF patients would only attract a benefit up to the MBS.

Here’s the rub However, at the same time as planning to scrap the Known Gap Scheme, HBF has reviewed all of its payments under its Full Cover arrangements – of which 2500 specialists are already signatories – which means for some items their payments will increase while others will decrease.

Anaesthetists in particular will face reduced fees.

Dr Heredia said that for some specialties and item numbers HBF paid significantly above the market, and in some it paid below the market.

“So, we decided to increase as many as possible where we’re paying below the market, to being 5% above the highest major competitor,” he said.

“That means services such as appendectomies, hernias, breast cancer surgery, tonsils etc going up, but here’s the rub, because being a not-for-profit and given pressure on premiums, we had to do this in a cost-neutral way. continued on Page 19

APRIL 2022 | 17

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Mind the gap continued from Page 17 “We have reduced those item numbers where we were paying well above market, but have kept them at 5% above the highest major competitor.

“So overall, with more than 82% of item numbers, we’ll remain the highest paying main insurer, and we have the largest number of no-gap item numbers. It will be something like 92% of items being fully no gap.”

Not all happy Since the changes were announced, HBF has been in talks with medical groups and doctors who are affected by payment decreases.

Australian Society of Anaesthetists president Dr Andrew Miller told Medical Forum that plans to reduce fees for anaesthetists who provided a no-gap service for all HBF members, and to remove the Known Gap arrangement, was a disappointment to the WA anaesthetic community.

“Since the formerly popular scheme was introduced more than

a decade ago, indexation of fees has already been much lower than practice cost increases,” he said.

“Many anaesthetists, however, had been prepared to accept lower fees for HBF patients because of the administrative ease of the program and for patient benefit in a market dominated by the fund.”

Dr Miller said HBF already had fees lower than most competitors when the effect of other funds' modest known gap was included, and lower by far than the recommended ASA and AMA fee, which had been properly indexed.

“For anaesthetists to remain as no-gap providers under the draft reductions, they would have to be willing to absorb a significant drop in fees for all patients insured with HBF,” he said.

“Unsurprisingly, participation seems likely to decline dramatically, according to the results of an informal survey conducted by the ASA. “A reduction in participation would place HBF members at a disadvantage through much larger out-of-pocket expense if the fund defaults to funding only 25% of MBS schedule fee as is proposed.”

Dr Heredia said he accepted that some doctors were concerned about the changes, particularly anaesthetists whose full cover rate would reduce, while still remaining above all of HBF’s major competitors.

He hoped that, on balance, most doctors affected by the decrease would think that it “still stacked up”.

“It also has to be said that a no-gap pathway is highly desirable for a lot of our members, but not every member, so if having a gap is not important, it will make it easier to find those providers.”

He said the fund had received calls from doctors – some positive, some confused.

“We’ve met with the AMA and the Anaesthetists’ Society, which understandably has expressed reservations, and they’ve given us some constructive feedback which we are looking at to see what, if any, tweaks we can make,” he said.

“The AMA also wanted some time to see the impact from doctors’ point of view, primarily concerning anaesthesia.

“Some people say why can’t you increase the specialties you want to increase and not take from us, which is great in theory, but we’re a not-for-profit, so it’s not sustainable.

“It’s hard to get doctors to understand that these things have a flow-on, so yes, we could increase everyone, but then our premiums increase, and then people drop out of insurance, and everyone’s worse off.”

Dr Miller said he understood the changes were still in draft form and the ASA recognised that participation in the HBF scheme was a business decision for private practitioners, and informed financial consent for all patients was essential.

ED: At the time of going to print, HBF was still in talks with interest groups about the changes.

Have your say at editor@mforum.com.au

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

APRIL 2022 | 19

Growing our own For many doctors working in rural and regional WA, it’s more than a job – it really is a way of life, as Marnie McKimmie explains.

Pictured: Dr Brittney Wicksteed

20 | APRIL 2022

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It is the teamwork, trust and terrain that captures the hearts of doctors such as Rural Doctors’ Association WA president Dr Brittney Wicksteed. They channel their energy into addressing inequalities in rural and remote healthcare.

“Seeing the skills of the rural generalist doctors in action is quite awe-inspiring – no matter what comes through the door, the team come together to deliver excellent patient care and are able to innovate,” said Kalgoorlie-born Dr Wicksteed, who has just finished a stint working in the Kimberley.

“One of the delights is getting to know entire families through continuity of care and being able to work across different settings – the patients are a real highlight of working rurally.”

Yet the number of doctors putting up their hands to take on this challenging work – in regions with known poorer health outcomes and higher levels of socio-economic disadvantage continues to fall far short of demand.

Efforts to address workforce shortages are now focusing on finding a “grow our own” solution. This includes a new push to get in early to “ignite the fire” among rural and remote high school students considering a future in medicine by allowing them to “dip their toes in”.

“We know that medical students from rural backgrounds with rural medical mentors are more likely to return and work rurally once they graduate,” Dr Wicksteed said.

“There are programs aimed at medical students and junior doctors to entice them to work rurally – it makes sense to appeal to high school students as well.”

Dr Wicksteed has called for the innovative Year 11 and 12 Health and Medical Specialist Program run at Manea Senior College in Bunbury, that does just that, to be rolled out across the State’s regional high schools.

She believes it could be a key to building a permanent local workforce in the regions.

Launched in 2013 and now receiving 80 applications a year, the Manea program introduces high school students to a range of health and medical fields and immerses them by placing them in health workplaces for short stints. This allows the teenagers to observe, help out and perform simple skills where appropriate. Guest speakers from all areas of the industry also share their wealth of experience, “both gritty and inspiring”.

“There’s the saying that ‘You can’t be what you can’t see’, and this is the case for country kids and their ability to aspire to careers such as medicine,” Dr Wicksteed said.

“For high school students who don’t have health professionals in their family networks, aspiring to study medicine is extremely daunting and may feel like an unrealistic aim.

“Having some familiarity with the environment, positive experiences and mentors can mean all the difference. This Manea program also gives them the opportunity to experience other rural/regional areas, including Kimberley trips. continued on Page 23

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APRIL 2022 | 21

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22 | APRIL 2022

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Growing our own continued from Page 21 “Being from a non-medical family myself, I did not know any doctors socially.”

Already set on a future working in the country, junior doctor Travis Papalia from Mt Barker/Collie says he is evidence that the “ignite the fire” strategy works.

Now based at Sir Charles Gairdner Hospital and planning to return to rural regions through a Rural Generalist Pathway, he said in his final years of high school he had settled on becoming a physiotherapist until a mentorship and participating in the Health and Medical Specialist program at Manea Senior College triggered a change in mind and a decision to pursue medicine.

“The experience of seeing these health professionals I shadowed impacting on the lives of those around them, it made me feel like,

‘Yeah, that’s what I want to be doing for the rest of my life’,” he said.

17, you’re studying to work in a job you’ve at least, in part, experienced and understood its essence.”

“I support this program wholeheartedly. Up until year 11, I wanted to be a range of different things, as all kids do. I wanted to be a chef because my parents watched cooking shows. Later on, an engineer because my older brother was studying that. A sport teacher because my PE teachers were awesome. Then a software developer, because of video games.

Manea’s program teacher Peter Thompson said the high school had been fortunate to have formed an invaluable partnership with the Rural Clinical School of WA.

“The key point is that I wanted to do these things at the time because I had the exposure to know just enough about them that I thought ‘Hey, I could do that!’

“This Health and Medical Specialist program offers students like me, who don’t come from medical families, that exposure. It lets you dip your toes in, so that instead of spending years at university doing a degree you thought you’d like at

“Their medical students mentor our students, teaching them simple clinical skills such as donning/ doffing PPE, wound care, bedside observations, applying a backslab or setting up drip lines. They also act as our patients in an annual simulated emergency, giving our students opportunity to put their first responder skills into practice.

“Staff at Broome Hospital and Bidyadanga Clinic, Bunbury Health Campus and numerous medical practices around Bunbury are also very supportive. continued on Page 24

Brittney practising medicine in all corners of the state

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APRIL 2022 | 23

Growing our own continued from Page 23 “Manea alumni also visit as guest speakers and teach clinical skills to current students and they have made themselves available to give advice to our Year 12s about to sit UCAT (University Clinical Aptitude Test) exams or medical interviews.

“We often hear in the news about rural or remote centres that are desperate for staff. We do sow the seeds of returning to the regions, or going remote, but find most of our students are already keen to do so, saying it was always their intention to return.”

Dr Papalia is one of them.

“Ideally, I’ll be working in the country for many years," he said.

“After growing up in the country, I want to offer the same experiences I had to my future children and return to being a part of a small country town. Similarly, as a health professional, I look forward to being able to contribute in my own way to the community I live in.

“I think often people are focusing on what they might lose moving to a regional area rather than what there is for them to gain.”

Dr Wicksteed says increased

support is needed for those who commit to rural and remote healthcare, as the job can at times be both “disheartening and upsetting”. Working in rural EDs where the incidence of alcohol-related presentations and family and domestic violence presentations were high, rarely a day went by without seeing people impacted by these.

“This is difficult to stomach when the underlying factors leading to these social issues are impossible to tackle as an individual,” she said.

Looking ahead at expected pressures that will add to an already

Data linkage to improve care in the bush Focusing in on chronic kidney disease, WA Country Health Service and Curtin University have joined forces to drive research that addresses the needs of geographically disadvantaged patients where the burden of disease is greatest.

The project will provide data on the outcomes of patients, from early stages to hospitalisation, to inform evidence-based clinical recommendations and guide the allocation of resources. It aims to prevent later stage disease.

With about 90% of cases of early-stage chronic kidney disease going undetected, the newly formed WACHS and Curtin University Research and Innovation Alliance is using large datasets to fill in information gaps and allow better ways to identify, manage and understand disease progression. This will enable the right care to be provided to patients at the right time.

“Diagnosing and managing kidney disease is challenging, particularly in regional areas,” said Alliance Curtin lead Professor Suzanne Robinson.

The move will see the linking of data from four major WA pathology providers to hospital records and establish a continuous medical record for individuals with biochemical markers for chronic kidney disease.

Chronic kidney disease affects people living in rural and remote areas at almost twice the rate of city dwellers – and Aboriginal people at more than four times the rate.

Rural and remote health inequalities include: Poorer health outcomes Higher levels of socio-economic disadvantage Access to health care services and innovative interventions Maldistribution of workforce Attracting and retaining clinicians and researchers that drive a culture of innovation Aboriginal people have a shorter life expectancy and worse health outcomes than non-Aboriginal people.

Source: Professor Suzanne Robinson 24 | APRIL 2022

“Using this linked data resource, the research team will be able to quantify the volume of individuals in the community with early-stage disease for improved health intervention design and implementation, service and resource allocation, and gain a greater understanding of the epidemiological factors associated with the progression of the disease.”

Combining data from state-wide clinical datasets with information on all individuals affected by chronic kidney disease in WA from 2022, the Improving Chronic Kidney Disease Outcomes Through Linked Data Modelling project is being led by WACHS, Curtin University, WA Department of Health and WA Primary Health Alliance.

“Western Australia, with geographical and digital isolation, necessitates innovative solutions to provide equitable and effective care for regional and remote consumers,” Prof Robinson said.

She said the alliance was a new model for how universities and health services could work together to develop research priorities, attract external funding for research and help commercialisation within the innovation ecosystem. It was a way to build the current MEDICAL FORUM | CARDIOVASCUL AR HEALTH

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FEATURE heavy workload, Dr Wicksteed says it remains to be seen just how long COVID-19 will disrupt the delivery of rural and remote healthcare in the months and years to come.

“The great fear is how the pressures on retrieval of unwell patients will translate to patients getting the care they need, whether they are presenting with acute coronary syndromes, psychotic illnesses, major trauma or sepsis.”

Dr Wicksteed believes key changes are needed to support rural and remote doctors: • Improve access to safe, healthy and family-friendly communities Provide safe and appropriate housing and childcare and employment and educational opportunities for partners and family members.

• Improve access to upskilling and education for doctors Set up networks that ensure skilled and experienced rural generalist doctors have access to high enough caseloads to ensure they remain accredited in their skills.

• Invest in the multidisciplinary team Increase efforts to attract, train and retain other health professionals rurally (nurses, midwives, physiotherapists, dietitians).

Encourage consultant specialists to live and work rurally, or deliver rural care.

demonstrating the types of enriching health careers they can have outside of the metro area.

• Make GP great again Address shortages caused by fewer new graduates interested in pursuing general practice as a career. Start with a full review of Medicare billing.

Invest in the National Rural Generalist Pathway to deliver more rural generalist doctors to the bush to help support local doctors.

• National Credentialing Simplify recruitment and allow movement across state borders to deliver essential care.

• Invest in the future healthcare workforce Capture the interest of high school students and

and future regional health workforce through education projects and programs that focused on the challenges of delivering healthcare in regional and remote settings.

The alliance is also working to quickly upskill frontline workers who deliver telehealth services, to meet increased demand due to the COVID-19 pandemic.

“We believe with the right investment, collaborations across the regional health system and health research sector, and commitment of partners we can work to address disadvantage through improved access to services, a more stable health workforce, implementation and evaluation of new models of care that better serve patients and better equitably resourced health services and health outcomes overall,” she said.

Rural Doctors’ Association WA president Dr Brittney Wicksteed said it was “fantastic” to see such dedicated efforts to improve the health outcomes and health experiences of those living in the bush.

Rehab in the home.

“This will complement the current and future medical graduates as more job opportunities are available in the regions, delivering care to people all over the State, while enabling doctors to contribute research,” she said.

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APRIL 2022 | 25

COVID-19 and the heart of the matter As the COVID pandemic continues to run its course, research is showing the wider implications of the disease.

By Kathy Skantzos

As the global death toll of the pandemic surpasses six million, new research has emerged showing a clear link between COVID-19 and the number one killer in the world – cardiovascular disease.

Epidemiologists first noted the link between COVID-19 and cardiovascular disease early on in the pandemic, with people with heart problems more than twice as susceptible to contracting COVID compared to the general population.

Now, more research is uncovering new evidence indicating that anyone who contracts COVID is at a significantly higher risk of developing heart problems and CVD, whether they have heart disease risk factors or not.

Research is indicating the “long COVID” symptoms experienced by so-called COVID “long-haulers” after contracting and recovering from the virus – such as heart palpitations, dizziness, chest pain and shortness of breath – could be related to heart disease spurred on by the coronavirus.

An observational study published in Nature Medicine in February 2022 shows a significantly increased risk of heart disease in people more than a year after contracting COVID, even if the infection wasn’t severe enough for hospitalisation.

The study, an analysis of large health care datasets in the US, points to a substantial risk and burden of CVD in people who contract COVID-19 and is raising alarm bells as we continue to battle the prolonged pandemic.

Professor Livia Hool, Chair in Cardiovascular Research at UWA’s School of Human Sciences and Founding director and chair of the Western Australian Cardiovascular Research Alliance, said the study clearly pointed to evidence of the significant impact of COVID-19 on CVD. “The good thing about this study is that it’s not only looking at the acute effects of patients that had COVID storm (COVID-19 cytokine storm syndrome or COVID-19-CSS), it’s looking at all people who have recovered,” Prof Hool told Medical Forum.

“It’s a study with large numbers and it’s showing that patients who have had even mild COVID infection have increased risk of cardiovascular events and disease.”

26 | APRIL 2022

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There was a group of studies that emerged in the early stages of the pandemic from Wuhan in China describing the effects of COVID-19 on heart health and the association between cardiovascular outcomes and the virus – this is the first 12-month follow-up longitudinal study.

“In the initial studies they were showing things like damage to the heart with COVID storm and what they found was roughly 30-40% of those patients also had myocardial damage and increased troponin levels. A follow-up a few months later found that around half of them, or 20%, still had ongoing cardiac damage,” Prof Hool explained.

“We know that 12 months after getting COVID, people are more likely to have coronary heart events or stroke. or to have embolisms.

Twelve months later, they’ve recovered but they actually have a higher risk of developing those problems.”

The research showed that people who contracted coronavirus had an increased risk of cardiovascular disease spanning several categories, including cerebrovascular disorders, dysrhythmias, ischemic and nonischemic heart disease, pericarditis, myocarditis, heart failure and thromboembolic disease, compared to people who were able to avoid the infection altogether.

“The ongoing risk of cardiac events is actually quite disturbing,” Prof Hool said.

“It’s a whole list of things from increased atrial fibrillation, increased acute coronary disease, increased risk of heart failure and increased risk of pulmonary embolism, which is not so surprising given that clotting was how some people died.”

She says WA could face a secondary pandemic in the form of a cardiovascular crisis, especially with the WA borders now open and case numbers rising in the state – as well as the other known risk factors linked to CVD such as obesity.

“If 20% of people have ongoing damage and if that translates to those who have mild COVID-19 infections, then we’re going to have, worldwide, a massive increase in heart failure over the next five to 10 years,” Prof Hool said.

“The disturbing thing about this study is that there could be people who only have had mild disease and/or they have no previous cardiovascular risk, facing the risk of developing mild cardiac symptoms.

“COVID-19 can damage the heart muscle and affect heart function because the virus attaches itself to protective angiotensin converting enzyme-2 (ACE-2)

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

receptors, which play a vital role in the cardiovascular and immune systems. Even though we are dealing with a virus that primarily affects the respiratory system, this has been shown to put more strain on the cardiovascular system and affect the heart.”

The Heart Foundation advises that COVID-19 can affect the cardiovascular system in many ways, including widespread inflammation, which can progress to lung injury, heart muscle injury and impaired heart function. The virus can cause cardiovascular complications, including atrial fibrillation, heart failure, blood clots in the legs and lungs, heart attacks and stroke.

As the body fights the virus, inflammation circulating in the body can damage healthy heart tissue. Coronavirus also affects the inner surfaces of veins and arteries, which can cause blood vessel inflammation, damage to small vessels and cause blood clots, all of which can compromise blood flow to the heart and other parts of the body.

“In this more recent paper they’re mentioning what people were speculating in the first round that it could be due to direct viral

continued on Page 29

APRIL 2022 | 27

Perth Breast Cancer Institute (PBCI) Breast Clinic A newly established Breast Clinic providing rapid assessment for patients with Breast Problems, located in the new Hollywood Hospital Consulting Centre.

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FEATURE

COVID-19 and the heart of the matter continued from Page 27 invasions of cardiac myocytes and subsequent cell death in the heart, it could be due to endothelial cell infection and inflammation, it could be transcriptional changes in the heart, and down to regulation of the ACE-2 protein,” Prof Hool explained.

Children are less susceptible to CVD because of how the ACE-2 protein interacts with their immune system, making it more efficient at fighting off the virus. However, it doesn’t stop children from getting heart problems completely.

In general, children who get sick with the coronavirus do not have serious problems as often as adults do. An uncommon but serious complication of COVID-19 is multisystem inflammatory syndrome in children (MIS-C), which has some similar characteristics to Kawasaki disease and can cause serious heart damage, cardiogenic shock or death.

Some children who survive MIS-C can be left with abnormal heart rhythms and stiffened heart muscle that prevents the heart from relaxing normally and beating properly.

Statistics show that people living in remote regions and Indigenous Australians have a higher risk of complications from heart disease and are more likely to be hospitalised because of it. While being isolated from COVID-19 is protecting communities from the virus, our state’s remoteness can present challenges for the delivery of healthcare.

“We’re in a first-world country and people can’t get health care. That’s one of the challenges in Western Australia. People living in remote, rural and regional areas and Indigenous people are much more likely to die from heart disease or to be hospitalised,” Prof Hool said.

People who have CVD don’t have any greater risk of dying from COVID-19 if they contract it, but they do have an increased risk of complications because they already

have an underlying cardiovascular problem.

“People with CVD should certainly be very careful to avoid contracting COVID, but they don’t have any further risk of dying from it than anyone else,” she said.

Meanwhile, researchers at Murdoch University’s Australian National Phenome Centre have discovered a new set of biomarkers for increased risk of CVD in patients with COVID-19 infections. The biomarkers indicate a strong correlation with existing known markers of CVD risk including atherosclerosis and myocardial infarction and could also form the basis of a new rapid test for COVID-19.

ANPC Director Professor Jeremy Nicholson said in a statement that the research has provided a quantitative measurement that will detect increased cardiovascular risk in COVID-19 patients, and potentially from a variety of non-COVID patients with other cardiovascular risk factors and indications.

“Other researchers have shown that COVID-19 infection massively increases cardiovascular risk in the year after the initial infection – we now have a new means to measure this risk directly on small volumes of blood plasma in just a few minutes,” Prof Nicholson said.

COVID-19, including lockdowns and the resource-intensive roll-out of the COVID-19 vaccination program in GP clinics.

The foundation’s Chief Medical Adviser and interim Group CEO Professor Garry Jennings said in a statement that the delays in heart health checks could have “serious and even fatal consequences”.

“What we don’t want to see is a drop in heart health screening coupled with what we are seeing overseas as a result of the pandemic,” Prof Jennings said.

“This could create a dangerous situation and a backlog of people who need preventative heart health care for years to come, placing additional pressure on general practice.”

The heart health check detects atherosclerotic disease early by identifying risk factors and managing them appropriately.

“Fewer people having a heart health check means that silent conditions like hypertension and hypercholesterolemia may go undiagnosed and potentially worsen, increasing people’s risk of a heart event in the future,” he said.

The growing number of deaths from COVID has surpassed six million, but heart disease remains the leading cause of death in WA and the world, with about 19 million people dying annually from heart disease.

As people who have CVD are at a higher risk of serious complications from COVID-19, the Heart Foundation stresses the importance of getting the flu and COVID-19 vaccines as well as a heart health check, and to follow heart-healthy practices including a healthy diet, regular exercise and to not smoke.

Recent Heart Foundation modelling shows that in the throes of the pandemic many people are not getting heart health checks that can offer early detection of heart attack and stroke risk.

Read this story on mforum.com.au

There were 27,000 missed or delayed heart health checks from March 2020 to July 2021 across Australia due to the impact of

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

APRIL 2022 | 29

PCH tackles rare diseases Perth is set to become home to a world-first centre to improve the lives of children born with uncommon diseases.

With almost three-quarters of these diseases starting in childhood, it is logical that a new global initiative to deal with rare diseases be based at a children’s hospital.

PCH is the hub for the Rare Care Centre, which will connect medical experts from around the world who deal with uncommon and undiagnosed conditions.

The project was launched last month after securing funding from several leading WA philanthropists who have pledged $10m over five years, starting from July.

They include the Angela Wright Bennett Foundation, the McCusker Charitable Foundation via the Channel 7 Telethon Trust, the Stan Perron Charitable Foundation and the Perth Children’s Hospital

Foundation using a significant contribution from Mineral Resources Limited.

The Rare Care Centre will link national and international specialists, incorporating clinical and non-clinical services, with a focus on Aboriginal health and mental health, with the aim to improve awareness and early identification of children with potential rare diseases.

This early detection will allow for a more accurate diagnosis and better access to community resources, clinical trials and research. It will also connect children and their families with education and disability services.

Clinical geneticist and the centre’s medical director, Dr Gareth

Baynam, said the aim was to improve the lives of children and young people living with a rare disease and their families by providing a globally connected model of care.

“Although they are called ‘rare’, cumulatively the impact of rare diseases is massive,” Dr Baynam said. “This is an area of such severe and large unmet need – rare and undiagnosed diseases are like a hidden, global endemic.”

He said these children and adolescents and their families living with rare and undiagnosed diseases were on two journeys.

“Firstly, just attaining a diagnosis is distressing and complex. On average it takes five years to get a diagnosis for a child with a rare disease,” Dr Baynam said. “That’s five years of uncertainty, mental distress and isolation.

“Secondly is the care journey, with only 6% of rare diseases having a specific drug treatment. “ Child and Adolescent Health Service chief executive Dr Aresh Anwar said collaborations like the new centre would help drive innovation in developing and delivers support services.

“For the families of children living with a rare or undiagnosed disease, it is a game-changer to know there is a dedicated centre to provide a comprehensive and coordinated treatment plan and deliver access to a global network of specialists and families living with the same diagnosis,” he said.

The centre will work with worldleading rare diseases experts, including the World Health Organization’s Global Network for Rare Diseases.

30 | APRIL 2022

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GUEST COLUMN

Rare but in the millions Perth Children’s Hospital’s medical director of Rare Care Professor Gareth Baynam shines a light on uncommon diseases.

While rare diseases affect less than one in 2000 people, they are also paradoxically commonplace.

There are at least 8000 of them globally – Duchenne muscular dystrophy, neurofibromatosis, Huntington disease and thousands of other conditions with names you might never have heard.

But while you may not know the names of all the rare diseases, there is a good chance you know or have treated someone living with one of them.

Globally, a minimum of 3.5–5.9% of people are living with a rare disease, equating to 263-446 million cases across the world. In Australia, there are more than 2

million people affected, including 63,000 WA children.

Rare diseases can affect all ages and stages. However, 70% start in some of our most vulnerable patients – children. There are about 70 rare diseases patients on each full-time GP’s books in WA. There is also thought to be about 300 million undiagnosed patients globally, an epidemic in itself. On average, it takes 5-7 years for a child with a RD to get an accurate diagnosis and sometimes decades in adults – if they get one at all.

Only 6% of those with a RD have a specific prognosis-altering drug therapy and only 5% of them have a specific code in the most

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

commonly used medical coding system (ICD-10), leaving people living with rare diseases feeling like they don’t count.

RDs are also the most expensive class of diseases. In the US alone, a subset of RD accounted for nearly $1 trillion a year in direct and indirect costs. To put into perspective, this is more than cancer, heart attack and stroke and diabetes combined.

In children, RD inpatient costs were 1.5 times higher than all common diseases combined. In adults, RD costs were on par with all common

continued on Page 33

APRIL 2022 | 31

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Mr Lester said that the group raised $26 million for the purchase of the Butler centre as investors looked to capitalise on the 7% per annum income it was expected to yield once it opened in July this year.

The project also showed that confidence is returning to the retail sector with anchor tenants The Good Guys, Goodlife Health Clubs, Beacon Lighting, Petbarn, Autobarn and Adairs preparing to open their doors for business in this fastgrowing northern corridor.

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“The group is usually the largest investor in each of our property syndicates, investing at least $1 million each project, reflecting our commitment to the syndicate’s success.”

Mr Lester said the group was continually looking for property investment opportunities across Australia.

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Interested investors are invited to call Russell Lester (0419 195 797) or subscribe via the lestergroup.com.au website, to be kept informed on future property investment opportunities

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GUEST COLUMN

Rare but in the millions continued from Page 31 diseases combined. The US figures are consistent with WA health system data.

RDs kill more kids than cancer and trauma combined – a shocking but true statistic.

Last December, a global grassroots campaign championed by those affected by an RD led to the adoption of the first-ever UN resolution on addressing the challenges of people living with a rare disease and their families. It was co-sponsored by 54 countries and unanimously accepted by all 193 UN member states. I was part of that advocacy movement and proud of the achievements.

key pillars of the UN Sustainable Development Goals, including access to education and decent work, reducing poverty, tackling gender inequality, empowering women and girls, and supporting participation in society.

care coordination and centres of expertise.

The resolution is a major global policy shift and promotes RD as a global priority. It promises greater integration of RD in the UN agenda and priorities, allowing the RD community a greater platform for dialogue and action to address the challenges impacting the quality of life of so many.

Interestingly, rare diseases discoveries also benefit people with common diseases. A number of the solutions accelerated by COVID were honed from rare diseases, including mRNA vaccines and privacy-preserving data sharing.

We can improve the lives of all people living with a rare disease and their families right now. Yes, there are challenges to diagnosis and finding disease-specific therapies, but we need to invest in and better provide these.

The resolution recalls the UN commitment to strengthen measures on addressing RD under its Universal Health Coverage. It also focuses on the importance of non-discrimination and advances

In the meantime, we can also raise awareness and provide better care for all, including improved

Primary health is also critical, and mental health is often overlooked.

Research is vital, as one in two new medicines come from diseases research, such as statins.

ED: Professor Baynam is also head of the WA Register of Developmental Anomalies at KEMH and program director of Undiagnosed Diseases Program at Genetic Services of WA.

Read this story on mforum.com.au

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APRIL 2022 | 33

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OPINION

We know it hurts We can’t ever lose sight of our job, argues retired Perth doctor Bruce Powell.

I watched the two-minute BBC TV trailer of This is Going to Hurt.

And it did.

I bought Dr Adam Kay’s book in 2017. I didn’t enjoy it then, and I don’t think it’s funny now.

I worked on the same chaotic hospital wards as Adam, witnessing the same struggles and sharing the same stories over a beer in the hospital’s bar. As doctors, we tell each other cautionary tales as a means of sharing our pain.

We punctuate them with farcical interludes and sprinkle them in bodily fluids, to deflect from our own, often unjustified, guilt and shame.

I skimmed This is Going to Hurt for new anecdotes. There weren’t any.

Decades of medical, anaesthetic and intensive care work had made

me familiar with all the apocryphal stories in Adam’s book.

Adam caricatures patients’ struggles and focuses on the impact this has upon the medical professional.

In one episode in his book, he reflects upon how “f.cked-up” the “whole birthday and blood thing is” with Jehovah’s Witnesses. I recall feeling the same way.

I was once tempted to ignore the family wishes of a Jehovah’s Witness and give a blood transfusion to their critically ill son. Why should I bear another death on my conscience?

I knew that transfusion might have him shunned by his community, but at least the young man on the ventilator would have the chance to build a new life.

A church advocate sidled over to me as I examined the patient’s drainage bags, steadily filling with blood from his wounds.

He craned his head towards me and whispered, “Don’t worry Doc, if he dies, it won’t be your fault, it’ll be God’s will.”

I already knew that it wasn’t my fault. Not the motorbike, nor the wall, nor the high-speed collision.

I had witnessed other Jehovah’s Witnesses die. It wasn’t clear if blood would have helped them.

If the boy in my care now died, I would not just remember, I would relive that sense of helplessness and despair.

Maybe Adam sought solace in recalling the most brutal of his own experiences and the stories that he

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Transfusion is my decision?”

“That’s right Mr Jackson,” I replied.

“Do what you have to do,” he replied. “Don’t let him die.”

I wrote a note documenting the game-changing conversation and stashed it in a sealed envelope in my boss’s office. There’d be no disfellowship on my watch.

Patient care is nuanced and complex and experiencing it at firsthand takes time to process.

It can be hard to be generous and reasonable when enraged by youthful idealism. heard? Storytelling before you have resolved your own grief can open old wounds, rather than heal them. The facts are mashed up with our own experience of those traumas and the story can become cruel and bitter.

Adam tells us that consultants laughed about the predicament of Jehovah’s Witness patients who were bleeding to death. He goes on to testify that “In the old days consultants would have just gone ahead and transfused.”

Maybe some seniors did ignore the

patient’s wishes, but not through arrogance, rather they were driven by a determination to save a life.

What happened to my Jehovah’s Witness patient?

The family and religious advisors left, and I stood at the boy’s bedside, struggling with my instincts to surreptitiously treat the boy as best I could.

However, what may have been the truth for Adam when he wrote this book isn’t the truth for me or, I suspect, for many of my colleagues.

When we cease to have compassion for those who suffer and whose care has been entrusted to us, where does that leave us as doctors?

ED: Dr Bruce Powell is a retired anaesthetist and now writer.

The father returned and quietly stood by my shoulder.

“I’m the next-of-kin, aren’t I?

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APRIL 2022 | 35

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Murdoch Square – the story begins The journey from a patch of no-man’s land between Fiona Stanley Hospital and St John of God Murdoch Hospital into a vibrant multi-use health, residential and lifestyle hub has been the preoccupation of developer Hesperia’s development director Ian Smyth since October 2016.

He says watching Murdoch Square, which is a 1.2ha first stage development within the 10ha Murdoch Health and Knowledge Precinct (MHKP), slowly materialise into a mini township is immensely satisfying.

Emerging from the site midway through 2023 will be five connected multi-storey buildings housing Montserrat's short-stay private hospital and cancer centre, a 182bed Aegis Aged Care facility, the State's first medihotel with 80 beds, disability accommodation, an international hotel, short-stay and residential apartments, medical suites, child-care facilities, extensive parking facilities and commercial and community services including dining and retail outlets.

Stanley Hospital to Murdoch Square, we see the precinct as an ongoing creation of people-focused places, with particular emphasis on creating enjoyable experiences for visitors, patients, and healthcare workers. The inclusion of diverse landscape settings provide respite, reflection as well as nourishment, celebration, and connection with the community,” said Hassell Principal Peter Dean.

“The beautifully landscaped plaza becomes a bustling centre with access to all the buildings from both the plaza and the surrounding streets,” Mr Smyth said.

The diverse usages at play in Murdoch Square will present an interesting social dynamic for its first inhabitants as they proceed to live and work and inevitably become a community, sharing facilities, spaces, time and perhaps even life stories!

private landscaping as well as direct access to the plaza and its facilities.

Aegis will also run the medihotel in collaboration with the South Metropolitan Health Service.”

Enhancing the lifestyle-friendly development will be a hotel run by the distinguished international hotel chain, Marriott, which Mr Smyth says will be a huge asset for those living south of the river as well as providing accommodation for outof-town families of both patients at the hospitals and students at Murdoch University.

While the area has naturally been seen in the past as a medical precinct, given its close proximity to two major tertiary hospitals, Mr Smyth says as Murdoch Square matures and other developments, earmarked for education and research in the broader MHKP, take off, the square will become a town hub.

“The concept is to create a town centre that services not only the facilities and commercial businesses within Murdoch Square, but also offers people who work and visit the two adjacent tertiary hospitals a place to meet and socialise,” Mr Smyth said.

“Much thought has been put into designing built structures and landscaping that promote multigenerational social connection,” Mr Smyth said.

International design firm Hassell Studio is the lead architect and has been responsible for the overall design, which features an attractive landscaped plaza at the heart of the development.

“Aegis was on the ground floor of planning with Hesperia, keen to create a new era in high-care residential aged care across eight to nine storeys that would integrate with the broader activity in the square.

“From just one of those sectors – health – with Aegis and the medihotel on board, so grew the commitment for a day hospital, a GP clinic, medical suites, pathology, radiology plus hospitality and residential apartments.

“Following our work on the Fiona

“Once completed, it will have its own

“The square is ready to come alive.”

“We have four sectors of demand in this one location – health, education, research institutes and tourism – these are strong ongoing drivers.

www.hesperia.com.au 36 | APRIL 2022

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Montserrat in the Square In October 2021, Montserrat Day Hospitals announced it was joining Murdoch Square with a state-of-the-art private hospital that will feature five operating theatres and first and second stage recovery beds. They will also establish and operate a haematology and oncology centre with 14 treatment chairs, together representing the group’s largest investment in WA to date.

Montserrat’s general manager in WA, Brendon Ball, said that while Montserrat was very much focused on day surgery, having overnight beds gave the organisation the opportunity to increase its services to its clinicians if their patients required extra monitoring after surgery.

The hospital will encompass two floors of the Aegis building, with the first level housing the theatres and procedure rooms, while level nine with its peaceful setting and beautiful views will accommodate the oncology and haematology centre (with 14 treatment chairs) as well as the overnight ward.

Mr Ball says specialties that will operate from Murdoch Private Hospital included gastroenterology, orthopaedic, plastic and reconstructive surgery, ophthalmology, oncology/haematology, gynaecology, ENT, pain, general surgery and urology.

Montserrat CEO Henry Barclay said he was delighted to see Montserrat continue to expand its WA services into the Murdoch area.

“After 27 years in the healthcare industry, Murdoch Private Hospital will be Montserrat’s most innovative yet,” he said, flagging that it could be a springboard for other developments in the future.

Mr Ball says the hospital will align specialists and allied health services with multidisciplinary teams to create a personalised treatment plan for every patient.

Doctors will have access to the latest advancements in technology and specialised nursing staff.

The hospital is expected to open its doors in October 2023, which will be the first Montserrat facility south of the river.

“We built the day hospital in Albany and have another in Bunbury, but our metropolitan facilities are north – Oxford Day Surgery, Western Haematology & Oncology Clinics in West Perth and Craigie Day Surgery.

“So, Murdoch Private Hospital will be a vital link for our regional and metropolitan centres and also play an important role within a significant health precinct south of the river where there is a large patient base and unmet need for health care services.

“We have had heard from many of the state’s leading doctors who have all struggled to get regular theatre time within the current hospital environment here in WA, as well as from younger doctors looking to secure consistent theatre time and establish their practices.

They’re all keen to get access to these state-of-the-art facilities.”

“In addition to the premises, we are also building our local team and are pleased to announce the appointment of Ms Bronwyn Grant as CEO of our new Murdoch Private Hospital. She takes up her position on April 1.”

www.montserrat.com.au MEDICAL FORUM | CARDIOVASCUL AR HEALTH

APRIL 2022 | 37

38 | APRIL 2022

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GUEST COLUMN

Doctors don’t get sick, right?

As he steps back as director of the WA service that looks after the welfare of doctors, Dr David Oldham reflects on the wins since the early 2000s.

When I finished medical school in 1982, there was a widespread belief within the medical profession that doctors didn’t get sick, at least not good doctors.

Fortunately, most doctors these days have a well-developed support network including family, friends, colleagues and a GP. Over the past five years the Doctors Health Advisory Service Western Australia has greatly expanded its range of services for doctors and medical students which now include a 24/7 telephone advice line, a Drs for Drs list (including GPs, psychiatrists and clinical psychologists), Doctors Welfare Guidelines for employers, and a comprehensive website www.dhaswa.com.au

Throughout medical school and my junior doctor years there was never any discussion about doctors’ health. Few doctors had a GP, and doctors were expected to diagnose and treat their own medical conditions. If doctors got a flu like illness, they were expected to carry on regardless (there was no pandemic then), and it was not unusual for doctors to work when they were sicker than their patients.

Furthermore, if a doctor got stressed, then it was thought this was the fault of the doctor.

There was a lot of tut-tutting and mutterings by senior doctors (often within strategic earshot of the person they were talking about) that Dr X was obviously not strong enough to work in medicine.

Working 60-80 hours a week and forsaking family and friends was worn as a badge of honour by many, even some of those who crashed and burned along the way.

On reflection I realise that many of my colleagues who “dropped out” as a student or junior doctor had health issues, often stress related.

With a little help and support many of these would have gone on to make excellent doctors. Instead, they simply disappeared and were no longer talked about.

I’m pleased to note that in the 40 years since I graduated there have been a lot of improvements in doctors’ health. All of the medical schools in WA now openly discuss students and doctors’ health issues.

Pastoral support and counselling are freely available to students.

Most students now finish university with a GP. In the prevocational years, all health services now have medical

education units whose primary responsibility is to support junior doctors. All intern and RMO positions are accredited by the Postgraduate Medical Council of WA (PMCWA) which ensure a minimum standard of training and support are provided.

There is now recognition by hospitals and departments that working conditions are a major, and often the major, determinant of junior doctor stress. Most junior doctors now work 40-60 hours a week and many have no overtime at all (albeit to save hospitals money). In recent years most hospitals have put in place junior doctors’ welfare programs.

The training colleges also now consider welfare issues when accrediting training positions, and offer a range of supports to trainees. Even so, there is still a reluctance by trainees to admit to health issues for fear of being branded “weak” or being dropped from a training program.

On completion of training, stresses continue. The stresses of exams are replaced by stresses such as running a private practice, raising a family, private school fees (not cheap!) and paying off a mortgage.

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

So, things have improved a lot over the past 40 years but there is still a lot of work to be done. The main issues for junior doctors are medical workforce related, including the need for family friendly rosters, adequate leave, part-time work options and payment for unrostered overtime.

Service registrar positions need to be accredited so minimum levels of welfare and support can be introduced and enforced. Training colleges can do a lot more to support their trainees. Bullying and sexual harassment is still quite widespread and a zero-tolerance approach to these is needed.

We have now reached the stage where we realise that doctors do get sick and are prone to the same mental and physical health conditions as the general population. Our next challenge is to accept this as normal and remove the stigma, particularly for mental health conditions.

Doctors needing help can contact www.dhaswa.com.au.

ED: Dr David Oldham was director of the Doctors Health Advisory Service WA from 2005-2021.

APRIL 2022 | 39

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GUEST COLUMN

Living with COVID is not that easy Living with COVID has a different meaning for people at high risk, says Rachel Seeley. She offers a consumer’s view on WA’s unfolding COVID situation.

For the Health Consumers’ Council, the first few months of 2022 have involved an intense period of listening, sharing and advocating for more consumer voices in the planning of the health system’s response to this new phase of the pandemic in WA. Through a series of discussions with consumer representatives and lived experience voices from across WA, a key message has been the ongoing uncertainty and fear in some parts of the community as people navigate the mindset change from ‘avoiding COVID at all costs’ to ‘living with COVID’.

Many consumers want to actively participate in preparing and helping others in the community to prepare.

By sharing their insights, resources, and creating opportunities to hear directly from the experts, we heard that people became more confident in their ability to contribute to their community’s wellbeing.

We also heard that there was a lack of information for those who have underlying conditions, who are immunocompromised, or who, for other reasons, are at much higher risk and may need to make additional preparations.

Since this gap was initially identified we have seen more resources made available for some of these communities.

The third strong message was around people’s concerns for the social implications of COVID. For example, who can people rely on if they’re a carer and they get sick?

How do people get access to care if they’re unable to leave the house?

How can they make sure they can continue accessing the health care they need, in a safe way, during the peak of COVID caseloads?

It’s important that those in the frontline, who will be seeing consumers throughout the

pandemic, are able to direct them to the answers they need.

Those who are medically vulnerable have told us the benefits of establishing a COVID plan together with their doctor – outlining health conditions and medications to show hospitals or other providers and ensuring clarity about the steps to take should they get COVID-19.

One high-risk consumer shared that keeping informed about treatment options also provided them some reassurance.

“It’s important I know where to go and what to do if I test positive for COVID-19. I believe I will qualify for antiviral treatment, so I want to know how to access them,” they told us.

“I am anxious on a daily basis and knowledge and planning are really the only way to flatten my anxiety curve.”

Mental health will be a big consideration for many consumers, especially those who are highrisk or medically vulnerable. It’s important to consider how the consumer can access support in ways that are safe for their circumstances, for example, by telehealth.

The consumer told us how important it was to be proactive about their mental health supports, seeking help from health professionals and support groups: “I am afraid of catching COVID, that is a part of the challenge. I don’t want everyone else living with COVID to mean me dying with COVID. That is only part of the equation though. It’s incredibly challenging to think about quality of life, for myself and my family.

“First there is the social isolation and the physical and mental health implications of shielding. Then there is the financial aspect of purchasing

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N95 masks, RATs, and stopping work to home school if needed.

There are also logistical challenges of how to actually reasonably shield.

“How do I protect myself from catching COVID (as my specialist has instructed me to do in no uncertain terms) and simultaneously give my kindy-aged kid the life she deserves in terms of school, activities, and playing with friends?”

Consumers should be encouraged to talk to workplaces about flexibility that may be needed to accommodate their risk factors, and to talk to family, friends and support networks about the options if they, or others in their family, become ill.

Given high vaccination numbers across the board, those who are highest risk may now find themselves being the only ones needing to take extra precautions in 2022.

“I find that many people in workplaces and businesses I come across are far less understanding in 2022. There is a lack of empathy, possibly driven by a lack of understanding around what being ‘severely immunosuppressed with multiple underlying health conditions’ means,” the consumer told us.

“I have already come up against problems with this in my daily life and I can imagine these will increase. As cases grow, I will need more support from my GP. I plan to sign up for WA COVID Care at Home if I test positive and I have a number to call my specialist team directly, but I’ll need the assistance and support of a good GP. “At this point in the pandemic, empathic people have never been so important in my life.”

ED: Rachel Seeley is part of the engagement team at Health Consumers’ Council.

APRIL 2022 | 41

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GUEST COLUMN

Getting down to business, COVID smart Governments and business need to remain nimble when responding to the COVID threat, says the research hub CEO Jayden Rogers.

The emergence of the Omicron variant has changed the COVID-19 landscape in Australia and that means Western Australian businesses need to adapt and plan for this.

New South Wales at the time of writing had almost 1650 hospitalisations due to COVID-19, which, in context, equates to every bed available at Fiona Stanley Hospital and Sir Charles Gairdner combined. It’s a scary thought, especially when those hospitals are already at full capacity.

At Linear Clinical Research, we are fortunate to work with global COVID-19 vaccine and therapeutic companies, leading infectious disease experts and closely follow what is happening overseas. Based on this, data and strategies we are implementing can hopefully provide ideas for other businesses to consider.

The importance of vaccines and having a booster is critical, which sees effectiveness against infection from Omicron increase from a lowly 34% after two Pfizer doses to 75% after three doses.

More so, vaccines are still holding up very well in preventing serious illness and death. Businesses must enforce vaccination requirements for both staff and customers because the potential cost of not doing so will far exceed the cost to implement it.

COVID is airborne and masks stop you from both contracting the virus and also from spreading it. This is even more important in light of many people having mild disease or being asymptomatic with Omicron.

This is critically important for industries interfacing with vulnerable populations such as childcare where children under five are yet to receive vaccinations.

Business needs to accept that

masks will be required for the foreseeable future and prepare for this, through stock levels, adjusted work processes and support for staff.

empt this situation. This is evident in the enormous challenge many pharmacies are now facing as they deal with people desperate to find tests.

Airflow ventilation is imperative.

If you can, monitor CO2 levels and aim to keep these below 700800ppm, through social distancing, open windows and use of fans.

HEPA filters should be used where possible. An excellent resource is the independent OzSage website.

The final element that is often overlooked is mindset, which any business leader will tell you is critical to performance. We need to accept that COVID-19 won’t simply go away or become endemic overnight, if at all.

Severe business disruption has been reported across the UK, US and in NSW, where some industries are reporting anywhere from 2050% of staff being granted leave due to having COVID-19 or being a close contact.

This is why reducing the rate of spread through vaccines and masks may save many businesses, so that an active case doesn’t completely shut you down.

A strategy to tackle this is scenario planning for staff shortages and supply chain disruption, which we are already experiencing, as well as developing rosters that separate workforces and establishing multifunctional teams that can cover different roles if (more likely when) staff shortages occur.

Rapid antigen testing will have a huge role to play, however, it requires thinking around the logistics – how to make them available to staff, where to test (if doing on-site you need to maintain strong infection control procedures) and how to report results and manage positive cases.

In the UK and US, it has become almost normal for people to use RATs prior to any socialisation.

Supply is the current issue, though this is starting to improve finally.

Until we can get more vaccines and treatments to other parts of the globe, the threat of new immuneescaping variants will persist beyond Omicron.

However, we can get through this – we need to be bold, invest effort and discipline over time and bring our people along with us.

We will require the intermittent use of targeted public health measures (e.g. masking and testing) alongside innovative business practices.

From the government, greater engagement and quicker decisionmaking will support business and government alike.

We need to further ramp up research into new vaccines and treatments, with several recent antiviral and antibody therapies showing great efficacy against COVID-19 illness, there is a pathway out of COVID-19 – but this will take months, if not years for them to be available to those in need.

Until then, we need to face the COVID threat head on, listen to the science and put people’s health first.

ED: Jayden Rogers is CEO of Perth’s Linear Clinical Research, a global site for early-stage clinical trials and a subsidiary of the Harry Perkins Institute.

Moving forward, we need greater proactivity from government and engagement with business to pre-

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

APRIL 2022 | 43

44 | APRIL 2022 42 | SEPTEMBER 2020

MEDICAL FORUM | CARDIOVASCUL AR HEALTH MEDICAL FORUM | RESPIR ATORY HEALTH ISSUE

MEDICAL FORUM | CARDIOVASCUL AR HEALTH MEDICAL FORUM | RESPIR ATORY HEALTH ISSUE

APRIL 2022 | 45 SEPTEMBER 2020 | 43

st

m 1 Fro ber vem o N

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ABP monitoring analyses ambulatory pulse waves, peripheral blood pressure, central haemodynamics, and arterial stiffness. Each component is automatically measured over a period of 24 hours and will be used to create a haemodynamic day/night profile. Patients will keep a diary for the duration of their test which is referenced during interpretation of data. Following each test a comprehensive analysis is produced by a cardio specialist who will provide a high quality ABP profile.

Key features • Peripheral blood pressure

PATIENT PREPARATION Patients are required to arrange an appointment for ABP monitoring with a Western Diagnostic Pathology collection centre. If patient preparation is required, a Western Diagnostic Pathology staff member will inform the patient at the time of the booking.

HOW TO ORDER Request ‘ambulatory blood pressure monitoring’ on a Western Diagnostic Pathology request form.

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• Central hemodynamic • Arterial stiffness • Central aortic pulse wave • Interval measures over 24hrs

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46 | APRIL 2022

PUB/MR/1605_V1_Sep21

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Take nothing for granted Just when you thought the world has been through enough, the last month showed it is never good to assume. The Ukraine situation is a wake-up call to all of us about the freedoms we take for granted and, on reflection, may have been too willing to abandon without question.

As COVID recedes… health issues such as IHD, which were relegated to secondary importance, need to regain their rightful place.

It should also cause us all to ponder our priorities at an individual and national level.

At home we lost two cricketing greats to heart attack within 24 hours.

I recall watching Rod Marsh as a kid in the 1970s from the outer of the WACA ground and like many West Aussies of a certain age can say they saw “caught Marsh bowled Lillee” as it happened.

Ischaemic heart disease (IHD) remains the single biggest killer in Australia. Some 37% of those are under age 75 and it is double in males (a gender gap not making the front page). Progress has been made over the years, especially with better treatments. Smoking remains the biggest preventable risk factor but sadly smoking rates in Australia have barely moved in eight years and despite lipid-lowering agents being widely prescribed, their end impact is less than one might have hoped for.

Dr Peter Bruckner, long-time Australian cricket team doctor opined that Shane Warne’s diet and smoking habit made heart disease predictable and that it was probably developing for years. Warnie is no orphan. On the positive, he lived life to the full, cramming more into 52 years than most would in two lifetimes. He was a sporting hero who never sought to be a role model.

This month’s theme is cardiovascular health in which we cover numerous aspects including article on some newer treatments such as left atrial appendage occlusion, 3D printing and transcatheter aortic valve replacement. Lipoprotein (a) is examined as well as a heart healthy diet and myocarditis. Anecdotally myocarditis may be more common than is being reported. Connections between oral and cardiovascular health are looked at as well as the effect of the pandemic on vascular health.

As COVID recedes and we return to a true normal, health issues such as IHD which were relegated to secondary importance need to regain their rightful place. As we start to reconnect with loved ones and even children not previously seen, we need to remember the importance of relationships and love in our lives.

The heart is the symbol of love – let us care for it and hug our loved ones.

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

APRIL 2022 | 47

Left Atrial appendage occlusion (LAAO) in atrial fibrillation

By Dr Richard Clugston, Interventional Cardiologist, Hollywood Atrial fibrillation (AF) is one of the commonest causes of stroke (particularly debilitating stroke).

Thromboembolism usually occurs when thrombus is dislodged from the left atrial appendage (LAA).

It is estimated that 90% of emboli in patients with AF come from the left atrial appendage.

Embolism may occur to the brain with silent or clinically overt, often debilitating, stroke. Clots may embolise to other organ systems with or without overt sequelae (e.g., acute gut ischemia, acute upper or lower limb ischemia, myocardial infarction).

Anticoagulation is a standard treatment in most patients with AF to prevent thromboembolism and stroke. The annual risk of stroke is lowered by approximately two thirds by anticoagulation, with those patients at highest risk of embolic stroke (high CHA2DS2VASc score) accruing the most absolute benefit.

Because anticoagulation is associated with an increased risk of bleeding the prescription of an anticoagulant involves careful discussion with the patient about relative risks and benefits. The HASBLED score is perhaps the most accurate of a number of bleeding risk scores. However, all are relatively

Key messages Thromboembolism from the left atrial appendage in patients with AF is a major cause of stroke Pharmacologic rhythm control, catheter or surgical ablation procedures may reduce the burden of AF but have not been proven to eliminate the thromboembolic risk, particularly in high-risk AF patients Closure of the LAA by percutaneous or stand-alone surgical techniques should be considered in all patients with AF in whom anticoagulants are contraindicated.

imprecise, especially for the individual patient. An anticoagulant is relatively or absolutely contraindicated in some patients.

While stroke prevention is the major imperative in high-risk patients with AF, other treatment strategies are considered concurrently.

Rate control in patients with AF provides symptomatic relief and, in some patients, restoration of sinus rhythm (SR) rhythm control is appropriate.

Rhythm control can be achieved by management of co-morbid

TOE - Left Atrial Appendage LA

LAA

LAA Thrombus Figure 1: TOE-Left atrial appendage 48 | APRIL 2022

Thrombus Resolved With Anticoagulation

conditions (weight reduction, reduction of alcohol intake, treatment of sleep apnoea, hypertension control, physical activity). Other rhythm control strategies include pharmacologic therapies, percutaneous catheter ablation of atrial fibrillation and/ or a variety of surgical procedures which have been developed to diminish the burden of AF. Successful rhythm control (restoration of sinus rhythm) has not been proven to abolish the risk of thromboembolism, and this is particularly so in patients with a high risk of thromboembolism and stroke. Most patient with AF who have a catheter or surgical ablation procedure, or in whom a pharmacologic strategy is used require ongoing anticoagulation.

Indications for LAAO Oral anticoagulation remains the standard of care for patients with atrial fibrillation and significant risk of thromboembolism, assuming there is no relative or absolute contraindication to prescription of an anticoagulant drug. Thrombus in the left atrial appendage can resolve after even short periods of anticoagulation. (Fig.1) Occlusion of the LAA is an alternative strategy to reduce the risk of thromboembolism and stroke when anticoagulants are relatively or absolutely contraindicated. There is currently no proven role for percutaneous LAAO in patients without AF. In patients with AF who have an embolic event while anticoagulated, LAAO can be considered as an adjunctive therapy, but this treatment has not been scientifically proven.

In percutaneous occlusion (LAAO) the left atrial appendage may be occluded percutaneously under local or general anaesthesia using one of a number of approved devices ( Fig. 2, closure of atrial appendage using Amplatzer Amulet Device). Analysing the data available to date indicates that percutaneous LAAO provides

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CLINICAL UPDATE

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CLINICAL UPDATE

TOE - Left Atrial Appendage Occlusion Device

LA

While the various strategies to provide rate and rhythm control in AF are important it is crucial to be cognisant that a successful catheter or surgical ablation procedure, or pharmacologic reduction of AF burden has not been proven to correlate directly with a reduction in thromboembolic risk, particularly in patients at high risk of stroke.

LA

Biplane 2D

4D TOE Amulet

Figure 2: TOE- Left atrial appendage occlusion device a similar reduction in stroke risk compared with standard oral anticoagulation.

Surgical LAAO Historically, the left atrial appendage has sometimes been occluded at the time of openheart surgery. Amputation and closure using a stapling device, and linear closure from within the left atrium are well established

highest risk of stroke are likely to accrue the most benefit.

It is essential that there is a careful discussion with high-risk AF patients about thromboembolic risk, and when anticoagulants are contraindicated that LAAO should be discussed.

The author acknowledges Dr Phillip Currie for the images.

surgical techniques. More recently, stand-alone thoracoscopic LAAO is performed in a procedure which is relatively quick, minimally invasive, and effective.

In patients with AF where anticoagulation is appropriate but there is a significant relative or absolute contraindication to anticoagulants, LAAO should be considered. Those patients at

– References available on request Author competing interests – nil

Read this story on mforum.com.au

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CLINICAL UPDATE

Transcatheter aortic valve replacement

By Dr Michael Muhlmann, Interventional Cardiologist, Perth Transcatheter aortic valve implantation (TAVI) is a much less invasive treatment for aortic stenosis than open heart surgery. Currently approved for intermediate and high-risk patients, it will likely soon be approved for low-risk patients.

It is often performed under local anaesthesia and sedation. Most patients are discharged home within 24 hours.

Aortic stenosis (AS) is one of the most common and serious conditions affecting heart valves.

Predominantly a disease of ageing, it develops as the valve calcifies and narrows. It can also occur in a congenital heart defect called a bicuspid aortic valve.

People with AS tend not to present with symptoms (including shortness of breath, chest pains, dizziness and a decline in activity level) until the valve is severely narrowed.

Some may be asymptomatic but close family members may note increased fatigue or reduced ability to do normal activities. The average survival in patients with symptomatic AS is about two years.

The classic physical finding in AS is a harsh crescendo-decrescendo systolic murmur maximal in the second right intercostal space and radiating to the carotids. It is very important to consider aortic stenosis in patients with any of the classic symptoms accompanied by a murmur.

Transthoracic Echo is the recommended initial test for AS and is the most important modality to assess severity. Peak and mean gradients across the valve, maximum velocity through the valve and valve area are primary measures used for assessing severity. Echo also provides information on left ventricular function and thickness, LV filling pressures and presence of other valvular abnormalities.

Aortic valve replacement (AVR) is the only effective treatment

Key messages Aortic stenosis is a common condition, increasing in prevalence as the population ages. Be vigilant in patients with symptoms and a murmur Transthoracic echo is the initial test to determine severity of AS TAVI is an established alternative to surgery for valve replacement.

Refer patients to a heart team for evaluation and decision regarding treatment.

for severe symptomatic and haemodynamically significant AS and is also recommended for asymptomatic severe AS with LV impairment. It is unclear whether AVR in truly asymptomatic patients with severe AS is of benefit compared with watchful waiting and these patients are being evaluated with ongoing trials.

Surgical AVR tends to be done through traditional open heart surgery involving midline sternotomy. Patients are placed on a cardiopulmonary bypass machine.

Most patients spend 24-36 hours in ICU and hospital stay averages 5-7 days. Many elderly patients are deemed high risk and not suitable for surgical AVR and in pre-TAVI days up to a third of patients were not offered treatment.

TAVI has been performed for the past 15 years. Rather than removing the old existing valve, this technique pushes a new valve into the place of the existing valve. The preferred access site is via the common femoral artery (transfemoral TAVI) but can also be performed via a transapical, transaortic, transcaval or a transcarotid approach.

TAVI valves are crimped on a catheter to allow delivery to the area of the aortic annulus. All valves are bioprosthetic, usually made from pig or cow tissue, and either balloon-expanded or selexpandable. Recent technological advances allow for smaller sheath

MEDICAL FORUM | CARDIOVASCUL AR HEALTH

size leading to less vascular complications, and a skirt attached to the valve reduces the likelihood of paravalvular leak. Careful preprocedural planning using CT scans of the aortic annulus and peripheral vessels are paramount to procedural success Patients with severe symptomatic AS are assessed by a heart team involving an interventional cardiologist and cardiac surgeon.

Patients are presented at a multidisciplinary team meeting to determine the best treatment for each individual. The concept of a heart team has been important in the progression of TAVI in Australia.

Numerous studies, including the landmark PARTNER studies, compare TAVI to cardiac surgery in patients with severe symptomatic AS. Early studies looked at patients not considered suitable for surgery and found significant mortality benefit in TAVI patients compared with medical patients. Subsequent studies looked at high and then intermediate risk patients and found TAVI was non-inferior to surgery.

The PARTNER 3 study looked at low-risk patients finding TAVI superior to surgery at reducing death, stroke or rehospitalisation at one year and that these benefits have persisted.

TAVI is now an established treatment for severe AS. It is important that any patients with symptoms and a murmur be screened with an echo. Refer patients with severe aortic stenosis to a heart team for evaluation and decision regarding the safest and most appropriate management.

TAVI is the preferred option in highrisk patients and is likely in time to be an option for low-risk patients.

Author competing interests – nil

APRIL 2022 | 51

Clinical value of 3D printing in cardiovascular disease

By Prof Zhonghua Sun, Curtin Medical School Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Coronary artery disease is the most common type of cardiovascular disease.

Aortic dissection and pulmonary embolism are the other two common forms presenting the symptom of acute chest pain similar to that of coronary artery disease, as observed in the Emergency Department.

Imaging diagnosis plays an essential role in the early detection of cardiovascular disease, with an intense focus on the characterisation of lesions and identifying vulnerable patients to guide timely treatment and avoid adverse cardiac events.

Cardiac computed tomography (CT) is the most commonly used imaging modality in diagnosing and assessing cardiovascular disease due to its wide availability and rapid technological improvements in scanning techniques with a high diagnostic value. Importantly, cardiac CT serves as the firstline technique to diagnose and screen patients with cardiovascular disease, thus, avoiding unnecessary

The CVD context

Key messages 3D printing has significant value in cardiovascular disease by replicating the complexity of anatomy and pathology Personalised 3D printed models assist surgical planning and treatment options.

3D printed physical models enhance doctor-patient communication in a busy clinical environment.

invasive procedures and reducing costs or complications.

One limitation of cardiac CT imaging at present is the high radiation dose, which might be a concern in the current medical practice. Another limitation of CT imaging (along with other imaging modalities) is the lack of ability to demonstrate complex anatomy and pathology in real-time three-dimensional (3D) view, despite the capability of reconstructing the volume data into 2D and 3D views.

This drawback can be overcome by the increasing applications of 3D printing technology in the medical domain.

3D printing was developed in the early 1980s. However, the recent surge in its use is due to technological advancements and its increasing applications in the medical field. This approach reduces the turnaround time to printing physical models and the associated cost of printing materials. The personalised 3D printed models based on medical imaging datasets, such as cardiac CT images, have significant value in cardiovascular disease.

The applications range from improving the understanding of complex cardiovascular anatomy and pathology (especially congenital heart disease) to presurgical planning and simulation of challenging cardiac procedures, enhancing the education of medical students or healthcare professionals and doctor-patient communication.

Both multicentre and single-centre studies have shown that 3D printed heart models help the surgeons to define the best approach before surgery, thus achieving a personalised therapeutic

How will the COVID pandemic affect those with vascular disease?

By Dr Robert Ma, Vascular Surgeon, Osborne Park Coronavirus has been impacting the way we live and practise since the beginning of 2020. Western Australia has been relatively less affected directly by the virus. As case numbers continue to rise here, it is timely to consider the impact of COVID-19 either directly or indirectly on vascular patients, based on interstate and international experience plus WA Health modelling and planning.

Does COVID-19 increase the risk of acute vascular presentations and how might we best serve patients afflicted with vascular pathology?

52 | APRIL 2022

Interstate and international experience Talking to colleagues from interstate, it is reasonable to expect that the volume of elective vascular surgery work in public hospitals will significantly reduce, if not completely stop. Private hospital workload appears to have continued, albeit with a 50% decrease in elective work.

Fortunately, most elective surgical delays can be done so safely, although anecdotally, increased numbers of acute presentations of all vascular pathologies (e.g., ruptured aneurysms, ischaemic limbs, or thrombosed renal access) has been noted.

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CLINICAL UPDATE

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CLINICAL UPDATE

A

Figure 1: A: Cardiac CT image shows the rightward displacement of the aorta in the case of DORV with aorta arising from right ventricle; B: Cardiac CT image shows the ventricular septal defect in DORV; C: 3D printed model of the case of DORV demonstrates both aorta and pulmonary trunk arising from the right ventricle.

Red asterisk * = aorta; blue cross + = pulmonary trunk; red arrow = ventricular septal defect.

B

processed by an experienced radiographer on a CT workstation with a segmented volume data file sent to an onsite 3D printer for printing the physical model of this case.

C

After 24 hours, a personalised 3D printed heart model (Figure 1C) was created, and the cardiologist presented it to the parents of the patient, explaining the condition and the extent of the disease.

Then, the patient is referred to a paediatric cardiac surgeon for planning the surgical treatment. strategy for each patient. Several randomised controlled trials have confirmed the advantages of 3D printed models over traditional teaching methods in the area of complex congenital heart disease.

An emerging interest in 3D printing in cardiovascular disease is its clinical value in enhancing doctor-patient communication in daily practice.

A scenario in a busy clinical environment exhibits the potential value of how 3D printed models can transform our practice by enhancing doctor-patient communication and

equipping doctors with more time to focus on the surgery.

A paediatric patient with suspected congenital heart disease was admitted under a cardiologist.

After checking the patient’s history and physical examination, the cardiologist refers the patient to undergo a cardiac CT scan that reveals the presence of a double outlet right ventricle (DORV) (Figure 1A and 1B).

Given the complexity of the congenital anomaly of this disease, cardiac CT images are post-

Key messages Internationally there has been a negative impact on vascular health due to COVID restrictions Arterial thrombotic events can be a presenting feature of COVID infection Keep a close watch on patients with vascular pathology and refer as needed.

Telehealth reduces in-person consultations but has limitations. As case numbers go down, we can expect an increase in workload as patients feel comfortable to seek attention for their ailments, and a resultant secondary strain on healthcare providers. A 90% backlog accounting for eight months of work was reported in the US. International literature backs up the anecdote.

Worldwide practice has changed – to reduce the volume of cases being treated, and to target reduced MEDICAL FORUM | CARDIOVASCUL AR HEALTH

Subsequently, the patient’s parents have a good understanding of their child’s condition while junior doctors can practise the operational procedures on the model for training, and the surgeons plan treatment approaches to minimise the risks or complications. This phenomenon would be expected soon in clinical practice, with the incorporation of 3D printing technology into routine diagnostic strategy and clinical decision-making.

Author competing interests – nil

length of stay, rather than the best practice approach for the individual.

During the 2020 lockdown period in the Netherlands, surgeons reported a statistically significant increase in advanced tissue loss, resulting in a tripling of the annual number of amputations.

In the US, vascular surgeons reported high rates of COVID exposure, reduced ICU bed availability, and changes in consulting practices with increased telehealth or redeployment. Again, in the US, national numbers of acute limb ischaemia revascularisations increased in 2020, while elective and emergency aortic and carotid intervention decreased (likely from decreased access to health care rather than decreased disease incidence).

Does COVID increase the risk of acute vascular presentations? continued on Page 55

APRIL 2022 | 53

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How will the COVID pandemic affect those with vascular disease? continued from Page 53 The reason for the increase in acute vascular presentations is going to be complex. Proposed theories include delayed presentations due to health care avoidance, reduced case volumes in diagnostic and treating facilities, and delays in treatment due to reduced access.

We also know that COVID infection increases thromboembolic risk even in patients with mild symptoms.

Venous and arterial complications are approximately 8%, even when a patient is on VTE prophylaxis, and patients with raised D-dimer are at a high risk of developing symptomatic thromboembolic events. Be aware that arterial thrombotic events can be the presenting manifestations of COVID. From mid-March and a week later in private hospitals, for a period of seven weeks, all category 3 cases

will be postponed, and only urgent category 2 cases will proceed with a cap on total numbers yet to be confirmed. The peak of cases is likely to occur within this time frame, on a daily basis it is expected we will see more than 10,000 cases a day, over 400 hospital beds occupied, and 56 ICU beds occupied.

The caveat to this modelling is that the state’s high number of doubledose and booster vaccinated individuals will hopefully see lower case numbers in hospital than predicted. Hopefully our patients might be less affected than our interstate and international colleagues experienced.

Managing vascular pathology

atherosclerosis or aneurysms, and consider the increased thrombotic risk that coronavirus poses to patients.

The vast majority of vascular surgeons I’ve spoken to have action plans for continuing to consult during the pandemic and will be able to triage and manage the patient accordingly. A telehealth consultation is an opportune time to screen the vasculopath regarding symptom deterioration, and surveillance.

If their symptoms have deteriorated or they’ve not seen a surgeon for more than a year, don’t hesitate to refer.

– References available on request Author competing interests – nil

We all know how difficult a vascular assessment can be via telehealth, so keep a close eye on patients who have significant risk factors for

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APRIL 2022 | 55

Myocarditis in the time of COVID

By Dr Steve Gordon, Cardiologist, Subiaco Myocarditis and pericarditis have been thrust into the spotlight due to risks associated with COVID-19 disease, and as a potential side effect of mRNA COVID vaccines.

These conditions represent inflammatory effects on the myocardium, or pericardium, and can co-exist. Severity ranges from minimally symptomatic and very low risk through to life-threatening cardiac decompensation and tamponade.

COVID vaccine-related myocarditis is recognised as a rare complication (2.7 cases per 100,000 patients) of mRNA vaccination. The risk complicating COVID-19 infection is much higher at approximately 11 cases per 100,000 patients. To date there has not been definite evidence of an increased risk after non-mRNA vaccines.

The majority of cases have occurred in younger (under age 30) patients, with the highest risk between 16 and 19 years. Most occur in the first week post vaccination, are more common after the second dose (versus first,) and substantially more common in males. Some evidence suggests a higher risk with Moderna than Pfizer, but this remains unproven, with no difference in disease severity.

The commonest presenting symptom of myocarditis (and pericarditis) is chest pain.

Myocarditis-related chest pain is generally reported as pressure, aching, or squeezing. Pericarditis pain in contrast is generally sharper, pleuritic, and better sitting forward than lying flat. Other common presenting symptoms include dyspnoea, general fatigue, and palpitations.

Physical signs (if any) associated with myocarditis may be tachycardia, arrhythmia (atrial or ventricular ectopy, AF, VT). In severe cases typical manifestations of CCF may be present. The physical sign of pericarditis is the pericardial rub.

In suspected myocarditis or pericarditis, the essential initial 56 | APRIL 2022

Key messages Myocarditis (and pericarditis) are uncommon common complications of mRNA COVID vaccines Appropriate investigation of suspected cases in primary care can triage those requiring hospitalisation Remain wary of other serious causes of chest pain.

investigations include an urgent troponin level, inflammatory markers (CRP, ESR), 12 lead ECG, and semi-urgent echocardiogram.

ECG changes associated with myocarditis are often non-specific (non-specific ST-T wave changes, Q waves, atrial and/or ventricular ectopy, and arrhythmia).

Widespread ST elevation and depression of PR segments accompanies pericarditis. Some guidelines recommend CXR though the diagnostic yield will be low if timely echocardiogram can be obtained. CXR be useful in excluding other causes of chest pain and dyspnoea or to assess cardiac size where access to echocardiogram is delayed. The possibility of the patient having COVID-19 disease as a cause should also be considered.

Inflammatory markers and troponin are commonly raised.

A normal troponin does not completely exclude myocarditis.

The echocardiogram may show LV dysfunction and wall motion abnormalities, and extent of any pericardial effusion. A normal echocardiogram may not completely exclude the diagnosis where very focal cases can occur which can be diagnosed with cardiac MRI. This is only (temporarily) subsidised

by Medicare when requested by a consultant physician, and where the investigations above have been inconclusive.

In primary care, the result of

troponin, ECG, and echo should allow a management decision.

Patients who are clinically very unwell, have elevated troponin, ECG or echo manifestations suggesting myocarditis, or concern regarding significant pericardial effusion should be referred to hospital. Patients with just pericarditis without large effusion can be managed with NSAIDs +/Colchicine in standard doses.

Consider cardiology referral for patients discharged from hospital with myocarditis, or monitoring of pericardial effusions, or where there remains a high suspicion of myocarditis with inconclusive investigations described above.

Remain alert for other serious causes of chest pain including acute coronary syndrome, pulmonary embolus, and aortic dissection. If in doubt refer to ED. The vast majority of cases tend to be mild and self-limiting, even in hospitalised patients. Recent reported experience from Royal Melbourne Hospital of 61 patients with post-vaccine myocarditis indicated 90% had early symptom resolution and median hospitalisation stay of four to six days. Patients discharged following a diagnosis of myocarditis should probably restrict physical activity for six months.

Our experience with patients experiencing chest pain post vaccination is that most do not have myocarditis or pericarditis.

Many are very anxious. A significant number have chest wall pain and costochondritis, also exacerbated by anxiety. Palpitation symptoms are also common, often correlating with mild sinus tachycardia, usual degrees of atrial or ventricular ectopy, or even normal sinus rhythm. A Holter monitor may be useful.

Many patients referred to ED with normal investigations and chest pain leave with a diagnosis of continued on Page 58

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Links between dental and cardiovascular health

By Dr Amanda Phoon Nguyen, Oral Medicine Specialist, Perth Increasingly, studies support the hypothesis that infection and inflammation may be actively involved in atherogenesis. Dental infections have been implicated as a possible association for atherosclerosis and cardiovascular disease (CVD).

Three pathways have been hypothesised to explain the consequences of oral infections on such systemic diseases.

1. Metastatic spread of infection from the oral cavity resulting from a transient bacteraemia.

High salivary levels of A. actinomycetemcomitans and systemic exposure to the bacterium are associated with increased risk for CVD 2. Metastatic injury by circulating oral microbial toxins 3. Metastatic inflammation arising from an immune response to oral microorganisms.

These oral infectious diseases include periodontal disease and apical periodontitis. Periodontal disease is a chronic infection of the supporting tissues of the tooth that can lead to teeth loss.

This inflammatory disease of the periodontal tissues is caused by groups of specific microorganisms, resulting in the progressive destruction of the periodontal ligament and the alveolar bone, with gingival pocket formation, recession of the gingiva, or both.

Dentists measure the depth of the pocket in millimetres using a periodontal probe as an indication of the severity of the destructive process. According to a recent CDC report, in the U.S, 47.2% of adults aged 30 years and older have some form of periodontal disease, and 70.1% of adults 65 years and older have periodontal disease.

Similarly, one-fifth of the overall Australian population has been found to have destructive periodontal disease, with a strong and consistent association between age and the prevalence of periodontal disease. Risk factors for periodontal disease include

Key messages Patients with CVD should be encouraged to maintain regular dental visits Patients with CVD should be urged to see their dentist, especially if experiencing toothache, sensitivity, or bleeding gums Good management of oral hygiene and dental health may reduce CVD risk.

smoking, type 2 diabetes mellitus, poor oral hygiene, genetics, immunodeficiencies and other systemic conditions.

Signs and symptoms of periodontal disease include bleeding gums during tooth brushing, painful chewing, red, swollen, or tender gums, gums pulled away from the teeth (recession of the gingiva), persistent halitosis, suppuration between the teeth and gums, teeth mobility and subsequent loss of teeth, and changes in the occlusion due to teeth mobility.

Treatment of periodontal diseases ranges from non-surgical treatment involving a thorough debridement (cleaning) of the tooth root surfaces to periodontal surgery. Patients typically see their dentist, oral health therapist, and/ or specialist dental periodontist on a regular basis to manage this condition.

Apical periodontitis (late consequence of an endodontic infection) is caused dental caries affecting the pulp of the tooth.

Infection usually reaches the periapical region of a tooth root from infected, necrotic pulp in the crown of the tooth via the root canal and apical foramen. It is commonly a chronic infection.

Apical periodontitis clinical signs and symptoms may range from asymptomatic, to formation of a periapical abscess, presence of sinus tract, and pain when biting or palpating around the tooth.

If there is an acute exacerbation, symptoms can be severe. It is a chronic infection and, in some cases, is diagnosed by the radiographic observation of a radiolucent area around the root of the affected tooth by a dentist and absence of a pulp response to application of a cold test. Apical periodontitis can be treated by endodontic treatment (otherwise known as a root canal), periapical surgery or the extraction of the tooth by a dentist or specialist endodontist.

Dental disease such as periodontal disease or apical periodontitis may occur together with some forms of CVD or represent an oral manifestation of the same disease. While there are unknowns, an emerging body of evidence strongly supports an independent association between periodontitis and CVD, and there are reports of an association between CVD and apical periodontitis and dental caries status.

This association has been hypothesised to be attributable to a common inflammatory response trait. More studies are needed to establish if dental disease can directly damage the cardiovascular system, and if the association is casual.

Author competing interests – nil

Read this story on mforum.com.au

People with untreated tooth infections have been reported to be almost three times more likely to have cardiovascular disease than patients who had dental infections treated.

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APRIL 2022 | 57

Simplifying the dietary approach to cardiovascular health.

By Jo Beer, Advanced Accredited Practicing Dietitian Only 8% of Australian adults eat the recommended intake of vegetables, according to the most recent ABS National Health Survey (2017-18). Poor quality nutrition is strongly associated with increased cardiovascular disease (CVD) morbidity and mortality.

Most Australians eat excessive amounts of processed foods that are high in kilojoules, saturated fat, added sugars and salt. Poor dietary choices also directly contribute to overweight, obesity and a plethora of other diseases, including a range of cancers.

In Australia, the age standardised rate of heart disease hospital admissions is 117 per 10,000 population. WA fares only marginally better at 115.

In 2017, a large cost of illness analysis by Nutrition Research Australia reported that increasing vegetable intake to five serves a day could reduce CVD by 16%, saving $1.4 billion in health expenditure.

There are many diet programs promoted for weight loss and cardiovascular risk reduction. All are different e.g., low carbohydrate versus low fat, versus moderate macronutrient change, and all claim to be the most effective, which can be confusing for doctors and patients.

Some clarity has recently been provided in a systematic review and network meta-analysis of

Key messages Recommend the MedDiet or DASH Diet Encourage more plant-based proteins and avoid processed meats An accredited practising dietitian can help patients be heart healthy.

randomised trials (BMJ, 2020).

The study of 21,942 participants looked at 14 popular diets that specifically targeted cardiovascular risk reduction in adults. They found that popular diets such as the low carbohydrate Atkins, low-fat Ornish, moderate macronutrient DASH and Mediterranean Diet (MedDiet) had the highest certainty of evidence and the most consistent effects for reduction in weight and blood pressure.

Of note, all diets showed modest weight and blood pressure reduction at six months, but these had diminished by 12 months, and improvements in cardiovascular risk factors had largely disappeared, except for LDL cholesterol with the MedDiet.

Fetal Origin of Disease and the gut microbiome Nutrition-related chronic diseases may be initiated early in life, with growing evidence of the importance of maternal nutrition on the fetus. This may be related

to excess gestational weight gain, overweight or obesity at conception, which increases the risk of paediatric obesity. Preventing this is an important step in avoiding cardiovascular disease.

There are increasing indications that foods enriching the gut microbiome play a role in CVD. Host-microbiota interactions involving inflammatory and metabolic pathways have been proposed to contribute to the pathogenesis of multiple immunemediated diseases and metabolic conditions including obesity, diabetes, and CVD. Both pre- and probiotics naturally found in certain foods are beneficial to the gut microbiome. Probiotics are live bacteria found in fermented foods such as sauerkraut, kimchi, or natural yoghurt with cultures.

Prebiotics (nutrients for the probiotic bacteria) are nondigestible fibres found naturally in many foods, such as oats, wheat, onions, bananas, garlic and leeks.

Maintaining a healthy body weight throughout life is one of the key recommendations of the Australian Heart Foundation and the 2021 Dietary Guidance to Improve Cardiovascular Health released by the American Heart Association (AHA). They recommend a healthy dietary pattern analogous to the Mediterranean diet.

This primarily includes a varied vegetable intake, beans, pulses, fruit, wholegrain cereals, nuts,

Myocarditis in the time of COVID continued from Page 56 pericarditis often without specific diagnostic features of it.

Diagnosis of these conditions has implications with regards to the choice of further vaccination 58 | APRIL 2022

options. Patients with diagnosed myocarditis should likely avoid further mRNA vaccines. Astra Zeneca or Novavax are options.

The decision on further vaccines following diagnosis of pericarditis will vary according to patient age and sex in different situations and

is best assessed by reference to the Australian government guidelines available at: www.health.gov.au/ COVID19-vaccines.

Author competing interests -nil

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intervention for Neurodegeneration Delay) is a hybrid of the DASH and MedDiet which has been associated with slower rates of age-related cognitive decline.

In summary, it is increasingly clear from the wealth of evidence that maintaining a healthy weight, no matter what age, with the emphasis on dietary patterns rather than individual foods or nutrients, is vital. Pursuing this from an early age and maintaining an appropriate body weight throughout life needs to be emphasised by all health professionals at every opportunity.

and seeds with low levels of unprocessed red meat (50g per day or 350g per week) and avoidance of processed meats such as ham, salami and bacon.

Added benefits for other chronic diseases The AHA also acknowledged the role of diet in reducing the risk of other chronic conditions such as

diabetes, cognitive decline and kidney disease.

Observational studies and RCTs indicate that a Mediterraneanstyle diet is inversely associated with the risk of type 2 diabetes and linked to a slower decline in cognitive ability and reduced risk of adverse kidney outcomes. The MIND diet (Mediterranean-DASH

Recommending the MedDiet or DASH diets offer the simplest, best-evaluated and mostachievable dietary patterns to reduce cardiovascular disease and mortality and the overall health of your patients.

Author competing interests – nil

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APRIL 2022 | 59

MediBizz knows medical business

MediBizz Australia is WA’s premier independently owned medical centre management company offering management solutions since 2012, establishing itself as a market leader and company of choice among medical practitioners.

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Our extensive network of medical centres have given us the scope to purchase stationery, equipment, and consumables at discounted prices which are then passed on to our clients.

We manage and operate our own warehouse facility where medical consumables and stationery, from Bed rolls, gloves, RAT kits, Compact towels, N-95 masks, ink toners, printers, copy paper, files, bin liners, tearoom refreshments, cleaning and many more products are stored.

Services and repairs medical equipment within a practice such as autoclaves, vaccination fridges, ECH machines, blood pressure monitors & sphygmomanometers and electric treatment beds to name a few.

MediLegal Services has partnered with expert personal injury specialist lawyers who can work exclusively with your practice patients on Workers Comp and Motor Vehicle Accident matters.

Option to maintain your equipment schedule for your accreditation assessment. Once the equipment has been tested and tagged you will receive a compliance certificate. We are an exclusive MESI equipment service provider for WA.

Through our partnership we can help people who have been injured in an accident that wasn’t their fault receive treatment and compensation in a time frame that is much quicker than industry standards.

Our qualified and experienced technicians will come out onsite to carry out the annual service and any repairs when required. This service is offered at very competitive rates and significantly less than our competitors.

We ensure your patients get what they are owed and feel comfortable and safe at work.

Claims can be complex when dealing with employers and insurance companies, so our objective is to simplify and take care of a patients claim from start to finish on a “no win, no fee’’ basis.

PRACTICE ACCREDITATION Our accreditation assessment framework for general practice provides a comprehensive review of your documentation against the 130 assessment criteria according to the 5th edition of the RACGP Standards for General Practice.

MediBizz will prepare all the documentation that is required for you to present on the day of your AGPAL accreditation. You will be furnished with the tools required to achieve compliance and a successful accreditation. Through our service we usually get approval on the same day.

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medibizz.com.au 60 | APRIL 2022

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Lipoprotein(a) for cardiovascular risk assessment

By Dr Michael Page, Chemical Pathologist, Jandakot The components of the standard comprehensive lipid panel – total, LDL- and HDL-cholesterol along with triglycerides – are well-known, as is the role of LDLcholesterol as a key cardiovascular risk factor and target for risk-reducing therapy.

Other, somewhat unintuitively named lipid-related tests (apolipoprotein-B, apolipoprotein A-I, apolipoprotein A-II, LDL subfractions, and others), while useful in some patients, are likely to remain outside the mainstream.

Lipoprotein(a), commonly abbreviated to Lp(a) and pronounced “lipoprotein-little-a” or “L-P-little-a,” is an exception that is nearly certain to gather pace as a part of routine clinical care in the near future.

Lp(a) is similar in size and structure to LDL, but carries a protein called apolipoprotein(a), which imparts additional atherogenic and prothrombotic effects. Its plasma concentrations are highly genetically-determined, more so than LDL, with relatively little influence from diet, exercise, and other environmental factors.

Its production and clearance pathways, while not fully understood, are distinct from those of LDL. This is partly evidenced by the fact that statins, which upregulate the clearance pathway for LDL particles, do not decrease Lp(a).

The atherogenic nature of Lp(a) is beyond doubt, based on large studies using the genetic technique of Mendelian randomisation. The relative risk of coronary artery disease is increased by at least double with very high concentrations of Lp(a), and perhaps significantly more (see Figure).

On this basis alone, some international guidelines have recommended that Lp(a) should be tested at least once in every adult’s lifetime. Others advocate testing Lp(a) in patients with other risk factors including premature atherosclerotic disease.

Key messages Measuring lipoprotein(a) for cardiovascular risk assessment is gaining prominence, particularly as lipoprotein(a)-lowering therapies advance through clinical trials Lipoprotein(a) is similar to LDL but has unique additional atherogenic properties, different clearance pathways and is not reduced by statin therapy Until specific lipoprotein(a)-lowering therapies are available, management of elevated lipoprotein(a) centres on other risk-reducing strategies, although high-risk patients may be considered for investigational agents or lipoprotein(a)-apheresis.

An unusual property of Lp(a) – that people with lower concentrations tend to have larger particles, and those with higher concentrations tend to have smaller particles – makes the accurate measurement of Lp(a) a unique challenge. As a result, not all Lp(a) assays available in Australia are highly accurate across the range of possible concentrations. Furthermore, some assays are calibrated to mass units (g/L or mg/dL) and others to molar units (nmol/L). The latter, which better reflects the number of Lp(a) particles, is more likely to become the measurement unit of choice.

In the meantime, some laboratories report mass units, some molar units, and some provide both on the report.

However, direct conversion between mass and molar units is unreliable owing to the variable mass of Lp(a) particles.

Until effective Lp(a)-lowering therapies become available, treatment recommendations for patients with high Lp(a) centre on other risk-reducing strategies such as initiating or escalating statin therapy and paying close attention to other cardiovascular risk factors.

Patients with very high levels may be considered by lipid specialist clinics for enrolment in clinical trials of novel Lp(a)-lowering therapies or even Lp(a)-apheresis, a process of regularly “filtering” Lp(a) from the circulation.

Whether therapeutically lowering Lp(a) reduces cardiovascular risk should first be answered in about 2024 by the results of a large randomised controlled trial of pelacarsen, an antisense oligonucleotide that degrades the mRNA that encodes apolipoprotein(a), thereby preventing the formation of Lp(a) particles.

Given subcutaneously once per month, it persistently lowers Lp(a) concentrations by about 80%. The results of the trial are keenly awaited.

There is not yet a Medicare rebate for the measurement of Lp(a). The out-of-pocket cost for the test is typically less than $50.

Author competing interests - the author has received consulting fees from Novartis.

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APRIL 2022 | 61

Doctor of laughs will see you now He gave up medicine for comedy but Dr Jason Leong tells Ara Jansen he’s still healing people with messages wrapped up in jokes.

Dr Jason Leong often tells his audiences he’s a real doctor, not a PhD holder – because he can actually contribute to society, there’s a small difference and varying levels of utility.

Clearly Jason Leong tells that joke better – because that’s what he does now.

After university Jason says he did what every good Asian son is supposed to do. He had a responsible job being a doctor.

He actually quite enjoyed the work but hated the politics of the Malaysian health system and found the bureaucracy soul crushing. The senior doctors around him seemed miserable and he couldn’t imagine the next 10 to 20 years like that.

So, he quit.

Risking the disapproval of parents, friends and colleagues, Dr Jason took a calculated risk and decided to pursue a passion – stand-up comedy. It proved an astute choice and has put him on stages all over Asia, across Australia and for shows in New York.

Dubbed Malaysia’s funniest doctor, Jason’s medical knowledge allows him to make jokes about doctors, the system and patients with a degree of insight. While it’s not the only thing he jokes about, he does like to use humour to veil real world messages which might be hard to stomach otherwise.

The class clown with a quick wit, Jason started honing his chops at school and then medical school taking every opportunity to join 62 | APRIL 2022

the debating team, host events, MC, speak in public and talk to new students. He says he always tried to inject some sort of comedy and fun into his presentations. That kindled a love for stand-up and it became his passion. He also found plenty of language confusion to fuel his standup stories when doing medical training in Dublin.

Jason’s wife Komella is an anaesthetist in a Kuala Lumpur hospital and supported her husband’s move knowing what he was experiencing.

“She was hugely encouraging and as a doctor she knew the perils of continuing in the profession,” he says. “The health care system needs a lot of reform and the burden falls on the most important asset, which is the doctors and the nurses.”

In his Netflix comedy special Hashtag Blessed, Jason gives his diagnosis on the nonsense of traditional healers, his disdain for business class flyers who show off (please take a bungee jump – wirelessly) and why you should always carry a stethoscope in your glovebox.

As a man of science, logic and rationale and a fan of tech, he takes every opportunity to advocate for science literacy. As a trained science professional, he wants people talking about things that matter.

“Being a doctor in comedy has definitely been an advantage because there’s not many with that background. There’s definitely a different point of view and I use that to my advantage.”

He also suggests his move to comedy is a great example of a larger career migration being made by other Asians of his generation.

“No one from my parents’ era would consider a career in the arts. They were so deeply entrenched in the sciences. For that generation – migrants often with limited resources – they wanted jobs which ensured security like lawyers, doctors and engineers. Steady jobs.

Now we’re YouTubers and comic artists who make a living. We’re going against traditional jobs and it’s nice to see that. No one would have thought that 15 years ago.”

As for Jason’s parents, he didn’t initially tell them he’d quit medicine for stand-up. They know now. He’s famous enough.

Apparently, they’re just relieved he can fend for himself.

Dr Jason Leong performs at the Perth Comedy Festival which runs from April 29 – May 15. He’s at the Astor Theatre on May 6 and 7.

Check out www.perthcomedyfestival.com for details and ticketing.

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LIFESTYLE

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LIFESTYLE

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WINE REVIEW

Cullen mastery The difficulty in introducing this great Margaret River producer is that there is so much that could be said but not enough space in which to say it all. Established in 1971 at Wilyabrup in the heart of the Margaret River region by Dr Kevin Cullen and his wife Diana, it was influenced by scientist Dr John Gladstones whose studies indicated the viticultural potential of the region. Di Cullen took on the winemaking and was integral, along with several other pioneers of the region, in putting Margaret River on the Australian wine map, and later the world wine map. Today, daughter Vanya Cullen is at the helm, and her winemaking prowess and refined palate have taken Cullen Wines to even greater heights. Their 49ha of estate vineyard is run on organic and biodynamic principles. Not only is the vineyard certified A Grade biodynamic, but more recently has become the first vineyard and winery in Australia to be certified carbon neutral. Their wines are individual and long-ageing, derived from ‘natural winemaking’ and relying on wild (natural) yeast, with minimal intervention and no additions. Their Bordeaux blend reds and Chardonnays are sought after internationally.

Review by Dr Craig Drummond Master of Wine

2021 Dancing in the Moonlight (RRP $30)

2018 Cullen Vineyard Sauvignon Blanc (RRP $29)

2021 Mangan East Block (RRP $55)

A captivating rosé-style using all red varieties from the Cullen Vineyard.

Produced using the French Saignee technique of running off free-run juice from just-crushed dark-skinned grapes after a short pre-fermentation maceration – the juice thus having a light colour. The wine an attractive onion skin colour. Bouquet is fresh, floral, vibrant with rose petal. On the palate a dry, slightly savoury style. Absence of oak allows full fruit expression, with flavours of cranberry, rosewater and Turkish delight. A wine for current consumption. For me this wine compares with the famous rosé of Tavel and Provence in southern France.

A seriously good and complex expression of this vibrant grape variety which will be long-lived.

Attractive limpid mid-gold colour.

Complex aromas of green bean and lime leads on to intense interwoven kafir lime, green capsicum, vegetal and grassy flavours. The oak (73% new French oak for three months) adds structure, but is harmonious and not overstated. Crunchy acidity carries the wine to a clean and long finish.

This massive wine is such an interesting blend of Malbec (59%) and Petit Verdot (41%). I don’t recall ever seeing this before. Both are ‘lesser’ Bordeaux varieties, often used to adjust tannin levels in blended wines. Petit Verdot has been described as “the winemaker’s spice”. The dense, deep black-purple is striking. Overt ripe fruit aromas of mulberry, satsuma plum, dark chocolate. Big on the palate with opulent flavours. Powerful tannins and high acidity (as expected from these varieties). Enjoyed this wine now, but I can only imagine how good it will be in 10 or 20 years from now.

2019 Grace Madeline (RRP $39)

'S EWER REVI

A wonderful example of a Sauvignon Blanc (67%) and Semillon (33%) blend with the SB component given five months in 100% new French oak. The nose shows powerful and intense fruit. Gooseberry and cut grass aromas, with some slight pungency. The palate displays purity, intensity, minerality. The Semillon shines through with herbal, pea puree and lime flavours. Great background acidity from a cooler vintage. Oak binds it together beautifully. This wine is so reminiscent of Bordeaux whites but with much brighter fruit.

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PICK

2020 Diana Madeline (RRP $150) My top wine of the tasting.

In my opinion this Cabernet Sauvignon-dominant Bordeaux blend has set the benchmark for this style in Australia over the past decade. Bordeaux wines of equivalent quality that I have tasted carry price tags way in excess of this wine. A blend of 92% Cabernet Sauvignon, 4% Merlot, 3% Cabernet Franc and 1% Malbec. Superb colour of deep ruby red with purple edges. Shows intense aromas of blackcurrant, black olive and dark chocolate. Deep flavours of plum, mulberry and clove. There is an earthy character synonymous with Margaret River Cabernet. Wonderful finegrained tannins. Fruit and oak are harmonious. This wine has power and elegance, structure and length, and a finish that continues to build. It will drink well for decades to come.

APRIL 2022 | 65

MUSIC

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Musical soundtrack for life In Sean Tinnion’s heart, just about everything has a musical soundtrack. The award-winning Perth-based screen composer invites listeners on a journey with his work.

By Ara Jansen If Sean Tinnion was a Disney character, he’d be the guy with musical notes constantly dancing around his body. They’d come together to form a song and break apart to become the next one, the character grabbing them to bring to life what he hears in his head.

Suffice to say, the Perth-based composer sees much of the world through music. He says it all started with Braveheart, the 1995 Mel Gibson movie.

Sean started playing piano at age four because of his granddad.

He took to it and fell in love. His granddad’s tutoring eventually gave way to paid lessons. By eight or nine his mum’s love of movie soundtracks had also infiltrated Sean’s heart and he eventually started watching films and dissecting how the music worked in scenes.

“I think I would have found playing the piano one way or another,” says Sean who moved to Perth from the UK in 2004. “It’s something I was meant to do.”

Sean’s first big discovery was James Horner, the late American composer and conductor known for his film scores which often mixed choral and electronic elements and featured Celtic motifs. His most notable works include Titanic, Avatar, Field of Dreams, A Beautiful Mind and, of course, Braveheart.

When Sean and his family moved 66 | APRIL 2022

to Perth, it was September. Rather than starting school close to the end of the year, he hung out at home, and not having made any local friends, he turned to his keyboard and started writing and composing music.

“I get writer’s block as much as the next person. I usually have to walk away and give myself a break and give my ears a rest. Often, I’ll try and do something unrelated to music, which helps clear my head and then an idea will arrive.”

As his skills on the piano grew, Sean’s interests widened to include other noted soundtrack composers such as Hans Zimmer, Alan Silvestri, Howard Shore, James Howard, Ennio Morricone and Thomas Newman.

But like any music lover, he also kept an ear on pop music and is no stranger to Coldplay or Dua Lipa.

He keeps fit and clears his head at the gym, which he finds a refreshing break. Sean enjoys the beach and nature, both of which inspire his projects. When he watches a movie or TV his mind is always on, thinking about how the piece fits with the action he’s seeing.

Since graduating from WAAPA in 2015, Sean has worked on a variety of projects from movies and documentaries to online games and advertisements. Recent projects include the award-winning documentary The Last Horns of Africa, From Sky to Sea, the documentary about WA’s Jaimen Hudson who begins his quest to become the world’s first underwater cinematographer with quadriplegia, and the Xbox survival game The Last Stand: Aftermath. From more than 50 projects under his belt, he’s won 18 score and soundtrack awards from film festivals around the world.

“I’m very emotional with my music.

I wish I knew where it comes from but it just happens. I go with the flow and as I’m watching something, the music starts to form in my mind.

“I never watch a movie without intently listening to the soundtrack and wondering whether I would have done it the same way or differently.”

While he spends most of his time working on screen projects and games, Sean is also committed to creating his own music. He released two albums – Avori and An Everlasting Serenity – in 2020 and has released two singles from Evolution, a third album due for release this year. He’s almost finished a Celtic album, which pays homage to his heritage and his love for the style.

“My own music is still very cinematic.

It’s almost like it’s looking for a movie to be in. Plus, it gives me a chance to collaborate with other musicians and it’s a pleasurable thing to do in between work.”

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