Medical Forum – February 2022 – Public Edition

The write doctor

Innovations & Trends | Diabetes, insulin pumps, fasting, safe theatres, rTMS, pancreatic cancer MAJOR PARTNERS

February 2022 www.mforum.com.au

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

Be prepared… and flexible

An edition focused on innovations seems apt at this time, as our State prepares to pivot and adapt to the first real presence of the virus that has kept the world on its toes for two years.

From this month, we will have to be as flexible as possible to stem the flow, while accepting life will be very different. What we knew about COVID yesterday could well change today.

It is risky even writing this editorial that will not be read until a few weeks’ time.

“We can’t predict what will happen in the next six months let alone next week... I wake up in the morning to news that changes what I thought the night before.”

An Australian infectious disease specialist admitted late last year that it was hard to predict what COVID looks like in the future, with much of the advice based on the best guestimates at the time.

“We can’t predict what will happen in the next six months let alone next week,” he said. “I wake up in the morning to news that changes what I thought the night before.”

And Melbourne public health professor Priscilla Robinson recently began an analysis of the current state of play with this: “I am tempted to say I just give up now.”

Thankfully she hasn’t given up, but perhaps we shouldn’t be too judgmental of health experts – and dare I say even politicians – with “gotcha moments” accusing them of constantly changing the advice and rules.

Putting COVID aside for a while – yes, life goes on – this month we look at an issue that seems to confuse patients and doctors alike – is type 2 diabetes a “forever” condition or can it be stopped?

And read the story behind our cover photo – a Perth surgeon and art collector whose first dab at novel-writing is – wait for it – a mystery involving a Perth surgeon turned art collector. Is that art imitating life?

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MEDICAL FORUM | INNOVATIONS & TRENDS

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CONTENTS | FEBRUARY 2022 – INNOVATIONS & TRENDS

Inside this issue 12

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16 20

FEATURES

IN THE NEWS

12 The write doctor

1

– Dr Michael Levitt

16 Winding back the diabetes clock 20 Dieting in the fast lane 58 Hockey is the bee’s knees

Editorial: Be prepared…and flexible – Cathy O’Leary

4 News & views 6 In brief 10 Bureaucracy v clinical frontline?

– Dr David Prentice

LIFESTYLE 60 Festival of Perth 61 Wine Review: Fermoy Estate – Dr Craig Drummond

11

Letter to the editor – palliative care – Dr John Hayes

24 26 29 31 41

Wearing your heart on your sleeve COVID 2.2 – how things will change Curtin Medical School graduates Bright sparks in health Some things change – others do not – Dr Joe Kosterich

ARE YOU THE NEXT WINE WINNER? The lucky winner of the December doctors dozen from Brown Hill Estate is Dr Luciano Marino from Forrestfield Medical Centre, pictured here. This month we have wines from Fermoy Estate, which Dr Craig Drummond explains in his review on page 61 have really come of age. To enter go the competitions tab at www.mforum.com.au or enter via our newsletter sent to your inbox each Friday.

CONNECT WITH US /medicalforumwa

/medical-forum-wa-magazine

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info@mforum.com.au

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MEDICAL FORUM | INNOVATIONS & TRENDS

CONTENTS

PUBLISHERS

Clinicals

Fonda Grapsas – Director Tony Jones – Director tonyj@mforum.com.au

ADVERTISING Advertising Manager Andrew Bowyer 0424 883 071 andrew@mforum.com.au

EDITORIAL TEAM

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Importance of genetic counselling Bhavya Vora

Cognitive aids in anaesthetic crisis management Dr David Borshoff

Pancreatic Cancer: Challenges and emerging strategies Dr Ian F. Yusoff & Dr Samarth Rao

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rTMS opens a new field in psychiatry Dr Davinder Hans

Insulin delivery systems for type 1 diabetes Dr Mary Abraham

Broome nacre’s orthopaedic use Prof Minghao Zheng

Real-time in vivo endomicroscopy Prof Camile S. Farah

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 Andrew Bowyer 08 9203 5222 andrew@mforum.com.au

GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au

CONTACT MEDICAL FORUM

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Rethinking dairy intake Prof Therese O’Sullivan & Analise Nicholl

Familial hypercholesterolaemia Dr Tom Brett

Guest Columns

Suite 3/8 Howlett Street, North Perth WA 6006 Phone: 08 9203 5222 Fax: 08 6154 6488 Email: info@mforum.com.au www.mforum.com.au

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From student to doctor Dr Christopher Chi

Docs’ battle for native forests Dr Bill Castleden

Climate change and doctors Dr George Crisp

Working for system sustainability Goh Khoon Seng

MAJOR PARTNERS

MEDICAL FORUM | INNOVATIONS & TRENDS

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When something’s not right Perth Children’s Hospital emergency department now features three pink phones that parents can use when they feel their children are not getting the medical attention they deserve.

Aishwarya Aswath

The phones are a part of the Aishwarya’s Care Call system, which was created with the blessing of the parents of Aishwarya Aswath, who died at PCH in April last year.

A report into the incident found Aishwarya’s parents Aswath Chavittupara and Prasitha Sasidharan tried to get the attention of clerks, nurses and doctors in the hospital on five separate occasions, pleading for them to look at their daughter who had a temperature of 38.8C. Aishwarya’s Care Call is in place at all WA public hospitals, allowing a patient, carer or family member to ask for help if they are worried by changes in someone’s medical condition.

Signs throughout hospitals outline the escalation process, including how to make a phone call if the matter is urgent.

VAD six months on A forum to reflect on the first six months of voluntary assisted dying laws in WA will be held on February 10 from 8.45am-12pm. People can attend in person in the G.1 Lecture Theatre at Fiona Stanley Hospital or join the forum online.

It will include presentations from the Voluntary Assisted Dying Board, WA’s VAD State-wide Care Navigator Service, the VAD Statewide Pharmacy Service and the VAD Community of Practice.

Free registration is through eventbrite.com.au.

Outside the square The 2021 WA Innovator of the Year awards recognised big advances in medicine, with Vision Pharma being named the overall winner. Vision Pharma, a joint venture between the Lions Eye Institute and PYC Therapeutics, was recognised for its innovative VP-001 to treat retinal diseases. Spearheading much of the work is Dr Fred Chen, who has dedicated his career to solving the mystery behind inherited retinal diseases, the leading cause of youth blindness.

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The Rio Tinto Emerging Innovation award went to Navier Medical for ‘Apricot’, its advanced coronary artery assessment. The Business News Great for the State Platinum Award went to VeinTech for its VeinWave technology.

The Wesfarmers Wellbeing Platinum Award was won by VitalTrace for its novel device for monitoring babies during childbirth.

Debt plan on the money WA’s leading GP training organisation has welcomed a Federal Government scheme to wipe the university debt of doctors and nurses who work in rural, regional and remote areas from this year.

WA General Practice Educating and Training chief executive officer Professor Janice Bell said the State was investing in training and placing GPs where they were most needed, and this incentive could make the difference in where they chose to work.

“This could prompt a surge of interest from trainee doctors — and we would welcome the opportunity to talk to any who are considering making general practice their specialty,” she said.

“Just one GP in a small community makes a massive difference.”

WAGPET placed 170 trainee doctors rurally in the last year – the biggest rural placement of the past five years – and this has increased to 177 for 2022.

A diabetes double WA diabetes charity Diabetes Research WA is funding two new projects, including a pilot study into the use of oral insulin in type 1 diabetes that could be a gamechanger for those with the chronic autoimmune condition.

Dr Mary Abraham, from the Telethon Kids Institute and Perth Children’s Hospital, has secured $60,000 from the 2022 diabetes research grants program to do a 12week study to see if oral insulin can be used alongside injected insulin.

Another project has also received $60,000 to investigate a new way to tackle disease-inducing chronic inflammation linked to type 2 diabetes.

UWA’s Professor Kevin Pfleger, Dr Elizabeth Johnstone and the continued on Page 6

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NEWS & VIEWS

RECOGNISED FOR

INNOVATION

INNOVATION IS ABOUT LEADING NOT FOLLOWING Perth Radiological Clinic has been chosen by world leading equipment manufacturers Philips Healthcare and GE Healthcare to help them create the next generation of medical imaging technology. Recognition of excellence is one of the hallmarks of a leader.

perthradclinic.com.au

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Dr Sanjay Jeganathan is president of the Royal Australian and New Zealand College of Radiologists for the next two years. He works at Perth Radiological Clinic and Fiona Stanley Hospital and holds an adjunct appointment at Curtin Medical School.

In moves at UWA, Professor Anna Nowak, Pro ViceChancellor (Health and Medical Research) is Acting Deputy Vice-Chancellor (Research) for the first six months of this year. She is on leave from her role as a medical oncologist at Sir Charles Gairdner Hospital.

NEWS & VIEWS Pandemic ups and downs

continued from Page 4 molecular endocrinology and pharmacology laboratory team at the Harry Perkins Institute are working with Monash University colleagues to find ways to block a newly-discovered diabetes pathway.

The group has found that key proteins on the surface of cells involved in chronic inflammation – called immunoglobulin-like cell adhesion molecules – are turned on by the process of transactivation, when other G protein-coupled receptor molecules on the cell surface are switched on. They hope to develop smart inhibitors of this pathway to keep inflammation under control and prevent type 2 diabetes complications such as atherosclerosis and kidney disease.

Their work will use bioluminescence resonance energy transfer technology, of which Professor Pfleger’s laboratory is a world-leader.

A national study of Australians’ responses to COVID-19 public health measures has found strong acceptance for such protective moves as physical distancing, hand hygiene and even lockdowns.

Flinders University researchers, as part of a team of regional health experts in Western Australia, the Northern Territory, Queensland, Victoria and South Australia, analysed feedback from 90 adult participants about their perceptions of the large-scale interventions rolled out during the first wave of the pandemic in 2020.

Lead author Associate Professor Narelle Campbell said that in spite of negative impacts of public health directives, such as mental wellbeing and restrictions of movement connected to lockdowns, people continued on Page 8

HBF has bought a 10% interest in dental chain Pacific Smiles for $41.9 million.

Jupiter Health and Medical Services has struck a deal with Mount Hospital that will see its orthopaedic, cardiology, bariatric and vascular specialists consult directly at Jupiter’s five GP clinics in Perth.

Associate Professor Alison Parr is St John of God Murdoch’s Doctor of the Year for 2021, recognised for her efforts in preparing for COVID-19 and Voluntary Assisted Dying legislation.

Professor Kevin Pfleger, who heads molecular endocrinology and pharmacology at the Harry Perkins Institute, has become president of the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists.

Vaccine trial hot-spot Hollywood Private Hospital has become the top recruiting site for a global clinical trial of a melanoma vaccine.

The hospital’s Professor Adnan Khattak, above, is the world’s top recruiter for the Moderna trial, which is investigating personalised mRNA cancer vaccines. Moderna is looking at whether mRNA technology is effective in harnessing the body’s immune system to identify and kill cancer cells.

Using cloud-based computing and a specifically developed algorithm, researchers hope to create individualised cancer vaccines to deliver customtailored medicines for each patient.

They will use a personalised mRNA cancer vaccine in combination with an immune inhibitor and compare it with treatment using the immune inhibitor alone.

Affinity Clinical Research, which is partnering with Prof Khattak, had enrolled 17 patients into the study by the end of last year.

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MEDICAL FORUM | INNOVATIONS & TRENDS

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IN BRIEF

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MAJOR PARTNER

Importance of genetic counselling Genetic counselling aims to help individuals, couples and families understand and adapt to the medical, psychological, familial and reproductive implications of the genetic contribution to specific health conditions.

Genetic counsellors have specialised education in genetics and counselling, assisting patients to make informed decisions about genetic testing, help them interpret test results and communicate the implications of the results not only for the patient but their family as well.

They also work with doctors to help make appropriate recommendations for ongoing surveillance and management of an increased cancer risk for their patients.

Genetic counselling involves:

• Interpretation of the patient’s personal and family history of cancer to assess the chance of disease occurrence or recurrence.

• Education on natural history of the condition, inheritance pattern, options for genetic testing, management, prevention, and support resources.

• Counselling to promote informed choices in view of risk assessment, family goals, ethical and religious values.

• Support to encourage the best possible adjustment to the cancer diagnosis in the patient or an affected family member.

Often patients ask, “Why do I need counselling? Can I not just have the test?”

While it is true that genetic counsellors are trained, these skills are most often used in the collection and provision of information. Some of the topics we cover include providing an overview of the genetic testing process and considering the outcomes in the context of an individual and their family.

Bhavya Vora Bhavya Vora is an Associate Genetic Counsellor with extensive national and international experience in familial cancer genetics. A double master’s degree in medical genetics and genetic counselling enables him to discuss medical and psychosocial aspects of genetic testing. He creates a supportive environment working in partnership with medical professionals and his clients.

Genetic testing does not always provide a yes-or-no/black-orwhite answer, and it is important that patients understand these limitations as well as other potential implications prior to proceeding.

The session provides an opportunity for the patient to raise concerns, ask questions, plan and prepare for the result, and organise relevant management options.

The process is a two-way flow of information aimed at promoting informed decision-making. It helps genetic counsellors to tailor the testing and information for the individual and their family. In addition, genetic counsellors assist with family communication and provide links for valuable support services such as clinical psychology or cancer support groups.

Cancer genetic testing could be considered if:

• An individual is diagnosed with cancer at a young age • There is a known pathogenic variant identified in the family • There is a family history of cancer and no living affected individual is available or interested in genetic testing.

Genetic counselling and testing options for familial cancer conditions are now accessible through cancergc. com.au in association with Breast Cancer Research Centre - WA (BCRC-WA) and Perth Breast Cancer Institute (PBCI). The genetic counsellor at cancergc.com.au works

closely with the multidisciplinary team at the PBCI to provide an excellent patient-centred care.

This specialist service is focused on offering easy access to clarify whether an inherited gene fault is the cause of cancers that have occurred in an individual or their family. Genetic testing information may change a treatment plan or help in making surgical management decisions. It can also help at-risk family members to understand and adapt to the implications of such conditions.

We offer personalised information in a non-judgmental, non-directive manner, promoting patient autonomy to assist making an informed decision. The service is dedicated to offer an appointment to every patient who is referred, with minimum wait period and quick turnaround time for the genetic test results.

It is easy to make the referral with options including:

• Healthlink ID: breastci • Through the website: https://cancergc.com.au/referrals • Fax: 6500 5574 The service also accepts selfreferrals from the patients via email: reception@bcrc-wa.com.au or phone call: 6500 5576.

PBCI Breast Clinic Suite 404, Level 4, Hollywood Consulting Centre 91 Monash Ave, Nedlands, WA 6009 Healthlink EDI: breastci Telephone: 6500 5576 Fax: 6500 5574 Email: reception@bcrc-wa.com.au www.bcrc-wa.com.au MEDICAL FORUM | INNOVATIONS & TRENDS

FEBRUARY 2022 | 7

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NEWS & VIEWS

continued from Page 6 recognised the pandemic’s silver linings such as safety and security, community resilience and the opportunity to reset priorities.

But a separate study by the Bankwest Curtin Economics Centre found the pandemic has significantly increased loneliness among Australians, with adverse health outcomes costing up to $2.7 billion per year.

Young people, particularly women, have been hardest hit, resulting in more risk-taking behaviours due to mental, physical health decline.

However, the report did find that public trust in government had been boosted because of COVID-19.

GP kudos The Royal Australian College of General Practitioners’ national award winner for community project of the year was picked up by Broome’s Dr Khean Shang Wong for his work treating parasitic worms in the Kimberley region.

Dr Wong said he was proud to receive the award for a project which had directly contributed to healthcare improvement and positively impacted the local community.

“Parasitic worms may not be a popular topic, but it is a serious health issue in the Kimberley region, and anyone can get it,” he said.

“I recognised part of the problem where I work was a lack of community awareness. There are simple steps people can take in terms of prevention and treatment, so I put together posters to help raise awareness across the region, as well as clear guidelines for managing parasites, which have been useful for patients.”

What’s the biggest threat?

Medical colleges across Australia and New Zealand argue that climate change is the biggest current threat to the future of the healthcare system and is calling on the Federal Government to commit to stronger 2030 targets.

The call came as the Royal Australasian College of Physicians released a report by the Monash Sustainable Development Institute

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Stroke of luck, for some WA Health’s expanded State-wide telestroke service is now in full swing, providing access to consultant neurologists by phone as well as real-time access to integrated communication and image viewing technology.

Phase one of the $9.7 million expansion includes a State-wide stroke consultant roster operating Monday to Friday from 8am to 6pm and a single point of entry for suspected acute stroke and transient ischemic attack patients who present across the health system.

It allows doctors in rural, remote and outer metropolitan areas to remotely transfer CT images, data, documentation and visual diagnoses of patients to a dedicated stroke consultant.

More than 30 stroke patients across WA had life-saving care through specialist stroke consultant advice in the first month of the service’s expansion last year.

which paints a dire picture of the future of the Australian healthcare system under unmitigated impacts of climate change.

The report includes a model of the cost of bushfires of varying magnitudes modelled between 2021 and 2030 inclusive. The analysis predicted the loss of 1480 lives, equating to 4024 years of life; healthcare costs of $69 million; and a $10 billion impact on gross domestic product.

The RACP report has been endorsed by the Royal Australian College of General Practitioners, the Royal Australasian College of Surgeons, the Royal Australian and New Zealand College of Psychiatrists, the Australian and New Zealand College of Anaesthetists and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Other signatories are the Australasian College for Emergency Medicine, the College of Intensive Care Medicine, the Royal Australian and New Zealand College of

Ophthalmologists, and the Australasian College of Sports and Exercise Physicians.

Vale Dr Katie Thorne Bunbury-based doctor Katie Thorne, who died last year at the age of 74 after a battle with ovarian cancer, is being remembered by many for her keen championing of women’s health, particularly the management of menopause and sexual dysfunction.

When she joined the Keough Institute for Medical Research in the late 1990s, she travelled from Bunbury to Perth every fortnight to run a women’s health clinic that became known as “Katie Day”.

In 2014, she was awarded a Rural Health West doctors’ service award.

MEDICAL FORUM | INNOVATIONS & TRENDS

GP Education Calendar Delivered by many of the State’s leading specialists, our GP education events are designed to help GPs stay up-to-date with the latest medical and surgical information.

All events are accredited by the Royal Australian College of General Practioners.

Designed for your convenience For your convenience, you can attend the events in-person or online, via webinar.

This attendance method will allow you to engage directly with event presenters, even if physical distancing requirements prevent in-person attendance.

You can also access the presentations after they have been delivered at a time that is suitable for you via our on-demand webinars, while still accessing CPD points.

To watch our on-demand webinars, please visit bit.ly/subi-gp-webinars

Upcoming events For details about upcoming GP education events, please visit sjog.org.au/subiacoGPs To sign up to our GP database and receive the latest event information, please contact our hospital’s Business Development Team via subiaco.cpd@sjog.org.au or (08) 6462 9689.

For more information subiaco.cpd@sjog.org.au MEDICAL FORUM | INNOVATIONS & TRENDS

(08) 6462 9689

sjog.org.au/subiacoGPs FEBRUARY 2022 | 9

Bureaucracy v clinical frontline?

Former Royal Perth Hospital doctor David Prentice details what he believes has gone wrong in health bureaucracy.

The problem with clinical governance in our WA public health system was brought to our attention by the loss of a child at Perth Children’s Hospital in April last year. It then became apparent that this case was the tip of the iceberg of critical incidents in our public hospitals.

We were subsequently informed that the then Minister for Health and PCH Chief Executive were to retain their well-paid positions to fix the problems, that they were indirectly responsible for causing.

The only person to lose their job was the Chair of the Child and Adolescent Health Service Board, who was a million miles away from the coalface.

We were told that there was a shortage of clinical staff in the emergency department that night in April at PCH. There is in fact a

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shortage of clinical staff in most of our state’s public hospitals.

Over the past two financial years, health department administration staff numbers increased by 32%, while frontline clinical staff numbers increased by 12.5%.

This was documented in Hansard August 3, 2021, by the Opposition spokesperson for Health.

The increased administration staff number correlates with the establishment of the Division of Clinical Excellence within the Health Department. This is newly housed in the old GPO Perth in Forrest Place, at significant cost. It is

apparently occupied by about 100 administrative staff and is relatively inaccessible to frontline hospital workers, so a true ivory tower.

If you do an internet search of the health department, there is a single web page which tells you that the Clinical Excellence division exists.

This web page lists six offices, that’s it. There are no contact details.

If you click on the link for Office of the Assistant Director General, it lists seven functions of this office, but again there are no contact details. The seven functions listed are essentially the functions of every health department on the planet.

So why call it the Division of Clinical Excellence and house it separately to the health department? Why is this Division of Clinical Excellence secretive and inaccessible?

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OPINION

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OPINION It appears that this office has no direct interaction with the Eastern Metropolitan Health Service Board, which is responsible for the governance of Royal Perth Hospital, where I worked.

This has reduced senior medical expertise, with a loss of patient care for complex cases.

Heads of department, often junior and with little experience at RPH, are installed and given a large financial bonus to implement bureaucratic-driven protocol, however ludicrous this may be from a patient care perspective. Again, EMHSB governance has been missing in action.

The Eastern Metropolitan Health Service Board is “ultimately responsible and accountable for the safety and quality performance of their organisation” according to Clinical Governance Framework October 2019 at health.wa.gov.au.

RPH is part of this organisation. I left RPH under duress a couple of years ago after 40 years of service, when the administration changed my service delivery at the stroke of a pen with no discussion. This adversely affected patient care.

There was no avenue of appeal for my concerns over patient care, when safety and quality performance (which they are responsible for) was at stake.

According to Clinical Governance Framework 2019, the EMHSB supposedly “are visible, engaged and accessible to staff as part of a strong, authentic leadership model.”

They are not. The old RPH Hospital Board was visible and engaged.

As I experienced, hospital administration interaction with frontline clinical staff is often adversarial. It wasn’t always like this.

Up until the mid-1990s, each hospital had a board which was based in the hospital framework.

This would include two or three senior medical consultants who worked in the hospital which they governed, along with members of medical administration and nonmedical professionals from outside the hospital.

Its structure meant that it was collaborative rather than adversarial when enabling patient care. It was visible, engaged and accessible to staff as part of a strong, authentic leadership model and frontline workers like me appreciated this.

At the same time as our public hospitals have been running short of frontline staff, 10 other senior colleagues have left RPH under duress over the past few years.

The loss of a child at PCH in April reflects systemic failure at multiple levels in our public health system.

These systemic failures must be addressed for Western Australian health outcomes to improve.

Employing a large number of administration staff at a secret location in 2019 and calling it Clinical Excellence did not prevent the April 2021 adverse event.

Employing frontline clinical staff rather than administration staff, communicating with them collaboratively and fairly as human beings with governance structures that are in fact “visible, engaged and accessible to staff as part of a strong, authentic leadership model,” just might have.

ED: Dr Prentice is a GP and stroke specialist. The WA Health Department was contacted for comment but declined.

LETTER TO THE EDITOR

A not-so-happy ending Palliative medicine specialist Dr Derek Eng and Louise Angus made it very clear that VAD is not palliative care (Medical Forum, Nov 2021).

Of the 11,000 doctors in WA, only 29 have trained as VAD practitioners. This means that 99.8% of doctors will not be ending patient’s lives.

With an estimated 633 applications over a 12-month period, the Health Department is going to be very busy processing applications. When the VAD Bill was before Parliament, we were told that there would only be around 50 VAD cases annually.

Our new Health Minister Amber-Jade Sanderson presided over the End-of-Life Choices Select Committee where seven of the eight members supported euthanasia from the outset. In brief, I believe the inquiry was stacked and was always going to support VAD. There was never any criticism of this political chicanery from AMA (WA).

MEDICAL FORUM | INNOVATIONS & TRENDS

The Palliative Medicine Specialist Group strongly opposed VAD, however The West Australian refused to publish their opinion piece until after the VAD Bill had passed the Lower House. They received no support when they complained to the AMA. Seven West Media meanwhile conducted an extremely powerful pro-VAD campaign and no one in the AMA leadership was prepared to voice policy opposing VAD. In short, there was a catastrophic failure of leadership.

The VAD laws will be reviewed in 2024, and most likely extended allowing advance euthanasia requests for early dementia patients. Canada has legalised assisted dying for the mentally ill, so expect that to be on the agenda as well.

If any doctor is unhappy with what has happened, blame the AMA. Dr John Hayes, Palliative Care WA member

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CLOSE-UP

First-time novelist Dr Michael Levitt is passionate about two things – art and helping people with itchy bottoms. He explains why to Ara Jansen.

If you ask Dr Michael Levitt why he became a colorectal surgeon he laughingly suggests it would take years of therapy to get to the bottom of that question.

The simplest answer might well be that his late father was a general and colorectal surgeon and both his brothers are doctors.

When Michael specialised in general surgery, it was expected that you would follow that training with some sort of sub-specialty training. That usually included a stint overseas, most often in England, which is what he did.

The Colchester hospital, where he landed, was a haunt for Australian surgeons and he followed that year in East Anglia with another 18 months in London. There he worked with surgeons who specialised in colorectal surgery and did some research, giving him further exposure to the specialty and cementing his future focus.

After he returned to Perth, he spent 15 years as a general and colorectal surgeon at Sir Charles Gairdner Hospital and St John of God Subiaco before leaving SCGH and accepting an offer to work, part-time, as director of medical services at Subiaco.

Almost a decade later, he resumed full-time clinical practice until he was asked to help out as head of surgical services at Osborne Park Hospital.

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A write turn opens a new chapter

CLOSE-UP “I still like my clinical work. In the health department, I was such a long way away from patient contact. Even seeing some old bloke in my rooms with an itchy bottom, being able to tell someone I might be able to help them, that’s still special.”

In 2003, Michael was awarded the Centenary Medal for services to public education about colorectal cancer and has also published three books on bowel health, the most popular, being 2018’s The Happy Bowel, a user-friendly guide for the whole family.

The 64-year-old has now published his next book, but this time it’s about his other passion – art. The Gallerist is a fictional mystery about a painting which falls into the hands of Perth gallery owner Mark Lewis, taking the reader behind the scenes of the local art world.

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Michael admits The Gallerist might well have been him in an alternative

life if he’d decided not to be doctor.

He insists it’s not a regret, but he very much enjoyed imagining what might have been.

The book is set in Perth and Lewis’s gallery is in Mt Lawley. His sympathetic drawing of the suburb and its surrounds reveals an author who not only shows the spirit of his town but his love for it, picking out spots and conversation points which will resonate with anyone who has lived here.

“I wrote about places I like and find beautiful, like the South Perth foreshore and Hyde Park, plus we’ve been eating at Kailis’s since we were kids.”

The book also features the Sir David Brand Centre in Coolbinia, which Michael was aware of but needed to do more research to feature in the book as the place where one of the

continued on Page 15

Within 12 months, he found himself in the position of medical codirector at OPH while continuing his surgical practice there and privately.

In 2018, Michael was appointed Chief Medical Officer with the WA Department of Health, a position many people assumed would have been in the thick of the State’s pandemic response.

“Luckily, that was the province of the chief health officer, Dr Andy Robertson, and I was grateful that he was the person in the firing line and not me,” says Michael. “But I told Andy that, if COVID-19 went on to cause an epidemic of haemorrhoids, I’d definitely be his man.”

Michael has recently left the CMO role and has started working with the WA Country Health Service in a position which will involve administration and advocacy.

When he took up the position as CMO, Michael chose to downsize his surgical practice and give up major abdominal surgery.

“I basically downsized to bottoms, hernias and functional bowel disease, which are my main interests. I might downsize a little more now, probably just looking after people whose bowels and bottoms everyone else has given up on.

MEDICAL FORUM | INNOVATIONS & TRENDS

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CLOSE-UP

A write turn opens a new chapter continued from Page 13 lead characters works. He admits in creating many of the characters and situations, he drew from elements of his own life, his love and knowledge of art and the people he knows.

In order to really feel like he knew the art works he was writing about in the book, including the story’s central and mysterious painting, Michael commissioned Perth artist Teelah George to paint him a series of works on board which he could reflect upon while writing.

Last year, Michael and his wife Carolyn exhibited part of their personal art collection at Ellenbrook Gallery. Their collection focuses primarily on Australian abstraction from the 1950s, ’60s and ’70s.

A sought-after public speaker as a doctor, he’s also spoken at the launch of art exhibitions and a book about Ernest Philpot as well as writing on art for various media and catalogues.

Michael has been collecting art almost all his life, starting with the money he saved up to buy his first piece when he was 13. It was a limited edition print by the late Australian abstractionist Sydney Ball from his Persian series. He paid $70 in 1970.

to set aside hours at a time to get into it. Over the few years it took to complete The Gallerist, there were months at a time when I made no contribution to it at all.”

“In retrospect, my decision to buy it was distinctly odd. My parents must have thought it was odd and probably wondered what was happening to me.

Michael hopes his latest work schedule will allow him the time to work on his next story. That is somewhere in between the work he does in the local Jewish community, being a husband, dad and granddad, collecting art and, of course, soothing those itchy bottoms.

“Later I sold that piece to my dad because I needed money when I moved out of home. He chalked it up to a business expense and hung the piece in the stairwell of the office block he had built in West Perth.

“For a long time, I used to be able to see it in the building. The building was sold in the 1980s, the print went with it and I always wondered what had happened to it.”

In a strange twist, but one so very Perth, that piece is now part of the Kerry Stokes Collection and while not hung in the stairwell, still resides in the same building.

The question of how art moves

The Gallerist is published by Fremantle Press and available from February 2.

between owners and the ways in which art – through its provenance and ability to move the human spirit – engages and inspires the viewer, are the central themes explored in The Gallerist.

Read this story on mforum.com.au

“Writing is an undeniably selfish undertaking. You have to be able

MEDICAL FORUM | INNOVATIONS & TRENDS

FEBRUARY 2022 | 15

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FEATURE

Winding back the diabetes clock

With type 2 diabetes one of our biggest growing chronic conditions, doctors are trying to understand how it can be tamed, as Cathy O’Leary explains.

For years, a popular adage associated with type 2 diabetes was “once a diabetic, always a diabetic”. Apart from the language itself moving away from giving people labels, experts are now challenging whether type 2 diabetes is necessarily a ‘forever’ diagnosis.

Historically, type 2 diabetes mellitus was regarded as a permanent, progressive and chronic condition. Even if someone was able to get a good grip on their glucose levels, they were regarded as having “controlled diabetes”.

Until recently, there has been little in the way of clear clinical guidelines on the concept of diabetes remission, with most material explicitly focusing on managing obesity and keeping diabetes in check rather than achieving remission.

Now, however, the tantalising prospect of diabetes reversal and even remission have emerged as realistic goals, achieved largely through weight loss from dietary changes or bariatric surgery.

While official health advice to consumers and doctors has still been slow to reflect this shift in thinking, the number of type 2 cases is threatening to overwhelm the health system, so a circuitbreaker is sorely needed.

Television science journalist Dr Michael Mosley ignited debate late last year when he featured in a series on SBS which challenged traditional mantra that type 2 diabetes could not be reversed.

Recently diagnosed himself, Mosley claimed that rather than go on medication, he lost 9kg by putting himself on an intermittent fasting diet, resulting in his blood sugars returning to normal, without the need for medication.

However, some dietitians warned that while reversing diabetes and going off medication was possible, many people would be unable to achieve this and could end up feeling like failures.

Prominent eye surgeon and 2020 Australian of the Year Dr James 16 | FEBRUARY 2022

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FEATURE Muecke also weighed into the discussion, arguing that putting people with type 2 diabetes on a lowcarbohydrate diet could put their disease into remission.

And he claimed health authorities and advisory groups had been slow to acknowledge the growing body of science that proved type 2 diabetes could be halted.

Government nod Significantly, the Federal Government released a new 10year diabetes plan last November which, for the first time, recognised that type 2 could be reversed.

Diabetes WA says its educators have been regularly quizzed by consumers about the possibility of reversing type 2. There has been criticism of the group’s website and resources, including from the WA Parliament’s Education and Health Standing Committee following its inquiry into the prevention and management of type 2 diabetes.

Prompted by widespread confusion, the organisation last year carried out a survey of more than 2000 people with type 2 diabetes to gauge their understanding about remission.

It found that a lack of consensus among health professionals, even about the definition of remission, was contributing to the problem.

Whether remission was possible divided health professionals, including GPs and endocrinologists.

“Two-thirds of consumers surveyed said they had been told by their health professional that diabetes remission was possible, while onethird were told it was not possible or their health professional was unsure,” the report said.

“Consumers often indicated the concept of diabetes remission had been endorsed by their GP, bariatric surgeon or their own lived experience of type 2 diabetes.

“It is hard to know why health care professionals said achieving diabetes remission is or is not possible. It could be because it would not be possible in a specific case, for example, if the patient had diabetes for a long time and the condition of their pancreas had deteriorated, or because they believed it was not possible in any case.”

Diabetes WA growth and

innovation general manager Sophie McGough, who is a dietitian, diabetes educator and previous co-lead of the Diabetes Health Network, told Medical Forum that the organisation wanted to provide clearer information to consumers and health professionals.

Diabetes remission is considered possible for people who have been diagnosed with type 2 diabetes in the past six years and are overweight. The best chance of diabetes remission is with weight loss of more than 10kg in a short amount of time, such as 8-12 weeks.

Ms McGough says reversal is more about good management of diabetes, such as improved glucose control, where people might come off their medications or regress back to earlier medication.

“While statements about diabetes remission being possible for everyone are inaccurate, at the same time we have consumers and GPs who are seeing that remission is possible for some.

“Reversal and remission tend to be used interchangeably but they are not the same thing. Reversal is what everyone is trying to achieve, which is all about improvements.

“So, we’re trying to marry those two worlds and find a happy medium so we can be clear for our consumers and health professionals.”

“We’re also concerned that a lot of diabetes management is focused on glycaemic control, but it’s also about cardiovascular risk, because that’s what causes the serious complications from diabetes.

Ms McGough says that while they did not want to offer false hope, there were concerns that the use of the word ‘progressive’ was making people feel stressed or unmotivated.

“Unfortunately, consumers and even health care professionals aren’t seeing the link between diabetes and cardiovascular risk.”

“The word has been used to take away some of the blame and fear about people having to start insulin for their T2D, when it’s not their fault that their diabetes has progressed. Often on diagnosis, insulin deficiency has already started to occur, so the person will be less likely to achieve remission,” she said.

“But when we offered people the latest evidence-based definition of diabetes remission, we saw an increase in hopefulness.

“We want to avoid people with financial interests taking advantage of people with T2D with what they believe is a solution or magic bullet for everyone, but by the same token we want to be able to offer evidence-based paths for people.”

She said management guidelines for GPs did not give a lot of guidance about the concept of remission.

There was also confusion among consumers and health professionals about the difference between diabetes reversal and remission.

Remission vs reversal A recently updated position paper

by Diabetes Australia defines remission as a HbA1c of less than 6.5% (48mmol/mol) for at least three months after stopping glucose-lowering medication.

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Endocrinologist Dr Greg Ong, who co-authored the Diabetes WA report on remission, said it gave hope to people with type 2 diabetes.

“We need to support our health professionals to actively consider remission as a treatment goal in appropriate circumstance, and have productive conversations about this with consumers,” he said.

Diabetes Australia has called for bariatric surgery to be more widely available for people with type 2 diabetes who meet the criteria.

It also warns that remission does not mean that type 2 diabetes is cured, as over time glucose levels can return to levels indicating diabetes.

UWA endocrinologist Professor Tim Davis agrees, and says dramatic weight loss in the overweight or obese can improve both insulin resistance and pancreatic beta cell function, but a continued on Page 19

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FEATURE

Winding back the diabetes clock continued from Page 17 diagnosis of type 2 diabetes implies significant beta cell loss, a lot of which may be irreversible.

‘When people in remission are stressed, such as with a severe infection, they can have temporarily very raised blood glucose levels, as there is a limited insulin secretory reserve in the presence of high levels of counter-regulatory hormones,” he told Medical Forum.

And people who do not achieve or sustain remission should not feel that they have failed because the health benefits of weight loss and a reduction in HbA1c are significant even if remission does not happen.

“One intermediate beneficial outcome for some patients between staying on current therapy and not requiring treatment for diabetes is coming off insulin,” Professor Davis says.

“Although this may not mean oral blood glucose-lowering therapies can also be stopped, freedom from the burden of regular injections is viewed as a worthwhile goal for many patients even if they do not achieve remission.”

Making it real Professor Davis says more research is needed to understand the real-world experience of remission, because there is a lack of longitudinal studies that have assessed its sustainability, whether remission is achieved through lifestyle changes, pharmacotherapy or bariatric surgery.

As with many diseases, type 2 diabetes has an earlier window of opportunity to turn back the clock, while a person is at a pre-diabetes level with raised blood glucose levels.

But appointments with doctors are often short, so motivating people to adopt healthy behaviours and ultimately a healthy lifestyle is a major challenge, she says.

“There is evidence that goals set with a health practitioner and regular review of those goals is important, because weight loss is probably the most important thing to focus on in prediabetes,” she said.

“If you lose weight, you’re far more likely to naturally achieve better glycaemic control, and we know that even a 5% weight loss can make a huge difference, regardless of what weight someone starts at.”

Professor Whitehead says many people with prediabetes will eventually go on to develop type 2, and not enough is being done in Australia to intervene.

“We have different methods for assessing if someone has raised glycaemic levels or not, and there are different definitions around the world as to what constitutes prediabetes,” she says.

“It’s something we really need to be talking about more here, and supporting GPs and nurses to recognise it as an important area.

Edith Cowan University professor of nursing research Lisa Whitehead says setting goals such as a 10% weight reduction not only helps patients control diabetes, it can help them avoid it in the first place.

MEDICAL FORUM | INNOVATIONS & TRENDS

“Anecdotally, some people at the prediabetes stage are told to go away and come back in six months for another blood test, when there are many important things that they could be doing to stop them progressing on to T2D.”

Diagnosis snap Professor Whitehead says that for most people getting a diagnosis of prediabetes is a light-bulb moment.

“A lot of the people we’ve interviewed in our studies say it was a real shock, even if diabetes ran in the family,” she says.

“There’s a bit of mixed literature out there about whether you should give someone a diagnosis of prediabetes – is it useful or does it stigmatise them – but when we looked at that in our studies, everyone said they would much rather have had the diagnosis than not being told.”

Professor Whitehead believes ongoing support from nurses is critical for people with prediabetes.

“Patients will see their GP but then having follow-ups with a nurse every three months or so, to touchbase with them and talk through issues and adapt their plans and goals, means they don’t lose interest and give up.

“We found that having that regular support from a nurse made people feel accountable, in a positive way.

We’re not talking rocket science – it’s just about someone talking to them about their blood sugars, weight and BMI, because that can make a big difference.

“They can also reinforce that setbacks are normal, because we’re not robots, we’re human, and sometimes you need mini-goals and a reminder that you don’t have to accept putting on more and more weight.”

FEBRUARY 2022 | 19

Dieting in the fast lane Humans have intermittently fasted since we lived in caves, but Kathy Skantzos weighs up the myriad of regimes now being used to help us eat less.

20 | FEBRUARY 2022

MEDICAL FORUM | INNOVATIONS & TRENDS

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FEATURE

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FEATURE Some argue that the human body was naturally designed to fast.

Rather than eating from the moment we wake up to when we go to bed, with a wide range of foods available to us all the time, we were meant to forage and hunt, feast and fast.

Fasting is evolutionarily embedded within our physiology and our bodies have evolved to be in sync with a circadian rhythm, adapted to eating during the daytime while allowing our bodies a chance to rest in the evening, rather than snacking after dinner.

And while intermittent fasting has been practised in various cultures and religions for centuries, it has been made popular most recently with Dr Michael Mosley’s The Fast Diet and The Fast 800, and Kate Harrison’s The 5:2 Diet Book.

Fasting, all ways There are many ways to fast and there’s not necessarily a one-sizefits-all approach. Intermittent fasting can be anything from 12:12, where there is a 12-hour eating window from breakfast to dinner, through to 23:1 where you eat one large meal a day in one hour, or fast on alternate days.

Dr Emily Calton is a Perth-based accredited practising dietitian and nutritionist who completed her PhD in public health at Curtin University. She is involved in a systematic review of intermittent fasting and explains there are four types of fasting.

“Intermittent fasting is a bit of an umbrella term but covers a variety of eating patterns. There’s either no calories or few calories consumed for periods of time, that could cover short periods of say 12 hours up to several days,” she told Medical Forum.

There is whole-day or alternate-day fasting, modified alternateday fasting, periodic energy restriction and time-restricted feeding.

“The most popular form is the 5:2 or modified alternate-day

fasting, which is where people concentrate on restricting food intake two days of the week and for the other five, they can eat whatever they feel like,” she said.

On the two fasting days, calorie intake is restricted to 20-25% of energy needs.

“Everyone has different energy requirements, based on their metabolism and how much exercise they do, but for most people that equates to about 2100 or 2500 kilojoules a day,” she said.

Whole-day or alternate-day fasting involves one day of zero calories followed by eating unrestrictedly the next day. Then there is periodic energy restriction, which is a very low-calorie diet for a longer period over a few weeks.

“The last category is 16:8, which is time-restricted feeding, and this is where someone eats for eight hours or less and then they’re fasting and not eating for 16 hours,” Dr Calton said.

“That’s probably the most popular form of time-restricted feeding but there are other options or varieties of that as well, such as 12:12, which is 12 hours of fasting and 12 hours of eating, and a 23:1 which is 23 hours not eating and one hour of eating.

“Ramadan is an example of time-restriction eating.”

Benefits of fasting There is evidence that intermittent fasting is linked to a range of benefits including weight loss, improved blood glucose control, reduced inflammation and the benefits that has on rheumatoid arthritis, reduced symptoms of neurological disorders, better cognitive function, improved blood pressure and cholesterol, enhanced immune health and induced autophagy for cell regeneration.

“Studies suggest there could be a benefit of intermittent fasting on rheumatoid arthritis, and some reported an improvement in pain.

Osteoarthritis sufferers reported decreased pain and swelling and improved range of motion,” Dr Calton said.

There is also evidence in animal studies that intermittent fasting could reduce brain inflammation and delay the onset and progression of neurodegenerative diseases such

MEDICAL FORUM | INNOVATIONS & TRENDS

as Alzheimer’s and Parkinson’s, and people who have tried intermittent fasting have reported improved mental clarity and less brain fog.

Primarily the key benefit of intermittent fasting is weight loss, with restricted eating windows generally leading to a reduction in calories as well as a drop in insulin levels which helps to burn fat.

“If someone is fasting, their insulin levels are going to be low and that means they’ll see a loss in muscle and a reduction in body fat,” Dr Calton explains.

“In order for intermittent fasting to result in weight loss, it still comes back to energy balance. There still needs to be a degree of energy restriction across the day or the week for someone to lose weight.”

Looking long-term Professor Amanda Salis, from the University of WA’s School of Human Sciences and a National Health and Medical Research Council senior research fellow, said that while research suggests that the 5:2 or 16:8 diet approaches are a promising option for weight management and potentially for various health conditions, there is still a gap in long-term randomised controlled studies in humans.

“With 16:8, there is not a lot of evidence of benefits in humans because of the newness of clinical research,” Prof Salis told Medical Forum.

“There is evidence in animals that eating less and eating intermittently is good for Alzheimer’s and tumours and lots of other conditions, so it looks promising, but these are small animal studies.”

She adds that fasting is a good alternative to conventional weight loss diets but there is no evidence to suggest that it’s a better approach.

“It could be another option to help manage weight and metabolic health. Part of the reason why this seems to work is because humans actually eat less overall when they continued on Page 23

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FEATURE

Dieting in the fast lane continued from Page 21 put some restrictions on when they eat. A good deal of the benefit is eating less overall.”

food and burn it off as energy and put it to good use, while at other times, it’s more likely to convert it into fat,” she said.

Fasting concerns

Fat loss could be a key reason why intermittent fasting is linked to improving a range of health conditions.

On the downside, fasting could be detrimental to people who have a history of eating disorders as it could spark unhealthy eating habits.

“Because adiposity is linked with so many other health conditions, if somebody is doing something that is helping to reduce excess weight, then that reduction, regardless of the way it is achieved, is going to help with so many other health conditions,” Prof Salis explain.

“Most studies so far don’t measure risks or signs of disordered eating, so we’re really in the dark about how to catch those disordered patterns,” Dr Calton said.

And there are metabolic benefits of not eating at night.

“If you’re eating during the day and not at night, your body is going to cope better with that food because your metabolism changes throughout the 24-hour cycle.

During some parts of the cycle, your body is better able to metabolise

“People have a punishment approach when it comes to eating and we really want to see people eating nourishing foods. It’s not just about what you’re not eating, it’s also about what you are eating, so having nourishing foods from the five food groups.

“It’s too early to know what the different diets may or may not be doing to disordered eating. For people with active eating disorders,

it is important to be in touch with a healthcare professional.”

People with type 1 or type 2 diabetes also need to be mindful of changes to their medications and insulin needs, as they may need to reduce their insulin dosages during periods of fasting to reduce incidence of hypoglycaemia.

“For anyone who has diabetes and taking medication, I always suggest seeing their GP or endocrinologist before considering intermittent fasting,” Dr Calton said.

Professor Salis also strongly supports the role of GPs, specialists and dietitians before people make significant changes to their diet, especially if they have a pre-existing medical condition.

Read this story on mforum.com.au

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Wearing your heart on your sleeve From counting steps and heart rate, to measuring biomarkers and delivering drugs, wearable tech is offering help for a range of conditions.

Dr Karl Gruber (PhD) reports Wearable devices that monitor health might have been around for more than a decade after the first Fitbit watch was released in 2009, but they have evolved significantly, allowing for the detection and monitoring of multiple biomarkers of health.

The devices are composed of two key components: a receptor and a transducer. The receptor recognises a target signal, such as heartbeat, and responds accordingly. The transducer then converts the receptor’s response into a useful signal, which can then be interpreted by a patient or doctor.

A skin patch was recently designed by researchers from the University of California San Diego and is able to monitor blood flow through major arteries and veins. The computer-controlled patch uses ultrasound to accurately monitor blood blow deep in the body.

The device may one day help clinicians detect people who are at risk of a stroke or heart attack, long before symptoms appear.

Australian researchers are also working in this space, developing new wearable technologies that are poised to revolutionise health care.

Local conditions With the heart in mind, Australia-based company WearOptimo is designing sticker-like devices containing sensors that provide real-time monitoring of different health markers, which are forwarded to a doctor. The aim is to provide doctors with early warning for patients who may be at risk of developing life-threatening conditions such as heart attack and heat stroke.

24 | FEBRUARY 2022

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FEATURE According to WearOptimo founder and CEO, Professor Mark Kendall, their wearable devices may one day save the life of seriously ill patients.

“For example, we are developing micro-wearable sensors to detect and alert dehydration while people are on the job, or dehydration in the elderly,” he said.

“Another micro-wearable sensor is being developed to help the early detection of heart attacks and cardiovascular disease, which is responsible for 20 million deaths per year.”

In Victoria, a team from Royal Melbourne Institute of Technology has designed a UV-active ink that changes colour when exposed to different UV wavelengths. The ink is part of a sensor that can be worn as a wristband or sticker to warn people when they have received too much sunlight. According to Professor Vipul Bansal, who led this research, the device could help reduce the risk of sun damage to the skin.

“Monitoring your personal exposure is important because people have different solar UV exposure needs.

Those with lighter skin are more sensitive to sun damage, while those with darker skin need more sun exposure to produce vitamin D,” he said.

More recently, University of Sydney researchers, led by Professor Emmanuel Stamatakis, are evaluating the potential of wearable devices such as Fitbit to help predict if a person has COVID-19.

The concept is to use a wearable device to monitor a person’s heart rate, physical activity or sleep patterns, and detect when something is amiss, which could be indicative of an influenza-like illness such as COVID-19.

“Wearable devices objectively track so many elements of our daily lives – from our step count and heart rate to our sleep. What we aim to find out here is if these measures could be used for early detection of illnesses such as the flu or COVID-19, potentially even before people are diagnosed,” Prof Stamatakis said.

Generally, wearable health devices can be classified in two broad categories: general wellness devices (e.g., Fitbit and Apple Watch) or regulated medical grade devices, which need TGA approval.

Money push The Australian Government has committed about $7 million as part of a Primary Health Care Research Initiative grant to support the testing and implementing new applications for existing wearable electronics as well as point-of-care testing in rural areas.

According to Health Minister Greg Hunt, this would lead to patients managing their own health, reducing the number of doctor’s visits.

Real-time monitoring of biomarkers has the potential to track the health of patients, particularly those suffering from chronic illnesses such as cardiovascular disease, diabetes or neurological disorders.

Even healthy people could benefit from wearable technology, as knowing how your heart behaves while you exercise, for example, may reveal important information about your health. Likewise, knowing other details about your body can help guide changes to improve and maintain health.

Other systems are more like a Fitbit and resemble a smart watch.

The Kardia Band System can record, store and transfer single-channel ECG rhythms. This device can detect the presence of atrial fibrillation and normal sinus rhythms.

The HealthSTAT blood pressure monitoring device measures systolic and diastolic blood pressure and pulse rate. It employs the radial pulse waveform to derive the central aortic systolic pressure. This device is intended for patients with palpable radial pulse, who have uncommon arrhythmias such as atrial or ventricular premature beats or atrial fibrillation.

For patients with diabetes, some devices measure and store glucose data, which can then be interpreted by a doctor.

Other devices, such as the Animas vibe system, not only read levels of glucose in the body, but also includes an insulin pump which can deliver a single dose of insulin when needed.

“The possibilities this presents for us to understand the impact of people’s daily habits on their health and to encourage change are only just beginning to be realised,” Prof Stamatakis said.

These devices generally have a small wire or tip that is inserted under the skin to detect glucose. In the case of the Animas device, a wire is inserted under the skin of the abdomen to measure glucose levels.

In Australia, only a handful of wearable health devices have been approved by the TGA and are available on the market, of those, they target three key areas: cardiovascular health, diabetes and motion disorders.

With movement disorders, wearable devices are used to measure movement and muscle activity.

What’s out there?

One of these cardiovascular wearable devices, the TelePatch cardiac monitor, can detect symptoms commonly associated with cardiac arrhythmia, such as shortness of breath and palpations.

Other devices such as Bioflux can capture events such as bradycardia, tachycardia, pause and atrial fibrillation. Data is delivered to a server wirelessly, where a doctor can analyse and interpret the collected data.

Another such device, the VitalPatch VitalConnect platform, works over a 96 to 120-hour period and can detect heart rate, electrocardiography, heart rate variability, R-R interval, respiratory rate, skin temperature, activity (including step count), and posture (body position relative to gravity).

MEDICAL FORUM | INNOVATIONS & TRENDS

The ViMove uses wireless sensor technology to measure activity of the lower back. Another device, the neuromuscular motion disorder long-term ambulatory recorderanalyser, is targeted at patients with Parkinson’s disease. It can monitor physical motion and activity, and use the data to determine if there are instances of kinematics of movement disorder symptoms, such as tremors.

But some wearable health devices remain more about general information and are not intended to replace a formal diagnosis or monitoring. Even those with medical value, their benefit depends on proper use by the patient and professional medical interpretation.

Read this story on mforum.com.au

FEBRUARY 2022 | 25

COVID 2.2 – how things will change COVID-19 arrived in Perth earlier than expected via an unvaccinated backpacker, but it is just the start as the hard border opens this month.

Dr Karl Gruber (PhD) reports Life is about to change in WA. The average person on the street will have to get used to keeping a face mask handy, as well as their smart phone loaded with the recently-launched ServiceWA app containing their vaccination certificate and the SafeWA check-in.

Going out to hear live music or to catch a film might be a very different experience in 2022, and travellers will need to be on top of the latest requirements by airlines and other States and countries regarding pre-departure and postarrival testing protocols.

Experts agree the best line of defence is still vaccines. Anyone who is not vaccinated has an increased risk of falling seriously ill or even dying from COVID-19.

There is also a higher risk of transmitting the virus if not vaccinated.

But many people will need to be reminded that being fully vaccinated does not mean they cannot catch the COVID-19 virus because a breakthrough infection can happen – specially with the Omicron variant. And some people will develop serious conditions and long COVID, even when fullyvaccinated.

Doctors, particularly GPs, can expect to be busy managing the ongoing vaccination roll-out, as well – for the first time – significant numbers of sick patients with COVID or recovering from it.

26 | FEBRUARY 2022

No end in sight?

When will the COVID-19 pandemic will be over? This is a question most of us have been wondering for a long time. But, without a magic crystal ball, we can only speculate.

If you ask an historian, the answer will be that pandemics usually have two types of ending. There is a medical ending, when cases are driven to zero, which occurred with Ebola. But there is also a social ending, that’s when people grow tired of the whole situation, and just learn to live with the virus.

According to Dr Allan Brandt, a historian from Harvard University, this is what is happening with COVID-19.

“As we have seen in the debate about opening up the economy, many questions about the so-called end are determined not by medical and public health data but by socio-political processes,” Dr Brand said in a news report.

But “learning to live” with the virus is tricky and it is important for countries to ensure they are making the best decisions when it comes to COVID policies.

In a statement to the New York Times, Dr Michael Baker, an epidemiologist at the University of Otago in New Zealand who helped devise New Zealand’s COVID elimination strategy, said that countries taking shortcuts on their way to reopening were putting unvaccinated people at risk and gambling with lives.

“At this point, I actually find it quite surprising that governments would necessarily decide they know enough about how this virus will behave in populations to choose, ‘Yes, we are going to live with it,’” Dr Baker said.

But the quick answer is that COVID-19 won’t go away, it won’t magically disappear from our lives.

It will just blend in and be part of our everyday happenings, much like the flu or other diseases.

Except that COVID-19 is not just another flavour of the flu.

From birds to bats As history goes, 1918 was a bad year. This was the year the Spanish influenza pandemic killed more than 50 million people.

The influenza A virus, the culprit behind the 1918 influenza pandemic was, like SARS-CoV-2, a zoonotic disease. This one came from birds.

More than 100 years later, the influenza A virus is still around, popping up here and there, and affecting over 1 billion people and killing an estimated 650,000 people every year, according to the World Health Organisation.

Now, after all our efforts of eliminating the COVID-19 virus seems to have been insufficient, many experts think COVID-19 will follow a similar path to that of the seasonal influenza.

According to Dr Lara Herrero, Research Leader in Virology and Infectious Disease, Griffith University, we may eventually see a

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COVID UPDATE

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COVID UPDATE

of writing, life was mostly normal in Perth, with only a handful of cases and no major restrictions or lockdowns. Other than wearing masks and needing proof of vaccination in some venues, life is business as usual.

new baseline of virus transmission.

“Once we see a stable level of SARS-CoV-2 transmission indicating a new baseline, we will know the pandemic has ended and the virus is endemic. This will likely include minor seasonal trends as we see now with flu,” she said in an article for The Conversation.

But now that our borders are open, everything will change. COVID-19 is already here, it arrived early in January, and now cases will continue to grow. The only question is whether WA will be ready to deal with all cases.

However, COVID-19 is not exactly like seasonal influenza. Not only is it a different virus, it has a higher infection rate and a higher mortality rate, compared to the flu, and we don’t know much about what longterm effects it might have on those infected.

Will our hospitals be able to cope with the burden? How many people will get the virus? How many will get very sick or die?

The WA bubble

In the meantime, WA is gearing up in the only way it makes sense to get ready: by ramping up on vaccination coverage, including boosters. The WA Government also recently announced that a $400

So far, people in WA have been the luckiest people in the world.

Throughout most of the COVID-19 pandemic, WA has experienced only a handful of cases. At the time

million package will be in place to increase the capacity of our health system to cope with the upcoming wave.

Only time, our commitment to getting vaccinated and a dash of luck will tell how we fare this year.

“The most important thing we can do to help reach a safe level of endemic COVID is to get vaccinated and continue to adhere to COVID-safe practices. By doing this we protect ourselves, those around us, and move together towards an endemic phase of the virus. If we don’t work together, things could turn for the worse very quickly and prolong the end of the pandemic,” Dr Herrero said.

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FEBRUARY 2022 | 27

From student to doctor What makes a good medical student? Christopher Chi, a foundation graduate of the Curtin Medical School has a few ideas.

So what does make a good medical student? Obvious answers may spring to mind – being kind, compassionate, able to auscultate a 2/6 grade heart murmur in a noisy ED (OK, maybe not that last one). While these might all be true, being a good medical student, and indeed being a good doctor, is much more than this.

As the founding secretary, I tried to help any way I could, whether it was sending emails reminding people to come to an upcoming movie night or getting fellow peers interested in social sport.

Being part of a student society was helpful in teaching me the importance of rest and socialising.

So where to now? I look forward to starting a job next year as a medical intern at St John of God Midland Hospital. Beyond that, I can’t say where life will take me, but having gone through as part of the first cohort of a new medical school, I can safely say that I will go forward with the skills necessary to thrive as a doctor.

As I reflect on the past five years at Curtin Medical School, I can’t help but be grateful for all the lessons I have learnt from Australia’s newest medical school.

It was 2017 when I got my first taste of what was to come. I was a wide-eyed high school graduate keen to learn and grow my medical knowledge. Having just moved from Sydney, I also took every opportunity to embrace the culture of WA including the reduced pace, the fantastic beaches, and a bit of footy fever!

On the first day of our orientation, our cohort of 60 packed into the newly-opened medical building.

Our excitement was auscultable!

We were told that we would be the future of healthcare in WA, meeting the needs of every West Australian.

These were obviously hefty words for a group of mostly 17 to 18-yearolds but we were keen and ready to take this challenge head-on.

We began our learning with a medical student staple – cellulitis.

Curtin’s curriculum was structured heavily around the problem-based learning model, where students receive information about a patient in a gradual way, giving time to ask questions in a logical and ordered manner.

As an example, we might have only been given a bit of information about a patient’s rash and had to figure out what questions we would ask them before we received the next prompt. After we completed the topic, we had to research a certain aspect of the condition, returning a week later to present it to our colleagues. This was a fantastic way of making content dynamic 28 | FEBRUARY 2022

Graduates Amy Ringuet and Christopher Chi

and engaging while also making it necessary for us to learn enough to explain and teach it to our peers.

From cellulitis, we moved to the cardiovascular system, the musculoskeletal system, and the renal system, covering anatomy, physiology, pharmacology, and much more along the way.

So, going back to what makes a good medical student? While kindness, compassion and a good ear are necessary, being able to ask for help, knowing how to rest and having a desire to teach are all great attributes too.

As we learnt more, we grew more confident in our ability to make connections between body systems and how they interact with one another. However, we were far from perfect as we collectively discovered after our first exam, being unable to collectively identify a myocardial infarction.

Nevertheless, we pressed on, gradually coming to realise that although we didn’t know everything, there was always support from staff and mentors.

We learnt that it was OK to ask for help, especially when we didn’t know what was wrong.

Along with our studies, we also had the opportunity to start up the students’ society. Curtin Association of Medical Students was founded in our first year, with a goal of bringing students together, supporting them through formal events, and helping develop a sense of camaraderie.

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FEATURE

Curtin celebrates the Class of 2021 WA’s third medical school has graduated its first cohort, which has been welcomed by a health system struggling to find staff.

Cathy O’Leary reports Back in May 2012, then-Premier Colin Barnett had doctors choking on their hors d'oeuvres at a function when he scolded the Australian Medical Association for opposing Curtin University’s plan to build a third medical school in WA. At the time, the AMA and the Australian Medical Students' Association had been warning that there was no capacity to train extra graduates on top of those coming out of the medical schools at the University of WA and University of Notre Dame.

But Mr Barnett was having none of it, telling the opponents that Australia did not train enough of its own doctors and was "plundering" disadvantaged countries of their medicos.

Curtin went on to overcome the hurdles, gaining Federal and State government support and duly opened its medical school in 2017, offering the only undergraduate entry program in WA. And last year it celebrated its first cohort of graduates – with the 53 inaugural domestic students completing

the five-year, full-time Bachelor of Medicine, Bachelor of Surgery (MBBS) course.

Curtin University Vice-Chancellor Professor Harlene Hayne said the new graduates had been trained to meet the needs of under-serviced areas of health care, with a strong emphasis on primary care, chronic disease, ageing, Indigenous and regional health.

“Curtin first established its medical school to help address the health and workforce needs of West Australians, and we are now incredibly proud to celebrate the first graduating cohort of Curtintrained doctors, who are eager and ready to provide competent and compassionate medical care, particularly to those people who currently have inadequate access to healthcare,” Professor Hayne said.

“They have had the benefit and privilege of being able to train and gain practical clinical experience at hospitals across the State, and in Curtin’s own purpose-built health campus at Midland and recently our new Kalgoorlie Rural Health Campus.”

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The dean of the medical school, Professor Sandra Eades, said the new doctors had been trained to the highest standards of the Australian Medical Council, and were ready to take on internships and future specialisation anywhere in WA or Australia.

“The key purpose and mission of Curtin’s medical school has remained unchanged from the time it was established, which is to increase the availability of highquality medical care and to educate doctors that are well-prepared for primary care, rural, and Aboriginal and Torres Strait Islander healthcare settings,” she said.

As part of their studies, many of the graduating doctors completed clinical placements in rural areas including Broome, Kalgoorlie, Geraldton and Albany.

Curtin has 120 places available this year – 110 domestic and 10 international – up from the 60 places offered in 2017.

FEBRUARY 2022 | 29

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NEWS

Bright sparks thinking outside the square

It is six years since three entrepreneurial friends in Perth – including a surgeon – put their heads together to find innovations that could save the health system time and money.

an alternative treatment for elderly patients and others who cannot have a general anaesthetic.

“In a big state like WA, the treatment of abscesses can mean a great deal of disruption for patients who need to travel long distances to access care,” Ms White told Medical Forum. “We thought that there had to be a better way.

Consultant general surgeon Dr Ming Khoon Yew, research scientist Melanie White and bioengineer Dr Alex Hayes set about using ‘design thinking’ to shake out problems and find novel solutions.

The first development of their med-tech start-up company, Inova Medical, is an easier and cheaper way to manage skin abscesses using a sterile, single-use device that allows medical professionals to penetrate and drain abscesses easily and safely.

Skin abscesses affect thousands of people every year in Australia and while some are easily treatable, others can lead to severe conditions such as sepsis, infective endocarditis, osteomyelitis, necrotising fasciitis and septic arthritis.

Hospital costs alone in WA to treat the condition are more than $5

Credit: CSIRO

million a year, and patients who have to wait days for treatment risk developing potentially dangerous complications.

Ms White says the team recognised that skin abscess treatment had been static and often involved a multi-day stay in hospital, general anaesthetic and surgery.

Their brainchild device, known as Abcease, can be used under a local anaesthetic, so patients are out of hospital more quickly and there is less strain and cost on the health system. The device is also

MEDICAL FORUM | INNOVATIONS & TRENDS

“The kit aims to make it possible to treat deep or complex skin abscesses in an ambulatory setting using local anaesthetic. It will potentially be used in emergency departments, radiology, or on the wards.”

In the long term, the Inova Medical team are looking to problem-solve in other areas where they see gaps in the system.

“The Abcease kit is our first product, and in the long run we aim to seek out and address a range of unmet clinical needs,” she said.

FEBRUARY 2022 | 31

Docs’ battle for native forests The role of doctors in campaigns to protect WA’s forests should not be forgotten, argues retired surgeon Bill Castleden.

In September last year, the Premier, the Minister for the Environment and the Minister for Forests issued a joint statement announcing that all logging of native forests in WA would cease in 2024, at the end of the current Forest Management Plan.

This announcement suggests that the nearly 50 years of campaigning to preserve WA’s native forests is nearly at its end.

Although I am sure doctors were involved well before me, what follows are my imperfect memories of the doctors’ contributions to saving the forests from 1998 when I first became fully involved.

At the time, Richard Court’s government was compiling the State’s first Regional Forest Agreement, which was meant to ensure that sustainability and environmental care were enshrined in the forestry operations that had caused so much dissent over the previous 25 years.

Recently retired from surgery and living in the South-West as an avocado grower, I became incensed at the way the debate was being handled by CALM, aided by Bunnings, both of whom profited from logging as much forest as possible. The destruction and waste in the forests was heart-wrenching for those who cared to look.

Encouraged by the Conservation Council, I set up an organisation which became known as Doctors for the Preservation of Old Growth Forests, or DFPOGF. The initial 28 doctor-members who put their names to and paid for the first full-page advertisement in The West Australian, rapidly swelled to more than 150 doctors whose names appeared in the last of the series of the ads that appeared before the State election at the end of 2000 at which Geoff Gallop was elected.

I found the unwavering support of John Hanrahan, WA’s first president of the Royal Australasian College of Surgeons, vital. He garnered support from the profession and spoke at rallies, and we ran the campaign from his West Perth office once the debate hotted up, and I felt I had to be in Perth to run it.

Another doctor who emerged from the first advertisement was Keith Woollard who had been active in medical politics through his

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presidency of the AMA, which also reinforced the campaign. He became so fed up with the conservative party’s apparent support for the logging industry that he formed a controversial new political party Liberals for Forests.

DFPOGF was but one of a number of new groups and well-known supporters whose voices entered the forest debate as it gathered momentum between 1988 and 2000. All had important parts to play, and perhaps groups of doctors were seen to add independence and credibility to the issue.

Another doctor, Dr Judy Edwards, who was Minister for the Environment, placed the old growth forests into reserves and parks.

From 2001, as a result of my campaigning in WA, I became involved in the formation of the national organisation, Doctors for the Environment, Australia (DEA) which has always had a core group of members with forest preservation as a key focus. I was aware that all was not sweet in the South-West forests of WA. From time to time, the WA Forest Alliance (WAFA) was having to campaign all over again to try to protect important pieces of unprotected old growth forest from logging operations.

DEA has always asserted that unchecked climate change is the most important threat to good health, so once it became apparent that standing unlogged forest stores more carbon than young regrowing forest after logging, it became a top priority for concerned doctors that all logging in WA’s native forests should cease.

I became reinvigorated and part of Margaret River’s contributions to the recent WAFA forest preservation campaign in which the film Cry of the Forests and the emergence of Nannas for Forests have been important facets. The State branch of DEA, and Dr Ann Ward in particular, has been very active and an important contributor to WAFA’s successful result announced last September.

Doctors, as a group, can feel proud to have been cogs in the wheel of a very long forest campaign in WA. I encourage environmentally and climate-concerned doctors who are unaware of DEA to join up via www.dea.org.au.

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FEBRUARY 2022 | 33

Climate change and doctors – ‘this is our lane’ Dr George Crisp lays out the case for the role of doctors in the climate change debate.

A few years ago, American doctors were warned to “stay in their lane” by the politically powerful National Rifle Association when it spoke about gun-related deaths and injuries. Their swift response was “this is our lane”.

There is no longer any doubt that climate change is one of the most serious and urgent health challenges we face – both in how it will affect our lives and practice as doctors, and in how we respond in preventing and managing those growing impacts.

The UN observed that health impacts were “unequivocal” in 2018, and a succession of peak health agencies around the world, including our AMA, have declared climate change a health emergency.

An editorial published in 200 health journals called on governments to take emergency action to tackle the “catastrophic harm to health” from climate change in the lead up to COP 26, where health is now a central theme.

Heat exposure was implicated in 345 million deaths in over 65-year-olds in 2019 (80.6% higher than in the 2000-05 average); air pollution from the recent bushfires resulted in 417 deaths and over 3000 hospital admissions; and the 2011 Queensland floods resulted in mental health costs estimated to amount to $5.9 billion.

We have passed a one degree celsius increase in average global surface temperature and on our current trajectory are headed for 2-3 degrees.

The direct effects from more intense and prolonged extreme weather events and higher temperatures are relatively easy to envisage, while the indirect effects that arise through compromise of ecological and human systems and disruption of the global hydrological cycle are generally not.

The consequences of “business as usual” include failure of critical infrastructure, spread of infectious diseases and escalating freshwater and food insecurity, and the projected displacement of many millions of people over coming decades.

Furthermore, there are tipping points within the climate system – temperature thresholds where positive feedback loops can be

34 | FEBRUARY 2022

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triggered resulting in self-sustaining acceleration of warming.

To have a good chance of preventing a 1.5C increase in global temperature, we need to reduce emissions by about 7.5% every year from now.

Quite simply, if we are to maintain anything like our current health outcomes, we must immediately start phasing out fossil fuels that account for three-quarters of our greenhouse gas emissions.

This is not politics but scientific fact.

In addition to greenhouse emissions, coal, oil and gas-related pollution is causing untold health damage around the world.

An estimated 8 million people die annually from air pollution from burning fossil fuels and there are many other toxic chemicals such as polyaromatic hydrocarbons and heavy metals released into the environment from their extraction and use, with long lasting health implications.

As highlighted in Lancet Countdown 2015 – many of the

actions we can employ to mitigate climate change, such as renewable energy with electrification of heat and transport, more sustainable food systems and greener cities, have significant health and economic co-benefits.

If viewed through the prism of health, acting on climate change becomes an opportunity to maintain and improve our health.

That is why we, as doctors, are central to action on climate change.

As with other major public health matters, to be effective and credible we need to understand the underlying scientific rationale.

We must upskill and incorporate climate change and effects of pollution into medical school and college curricula.

Our health services produce around 7% of national emissions, and therefore contribute considerably to ill health. We have the same role and responsibility in making them healthier and safer by phasing out fossil fuels in healthcare as we did with tobacco.

work to promote health every day and put out money into schemes that undermine it. We can ‘divest’ or pressure our superannuation funds and banks to offer healthier investment options.

Understanding vulnerability in our patients and healthcare infrastructure to heat and other extreme events will be increasingly needed across healthcare facilities, from small practices to tertiary hospitals to prevent avoidable illness and interruption of service delivery.

And, perhaps even more importantly, we should be speaking out in public and to decisionmakers about the necessity for urgent adaptation in healthcare and essential services, about mitigation to prevent increasingly unmanageable harm and suffering, and about the health benefits that come from reducing pollution, and more sustainable diets and active lifestyles.

That is why climate change is absolutely ‘our lane’.

We can choose socially responsible investments. It makes no sense to

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FEBRUARY 2022 | 35

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It’s time to grow up Medtech company CEO Goh Khoon Seng believes innovations will be needed to make the health system more sustainable post-COVID. As vaccination rates bring us closer to a post-pandemic period, it’s time to think about what that means for hospitals around Australia.

There is evidence suggesting better medical infrastructure is needed to handle the next pandemic – more beds for intensive care units and operating theatres, but also more doctors, surgeons, nurses and allied staff.

COVID-19 has no doubt burdened the healthcare system, but while building more healthcare facilities is a necessary part of the solution and will allow more patients to be treated, it is also a stop-gap measure.

Rather than just investing in more resources, we should invest and focus on developing technologies that enable our health system to become more efficient. This sustainability will enable new and developing technologies to provide an opportunity to make the best and most efficient use of the available resources.

One of the developing technologies that may help us conserve valuable resources is regenerative medical technology – bioresorbable scaffolds that allow patients to regrow their own damaged tissues and bones, rather than replacing them with permanent implantable prostheses.

These scaffolds help the healthcare system become more sustainable for the simple reason that they reduce patient follow-ups.

Immediately post operation, it’s important that a patient visits their surgeon regularly. At present, permanent metallic and polymer implants are commonly used to replace or assist in the healing of damaged tissue and bones. But these implants require ongoing maintenance, and can get infected, break or loosen over time.

That places significant demands on a surgeon’s time (a valuable resource) and the patient’s time as

well, many of whom may not be equipped to travel regularly to a hospital.

For example, a surgeon might complete 50 knee implants annually over a two-year period.

By the third year, the surgeon will have 100 patients to follow-up, in addition to a steady stream of new patient consultations.

Ultimately, a large proportion of the hospital’s resources and this experienced surgeon’s time will be spent following up on existing patients, making it increasingly difficult to attend to new cases.

But these are problems we can address through regenerative medical technology.

With regenerative implant devices, once the bone or tissue has been naturally regenerated, the patient is free of foreign materials and structures. Consequently, they don’t need to come back for

MEDICAL FORUM | INNOVATIONS & TRENDS

frequent visits, freeing up hospital resources for others in need.

Patients can be discharged from regular monitoring after the surgeon evaluates if the bioresorbable material has fully degraded, and the patient’s own bone and tissue are functional for daily activities.

It is innovations like these that will be crucial in coming years to ensure we have a sustainable and fit-forpurpose health system, rather than spending ever more taxpayer money on building resources that may never get used.

ED: Goh Khoon Seng is the CEO of medtech company Osteopore International, which does Perth-based research.

FEBRUARY 2022 | 37

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FEBRUARY 2022 | 39

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Some things change – others do not This year will require everyone in the health sector to be adaptable and innovative as COVID becomes an endemic virus. It will also require a pivot back to all the non-COVID health issues which have been ignored to varying degrees over the past two years.

Humans are social beings. A 2018 American report found that “loneliness had the same impact on mortality as smoking 15 cigarettes a day, making it even more dangerous than obesity.”

Mental health, especially for the young, remains an area where little progress has been made. The huge spending suggests it will require other than additional shekels and more of the same to solve.

It was fascinating to attend (virtually) the International Summit on Psychedelic Therapies for Mental Illness. The two-day summit had prominent speakers from Europe, UK and USA together with locals. The presentations and panel discussions were broad-ranging and included the real-life experience of patients and physicians with first-hand experience.

The FDA regards MDMA as a ‘breakthrough’ therapy for PTSD and trials on psilocybin for depression have been encouraging. Last year the Federal Government allocated $15 million for trials using psychedelics and some of these will commence soon. An application to have the scheduling changed from nine to eight was rejected by the TGA. Whilst this disappointed some (including Mind Med who ran the summit), it was probably not a surprise that the TGA would not preempt the findings of trials yet to be completed. However, we tend to follow North America and somewhere in the foreseeable future, psychedelic therapy will become likely available here.

This month we have articles on a range of innovation topics including detection of pancreatic cancer, better insulin delivery, use of Broome nacre in orthopaedic surgery and use of transcranial magnetic stimulation for treating resistant depression. Also covered is familial hypercholesterolaemia, endomicroscopy, cognitive aids in anaesthetic crises and a re-examination of dairy intake in children.

Some things do not change. Humans are social beings. A 2018 American report found that “loneliness had the same impact on mortality as smoking 15 cigarettes a day, making it even more dangerous than obesity.”

The impact on people who have lived without family contact the past two years is a hidden epidemic of which the consequences will continue to be felt when COVID itself is a memory. This is in addition to those who died alone and whose families were unable to say goodbye or, in some instances, identify the body.

While February is late for new year’s resolutions, let us resolve to make time with family and friends a priority in 2022.

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FEBRUARY 2022 | 41

CLINICAL UPDATE

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Cognitive aids in anaesthetic crisis management

By Dr David Borshoff, Anaesthetist, Subiaco Anaesthetists have always played a leadership role in patient safety. Stanford’s David Gaba and University of South Australia’s William Runciman, both giants in their field of anaesthesia and patient safety, recognised the organisational similarities between aviation and anaesthesia and adapted aviation safety initiatives.

In particular, the introduction of simulation, crew (crisis) resource management and the use of cognitive aids have been embedded in specialist training programs.

What is a cognitive aid?

In its simplest form, a cognitive aid (CA) can be defined as any external representation supporting the cognitive processes demanded by a task.

In the peri-operative environment they include checklists, ‘track and trigger’ charts as well as crisis manuals. CAs have been shown to improve mortality and morbidity rates in healthcare settings and are considered an integral component of patient safety. Simulation studies demonstrate better communication, a reduction in adverse events, improved implementation of evidence-based guidelines and less errors of omission.

Written or electronic checklists, guidelines and protocols are formatted specifically using minimalist design principles to assist the user in completing complex and ‘tightly coupled’ tasks (requiring high degrees

Reviewing crisis protocols during ‘downtime’

Key messages Cognitive aids are an integral safety component of High Reliability Organisations (HROs) such as aviation and nuclear energy During complex life-threatening crises, individuals rely on cognitive tasking far beyond the information processing capacity of the human brain Evidence suggests the surgical safety checklist and crisis management cognitive aids lead to better patient outcomes.

of synchronisation amongst team members).

Integrated collections of singlepage CAs for operating room

emergencies were first implemented in 2003 by Gaba in US Veterans Affairs hospitals. This was followed by commercially available, colourcoded, aviation-type manuals such as The Anaesthetic Crisis Manual and freely available downloadable manuals or checklists such as the Stanford Emergency Manual and Harvard’s Operating Room Emergency Checklists.

Despite widespread use and the specific design parameters of aviation’s Quick Reference Handbook (QRH) checklists, on which many were based, crisis management cognitive aids in anaesthesia are not standardised.

The most successful present a twopage layout with directives on one side and supportive information opposite.

The concept is relatively simple.

Ideally, the operating room team responding to a crisis will be directed by a team leader.

Depending on the context, this may be the anaesthetist, a member of the MET team or critical care consultant. The role of a ‘reader’ is assigned to a staff member who will use the appropriate manual protocol to follow team actions, confirming task completion or prompting when necessary if steps are missed.

Widespread implementation of

42 | FEBRUARY 2022

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anxiety associated with the ‘am I missing something?’ phenomenon and provide a shared mental model for all team members.

However, with emergency manual incorporation into curriculums and simulation training, as well as College and Society endorsement, newer generations of anaesthetists appear more accepting. With rapidly expanding medical knowledge and the medicolegal implications of adhering to best practice guidelines, it is likely routine use of manuals is not far away.

Despite these relatively recent developments in the field of anaesthetic crisis management, it is with a somewhat heavy heart that we anaesthetists must acknowledge the concept of resuscitation protocols and drills was first documented almost a century ago by a surgeon, W. Wayne Babcock, famed for the well-known instrument.

In his 1924 article, Resuscitation during anesthesia, Babcock asked: Cognitive aid example

“Have you a plan of action so developed that the right thing is always done in the emergency and time is not frittered away with useless or non-essential details?”

crisis manual type CAs has not been as successful as the WHO’s Surgical Safety Checklist. This can partly be explained by reluctance of practitioners to accept that cognitively ‘offloading’ during crisis management using CAs is actually good medical practice – not indicative of weakness or incompetence.

The aviation adage that regulations are written in blood reflects the loss of life underpinning checklists and protocols. It equally applies to healthcare. We should heed Dr Babcock’s advice and utilise crisis management cognitive aids to maximise team performance and provide the best emergency care.

Studies have repeatedly shown even the most senior clinicians can miss important steps in treatment guidelines, especially with high pressure, time sensitive and rare or infrequent events. CA support can alleviate

– References available on request Author competing interests – the author is a director of Leeuwin Press

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Pancreatic Cancer: Challenges and Emerging Strategies

By Dr Ian F. Yusoff & Dr Samarth Rao, Hollywood Pancreatic cancer (PC) is relatively uncommon in Australia (2.7% of cancers, lifetime risk just over 1%). The incidence of PC is rising rapidly in WA (about 0.75%/year) and by 2030 it is expected to be the second leading cause of cancer deaths.

Pancreatic cancer is a disease of older individuals with the incidence peak in the seventh decade and unlike other gastrointestinal malignancies a shift to younger patients is yet to be observed. WA has amongst the world’s highest five-year survival rate for PC, but this remains dismally low (14% in 2017). The main contributors to the poor prognosis are late presentation (85% of patients have locally advanced or metastatic disease at diagnosis) and chemoresistance.

With current technologies, the low prevalence of PC makes average risk screening unfeasible; false positive rates would be high and cost prohibitive. Interest has shifted to high risk groups with a D-E-F (define, enrich, and find) paradigm proposed.

Three groups of interest Pancreatic cysts are common, identified incidentally in approximately 10% of those over 70 undergoing cross sectional imaging (i.e., “incidentalomas”).

Up to 15% of PCs may arise in mucinous pancreatic cysts.

Inflammatory and non-mucinous cysts have no malignant potential.

Importantly, the majority of incidental mucinous cysts carry a very low malignant potential. The clinical challenge is how to enrich this population.

Clinical, imaging and fluid analysis “high risk features (HRFs)” have been recognised and these dramatically increase the risk of a cyst harbouring malignancy.

These include a solid nodule (Fig 1), significant main pancreatic dilation, rapid growth, a symptomatic cyst, and high-grade dysplasia on cytology.

Evidence-based guidelines have been developed to focus on who, how and when to survey. They remain imperfect tools but, in general, recommend baseline clinical assessment and annual Ca19-9 and MRI for at least five years. Patients who have or develop HRFs undergo an endoscopic ultrasound (EUS) and fluid sampling (for cytology and molecular profiling). Using this approach, the majority of cysts referred for resection harbour malignancy or high grade dysplasia.

A family history of PC and specific germline mutations are known risk factors for PC (Table 1). Familial pancreatic cancer (FPC) accounts for 5-10% of cases of PC. These patients develop PC at a younger age and smoking is an amplified risk factor.

The risk of cancer depends on the affected relatives and the specific germline mutation (Table 1). Early evidence suggests annual surveillance with EUS detects cancers more frequently, at an earlier stage and improves three year survival. However, many questions remain unanswered (cost effectiveness, overall survival, effect of false positives) and in an attempt to address these an Australia-wide study has been established (https://www. pancreaticcancer.net.au/researchfamilial/screening-trial/).

Surveillance will include annual EUS, annual Ca19-9 and at some centres, annual MRI. The entry criteria include: • Age 50-80 • ≥ 2 blood relatives with PC. If two family members are affected, then both must be FDRs. If > 3 then at least one FDR, or • known genetic syndrome (such as Peutz-Jegehers, FAMMM, BRCA 1 with an affected family member).

However, individuals with type 2 diabetes for less than 12 months have a 5-8 fold relative risk of PC. Approximately 1% of individuals aged over 50 with new onset diabetes have PC. A fivefold increased risk for PC may not be sufficient to justify surveillance (given how common diabetes is) so further enrichment is needed.

Models are being developed with CT and EUS used as the “find” tools.

Prevention This can be helped by modifying risk factors for PC (e.g., smoking, obesity, fatty pancreas, and a diet high in saturated fat). It has been estimated that 21% of current and 15% of future PC burden in Australia is attributable to smoking and that 75% of abdominal malignancies could be prevented or favourably influenced by lifestyle modification (diet, exercise, alcohol, and smoking).

There is a great deal of interest in chemoprevention of PC. Metformin, aspirin and betablockers are some of the drugs being investigated with none currently in routine use.

In patients with genetic syndromes conferring a very high lifetime risk of PC (e.g., PRSS1 mutation) prophylactic total pancreatectomy is being offered at an age 10 years younger than the youngest affected relative. If the patient is non-diabetic, autologous islet cell transplantation is performed.

ED: By Dr Yusoff and Dr Rao are gastroenterologists, both working in Hollywood.

Author competing interests- nil

The relationship between diabetes and PC is multifaceted and not fully understood. Individuals with longstanding type 2 diabetes have a 1.5 fold increased risk of PC.

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We’re expanding,

Welcome Dr McRae

Introducing Dr Simon McRae

MBBS, FRCPA, FRACP Dr McRae is a senior consultant haematologist with over 20 years’ experience in both clinical and laboratory haematology. He has a focussed interest in thrombotic and haemostatic disorders, but also has broad experience in the management of malignant haematological conditions.

Dr McRae completed haematology training in Tasmania, New South Wales, and Scotland. He then undertook a 3 year clinical fellowship in venous thrombosis management at McMaster University, Ontario. He has worked as a consultant haematologist throughout Australia including time as the Director of Clinical Haematology at both the Royal Adelaide and Launceston General Hospitals.

He has a particular interest in the management of venous thrombosis and bleeding disorders and has been involved in clinical trials as a principal investigator for over two decades. He has over 50 peer reviewed publications and book chapters, and has been a contributing author to consensus international guidelines in his areas of interest. He has previously served on the executive of the Australian Society of Thrombosis and Haemostasis (ASTH now THANZ), and was chair of the Australian Haemophilia Centre Directors Organisation (AHCDO) for over 6 years.

Dr McRae believes strongly in providing clear information to allow patients to make informed decisions regarding their own management, and the tailoring of evidence based treatment to meet individual patient needs.

Our Haematologists:

Dr Maan Alwan, Prof. Ross Baker, Dr Peter Tan

Our Clinic: • Patient focused with family support & involvement • Tranquil setting • Clinical Trials • Allied Health

REFERRALS:

Email: info@whoc.com.au EDI: haemwest Fax: (08) 6146 1499

URGENT REFERRALS: Ph: (08) 6146 1440

Email: urgent.haem@whoc.com.au

Western Haematology & Oncology Clinics 18 Prowse Street, West Perth WA 6005 P: 08 6146 1400 E: info@whoc.com.au www.whoc.com.au 46 | FEBRUARY 2022

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rTMS opens a whole new field in psychiatry

By Dr Davinder Hans, Psychiatrist, Hollywood Since November 2021, rebates for repetitive Transcranial Magnetic Stimulations (rTMS) have become available for the prescription and delivery of up to 35 sessions (initial treatment course) and for the prescription and delivery of a retreatment course for patients experiencing improved symptoms during initial treatment course but with subsequent relapse in illness of up to 15 sessions.

It is rebated for patients over the age of 18 with major depressive disorder, who have tried at least two classes of antidepressants and remain unwell, and who have not received rTMS therapy previously.

The history of rTMS dates back to the 1790s in a number of bioelectricity experiments.

Galvani and Volta, considered the forefathers of electrophysiology, discovered that nerves can carry electrical energy deep within the nervous system. In the 1830s, Michael Faraday was influential in introducing the idea of electromagnetic fields, and this idea expanded 50 years later to showing that low-intensity electrical stimulation to the brain revealed that the cortex held a specific map for motor functions.

In the 1960s, magnetic fields were being used by scientists to stimulate human muscles, and, in 1985, Dr Anthony Barker created the first transcranial magnetic stimulation device.

He proved the ability of magnetic stimulation to influence the motor cortex by using a magnetic field to alter the brain’s electrical signals in this area and producing localised activation of the first dorsal interosseous muscle of the hand. This was done by applying TMS to the brain’s motor cortex in the opposite hemisphere, which controls the movements of that particular muscle. This is still how the resting motor threshold is obtained today.

In the 1990s, studies indicated that TMS was a safe and effective

Key messages rTMS is an effective, non-invasive treatment option for depression with a favourable side-effect profile in those suitably prescreened Contraindications for rTMS include a history of seizure disorder, intracranial ferromagnetic items, or magnetically programmed devices Further indications for the use of rTMS are currently being examined. treatment for depressive symptoms. The first Australian randomised controlled trials indicating efficacy were conducted in 1997. TMS therapy for depression was approved in Canada in 2003 and by the FDA in 2008.

TMS represents a painless and noninvasive treatment with minimal effects on a person’s daily routine.

The patient sits in a chair with a magnetic coil placed adjacent to their dorsolateral prefrontal cortex.

The coil creates a magnetic field inducing tiny electrical currents in targeted regions of the brain.

These electrical currents (also known as eddy currents) are then able to enhance the activity and signalling in the prefrontal cortex, which strengthens its ability to communicate and function with other areas of the brain that regulate mood.

There are several major contraindications when considering patients for rTMS – a history of a seizure disorder, the presence of ferrous metal in the skull or brain, or the patient having a magnetically programmable medical device such as a pacemaker.

tingling, spasms or twitching of facial muscles (during the stimulation), and light-headedness.

Serious side effects are rare and include seizures and mania (particularly in people with bipolar disorder). The referral process for rTMS should involve pre-screening to exclude these contraindications.

Electroconvulsive therapy (ECT) is another form of neurostimulation treatment that is well known and has proven efficacy for the management of depression particularly for severe depressive symptoms. While ECT is a safe and effective treatment for depressive symptoms, rTMS is less invasive and has a distinctly favourable side effect profile in comparison (including the patient being able to return to their daily activities immediately following a treatment).

Most rTMS devices use a coil shaped like a figure-eight to deliver a shallow magnetic field that affects more superficial neurons in the brain. The H-coil allows more widespread activation and a deeper magnetic penetration to structures such as the insula and is used in disorders such as obsessive compulsive disorder (studies are underway examining efficacy in disorders such as Anorexia Nervosa).

At present, the RANZCP guidelines endorse the use of rTMS for major depressive disorder, schizophrenia (for auditory hallucinations), and obsessive compulsive disorder.

TMS has also shown potential in other presentations including posttraumatic stress disorders, autism spectrum disorder, substance dependence, tinnitus and chronic pain disorders.

Author competing interests – nil

Side effects of treatment are generally mild and improve shortly after an individual session and, if present, decrease in incidence over the course of treatments.

They include headache, mild scalp discomfort at the site of stimulation,

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Reconnecting Together Older adults mental health has declined as a result of the COVID pandemic as living alone at home, isolated from their family and friends has led to higher rates of people suffering from anxiety and loneliness. GPs, especially, will be acutely aware of this patient cohort.

The flow-on mental health impacts are being addressed by the Federal Government with funding through the WA Primary Health Alliance for the program, ‘Reconnecting Together’, which aims to help both older adults and carers find support groups in their local community and be provided psychological counselling where appropriate.

The program is being offered in the metropolitan area by Clear Health Psychology, led by Principal Clinical Psychologist and Managing Director, Dr Maxine Hawkins, who has extensive public and private experience, both here and in Melbourne, in the areas of psychooncology, palliative care, cystic fibrosis, lung transplant, sleep disorders and chronic illness.

Clear Health Psychology has grown to 13 practices and 130 psychologists across the Perth metropolitan area.

Their psychologists work with children, adolescents, couples, and adults. They also have psychologists who have a special interest in supporting the psycho-social needs of older adults.

Dr Hawkins says, the Reconnecting Together initiative is a vital program that not only has wellbeing at its heart but, is also a preventative strategy to keep the elderly mentally motivated and independent.

“Ongoing connection to community is so important for the elderly. It also helps them to remember who they were and to draw on some of those qualities – those strengths and attributes – to enable them to continue to be that individual,” she said.

The program is free and can be easily accessed by a GP or allied health referral and also by self-referral (see links below). A dedicated project officer at Clear Health Psychology can help clients and doctors with the connection process.

The program aims to: • Reconnect older people (65+ and 55+ for Aboriginal and Torres Strait Islander people) with community networks.

• Restore access to services that may have been disrupted by the pandemic.

• Enable early intervention and, where appropriate, provide psychological therapies to improve mental health and wellbeing.

Dr Hawkins said the referral process has been streamlined, acknowledging that writing a referral can be an added burden to a busy GP, which is why the referral criteria has been widened to allow for self-referral.

But clients, GPs, and health professionals alike, need to be aware of the program.

Brochures are available from Clear Health Psychology and links to referral forms are on the practice website.

“Like any health promotion initiative, independent of how wonderful and marvellous it is, it does take time for people to firstly hear about it and secondly to incorporate it as standard practice.

GPs are becoming more aware of Reconnecting Together and we encourage them to remind their patients if they think they would benefit from it.

“If a GP mentions a program on a second or third visit, such is the respect in which they are held, that a patient is likely to take notice.”

As WA prepares to lift its borders and in preparation for increased COVID cases, Clear Health Psychology is well able to migrate its in-house services to telehealth.

“It is a critical time to keep helping older adults to feel connected and looking after their mental health. We are looking forward to helping as many older adults and their carers as possible with this wonderful WAPHA initiative.”

Completed referral forms can be faxed to 08 6313 6476 or emailed to agedcare@clearhealthpsychology.com

clearhealthpsychology.com.au/reconnecting-together 48 | FEBRUARY 2022

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The new age of automated insulin delivery systems for type 1 diabetes

By Dr Mary Abraham, Paediatric Endocrinologist & Researcher, PCH & TKI One hundred years after the discovery of insulin, technological advancements herald the dawn of a new era of automated insulin delivery systems for managing Type 1 diabetes (T1D).

Continuous glucose monitoring (CGM) devices with improved accuracy with reduced/no finger pricks are fully subsidised (federal initiative) and available to children and young adults up to the age of 21 years. These devices are inserted subcutaneously, last for 7-14 days and provide 5-minute glucose readings, with data available in real-time to the user to help make treatment decisions.

Continuous subcutaneous insulin infusion therapy involves constant delivery of rapid acting insulin through an insulin pump.

This includes basal insulin as background continuous insulin and bolus insulin delivered with meals and corrections. There is private health insurance coverage.

Insulin pump settings for basal and bolus insulin are programmed into the pump, based on the individual’s total daily insulin requirement and/or weight. These require to be adjusted with regular review of glucose levels as insulin requirement is variable, subject to diet, exercise, stress, illness etc.

Stand-alone pumps require the user to make diabetes-related decisions and have limited ability to adjust to individual needs.

CGM and/or insulin pumps have improved metabolic control, reduced glucose fluctuations, reduced time spent in hypoglycaemia and improved quality of life. In spite of these advancements, only a minority of

children and adults achieve the recommended HbA1c target of <7%, highlighting the need for newer therapies and interventions.

Automated systems Although CGM and insulin pump therapy were initially designed as stand-alone systems, further advancements incorporated algorithms to utilise CGM information (sensor glucose) to inform insulin delivery, paving the start of automated insulin delivery systems (Figure 1).

The first step was directed to minimise hypoglycaemia and algorithms were incorporated to suspend basal insulin delivery with hypoglycemia.

With Low Glucose Suspend, basal insulin delivery is suspended when sensor detects hypoglycaemia. The next step to prevent hypoglycaemia with Predictive Low Glucose Suspend switches off basal insulin delivery with prediction of hypoglycaemia. There are two systems currently available with predictive suspend: PLGM system (Medtronic 640G pump and its sensor) and Basal IQ (Tandem t:slim pump with Dexcom G6 sensor).

Further advancements increase automation, in the pursuit of a fully automated closed-loop system, also called artificial pancreas as it attempts to replicate the physiological insulin delivery dependent on ambient glucose levels in individuals.

Currently, available systems are semi-automated and referred to as hybrid closed-loop systems.

Basal insulin delivery is dependent on sensor glucose levels and is therefore automated. However, the

user manually boluses for meals and corrections. The Medtronic 670G was the first FDA/TGA approved system commercially available and has improved glycemic control.

Increasing trust in automation and user experiences has led to further advancements in algorithms with automated correction boluses and additional target set-points with improved user functionality. Closedloop systems such as Control-IQ (Tandem t:slim with Dexcom G6) and the advanced algorithm in Medtronic 780G deliver autocorrections and permit remote monitoring of glucose levels, an important feature for caregivers of children with T1D. These systems are anticipated to be available soon for clinical management.

There are several automated insulin delivery platforms utilising various combinations of insulin pumps, CGM systems and algorithms. Few are commercialised, with others in various stages of development.

Despite the promising efficacy, the latency in the roll-out of these systems, the limited capacity for algorithm individualisation and the expense have also led to a community of ‘do it yourself’ systems to improve glycaemic control.

In the pursuit of a fully automated system, studies are looking into incorporating physiologic data (food and physical activity) into the algorithms to provide more accurate predictions and to finetune insulin delivery. Automated multihormone closed-loop systems are also in development which deliver glucagon in conjunction with insulin to mitigate the risk of hypoglycaemia and increase the aggressiveness of insulin therapy.

Figure 1: Pathway to automation

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Converting Broome nacre into a bone substitute for orthopaedic use

By Professor Minghao Zheng, UWA Medical School & Perron Institute As people around the world are living longer, we are seeing an increased demand for bone substitutes and graft for surgical treatment of orthopaedic conditions. More than two million bone grafting procedures to treat bone defects are performed annually worldwide, making it the second most frequent tissue transplantation.

Ideal graft material is autograft from the patient’s own source but the need for extra invasive procedures for sourcing of autograft material, sometimes resulting in donor site morbidity, presents significant clinical and economic disadvantages. Allograft or xenograft (using biochemical processed bone sourcing from deceased people or from animals) have always presented a risk of transmitted diseases and potential immunogenic reaction.

Synthetic bone substitutes, on the other hand, have the problem of effective osseointegration. There is an unmet need to address the limitations of bone substitute and to improve its bio-functional properties.

Nacre is a natural organic-inorganic component, which forms the shell

Key messages An ageing population sees increased demand for bone grafting Autograft is ideal but there is a need for other options Nacre can be converted into a bone substitute material with enhanced biological performance. of molluscs, such as pearl. This process shares an equal position with the animal and human bone formation as the only two natural bio-mineralisations ever discovered.

Inspired from an intriguing archaeological discovery of ancient Mayan skulls, which have perfectly fitting teeth made of nacre that radiographs showed had roots perfectly integrated into the surrounding bone, the marriage of bone and nacre has been highlighted as a promising solution to a shortage of bone implant materials.

A study at the University of Western Australia by Dr Rui Ruan and myself has shown that nacre possesses potent osteogenic properties and could potentially be suitable as a

source for bone substitute material.

Others have also shown that there are bioactive components in nacre that have potent osteogenicity to grow human bone.

Broome is the home of Australian South Sea Pearl production. Pearl production is the primary objective of the industry and a large quantity of shells, nacre, is produced as byproduct.

The study discovered that nacre from Broome was rich in trace elements and free of any environmental contamination, and the best in enhancement of biomineralisation and bone formation. The team has subsequently developed a patented technology of using nacre to make a bone substitute named PearlBone.

In the preclinical study of a rabbit critical bone defect model, PearlBone displayed better bone healing efficacy when compared to the most commonly used bone substitute, hydroxyapatite.

A Broome-based biotech company, Marine Biomedical, has now been established based on the PearlBone technology. The company will use nacre from Broome to manufacture PearlBone under the good manufacture practice (GMP) guidelines to obtain FDA market authorisation of the product for orthopaedic use. This is the first medical manufacturing company set up in Kimberley region and will shine a light on the local pearling industry.

Author competing interests – Author is the inventor of the product described

Bone healing process after the implantation of nacre-coverted bone substitute

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FEBRUARY 2022 | 51

Real-time in vivo endomicroscopy: endless possibilities

By Prof Camile S. Farah, Oral Physician & Pathologist, Nedlands Technological advancements such as automation, robotics and artificial intelligence are driving the fourth industrial revolution. These same principles and technologies are finding their way into clinical practice and have the potential to revolutionise patient care.

A technology that has broad clinical application in medicine, surgery and pathology is realtime in vivo endomicroscopy, a minimally invasive technique for obtaining histology-like images from inside the body, also known as optical biopsy. In endoscopic terms, it replaces the camera with a microscope.

One such platform is based on miniaturised confocal laser endomicroscopy (CLE) the size of a pen, producing in vivo high resolution digital images of cellular and sub-cellular structures at a thousand times real magnification without the need for tissue biopsy or laboratory processing, providing diagnostic information in real-time at the point of care.

Embedded within the tip of the miniaturised probe is a mechanical scanner, comprising a pair of lenses that focuses blue laser light (488nm) up to a depth of 800µm (Fig 1).

Fibre optic-based confocal endomicroscopes fall into two broad categories based on the

Figure 2

52 | FEBRUARY 2022

position of the scanner compared to the light guide (either proximal or distal) and the composition of the fibre optic probe (either single or bundle), each with distinct advantages and disadvantages.

Single-fibre distal scanning endomicroscopes (so called endoscope-based eCLE) offer higher image quality and resolution with variable focal depth allowing imaging over a wider range, while bundle-fibre proximal scanning endomicroscopes (so called probed-based pCLE) benefit from their smaller size.

Confocal imaging can be based on tissue reflectance or fluorescence. Fluorescencebased endomicroscopes can be used with a variety of topical or intravenous contrast dyes, and can image cervix, colon, brain, breast, lung, kidney, liver, eye, oesophagus, muscle, tendon, and oral cavity amongst others (Fig 2). The platform can be used for pathological diagnosis, surveillance of disease processes, monitoring of drug distribution, and surgical margin clearance.

Commercially available CLE platforms can generate PACScompliant DICOM 3D datasets which are streamable over local or remote networks enabling off-site assessment and truly integrated digital pathology workflows

Figure 1

between surgeon and pathologist.

3D video reconstructions enable better understanding of disease processes.

Likewise, the platform can be used in outpatient clinics for cutaneous or mucosal lesion assessment, or for inpatient procedures such as endoscopy, colonoscopy, cystoscopy and bronchoscopy, given the miniaturised lenses and scanners found at the distal tip of probes. These can easily access endoscopic working channels. In essence, the platform brings together the strengths of diagnostic imaging and tissue histopathology in the palm of one’s hand.

The technology has been assessed in a wide variety of human tissues and can easily differentiate normal tissue from cancer and pre-cancer (Fig 3), but also has wider applications in pharmacotherapeutics, vascular anomalies, and studying the microbiome.

In oncological surgery, it can detect residual disease and more accurately determine clear surgical margins and has the potential to minimise adverse effects of adjuvant therapies. Images are comparable to traditional histopathology enabling visualisation of architectural, cellular, and subcellular features including cellular crowding, nuclear and cellular pleomorphism, and altered

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epithelial stratification in a manner similar to standard histopathological examination (Fig 4).

Coupling the technology with fluorescence-tagged specific disease biomarkers, it has the potential to detect the presence of lesions and determine their surgical clearance, enabling live molecular imaging at the cellular level, and bring us closer to patient-centred precision medicine.

Future applications include image segmentation, machine learning and artificial intelligence to generate quantitative readouts of pathological processes in a manner similar to that seen in automated radiological, cytological, and histopathological data-driven approaches. Potential applications are only limited by the user’s imagination and the clinical need.

Figure 3

– References available on request Author competing interests – the author is Managing Director of Optiscan Imaging Limited (ASX: OIL), an Australian-based developer, manufacturer, and vendor of single-fibre distal-scanning fluorescence confocal endomicroscopes for clinical and research applications.

Figure 4

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CLINICAL UPDATE

Rethinking dairy intake

By A/Prof Therese O’Sullivan, ECU, & Analise Nicholl, Dietitian Whole-fat dairy products are just as healthy for children as reducedfat* equivalents, according to a new study led by researchers from Edith Cowan University (ECU) in a project called the Milky Way Study.

left them wanting more, and they ended up getting the extra calories from other, potentially less healthy options.

In addition, dairy products may lose some important nutrients after processing to remove the fat, for example, omega-3 fatty acids which can contribute to heart and brain health. Wholefood milk, cheese and yoghurt all contain live cultures, or probiotics, largely associated with dairy fat. The considerable health benefits of fermented dairy products can be reduced or lost when dairy products have fat removed, or when plant-based alternatives are used.

The study aimed to shed some light on the common thinking that, from two years of age, children should switch to lower-fat dairy products to prevent weight gain and cardiovascular problems later on.

The researchers noted that several decades of public health concerns that the excess calories and saturated fat content in wholefat dairy products could cause weight gain and cardiovascular disease have undermined belief in the health benefits of this food group. As a result, parents can be confused about which types of dairy products are the best choices for their kids.

Updated Australian Dietary Guidelines are currently in the pipeline, and it is hoped the Milky Way Study can contribute useful information to help inform decisions about the new paediatric guidelines. The study measured, for the first time, how children’s obesity, body composition, blood pressure and blood biomarkers were affected by changing to lower-fat dairy consumption. Over a three-month period, 49 healthy children aged four to six were randomly allocated into one of two groups. One group received whole fat dairy products in place of their normal dairy intake, whereas the other received reduced-fat dairy products.

All products were provided free and in plain packaging, to keep families and researchers blind to each child’s dairy group.

Key findings of the study were that, regardless of the type of dairy consumed, children ended up consuming the same total amount of calories per day and did not experience any significant differences in body fat or cardiovascular health markers.

Key messages It has been assumed that low-fat dairy is better for children Parents can be confused by mixed messages New work shows that full fat dairy may be a better option for children than lower-fat dairy. *Note: whole-fat milk = 3.4% fat; fatreduced milk can range from 50% fatreduced (around 2% fat: Hilo milk), all the way to low-fat and then skim milk (around 0.1% fat). We use the term ‘reduced-fat’ to describe our largely 50% lower fat products.

It had previously been thought young children would benefit from low-fat dairy products due to their lower levels of saturated fats and lower density of energy, in turn helping avoid obesity and risk of associated cardiometabolic diseases.

The results suggest healthy children can safely consume whole-fat dairy products without increased obesity or adverse cardiometabolic effects.

The findings of this new study may help parents decide on what dairy products their children can safely consume, opening the door to regular consumption of whole-fat products.

Researchers are now looking at other questions around this topic, including investigating changes in levels of fatty acids in the children’s blood samples before and after they changed to the Milky Way Study whole-fat or reduced-fat dairy products. Here, their goal is to establish if there is a link between levels of individual fatty acids – whether saturated, unsaturated or polyunsaturated – with cardiometabolic health risk. Other projects are looking more closely at what food choices kids make when following a diet based on low-fat dairy products, and how different dairy fat levels affect a child’s gut microbiome.

ED: Analise Nicholl is an accredited practising dietitian and a PhD candidate at ECU. Author competing interests –the authors were involved in the study mentioned.

The logic behind these findings is that there may be differences in levels of satiety between children who consume whole-fat vs lowfat milk. In other words, giving children low-fat dairy products

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CLINICAL UPDATE

Familial hypercholesterolaemia – more common than we realise

By Dr Tom Brett, GP & Academic, University of Notre Dame Despite almost 40 years elapsing since Brown and Goldstein’s 1985 Nobel prize in Physiology or Medicine for their ground-breaking research concerning the regulation of cholesterol metabolism, awareness among the general public and health professionals about hereditary conditions such as familial hypercholesterolaemia (FH) remains low.

Early diagnosis in children at toddler immunisation stage, or even newborn screening, offers opportunities for reverse cascade testing to parents. This approach facilitates diagnosis of the transmitting parent, the commencement and maintenance of appropriate treatment for the parent and the future treatment of their child from age 8-10 years.

With a one in 250 general population prevalence, Australia has 100,000 individuals with inherited FH. Currently less than 10% are ever diagnosed and most remain untreated. The situation is similar worldwide with up to 40 million affected.

Diagnosis in the toddler with potential to save the life of the FH-affected parent is a powerful argument for this approach. Such early diagnosis allows time to plan and reduce the cumulative cholesterol burden from a young age while simultaneously adding decades of healthy life and the associated socio-economic and societal benefits.

The increased cholesterol burden is present from birth, with individuals at increased risk of premature heart attacks and death due to the progressive accumulation of atherosclerotic cardiovascular disease (ASCVD).

Inheritance Early detection and lifelong management are the keys to successful treatment and normal life expectancy. About 50% of firstdegree relatives of newly diagnosed index cases will also inherit FH, mainly due to a defect in receptors on their liver cells responsible for removing the ‘bad’ cholesterol (LDL-c) from the circulation. Diet and exercise alone are insufficient to manage it.

Cascade testing of first- and second-degree relatives in a wellorganised, systematic manner offers the best opportunity for diagnosis and treatment. The Consensus Statement of the European Atherosclerosis Society and the International FH Foundation recommends that most FH patients be managed in primary care and preferably in the family context.

Provision for management of more complex cases including pregnant women and children should involve specialist FH clinics. A shared-care approach with the patient’s GP is the ideal.

Treatment & genetics The mainstay of treatment is with statins (based on clinical trials) capable of reducing LDL-c levels by 25-55% when taken regularly; initiation and adherence remain major challenges.

The risks from myocardial infarction and stroke can be reduced. Patient resistance to statins occurs but evidence from randomised trials shows that major side-effects are rare. Most adverse reactions can be managed by switching statins and employing non-statin therapies (e.g., Ezetimibe).

CSK9 inhibitors facilitate the recycling of LDL receptors to the surface of hepatocytes, thereby clearing 60% LDL-c from the circulation. A downside is their two- to four-weekly injection requirements, expense and limited access on the Australian PBS. Other novel, emerging treatments for FH include Bempedoic Acid (now FDA approved.). It acts upstream of statins inhibiting cholesterol production with no effects on striated muscle or myalgia. Inclisaran (another injectable medication) reduces hepatic synthesis of PCSK9 utilising small interfering RNA therapeutics.

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Results from Orion trials show that inclisaran can achieve over 50% reduction in LDL-c levels when combined with statins and/or ezetimibe. Its twice yearly injection and minimal side-effects has potential for less polypharmacy and greater treatment adherence.

The advent of genetic testing for FH on the Australian MBS in May 2020 marked an important landmark opportunity for more accurate diagnosis of FH. Patients meeting FH phenotypic criteria (score of 6+ on the Dutch Lipid Score) can be referred to specialist who can authorise genetic testing.

If genetic mutation is positive, the GP can initiate subsequent genetic tests among first- and seconddegree relatives. Appropriate preand post-test counselling should be provided to such relatives.

Genetic testing offers diagnostic precision thus facilitating subsequent cascade testing. It also offers GPs a more defined role in recognising close family relatives likely to benefit from genetic testing while also encouraging greater involvement in ongoing care management at the primary care level.

FH is recognised by the UK National Institute for Health and Clinical Excellence (NICE) as the exemplar for personalised medicine – getting the most appropriate medicine to the right patient at the right time for the best outcome.

Implementation requires a seamless and adequately funded model of care between general practice, genetic, and specialty services.

– References available on request ED: Dr Brett is the Director of General Practice and Primary Health Care Research at the University of Notre Dame.

The author is Lead Investigator on NHMRC Partnership Grant, part sponsored by WA Department of Health, into ‘familial hypercholesterolaemia in Australian general practice.’

FEBRUARY 2022 | 57

Hockey is the bee’s knees The Access Cardiology Western Hockey Masters Gala Day at Perth Hockey Stadium late last year saw some of WA’s legendary masters hit the field to highlight the wonders of modern medicine.

The annual Bionic Cup, a field hockey match played between knee and hip replacement recipients, was expanded in 2021 to include the Survivors Cup, which saw players who have had heart problems pitted against those who have had cancer.

In its sixth year and supported by Medical Forum, the Bionic Cup’s record now stands at three-all after the Knees defeated the Hips 2-1 on December 15.

The Hearts claimed the inaugural Survivors Cup, with another 2-1 score line in their favour against Team Cancer.

Players were in good hands on match day, under the eye of senior exercise physiologist Dr Brendan Joss from Health Function Rehabilitation Care.

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SPORT

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SPORT

for life, with people of all ages competing regularly.

Team Knees captain David Lockett acknowledged that although his side missed some chances, after years of experience, their efforts were more controlled across the board.

“We encourage people of all abilities and ages to come and play because hockey’s a social game more than anything,” he says.

“I think we had a bit more dominance over them this year and we were a little bit more controlled around the back and the midfield,” he says.

“We have people up to 80-yearsold now playing international matches at Masters tournaments.”

Hearts captain Heath Tyrell says his side performed well under the circumstances.

“We had 14 players who hadn’t really played together before this match,” he says.

“We started off scratchy and went one-nil down, but we managed to gel and bring it back to two-one in our favour, so a really good effort from the Hearts team.”

Both captains and their sides are competitive on the field but

share the same sentiment that the biggest prize is being able to continue to play the sport they love, regardless of age or ability.

“I’ve been playing for 57 years but anytime you can go out there at this age and play hockey with your mates is an absolute bonus,” Lockett says.

Tyrell agrees that hockey is a sport

Alongside the two key fixtures are the Masters All-Star Games, with hopes to further add to the gala day in the future.

Hockey WA CEO Fabian Ross says the event has grown year after year.

“We have a really strong Masters contingent here in WA, so for them to be able to play in such a spectacle is great for the sport and especially for those competing who have overcome these life-changing surgeries,” he says.

The Australian Orthopaedic Association president, Dr Annette Holian, says the tournament provides not only the orthopaedic profession, but the medical profession as a whole, a chance to reflect on the significant contribution that modern medicine and surgical techniques make to thousands of people each year.

“Being able to enjoy the freedom of movement, let alone undertake sporting endeavours, wouldn’t be possible without significant advances in prosthesis technology and the improvement of surgical technique over the past 85 years,” Dr Holian says.

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FEBRUARY 2022 | 59

PERTH FESTIVAL

Festival celebrates the ocean Paying homage to the ocean, this year’s Perth Festival looks out across the horizon and into our hearts.

Some days it’s easy to forget we actually live on an island. Granted it’s a big one, but we’re still surrounded by ocean. Living in Perth, our collective psyche is very much attached to the water – the river, the odd dam and swimming pools, but most significantly, the beach and that blue ocean.

As a child, Perth Festival director Iain Grandage remembers summers of peeling skin, endless days at the beach, the Rottnest ferries that rocked and rolled and the cleansing afternoon breeze. Then there’s the feeling of sitting under an endless blue sky, watching the blazing sun set and how at the close of a hard day an ocean swim can refresh and replenish the spirit like nothing else.

It’s what makes the theme of the third part of the elemental cycle of Perth Festival 2022 not only perfect but multi-faceted.

This year, the festival celebrates wardan, the ocean.

“The ocean is many things – peaceful respite and calm or a place of danger or barrier,” says Grandage. “I’ve always found it a place of freedom and play, but for many migrants it’s water which can prevent a new life beginning. That great expanse to our west is full of mystery and the unknown depths – we stare at it with wonder.”

That richness includes a program which looks at the ocean in a literal sense through to those vast internal oceans, littered with shared experiences, traumas and triumphs.

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Grandage says the closing event will allow people to fully celebrate the Noongar stories of the ocean in a very tranquil way.

Other works and events in the festival celebrate the ocean in overt and more subtle ways from the Strangers on the Shore exhibition using artefacts from the WA Maritime Museum and the WA Symphony Orchestra and WA Youth Orchestra debuting Become Ocean to the world premiere of Panawathi Girl by David Milroy, Meyne Wyatt in City of Gold, and Mary Stuart, adapted by WA playwright Kate Mulvany and starring Caroline Brazier and Kate Walsh.

This year’s festival once again showcases and celebrates WA talent as well as some national and international visitors working alongside locals offering fresh perspective, new energy and mutual learnings.

In this festival, Grandage is particularly proud of the big community event Noongar Wonderland at Perry Lakes, which at the time of publication was due to close the festival. Unfortunately, the opening event, Escape in Fremantle, was cancelled due to COVID. Noongar Wonderland is a multisensory experience guided by the stories of country and ocean. As ancient meets the future, audiences are invited to wander between the lakes and take part in a dance party or sit with an artist and handcraft something age-old and new.

“This festival program also seeks to recognise the profound longing and difficulty of being separated from loved ones that has marked these COVID times. The ocean has kept us safe but also distanced us. We hope what we’re building helps recognize the strength of our community here because in the end, hope is what we hold onto and helps define our future,” Grandage says.

ED: Perth Festival events were correct at time of publication but are subject to change due to COVID. For all event details: www.perthfestival.com.au

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By Ara Jansen

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WINE REVIEW

Fermoy Estate marches on This significant Margaret River wine estate continues on its path to greatness.

My review in 2012 highlighted improvements and, under the vastly experienced winemaker Jeremy Hodgson since 2015, this last tasting has seen these wines come to fruition.

Fermoy Estate was planted in 1985 in Wilyabrup, in the heart of the region.

Their 27ha of vines include all the mainstream varieties of the region – Semillon, Sauvignon Blanc, Chardonnay, Cabernet Sauvignon, Merlot and more recently Shiraz. The wines are marketed in several quality levels (and price brackets).

Fermoy Margaret River 2021 Semillon Sauvignon Blanc (RRP $25) The slight dominance of Semillon (58%) gives this blend the ‘Margaret River stamp’. It shows vibrant fruit aromas, with the pungency of Sauvignon Blanc and the ‘fresh cut grass’ character of Semillon shining through. However, there is more than fruit character, with the Sauvignon Blanc component fermented and matured in oak and the wine left on yeast lees, which all adds a texture and complexity. Palate shows green apple and stone fruit, and a lemon curd character from winemaking intervention. Minerality and firm acidity give structural integrity.

Good current drinking but has the substance to go for several years.

Review by Dr Craig Drummond Master of Wine

Fermoy Margaret River 2021 Rose (RRP $25)

Fermoy Margaret River 2018 Chardonnay (RRP $35)

Shows an attractive salmon pink colour, fragrant lifted aromas of raspberries, rose water and fruit pastilles. Palate is dry and spicy, with redcurrant and raspberry, and a savoury background. Made with predominantly Shiraz grapes, with a small addition of Chardonnay and Pinot Noir. A portion of the blend fermented and matured in oak and left on lees, the remainder fermented at cool temperatures in stainless steel to give aromatic fresh fruit characters. Drinking well now with good length and clean finish.

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.

Fermoy Margaret River 2017 Cabernet Sauvignon (RRP $45) Beautiful deep red with a beetrootpurple meniscus reflecting its youth.

Nose is loaded with cassis and cigar box from oak. Fine grained powdery tannins and firm acidity give structure. A classical Margaret River Cabernet from a cooler vintage, which translates to slower ripening fruit, higher acidity and more restrained fruit characters, but often resulting in longevity. I would give this wine 15-20 years.

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'S EWER REVI

PICK

Fermoy Margaret River 2018 Shiraz (RRP $30)

It is unexpected that I would rate Margaret River Shiraz ahead of Cabernet, but here we are, this is my wine of this tasting. The Cabernet is a close second. Again, a product of that cracker 2018 vintage. It displays a beautiful ruby colour. Nose abounds with white pepper, cinnamon spice, fragrant violets and blueberry. Palate is supple, long and complete. Full fruit flavours of sweet red berries, with varietal pepper and spice. With fine-grained tannins, it is balanced, intense, long on the finish and a great wine.

FEBRUARY 2022 | 61

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