COVID special report
Destination WA General Medicine | Facelift evolution, healthy ageing, polymyalgia rheumatica, CKD MAJOR PARTNERS
December 2021 www.mforum.com.au
A/Prof Chris Merry Cardiothoracic surgeon, WA
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EDITORIAL BACK TO CONTENTS
Cathy O’Leary | Editor
Where we’ve been … and where we’ll land “…hindsight is all well and good, but our leaders and health advisers have had to do their best in extraordinary times.”
As we go to print, about 70% of West Australians aged over 12 have been double-jabbed against COVID. That’s still well short of the ambitious 90% target set by the State Government. Perhaps it’s COVID fatigue, but the mood in the room seems to have changed in recent months, after almost universal support for government decisions and mandates earlier in the piece. It’s been a tough year for WA families separated by borders, and this Christmas looks like being much the same. But many locals also feel grateful we have managed to dodge the coronavirus bullet while we get vaccinated – when many countries were not so lucky. This edition is something of a retrospective, looking at what happened this year and what we learnt. Let’s also remember that hindsight is all well and good, but our leaders and health advisers have had to do their best in extraordinary times. And what can we expect in 2022? One thing is for sure, the pandemic is coming our way, either in a dribble or a stampede (our hospital admins and GPs are clearly hoping for the former). Fingers crossed all our preparations pay off and cool heads prevail. And finally, while this edition is unashamedly COVIDheavy, we kick off with a story that helps put life in perspective. We heard so much this year about people’s right to ‘choice’ but there was certainly no choice for a young Perth boy when he was diagnosed with a rare and lethal cancer six years ago. Read on for some good news which has made 2021 a year of celebration for his family. Merry Christmas!
SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission. DISCLAIMER Medical Forum is published by Medical Forum WA as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with advertisers other than as publisher of promotional material. Medical Forum cannot and does not endorse any products.
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CONTENTS | DECEMBER 2021 – GENER AL MEDICINE
Inside this issue 10
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FEATURES
NEWS & VIEWS
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COVID special report
1 Editorial – Cathy O’Leary 4 In the news 6 In brief 8 Letter: VAD – Drs Richard Lugg & Peter Beahan
In the swim – Dr Rachel Harris
Finlay rings the bell Close-up: Dr Katharine Noonan
LIFESTYLE 72 Music: The wait has been worth it 73 Wine review: Sandalford – Dr Craig Drummond
74 Wrapping gets a good rap
COVID Reports:
22 Vaccines 24 Treatments 26 Testing 26 GPs and testing – Dr David Rutherford 28 Global perspective – Dr Priscilla Robinson 30 No time to breathe – Gail Carmody 35 Christmas Greetings: 39 Home for Christmas 40 Radiation oncology boon 42 Helping hand from afar 43 Private ED opens 45 New day hospital opens 47 Bring on a new year! – Dr Joe Kosterich 65 Spare the steroids 69 Gut-autism link
ARE YOU THE NEXT WINE WINNER? Dr Tricia Charmer from University Medical Centre UWA is the happy winner of the October doctors dozen from Fraser Gallop Estate. Feeling lucky? For your chance to win a dozen bottles of wine from Sandalford Estate – reviewed by Dr Craig Drummond on P73 – go to the competitions tab at www.mforum.com.au or enter via our newsletter delivered to your inbox each Friday.
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A little bit of culture – TB or not TB By Dr Avani Kharodkar
NSVT – who to treat, who should treat Dr Luke Matar
Perth men’s study on ageing well Professor Leon Flicker
Evolution of the modern facelift Dr Linda Monshizadeh
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Managing peritoneal dialysis-associated peritonitis Dr Aron Chakera & Dr Kieran Mulroney
#Flozinator: SGLT2i and CKD Dr Anoushka Krishnan
Exercise medicine for cancer Professor Robert Newton
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GPs’ role in antenatal alcohol advice Sheynae Griffiths & Dr Ramya Raman
Oral manifestations of syphilis Dr Amanda Phoon Nguyen
Polymyalgia Rheumatica Dr Charles Inderjeeth
Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Journalist Dr Karl Gruber (PhD) 08 9203 5222 journalist@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Clinical Services Directory Editor Karen Walsh 0401 172 626 karen@mforum.com.au
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The only certainty is uncertainty Dr Bruce Powell
What have we learnt? Dr Andrew Miller
Another year, ‘unprecedent’ remains Dr Sean Stevens
Prepare, plan, pivot, refine. Repeat. Dr Brenda Murrison
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IN THE NEWS
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MND research boost Two research projects at the Perron Institute have shared $500,000 in the latest round of grants from Australian motor neurone disease foundation FightMND. In this latest round of grants, Principal Investigator Professor Anthony Akkari from the Perron Institute and Murdoch University and his team have been awarded $250,000 to identify new genetic markers for MND clinical trials. “Genetics can significantly impact variability in MND, with growing evidence suggesting that exploring difficult to access regions of the human genome can uncover complex disease mechanisms,” he said. “Establishing molecular targets and more genetic markers could improve patient stratification for clinical trials by identifying patient sub-groups.” The second $250,000 FightMND grant will be used to understand the genetics of MND by co-developing targeted gene therapies to address primary triggers and causes. Co-investigators are Professor Akkari and Dr Loren Flynn, also from the Perron Institute and Murdoch University.
Fake jab The RACGP says it is “deeply concerned” to learn of an incident involving alleged vaccine fraud by a registered nurse at a Perth medical practice. Last month, a registered practice nurse allegedly injected a teenage patient, who was known to the nurse, with a COVID vaccine but did not depress the plunger. She was then said to have disposed of the syringe with the vaccine still inside before recording the patient as having received a dose by a colleague. The incident was reported to WA Police after practice owner, former RACGP WA Chair Dr Sean Stevens, observed irregularities. The nurse has since been charged. In a statement, the RACGP said it was providing support to the practice. “The WA Police are investigating, and we stand ready to support their investigation,” it said.
Anthony Akkari and Loren Flynn
a report has found. Aishwarya died from sepsis on May 1 this year, her condition having deteriorated while her parents pleaded for care in the emergency department to be elevated. A report by the Australian Commission on Safety and Quality in Health Care found significant issues at the ED in the months prior to her death. The triage and waiting areas were “particularly vulnerable and sub-optimally staffed”, doctors and nurses were burnt out and a major increase in ED presentations was not met with sufficient urgency. “The anguish and pain of the family were in the public domain … the health system, the hospital and large numbers of staff at all levels, found themselves unprepared, deeply saddened and devastated,” the report said. Several junior staff have been referred to AHPRA over the incident. Aishwarya’s parents have said they are dissatisfied with the two reports into her death and are considering ordering their own independent inquiry.
PCH found wanting Understaffing at Perth Children’s Hospital had left doctors and nurses “exhausted and demoralised” before the death of seven-year-old Aishwarya Aswath, 4 | DECEMBER 2021
Taking on diabetes Ramsay Health Plus in Nedlands has launched a new program, Diabetes Care Plus – a team approach to
exercise and education using a dietician, exercise physiology and diabetic educators. Specialist coordinator Ciara Sheils said the program was aimed at helping people self-manage their type 2 diabetes. “The goal of our specialists is to help participants with nutrition, physical activity, medication management and blood glucose monitoring, as well as providing education on behaviour and lifestyle changes,” she said. Patients can access the service with a referral from their GP and it is covered by Medicare.
Diabetes therapy hope WA researchers have pinpointed five promising leads that could be used to create a new peptide therapy to tackle the growing health impacts of obesity and type 2 diabetes. Around two in three Australian adults and one in four children are classified as overweight or obese and 288 people – or one person every five minutes – develop diabetes every day nationally. continued on Page 6
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MAJOR PARTNER
A little bit of culture – TB or not TB Differentiation of intestinal tuberculosis from Crohn’s disease can be challenging due to overlapping clinical, endoscopic and histopathologic features. However, this distinction is important as treatment for these two conditions differs considerably. We present a case where clinical and pathological suspicion were important factors in reaching a diagnosis, despite absence of acid-fast bacilli in tissue sections and negative microbiological molecular testing.
Case history A 27-year-old female, originally from Bhutan with a history of latent tuberculosis, underwent upper and lower gastrointestinal endoscopy to investigate a history of abdominal pain and iron deficiency. Upper GI endoscopy was normal. However, colonoscopy demonstrated a segmental ileocolitis involving the ileum, caecum, ascending colon and transverse colon, with features of chronicity. The clinical features were suggestive of Crohn’s disease although given the patient‘s history, mycobacterial colitis was in the differential diagnosis. Histopathological examination showed active ileo-colitis with ulceration,
non-necrotising granulomatous inflammation and only subtle architectural distortion. Mycobacterial and fungal organisms were not detected with special stains. Although Crohn’s disease was a consideration, there were no welldeveloped features of chronicity. In spite of the absence of acid-fast bacilli on special stains, the microscopic findings were concerning for mycobacterial infection. TB PCR testing performed on the formalin fixed biopsy tissue was negative. A repeat colonoscopy was performed to obtain fresh tissue and the culture of this fresh colon biopsy tissue subsequently grew mycobacterium tuberculosis.
Discussion TB-associated granulomatous colitis can mimic Crohn’s disease clinically and in the absence of other clinical manifestations of TB, differentiating between intestinal TB and Crohn’s disease can pose a significant diagnostic challenge. Both diseases can present with clinical symptoms of weight loss, abdominal pain, fever, bowel obstruction, bloody diarrhoea and endoscopic findings of
By Dr Avani Kharodkar, Dr Stephen Lee, Dr Smathi Chong & Dr Frank Brennan Department of Histopathology and Microbiology, Clinipath Pathology, Osborne Park, WA; Dr Frank Brennan is a Gastroenterologist at Advanced GI WA. skip lesions, ulcerations and terminal ileum involvement. Diagnostic histopathologic features of intestinal TB such as confluent caseating granulomas within the submucosa and acid-fast bacilli are infrequently seen in biopsies and these features were not present in this case. The diagnosis of intestinal TB and Crohn’s disease requires a high degree of suspicion, especially when encountering a patient originally from an endemic area. Special stains such as Ziehl -Neelsen (ZN) and PCR-based assays are used for rapid detection of mycobacterial infection; PCR-based tests have high sensitivity and specificity although cannot differentiate between viable and non-viable organisms. They may remain positive for prolonged periods after the patient has been treated with anti-TB therapy and therefore are of limited use in follow-up of known TB cases. In addition, PCR assays may have limited sensitivity in detecting extrapulmonary mycobacterial infections. A negative ZN stain or tissue PCR therefore does not exclude a diagnosis of TB and mycobacterial culture remains the gold standard for definitive diagnosis. It is therefore important that in cases where the index of suspicion for intestinal TB is high, fresh biopsy material should be obtained for culture. – References on request
Colonic biopsy (H&E image, 20X magnification) shows granulomatous inflammation.
Colonoscopy shows segmental colitis.
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GP, lecturer and supervisor Dr Ramya Raman is chair-elect of the RACGP WA. Nationally, lawyer Paul Wappett has taken on the role of CEO at the RACGP. One is his priorities will be the transition of GP training back to the college in 2023.
Dr Rachel Foong has been awarded the 2021 Asthma and Airways Career Development Fellowship, funded by the National Asthma Council Australia and the Thoracic Society of Australia and New Zealand. She is an NHMRC Early Career Fellow at Telethon Kids Institute and Curtin University.
International melanoma expert Professor Jonas Nilsson from the Harry Perkins Institute has won a Business Events Perth Aspire Award. It will allow him to present research at the Australasian Melanoma Conference and Society of Melanoma Research Annual Meeting next year. Dr Leo Ng, from Curtin’s School of Allied Health, has also won an Aspire Award for expertise in physiotherapy and work in developing a new app.
IN THE NEWS A last wish
continued from Page 4
Doctors with dying patients are being asked to consider nominating them for a last wish to visit a special place. Ambulance Wish Western Australia has launched a new service, the first of its kind in the State, to fulfil final wishes for people who are terminally ill or receiving palliative care.
Funded by grants from Diabetes Research WA, Dr Vance Matthews from the UWA School of Biomedical Sciences Dobney Hypertension Centre and his team have discovered in preclinical trials that five small peptides derived from the protein TNFSF14 can reduce obesity and problems with glucose homeostasis. The work has been published in the International Journal of Molecular Sciences. “Obesity in adults can result in adverse metabolic conditions with worrying health impacts and there’s a massive global need for new ways to manage this,” Dr Matthews said. “Our work has focused on five promising peptides and we have now confirmed one of those reduced high fat dietinduced glucose intolerance, insulin resistance, abnormal blood insulin levels and non-alcoholic fatty liver disease, so this new technology for type 2 diabetes care and management is very exciting.” Dr Matthews said his team was keen to further test all five peptides. Diabetes Research WA executive director Sherl Westlund said the work could pave the way for new ‘diabesity’ medications.
Using two recently donated, decommissioned ambulances, the charity provides a no-cost service to allow people in end-oflife care to visit a place of personal significance, such as an old friend or the beach. It provides the resources, specialist transport and medical care required. Individuals, clinicians and family members can apply for a final wish. Ambulance Hydi was donated by BP Kwinana and named after their refinery equipment. It was the emergency response ambulance but following the closure of the refinery and the creation of a clean energy hub, the ambulance was no longer required on site. The second vehicle, Kees, was donated by St John Ambulance WA. It has been named in honour of the late Kees Velboer, the creator of Stichting Ambulance Wens continued on Page 8
Melanie Gates is the new CEO of Diabetes WA.
Telethon Kids Institute child health researcher Dr Hayley Passmore was one of four nominees for Western Australia’s 2022 Young Australian of the Year.
Another TKI researcher – autism expert Professor Andrew Whitehouse – has become the youngest person to ever be inducted as a Fellow to the prestigious Australian Academy of Health and Medical Sciences.
Meet the team The team at Medical Forum wish you a happy and safe Christmas and New Year. Our offices will close on Friday, December 17 and reopen on Tuesday, January 4. From left to right, new owner Tony Jones, newsletter assistant Quinn Hampton, journalist Dr Karl Gruber, production editor Jan Hallam, CSD editor Karen Walsh, advertising manager Andrew Bowyer, clinical editor Dr Joe Kosterich, managing editor Cathy O’Leary and new owner Fonda Grapsas. Absent: Graphic designer: Ryan Minchin.
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IN BRIEF
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continued from Page 6 (Ambulance Wish Foundation, The Netherlands) which inspired the establishment of Ambulance Wish WA. To apply for a wish to be granted or to volunteer go to www.ambulancewishwa.org.au
Vale Bill Musk WA has lost one of its foremost respiratory and occupational physicians, Professor Bill Musk, who died suddenly at home on November 3, aged 78. The Lung Foundation Australia paid tribute to his work with the Australasian Lung Cancer Trials Group and his generous efforts to develop resources for patients. Professor Musk wrote regularly for Medical Forum and will be remembered as a world-class researcher.
Hospital booze patrol An intervention to reduce alcohol abuse and associated emergency department presentations has
proved successful at Fiona Stanley Hospital. Led by Edith Cowan University’s Professor John Olynyk and FSH gastroenterologist Dr Simon Hazeldine, the study found patients who had alcohol screening and brief intervention management of alcohol-related problems in the ED had lower levels of at-risk alcohol consumption and reduced ED representations when combined with GP follow-up. Alcohol consumption was significantly reduced after one month for those ED patients who had the intervention. This was sustained at three months in the intervention group who also had a referral letter sent to their GP at discharge. Alcohol-related events account for about 10% of ED presentations.
CT scan caution Curtin University researchers have raised concerns about the radiation dose, cost and efficiency of CT scans on the back of a marked increase in their use on injured patients in WA hospital emergency departments.
Emergency Medicine, found that over 11 years from 2004 to 2015, while the number of injury-related ED presentations increased by 65%, the use of CT scanning in these presentations increased by 176%. Lead author Dr Ninh Ha from Curtin’s School of Population Health said the research found the increased use of CT scans did not lead to more diagnosis of severe injury, less time in hospital or an obvious reduction in mortality. “CT scans have been increasingly used in emergency departments around the world because they offer rapid and accurate diagnosis, especially for people with injuries, however, each scan also introduces significant amounts of radiation into the body, which can cause a small, long-term risk of cancer,” Dr Ha said. “For example, a CT of the chest exposes the patient to the same amount of radiation as 400 chest x-rays, so it is important to understand whether CTs are warranted and to weigh up harm versus benefit including the impact of over-testing. Our research found no evidence that the increased use of CT scanning led to better patient outcomes.”
Their study, published in Academic
LETTER TO THE EDITOR Dear Editor, We wish to respond to the article, Comprehensive end of life care needed, by Dr Derek Eng and Ms Louise Angus, in the November edition of Medical Forum. They say that ‘now more than ever, palliative care needs our full support and to be understood.’ Yet, with the many recent debates, palliative care has had a great deal of attention and received additional government funding. The statement that the WA palliative care workforce is inadequate should be put in perspective. Australia ranked second out of 80 countries surveyed by The Economist Intelligence Unit’s Quality of Death
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Index 2015, which focuses on the quality and availability of palliative care to adults. In terms of the availability of appropriately trained staff to provide palliative care in hospitals or in the community, Australia ranked first, and in terms of affordability of palliative care, it ranked equal first.
would suffer badly in the absence of medication referred to as terminal sedation. It is also wrong to suggest that dying patients can access VAD more easily than palliative care.
Repeated use of the terms Physician Assisted Suicide and Active Voluntary Euthanasia is provocative, as these are not terms currently used. The WA VAD legislation itself states that VAD is not suicide. When stating that palliative care does not deliberately hasten the process of dying, does that apply to all cases? After all, palliative care deals with some patients who
VAD is supported by a sizeable majority and is now law. It is a matter of choice for the patient. It is good that the authors do accept their duty to refer patients in accordance with the law. Dr Peter Beahan, retired anaesthetist Dr Richard Lugg, retired public health physician, convenor Doctors for Assisted Dying Choice WA
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IN THE NEWS
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NSVT – WHO TO TREAT, WHO SHOULD TREAT The 1 November 2021 changes to MBS descriptors for non-surgical vein treatments (NSVT), if not properly understood, may deny worthy patients’ treatment.
Varicose veins are commonly symptomatic (50% having RLS in our cohort) and even if not, patients are often willing to pay out-of-pocket costs for NSVT.
In summary, MBS rebates apply if patients have “significant signs or symptoms attributable to venous reflux (including one or more) of:
Varicose veins are often not simply a cosmetic issue, regardless of the associated aesthetics.
Ache, pain, tightness, skin irritation, heaviness, muscle cramps, limb swelling, discoloration or any other sign or symptom attributable to venous reflux.” The admixture of signs/symptoms together is rather confusing, but I will attempt to clarify. Symptoms are subjective and must be interpreted in a holistic context. Symptoms are not confirmed by the presence of large veins or reflux on Doppler, nor denied by their absence. Restless leg syndrome (RLS) in association with reflux would qualify, vein-related emotional distress due to cosmesis probably not!
by DR LUKE MATAR Treatment is indicated in those with C3-C6 disease to prevent progression. C2 disease will qualify for MBS rebates when associated with significant symptoms and C1 disease will now qualify if non-cosmetic and associated with documented proximal reflux of > 0.5 seconds.
The CEAP classification below is a useful guide but proper application requires an experienced and trained eye as relevant findings may be easily missed. C3 (oedema) may be quite subtle and C4 skin changes are frequently undiagnosed/misdiagnosed by GPs. Corona Phlebectasia C4c (fig 2) is often mistaken for C1 rather than C4 disease and usually indicates significant saphenous reflux with increased risk of progression to venous ulcers.
Unfortunately, patients commonly advise “my GP said they are just cosmetic”, despite advanced signs of venous disease including pigmentation and Lipodermatosclerosis. Patients requesting treatment for their varicose veins deserve to be taken seriously and should be referred for NSVT to an appropriate practitioner, as per the MBS criteria below. “It is recommended that the medical practitioner performing the above procedures has successfully completed a substantial course of study and training in duplex ultrasound and the management of venous disease, which has been endorsed by their relevant professional organisation.” Just as the title ‘Cosmetic Surgeon’ does not guarantee a surgically trained practitioner, ‘Surgeon’, ‘Vascular Surgeon’, ‘Radiologist’, ‘Interventional Radiologist’ or even ‘Phlebologist’, do not guarantee someone who is able to deliver optimal NSVT.
Fig 2 – Left Leg – showing C3 & C4c signs
Fig 1- Revised CEAP Classification 2020
Private medicine remains a situation of “buyer beware” and whilst it is important to understand a practitioner’s background and training, more important is the relevant experience, case load, and outcomes delivered. Paper qualifications alone do not denote satisfactory training or outcomes with NSVT, especially given their recent introduction and rapidly evolving nature, which require a high degree of technical skill with Duplex ultrasound and ultrasound-guided procedures. In summary, patients should not be denied referral if they wish to have their varicose veins treated but referring doctors should understand the limitations of a practitioner’s title per se and advise patients that if their concerns are simply cosmetic, MBS rebates likely do not apply but treatment is still available if they are willing/able to pay for it.
Perth's Only Dedicated Varicose Vein Clinic 6/28, Subiaco Square Road Subiaco WA 6008 | (08) 9200 3450 | veinclinicperth.com.au
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FEATURE
Commitment helps Finlay ring the bell While this year was dominated by our unwelcome guest COVID, it wasn’t all bad, as Cathy O’Leary explains.
For many West Australians, 2021 has been a year of uncertainty, missed family reunions, and anxiety about what the pandemic still has in store for us. But for the Higgs family, it was the year their youngest son Finlay got to ring a bell on a hospital cancer ward, marking his five-year remission from a rare cancer – stage 4 high-risk refractory and relapsed hepatoblastoma. His survival was made possible by Perth doctors using the latest research and knowledge to tailor an unconventional treatment plan for Finlay, who ultimately faced a less than 10% chance of survival. Back on the Australia Day long weekend in 2015, Finlay was a seemingly healthy 18-month-old when his parents, Katey and Darren, noticed that the right side of his stomach seemed distended. He was initially taken to Joondalup Health Campus for an ultrasound, and then referred to Princess Margaret Hospital where his parents were given the news their son had a rare “one-in-a-million” liver cancer. Not only did he have a large tumour growing in the right lobe of his liver, it had spread through his diaphragm and metastasised in multiple spots in both his lungs. “It was a bit of a blur, you go into a bit of shock, and initially I couldn’t cope, and then a few days in you realise it’s really happening,” Mrs Higgs tells Medical Forum. “And then, all of a sudden, I switched into gear and said, ‘give me all the information you’ve got’. You have to learn pretty quickly. “Our primary oncologist was pretty upfront. She said it’s primary liver, it’s stage 4 high risk, it’s spread, and the prognosis is less than 30%. “While they tend to drip-feed information so as not to overload you, we soon knew what we were facing, and hospital quickly became our home.” Finlay began a gruelling 18-month journey of chemotherapy and surgery, including multiple liver and lung resections, with him initially responding to treatment before relapsing mid-2016. By that time, he had already received 12 rounds of chemotherapy – above the protocol levels – so a surgeon who had already done several lung resections agreed to go in one last time, in the hope of removing the last of the cancer.
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FEATURE August this year marked five years since Finlay had that last surgery and was put on ‘watch and wait.’ He has been cancer-free ever since. As per tradition, Finlay, now aged 8, was invited back to Perth Children’s Hospital clinic 1H to “ring time” on his cancer. “I couldn’t predict how I was going to feel when we got to that fiveyear milestone, but it was very, very good,” Mrs Higgs says. “It was like a big ‘up yours’ to cancer – we thought ‘go ahead and do it kiddo.’ “There’s lot of things ongoing but when his oncologist used the term ‘we’ve cured him’, it was unbelievable.” Mrs Higgs says they were indebted to researchers who had paved the way for treatments to deal with Finlay’s rare disease, in particular the Children’s Leukaemia and Cancer Research Foundation and the Telethon Kids Institute. “People can learn from his case and the protocols the doctors used. We owe so much to research, and it’s so good they’re doing such amazing work right here in WA.” The Higgs, who have two older children, Harrison, 9, and Milla, 11, know that Finlay still faces health challenges caused by side effects of his treatment – including severe osteoporosis, hearing loss and developmental issues. He will need to keep visiting PCH’s late effects “survivors” clinic for yearly check-ups. “But we appreciate other families are not as lucky as us,” Mrs Higgs says. “The day Finlay rang his five-year bell, another little one we know was starting the whole journey again for the fourth time. “There is a bit of survivor’s guilt, but we just feel so blessed that we got this gift, that Finlay beat the odds.” Andrea Alexander, CEO of the Children’s Leukaemia and Cancer Research Foundation, first met Finlay in 2016 soon after he had been diagnosed with a cancer that is detected in fewer than one in a million children worldwide.
Because of the isolating nature of his diagnosis, the foundation was determined to help Finlay realise his dream to go camping with his family, and launched the Friends of Finlay Campout as a fundraising event. Andrea says she would be happily unemployed tomorrow if research discovered a cure for cancer. “It’s unfortunate that many of us know of or love a child who has been diagnosed with cancer or leukaemia, and the number of Australian children impacted by these diseases is staggering,” she says. “While we have witnessed survival rates improving throughout the foundation’s 40 year-plus existence, there is much work to do to improve this journey for children of the next generations,” Andrea says. “There are still particular cancers such as brain tumours and
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neuroblastoma with survival rates as low as 50%, and while research is being conducted, it needs more funding. “Research is the only answer to finding a way for our children to live cancer-free. Increased funding equates to further research, resulting in better outcomes. It’s that simple.” Meanwhile, the one thing Mrs Higgs is now struggling to get her head around is Finlay’s new-found passion for skateboarding. “He’s already giving me a few grey hairs because of all the osteoporosis risks, even though he has all his safety gear,” she says. “We worry that he’s doing quite a high-risk sport, but after everything he’s been through, he’s got to live his life and do what he wants to do.”
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Many things fascinate Dr Katharine Noonan, which is why she’s chosen a life in public health over a clinical specialty.
Ara Jansen reports Dr Katharine Noonan gets a lot of things done in both her professional life in public health and in her personal life. She eschewed a traditional specialty in favour of excavating many areas and gaining a depth of knowledge, which has served to strengthen her ability to see the bigger interconnected picture. This is also how she solved her dilemma about crafting a career where she can love medicine and the humanities. Joined by a few family members and her best friend, Katharine recently eloped to Tasmania to marry David, her “data nerd”. She says it’s refreshing being with someone in a non-medical field and who finds her work interesting. Plus, it reminds her there’s a bigger world out there. That bigger world has been a constant fascination to Katharine, who has worked on numerous public health issues from COVID through to domestic violence. Working on projects that interest her, using her medical knowledge and firing her imagination certainly seems to be hallmarks of her career to date. Katharine did medicine at UWA after having a year off with an accompanying crisis about whether it really was the right path. Once she started, she really enjoyed it. She did a year with the Rural Clinical School of WA in Kalgoorlie and her internship at Fremantle and Albany hospitals.
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Variety is the spice of medical life
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With a nurse for a mum and her dad a radiologist, medicine as a career came into the picture early. Her younger brother, who has type 1 diabetes, was her first patient when she became involved in his care at age 14. While loving the science of medicine, Katharine often wondered if there was a way to integrate her love for languages and history.
All-rounder “I think there is both the opportunity and the need to have those soft skills – which is a term I hate,” says Katharine. “Humanities can benefit medicine and my crisis was that I loved those things too, so I wondered if it was the right path. The work I’m doing now is very much policy-based and has that side to it, a lot more than I envisaged. “Towards the end of medical school, I had these moments where I was thinking about the prospect of specialty training and working only in that area. Then I realised there was so much more out there for me and thought maybe research was the way to go as a way to combine all the things I was interested in.” After an internship and a six-month
residency at PMH, she took up the Rhodes Scholarship she’d been awarded two years previously and headed to Oxford to complete a masters in global health science. She also worked in the NHS for a public sector consulting firm in London. “When I looked back at some of the extra units I did, I realised I was really interested in public health and since then I have ended up working on projects as varied as sexual health and consent, and mental health.” One of them was the Western Desert Kidney Health project (WDKHP), a community-based, participatory research project that grew from the desire of the Aboriginal community in the Goldfields to reduce the effects of renal disease and type 2 diabetes. “I’d never thought I could do those things in my career as a doctor,” she says. “Doing a public health degree helped show me this was a legitimate field of health. It was a lightbulb moment.
Searching the core “I realised you can be in the middle of trying to address the problem in front of you and, instead, you really need to step out and look at the systems in place and the bigger
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trends, issues and root causes. That’s why public health is perfect for me. As a doctor I can see the need or the outcome of a health system and am able to influence those systems and policies.” Katharine, who is currently working for the Department of Health and completing her public health training, recently moved from COVID work to the Office of the Chief Health Officer to work on projects around alcohol-based violence and investigations into regulatory changes to opioid prescribing. “I spent a year on the COVID work, looking at the operational side of things and planning for the future of how public health is going to work as we transition. I found that very interesting.” She also wears several other hats as an Honorary Fellow at the Telethon Kids Institute where she works on a research project to Strep A and rheumatic heart disease. She was a key contributor to the RHD Endgame Strategy, a report released last year that lays out a blueprint to eliminate rheumatic heart disease by 2031.
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DECEMBER 2021 | 13
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Variety is the spice of medical life continued from Page 13 “There’s so much we need to learn and it’s such a complex area. Equally it’s intriguing, fascinating and a difficult public health problem that doesn’t exist in developed countries outside Aboriginal communities.” This year, Katharine was elected vice-president of the AMA (WA). As the first female VP in 24 years and the first doctor-in-training to hold the position, she joined the AMA (WA) Council in July 2019 and the board in August 2020. “The AMA has gone through a transition and a growth phase with some new members on the council and different issues on the agenda. I initially thought I was too young and not fellowed but was encouraged to go for it. While there is another VP as well, I think being the first female in 24 years is a step closer to better representing the makeup of the medical profession.”
New AMA faces For her part on the council, Katharine would like to see the AMA “focus on its core bread and butter work that it has done really well in the past around fundamental public health issues.” These include violence linked to alcohol and obesity. She is particularly passionate about the AMA stepping up as a voice on family domestic violence, an issue which predominantly affects women and is often tied to alcohol. She says the issue has been exacerbated by COVID, particularly in marginalised communities. Linked to that, she believes there’s work to be done advocating for better pay for doctors who are specialists in treating sexual violence and the related forensic medicine, given that forensic medicine is not yet a college specialty. “I also want the AMA to be a stronger voice for rural and remote care and issues like the syphilis outbreak. It would be good if we could respond with as much vigour as we have for hospital ramping on those pervasive and longer-term issues.”
Katharine has been encouraged by the work the AMA is doing nationally around climate change and sustainability. In March, the AMA and Doctors for the Environment Australia made a joint call for an emissions reduction in healthcare to net zero by 2040 and an interim goal of 80% by 2030.
country. Geneva is on her radar as a potential option.
“It’s something that might have made more progress if not for COVID, but it’s great to see some changes being made.”
“David loves the thrill of the climb, whereas I’m more about enjoying the scenery. He does Bluff Knoll once a year in the dark to see the sunrise. We did some hiking while we were in Tasmania too.
When her mind isn’t on the bigger implications of public health issues Katharine gets mindful by playing with clay and throwing her own cups, plates and pots. Her chubby grey cat Maude is her muse. “You have to concentrate on what’s on the wheel and it’s very tactile. You have to pay attention to what your hands are doing and at the same time, you are letting your hands feel their way. It really allows me to zone out.”
Right balance
To fire her body and keep mentally healthy, there’s classes in boxing, yoga, pilates and barre. She and David enjoy hiking together and her previous bigger adventures have included Kilimanjaro and Machu Picchu.
“At home I love being in the garden, planting and picking herbs. Again, it’s using your hands and being able to unplug. I really resent buying basil and paying $3 for it, so I get satisfaction in growing it. There’s also rosemary for the food, or lemons for a gin and tonic.”
Read this story on mforum.com.au
She recently reignited her love for French and is working towards a diploma. At some point she wants to be good enough to work in public health in a Francophone
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DECEMBER 2021 | 15
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WA to face its first big test Unless COVID sneaks into WA in the meantime, early next year is when we will face our first real test of managing pandemic casualties. Cathy O’Leary looks at the year that was and what we can expect in 2022.
For months, the question on the minds of many West Australians has been not ‘if’ COVID will finally penetrate our bubble, but when. Many jurisdictions around the world have already felt the pain of the pandemic and are now moving to a new-normal, using phrases such as ‘living with COVID’ and ‘endemic COVID’. In WA, the past 12 months has been bitter-sweet. The State has managed to avoid hospitalisations and deaths, but the price has been its residents being cut off from much of the world and even our own country, with tough border restrictions becoming routine rather than exceptional.
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DECEMBER 2021 | 17
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WA to face its first big test Now the State Government has revealed its road map out of closed borders, with a predicted opening up in late January or early February. This is a daunting prospect for some, including health bureaucrats, given public hospitals are running over-capacity and have ambulances regularly ramped at their doors even without COVID.
vaccination progress, and meeting the ambitious target of 90% of 12-year-olds and over being double-dosed.
travellers entering WA will not face any isolation requirements. International and interstate visitors will have to return a negative PCR test 72 hours prior to departure and be tested within 48 hours of arrival.
By mid-November, around 70% were fully vaccinated, meaning more than 200,000 West Australians adults still need to roll up their sleeves over the next few months.
Ambitious target
In his long-awaited announcement, Premier Mark McGowan committed to setting a firm date for reopening once the State reaches 80% fully vaccinated, which is expected to be early this month.
But how the reopening will play out hinges on improving WA’s sluggish
Under the plan, with the exception of unvaccinated overseas arrivals,
But it will not be a moment too soon for many people desperate to be reunited with family or travel the world.
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Face masks will be needed in high-risk indoor settings such as public transport and in hospitals and aged care facilities, while those without vaccination passports will be denied access to premises such as nightclubs and events with big crowds. Casual contacts of COVID cases will no longer be required to self-isolate but will need to test negative, and close contacts will have their quarantine period halved to a week.
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Mr McGowan added a caveat – if the 90% vaccine rate is not achieved by the prescribed date, the border would still reopen, but with additional restrictions.
More is better At a recent Perth forum, provocatively entitled Fortress Australia and organised by the University of WA’s Public Policy Unit, Australian Medical Association national president Dr Omar Khorshid threw his support behind a higher than 80% vaccination rate in order for the State to safely open. “I’d like to say we should open up at 80% vaccination but it may well be that WA needs 90% or even 95%, otherwise all we do is go back into lockdown,” he told the meeting. “Opening up is not Freedom Day, opening up the borders does not keep WA safe – it means we go back to restrictions. “And if we need to tighten those restrictions because the health system is failing, we’ll go back into tighter restrictions, including lockdowns. That is the future, and I think we need to be honest and prepare West Australians, otherwise it’s going to be very, very difficult. “We’re not COVID-zero, we’re not ever going to be safe from this virus, and I think that’s the big political challenge for all our leaders – how to go from “we are safe, we’re looking after you” to saying, “people are going to die from this virus, and that’s okay as long as we’ve done everything we can to prepare.” Dr Khorshid questioned whether enough had been done to prepare not just the public hospital sector, but GP and specialist clinics, including protocols for personal protective equipment if there was a big influx of potential COVID cases coming through their doors.
“PPE might seem a bit ridiculous, but if you don’t you’re exposing your staff, and we know the vaccine is not 100% effective, so what does that look like, who pays for the additional cost of slowing things down so a whole system is highly efficient most of the time,” he said. Vaccine policy researcher Dr Katie Attwell from UWA’s School of Social Sciences told the forum that having the pandemic spreading in New South Wales and Victoria had been an enormous driver of people getting vaccinated. “The question of how that translates to WA is an interesting one, given the political capital that our State Government currently enjoys and its immense popularity, and while we’re going out for dinner and hugging our families, we should be thankful for that,” she said. “But what are we going to need to reopen our borders and be able to face down that pandemic which is coming for us? We have not had the pandemic yet – we’ve had little tiny outbreak fires that get put out and then we’re back to this kind of wonderful life that we enjoy. “And what we’ve seen in the eastern states is that when the virus does come, people will die.” Dr Attwell said that with no COVID in the State, the vaccination status of each person did not matter, but down the track it would matter enormously. More was needed to be done, including more mandates and incentives, particularly for disengaged communities. The Royal Australian College of General Practitioners shares those concerns, particularly
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about Aboriginal and Torres Strait Islander people who are at increased risk as Australia opens up, due to dangerously lagging COVID vaccination rates. While about 81% per cent of all Australians aged 16 and older are fully vaccinated and 90% have had one dose, that figure sits at 55% fully vaccinated and 67% one dose for Aboriginal and Torres Strait Islander peoples. The Aboriginal and Torres Strait Islander Health Chair, Professor Peter O’Mara, said the gap in vaccination coverage compared to the general population was worse in jurisdictions less affected by COVID outbreaks, including WA where the rate of first dose is below 55%. “We urgently need to ramp up vaccine access and education for Aboriginal and Torres Strait Islander communities, particularly for younger community members and certain jurisdictions such as WA, which we know is really lagging behind,” he said. Professor Jaya Dantas, from Curtin University’s School of Population Health, told Medical Forum she was disappointed there was still no clear date for the State’s reopening, and she believed the 90% target was unnecessarily high. But she was confident WA could manage any COVID cases when the border opened. “If we open up our borders and take people who double-vaccinated and had a negative test just before coming, I don’t think that we’ll have a huge increase in case numbers,” she said. “There will be small numbers, but many could be managed carefully
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The only certainty is uncertainty Doctor-turned writer Bruce Powell argues we should have accepted the uncertainties about COVID from the start and not quibbled about getting vaccinated.
If 2021 has shown us anything, it’s that sh#t happens and anything is possible. Unfortunately, that single truism has our puny brains turn to putty. The unknown brings us an acute sense of discomfort, driving often irrational, destructive choices. Moreover, we would rather be lied to than confront the nature of our fragile existence. Life’s ambiguity fuels our anxiety and magnifies our perception of threat. Studies have shown that even hard-nosed investors would rather pay a financial penalty and know an outcome quickly, than wait. “I’d rather just know that I failed, than wait any longer.” Remember saying that while waiting for exams results?
Neuroscientists tell us that our amygdala light up during uncertainty, multiplying the brain’s estimates of adverse consequences. Of course, there was a time when that anticipation had an evolutionary benefit. Cynicism and avoidance might once have conveyed survival attributes, but not now. Now, we must embrace that aroused state, examine our anxieties, to make the wisest choices.
have rapidly evolved to become consumed by the ‘what if?’. The luxury of time, granted by our modern lives, has afforded us the chance to confront more of our unknown. The mysteries of life are now pondered at great length, inescapably, over a multitude of media. It is in that context that we welcomed COVID into our lives. “Why? What? How? An act of war or an act of God? Is it real at all? Wouldn’t it be easier to deny its existence?”
We have evolved to ignore large portions of our experience to just focus on what is important. We have come to make ‘guesstimates’, apply rules of thumb and use heuristic methods to produce solutions that are sufficiently pragmatic to meet life’s deadlines.
Almost two years on and despite millions of dead, we still question COVID’s significance. We rage at the denial of our rights to travel and work, embracing dogma and superstition, irrespective of the cost. We crave absolutes, however illogical and nonsensical they may
However, 21st century humans
WA to face its first big test continued from Page 19 in home isolation, so I think this fear that we’ll have large numbers of cases really needs to be tested. “There seems to be this constant worry that when we open the border, we’ll have this surge and our hospitals won’t be able to cope, when other countries which saw big
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numbers early on have managed.” Professor Dantas said with vaccination mandates for more than 70% of the workforce, she expected rates to increase over the next few months. “You will still have vaccine objectors – and that will sit at about 5-6% – but the rest will get vaccinated, except for children and those
unable to. But we really need to look at pockets where rates are low. “Personally, I think mandates are good because they serve the purpose of saying we are in the midst of a global pandemic, and this is about community good. And with mandates among those people who have been hesitant or complacent, their vaccination increases.”
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challenges that fear. They are most easily anxious and least easily reassured. Someone once said, “It’s not a race.” Ironically, vaccination is quite a lot like a race. No one knows exactly how things might end. All we can do is prepare well and line up early at the start. We might stumble and fall, or triumph gloriously. That is the ubiquitous nature of any race and uncertainty is part of that confronting conundrum. Western Australia remains locked in thanks to our reticence to lead, to accept uncertainty and engage our community in a comprehensive, compulsory vaccination program at an early stage. be. We refuse to gain any solace in science, since she never provides 100% guarantees. We have learned that “God DOES play dice with the universe”, and there is a randomness that supersedes all else. We reject the pragmatists and the truth-tellers, replacing them with soothsayers and narcissists. We sleep better at night with a resolution of the uncertainty in our hearts, not the truth. We allow politicians to portray an illusion of certainty and yet we know in our hearts that there is none, only probabilities. The consequences of this illusion of certainty are an unintelligible strategic response to crises such as
Professor Dantas said, retrospectively, WA had really protected its citizens this past year. Its harsh border closures – one of the harshest in the world – had meant almost zero community transmission. But the State needed to move on, just as the world had, allowing families to reunite and Australians to return home. “Many West Australians are very parochial, they’ve lived here and don’t necessarily travel overseas very much, so it’s been wonderful,
COVID. My own family, between the four of us, have had three different vaccines, thanks to waivering policies in the quest for absolutism. When the booster arrives, at least two of us will get a new immune experience, since an AZ boost is apparently a “no-go”. So, what are we to do? We must not fear the flat dark waters of our lives. We must take a deep breath and plunge below the forbidding surface, gaze upon the good and the bad of the reality that lies beneath. We aren’t all similarly responsive, not all of us are keen snorkellers.
COVID is not anyone’s fault, but our refusal to acknowledge the uncertainty of the path ahead absolutely is. Health executives, media moguls and politicians alike, must lessen our fear of chaos, not stoke it. In the future, we must embrace uncertainty and have faith in our processes. We must communicate in absolutes, not exploit our anxieties. We must accept uncertainty, and when necessary, jump in with both feet, since that is all that we can do. We may not relish the discomfort at the time, but in hindsight, the element of surprise might make our successes all the sweeter.
The least tolerant of us are also those who resist data that
but when families are separated or have lost parents and haven’t been able to go and grieve for them, that shouldn’t have happened,” she said. “We’ve done well in our freedoms here, but our State is not open, and we’re still catching up. After 20 months, we need to move on.” Dr Khorshid told the UWA forum that COVID had impacted every Australian, not necessarily a health impact but a psychological, employment or financial impact.
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“But when we get to the end of this year, or the middle of next year, or the end of next year, whenever it is, we can look back with pride at the fact that our leaders, our institutions, our medical professionals, our health workers, and everybody involved in the public health response have actually mobilised, and they’ve kept us safe,” he said.
DECEMBER 2021 | 21
Vaccines living in the real world COVID vaccines have been developed and administered in record-breaking time, but Dr Karl Gruber (PhD) looks at how effective they have been and what is still needed.
Vaccines have long been recognised as one of the most important developments of modern medicine. They reduce disease, disability and death from a wide range of infectious diseases, saving the lives of millions of people each year. Globally, immunisation programs are estimated to prevent about six million deaths a year and have saved $586 billion from the direct illness costs across 94 low- and middle-income countries. So, we know they work. The COVID-19 pandemic is not a unique event. However, this pandemic has offered some revelations, not the least the capacity to deliver much-needed technological developments in record time. It has also highlighted shortcomings such as equity and access to life-saving vaccines and medical treatments for everyone – even those who can’t afford it. It has taken a global effort to develop, test and deploy vaccines in less than a year, a significant outcome in the history of medicine. However, the vaccine development was not the product of a rushed process, rather, it was due to the establishment, long before the pandemic started, of a solid research pipeline, and technologies that allowed for the development of safe and effective vaccines. It was also possible thanks to the amalgamation of a series of factors that only a pandemic could bring together. Vaccines normally take a long 22 | DECEMBER 2021
time to develop, a decade or more sometimes. But, according to Dr Mark Toshner, Director of Translational Biomedical Research at the University of Cambridge, that time lag is not necessarily to ensure a safe vaccine.
deployed in February 2021. By midNovember, Australians had reached the Federal Government target of 85% of people aged over 16 double vaccinated. Relative to other states, WA remains behind in vaccination coverage.
“It’s 10 hard years of battling indifference, commercial imperatives, luck and red tape. It represents barriers in the process that we have now proved are ‘easy; to overcome,” he said in a statement.
However, the WA Government has established tough new legislation that requires virtually all workers in WA to get fully vaccinated by the end of the year – or lose their jobs.
Governments’ responses to the COVID-19 pandemic removed those barriers for scientists. “You just need unlimited cash, some clever and highly motivated people, all the world’s trial infrastructure, an almost unlimited pool of altruistic, wonderful trial volunteers and some sensible regulators,” Dr Toshner said. Now that the vaccines are in the arms of the general population, a critical question in the mind of clinicians and patients is how safe and efficient are these vaccines? As of December 2021, 22 COVID-19 vaccines are in use around the world and dozens more are in the pipeline. In Australia, only three vaccines have been approved and offered to the general population: Vaxzevria (AstraZeneca), Comirnaty (Pfizer) and Spikevax (Moderna). The vaccines from AstraZeneca and Pfizer were the first to be approved and implemented in Australia, with the first doses being
As to quality of vaccines, two key concepts come into play: efficacy vs effectiveness. Vaccine efficacy measures the performance of the vaccine in clinical trials, and studies so far have shown that all Australian-approved vaccines are highly efficient. One clinical trial based on 43,548 participants from the US, Argentina, Brazil, South Africa, Germany and Turkey, showed that the Pfizer vaccine had an efficacy against infection of about 95% following the second dose, in people 16 years or older. In contrast, AstraZeneca, according to WHO, has an efficacy of a little over 63%, a figure mostly backed by a clinical trial of 23,848 participants from Brazil, South Africa and the UK. However, efficacy is just one side of the story. Vaccine effectiveness is what most people should really care about – effectiveness measures how well a vaccine performs in a real-world setting. Vaccine effectiveness for both Pfizer and AstraZeneca were significantly different from the promising efficacy data. One large
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study that analysed data from 384,543 people age over 18 years from across the UK, found that these two vaccines indeed offered protection from COVID-19, but not as much as promised and not for as long as we had hoped. The study found the effectiveness of the Pfizer vaccine 14 days after the second dose was about 94% for the Alpha variant of the virus and 84% for the Delta variant. For AstraZeneca, the study found that effectiveness was 86% for the Alpha variant and 70% for Delta. According to Dr Jürgen Richt, Director of the Center on Emerging and Zoonotic Infectious Diseases at Kansas State University in the US, a more important issue is waning protection. As more data comes in, it’s becoming clear that vaccine effectiveness decreases over time. One study that analysed data
from 1,475,391 participants found that, after five months, vaccine effectiveness dropped to 47.3% for AstraZeneca and to 69.7% for Pfizer, among people over 16 years of age. For people over 65 years of age, these figures turned to 36.6% effectiveness for AstraZeneca and 55.3% for Pfizer. “The critical antibodies we need to protect us against SARS-CoV-2 are neutralising antibodies. High levels of SARS-CoV-2 specific neutralising antibodies are induced after mRNA vaccination especially after the second vaccination with the Pfizer/ Moderna vaccine,” Dr Richt said. “However, after a period of time the levels of these antibodies in the blood drop and, therefore, a booster vaccination after six months is recommended for certain age groups and individuals with comorbidities or at high risk.”
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According to Dr Zoë Hyde, Senior Research Officer at the Western Australian Centre for Health and Ageing at UWA, the current data paints a very clear picture: we need vaccine boosters. “The vaccines’ real-world performance has held up pretty well compared to the clinical trials, but we’ve learnt these are threedose vaccines, not two,” Dr Hyde said. In response to this issue, booster vaccines are now on the table in most countries that can afford them, including Australia, where boosters have been available since November. Public health experts will be hoping most people step up and get the third jab to boost our protection against COVID.
DECEMBER 2021 | 23
What have we learnt? Former AMA (WA) president Andrew Miller has not been backward about coming forward with his views about how COVID has been managed. Here he reflects on lessons so far.
The most fundamental thing I have learnt since January 2021 is that pandemics are time-critical strategic information wars. By this, I mean the spread of the disease throughout the community sets the tempo of the responses required, if we wish to modify the health outcome, which we of course have to, otherwise we would have excess mortality causing widespread health and economic chaos. To decide the appropriate response, information comprises one half, values the other. Understanding the likely hospitalisation and fatality rate in different age groups came
early but then there are differing attitudes deciding an acceptable death rate.
in neighbouring countries very few were lost.
In balancing societal needs against individual needs, the usual cohorts that do badly in healthcare and economic outcomes are worse off than ever. A lot of the subsequent arguments about controls, such as border closures, have been based mainly on these kind of value judgments, as infamously shown in Sweden's early permissive approach to COVID spread that resulted in the King, no less, eventually apologising that nearly 8000 people died, while
There have been many attempts to present those approaches that differ from our usual ethical stance in health, which is to provide everyone with all reasonable treatments, even those who we know are going to die soon, as long as that treatment is not futile. We know that preventing spread of COVID is not futile so we should do it for everyone, whether they are aged or diseased or anti-vax. COVID does not discriminate, neither should we. How though, can we process
Treatments coming to the fore While prevention is better than cure and vaccines remain the best frontline defence, Cathy O’Leary looks at growing interest in ways to treat COVID-19. Just as the development of vaccines for COVID-19 has occurred at lightning speed relative to other drugs, the growing arsenal of antivirals to treat the disease is also forging ahead.
Many health experts believe the key to finding successful treatments is to keep widening the net, particularly when there is still limited evidence of the effectiveness of some drugs.
While Australia is still focused on reaching high COVID-19 vaccination targets, particularly in WA where rates lag, treatment options for the virus are set to become increasingly important as the country starts to live with the disease.
Australia’s dedicated COVID treatments – remdesivir and sotrovimab – are currently being used to treat patients across the country, while the Federal Government has signed up to buy 300,000 courses of molnupiravir,
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which is yet to be approved by the Therapeutic Goods Administration. Molnupiravir, originally developed to treat influenza, is a capsule that is taken twice a day for five days by adult patients with mild-tomoderate COVID symptoms. It has the advantage of not needing to be refrigerated, allowing it to be used in the community or as a targeted intervention at high-risk locations and in rural areas. It is
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information in a time-critical fashion when there is so much of it, especially in a social media world that can provide prominence to voices that are unscientific? I am discriminating about the experts I listen to, and I am open to a variety of sources. This enables an open-minded person to rapidly filter information by saying, for example, what would Fauci or Peter Doherty or Raina MacIntyre or Lidia Morawska say? And with the marvel of Twitter, we can see the answer in real time. I have gravitated toward a diverse group that have several criteria – authority and experience, a lack of conflicts, and a “leave no one behind" approach. Eventually in 2021, a large group of these experts coalesced in Australia into OzSAGE (Oz Strategic Advisory Group of Experts) to provide independent advice. They are progressively releasing contemporary, locally applicable advice on all COVID-related topics, which provides a compass and counterbalance to the political voices.
drive advocacy for settings from government and other authorities. Health is only one voice at the Cabinet table. There will be books written on why there was denial for so long that this is an airborne pandemic. Seeing aerosol engineering experts all over the world talked down to by medical professionals, who were clearly wrong and doubling down using appeals to authority, was extremely frustrating. The suspicion remains that bureaucrats preferred a droplet dogma because of the ramifications of needing to provide clean air to make healthcare workers and everyone safe. We still see problems across Australia in getting masks, ventilation, CO 2 monitoring and HEPA filtration right. The pandemic arrived in Australia when general practice was already under-appreciated and underfunded, as with the public health system. There was no reserve into which patients needing triage, diagnosis and care could possibly fit in any great numbers.
Why is it an information war? There are competing objectives among those who influence the public health and economic responses to COVID. Naturally self-interest will
Reliance on border controls, quarantine, elective procedure cancellations and lockdowns was required and each of these became a battle about specifics.
also considerably less expensive than some treatments that require intravenous transfusions.
500,000 treatment courses of its investigational COVID oral antiviral candidate, provided it passes ongoing phase 2-3 clinical trials and is approved by the TGA.
According to its developer Merck, molnupiravir could halve the chances of dying or being hospitalised in those people most at risk of contracting severe COVID. So far, the drug has only been granted a provisional determination by the TGA, the first step in the approval process. If it gets the green light, molnupiravir could be available early in the new year, under an advance purchase deal struck between the Commonwealth and manufacturer Merck Sharp & Dohme. Meanwhile, Pfizer Australia has confirmed it will supply at least
Should it prove effective, the treatment, known as PF-07321332, would be administered in combination with HIV protease inhibitor ritonavir as an early treatment or potential prophylaxis for people exposed to COVID. According to Pfizer, this combination, Paxlovid, is the first orally administered experimental drug to be evaluated in clinical trials to specifically target COVID-19. It is designed to slow the virus by blocking the activity of the main
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The false dichotomy of economy and health was demonstrated very early to be a hoax, but still for whatever reason we have had to battle again and again to remind politicians that, as cases go up, the economy goes down. The UK, Denmark, the US and Singapore have all demonstrated what every frontline doctor knows, which is that if you allow Delta to spread when only 64% of humans (80% of over 16yrs) are vaccinated with two doses of a three-dose vaccine, there will a lot of disease and a load on systems ill-equipped to take more. Burnout of the workforce has been ongoing and our permanent reliance on Ireland and the UK to staff our shortfall has been shown to be short-sighted. The work to be done on vaccinating children under 12 and making sure that people understand airborne spread will continue, and the tools we have learnt to use in the past two years will become more organised. In the end, obvious reality becomes undeniable, and we can only hope our democratic system is up to ensuring that leaders will do the best they can to save as many as we can. Like we do for every other disease every day.
SARS-CoV-2 protease, an enzyme essential for viral replication. Its clinical trials are ongoing. The drug would be used in combination with ritonavir, which would help break down PF-07321332 so it is active for longer. The Pfizer drug is expected to be made available over the course of next year, but its availability still depends on the results of trials as well as the TGA approval. Australia is also expecting to be supplied during 2022 with 15,000 doses of the breakthrough Roche antibody-based treatment, Ronapreve, which is likely to be used intravenously for COVID patients in hospital.
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Are RATs coming to WA? The Australian Government is pushing for the use of rapid, antigen-based COVID tests, but will WA get on board? Dr Karl Gruber (PhD) reports
COVID-19 is still a major problem in most parts of the world, including Australia. Rapid identification of people infected by the SARS-CoV-2 virus is the cornerstone of efforts to control the COVID-19 pandemic. Rapid antigen testing, or RATs, promise results within 20 minutes compared to the more than 24 hours required by the PCR-based test that detects viral DNA. However, questions still loom in the minds of experts because these rapid tests are less accurate than traditional tests. More recently, the TGA announced the approval of home-based COVID-19 rapid tests, but will they
live up to their promise of helping curb the pandemic?
What are RATs? Antigen tests use a nasal swap as for a PCR test, but the test usually takes less than one hour to produce a result, although they are not as accurate. This is a problem, especially if we are trying to control a pandemic. The Royal College of Pathologists of Australasia has already expressed concern about the use of RATs in Australia. According to its president Dr Michael Dray, these tests should never be used on their own for diagnostic purposes in a symptomatic patient
“where a false-negative result may provide unwarranted reassurance and lead to ongoing community transmission,” he said. Despite all the hurdles, experts argue that RATs may be useful. According to Dr Paul Griffin, Director of Infectious Diseases at Mater Health Services and Associate Professor of Medicine at the University of Queensland, the key is to use these tools in the right way. “We need to utilise all available tools in our arsenal to control COVID-19. This should definitely include rapid antigen tests. However, like all tests, they need to
These testing times Dr David Rutherford (pictured) and Dr David Smith explain what GPs need to know about COVID testing. It has been a long 18 months living with COVID-19, despite being in a luckier State than most. Changes to general practice have been enormous, including pivoting to telehealth and keeping up with ever-changing guidelines for testing and vaccination. It is timely to clarify the role of testing in WA. Since vaccination started in February, the number of serology
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results have steadily increased. Some of these are for overseas travel when required for certain country entry requirements (mostly China), but increasingly they appear to be done to check immune response to vaccination. The laboratories must contact the Public Health Emergency Operations Centre, which is notified of any positive COVID tests, either through PCR, rapid antigen testing or serology.
In most cases there is little clinical benefit to checking serology, with the exceptions of exposure to COVID-19 in the past for someone who was not tested at the time. This will alter management. As we know from the data, all the current vaccines have high effectiveness but are known to be particularly effective at preventing severe illness and reducing the need for hospital/ICU admission.
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be used in the right way and their results interpreted in the correct context,” he said. The idea is not to replace PCR tests with RATs, but to use them as a complement to PCR tests. “Rapid antigen testing will not replace the use of these laboratorybased PCR tests, but I see it as something that could be used in finite circumstances, in a complementary fashion,” Dr Griffin said. From a technical perspective, the widespread implementation of RATs will need careful monitoring to ensure accuracy of results. According to Dr Lynette Waring, Chair of the RCPA’s Microbiology Advisory Committee, this is not a trivial task.
“Firstly, all positive RATs must be verified by an additional molecular test due to the high likelihood of false-positive results. There is also the question of how often a person needs to get tested. For example, you need to take into account the incubation time of the virus, which is anything from a few days to two weeks. According to Dr Priscilla Robinson, Adjunct Associate Professor at Latrobe University, this means multiple testing is needed. “You need to be able to test roughly every transmission cycle. So, if you have a negative test, you need to test again in two or three days to make sure that you've remained negative. Because the rapid antigen tests are not quite as sensitive as the PCR tests, you need a high level of virus to detect with a RAT test, compared with a PCR test,” Dr Robinson said. In addition, results from RATs need to be properly recorded and reported to public health authorities, and action needs to be taken whenever a positive result occurs. “In addition to isolating a RATpositive individual while awaiting the result of the definitive molecular test, the appropriate interim
While serology can show a positive response to either infection or vaccination, it does not indicate whether there is any residual protection from either source. If there is any concern that vaccination coverage may be weakening in an individual, then it is best to recommend booster vaccination, rather than checking serology. This can be done for immune-compromised patients two months after their last dose or after six months for immunecompetent patients. Currently there is no clinical indication for more than three doses. Serology has no place for testing in suspected acute COVID-19. Nose and throat PCR remains the
test of choice for suspected acute COVID-19. PCR is organised through many laboratories and hospitals in WA. When people are symptomatic, it is most important to look out for higher risk patients including health care workers, Uber and taxi drivers, port workers, security guards, flight crew, truck drivers, those working or living in residential facilities, prisons and abattoirs, and interstate travellers or their close contacts. The interstate border restrictions change regularly based on risk, so it is good to keep abreast of this through the WA Health Department website. In the future, once vaccination rates reach a certain level and borders
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response at the testing site must be predetermined and acceptable to public health authorities. RAT kits must be transported, stored and handled correctly at each nonclinical test site, and each test site should participate in a registered quality assurance program (QAP) conducted at quarterly intervals,” Dr Waring added.
RATs in WA By last month, the Therapeutic Goods Administration had approved 147 RATs. However, none of these tests is available in WA as an acute illness diagnostic tool for detecting COVID-19. There is an exemption – RATs can be used as a tool to detect COVID-19 in transport, freight and logistics drivers coming from medium, high and extreme risk jurisdictions. While home-use RATs are now sold in shops in some States, they are not available in WA because experts do not recommend their use while there is no community transmission. Whether the regulations will be relaxed to allow rapid tests to be more widely available, remains unclear.
reopen, more people will be in home quarantine. It is important to maintain high vigilance and to test using PCR when symptoms are present. If someone has flu-like symptoms, ideally telehealth should be used first, or a negative COVID test returned, before seeing face-to-face, as per RACGP guidelines. Rapid antigen testing is currently not available in the community in WA. Finally, vaccination remains the best protection for individuals and the community as a whole. ED: Dr Rutherford has continued his work in GP/travel medicine while working at PHEOC, and Dr Smith is a clinical microbiologist at Pathwest.
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We’re not safe, until we’re all safe Public health epidemiologist Dr Priscilla Robinson argues that when it comes to COVID, we have to think globally.
Two years on from the start of the SARS-CoV-2 pandemic, we in Australia are starting the process of getting back to a new normal life – including how we interact with our world and all of its peoples. We are quite late in this process. Europe, which experienced the pandemic surge much earlier than we did here in the global south, has been returning to a new normal for several months. Some of us have friends and relatives who have managed to get on a plane and go to a different country. In Australia, we were lucky in that
we are an island with relatively few international entry points, and we had good warning that COVID was coming. I am not so sure we really were the envy of the world in managing our part of the pandemic. While our remoteness protected us for much of 2020, we proved to be as vulnerable as everyone else when the surge we experienced in Victoria and NSW over the past few months pointed to a level of complacency about the effectiveness of our public health controls, which crashed when Delta arrived.
Public health controls are about a complete package of measures, but it seems that our political leaders decided to pick and choose which ones to use, and for how long, and have even changed the rules to ensure that they can do that – for example, the recent change in Victorian laws about how they can declare a pandemic. Victorian population attack rates have now passed the 1% mark, and NSW is close behind. Australian rates will continue to rise until the number of cases and complete vaccination rates provide true herd immunity.
Another year, ‘unprecedent’ remains Dr Sean Stevens, past chair of the Royal Australian College of GPs WA, reflects on a remarkable year. Unprecedented seems to be the word for this pandemic. Unprecedented circumstances, unprecedented health crisis, unprecedented vaccine program, unprecedented response. And through all of these unprecedented happenings, our profession was at the centre of it. I have never been so proud to be a doctor and a GP seeing how our profession responded to this crisis.
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It is little wonder that the public perception of the health profession is at an all-time high.
Seeing patients for carpark consults, social distancing, masks and elbow bumps have become the norm.
While we have had some lockdowns, we have escaped lightly compared to our eastern states colleagues, and especially to our international colleagues. Pivoting rapidly from faceto-face consults to telehealth became eminently achievable and seeing our general practice teams pull together to do this was truly impressive.
From a COVID perspective, however, general practice has been dominated by the vaccine roll-out. As at the end of October, GPs and our teams have delivered 54% of all vaccines in Australia and this number is climbing. State and Federal governments have acknowledged this, and
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In fact, ‘herd immunity’ is another example of a conventional definition that seems to have somehow altered from the ‘herd’ being the entire community to only people eligible for vaccination. Herd immunity levels for the prevention of transmission of COVID are not really known; estimates vary between 70% and 100%, depending on the data source. And that is of the WHOLE population, not just people eligible for vaccination, but everyone, children from birth onwards. Worldwide. Speaking of worldwide, globally rates of infection have varied hugely. Some 20 countries (such as the US and several European countries) have had infection rates of 10% and more, and one country has broken the 20% barrier. Some countries have had very low rates of infection, China being a good example where national rates have yet to reach 1%. Several countries, including several in the throes of major political upheavals, report low rates, partly explained by a lack of public health capacity. However, you would not know it from the media. Many countries have avoided this pandemic,
many practices have done this at a financial loss. When the government announced the rebate, at a compulsory bulk-bill Level A consult equivalent, the argument was made that it would be a mass vaccination program and so the encounter would be quick. The controversy with AstraZeneca and thrombosis with thrombocytopenia syndrome (TTS) soon put paid to this notion, but unfortunately the rebate didn’t change. The community anxiety around AZ reached fever pitch in May and June when vaccination rates dropped, people became very confused, Pfizer was not widely available, and people just wanted answers. This is where the trusted bond that many Australians have with their
particularly small Pacific Island nation states, but they have also fallen off the vaccination radar. There are two major ways for resource-poor countries to access COVID vaccines. Firstly, vaccines are meant to be provided to resource-poor countries through the WHO COVAX program, by which wealthy countries subsidise vaccines for low-income countries to access at cost or free. However, at current rates with less than 2% of low-income country populations currently fully vaccinated (and no prizes for guessing who the 2% are), it will take about 50 years for these people to be protected. The second way for vaccines to reach people who need them is for COVID vaccine intellectual property rights to be temporarily suspended, as urged by many supporters of the TRIPS waiver being negotiated at the World Trade Organization. Had a TRIPS waiver been granted early in the pandemic, many resource-poor nations would have had the resources to be able to protect themselves, and, as many of the treatments and vaccines had been developed using public monies, it is arguable that ethically there should have been no issues with waiving IP rights.
GP was invaluable, we were able to have the conversations, allay any unfounded concerns and put risks in context. It did become rather repetitive at times, but I think we did the community a great service. At a personal level, I saw our GP-led Respiratory Clinic morph from a clinic that saw, assessed, treated and swabbed people with respiratory symptoms, to a clinic that vaccinated seven days a week. Our team showed amazing resilience and grew, adapted and changed, managing to vaccinate 30,000 people in seven months in a safe, efficient and caring manner. The unsung heroes, though, are the GPs in every corner of Australia that will set up a clinic to vaccinate six people, with all of the logistics,
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Sadly, there are still several wealthy countries holding out against TRIPS waivers for COVID-related products. Why does this matter? Well, as soon as travel starts up again COVID will reach these immunologically naïve peoples and it will spread, and apart from the inconvenience of having a lack of services due to local people being sick, having new and fertile ground to spread arguably also provides seeding grounds for new SARS CoV-2 variants. Many such COVID-free, poorly vaccinated countries are holiday destinations and cruise stopover ports for wealthy travellers. It was wealthy travellers who seeded many of the original COVID seeding grounds. Remember the returned skiers from Aspen who started Victoria’s problems early in 2020? Remember, we are not all safe until we are all safe. ED: Assoc/Prof Deb Gleeson assisted in this article by providing reference materials and ideas about TRIPS agreements.
time out of practice, cost, just to ensure that their patients are safe, and the vaccine program proceeds. I’ve seen general practices and Aboriginal community-controlled health organisations go to extraordinary lengths to ensure all people have the opportunity to be vaccinated, chasing up all of our fellow Australians who are vulnerable or hesitant to ensure they are protected before COVID hits. As we near the end of our second year of living with COVID, many of us are exhausted. A lot has been asked of the health industry and front-line doctors and nurses in particular. I hope that next year will bring some respite, but somehow, I doubt it, as unfortunately we are still living in unprecedented times.
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Prepare, plan, pivot, refine. Repeat. Dr Brenda Murrison reflects on life with COVID as a regional GP and practice owner.
Looking back on 2021, poor communication and a lack of guidance from authorities in general characterised the year. Often the media has announced things long before anyone else told us anything at the practice level, and this has been confusing for patients and horrendous for practices to manage. Being based in Bunbury, myself, and with a high number of our practices based in the regions, my concerns as a practice owner in the
main have been around the safety of our teams and the communities we live in and they revolve around the following issues: Intensive care beds – or lack of them. WA lags the national average with 8.5 beds per 100,000. Our staffed beds have dropped from 179 to 159 during the last year but we do have surge capacity for 300. Cold comfort I’d suggest. If you live in the regions, you are an awfully long way from intensive care beds. Rapid antigen testing (RAT) – here in WA we are in the unlucky
position of being one of two States who cannot have a licence for RAT in our practices. We need this resource to manage safely moving forward to 2022 when we will have COVID in our community. Vaccination – rates in regional and rural WA have lagged the cities in a fairly spectacular way, which is indicative of the fate of rural and regional health in general. If vaccination is the pillar of our response, how could we have got this so wrong? The rollout has been a debacle, poorly coordinated
No time to breathe Doctor burnout is real but still surrounded by stigma, says healthcare coach Gail Carmody. The COVID-19 pandemic has been a difficult time for everyone, but healthcare workers are some of the most affected. Before the pandemic, burnout from work had already been a common problem for these workers, with physical and mental stress, toxic work hours and uncertainty taking their toll on many. In a national survey of Australian healthcare workers, more than half of the respondents said they felt burnt out by the demands of the pandemic. Unfortunately, it is a
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reality that Australian doctors have higher rates of burnout and more attempts at suicide than the general population. In a study by Hoffman and Bonney, they identified three key causes based on junior doctors’ responses to their interviews. One factor is the expectations they set for themselves. Most junior doctors felt anxious when working independently because they were concerned with their ability and level of competence. Second is
the expectations and responses of others as junior doctors had an overall feeling that they were not supported enough by their seniors. Lastly, achieving a good work-life balance was identified as important but difficult to achieve. Healthcare workers are constantly under pressure, with barely any avenues for rest and recovery. When they experience burnout, it is especially alarming as it impacts on themselves, their patients and the workforce.
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and financed, the reality being it has been loss-making to be involved in the vaccine rollout for many practices. Fortress WA – yes, we have loved the “bubble” but life can’t go on like this. We need to learn to live with COVID in our midst. The fortress has protected us to allow vaccination rates to get up to an acceptable level to open, but has also been our biggest foe – we cannot get skilled workers into the country inclusive of doctors, and several of our doctors are stranded overseas unable to get back in. Mandatory vaccination and exemptions – as an owner GP, I was relieved when vaccines became mandatory as it’s a victory for common sense that should have come sooner in reality. Like all GPs, we are starting to see the people who are anti-vaccine start to book in for appointments for exemptions, but with so few true reasons for these, very few will qualify to get them. It certainly is exhausting explaining over and over again why we can’t oblige. Clean air – HEPA filters, carbon dioxide monitoring (hello aloe vera and mother-in-law tongue plants), ventilation. All the new things we
will need to think of in a consulting room moving forward. The fundamentals – point of care testing, environmental cleaning. waste management, PPE, N95, fit testing, social distancing, scrubs, hand sanitiser. Funding of our services in an outbreak – what will be MBS and what will be State-funded when we are caring for large numbers of patients in the community? What will be expected of us as GPs, as we care for patients with mild, moderate and severe COVID in our communities? Burnout – stressing that staff aren’t taking enough leave to rejuvenate and then worrying about what will happen post-pandemic when lots of people want to take leave at the same time. Planning, planning, planning – trying to keep a step ahead at all times and to predict as best we can what might come next. We are indeed in the lucky State in the respect that we have watched and learned from the eastern states and their experience.
a radio, TV or newspaper calling. After a while, particularly for the issue of vaccine hesitancy, it’s hard to think of more to say to try and persuade people to come in and get the vaccination done. How many lockdowns will it take, or will it be the ambulance sirens increasing that will make the difference?
From a personal point of view there have been a lot of additional pressures in dealing with the media, and not a week has gone by without
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Despite this, it was found that most medical professionals isolate themselves to deal with burnout. Although everyone deals with their mental health in different ways, no one should have to go through difficult times alone.
physical, mental, and even spiritual wellbeing. Now more than ever, with the ongoing pandemic, it is vital that healthcare professionals receive better mental health monitoring and support from employers, colleagues and loved ones.
Often healthcare workers are reluctant to seek professional help for their mental health, as they are conscious of what others would think. Most hold a high standard for themselves, so they perceive mental health as a weakness. Moreover, some might also fear their job security if word got out that they needed help.
Although changes in the workflow are important to address burnout, cultivating good mental health practices must start with ourselves.
negative thinking patterns, and reduce stress and anxiety. • Avoid spending time with toxic people. Be with more people who inspire you and motivate you to become your best self. It may be difficult to let go of some relationships but do it for yourself and your mental health. • Stop comparing yourself with others and believe that you are an amazing human being. When the only person’s opinion that matters is your own, you’ll quickly find yourself caring about judgment from other people much less.
All these reasons are valid and understandable, but we must find a way to address these. It is important that those who provide care for others be in good
Here are three ways to cultivate good mental health: • Avoid suppressing your thoughts. If you keep in all your negative emotions, it compounds and adds to your feelings of stress and anxiety. Instead of running from your emotions, acknowledge them and do what you can to find a solution. Early support can also help you manage emotions, challenge
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Life has had to go on, with my eldest daughter starting university, and my youngest kids having school, sport and music as normal. My husband’s 50th birthday was postponed as friends couldn’t get here from the eastern states. Add all the challenges that everyone else has endured this last year. And like many of my colleagues in the regions, I’m an international graduate originally, so the perils of distance, the inability to have family visit as they would do usually, has been hard. Knowing that in the event there was an emergency I will be able to get there, but goodness knows when I might be able to come back to WA again. And then back to work again. Prepare, plan, pivot, refine. Repeat.
ED: Dr Murrison is founder and CEO of Brecken Health Group.
Healthcare professionals need support too, and there is absolutely nothing wrong with that. ED: Gail Carmody is a registered nurse with an MBA, and is director of Coaching for Healthcare.
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CHRISTMAS 2021 SEASON’S GREETINGS FROM WA HEALTH PROFESSIONALS The Medical Forum team wishes all its readers and supporters a very Merry Christmas and a Happy New Year
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SEASON’S GREETINGS
On behalf of the Doctors and staff at SKG Radiology, we thank you for your continued support throughout the year and wish you and your family a safe and happy festive season.
www.skg.com.au 36 | DECEMBER 2021
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Hanging tight and counting the wins What a year it has been, and not just because of the ongoing challenges presented by a certain coronavirus – that curiously resembles a Christmas bauble. In a strong show of optimism and confidence by WA’s health sector, there has been a surge in spending on infrastructure and equipment in 2021, despite the omnipresent COVID. In this Christmas feature, we showcase some of those projects and achievements, as well as people whose lives have changed because of the medical care they have received in WA. A new private emergency department and state of the art cancer treatment technology have come online, with a new private hospital on the books. And a Geraldton grandmother is counting her blessings after beating a rare cancer. We wish you, your families and medical practices a safe and happy festive season, with a chance to recharge for the interesting year ahead.
Thank you to all of the healthcare workers who have selflessly given themselves to others during this trying year. You are true heroes and from all of us at Mount Hospital, we appreciate you and wish you a Happy Christmas!
150 Mounts Bay Road, Perth WA 6000 mounthospital.com.au | Mount Hospital Community of Care
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Let light shine out of the darkness. 2 Corinthians 4:6
May the peace of Christmas reign in our world and with you. To our doctors and all involved in the health care community, we wish you a Christmas filled with love and compassion.
www.sjog.org.au 38 | DECEMBER 2021
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Better than winning Lotto Early childhood teacher Elaine Battilana is back enjoying her favourite coastal walks in Geraldton, after having challenging surgery on a large tumour wrapped around her spinal cord. The 62-year-old’s medical journey started in 2020 when she was diagnosed with the rare bone cancer, chordoma, needing surgery to remove the tumour and then suffering a life-threatening infection post-surgery. Despite all of this and the loss of both her parents during this time, the grandmother has continued to be positive and reflect on how lucky she is to have come out the other side. Elaine had previously dismissed her lower back and hip pain as part-and-parcel of ageing, before CT scans revealed the tumour in her L1 vertebrae and cancer was diagnosed. She was initially referred to neurosurgeon Andrew Miles at NeuroSpine Institute in Perth, before being assessed by spinal surgeons Paul Taylor and Greg Cunningham who undertook the complex surgery. The chordoma presented a medical challenge because not only was it in an unusual location on the spine, it had also grown in size to wrap around nearly half of Elaine’s spinal cord. The surgeons knew they had to get the tumour out in one piece. Splitting it in half to easily remove it would have meant certain death, because the tumour would been able to seed and spread around the body.
tumour centres in Europe and spent many hours planning the treatment. After more than 14 hours, they had successfully separated the tumour from the spine and nerves, along with inserting the stabilising rods and screws to hold the spine straight. The second stage surgery involved delivering the tumour out through the chest, past the heart, lungs and major blood vessels supplying the legs, along with reconstructing the spine so Elaine could stand afterwards. While the operations were successful and allowed Elaine to return to Geraldton, soon after an infection set in at the site of the surgery and she was rushed by the Royal Flying Doctor Service back to Perth. She then spent four weeks in hospital, undergoing four more surgeries to clean and debride the wound, as well as having many rounds of IV antibiotics. While her infection was a setback, she pushed ahead with her rehabilitation. Last Christmas, she was back home and set a goal of a daily walk along the coastal walkways of Geraldton. By February this year she was back driving and has since been able to resume many activities while giving up strong pain medication. Elaine says she feels fortunate to be back on her feet and free of the rare cancer, after the surgical team was able to “break her in half, remove it in one piece then put her back together again.” She describes it as “better than winning Lotto.”
The doctors consulted with colleagues at two large spinal
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WA-first radiation therapy offers new view Louise Coffey, left, general manager of GenesisCare Oncology WA and Amanda Barnes, centre leader, GenesisCare St John of God Murdoch.
Perth doctors will now be able to visualise tumours and adapt radiation treatment in real-time, using innovative new technology. The Elekta Unity MR-Linac machine, housed in the new $17 million integrated cancer centre at St John of God Murdoch Hospital, is the first of its kind in WA. It will allow radiation oncologists to visualise cancerous tissue during treatment, combining MRI diagnostics with highly targeted radiation therapy. The combination enables clear differentiation of soft tissues during treatment and will allow for adjustment in real-time, known as adaptive planning, to account for movement in the tumour and surrounding healthy tissue. The successful delivery and installation of the MR-Linac technology marks an important milestone for the integrated cancer centre, which is due to open its doors to patients by the end of the year. The cancer centre is the result of a partnership between Centuria Healthcare, SJOG Murdoch, and leading radiation oncology service provider GenesisCare. 40 | DECEMBER 2021
GenesisCare radiation oncologist and medical director of the new facility, Dr Tee Lim, said the technology at Murdoch heralded a new era for adaptive radiation therapy in WA and offered cancer patients access to a highly precise non-invasive treatment option. "Many tumours are located in organs that move during or between radiation treatment sessions. Often, tumours are located near sensitive organs or tissues, such as the bladder or bowel, which we obviously want to protect during treatment," Dr Lim said. "The new system allows us to visualise cancerous tissue during treatment in real-time, adapting the plans and margins to minimise exposure to surrounding healthy tissue and limit side effects." "This new treatment technology is a game-changer for WA cancer patients.” Ben Edwards, CEO of SJOG Murdoch, said the new service would strengthen the site's comprehensive cancer care south of the river. "The new service will create a real hub in Murdoch for comprehensive cancer treatment,” he said.
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"We are pleased to see the arrival of the state-first technology for radiation therapy services which is supported by direct access from both our dedicated cancer inpatient ward and palliative care services at the Murdoch Community Hospice." In a partnership between Elekta and GenesisCare, the new treatment team at Murdoch will participate in ADAPT-MRL, a long-term prospective and retrospective registry which will collect medical information from patients who have received treatment on the MR-Linac. The new cancer centre at Murdoch also offers theranostics and nuclear medicine services and will house the latest molecular imaging equipment, including a PET-CT scanner, which are critical for directing and monitoring new targeted molecular therapies. The facility will be able to treat up to 1000 cancer patients a year.
Ramsay Health Care wishes our referring GPs, specialists and their families a joy filled festive season. Our five WA hospitals will continue to care for our community during the holiday period and beyond. Stay safe and have a very happy new year.
Greg Hall
Chief Operating Officer – Hospitals
Joondalup Health Campus • Hollywood Private Hospital • Peel Health Campus • Attadale Private Hospital • Glengarry Private Hospital
People caring for people
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Helping hand from afar Hospitals in Cuba have received more than $75,000 worth of urgently-needed medical aid from Australia, but more is needed, including syringes, dressings and older blood pressure and ECG machines. The medical supplies were sent by the non-partisan Australia-Cuba Business Council, in response to the humanitarian crisis caused by COVID. The 800kg aid package consisted of about 26,000 needles, basic medical supplies including wound dressings, bandages and vitamins, particularly perinatal vitamins and supplements for children impacted as a result of shortages that have swept the country in the past 12 months. According to the council’s chair Kim
Prior, it is an important response by Australians to the Cuban plight, given Cuba has done much to assist other countries throughout the pandemic. He said the small island nation had shown international goodwill and resilience during the crisis, while itself suffering severe economic hardship as a result of the ongoing pandemic and continuing sanctions from the United States. The country dispatched about 2000 doctors and nurses worldwide last year to assist with the pandemic and has developed three COVID-19 vaccines, Abdala, Soberana 02 and Soberana Plus, to combat the virus. Cuba closed its international borders to all non-residents in March 2020 and has since
maintained one of the tightest lockdowns in the world to prevent the spread of the virus. While those restrictions helped to ease the spread during the first wave, the measures have crippled the country economically, with an estimated loss of $30 billion to the gross domestic product last year. The restrictions have also failed to contain the more contagious Delta variant, with nearly half a million cases occurring since June this year. The increase in numbers has put significant strain on Cuba’s hospital system which, while well-staffed, has had difficulty obtaining the medical resources needed to meet the increase in patient numbers.
On behalf of the doctors and staff at Emerald Clinics, we wish you a happy festive season. Thank you to all our referring doctors and staff for your continued support. Join us in the New Year on our clinical care and research quest to pioneer new ways to care for your patients.
info@emeraldclinics.com.au www.emeraldclinics.com.au
42 | DECEMBER 2021
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CHRISTMAS 2021
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CHRISTMAS 2021
Hollywood’s ED opens Perth patients seeking urgent medical help now have a new option, with the opening of the first private emergency department north of the river.
Patients who present to the ED will have access to a range of medical, surgical and allied health services on the one hospital campus. “It is important the people of Western Australia have diversified health care options,” Health Minister Roger Cook said. “This significant investment will help meet the health care needs of residents today and well into the future.”
The $67 million development was unveiled at Hollywood Private Hospital last month and is expected to help reduce pressure on the public health system. The ED, part of a project which features six levels and three new wards, is open to both private and public patients, with a doctor’s consultation fee applicable. It is the second private ED in the State and has 13 treatment bays (including an isolation room), a triage assessment room, a resuscitation room and a waiting lounge area. An additional 60 inpatient beds will be available in the wards above the ED and there is the capacity to open a further 30 beds at a later date.
Hollywood is WA’s largest hospital and the new development expands the hospital’s size to over 900 licensed beds. The ED project is the final stage in a five-year, privately-funded $200 million investment by Ramsay Health Care to provide comprehensive health care services at Hollywood.
Hollywood CEO Peter Mott said the $48 million Hollywood Consulting Centre opened last year and brings together a suite of cancer services under one roof. “Our very successful cardiothoracic surgery service was also launched last year and there was a major expansion of our mental health services around the same time,” Mr Mott said.
We hope you have a
wonderful festive season and we look forward to working with you in the new year
perthurologyclinic.com.au
1800 487 656 refer@perthurologyclinic.com.au healthlink: puclinic
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‘
We wish all our referring doctors and our patients a happy and safe festive season. Thank you for your support this year and we look forward to working with you again in 2022.
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CHRISTMAS 2021
New hospital takes off Short-stay hospital operator Montserrat has partnered with WA developer Hesperia to develop its fifth short-stay hospital in WA, to be known as Murdoch Private Hospital. It will be located in the Murdoch Health and Knowledge Precinct and is due for completion in mid-2023. It will include five large theatres, supported by short stay in-patient beds. Surgeons will have access to theatre lists in an integrated hospital with highly trained staff and state-of-the-art equipment. Montserrat’s new cancer centre will offer a full range of treatments for cancers and blood disorders. Doctors will have access to the
latest advancements in technology and research through on-site clinical trials.
More than 30 specialist surgeons are already expected to join the precinct.
Montserrat CEO Ben Korst said the hospital would offer complex short stay services for orthopaedics, general surgery, plastic surgery, urology, gastroenterology and ophthalmology.
Patients will also have access to rapid diagnostic services from onsite pathology provided by Western Diagnostic, as well as healthcare imaging services and a pharmacy.
– GREETINGS – from Dr Sekaran Gana and Apollo Cardiology As we enter the holiday season we wish all our referring Doctors and their medical team a peaceful Christmas, full of good cheer and celebrations with your family and friends Health and happiness is wished to you all for 2022, where we look forward to supporting you with all your Cardiac patients.
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Perth Vascular Clinic team would like to extend our warmest greetings of the season, best wishes of health for 2022 to all our referring doctors, colleagues & their families. We appreciate your outstanding continued support and look forward to working with you all in the New Year to mutually care for the health and wellbeing of our patients. Best of health to you all Marek Garbowski & Perth Vascular Clinic Team
Perth Vascular Clinic is WA’s leading vascular solutions centre offering state of the art management and treatment of conditions affecting vascular health, with convenient access to rooms-based minimally invasive vascular investigations and treatment. Dr Marek Garbowski is a qualified & highly experienced vascular & endovascular surgeon in all aspects of diagnosis and management of arterial & venous diseases, specialising in: Comprehensive assessment and patientoriented best medical and surgical management of all vascular problems. Open and Endovascular management of Peripheral Vascular Disease, Aneurysms & Carotid disease Endovenous management of Pelvic Congestion Syndrome Thoracic Outlet Syndrome surgery
Specialised in all aspects of Varicose Veins – primary & redo surgery minimally invasive treatments including Radio Frequency Ablation (RFA) and Sclerotherapy Comprehensive care of leg ulcers & diabetic foot problems All aspects of vascular and dialysis access Management of Hyperhidrosis (Thoracoscopic Sympathectomy and miraDry)
All enquiries & appointments bookings Phone: 6116 4955 | Email: reception@perthvascularclinic.com.au Visit our comprehensive website
www.perthvascularclinic.com.au 46 | DECEMBER 2021
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OPINION BACK TO CONTENTS
Dr Joe Kosterich | Clinical Editor
Bring on a new year! In medicine, we are interested in and guided by evidence. As far back as the 1990s there was a view that one of the joys of evidence-based medicine was that you could find evidence to support just about anything.
Christmas is not joyous for all, but for most it is a time to be with family and friends. Hopefully, as you read this, a formal date has been set for WA to rejoin Australia. The loss of connection felt by many is real and lost time cannot be replaced.
Of course, there can only be research evidence for that which has been studied. In turn the only matters that are studied are those which attract funding. As the saying goes, absence of evidence is not evidence of absence. It is easy to point the finger at industry-funded research, but at least any conflict of interest is apparent if the funding source is disclosed. We assume that government-funded research is not tainted. Yet as the Wall St Window notes, distortions can occur. “Firstly, scientists are encouraged to pursue research tied to political agendas…” And “…feedback provided by the scientific community on the validity and implications of discovery becomes less important.” What will historians, in decades to come, make of the pandemic response? This month we have articles on topics including polymyalgia, syphilis, renal health, the role of exercise in cancer, alcohol use in pregnancy, the evolution of facial plastic surgery, and learnings from those ageing well. Christmas is not joyous for all, but for most it is a time to be with family and friends. Hopefully, as you read this, a formal date has been set for WA to rejoin Australia. The loss of connection felt by many is real and lost time cannot be replaced. We are no longer in March 2020 and need to accept the reality of living with what is effectively an endemic virus, recognising that whilst we can do our best, some will get a serious illness and some will die as occurs with flu, pneumonia and other infections. This can be minimised but not eliminated. We need to resume normal life whilst taking precautions proportionate to the risks. Thank you to readers for your support in 2021. A Merry Christmas to all and may 2022 be a good year.
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Complex non-melanoma skin cancer patients?
Dermatology Dr Kate Borchard Dr Judy Cole Dr Glen Foxton Dr Louise O’Halloran Dr Jamie Von Nida Dr Yee Tai
Refer cases to the Non-Melanoma Skin Cancer Advisory Service for multidisciplinary review
The benefits of a multidisciplinary approach to patient management are well known. The Non-Melanoma Skin Cancer Advisory Service (NMSCAS) has been established to enhance the care of patients with complex non-melanoma skin cancers. To submit cases to the NMSCAS for advice or management, visit genesiscare.com/au/refer-a-patient then click on Refer to the WA non-melanoma skin cancer advisory service to download the forms. Case information must be received no later than 1 week prior to the scheduled meeting.
NMSCAS meets every third Thursday of the month Clinipath Pathology 310 Selby Street North Osborne Park WA 6017
NMSCAS specialist team:
Pathology Dr Trevor Beer Dr Gordon Harloe Dr Joseph Kattampallil Dr Stephen Lee Dr Ben Ryan Plastic Surgery Dr Adrian Brooks Dr Sharon Chu Dr Mark Hanikeri Dr Qadir Khan Dr Daniel Luo Dr Linda Monshizadeh Dr Remo Papini Radiation Oncology Dr Sean Brennan Dr Eugene Leong Dr Susan Mincham Dr Evan Ng Dr Kasri Rahim Dr Craig Wilson Dr Yvonne Zissiadis
All enquiries: mdtskinwa@genesiscare.com 0452 277 752
48 | DECEMBER 2021
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What does a 25-year study of Perth men teach us about ageing well? By Dr Leon Flicker Director, WA Centre for Health and Ageing Australia is ageing rapidly. Over the next 40 years, people aged over 85 years will increase from 2.1% to 5% of the population and over four times the total number. In 2020 there were 6,400 centenarians but by 2060 there are expected to be over 40,000. There is considerable debate regarding what constitutes successful or healthy ageing with little consensus. In response to worldwide population ageing, the World Health Organization (WHO) has produced a blueprint for Ageing and Health that has adopted a life course approach to health determinants. The WHO report defines healthy ageing as the process of developing and maintaining the functional ability that enables wellbeing in older age. This functional ability determined by the intrinsic capacity of the individual, relevant environmental characteristics and interactions between the individual and the environment. The Health In Men Study (HIMS) is a study of Perth men originally commenced as a randomised trial of ultrasound screening for abdominal aortic aneurysm. The study initially included men aged 65-79 years identified in 1996, and over 12,000 attended for screening. Since that time, HIMS has received eight NHMRC grants that have been the major source of funding for eight further waves of questionnaires, but also physical and blood measurements. The study has been fortunate to have linkage to hospital, morbidity, and mortality datasets. Of the original group of men, more than 1000 are still alive and 300 are still active in the study. The youngest men are just reaching 90 years of age and the oldest has just turned 105. Our main findings are that both survival and successful ageing have complex determinants, requiring a mix of the right genes and the right lifetime exposures for that particular individual. There are
in older men, concerns telomere (the end of chromosomes and a measure of biological ageing) length. We found that telomere length correlated with levels of sex hormones in older men, but there was a U-shaped relationship between telomere length and mortality, with both short and long telomere length associated with increased mortality compared with the telomere length in the mid-range. This effect was mainly due to an association with increased mortality from cancer with longer telomere length in these older men.
Key messages
People over age 85 are in the most rapidly growing sector of the population
Risk factors affecting younger and middle-aged people may not have the same effect in very old people.
A life-course approach to healthy ageing requires the prevention of chronic illness, the maintenance of function whilst ageing and appropriate health services targeted at older people. some lifestyle interventions such as physical activity and stopping smoking that are good for all. Physical activity has major benefits, not only for survival and decreasing risk to cardiovascular disease, but also for better cognition and quality of life. A lot of the effect of physical activity seems to be early in the response curve, meaning much of the benefit occurs in moving away from being sedentary to doing just a little each day. Conversely, we found that in older men, being slightly overweight increased survival compared with so called normal weight. This shows we cannot confidently use risk factors from middle-aged people to predict their effects in older people. Another observation, suggesting we need caution in determining risk
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We have also been looking at the differential exposure of air pollution on men in Perth, which has quite low levels of pollution. We found that even in Perth, men exposed to higher levels of pollutants had a higher mortality suggesting that even low levels of pollutants have harmful effects. The levels of pollution were associated with the level of blood lipids that may explain some of the risk for cardiovascular disease. From our studies of older men, it has become apparent that predictors of healthy ageing may vary across the life course. As the last surviving men reach 100 and beyond, we will be able to compare these men to those who have passed before. In comparing this, we will be able to look at their risk factors, illnesses and trajectories of disability into advanced old age. The WHO has encouraged better understanding of healthy ageing trajectories and what can be done to improve them. A life course approach to prevention of illness and maintenance of function will be important in maximising our longevity dividend. Coupled with effective health services targeted for the booming numbers of older people this will ensure the Australian community meets the coming ageing challenge. Author competing interests – the author is involved in the study discussed.
DECEMBER 2021 | 49
Metropolitan Anaesthesia is one of Perth’s most respected anaesthetic groups. Directly evolving from groups first established 60 years ago, Metropolitan draws on the experience and wisdom of generations of Western Australian anaesthetists. Members include some of Australia’s high-profile anaesthetists contributing to academia, textbooks, and international research, providing the foundation for its reputation as an excellent and ethical provider of anaesthesia services. Our collegiality, mentor system and philosophy of providing excellent service while also giving back to the profession, attracts new practitioners and encourages engagement with the most recent anaesthetic developments. We continue to grow and welcome those new applicants wanting to be part of an inspiring and supportive anaesthetic practice. Metropolitan Anaesthesia is a leading provider of anaesthetic services across all specialities.
CONSULTING LOCATION Unit 6/1 Station street Subiaco WA 6008 Phone: 08 6267 6040 Fax: 08 6267 6210 www.metroanaes.com.au 50 | DECEMBER 2021
For Anaesthetic cover please contact: Tarnya Wilson - diary@metroanaes.com.au Anaesthetists joining enquiries please contact: Cara Suiter - manager@metroanaes.com.au MEDICAL FORUM | GENER AL MEDICINE
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Evolution of the modern facelift By Dr Linda Monshizadeh, Plastic Reconstructive Surgeon, West Perth Globally as we collectively grow older, we have become obsessed with fighting the ageing process and maintaining a youthful look which has been associated with “attractiveness and productivity” within society. Facelift surgery and its evolution relates directly to our understanding of anatomy and the progress made in anaesthesia, antisepsis and antibiotics. The first prototype of a facelift involved simply cutting out an ellipse of skin and closing the gap (1901, Hollander). The first true facelift involved dissecting the skin from the overlying fat, redraping the skin by pulling it tighter and cutting the excess skin (1916, Lexer). This ‘skin only’ facelift would become the predominant type of facelift for the next 60 years and resulted in the classic ‘wind-swept look’. Key issues included lack of longevity in results and poor scars secondary to the tension on the skin. It was not until World War II when surgical understanding of facial anatomy improved considerably. Skoog of Sweden first described a deeper fascial layer which was more accurately described by Mitz and Peyronie in 1976, following their study on cadavers.
Key messages
Facelift surgery and its evolution relates directly to our understanding of anatomy and the progress made in anaesthesia, antisepsis, and antibiotics
Facial ageing reflects the cumulative effects of time on all the different tissues of the face
Modern facelifts address all aspects of facial ageing. The term Superficial MusculoAponeurotic System (SMAS) was coined by their tutor Paul Tessier, a pioneer of craniofacial surgery who also developed the technique of subperiosteal dissection to reposition soft tissues following their release from the facial skeleton. The SMAS facelift involved manipulating this deeper tissue and reducing tension on the skin, which paved the way for the modern facelift. Furnas (1989) described the ligaments of the mid-face, which improved our understanding of the support system of the facial soft tissues and the role they played in the ageing process. Sam Hamra
was the first to introduce the inclusion of cheek fat (malar fat) to the facelift, which was published as the ‘Deep Plane Facelift’ in 1990. He was the first to include the orbicularis muscle of the lower eyelid in the Deep Plane Facelift (published 1992 as the ‘Composite Facelift’). Different techniques have evolved by manipulating the SMAS in various ways including SMAS suspension, cutting out a section of SMAS and closing it (SMASectomy), folding SMAS over itself and suturing it (SMAS plication) and the “deep plane” facelift incorporating sub-SMAS dissection which keep the skin attached to the deeper tissue as a composite tissue flap. Facial ageing reflects the cumulative effects of time on all the different tissues (skin, soft tissues, and craniofacial skeleton) of the face. It includes epidermal and dermal thinning, degradation of elastin fibres, reduced collagen turnover, redistribution of facial fat, and changes in the relative dynamics of bone apposition and bone loss leading to appreciable bone loss around the mouth and malar areas. Repetitive muscle movements also contribute to rhytids and platysmal banding in the neck. The modern facelift addresses all these changes to allow for natural results which keep all parts of the face in harmony. The authors technique of choice is the extended deep plane facelift incorporating key ligament release and sub-SMAS and sub-platysmal dissection into the neck which allows for tension free repositioning of tissues and is a powerful technique to restore a youthful face, neck, and jawline. Autologous fat grafting helps restore volume loss in key areas of the face. Finally, skin resurfacing and modification of facial animation (via chemo-denervation) further address ageing changes that cannot be addressed by surgery alone, enhancing patient outcomes.
Patient pre- and four-weeks post-op deep plane face and neck lift, upper eyelid blepharoplasty and fat grafting to key areas of the face
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Author competing interests – nil
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Managing peritoneal dialysisassociated peritonitis By Dr Aron Chakera, Nephrologist, & Dr Kieran Mulroney, Medical Researcher For patients with end-stage kidney disease (ESKD), there are two main dialysis options – peritoneal dialysis (PD) and haemodialysis (HD). Peritoneal dialysis involves the regular instillation of fluid through a catheter into the abdominal cavity, and supports greater degree of patient autonomy, better quality of life, and is substantially cheaper than HD. Despite the many advantages of PD, the number of ESKD patients in Australia who are on PD remains low compared to other countries. Data obtained by the Standardised Outcomes in Nephrology Group (SONG-PD) have demonstrated that the real and perceived risks associated with peritonitis are a major factor in patient and physician reluctance to use PD. Peritonitis usually presents as abdominal pain and cloudy dialysate bags due to the presence of the infecting bacteria (or fungi) and the neutrophil-rich inflammatory response. Although implementation of best-practice guidelines has been successful in reducing some of the inherent risk of developing PD peritonitis, it remains common, with a current peritonitis rate in Western Australia of one episode in every 28 months on treatment. The PROMPT study, (run from WA), determined for every extra hour before administering antimicrobial therapy, the risk of death or technique failure increases by 6.8%. Treatment therefore relies on empirical administration (usually
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intraperitoneal) of broad-spectrum antimicrobials as soon as possible. With the impending crisis posed by antimicrobial resistance, with rates predicted to exceed 25% by 2030 in some cases, the need for rapid tests that can both confirm infection (to prevent unnecessary antibiotic use) and predict antimicrobial susceptibility (enabling use of targeted narrower spectrum agents) is essential. Introduction of rapid point-ofcare tests, either administered by patients or staff at presentation, show potential to change management of PD peritonitis. PERiPLEX is a recent innovation using the same lateral flow technology found in many over-thecounter pregnancy tests to detect two markers (IL-6 and MMP-8) that are part of the host response to infection. The test is highly sensitive and specific, with results available within five minutes, providing confidence in the decision to avoid or administer antibiotics (the number needed to test to change clinical decision making is only six). Variations of this test using other markers are being developed and these assays are likely to prove of particular benefit for remote and rural patients where there can be considerable delays in accessing health care. In this setting, they could be used to guide homeadministration of antibiotics when peritonitis is suspected, and the test is positive.
To reduce broad-spectrum antimicrobial usage and provide better antimicrobial stewardship, replacements for existing pathology processes are needed. Detecting the presence of microorganisms without a lengthy culture step is challenging and efforts to use nucleic-acid amplification tests (like PCR or whole-genome sequencing) have been frustrated by technical challenges arising from the complex nature of PD effluent. We have pursued another path, using fluorescent dyes to label the proteins and nucleic acids in microbial cells and then enumerating cell numbers in PD effluent using a flow cytometer. With this technique, we have been able to identify the presence of infection in less than hour from receipt of specimen, even in culturenegative cases. We have further adapted the flow cytometry technique by quantifying changes in bacterial (or fungal) size, shape, nucleic acid content and cell wall integrity in the presence of different antibiotics and referencing these changes back to unexposed control samples of the same microbial cells, a method known as the Flow Cytometry Assisted Antimicrobial Susceptibility Test (FAST). This can generate accurate susceptibility profiles within 3-5 hours (compared to days for traditional culture-based laboratory techniques). Collectively these tools
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can provide clinicians with actionable information to guide clinical management decisions before patients leave the emergency department. As with any new technology, there are barriers to widespread adoption. Real-world demonstrations of diagnostic performance are required to meet the appropriate regulatory hurdles, and these are currently being undertaken, along with health economic analyses to quantify the potential value to the healthcare system. Finally, there is a need for engagement with both patients and clinicians to teach, educate, advocate and drive adoption: even a perfect test has no value if there is insufficient confidence and demand to ensure that it is used. In summary, outcomes from PD peritonitis can be improved by early administration of effective antimicrobial therapy. Advances in point-of-care and rapid culture-independent diagnostics have the potential to bridge this gap. Adoption of this technology is likely to improve confidence and utilisation of PD, providing reassurance for patients and clinicians and reducing health-care costs. ED: Dr Chakera works at SCGH and Dr Mulroney works at Harry Perkins Institute of Medical Research. Author competing interests – the authors are currently testing the PERiPLEX kits as part of a research study funded through a Research Translation Project Grant from the WA Department of Health
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#Flozinator: SGLT2i and chronic kidney disease By Dr Anoushka Krishnan, Nephrologist, Nedlands Recently, the hashtag flozinator took the Twitterverse by storm and not without good reason. Sodium-Glucose Linked Transport 2 Inhibitors (SGLT2i) are revolutionising the management of not just Type 2 diabetes mellitus (T2DM) and diabetic chronic kidney disease (CKD) but also heart failure and now non-diabetic CKD. Isolated from the root bark of apple trees in the 1830s by French scientists, the chemical phloridzin was first used to treat malaria and then found to inhibit the reabsorption of glucose in the kidney. Decades later, the SGLT2i were born. The SGLT2 protein is present in the proximal tubules of the kidney and aids the cotransport of glucose and sodium, contributing to nearly 90% of glucose reabsorption.
Key messages
SGLT2i benefit renal and cardiac health separate to lowering glucose
The risk of hypoglycaemia in nondiabetics is low.
SGLT2i inhibit this process with resultant glycosuria and glucose lowering effects. They also inhibit sodium reabsorption increasing natriuresis with resultant improved tubulo-glomerular feedback and reduced renal hyperfiltration and albuminuria. SGLT2i have pleiotropic effects, independent of their glucose lowering effects, leading to positive outcomes on cardiac and renal health. In the kidneys, SGLT2i
act directly to reduce glomerular hyperfiltration, restore cellular metabolism, reduce inflammation, reduce renal hypoxia, increased natriuresis and indirectly by reducing sympathetic activity, improving blood pressure and aiding weight loss. Recent trial data (CREDENCE) showed a significant benefit of canagliflozin in people with T2DM and CKD with estimated glomerular filtration rate (eGFR) 30 to <90 mL/ min/1.73 m2 and severe albuminuria (urine albumin: creatinine ratio [uACR] >33-565mg/mmol). Canagliflozin led to a 30% reduction in the composite risk for kidney failure (sustained eGFR < 15 mL/min/1.73 m2 or treatment with dialysis or transplantation), a doubling of serum creatinine level, or death from kidney or cardiovascular causes.
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CLINICAL UPDATE The DAPA-CKD study involving 4,304 participants with albuminuria (uACR 22-565 mg/mmol) and eGFR of 25 to 75 mL/min/1.73m2 with or without T2DM and on reninangiotensin-aldosterone system inhibitors (RAASi) was stopped early due to the overwhelming efficacy of dapagliflozin. Dapagliflozin slowed the rate of decline in eGFR, reduced progression to end stage kidney disease and renal and cardiovascular mortality, regardless of diabetic status. Cardio-renal benefits were seen across all levels of albuminuria, all stages of CKD including stage 4 CKD (624 patients) and across all levels of HbA1C (in diabetics). It would be pertinent to note that this study excluded patients with Type 1 diabetes, polycystic kidney disease, CKD from lupus nephritis or ANCA vasculitis and those on immunosuppressants six months prior to enrolment. Acute kidney injury (AKI) risk was of initial concern, with eGFR frequently dropping by 3-5ml/min after commencement, attributed to reversible intrarenal hemodynamic
effects and cofounding AKI risk factors (e.g., advanced age, higher use of RAAS inhibitors and/or diuretics). However, meta-analyses from several large-scale trials and propensitymatched studies showed that conversely, SGLT2i are associated with lower AKI risk (unlike the tradeoff with RAASi, where long-term CKD protection is counter-balanced by increased AKI risk). Nevertheless, a thorough physical exam and determination of volume status with appropriate reduction of diuretics if eu/hypovolemic are key to avoiding volume depletion, both at initiation and as part of future ‘sick-day’ management. SGLT2i only lower plasma glucose levels by blocking reabsorption of filtered glucose, which falls as plasma levels fall. Thus, the risk of hypoglycaemia is low in the absence of therapies that otherwise cause hypoglycaemia. Other adverse effects of SGLT2i include a higher risk of urinary tract infections and genital mycotic infections, both managed with meticulous groin fold hygiene, and consideration of pre-emptive
cephalexin for urinary symptoms or clotrimazole for thrush. There is a small but significant risk of euglycemic ketoacidosis, particularly in long-standing T2DM with reduced beta-cell reserve. This is diagnosed by blood pH <7.3, bicarbonate <18, ketonemia and no significant elevation of blood glucose. Management includes fluid resuscitation with insulin/ dextrose infusion until keto-acidosis resolves. SGLT2i should be ceased at least 3 days prior to elective surgery to minimise this risk. Sick-day advice is imperative for patients on SGLT2i particularly when unable to manage adequate food and fluid intake. In September 2021, dapagliflozin was approved by the Therapeutic Goods Administration (TGA) for use in adults with proteinuric CKD (CKD stage 2, 3, or 4 with eGFR>25 ml/min and uACR> 30 mg/mmol). Having had a paucity of novel agents that have promised to stem the progression of CKD, since the advent of RAAS inhibitors three decades ago, these are very exciting times indeed! Author competing interests - nil
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Exercise medicine for cancer By Professor Robert Newton Exercise Medicine Research Institute ECU Traditionally, exercise and sports science has been about athlete performance and physical activity for health. Over the past 50 years there have been remarkable advances in our understanding of the most sophisticated ‘machine’ in the known universe. While most of us acknowledge that physical activity is essential for human health, it is only in the last 10-15 years that exercise has been acknowledged as a medicine creating greater chemical and physical disturbances within the body than many drug therapies, but without any side effects and in many instances with greater efficacy than the most advanced exogenous treatments. It is well-established that being physically active is related to enhanced survival for patients with cancer. For example, one study reports a 61% lower risk of prostate cancer specific mortality in men who did three or more hours per week of vigorous physical activity compared to those completing less than one hour per week. This survival advantage varies across different cancers, but the beneficial relationship is pervasive. Such knowledge is derived from epidemiological research and is not indicative of cause-andeffect as there is the possibility of reverse causation by which more healthy patients feel better and live longer, while also performing more physical activity. There is also well-demonstrated relationship between physical activity and risk of cancer recurrence and progression with one meta-analysis reporting a pooled relative risk of 0.65 across breast, colorectal and prostate cancers. While this should be encouragement enough for clinicians to recommend and patients to embrace physical activity and exercise, demonstrated cause-and-effect is needed. To this end there are three large
Key messages
Exercise produces an anti-cancer environment through a range of mechanisms
Maintaining or increasing muscle mass is critical for cancer patients, who should be active most if not every day and do resistance training at least twice a week
Accredited exercise physiologists are the most appropriate allied health professional to assess and prescribe exercise medicine for patients with cancer. international randomised controlled trials currently being undertaken involving targeted exercise interventions with the primary outcome being progression-free survival. Our team at ECU is leading one of these trials in men with advanced, metastatic prostate cancer and we are currently open for recruitment. Considerable research effort in exercise oncology is being directed towards understanding the mechanisms by which exercise suppresses cancer progression and viability. There are at least 12 identified mechanisms whereby both acute exercise and chronic physical training suppress cancer cell proliferation and inhibit metastasis. Our team is particularly interested in cytokines produced from muscle tissue, which are termed myokines, and have been demonstrated in vitro to suppress tumour growth as well as signalling immune cells to identify and destroy cancer cells. We reported this year that three months of exercise training incorporating both cardio and resistance exercise significantly altered the myokine profile systemically in patients with prostate cancer on ADT who were overweight or obese. We also conducted an in-vitro experiment and found that the resting blood serum sampled post the training
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intervention suppressed growth rate of prostate cancer cells by 22.5% compared to the effect of pre-exercise serum. While this is an exciting finding, it has been established in healthy humans that an acute bout of exercise results in a much larger surge in myokine release although transitory. We are currently conducting an experiment in men with advanced prostate cancer drawing blood pre-and post a vigorous bout of exercise to evaluate if such patients can elicit these myokine surges while also evaluating the growth suppressive effect in prostate cancer cell lines. In these studies, we are using serum and therefore evaluating the direct cell signalling between myokines and the cancer cells. This is but one of a dozen potential anti-cancer mechanisms driven by physical exercise. There is a clear relationship between muscle mass and its quality and measurable clinical outcomes such as chemotherapy toxicities, overall and cancer specific mortality. We are gaining greater clarity of the mechanisms of this relationship and certainly myokine signalling is clear. In practical clinical terms, it is a priority for patients with cancer to maintain or increase their muscle mass and to activate that musculature daily to dose their bodies with the anti-cancer medicines endogenously produced acutely and chronically. To achieve this, we routinely prescribe resistance training for all patients undergoing a cancer journey regardless of type, stage or even when undergoing difficult treatments. To facilitate, we recommend consultation with an accredited exercise physiologist and the professional body provides a search facility at https://www. essa.org.au/find-aep Author competing interests – nil
DECEMBER 2021 | 57
GPs’ role in providing antenatal alcohol advice By Sheynae Griffiths & Dr Ramya Raman It is well established that alcohol consumption during pregnancy is harmful to a developing fetus. The teratogenic effects of alcohol include low-birth weights, premature birth, miscarriage, stillbirth, and birth defects such as fetal alcohol spectrum disorders (FASD). However, in Australia 26% of women continue to consume alcohol during pregnancy. One reason for this is delayed antenatal education and lack of understanding about alcohol’s effect on the developing fetus. These concerns can be addressed early and opportunistically by health care practitioners providing antenatal care. In WA, the recent data highlighted that 45% of antenatal care providers routinely ask about
position to improve this further and provide early antenatal advice about the harms of alcohol consumption during pregnancy, as GPs are the patients’ first point of contact with the healthcare system.
Key messages
Alcohol consumption during pregnancy is harmful to a developing fetus. In Australia, 26% of women continue to consume alcohol during pregnancy
The Pregnancy Care Clinical Care Guidelines developed by the Department of Health (2020) recommend that antenatal health care providers advise women who are pregnant or planning a pregnancy that not drinking alcohol is the safest option. The guidelines recommend that this advice should be given at the patient’s first antenatal visit. By providing advice and education as early as possible, potential fetal alcohol exposure can be minimised, improving outcomes for both mother and baby.
For women who are pregnant or planning a pregnancy, not drinking alcohol is the safest option
Antenatal care providers in primary care are ideally positioned to deliver early education and advice to patients about the risks of alcohol in pregnancy.
alcohol consumption during antenatal visits. General practitioners are in a unique
On this background, a clinical
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those who request, regarding communication skills, assessment tools and community resources for maternal alcohol consumption. 4. Re-audit to assess improvement and identify any barriers that may arise following the implementation of recommendations.
audit of alcohol advice provision in antenatal patients was completed at an outer metropolitan general practice in Perth. This audit included 55 antenatal patients who visited the practice for their first antenatal appointment throughout 2020, which represented approximately half of the antenatal patients seen at the practice that year. The results showed only 1.8% of patients included in the audit had documented evidence of alcohol advice being provided by the GP or the practice nurse at the first antenatal visit. The small sample size and retrospective audit of documentation as a reflection of clinical practice have limitations.
The aim of this audit is to improve the rate of provision and documentation of antenatal alcohol advice at this general practice. As such, the following recommendations were made to the practice: 1. All antenatal patients are given alcohol advice at the first antenatal appointment and the provision of such advice is documented in a consistent manner in the patient notes. 2. Standardised documentation format such as ‘alcohol advice given’ to allow clinical practice to be accurately reflected in the patient notes. 3. The provision of staff education and learning resources to
Antenatal care providers in primary care are ideally positioned to deliver early education and advice to patients about the risks of alcohol consumption in pregnancy, and consequently, improve outcomes for their patients and their babies. Acknowledgements We would like to thank the general practice where the audit was conducted and the entire team for their assistance and support. – References available on request ED: Sheynae Griffiths is a final year medical student at the University of Notre Dame. Dr Ramya Raman is a GP lecturer, supervisor, and Chair Elect of the RACGP WA. Author competing interests – nil
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Oral manifestations of syphilis By Dr Amanda Phoon Nguyen, Oral Medicine Specialist, Perth There is an ongoing outbreak of infectious syphilis. While more commonly affecting young Aboriginal and Torres Strait Islander people in regional, remote, and very remote areas, increasing cases are now being detected in the broader population in major Australian cities. The WA Government has issued an alert to dental practitioners due to the increase in syphilis notifications. The rate of syphilis notifications here has doubled between 2016 and 2020. Syphilis is a systemic infectious disease caused by the filamentous, anaerobic spirochaete Treponema pallidum. The disease can be transmitted sexually (acquired syphilis) or vertically via the placenta (congenital syphilis). Communities at risk include people
Clinical presentations
Key messages
There are three main stages with different clinical presentations and infectivity. Oral lesions may occur at any of the three main stages of the clinical course, including the primary, secondary, and tertiary phases.
Syphilis cases are on the rise Oral lesions may occur at any stages of the clinical course
Oral syphilitic infection should be considered when a patient presents with oral lesions and relevant history.
who experience homelessness, those who use methamphetamine and/or inject drugs, CALD people, 16-35 year-olds, Aboriginal communities in remote areas, particularly in regions with syphilis outbreaks (Goldfields, Kimberley, and Pilbara), women of childbearing age (currently represent 30% of all infectious syphilis notifications in Perth) and men who have sex men.
Oral manifestations of syphilis are multiple and highly variable, and often detected in secondary stage. Primary syphilis is detected as ulcer in all patients, while secondary syphilis is detected as ulcer in about 50% of cases. Oral presentation may not be synchronous to cutaneous. Because of the heterogeneity of the oral clinical aspects, the differential diagnosis includes many diseases: traumatic or cancerous or non-specific inflammatory
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CLINICAL UPDATE ulcers, autoimmune (pemphigus/ pemphigoid) or immune-related lesions (lichen planus, erythema multiforme), traumatic (frictional keratosis) or hyperplastic/dysplastic plaques, and other infectious diseases such as tuberculosis, deep fungal, herpes lesions and hairy leucoplakia. The mouth is rarely the site of primary syphilis. A chancre, a painless, indurated ulcer at the site of inoculation, develops within one to three weeks of acquisition. Primary syphilis is usually the consequence of orogenital or oroanal contact with an infectious lesion. Kissing may, very rarely, cause transmission. Primary syphilis of the mouth manifests as a solitary ulcer usually of the lip or, more rarely, the tongue. Chancres may resolve without treatment. The features of secondary syphilis reflect the hematogenous spread of T. pallidum, and similarly to its other mucocutaneous features, the oral manifestations of secondary syphilis can be more extensive and/or variable than those of the primary disease. Oral lesions arise in at least
30% of patients with secondary syphilis, although very rarely oral ulceration may be the only manifestation of infection. The two principal oral features of secondary syphilis are mucous patches and maculopapular lesions, although nodular lesions may rarely arise. Others include macroglossia, painful fissuring and/or papular lesions on the anterior 2/3 dorsum tongue. Clinical disease arises in about one third of patients with untreated secondary syphilis. The oral complications of tertiary syphilis centre upon gumma formation, and much more rarely, syphilitic leucoplakia (and controversial risk of oral squamous cell carcinoma) and neurosyphilis. Gummas tend to arise on the hard palate and tongue, although very rarely they may occur on the soft palate, lower alveolus, and parotid gland. Gumma manifests radiologically as ill-defined radiolucencies that may resemble malignancy. The areas of ulceration eventually heal, although the resultant scarring can, at least on the tongue, cause fissuring.
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Early features of congenital syphilis include diffuse maculopapular rash, periostitis (frontal bossing), and rhinitis. Late features, manifesting at least 24 months after birth, comprise the Hutchinsonian triad of interstitial keratitis of the cornea, sensorineural hearing loss, and dental anomalies such as Mulberry molars.
Diagnosis The diagnosis of syphilis may require a knowledge of the patient’s sexual history, physical examination, and an interpretation of serological and microbiological findings. The diagnosis is often made on clinical and serological grounds. Management includes benzathine penicillin G, tetracycline, azithromycin, or doxycycline. However, resistance to azithromycin has emerged rapidly. Author competing interests – nil
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Polymyalgia Rheumatica By Dr Charles Inderjeeth, Rheumatologist, North Metro Health Service Polymyalgia rheumatica (PMR) is a common inflammatory condition of unknown aetiology characterised by symmetric stiffness of the proximal limb girdles (neck, shoulder, and pelvic girdle). PMR may be associated with a serious condition, Giant cell arteritis (GCA) or temporal arteritis, a vasculitis affecting the cranial arteries, characteristically presenting with new onset temporal headache with or without visual symptoms. Both conditions rarely affect patients under age 50 and are characterised by constitutional symptoms (weight loss, fever fatigue), an elevate acute-phase response, (i.e. raised ESR and CRP) and typically, rapid response to corticosteroids. PMR has a female preponderance (2:1) and is more common in those of northern European origin.
Presentation and investigations The classical presentation is aching and stiffness in the shoulder and hip girdle. Although onset is usually acute, onset may be sub-acute or insidious. Associated systemic features include anorexia, weight loss and low-grade fever. An elevated erythrocyte sedimentation rate (ESR) >30 mm/hr or C-reactive protein (CRP) >6 mg/dl is usually found but may be normal in some patients. Mild normochromic anaemia is also a common presentation. Synovitis may be a feature affecting the shoulder and hip joint and can be demonstrated on imaging (ultrasound). Some patients may have features of a peripheral synovitis, although the latter should raise the possibility of a polymyalgia-onset rheumatoid arthritis. Diagnostic criteria for PMR have been developed based on symptoms, ESR and response to low-dose steroids. However, consensus has not been reached on a single set of criteria. 62 | DECEMBER 2021
Table 1: Differential diagnosis of polymyalgia and PMR Mimics
Key messages
The cardinal features of PMR are
Malignancy Paraneoplastic – Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) Myeloma Leukaemia or lymphoma Metastatic cancer
sudden-onset bilateral shoulder and pelvic girdle pain and stiffness, together with raised inflammatory markers.
Ruling out other causes and
Polymyalgia rheumatica ± Medium and large vessel vasculitis including Giant cell arteritis
associated conditions and complications of the condition and treatment is essential
Arthritic disease Osteoarthritis of the cervical/lumbar spine Rheumatoid arthritis Spondyloarthritis SLE Connective tissue disease Crystal arthritis
Prompt treatment with steroids is highly effective and is both diagnostic and therapeutic.
It is crucial to exclude active infection, cancer and other inflammatory conditions. Clinicians must be aware of conditions that mimic PMR. Such conditions include the inflammatory and noninflammatory (e.g., mechanical) disorders (Table 1). Table 2 outlines some of the baseline tests in PMR. Polymyalgic-onset rheumatoid arthritis (RA) is an important condition that can mimic PMR. Antibodies against cyclic citrullinated peptide (anti-CCP) are the earliest serological markers for RA. The updated EULAR/ACR criteria have incorporated anti-CCP to help discriminate between RA and PMR. The importance of this distinction is made more urgent because of the appreciation of the need to treat RA early and of the provision of more effective agents such as the biological disease modifying antirheumatic drugs (DMARDs). Patients with PMR should be assessed and monitored for symptoms of GCA (temporal severe headache, prominent temporal artery, scalp tenderness, visual symptoms) as the treatment of PMR with lower doses of prednisolone may not prevent the development of GCA.
Management and complications Patients with straightforward PMR do not need specialist referral, however, patients with atypical
Muscle disease Autoimmune myositis (Polymyositis, Dermatomyositis) Drug induced myopathy (e.g. statins, glucocorticoids, colchicine) Infection Viral Bacterial Metabolic disease Thyroid and parathyroid disease Metabolic bone disease (e.g. abnormal Vitamin D, calcium and phosphorus metabolism) Miscellaneous Fibromyalgia syndrome Parkinson’s disease
presentation, diagnostic difficulties, not responding to traditional treatment or relapsing disease should be referred to a specialist. Although mild symptoms of PMR may respond to non-steroidal antiinflammatory drugs, corticosteroids are the drug of choice. PMR typically responds to a daily dose of 15mg (range 12.5-25mg) of oral prednisolone. Response is generally prompt, within 24 to 48 hours, with complete abolition of symptoms in most cases and normalisation of the acute phase response within a few weeks. Failure to respond should trigger a re-evaluation of the diagnosis and possible cause. In those who respond (remission), the dose of prednisolone is maintained for one month and then reduced by 2.5mg/day every 2-4 weeks in patients with PMR until a dose of 10mg/day is reached. The dose is then reduced by 1mg/ day every 4-8 weeks depending on response. In most patients the
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CLINICAL UPDATE Table 2: Tests to exclude differential diagnoses
and inflammatory markers. This may have the advantage of lower cumulative dose and reduced osteoporosis risk.
ESR CRP Full blood count Rheumatoid factor (and/or anti-CCP), ANA Immunoglobulins, Protein electrophoresis and Bence-Jones urine test to exclude myeloma Creatinine kinase, to exclude myositis Thyroid function tests, to exclude hypothyroidism Chest x-ray, to screen for malignancy Other tests depending on presentation and risk factors, e.g. 25-hydroxy vitamin D in older patients
dose is generally maintained at 5-7.5mg/day for approximately six months to avoid relapse of disease with too rapid reduction. In general, treatment can be ceased by two years, although earlier in some patients. Some patients require treatment beyond two years and sometimes indefinitely. PMR can also be treated with intramuscular depot methylprednisolone acetate using a regime of 120mg every three weeks for 12 weeks followed by monthly injections reduced by 20mg every 12 weeks depending on symptoms
In patients with GCA-complicating PMR, the starting dose is higher – 50mg per day (range: 4060mg per day) typically required for suppression of disease activity. For patients with visual symptoms, ophthalmology review is recommended and treatment is often initiated with higher doses (up to 1mg/kg) or intravenous formulations such as methyl prednisolone. Treatment should not be delayed while awaiting temporal artery biopsy because of the risk of blindness and corticosteroid therapy has no effect on biopsy result for up to four weeks after initiation. It is essential to minimise the adverse effects of chronic cumulative glucocorticoid use. Methotrexate, usually at a starting dosage of 10-15mg per week, is the most used glucocorticoidsparing therapy for PMR. Limited studies suggest that methotrexate at 10mg per week was associated with shorter prednisone treatment,
suggesting this approach may be useful for patients at high risk of steroid-related toxicity. While less studied than methotrexate, azathioprine 150mg daily may also be useful as adjunctive therapy. IL-6 (approved for use in GCA) plays a major role in sustaining disease activity in PMR, so IL-6 blockade has been explored as a possible treatment, with promising results. TNF blockade has been evaluated and is not recommended for managing PMR. Patients treated with corticosteroids long-term (> 7.5mg daily for over three months) should optimise their vitamin D intake, with supplementation as necessary. Supplementation should be considered for those who cannot tolerate adequate dietary calcium. Bisphosphonate therapy is recommended and approved in Australia as a preventive measure in patients at high risk of fragility fractures: osteopenia (T – score < -1.5) and patients with a history of fragility fracture. Author competing interests – nil
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Experts warn to go easy on oral corticosteroids A review warns against the risks of over-prescribing oral corticosteroids on some patients with asthma.
Dr Karl Gruber (PhD) explains The use of oral corticosteroids (OCS) in patients with asthma should be monitored more closely in order to avoid potentially serious side effects, experts have warned. It is one of the key messages of a new position paper that reviews our current knowledge on the use of OCS in asthma and the prevalence of side effects associated with overuse. The position paper, published in September in the journal Respirology, was written by experts in the field and is backed by the Thoracic Society of Australia and New Zealand. The paper makes recommendations on what doctors can do to minimise the use of OCS in asthma patients, and reduce harm associated with adverse side effects, such as weight gain, insomnia, mood disturbances and skin changes. The authors recommend doctors use evidence-based strategies to reduce the need for OCS, such as avoiding ‘salbutamol only’ treatment, ensuring patients have a good inhaler technique, treating comorbidities efficiently, and referring early for biologic drugs.
In addition, asthma education, smoking cessation, specialist and multidisciplinary review and optimised medications can also help to reduce OCS use and improve patient health.
Weight of numbers Dr John Blakey, a consultant in respiratory and sleep medicine at Sir Charles Gairdner Hospital and an author of the new paper, says that because asthma is so common there are thousands of people
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experiencing preventable harm each year. “There is a pressing need for OCS stewardship, that is to say a Goldilocks approach of using OCS when they are necessary, but taking all reasonable steps to reduce the need for their use and to minimise the cumulative dose when they are employed: not too much, not too little, but the right amount,” he said. continued on Page 67
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Experts warn to go easy on oral corticosteroids continued from Page 65 Worldwide, around 300 million people suffer from asthma, involving intermittent airflow obstruction and bronchial hyperresponsiveness. In practice, people with asthma commonly experience symptoms like wheezing, coughing, shortness of breath and chest tightness or pain. In Australia, about 11% of the general population, or about 2.7 million people, reported having asthma according to a 2017-18 survey from the Australian Bureau of Statistics. For many of those affected, OCS are the first line of treatment. “Around one in six people with asthma will have an attack this year requiring rescue treatment with oral corticosteroids. That equates to hundreds of thousands of
prescriptions for OCS annually,” Dr Blakey said.
Steroid downside While in most cases asthmaassociated symptoms can be controlled with inhaled corticosteroid medications, a significant percentage of patients experience side effects. “In recent years we have recognised that a relatively small cumulative dose of OCS (500-1000mg prednisolone) increases the chance of adverse outcomes such as diabetes, depression, heart disease and blood clots,” Dr Blakey added. According to the data reviewed in this paper, the risk of depression and anxiety is three times higher in patients with asthma requiring maintenance OCS, compared to those patients who do not take oral steroids to control their
asthma attacks. Likewise, asthma patients taking OCS seem to have an increased risk coronary heart disease, cerebrovascular disease and heart failure as well osteoporosis and fractures. The bottom line is that doctors who are treating patients with asthma should be mindful of potential side effects and consider alternative approaches. “The right treatment for the right patient from the right place. We hope this position paper will assist prescribers, but also make clear to people with asthma what the current standard of care is to give them the best chance of avoiding preventable harm from OCS,” Dr Blakey said.
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Gut-autism link weakens A team of researchers, including Professor Andrew Whitehouse from Telethon Kids Institute and the University of WA, has challenged the growing popular belief that the gut microbiome drives autism. Findings from the collaborative Autism CRC study, led by Mater Research and the University of Queensland, could put the brakes on the experimental use of microbiome-based interventions such as faecal microbiota transplants and probiotics, which some people believe may treat or minimise autistic behaviours. The researchers found changes in the gut microbiome of people on the autism spectrum appeared to be due to fussy eating, which is more common among autistic children due to sensory sensitivities or restricted and repetitive interests. The findings were published in the scientific journal Cell last month.
Researcher Chloe Yap said the team examined genetic material from stool samples of 247 children, including 99 children diagnosed with autism. “While it’s a popular idea that the microbiome affects behaviour, our findings flip that causality on its head,” Ms Yap said. Professor Whitehouse, who is Autism CRC’s research strategy director, said the findings provided clarity to an area that has been shrouded in mystery and controversy. “Families are desperately seeking new ways to support their child’s development and wellbeing, and sometimes that strong desire can lead them to diet or biological therapies that have no basis in scientific evidence,” he said.
than trying fad diets. This is a hugely important finding.” Senior investigator Dr Jake Gratten said that out of more than 600 bacterial species identified in the gut-microbiomes of study participants, only one was associated with a diagnosis of ASD. “There’s been a lot of hype around the gut microbiome in autism in recent years, driven by reports that autistic children have high rates of gut problems, but that hype has outstripped the evidence,” he said. “We are already seeing early clinical trials involving faecal microbiota transplants from non-autistic donors to autistic people, despite not actually having evidence that the microbiome drives autism. Our results suggest that these studies are premature.”
“The findings of this study provide clear evidence that we need to help support families at mealtimes rather
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LIFESTYLE
In the swim
For one Perth doctor, the black cloud of COVID lifted a little this year when she attended the world’s pinnacle sporting event.
Cathy O’Leary reports Sport and exercise medicine physician Rachel Harris could arguably be considered a product of her 1980s childhood. For as long as she can remember she was always in the water, including at Claremont UniSwim where her father Len worked as a pool attendant – one of several jobs he juggled to get through medical school as a mature-age student. Her brother was having swimming lessons and she wanted to learn too, so she started at the age of three-and-a-half and didn't stop. Len became a doctor, and later so did his daughter. But in the meantime, Rachel also developed into an elite swimmer, winning gold at the 1998 Commonwealth Games in Kuala Lumper and competing in the Sydney Olympics in 2000. This year – 21 years after Rachel went to Sydney – the synergy of swimming and medicine came the full circle when she travelled to the Tokyo Olympics as team doctor for the Australian water polo teams. It meant she was away from her family for more than six weeks, but she is aware of the “huge privilege” of attending the Olympics and being able to travel overseas when many people could not.
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Dr Rachel Harris is second from the left, with Kate Moore (Lead Physio), Bronwyn Smith (team Manager) and Bec Rippon (Assistant Coach).
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LIFESTYLE “We then faced two weeks of quarantine when we got home – and rightly so, because most people felt incredibly lucky that we were even able to go over there, and there was some moral and ethical conflicts that we were able to do that in the middle of a pandemic,” she says.
“It brought back some memories, but being in the Sydney Olympics seems like a lifetime ago,” she says. “I grew up around the swimming pool, I just loved swimming and was in State championship events by the time I was nine or 10, and by the time I got to 12, it was getting more serious and things really took off.”
“As many of our people came out of quarantine, Sydney and Melbourne were going into lockdown so there were no welcome-home parties – you came home to another nose swab and COVID test.”
Lure of sport She believes those early years helped pave the way for her interest in sport and exercise medicine. “When I came out of med school, I did my resident years at Royal Perth, and then I was looking at intensive care medicine, but as soon as I got my contract to get onto the training program, I thought what am I doing?
Although keen to get home to husband Ric Renton and their two-and-a-half-year-old daughter Poppy, Rachel enjoyed her quarantine at Howard Springs in the Northern Territory because it was a rare chance to sit and catch her breath.
“When I stepped back and thought what I really wanted to do, what filled me with passion, it was the idea of helping people to get the best out of themselves through exercise and sport, so I went down that path, and I’m really happy I did.” Rachel took on the role of water polo chief medical officer in 2017, which meant she had a ticket to the Olympics with the men’s and the women’s teams. She also became CMO for Paralympics Australia in 2019. Pre-COVID, she was meant to go to Tokyo for both the Olympic and Paralympic Games, but with all the quarantine requirements it was not feasible for her to attend both, as she would have been away for 14 weeks. She still helped with the preparation for the Paralympics team, and anxiously watched their performances from home. “I’m always in awe of the incredible resilience of all the Paralympic athletes, and for many of them it’s an avenue to realise their uniqueness rather than being about disability, and it’s about how able they are to do so many things,” Rachel says. “For some of them, being involved in sport is an avenue to understand their independence and where they fit in the world, it’s so wonderful and liberating for them. “And for the family and support people of those who have some form of impairment and face many challenges, to see them travel the world and live out their dreams is incredible.”
Focus on women
Rachel with husband Ric Renton and daugther Poppy.
Being a team doctor in Tokyo was “next-level difficult” because of COVID, but one bonus was having only minimal illness because there were strict hygiene protocols and constant mask-wearing.
Olympic challenge “It was a very different Games, and as Australians we lived as a bubble within a bubble. We didn’t go out into the community,” Rachel says. “While there was dubbed crowd noise on TV, when you went out into the stadium there was only the sound of 20 hands clapping. For players in some sports, it would have been very different without the roar of the crowd, and you were able to hear your teammates and yourself breathing, and the opposition saying things. “And COVID was never very far from your mind because we were doing daily saliva tests and health reporting and masks were everywhere, and there was limited interaction with other sports.” Rachel and the rest of the team had to leave Tokyo within 48 hours of competing, whereas when she competed in Sydney, she was able to attend every day of the Games.
MEDICAL FORUM | GENER AL MEDICINE
Back in Perth, she works part-time at Perth Orthopaedics as a sports injury physician and is a project lead for an Australian Institute of Sport initiative to improve education and resourcing for female athletes. “I think many people believe that athletes are so in tune with their bodies, but research from Griffin University a couple of years back asked almost 200 elite athletes if they could identify female sex hormones, and only 14% were able to identify oestrogen and progesterone,” she says. “So, we have a long way to go to educate that unique female issues such as pain with menstrual cycles or breast pain are real things. “It’s things like making sure you have the right bra support, and that’s really important not just at an elite level but also in community sports. “There are also non-health related things in terms of performance – because up until recently female cricketers were wearing men’s shoes because the companies hadn’t made shoes for women, despite their feet generally being narrower. There’s still a lot we can do.” And as Rachel reflects on what she has been able to achieve in 2021 – a year that will not be remembered as the most productive time for many people – she considers herself “incredibly lucky”.
DECEMBER 2021 | 71
The wait has been worth it Sister singing duo Vika and Linda Bull have delivered a stunning album of original songs written by loved Australian tunesmiths and rounded out by joyful vocal surprises, says Ara Jansen.
You’d be forgiven for thinking there must be a mistake when Vika Bull says it has been 19 years since she and her sister Linda released an album of original songs. “You can’t believe it? I can’t believe it,” says Vika Bull with a laugh. “It’s not like we haven’t been busy for the past two decades.” Known to Australian music lovers simply as Vika and Linda, the sisters have been a treasured part of Australian music for well over 20 years. After three classic albums with The Black Sorrows, they released their platinum selftitled debut in 1994 and since then have sung on No. 1 albums by Paul Kelly, Kasey Chambers and John Farnham and performed gigs for the Dalai Lama, Nelson Mandela and the King of Tonga. Across their career they’ve recorded 10 other albums, comprising live collections, a gospel album that came out of lockdown (which hit No. 2 on the ARIA charts last year), a chart-topping greatest hits package and collections of covers. The kernel of their latest album, The Wait, began in 2017. After several false starts the sisters finally started recording in April this year racing through a dozen songs in a furious eight days. 72 | DECEMBER 2021
Linda asked musical friends who know the pair well to write the songs. The result is a robust collection from a cavalcade of the country’s most-loved and talented songwriting royalty including Paul Kelly, Don Walker, Chris Cheney, Kasey Chambers, Bernard Fanning, Matt Walker, Neil Murray and Mick Thomas. For Vika, who has always found studios arduous, The Wait was a joy to make and the most fun she’s had recording. “We worked very quickly,” she said. “We knew anything could happen so we got a fantastic band together, got the guns out and worked hard,” she says. “We got about 70 songs and a lot of thought went into which ones we chose – do we like the melody, can we sing this song, can we relate to it. We were touched, moved and humbled by the fact that these writers wanted to give us their songs. “Songwriting is not easy and people put their heart and themselves into it. We didn’t want to stuff that up.” While The Wait features two strong women, distinctive voices and unique harmonies, there are also some unexpected vocal
performances. The most notable being the sisters swapping roles, as Vika is “known as a belter” while her sister the balladeer. Linda rocks out in the dirty Since You’re Gone while Bernard Fanning’s aching Like a Landslide lets Vika explore a different side to her voice. “We’ve grown up and changed as singers, so our sound had to change too. We didn’t want to be typical Vika and Linda so we stretched ourselves. I don’t normally sing soft and tender so this album shows another side to my voice. It was challenging but enjoyable. I don’t know that a lot of people know that Linda and I can sing like this, so now we get to show that off.” The album’s title is not lost on Vika either. The Wait is not an exhausted sigh of a long time coming but a declaration of triumph. Suffice to say, it has been well worth the wait.
The Wait is out now. Vika and Linda perform at Her Majesty’s Theatre on June 18, 2022. Tickets from www.bandsintown.com
MEDICAL FORUM | GENER AL MEDICINE
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MUSIC
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WINE REVIEW
Sandalford’s success – history and innovation The Sandalford Swan Valley vineyard is one of WA’s oldest, having been established in 1840 by John Septimus Roe, the first surveyor-general of the colony. The planting of these vines, brought from South Africa, was the dawn of the Swan Valley wine industry. Over the years the property has had a varied history until it was purchased by Perth businessman Peter Prendiville some 20 years ago. A significant injection of capital has seen a revamping of the Swan Valley property with improved viticulture and upgrading of the winery, tasting area and restaurant. Much of the premium fruit now comes from a large property in Wilyabrup, purchased in 1970, which has also enjoyed continuing modernisation and improvement. The combined vineyards now total over 100ha. The recent appointment of Ross Pamment, previously chief winemaker at Houghtons, will assure the continued high quality we have enjoyed in Sandalford wines.
Review by Dr Craig Drummond Master of Wine
Sandalford 1840 Swan Valley Chenin Blanc 2020 (RRP, $30)
Sandalford Margaret River Estate Reserve 2018 Shiraz (RRP, $35)
Sandalford Margaret River Estate Reserve 2019 Chardonnay (RRP, $35)
A variety I have always admired from the Swan Valley, together with Verdelho and Grenache. It was a ‘near perfect’ 2020 vintage. If you are expecting the light tropical fruit style often seen in Chenin, you won’t find it in this wine. A much more complex style, with a portion of the blend fermented in French oak, making it a more robust and foodfriendly wine. Aromas of quince and lanolin emerge after a little breathing – needed before drinking to dissipate the slightly reductive ‘sulphitic burnt matchstick’ edge which results from modern reductive winemaking. Shows the firm acidity of the Chenin Blanc variety which gives these wines from ‘the valley’ their amazing ability to age. Will develop honeysuckle and toasty characters over 6-8 years.
A great wine from that great 2018 vintage. The youthful garnet colour suggests a wine with a long future. Nose is exuberant, with blackberry, cinnamon spice and oaky characters coming through. Palate has great concentration. Flavours of blackcurrant, mulberry, black pepper. Fine-grained grippy tannins, integrating oak, fine linear acidity. Shows great balance and ‘line’ with lingering flavours. A 12-15 year wine.
Attractive bright mid-gold colour. On the nose, nectarine, melon and cashew. Evident oak will further integrate. The palate shows great textural mouth-feel. The cooler 2019 vintage has resulted in more restrained fruit, higher acid, and a lower than usual alcohol level (12.5%) for Chardonnay. White peach and nectarine flavours, with a touch of spice. A Chardonnay very much in that great Margaret River mould. Drinking well but the acidity will carry it for a few more years yet.
MEDICAL FORUM | GENER AL MEDICINE
'S EWER REVI
PICK
Sandalford 1840 Swan Valley Grenache 2021 (RRP, $30)
This wine excites me and is my favoured wine of this tasting. It is so varietally expressive from the typical beetroot red colour, the fresh fragrant confectioned aromas of musk and pear drops and scented red fruit, to the fruit-driven palate of raspberry and redcurrants. The high alcohol (typical of Grenache at 14.5%) gives warmth in the mouth. A wine optimal now, but can be enjoyed over a couple of years. Worth giving a short time in the fridge for summer drinking.
DECEMBER 2021 | 73
Wrapping gets a good rap An inexpensive present can be elevated to be so much more when it’s wrapped with a little bit of thought. With the festive season upon us, Ara Jansen offers ideas to make your presents look fabulous.
There’s an art to a good wrapping. There’s also an art to a good rap, but we’re leaving the rapping to a merry relative at the Christmas table and instead exploring impressive and easy ways to wrap gifts. Ultimately, you can use these ideas year-round but for Christmas consider a festive or summer theme. My Poppet craft blogger Cintia Gonzalez loves to make things. She’s also an expert at using everything she can find, or has on hand to wrap a present, with a particular flair for recycling and upcycling. A few strategic cuts and she can artfully turn a cereal box into a wrapper and a soft drink bottle into a gift box. When it comes to wrapping and gifts, Cintia haunts thrift, vintage and second-hand stores for materials she can fashion into a cover for a present – whether it’s an old biscuit tin, tea towel, foreign language newspaper or a flour bag. At home she’ll use the tissue paper 74 | DECEMBER 2021
which wrapped a purchase or cover up the logo on a brand bag with stickers or magazine cut-outs. “It’s always fun to give gifts wrapped in a different way,” says Cintia. “I’m thrifty so I also like the idea of not having to spend money on it. I have a wrapping drawer and that has everything recycled, from a present we received, to tissue and pieces of fabric I use to make bags. “It’s nice to encourage people to reuse things like fabric or a scarf, so someone else can get some joy from it, especially if it’s not a design you like. The key is to think ahead a bit and collect a few things.” Fun and considered wrapping can elevate an average or inexpensive present to impressive. Instead of a bottle bag, wrap in foil (without tape) and attach greenery from the garden or a hang an ornament. Foil is perfect if you find yourself without wrapping paper on hand. Emergency options include newspaper, magazines, baking
paper, brown paper and bags, artwork, colouring books, scarves, maps, an old street directory, boxes and coloured or plain copy paper. Wrapping something in a tea towel and securing it with a ribbon gives the receiver two gifts. The Japanese art of furoshiki shows you how to wrap in cloth. It’s ideal for shapes like books and smaller boxes but can be used for a myriad of shapes. It requires a square piece of cloth with a reversible pattern. For something awkwardly shaped like a ball, rather than wrangling paper and tape, drop it in a pillowcase, drawstring or calico bag. When it comes to ribbon or ties there’s traditional ribbon or opt for yarn, jute, kitchen string, raffia, rope, fabric strips, a scarf, pipe cleaners, hair ribbons or anything on hand. Cintia says wrapping is also an opportunity for crafts with your kids. Invite them to draw, paint, potato stamp or glitter on the wrapping for a friend’s present. They’ll feel like they’ve contributed to a bought item – and they love the mystery of wrapping!
www.mypoppet.com.au
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CHRISTMAS TIPS
Built to care Here’s to 2022, we wish you and your loved ones a happy, safe and prosperous festive season.
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With the end of 2021 fast approaching, we’re all feeling ready for a fresh start. At BOQ Specialist, we want to ensure that you and your practice finish the year with your best foot forward and are ready to kickstart 2022. That’s why, we’re offering fixed interest rates from 2.49% p.a. for four years and 2.59% p.a. for five years on new equipment and fit-out purchases financed with us before 31 January 2022.*^ With Government support and rates as low as these, there’s never been a better time to upgrade your equipment or fit-out and set your practice up for the new year ahead. Visit us at boqspecialist.com.au/eoy or speak to your local finance specialist on 1300 160 160.
BOQ Specialist. The bank for medical professionals
*Subject to credit approval. The issuer of these products and services is BOQ Specialist - a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL and Australian Credit Licence no. 244616 (“BOQ Specialist”). Terms and conditions, fees and charges and lending and eligibility criteria apply. Any information is of a general nature only. We have not taken into account your objectives, financial situation, or needs when preparing it. Before acting on this information you should consider if it is appropriate for your situation. You should obtain and consider the relevant terms and conditions from boqspecialist.com.au before making any decision about whether to acquire the product. BOQ Specialist is not offering financial, tax or legal advice. You should obtain independent financial, tax and legal advice as appropriate. We reserve the right to cease offering these products at any time without notice. ^Equipment or fit-out purchase must be financed via a chattel mortgage with fixed terms equal to or greater than 48 months. The above fixed interest rates are only available for loans under the SME Recovery Loan Scheme. For loans outside of the Scheme, an additional 0.30% above the above fixed interest rates applies. Signed loan documentation must be received by 31 December 2021, with settlement completed by 31 January 2022. Not available for leases, rental purchases, internal refinances, escrows, residual/ balloon refinances, residential or commercial property and goodwill loans. A full documentation fee of $495 applies. This offer expires on 31 January 2022 and is subject to change without notice at the discretion of BOQ Specialist. This offer cannot be taken in conjunction with or in addition to any other packages, negotiated interest rates or special offers. Information is current as at 1 November 2021.