Medical Forum – March 2021 – Public Edition

Still searching PATIENT TRIALS HOLD THE KEY

Pain Management Living with pain, CRPS, metabolic health, spinal surgery, vaccines

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March 2021 www.mforum.com.au

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

Pain – it's personal Pain control is one of the possible uses for medicinal cannabis, which we also feature this month, with its developers arguing it holds real promise in the treatment of many diseases.

It’s not surprising some people struggle when asked to rate their level of pain on a scale of one to 10.

Is it preferable to be stoic and pick a low number or is it best to go right to the top end to ensure your pain is taken seriously?

Yes, pain is subjective.

A few years ago, I was brought crashing down to earth by a herniated cervical disc which caused excruciating pain (okay, I rated it 9 out of 10). Heavy-duty drugs barely made a dent, and the recovery was slow.

But the experience gave me a small insight into what people with chronic pain have to endure.

This month, we explore a range of perspectives on pain, from the management of fibromyalgia to new approaches to help people live with pain rather than looking for a magic bullet.

Pain control is one of the possible uses for medicinal cannabis, which we also feature this month, with its developers arguing it holds real promise in the treatment of many diseases.

But our e-poll of subscribers suggests many doctors want more evidence, and that could come from the dozens of clinical trials underway.

Pain comes in all shapes and sizes and is no stranger to two of our guest columnists. After suffering horrific injuries in a cycling accident, Dr Bruce Powell was forced to re-invent himself.

And Catherine Hughes channelled grief from losing her baby son Riley to whooping cough into muchneeded advocacy for vaccination, and how timely is that right now?

SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission.

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MARCH 2021 | 1

CONTENTS | MARCH 2021 – PAIN MANAGEMENT

Inside this issue 22 14 10

18

FEATURES

NEWS & VIEWS

LIFESTYLE

10 HBF’s new horizons

1

Editorial: Pain – it's personal – Cathy O’Leary

48 Health histories in

In the news

50 Outdoor cinema fun 51 Film giveaways: French Film

– Cathy O’Leary

14 Close-Up: Dr Erik Hagen – Ara Jansen

18 Cannabis research – Karl Gruber

22 Living with Pain

4 6 8 30 35

In brief

WA’s new museum

Festival and French Exit

IUD warning COVID vax update

52 Christmas socials

Reflections on pain

Win...

For your chance to win this month’s movie prizes, click on the competitions tab on www.mforum.com.au or enter via our new Medical Forum Weekly newsletter, delivered to your inbox.

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CONTENTS

PUBLISHERS

Clinicals

Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au

ADVERTISING Advertising Manager Andrew Bowyer 0403 282 510 andrew@mforum.com.au

EDITORIAL TEAM

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36

38

40

Iron deficiency & iron infusion S. Nichol RN et al

Complex Regional Pain Syndrome Dr Philip Finch

Medicinal cannabis for chronic pain Dr Matthew Moore

Metabolic health – can lifestyle measures deliver?

Kirsty Woods

41

42

45

Computer navigation in spine surgery Dr Paul Taylor

Digital transformation of medical education Dr Ramya Raman

Temporomandibular joint disorders Dr Amanda Phoon Nguyen

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

Guest Columns

Clinical Services Directory Editor Karen Walsh 0401 172 626 karen@mforum.com.au

GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au

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28

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CONTACT MEDICAL FORUM

‘Believe me and my pain’ Pip Brennan

As luck would have it Dr Bruce Powell

Vaccination not vaccines that save lives Catherine Hughes

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

32 Fibromyalgia and neuroinflammation Dr John Quintner & Melanie Galbraith

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MARCH 2021 | 3

IN THE NEWS

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Brain-drain warning One of Perth’s leading researchers has warned of a brain drain and fewer medical discoveries unless the Federal Government boosts its research investment.

The Association of Australian Medical Research Institutes president, Professor Jonathan Carapetis, who heads the Telethon Kids Institute, said decades of investment in medical research had guided Australia’s response to COVID-19, averting the public health catastrophes that had occurred in most other countries.

But its world-class medical research sector faced an uncertain future, as the economic impact of COVID-19 caused declines in philanthropy, gift-giving, and revenue from international education. Professor Carapetis said the anticipated decline in research funding meant fewer medical research careers could be supported, and fewer new discoveries and treatments would be developed.

As part of the 2021-22 Budget, AAMRI is calling for an additional 300 investigator grants to be funded and targeted at early to mid-career researchers.

Pain, pain, go away Australian researchers are pioneering cell replication techniques which are set to fasttrack chronic pain research.

Flinders University scientists have for the first time established a sensory neuron model able to massproduce two types of key sensory neurons involved in pain sensation.

Usually, the neurons need to be isolated from animals and, because they involve a wide variety of cell types, it is difficult to collect large amounts. But using a new technique, researchers have found a way to reproduce millions of cells, providing ample resources for

Of local note, UWA Professor of Paediatrics Peter Le Souëf was the first witness in the court case providing expert testimony on the damage to children’s health from exposure to second-hand smoke.

testing thousands of samples or potential drug libraries.

Local doctor helps to butt out Last month marked 30 years since a landmark Australian court decision on second-hand cigarette smoke which led to people now being able to work in offices or dine at a café without smoke drift.

Federal Court Justice Trevor Morling handed down a judgement on February 7 1991, finding that secondhand smoke caused lung cancer in non-smokers, and asthma attacks and respiratory disease in children.

Animal fire victims Hollywood Private Hospital has donated medical equipment to Give Our Strays A Chance to help treat animals injured in the recent fires north-east of Perth. The charity appealed for medical supplies to distribute to wildlife rescue groups continued on Page 6

Pandemic conditions?

Research led by the University of Western Australia has revealed that climate change, environmental degradation of land and human activity are creating a breeding ground for viruses such as COVID-19 and there may be an even deadlier pandemic on the horizon.

Scientists say COVID-19 has made it imperative to understand how critical it is to reduce human impacts on the environment, such as the consumption of products associated with increased deforestation and unsustainable agricultural practices, to prevent the occurrence of pandemics.

4 | MARCH 2021

Dr Kirsten Martinus from UWA’s Department of Geography and Planning said as the global population had increased in the past

50 years with humans encroaching into areas of high biodiversity, so had the occurrence of diseases such as Ebola, SARS and COVID-19.

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The Injury Prevention Summit 2021 will be held at the Duxton Hotel on March 25, showcasing the state’s injury prevention and safety promotion activities.

Registrations close on March 18. www.knowninjury.org.au/ summit2021

Construction has started on Brightwater Inglewood which will include a contemporary 128-bed residential aged care community, a dedicated research centre and a corporate office. It is expected to be completed in April next year.

Multiplex has been awarded the Early Contractor Involvement tender on the Joondalup Health Campus Development Stage 2. If it gets the go-ahead, the project will be finished by late 2025 at a cost of $256.7 million.

IN THE NEWS explain why older people and men are more at risk from the disease.

continued from Page 4 treating animals injured and burnt in the fires.

Hollywood registered nurse Jo Slater organised a carload of medical equipment and surgical supplies that were past their expiry date to donate to the cause. It included bandages, syringes, bloodtaking equipment and gloves. Chief Executive Peter Mott said it was a great outcome for the hospital’s expired medical equipment to be used to treat injured wildlife.

An observational study by researchers including Telethon Kids Institute and Curtin University found that older people and men tend to have more of the receptor ACE2 on the cells of their lower lungs, which may go some way to explaining their higher risk of COVID-19.

Their study, published in Respirology, also found that asthmatics tend to have fewer ACE2 receptors on their lungs which might help explain why a relatively small number of them suffer from severe COVID-19.

Heart-to-heart All in the detail

The Heart Foundation wants health services to resume face-to-face cardiac rehabilitation to ensure heart attack survivors complete the program.

A survey found 73% of survivors who attended a cardiac rehabilitation program in person in the past six months completed the whole program, compared to only 14% who completed the sessions via telehealth.

Older … and male A virus receptor which allows COVID-19 to get into our cells could

A budding scientist using his chemistry skills to drill down into the fine detail of molecules is one of three students to be awarded prestigious Forrest Scholarships to carry out research at the University of Western Australia.

Wei-Ming (Sean) Li will focus on developing greater understanding of the structure of tiny molecules that scientists often struggle to observe in minute detail. He will examine molecular bonds to understand how chemicals within cells of small organisms mix and react together.

New modelling by the University of NSW predicts demand for cancer surgery will rise by 52% within two decades, with low-income countries bearing the greatest burden. Researchers estimate the number of cancer cases needing surgery will rise from 9.1 million to 13.8 million from 2018 to 2040.

The WA Rural Health Conference is being held on March 27-28 at the Perth Convention and Exhibition Centre, with the theme Lessons from Past Disasters. www.ruralhealthwest.com.au

Kudos for Ishar The Mirrabooka-based Ishar Multicultural Women’s Health Services is a finalist in the inaugural HESTA Impact Awards for sustainability, gender equity, diversity and health. The awards are aimed at health and community services taking positive steps to create more equity.

Ishar was one of four finalists in the category of Outstanding Organisation, recognised for its impact on improving health outcomes and patient wellbeing. Judges said the service provided inclusive, holistic and culturally sensitive services for refugee and migrant women.

6 | MARCH 2021

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IN BRIEF

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Iron deficiency & iron infusion: a QoL survey Introduction Iron deficiency is the most common nutritional deficiency in developing and developed countries1. It can affect any age and stage of life. More than 1 million Australians were iron deficient or anaemic in 2016.

The most common cause of anaemia is iron deficiency, which is recognised as a cause of underperformance2.

Patients often present with non-specific symptoms of fatigue, poor cognitive function or exercise intolerance.

Physical symptoms include restless legs or dizziness. Investigations reveal iron deficiency. If left untreated, patients will become anaemic. This is preventable if their iron deficiency is managed.

Most patients will be given oral supplements. Intravenous iron is indicated when oral iron is ineffective, not tolerated or there is a need for Table 1 Physical symptoms 1. Fatigue 2. Irregular heartbeat 3. Shortness of breath 4. Cold hands/feet 5. Decreased appetite 6. Strange cravings 7. Tingling/crawling feeling in the legs 8. Tongue soreness 9. Weakness 10. Dizziness 11. Altered Mood

rapid replenishment3. Newer iron preparations allow for infusions to be given in infusion clinics and GP practices. Patients referred to the WA Specialist Clinic undergo prescreening and are asked about their symptoms and their impact.

The study focus was to see if patients reported an improvement in symptoms and quality of life post-infusion rather than outcomes being based purely on ferritin and haemoglobin levels.

Methods A survey was developed listing 11 symptoms which patients scored from 0-10 (Table 1). There were also two questions asked to identify the statement that reflected their energy levels and impact on achieving daily tasks (Table 2).

Patients completed the survey on their infusion day, and again four weeks post-infusion. Participants were: • Patients attending the clinic aged between 16-70 years.

• Pregnant women / patients attending to manage chronic conditions were excluded.

• 96% of the participants were female (representative of clinic demographics).

• 270 initial questionnaires were distributed over two, three-month periods.

• 122 patients completed the post infusion questionnaire.

• 45.18% completed both questionnaires.

Table 2 1. How much energy do you have?

Full of energy Usually full of energy Occasionally energetic Usually tired and lacking energy Always tired and lacking energy 2. If your energy levels are decreased does it impact on household tasks?

I don’t need help

By S. Nicholl RN, L. Power RN, Kylie Elliot RN, C. Henson RN, C. Allen EN, Dr P. Kruger, Dr C. May, Dr R. Tampi The WA Specialist Clinic, 310 Selby St North, Osborne Park The scores for each symptom were added together and the sum of the score was compared pre and postinfusion.

The results demonstrate a decrease in symptoms pre and post-infusion. But the sample size was not large enough to demonstrate a statistical difference in outcomes. Median scores were also compared.

The largest decrease in median score was noted in the symptoms of weakness where the score decreased from 7 to 2. The median scores also did not demonstrate a statistical difference.

Discussion The study demonstrates that the improvement of symptoms after iron infusion are as important as restoring iron balance.

Patients’ additional comments included frustration at having to endure low iron stores for long periods, being treated with iron tablets which they could not tolerate, and when their iron stores were in the low normal range, they had difficulty accessing iron supplementation.

Conclusion The study shows a reduction in the severity of the patients’ symptoms.

However, the sample size in this instance was too small to achieve the statistical outcomes that were predicted. Iron is an important element in many biochemical pathways.

Low iron levels are known to impact negatively on several conditions including heart disease and irritable bowel disease. Iron deficiency leads to many of the debilitating symptoms patients describe. Clinical assessment, including discussion regarding the impact on quality of life should be central in assessing iron deficiency.

ED: Full article with comparison graphs, and references are available on request.

Occasionally need help with some tasks Need help with some tasks each day

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200 Patient Results: 9371 4340 For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

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MARCH 2021 | 7

IUD advice A review by Perth sexual health clinicians has found a possible link between intrauterine devices in women becoming unexpectedly dislodged and the surging use of menstrual cups.

Cathy O’Leary reports Doctors at Sexual Health Quarters in Perth started tracking clinic data last year after noticing reports of a phenomenon of IUDS being expelled in women who used the rubber or silicone cups to collect blood during their period.

The reusable feminine hygiene products have rapidly grown in popularity in Australia because they are considered an eco-friendly and cost-effective alternative to tampons and sanitary pads.

Dr Matilda Oke and her colleagues reviewed 520 patients who had an IUD inserted in the 12 months from January 31, 2019, with the majority using Mirena hormonal IUDs (67%), followed by 28% with Copper T standard IUDs. By the end of the follow-up in June last year, 22 of the IUDs had become unexpectedly dislodged, with almost half of them occurring in women who used menstrual cups and many of them noting that the IUD had been expelled at the time the cup was removed.

Dr Oke said her team believed there were two possible mechanisms that explained the IUDs becoming inadvertently dislodged.

One was that when women removed the menstrual cup, it might catch the IUD strings, and the other was that menstrual cups might apply a negative pressure to the cervix which could dislodge the IUD. 8 | MARCH 2021

Dr Oke said although they could not prove a causal link, they wanted to raise awareness among women and health care professionals of the potential for IUDs to be dislodged.

“We’ve seen a huge increase in the number of women using menstrual cups and while they’ve been around for a long time, they’ve been given this new lease on life for environmental reasons, and the fact that they’re cost effective and last a long time,” she said.

“I think they’ll continue to grow in popularity, and we’re not trying to scare people off using them, it’s just about being sensible.

“If women opt to use menstrual cups, we want to make sure they’re using them correctly, so this is an opportunity for education around that.”

The Perth review found that of the 10 IUDs dislodged in women using menstrual cups, six were Copper T standard IUDs and the remaining four were Mirena IUDs.

The clinicians believe Copper T IUDs are more prone to expulsion because they tend to make menstrual flow heavier and longer, and therefore women are more reliant on the cups. But the Mirena tends to make periods lighter, so women might not be as fussed about using menstrual cups.

Dr Oke said that, as a result of the review, SHQ clinicians now routinely asked patients about the menstrual products they used and advised those who used a cup to take care not to pull out the IUD. She said more research was needed to firm up the association between the use of menstrual cups and IUDs being dislodged.

“If that research finds there is an association, then people can be advised and make an informed decision for themselves,” she said.

“It’s about being able to use these cups alongside contraceptives as effectively and safely as possible.”

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NEWS & VIEWS

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MARCH 2021 | 9

New horizons for HBF Health insurers are marching into new territory and former Ramsay executive Dr Daniel Heredia will be on the bridge for HBF.

Cathy O’Leary reports

Health insurers are pushing on with their plans to becoming service providers as well as merely bankrollers for members’ health procedures. Medibank is investing in the primary care operator Myhealth Medical Group, while HBF is about to open the first of 15 planned dental clinics.

Dr Daniel Heredia, the former Hollywood Private Hospital director of medical services, started his new role last month as HBF executive general manager health services. The first item on his busy dance card, in this newly minted role at WA’s biggest health insurer, is teeth.

A few weeks into the job, he is about to oversee the rollout of 15 HBFbranded dental clinics, the first in Joondalup this month, with the rest expected to open over the next four years.

But the expansion into dental means much more than providing the odd scale and clean or filling – it signals the start of a marked shift by HBF into the business of providing health services, and Dr Heredia argues it is a change that is long overdue.

Sure, the insurer has had a small foray into service provision outside the scope of basic insurance, including its pharmacy alliance, first with Friendlies Chemists, now with Pharmacy 777.

It has also offered the COACH program for 11 years, with almost 350 patients with high-risk conditions such as heart disease and type 2 diabetes helped by a structured coaching program.

New ideas But the move into dental, coupled with Dr Heredia’s brief to develop stronger links with hospitals and medicos, is a case of doing things differently for a business that was largely run by accountants and lacked significant medical expertise.

“It signals a change in direction to focus on the health of the members, moving beyond being a payer to being a deliverer of services,” Dr Heredia said.

“We’ve started with the COACH program, but this role and what’s coming are a significant shift, the first of which will be the dental clinics, with the first opening in Joondalup soon, and plans to have 15 of them up and running in the next three or four years.”

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FEATURE

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FEATURE

The dental clinics can be used by anyone, not just HBF members, and Dr Heredia says they won’t be built on the cheap and will be high quality and convenient. An agreement with Pacific Smiles Group extends the dental clinic network to Queensland, Victoria and New South Wales.

“The intention is for our members to have choice, but that’s not to say you have to go to a HBF dentist,” he said.

“We think there is an opportunity to do things better and, as a not-for-profit company, we can continue to invest in whatever we think will be the best experience for people, including (having clinics) in shopping centres where people are already visiting.

“The aim is to make them convenient with good access, so running seven days a week with extended hours so you don’t have to wait long if you have tooth pain.

“It’s about trying to improve the experience and access, and hopefully over time have better control over out-of-pocket costs.

We’re confident that over time it will be a better value proposition for patients.” continued on Page 13

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MARCH 2021 | 11

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FEATURE

New horizons for HBF continued from Page 11 Dr Heredia has touched on a common bug bear of people with private health insurance – the sometimes large and unfathomable gap payments – and he said the time was right to look for more than a quick fix.

Bridging the gaps “Out-of-pocket expenses is a significant issue for all health insurers, and we’re very focused on that and, having come from the hospital sector after 10 years, we have to do things differently,” he said.

“It’s so hard for a patient to have to make a choice after paying for their premium and potentially get hundreds if not thousands of dollars in bills.

“The sector has been under pressure for a number of years and there is a constant cycle of the more you spend, the more premiums go up, and then people want to drop their cover or get rid of it altogether, and that puts more pressure on price.

“So, at some point, everyone has to look at it differently and say this isn’t sustainable to be in a cycle of prices going up.

“It can get lost sometimes that many people who’ve bought insurance don’t have a lazy $3000 or $4000 sitting around, but they do it as an investment in their health, so that when they need care, they can access it.”

Dr Heredia rejects concerns that insurers are trying to muscle in on existing primary care providers or dictate the rules, and says that HBF must work with hospitals, services providers and doctors to try to bridge any gaps.

He said his experience as a clinician in hospital management for more 10 years would help him liaise with other players in the health sector.

Cautious approach “Some people are cautious or opposed because in WA we haven’t seen insurers moving into service delivery compared to the east coast where it’s not a big deal for a

health insurer to run a dental clinic,” he said.

cover was just 44% in March last year – the lowest since 2007.

“There will be challenges and it will take time for our members and health professionals to become comfortable with it.

But there was a ray of sunshine in the last quarter of 2020, with about 100,000 people more than usual for that period signing up for private health insurance.

“None of these things are meant to substitute medical care, so we’re not trying to divert people from their GP because they have a health check in a pharmacy. If something doesn’t look right in one of these checks, the immediate advice to them is to see their GP.” Dr Heredia said he had also learnt some lessons from his secondment last year to the WA Health Department where he worked as Deputy Chief Executive for COVID Health Operations.

“My biggest lesson from being part of the COVID response was that of leadership,” he said.

“I was fortunate to work with, and learn from, some of the best health care leaders in the country, and I learnt the importance of being able to communicate effectively and inspire people in times of uncertainty.

“I also realised the need to be decisive, accountable and responsive to feedback.”

Meanwhile, health insurers face ongoing pressure to retain members or stop them downgrading their policies, known as the death spiral. The proportion of Australians with private hospital

MEDICAL FORUM | PAIN MANAGEMENT

Flexibility needed Dr Heredia said that while HBF had more than 50% of the market share in WA, insurers had to be more flexible, refresh their policies and create new streams of business.

“Downgrading is not always a bad thing because members need change over time, so our aim is to provide a broad range of covers to suit different life stages and budgets, whether that’s upgrading or downgrading,” he said.

“For example, a member might no longer need pregnancy and birth cover, so they select to go down a tier in hospital products.”

Dr Heredia said health insurers were also working with the Federal Government at proposed reforms to the sector, such as allowing young adults to remain on family policies for longer and reducing the cost of prostheses for which insurers paid significantly more than the public sector.

“While Australia is fortunate to have a high-quality, balanced health care system, we need to be doing things differently to ensure its long-term sustainability,” he said.

MARCH 2021 | 13

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CLOSE-UP

Life in the emergency lane This time last year, Dr Rik Hagen was on the verge of retirement.

He had even almost been to his own goodbye party.

By Ara Jansen

Suddenly, almost overnight, every extra pair of hands was needed at St John of God Murdoch Hospital and Dr Rik Hagen agreed to delay leaving the emergency department where he had worked for more than two decades.

Besides, it “looks bad on the CV if you bugger off at the start of a pandemic,” the senior emergency medical officer says with a laugh.

Dedication, hard work and ability to be a team player in a crisis earnt him the title of 2020’s St John of God Murdoch Hospital Doctor of the Year.

Now the 71-year-old is working a couple of shorter shifts a week and fills in when needed. It is suiting him perfectly. By his own admission, he’s had more comebacks than John Farnham.

Erik ‘Rik’ Hagen was a late bloomer, starting medicine at 27 on top of his agricultural degree. After working in the Wheatbelt for four years and already a father to two, he decided medicine was what he really wanted to do.

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CLOSE-UP While fellow students were busy partying and almost a decade younger, Rik treated his studies like a job and did quite well “until they shook off their sloth and caught up”.

He could have done surgery, but with a growing family – now with three of his four children – there wasn’t the time. He spent between 1985 and 1997 working as a rural GP in the South West town of Harvey doing 50 to 100 baby deliveries a year. Rik enjoyed getting to know people, being able to have continuity of care and knowing Bunbury Hospital was close enough in case anyone got into more trouble than he could handle.

team when Brock had his fatal crash during the 2006 Targa West rally.

Alongside a busy medical career, Rik has also worked his way up to become a top medico in Formula One and World Rally Championships. He is currently the WRC Deputy Medical Delegate for Asia and Oceania at Fédération Internationale de l’Automobile

“Unlike the metropolitan area, in the country if you ever saw an ambulance racing through town, you knew you were going to have to go to the hospital to do something,” says Rik. “There was a really good hospital in Harvey.

We had a visiting surgeon come every two weeks, but we did the anesthetics and obstetrics ourselves. It was the old-fashioned kind of GP, which, sadly, I’m not sure exists much anymore.”

(FIA). That means these days, rather than being on ground tending to accidents, he visits event sites ahead of time to assess their readiness.

“I first got involved when I was in Harvey in 1989 during Rally Australia,” says Rik. “A friend was continued on Page 16

Dr Rik Hagen with Murdoch CEO Ben Edwards; and, below at work in the ED.

Travel headache With part of his family in Perth for school, Rik felt too much like a FIFO, so in 1997 he took a job at St John of God Murdoch in the emergency department and he’s been there ever since. He has also worked for the Royal Flying Doctor Service and is currently a flight doctor for Medical Air. While working as a clinical skills tutor at the University of Notre Dame, he started writing stories about his medical experiences which he shared with his students.

Then during a three-month break in Melbourne a few years ago he wrote a dozen more stories and thought they might be worthy of a book.

An enquiry to a local publisher ended with a contract from a London publisher and Imperfect Recollections was published in July last year. There are more stories for book two on the way.

In Imperfect Recollections, Rik doesn’t reveal names and has left people guessing about who the characters are from the town he talks about. The final story, however, is self-evidently about the death of racing legend Peter Brock.

Rik was working on the medical MEDICAL FORUM | PAIN MANAGEMENT

MARCH 2021 | 15

CLOSE-UP

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Life in the emergency lane continued from Page 15 involved and asked me to give her a hand. I got involved and eventually became their chief medical officer and did a lot of local rallies.”

Rally cry He says one of the most challenging events to work on as a medico was the Australian Safari, a drive from Kununurra to Kalgoorlie.

While helicopters kept an eye on the drivers and cars, the distances made it exceedingly difficult to get to anyone in a hurry.

These days a satellite-based system called RallySafe or RaceSafe, which was created in Tasmania, is now used all over the world and makes tracking drivers and issues overland much easier. The system transmits hazard warnings via in-vessel units in motor sports events on land and water, providing tracking and timing updates. It alerts organisers if there has been an accident plus

gives the location for the rescue services to find.

Rik eventually rose to senior national and international positions including being a representative on

the FIA Medical Commission, which meets in Paris twice a year. On behalf of Motorsport Australia, he’s been the chief medical officer at four Korean Grand Prix and deputy

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CLOSE-UP Rik says two words sum up his career: bloody lucky.

chief medical officer at the first Russian Grand Prix.

Now, as a FIA delegate, he’s hoping there will be a World Rally Championship event in Japan later this year, after having inspected the Japanese hospital site and medical system in 2019.

“I always tell my friends I’m not a petrolhead, but they just say ‘yeah, right’.” Sometimes he manages to convince them that he is genuinely fascinated by how it all comes together.

At an age when people probably see more of the green on a golf course than the green of their scrubs, Rik’s reason for staying in medicine for almost five decades is quite simple: “You meet people and help them, and you don’t have to be macho and it’s ok to cry.”

People person “People come in, they are in distress and you can help them, most times. Thousands of years ago, Hippocrates said the goal of medicine was: To cure sometimes, to relieve often and to comfort always. To me, everyone has a story, and a life is full of heroism. I

enjoy that. An old friend once told me ‘once you take out 200 lungs, it’s all a bit ho hum’, so, for me, it’s the people you meet along the way, both friends and colleagues, who make life interesting.

“It’s said all emergency department people tend to be Type A personalities who get off on adrenaline. I can still respond like that but these days I tend to leave it to the younger guns. Now it takes longer to recover from the adrenaline highs. I still really enjoy helping people. Maybe I have just settled down a lot. Ah yes, I remember enthusiasm!”

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While a fivemonth trip to the UK and Norway (where his parents were originally from) was put on hold because of COVID and Rik not retiring, his now casual status in the ED is allowing him to spend more time down south, digging into historical and spy novels and avoiding the “twin ogres” of bridge and golf while lavishing attention on his eight grandkids. Besides, who else is allowed to give them too much red cordial and Cheezels – and then send them home!

Apparently that retirement party from the hospital is now imminent.

Paging John Farnham.

Read this story on mforum.com.au

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MARCH 2021 | 17

Cannabis research forges on Cannabis-based medicinal products hold promise in the treatment of various conditions but, as Dr Karl Gruber (PhD) reports, there is still a way to go.

It is difficult to find any medicine or remedy that elicits more questions and debate among doctors, patients, researchers, policy makers and the public than medicinal cannabis.

Is it safe? Does it work? How does it work? Is it addictive? Should the public be allowed to grow it?

These and many more questions constantly orbit around cannabisbased medicinal products, drawing the interest of a wide range of stakeholders, from patients suffering a myriad of different conditions to entrepreneurs wanting to create the next wonder drug.

The interest in medicinal cannabis is growing and more products are becoming available. Three months ago, the Commonwealth Department of Health’s Therapeutic Goods Administration (TGA) announced its decision to allow certain medicinal cannabis products to be sold over the counter.

GPs are facing a growing number of patients with questions about medicinal cannabis and wanting to try it. But clear answers to key questions about cannabis products are not always readily available.

Cannabis: the basics Cannabis sativa, also known as Indian hemp, is a plant native

18 | MARCH 2021

to Eastern Asia and used since ancient times as a source of textile fibre, food, oil and medicine.

The medicinal properties of cannabis products can be traced to the myriad of chemicals produced by the plant called cannabinoids.

These are substances carrying a specific chemical structure capable of binding to cannabinoid receptors found in the brain and other parts of the human body, such as organs, connective tissues, glands, and immune cells.

These receptors are an integral part of the endocannabinoid system, a cellular communication network that affects the function of the immune and nervous systems, as well as the function of all organs in the body, ultimately affecting processes such as mood, memory, sleep and appetite.

Clinical evidence Studies testing the clinical efficacy of cannabis products are ongoing, and evidence so far has shown variable degrees of benefit for treating symptoms in conditions such as multiple sclerosis, chronic (non-cancer related) pain and certain types of epilepsy. Patients going through palliative care and chemotherapy-induced nausea and vomiting have also benefited from using cannabis-based products.

Currently, the strongest clinical

evidence supports the use of cannabidiol for the treatment of drug-resistant epilepsy in children and young adults up to 25 years. In this cohort, the use of a cannabidiol-based product, alongside standard treatments, has been shown to provide significant benefits in the treatment of symptoms in about half of those taking it.

For other conditions, such as multiple sclerosis, chronic (noncancer related) pain, evidence is sketchier, with studies showing variable outcomes in drug efficacy for treating symptoms. In other words, some patients may experience significant relief of their symptoms, while others may experience only small or no benefit.

Regulations Cannabis-based drugs were legalised in Australia in 2016 and are regulated by the commonwealth and state governments. Most products fall within Schedule 8 (controlled drugs) or Schedule 4 medicines (prescription only medicines).

These are medicines that only contain the non-psychoactive cannabinoid, cannabidiol (CBD).

TGA registration comes with perks: it means that a drug has been assessed for quality, safety and efficacy. But, so far, the only

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FEATURE

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FEATURE cannabis-based medicine registered with TGA is Sativex, a drug prescribed to improve symptoms related to muscle stiffness (spasticity) in multiple sclerosis.

Other cannabis drugs are currently in the clinical pipeline, some here in WA. Emyria, a Perth-based company, is conducting clinical testing of various cannabis-based drugs, targeting mental health problems and irritable bowel syndrome.

The company is employing an innovative approach, testing their drugs with actual patients and generating clinically relevant data. With the rescheduling of cannabis products on the table, the availability of high-quality products, and a legal pathway to reach patients, Emyria saw an opportunity.

to get a drug perfected and onto the market. Zelira and Emyria are taking an innovative approach.

“What we've developed in the country is something we ought to develop and it completely turns the concept of drug discovery on its head,” Dr Hopkins said. Cannabisbased medicines can be tested in the general population before they are approved by regulatory bodies, he says, because while the efficacy of cannabis products may still be in question, their safety is not.

“We asked, ‘Why don't we provide safe access to patients when other treatments might not be working and collect high quality clinical evidence that can be used to support drug development,” said Dr Michael Winlo, managing director of Emyria.

Another Perth-based company in the medicinal cannabis space is Zelira Therapeutics. The company is currently conducting various clinical trials, testing the efficacy of different cannabis-based drugs for conditions such as autism, some cancers, insomnia, and chronic pain.

Recently, Zelira joined forces with Emyria to conduct an observational clinical trial for patients diagnosed with autism spectrum disorder, testing the drugs HOPE 1 and HOPE 2. The effort builds on the successful launch of these drugs in the US in 2019. While their HOPE formulation is now expanding across the US, in Australia it gained TGA approval late last year and Zelira’s Managing Director, Dr Richard Hopkins, says the time is ripe to break new ground in Australia.

According to Dr Hopkins, the new clinical trial is one of the world's largest observational studies and one of the world's first individual trials for autism.

Autism is not the only condition Zelira is targeting in Australia. Last

According to Dr Winlo, this strategy may help accelerate the process of testing drugs and reduce the time it takes for them to reach patients.

year, the company launched Zenivol, a cannabisbased formulation aimed at patients with chronic insomnia, following TGA’s approval through their Special Access Scheme.

A disrupting force According to Dr Hopkins, Australia’s current regulatory schemes and the safe nature of cannabis products offer an opportunity to test efficacy while reaching out to patients.

Normally, a pharmaceutical company would spend billions of dollars and it would take 10 years

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"Our care model provides patients with safe access to unregistered treatments like medicinal cannabis. At the same time, we are gathering robust and ethically-sourced data with our patients. We then use this evidence to help identify the most promising doses and indications that could lead to formally registered drug treatments,”he said.

“In a way, we are actively filling in the evidence gap that exists for these treatments while also pioneering a new model of evidence-generating care that can help accelerate drug development more broadly.”

Cannabis prescribing However, a lack of registration has not stopped medicinal cannabis from reaching patients. Today, continued on Page 21

MARCH 2021 | 19

20 | MARCH 2021

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Cannabis research forges on continued from Page 19 more than 100 cannabis-related medicinal products are available as prescription medications, though they must go through some regulatory hurdles.

GPs wanting to prescribe cannabisbased products need to seek approval through TGA’s Category B Special Access Scheme, the most common pathway. In essence, it means that GPs need to justify why a specific patient would benefit from a particular cannabis-based product, but this is just the tip of the cannabis iceberg.

“Many of these products appear to be very similar and are largely undifferentiated. Some come from Canada, some are grown in Australia. Many are oils, some are capsules or sprays. It's a very crowded space,” Dr Winlo said.

“The other complication is that it's not easy to write a prescription. It's not as simple as writing a script.

You have to explain what else patients have tried. Why is nothing else working? How are you going to monitor this patient?

“So there's a bit of extra paperwork and it takes a bit more time. If you're not used to doing special access or navigating all these product choices, it can be daunting and a deterrent, not to mention the lack of high-quality clinical research that usually helps doctors make these decisions.”

What this means for a GP is that a solid understanding of all the available cannabis products is required, as well as clear information about their efficacy, dosage, side effects, among other aspects. With the growing number of cannabis-based product, this is no easy task.

Medical Forum poll Early results from a recent e-poll of GPs and specialists conducted

by Medical Forum shows that a significant majority (82%) of GPs have never prescribed medicinal cannabis. Among these doctors, about 78% claim that they are not convinced of the benefits associated with MC. Among the few doctors who say they have prescribed MC,

Dr Michael Winlo

Dr Richard Hopkins

70% said that chronic pain was the main condition treated.

Black markets

Overall, 94% of all respondents agreed that more clinical research was needed on the efficacy or safety of medicinal cannabis.

Is it safe? Does it work?

In the case of Sativex, the active ingredient, nabiximol, contains the cannabinoids delta-9tetrahydrocannabinol (THC) and cannabidiol. According to the National Prescribing Service (NPS) Medicinewise website, the drug can improve spasticity symptoms in less than half of patients and has two common side effects: dizziness and fatigue.

In addition, 10% of patients treated with this drug experience depression, disorientation, dissociation and euphoria.

Delusions, hallucinations and paranoia were also reported for some patients.

For the vast majority of cannabisbased medications that lack TGA registration, it is hard to assess efficacy or safety. Regarding quality, the TGA has established guidelines that define the quality requirements for all imported medicinal cannabis products, which need to comply to an international code, the Good Manufacturing Practice (GMP).

Despite these efforts, not all cannabis-based products available in Australia follow regulatory guidelines.

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For every regulated product that is costly or hard to get, there is always a cheaper, shady alternative, and cannabis is no exception. A current problem in the medicinal cannabis space is the widespread black market of products. These products represent a risky alternative to regulated, TGA-approved, products. Without any regulatory control, it is hard to ensure these products meet adequate safety and quality standards.

Despite the risks, some people still buy these unregulated products.

For Dr Hopkins, it is all about the mindset of users. If you are buying a cannabis product for your child or elderly parent, you are serious about it and will look for the best option. But if you are looking for a recreational drug, that’s another story, he said.

Cannabis-based medications stand as a promising approach for the treatment of symptoms from some serious diseases, but it is still early days.

Companies and doctors who have invested in this area argue that allowing legal access to highquality, TGA-regulated products could significantly improve the lives of many Australian patients who, so far, have not been able to find relief with standard treatments.

But some of those less invested stakeholders want to see more runs in terms of clinical trial data and evidence before jumping on board.

MARCH 2021 | 21

Tackling pain without the pills Pain is a complex concept that manifests in different ways. Cathy O’Leary reports on new initiatives to help GPs and other health professionals ease the pain for patients.

22 | MARCH 2021

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FEATURE

FEATURE

KEY MESSAGES All pain is real Stay active and exercise Start doing meaningful activities – nothing is off limits Start gently with feared movements or activities – you will adapt and become stronger Maintain social life and engagement Scans don’t always tell the full story If you feel pain, it doesn’t mean damage Pain is an alarm to protect but sometimes it can be too good at its job Many factors influence how sensitive the alarm is Your body is inherently strong and adaptable Don’t panic if you have a setback

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Source: Adapted from Guardian Exercise Rehabilitation pain guide

American nurse Margo McCaffery's oft-quoted definition of pain hails back to 1968 but it still has relevance today: “Pain is whatever the experiencing person says it is, existing whenever and wherever the person says it does.”

For clinicians treating patients in pain, particularly chronic or persistent pain, the sentiments from more than half a century ago underline that pain is personal.

It is subjective and difficult to pin down, even on a 1 to 10 pain score.

And while acute pain from surgery or an injury tends to have a more distinct timeline, chronic pain is another story.

While we have more pharmacological agents to treat pain, concerns of an ‘analgesic culture’ and drug addiction are tempering the zealous prescribing of powerful painkillers.

‘Do something’ culture But at the coalface, clinicians face intense pressure from patients to “please do something”, amplified

by consumer marketing and health blogs which tell people that pain is bad and needs to be eliminated at all costs.

Now many pain specialists are using the narrative of ‘living with pain’ where patients learn to accept that some pain might be inevitable, even if this can be a hard pill to swallow.

Good evidence is emerging that basic lifestyle measures such as exercise and getting a good night’s sleep can also make a big difference in how people manage their pain. This shift has led to a surge in local programs to retrain thinking.

Perth exercise physiologist Ben Davis is the national clinical lead for Guardian Exercise Rehabilitation which has just released a free and publicly-

MEDICAL FORUM | PAIN MANAGEMENT

available pain management guidebook.

It is aimed at helping individuals themselves, but can also be used as a resource by health care professionals, including GPs, to work through chronic pain issues with their patients.

“The aim is self-management of pain, and helping people to understand chronic pain and the mechanisms around it, because there are misconceptions that pain equates to damage to the body and often that’s not the case at all,” Mr Davis said.

Self-management “It also looks at the real-life contributors to pain, and how people can try to manage them, and things that can help like exercise, a healthy diet, mindfulness and good sleep hygiene – and all the tips and tricks.

continued on Page 24

MARCH 2021 | 23

Tackling pain without the pills continued from Page 23 “And this approach works best if it’s integrated with a clinician’s input.”

Mr Davis said it was now recognised that the longer pain persists, the less relevant the original tissue damage becomes.

If someone has a disc herniation in the lumbar spine, there is good evidence that over time the herniation may biologically reabsorb or become less relevant.

“But psychological and social factors start to take hold and make the nervous system more sensitised,” he said.

“Because pain is fundamentally a protective alarm that goes off telling us to stop doing something, in people with chronic pain that alarm becomes too good at its job, so it goes off when it shouldn’t. It’s all about trying to calm down that alarm system and bring it back down to a more rational level so it only goes off when it should.”

Mr Davis said one of the biggest misconceptions was that pain equals damage but it was only part of the puzzle.

“Pain is necessary for survival and if you put your hand on a hot grill and didn’t feel pain then you’d burn the flesh off your hand,” he said.

“But in people with persistent or chronic pain, that alarm stays on, it’s like having a fire alarm continuing to go off after the fire has been put out.

“We’re trying to flip the narrative because often people in pain put up barriers and say they can’t do this or that, so we work on what they can do.”

If someone has poor metabolic health, that can potentially have a negative effect on their inflammatory system, which could drive the pain.

Sore but safe “It might sound like a cheesy slogan, but you can be sore but safe, so you might feel a bit of pain but it’s still safe to move and engage in things you enjoy. It can be a bit of a trade-off,” Mr Davis said.

24 | MARCH 2021

The PPP team, from left, Sabrah Imtiaz (dietitian), Laura Rance (co-ordinator), Helen Brown (consultant pharmacist), Helen Griffiths (Chronic Disease Metro Team Leader) and Travis King (exercise physiologist). Missing is clinical psychologist, Sanri Blom.

“If you enjoy playing lawn bowls with your friends and it’s worth it to you, but your knees are a bit sore later, then it’s safe. It’s about the mindset.”

Mr Davis said someone with acute onset low back pain might want to be referred to a surgeon, or they want to be sent for a scan, when that was not necessarily bestpractice care.

Some GPs would still send them for a scan because they felt obliged to find the diagnosis.

“The reality is that this person has back pain, and we know 87% of people without low back pain will have a disc issue in a scan,” he said.

in Perth. It draws on the Turning Pain into Gain program developed

by Joyce McSwan.

Public programs Funded by the WA Primary Health Alliance and the Federal Government’s Primary Health Networks, group sessions enlist the advice of a range of health professionals, including clinical psychologists and dieticians, to change the narrative away from a focus on pharmacological solutions.

Yes, sometimes pain relief has its place, but an over-reliance on pills is unhelpful.

“I’m not anti-scans but it’s important health care professionals provide the right context, so if they do scan, they might say, ‘yes we found something but it’s quite normal’.”

Registered nurse Laura Rance, who coordinates PPP care at 360 Health + Community in Rockingham, said it attracted people aged from 16 to those in their 70s, who were usually referred by their GP or specialist.

Helping people to cope with ongoing pain is also the focus of the Persistent Pain Program (PPP) which operates across several sites

Many had conditions such as fibromyalgia, endometriosis, osteoarthritis, rheumatoid arthritis and chronic back pain.

“The advice for people that have just had low back pain is reassurance and advice to remain active.

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FEATURE

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FEATURE The free six-month program, which is also offered by Black Swan Health in Wanneroo and Midland and by Arche Health in Armadale, covered self-management techniques such as deep breathing, relaxation, staying active and eating well.

“The main chunk of the program is group education sessions, and we cover six topics, the first being the science, or why we get pain and why some of us get pain when there’s technically nothing going on in the body to be causing the pain,” she said.

“The second part is with the consultant pharmacist who talks about the different medication options and the side effects, and new things coming in like medicinal cannabis and PEA (palmitoylethanolamide).”

The third session is about pacing and ways to keep moving, and the fourth part is about foods that can cause inflammation in the body and others that might help to reduce inflammation.

The fifth session is about sleep, because people with chronic pain often have significant sleep issues,

while the last topic covers the psychology behind pain and how people can retrain their thoughts and behaviour.

Ms Rance said many people came to accept that it was not about getting rid of the pain but rather finding a new normal.

Ms Rance said some chronic pain would never go away, and that could be difficult to accept. And sometimes it was hard to measure pain unless people had a very obvious physical injury.

Data collected by the program, which has been running in Rockingham since 2018, showed 58% of clients who were taking opioids at referral had at least halved their use by the end of the program.

Finding an answer

Their number of visits to the GP had also reduced because they were better managing their pain, and their mental health had also improved.

“A lot of people are still looking for an answer as to what is causing their pain, so we go through how the body actually processes pain, because many people don’t understand what’s happening,” she said.

“It’s so subjective, and there can be a lot of influences affecting how people feel pain, so if they’re having a bad day the pain will be worse, and past experiences or the way they’ve been brought up can influence how they feel pain.

“I have fibromyalgia and that’s why I wanted to run this program because I know exactly what the clients coming in here are going through, I can really relate to them.”

“We get a lot of feedback that their pain hasn’t changed a lot but they’re better able to manage it and they feel a lot more comfortable handling and dealing with it,” she said.

“We haven’t fixed them, but they feel more confident managing their pain.”

ED: For details on PPP go to https://www.360.org.au/services/ physical-health-condition-support/ pain-management/ For Guardian Exercise Rehabilitation’s free chronic pain management guide go to www.guardianexercise.com.au/ painguide

On-demand webinar series You can now access educational presentations delivered by our leading specialists, at a time that suits you.

For each on-demand webinar viewed, you will be able to receive CPD points as endorsed by the Royal Australian College of General Practitioners.

Book now at bit.ly/subiacoondemand Our 2021 GP education events will all be available live or on-demand. For further information visit sjog.org.au/gphub

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MARCH 2021 | 25

26 | MARCH 2021

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GUEST COLUMN

‘Believe me and my pain’ Pip Brennan, Executive Director of Health Consumers Council, writes on the results of a nation-wide survey of people living with pain.

GPs ideally are the hub of a patient’s care and build strong relationships with their patients over time. For those living with chronic pain, the relationship with their GP can be crucial.

This has been a consistent finding of Chronic Pain Australia, a non-profit health promotion organisation dedicated to reducing the social and other barriers related to living with chronic pain.

Each year, Chronic Pain Australia undertakes a comprehensive survey of Australians living with chronic pain*. The results are launched during National Pain Week to bring attention to chronic pain and ensure the voices and experiences of people in pain are heard.

As GPs are always busy and may not have had time to access this survey, we thought a summary of the results would be a timely reminder of what patients say matters to them.

In 2020, more than 200 people in pain across Australia participated in the survey, which reflects what many WA health consumers tell us repeatedly – there is no single journey for people living with chronic pain.

Often, it is a path filled with unknowns; consumers often face persistent, debilitating and confusing symptoms and a barrage of tests and treatment trials, all the while being told that medically they are a ‘mystery’ or that their pain is confusing, hard to explain or, unfortunately not uncommonly, all in their head.

Or even “being made to feel like I don’t do enough to manage my pain and that somehow I am responsible for the pain that I have”.

It’s no wonder then that 44.6% of people living with chronic pain also experience depression or anxiety (Hoole et al 2014, via PainAustralia).

How well do you think your GP manages your chronic pain?

GPs scored 5/10 for this question.

Asked if there was just one thing their GP could do to help manage their chronic pain, 50% of respondents said “believe me and my pain”.

People were then asked, “What are the most important things for GPs to know, understand and do when treating someone is living with chronic pain?”

• we are not one-size-fits-all; • pain is real, debilitating and exhausting; • pain affects all areas of our health and lives; • we are not all drug-seekers; • living with chronic pain can be isolating and depressing; • understand that we have been conditioned to expect no medical professional will believe us.

Those living with chronic pain have known for years that it is a bigger issue than any one service or provider. Seeking the right health support team who is knowledgeable and well versed in pain management is just as vital as seeking a specialist in any other area.

It’s not a one-size-fits-all approach, and many patients will need to see multiple providers before they find what works best for them. From pain specialists, physiotherapists and psychologists, to chiropractors,

MEDICAL FORUM | PAIN MANAGEMENT

remedial masseurs, dieticians, occupational therapists, nurses and social workers, there are options available to manage pain.

Unfortunately, more than 80% responded that these options were not affordable for them. The majority stated the Federal Government should provide a full rebate for accessing allied health professionals to manage chronic pain.

When it comes to consumers living with chronic pain, their message for health services is clear: believe us when we say we are in pain, and provide supports, referrals and resources to a multi-disciplinary team of specialists who can help us manage our pain.

“Just understand. Have some compassion. Have some common sense, not everyone has a perfectly aligned spine, not everyone has a high pain threshold, not everyone can cope without relief, not everyone can just suck it up and be tough.

We need kindness from people, not vilification. We are victims of our pain and now we are victims of the system too and we feel like we are being left behind.” *Full survey results available at https://www.nationalpainweek. org.au/index.php?option=com_ content&view=article&id=368

MARCH 2021 | 27

As luck would have it Bruce Powell was an anaesthetist and head of DonateLife WA when a cycling accident in September 2018 ended his clinical career in an instant. But life is not over.

It seems rather narcissistic to tell people that you are ‘lucky’. It often seems that you’re just being coy or encouraging some compliment in return.

Of course, as doctors we are all lucky. Generally, pretty smart, widely respected and usually affluent, we’re the random combination of genomes and the socio-political geography we inherited.

If we are not careful, we take those circumstances for granted.

Rather than exploit our community standing to foster confidence and unity, we explore the influence and favour that our privileged position enables. The medical profession becomes a rich vein of negative soundbites and pessimistic anecdotes.

We complain and undermine as our first reaction, rather than acknowledge the good, and seek to lead any necessary adjustments to the bad.

Like walking on the glorious beaches of WA every morning with the doggie – sometimes it’s “rather

windy” or “terribly hot”. It’s only when a visitor from another land strolls with us and remarks that “this place is heavenly” that we look up and experience our fortune and joy through their eyes.

It wasn’t long after my official, enforced ‘retirement’ that COVID began its advance and hospitals across the world came under siege.

It seemed so unfair to be sidelined when the growing emergency demanded all hands on deck.

My wife once heard me tell someone in a bar, coincidentally not long after I was allowed to start drinking alcohol again, that I was the ‘lucky one’. Given that I couldn’t remember the three or four months after the crash, while she had sat by my bedside and held my hand through it all, I could see why she might be a tad irritated.

Perhaps ‘luck’ is the wrong word?

Perhaps there was an opportunity to rekindle my ICU career? I excitedly emailed my neuropsychiatrist and sought his thoughts for a late call-up.

“Are you having a laugh?” he replied.

Sadly, for me, there was to be no more wrestling with the politics of organ donation or post-op stridulous thyroids.

Eighty spare hours per week was a stretch to fill, confined largely to annoying people on MedTwitter with my Pommie sarcasm after POTUS blocked my account.

Meanwhile, medical and nursing colleagues across the world risked

their own health to avert the looming pandemic catastrophe.

We all have to consider our challenges in the context of those around us. After all, I was the only one in my rehab clinic not in a wheelchair. Sure, I had lost most of who I had been, but, then again, I wasn’t in a PPE mask for 12 hours a day either.

As a state, we have avoided COVID because we are thousands of kilometres from anywhere. As a nation we have a small infectious problem, and a vaccine is on the way. We even have the luxury of waiting to see if the jab works and is safe before we start inoculating our own.

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GUEST COLUMN

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GUEST COLUMN My point is that the only thing that is certain is uncertainty. The rest is random and haphazard. If the cards fall our way, we should be grateful.

Not because it worked out perfectly for us, but it could have been worse.

ScoMo or POTUS, figure it out for yourself.

Hence, everything is possible, but some things are just more probable than others.

Will the vaccine help? Probably.

Will Fremantle win a premiership?

Possibly.

What is certain is that we can choose to be flexible and open-minded to the challenges that arise.

There is no certainty anywhere in the universe. Chaos is at the very nature of particle physics, never mind border-closure policy.

Finally, our patients struggle with the assertion that we cannot guarantee a positive result. As a profession, we can still play a leading role. We can assure them that by following the advice and the health rules, they maximise their chances of being ‘lucky’.

The very fact that we get to write rules, make policy, rather than react to the latest outbreak and fill our morgues with bodies, is like winning the lottery.

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MARCH 2021 | 29

It’s vaccination not vaccines that save lives Catherine Hughes and her husband Greg became unexpected vaccination advocates in 2015, after losing their 32-day-old baby son Riley to whooping cough complications.

Six years ago, I held my tiny baby as he succumbed to pertussis, too young to be vaccinated.

Five years ago, I had coffee with a mother who shared with me the painful story of losing her daughter to SSPE (subacute sclerosing panencephalitis) caused by the measles she contracted at 11 months of age.

Four years ago, I met a beautiful family who move mountains every day to ensure their son, who lost his limbs to a meningococcal infection, can live a normal life.

Three years ago, I connected with a brave mum whose young, immune-compromised daughter had unexpectedly passed away in the night from a HiB infection.

Two years ago, I hugged a man who had lost his elderly father to invasive pneumococcal disease.

One year ago, I became friends with another West Australian mum who had lost her gorgeous and vibrant two-year-old daughter to influenza complications.

And this year? Unsurprisingly, it’s the tragic stories emerging from families who have lost loved ones to COVID that are breaking my heart.

There’s no doubt that losing my son propelled me into vaccine advocacy, but ultimately it’s due to these other devastated families that I choose to continue this challenging journey.

Their heart-wrenching stories – coupled with the compelling evidence that backs up the safety and efficacy of vaccination – makes immunisation advocacy a very clear and sensible choice for me.

Nobody should suffer from a disease that can be so simply prevented by a needle, and my mission is to encourage others to stand up and advocate for immunisation, whether they’re a doctor, teacher, parent or grandparent. Vaccination has become a ‘dinner-table’ conversation, and the whole community has an important role to play in immunisation advocacy.

My son lived for 32 days before he lost his life to pertussis. It was just the day after his death that we were

contacted by anti-vaccine activists, who have harassed us for years.

They accused us of being paid actors or claimed that we were lying about his cause of death, or that the doctors were lying to us.

My husband and I quickly realised that the painful reality of our son’s death was extremely confronting for parents aligned with the antivaccination movement. After all, our son was unvaccinated (due to his age) and had died from a vaccine-preventable disease – so for many vaccine-rejecting parents, it was easier and ‘safer’ for them to construct or believe a far-fetched, alternative reality.

Although the Australian anti-vaccine movement can be extremely vocal at times, it’s reassuring to know that they are in the minority because 95% of Australian parents choose to vaccinate their children. We can only hope that this sensible approach is reflected in the upcoming COVID vaccination rollout.

What’s far more common than antivaccine activists are the everyday

Can breastmilk protect babies from COVID-19?

Perth researchers are investigating how antibodies in breastmilk could protect babies and young children from COVID-19.

Results from the University of WA study, funded by the State Government, are expected to guide breastfeeding recommendations for best infant care during the pandemic.

Using the world’s largest, longterm human milk study, researchers from UWA’s School of Molecular Sciences have been awarded $223,000 to investigate the activity of antibodies in protecting children from COVID-19.

Lead researcher Professor Valérie Verhasselt said human milk was recommended as the 30 | MARCH 2021

how important maternal antibodies were to protect the child from infection.

sole source of infant nutrition, so it was important to understand whether it could protect infants from COVID-19 and how.

“While we are 99.99% sure a child cannot get COVID-19 through breast milk, there is still much research to be done to reveal the capability of human milk to prevent COVID-19 infections,” she said.

The team will analyse 500 milk samples from 25 COVID-19 infected and 25 non-infected mothers collected at 10 time points from giving birth.

Professor Verhasselt said the study would hopefully show how maternal COVID-19 infection affected the protective effect of breastmilk and

It would also look at the importance of prolonged breastfeeding to prevent infection and disease in children as well as community transmission by asymptomatic children.

Professor Verhasselt said the results would help develop vaccination strategies, including the need to vaccinate lactating mothers for the best approach to prevent COVID-19 in children.

“It may also lead to the development of new therapeutics, such as milk-derived antibodies, to prevent severe disease in at-risk populations,” she said.

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GUEST COLUMN

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GUEST COLUMN people who have some pretty legitimate questions or concerns about vaccines (often referred to as the ‘vaccine hesitant”). This is where our work as immunisation advocates needs to focus on – those who are ‘on the fence’ about vaccines, and whose minds we can potentially sway.

So how do we sway these genuinely hesitant or curious individuals? There isn’t a one-size-fits-all model, and often multiple strategies are needed.

When I work with parents who are worried about vaccinating their children, I use a combination of emotive stories and evidence-based information that is in tune with the level of detail the person would like.

I draw the conversation back to the risks of the disease, reminding them why vaccination is so highly recommended, and leave them plenty of space and time to ask questions or share their thoughts.

In these conversations, the vaccinehesitant tend to want three things – they want to be heard, they want their information needs appropriately met, and they want to feel that it’s OK to have questions about vaccines. Patience is the key, and the conversation is as much about building rapport and trust as it about discussing vaccines.

Now, more than ever, it’s crucial that we consider the role that we can all play in advocating for vaccination and think about ways we

can effectively communicate with our friends, family, neighbours and patients who may have questions or hesitations about the COVID vaccine.

After all, it’s not vaccines themselves that save lives, but the process of getting people vaccinated.

All the effort in the world can be made into vaccine development,

production and distribution, but if we fail to invest efforts to bolster community confidence in the vaccine, the battle to prevent COVID and save lives becomes so much harder.

ED: Catherine is co-founder and director of Immunisation Foundation of Australia.

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MARCH 2021 | 31

Fibromyalgia and neuroinflammation: shall the twain ever meet?

While medical science debates this question, one thing is for sure, they are not phantoms, write Dr John Quintner and Ms Melanie Galbraith.

Fibromyalgia (pain in the muscles and fibrous tissues) is the name given to a group of symptoms, some of which are commonly found in the general community.

This means that fibromyalgia is not a clear-cut medical condition.

It falls into the category of a ‘symptom cluster’.

Clusters of stars appear in the night sky where our ancient forebears drew lines around groups of them and gave these constellations various names (e.g. Andromeda, the chained maiden; Aquarius, the water bearer). But we now know that the stars making up a constellation may be light years apart and are not otherwise connected.

Rheumatologists did the same thing when they grouped together a number of symptoms that do not necessarily bear any known causal relationship to one another, and then called the condition ‘fibromyalgia’.

The individual symptoms in the fibromyalgia cluster differ in their severity – from the very mild to the most severe – and result in varying degrees of physical and mental disability that includes widespread pain and tenderness, fatigue, disturbed sleep, low mood, problems with memory and thought processes.

Plausible explanations There is a striking similarity between the fibromyalgia symptom cluster and sickness behaviour in animals. Sickness behaviour can be induced in animals by injecting them with substances called cytokines (cell messengers). It is therefore reasonable to assume that there must be biological explanations for the symptoms of fibromyalgia.

The terms ‘central sensitisation of nociception’ and ‘neuroinflammation’ are neurophysiological processes 32 | MARCH 2021

believed to be involved in patients diagnosed with fibromyalgia.

Central sensitisation of nociception Nociception means, ‘harm detection’. Central sensitisation of nociception implies that nerve cells in the spinal cord have become sensitive through the action of cytokines released from neighbouring cells of the immune system. This means they are then liable to fire off more easily and can generate bursts of impulses that travel up the spinal cord to the brain producing the sensation we call ‘pain’. These changes in spinal cord nerve cell function have been shown to occur in animal studies.

Cytokines are used to help cells within the nervous system to communicate with each other, and with other cells in the body.

Significantly increased serum levels of cytokines (and other important molecules) have been found in fibromyalgia patients compared with healthy controls.

Nerves which usually respond to light touch to the skin can now

excite sensitised nerve cells in the spinal cord, resulting in pain (the phenomenon is called ‘allodynia’).

When this happens, non-inflamed tissues around an area of tissue damage can also become sensitive and give the same response to various non-damaging stimuli (such as light touch, moderate cold or heat, and vibration).

Central sensitisation of nociception means that the spinal cord nerve circuitry can alter, distort or amplify the many signals it receives, not only from any damaged bodily tissues but also from other normal sources.

Although there are some clinical clues that the central nervous system of a person is sensitised, it is not possible to objectively measure the process. Clues include an increased response (including pain) to a non-tissue damaging stimulus applied to the skin in the area of the pain complaint, the report of pain in response to gentle passive movement of the relevant part of the body, and a painful response to deep pressure applied in the area of pain (tenderness).

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GUEST COLUMN

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GUEST COLUMN Neuroinflammation Neuroinflammation is a type of inflammation that refers to reactions occurring within the central nervous system (brain and/ or spinal cord) characterised by the release of cytokines from resident immune cells, as well as from other resident cells (including mast cells which generate mediators of inflammation, cells lining brain blood vessels), and from immune cells residing outside the central nervous system.

There are various degrees of neuroinflammation, some of which are beneficial and others that can be harmful to the nervous system.

When neuroinflammation is unchecked, it can be damaging to nerve cells, as occurs in a wide variety of medical conditions in which abnormalities of nociception (including pain) occur. These include: infections of the central nervous system, major depressive disorder, stroke, traumatic brain injury, spinal cord injury, autoimmune diseases, after major surgical procedures, autism, and in neurological diseases, such as multiple sclerosis and Alzheimer’s disease.

(moves to another place) has been identified within cells, where it sits on the membranes of mitochondria, which play a major role in the production of cellular energy by serving as “batteries” that power various cell functions.

TSPO is always present in low concentrations in the healthy brain but the glial cells produce increased amounts following brain injury and in neurodegenerative conditions such as multiple sclerosis and infection. TSPO has therefore been used as a biological marker for brain injury and infection.

Additional evidence of neuroinflammation includes objective biochemical abnormalities in the content of cerebrospinal fluid* and increased levels of lactate (which appears to act as a signalling molecule) in the cerebral ventricle.*

Central sensitisation & fibromyalgia According to leading neurobiologist Clifford Woolfe: “The data overall seem to support a major role for central sensitisation in the generation of the symptoms of fibromyalgia”.

It appears that neuroinflammation can alter nerve pathways in ways that enable them to contribute to the generation, amplification and unpredictable spread of pain.

Therefore neuroinflammation may play a decisive role in many chronically painful conditions, even when there is no evidence of tissue damage.

It is therefore disappointing that the recent classification criteria for fibromyalgia (using the Widespread Pain Index & the Symptoms Severity Scale) do not include any physical examination findings that could alert a clinician to the possibility of central sensitisation.

How is it detected?

A recent PET scanning study by Albrecht et al. (2019) provided the first in vivo (in living people) evidence supporting a possible role for neuroinflammation in the pathophysiology of fibromyalgia.

However, they did not screen the

Evidence of neuroinflammation can be indirectly visualised by using Positron Emission Tomography (PET)*. Through the use of a radioactive tracer, the protein molecule TSPO, a translocator

Fibromyalgia, sensitisation & neuroinflammation

NEW SS RE ADD AME & N iously

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31 subjects for clinical evidence of central sensitisation. The investigators simply assumed it would be present in all subjects.

To properly study this relationship, all subjects with fibromyalgia should have one or more clinical features attributable to central sensitisation of nociception.

Where to from here?

The breakthrough in imaging techniques is likely to improve greatly our understanding of many chronically painful conditions and may eventually lead to therapies targeted at ‘calming down’ the activated glial cells thought responsible for neuroinflammation.

Conclusion Neuroinflammation has been implicated in the pathophysiology of many chronic pain states, including fibromyalgia. The common belief that these conditions are caused by predisposing personality factors is now unsupportable.

Nevertheless, psychological and social factors are important in determining how a patient presents to his or her health professionals, family members and others in the wider community. *Note: The various investigations mentioned in this article are not as yet available through our health system. The reason they are mentioned is to provide credible scientific supporting evidence of an underlying biological process in those who have been diagnosed as suffering from fibromyalgia.

– References on request ED: Dr Quintner and Ms Galbraith are pain educators at Athritis & Osteoporosis WA

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Reflections on pain Pain is the most common symptom presenting to doctors, yet arguably we don’t understand it all that well. It is something felt by all of us at some stage, but the experience is unique to each individual.

Doctors are often caught in the middle.

We do not want to deny pain relief to those in distress. Neither do we want to be a ‘soft touch’ and eventually incur the wrath of regulators.

In second-year medical school we were taught about pain versus pain behaviour, which I ponder when looking at the difference in attitude to the pain of sportspeople such as AFL footballers and most of the rest of us. There is no right or wrong, simply a different level of acceptance of pain and discomfort.

In the 1990s, pain was made a vital sign. This was well-intended but may have contributed to the opioid crisis, especially in the US where close to 70,000 deaths are recorded annually from prescription medication overdose.

Funding of hospitals included consideration of feedback surveys.

Patients not receiving prescriptions gave bad reviews, leading to allegations of hospital administrators pressuring doctors to accede to demands. Individual doctors also feared bad reviews and found prescribing the easier option.

A $US 8.3 billion settlement was reached between Purdue Pharmaceuticals and the US Federal Department of Justice over the promotion of prescription opiates last year.

In Australia, we have also had problems although not as bad.

Nonetheless, regulations regarding prescriptions for opiates were tightened last June.

Doctors are often caught in the middle. We do not want to deny pain relief to those in distress. Neither do we want to be a ‘soft touch’ and eventually incur the wrath of regulators. Appointments with public pain clinics can take 12-18 months from time of referral. Chronic pain does disproportionately affect those in lower SES groups who are least likely to have private insurance.

This month, we examine aspects of pain, including TMJ problems, spinal surgery, use of medicinal cannabis (for the record, I am medical advisor to Little Green Pharma) and new ideas on CRPS. Lifestyle approaches to weight loss are also featured as is adaptation in GP education.

To the proverbial man with a hammer, most problems look like nails. To doctors most problems can look like they need a script.

Other methods of managing pain such as exercise, physical therapy, mindfulness, weight loss (if applicable), psychological methods and even some degree of acceptance are less favoured. Government policy, which subsidises pharmaceuticals to a greater extent than other options, doesn’t help.

Rightly or wrongly we cannot make everyone pain free 100% of the time. We can but do our best. Maybe this is a message that is not conveyed as honestly as it could be.

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MARCH 2021 | 35

Complex Regional Pain Syndrome – a centrally mediated condition?

By Dr Philip Finch, Pain Specialist, South Perth Complex Regional Pain Syndrome (CRPS) is often thought of as a peripheral condition with onset after injury (e.g. limb fracture, surgical procedure). The syndrome dates back at least to the American Civil War when neurologist Silas Weir Mitchell described the presentation of soldiers who developed severe neuropathic pain in a limb after low-velocity musket ball injuries. He coined the term, Causalgia.

Not only did they present with severe ‘burning’ pain, florid autonomic symptoms and allodynia in the injured limb (excessive sensitivity to non-noxious stimuli), but also sensitivity to loud sounds (e.g. noise of a military band).

Such symptoms have puzzled observers, leading to accusations of malingering or suggestions that

It was also greater on the entire affected side of the body. Sensitivity to sound (hyperacusis) and light (photophobia) in a group of people with CRPS and in people without pain was measured. Acuity for quiet sounds was unchanged. Tolerance for loud noise was lower in the CRPS group, particularly on the affected side. Loud noises made pain worse in both groups.

Key messages

CPRS has a long history but remains poorly understood

Research suggests a possible central mechanism

If confirmed, this may change attitudes. the condition has a psychological aetiology.

Whilst looking at the origins of the condition, Professor Peter Drummond and I decided to examine patients for evidence of central sensitisation and pain pathway modulation.

Sensitivity in many sensory modalities (e.g. pressure, sharpness, light touch, warm and cold) is greater in the painful limb in people with CRPS.

Sensitivity to bright light was greater in the CRPS group than in people without pain, particularly on the CRPS side. Visual discomfort (photophobia) was found to be greater on the affected side. It appears that a ‘volume control’ mechanism for light, sound and pain may not function as well on the painful side.

This provides some clues about brain pathways that may have

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CLINICAL UPDATE

CLINICAL UPDATE

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switched around) were stronger in intensity, suggesting a rampingup of their ability to smell. The mechanism for this phenomenon is not clear.

We have, therefore, had to redesign our experiments to test both nostrils at once by presenting odours to the midline, but in a random sequence.

We intend retesting our longsuffering CRPS subjects using this new algorithm. The results, to date, are reasonably positive. Hopefully, further clarification will make it more compelling.

Professor Peter Drummond

changed in CRPS, which, in a sense, is good news in that we can consider a paradigm shift and possible new ways to best to manage the symptoms.

Professor Drummond and I have now also studied more than 20 people with CRPS of a limb and a similar number of pain-free controls for changes in olfaction (mediated by olfactory nerve and trigeminal afferents). The responses to six different smells (some mildly

If our results are clearly positive, then we will have studied facial touch, hearing, visual response to bright light and now smell in CRPS patients. We sincerely hope that such results will give meaning to our patients reported alterations of these senses, and help disprove the contention by some that their reports are psychologically based or fanciful embellishments of their condition for financial or other gains.

confronting) were measured. In general, patients with CRPS in a limb find that the sense of smell is enhanced or altered on the right side if their CRPS is in a right-sided limb, but the results are not clear for left-sided CRPS. Our method involved testing the left nostril first and then the right.

There was a surprise finding.

Author competing interests - the author has been involved in the research described

Control subjects reported that odours presented to the second nostril (even with the sequence

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MARCH 2021 | 37

Medicinal cannabis for chronic pain – it’s worth a trial

By Dr Matthew Moore, GP, Dunsborough I get it. I was hesitant too. We work our whole lives for our reputations. Heck, I didn’t want to be known as ‘Dr Pot’. But the overwhelming initial anecdotal evidence is what motivated me to do what I am doing today. And believe me, my patients are better for it.

Here is my journey and why you may want to consider medicinal cannabis, at least for your chronic pain patients.

Having watched industry developments in North America for many years before moving to Australia, when cannabis became legal to prescribe here in 2016, I was paying attention.

My first patient had post-surgical abdominal pain from both adhesions and a neuropathic aetiology. He was in a bad way, on substantial doses of both opiates and benzodiazepines, and tanking both physically and mentally. His current status was the driving force behind overcoming my discomfort with prescribing.

Honestly, I am open-minded and had every intention of doing so ‘one day’, but he was desperate. He was a father and husband, just like me, and was losing hope. I bit the bullet and applied for approval and wrote my first medicinal cannabis prescription.

Medicinal cannabis worked well in this case. And with frequent consultations, while titrating up his cannabis oil and slowly decreasing his opiates and benzos, he was able to cease both, control his pain and improve his quality of life.

We, as practitioners, commonly deal with the frustration of reaching the ceiling of medication management with the downregulation of receptors and subsequent drug tolerance. But the frustration is mostly for our patients as they see their dosages rise while their quality of life plummets.

In seeing this ‘end of the road’ in their treatment, life can get hard.

38 | MARCH 2021

(anxiety, PTSD)

cannabis approvals. There are now more than 180 authorised prescribers. This increase is mainly due to public and medical education that shows that it is a viable option, and not dangerous.

Key messages

There is research to underpin use of medicinal cannabis

It is safe to use, but not first line Quality of life can be significantly

More clinicians are having success with this alternative treatment.

improved.

Hope is lost and it’s a slippery slope as depression sets in. We shouldn’t blame our patients. We’d probably be the same if we had to live with significant pain despite maximal doses of conventional therapies.

Of the 6000-plus monthly SAS-B approvals now in Australia, 7080% are for chronic pain. From December 2019 to December 2020, there had been an increase in SAS-B approvals of nearly 60,000 bringing the total since 2016 to more than 85,000 medicinal

The same as you, I follow guidelines based on research. When people state that there isn’t enough data, that’s simply not true. There is. No, not to the extent that we need in order to use cannabis as a first-line therapy. But enough to show that it’s safe and that more research is needed.

Recent decisions worldwide, including the UN removing cannabis from the list of dangerous drugs, will see the cannabis research space expand.

Whether you agree with its use or not, it is relatively safe, has minimal

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CLINICAL UPDATE

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CLINICAL UPDATE side effects and increases the chance that you may actually get your dependent patients off their opiates and benzodiazepines. This has real value.

We must continue to educate ourselves as clinicians. The body of knowledge in and around cannabis as a medicine is increasing. We need to know how to navigate this space for our patient population.

Reading is what we do, right? And it may give you the confidence needed to accept the risk and talk to your patients about the potential option of medicinal cannabis.

Author competing interests – nil Graphic source: Australian Government Department of Health, Submission to the Senate Community Affairs References Committee, Senate inquiry into the current barriers to patient access to medicinal cannabis in Australia, January 2020. Condition % applied to 2020 SAS B Figures.

2018 to 2020 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0

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Metabolic health – can lifestyle measures really deliver?

By Kirsty Woods, Exercise Physiologist, Bentley A recent US study defined metabolic health as having ideal levels of blood sugar, triglycerides, high-density lipoprotein (HDL) cholesterol, blood pressure and waist circumference without using medications. All will recognise these markers as key components of metabolic syndrome, where obesity, type 2 diabetes (T2D) and cardiovascular disease are common, advanced metabolic end points.

While medication is the cornerstone of current treatment, lifestyle change may be particularly effective as it addresses the root cause.

However, it can be difficult to implement and results vary widely.

Metabolic measurement can take the patient on a health journey.

Indirect calorimetry, in similar ways to measuring blood pressure when managing hypertension, can be used to measure the effects of lifestyle interventions on a patient’s energy metabolism.

This technology is not yet commonly used in general practice, but its clinical potential has long been recognised. Daily caloric needs, fat utilisation and how efficiently energy is used are all measured. Coupled with pathology and body composition, it provides insight into how a patient’s metabolism affects their health. Thousands of tests confirm that patients with low levels of fat utilisation have trouble losing weight.

Evidence-based lifestyle interventions incorporating exercise and nutrition, informed by measurement and patient history, can then be implemented. The measurement and supporting data remove the guesswork associated with conventional lifestyle interventions and perhaps, most importantly, provides validation and motivation for the patient to continue.

Case study A 53-year-old male patient was referred with a BMI of 28.3, T2D 40 | MARCH 2021

lifestyle management programs internationally.

Key messages

Managing obesity remains a challenge worldwide

Objective measurements improve compliance and outcomes

A team approach further assists. and NASH. Through dietary measures he had managed to lose 10kg and reduce his HbA1c from 9% to 6% but had stalled at 100kg for almost 18 months. T2D remission had motivated him to go further.

Testing indicated poor metabolic efficiency and poor fat utilisation.

Resistance exercise and deeper intermittent fasting were recommended. This resulted in a further 20kg weight loss (without hunger, or significant muscle loss).

His HbA1c is now 4.3%. Additionally, he has passed an OGTT and has maintained this total weight loss (30kg) for over two years.

Drawing conclusions from an n=1 is problematic, but it provides useful insights into reasons for success (or failure).

With a major NHS program underway for T2D remission in the UK, for veterans in the US, and similar programs in Canada, Netherlands and Germany, hopefully Australia can also be part of the resurgence in lifestyle program targeting metabolic health.

A key challenge in general practice remains how to deliver and monitor effective lifestyle management at scale.

Developing integrated teams and including metabolism testing to current lifestyle programs may help to deliver real impact. Linking or embedding allied health within general practice could further improve the efficacy of these prescribed lifestyle interventions.

– References available on request Author competing interests – the author works with the company that owns the technology mentioned in the article

Weight-related metabolic disease is a global challenge and there is renewed interest in effective GP-led MEDICAL FORUM | PAIN MANAGEMENT

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CLINICAL UPDATE

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CLINICAL UPDATE

Computer navigation in spine surgery

By Dr Paul Taylor, Spinal Surgeon, Murdoch & Perth “Low back pain and neck pain are the two largest causes of musculoskeletal disability” – Global Health Metrics, Lancet. 390, 2017 Pain in, or coming from, the spine is common. In a relatively small number of cases, spine surgery can help alleviate the pain. However, it is an inherently painful option and there is a clear proportion of patients who never really ‘climb out of the hole’ of pain and suffering post-surgery, nor feel an overall benefit from surgery.

Pain is one of the most complex human experiences and varies enormously between individuals.

Many factors involved in the degree of the suffering experienced are outside of the surgeon’s control (though always considered and managed where possible). Some elements, however, are, to some degree at least, within the surgeon’s control.

Put simply, the basic problem with spine surgery is that the structures we need to access are deep and encompassed by muscle that contracts with almost every movement we make. We need to dissect this muscle from its attachments, stretching it open to gain visibility underneath. This defunctions and often denervates

Key messages

Spinal pain is common, multifactorial and not always relieved by appropriate surgery

New computer-assisted surgery can improve outcomes in suitable patients

Minimally invasive surgery can reduce pain, blood loss and hospital stay and speed up recovery.

fibres producing mechanical disadvantage for the remaining muscle. All of this is painful.

We often need to dissect more muscle and sometimes bone than we would like to as we need to recognise various anatomical elements in order to form a three-dimensional picture of the pathology in order to operate safely. This is particularly so when inserting implants into the spine such as pedicle screws.

In traditional methods, we often need to ‘strip’ the spine fairly aggressively in order to place screws safely to get a sufficient view. Minimally invasive spine surgery methods attempt to reduce the degree of dissection and muscle trauma and, therefore, reduce the pain associated with the procedure. This reduction in

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pain has been well proven in the literature. One method to achieve pain reduction is using computer navigation and percutaneous screw insertion. This is, in essence, an augmented three-dimensional visualisation technology in that we place screws ‘virtually’ on a trajectory displayed on a computer screen, whilst simultaneously inserting the screw in real time into the patient.

The system is loaded with a pre-op CT scan, we fix a 3D array to the patient, usually with a clamp on the tip of a spinous process or with a narrow pin into the top of the iliac crest, and we then ‘demonstrate’ a small portion of bony anatomy to the navigation device by tracing it out and the computer does the rest.

Navigation has been shown to improve the overall accuracy of pedicle screw placement but relying solely on navigation can increase the risk of implant misplacement as a result of technical errors.

Overall, minimally invasive spine surgery has been well shown to reduce pain, blood loss, hospital length of stay and speed of recovery. As with all complex surgery, appropriate patient selection greatly influences outcomes.

Author competing interests – nil MARCH 2021 | 41

Blended learning – digital transformation of medical education

By Dr Ramya Raman, GP, Educator, WAGPET & UND We are in a period of unprecedented disruptions – the COVID-19 pandemic has challenged our sense of normality.

Lockdowns aimed at ‘flattening’ the curve impact our lives, including the delivery of medical education in WA. Last year, lectures stopped, clinical placements and examinations were disrupted. Distress and anxiety percolated throughout medical schools, hospitals, general practices and postgraduate trainees. A drastic reduction in elective surgery and routine work limited customary hands-on clinical learning opportunities.

The switch to digital engagement models (e.g. telehealth, online learning) resulted in upskilling by clinicians to manage remote

patient demands and focusing on the adoption of alternative working models but less time to teach in clinical placements and supervise trainees.

This year affords an opportunity to review and reconsider our previous ways of working. Online learning is not novel. However, with the COVID-19 pandemic, we rapidly moved towards exclusive online teaching, assessment delivery, clinical video teaching visits and examination delivery. Many students and trainees were able to return home (interstate) to be with their families, continuing to learn via live-streamed case studies and clinical discussions.

Studies show online learning allows us to break space and time boundaries. It improves

collaborative and individualised learning effectiveness and is more convenient. An advantage is the ability for students to learn at their own pace and provide ‘caption’ texts for learners who may have learning difficulties (e.g. hearing impairment).

Extra time is available through online activities allowing students to think about concepts critically and gain a deeper understanding.

Those who may shy away from asking questions in face-to-face lectures can digitally engage, which encourages active learning and participation.

The pandemic experience has also highlighted the importance of ‘community’ and ‘human interaction’ in medical education.

A major drawback of online

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CLINICAL UPDATE

CLINICAL UPDATE enable trainees to gain clinical reasoning skills before their bedside learning and also has a positive impact on skills training and problem solving when direct patient contact is not possible.

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Synchronous models of learning require the student and educator to be at the same place at the same time. Asynchronous models are not bound by time or place. Students can access the course/event at their convenience. education felt by many students and trainees is disconnection from peers. Some feel daunted by the tech-savviness necessary for online study, technical platform failings and the blurred lines between our professional and personal lives.

Valid questions are emerging about the effectiveness of teaching ‘clinical reasoning’ and ‘clinical competence’ online. Case-based discussions (an effective clinical reasoning teaching approach) have been used to deliver curriculum.

Nevertheless, student learning styles play a vital role to enable effective and impactful online delivery.

Certain aspects of medical education (e.g. clinical examinations, sharpening clinical acumen, procedural skills, interpersonal skills and communication style) are not easily substituted by online tools and methods.

The pandemic has prompted us to rapidly evolve blended learning – characterised by a combination of synchronous face-to-face teaching and online (asynchronous) education. This can have a positive effect on learning compared to the traditional methods. Academic results have shown it to be just as effective. Use of virtual patients

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This pandemic has taught us that we can utilise a sophisticated model combining both online learning and real-time engagement (e.g. live chat questions in lectures or webinars, polling questions for small group teaching, synchronous conferencing techniques with small breakout rooms).

COVID-19 has only hastened this evolution in medical education.

Harnessing the power of digital technology combined with faceto-face teaching is likely to be the effective learning model in medical education moving forward.

Author competing interests – nil

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CLINICAL UPDATE

Temporomandibular joint disorders

By Dr Amanda Phoon Nguyen, Oral Medicine Specialist, Perth Temporomandibular Joint Disorder (TMJD) is an umbrella term for a complex, multifactorial group of conditions. The most common types of TMJD include pain disorders related to the muscles of mastication: myalgia, arthralgia and headache (attributed to TMD); and disorders associated with the temporomandibular joints primarily due to disc displacements and osteoarthritis.

It is estimated to affect between 5% and 12% of the population, with women at least four times as likely to experience the disorder.

Medical practitioners will encounter numerous patients suffering from these group of conditions.

Signs and symptoms of TMD include pain modified by jaw movement, function or parafunction, temporal region headache, regional pain, jaw locking, interference with mastication, TMJ noise (clicking or crepitus) and headache modified by jaw movement function or parafunction.

The TMJ is primarily innervated by the auriculotemporal branch of the mandibular division of the trigeminal nerve (V3), which also innervates the anterior wall of the external auditory canal. Neoplastic and inflammatory processes involving the sensory distribution of these nerves may refer to the ear and TMJ causing referred otalgia, ‘fullness’ and tinnitus.

Multiple pathological processes may mimic TMJD. These include trauma (fractures and/or haematomas), infection, developmental defects (e.g. coronoid hyperplasia), synovial proliferation, myositis ossificans, inflammation (parotid gland, temporal bone, temporal arteritis), and referred pain of cardiac origin, odontogenic causes, or facet joint degeneration, and primary or secondary malignancies.

Three questions can be used to screen for temporomandibular disorders which have demonstrated reasonable sensitivity and specificity.

Anatomy of the temporomandibular joint (TMJ) region. Image from Whyte A, Phoon Nguyen A, Boeddinghaus R, Balasubramaniam R. Imaging of temporomandibular disorder and its mimics. J Med Imaging Radiat Oncol. 2020 Oct 28. doi: 10.1111/17549485.13119. Epub ahead of print. PMID: 33118323.

Key messages

TMJ disorders are common Three screening questions are useful

Conservative treatment is used in most cases.

1) Do you have pain in your temple, jaw, or jaw joint at least once a week?

2) Do you have pain at least once a week when opening your mouth or chewing?

3) Does your jaw lock or become stuck at least once a week?

Significant associations have been found between TMJD and beliefs and activity interference, depression, anxiety, somatisation and catastrophising behaviour.

Sadly, there is also consistent evidence to suggest an association between early life adversity and TMJD. It has been reported that a higher proportion of patients with TMJD have disclosed a history of physical and/or sexual abuse.

a willingness to explore a patient’s current and previous psychosocial history. A tailored and multimodal approach to treating chronic temporomandibular disorders is important. For the majority of patients, a conservative approach to management should be adopted, and TMJ surgery is not typically indicated as initial therapy.

Conservative management includes patient education and reassurance, jaw rest, soft diet, passive stretching exercises, habit reversal and behaviour modification, stress relief, occlusal splint therapy and/ or pharmacotherapy. Referral to an oral medicine specialist should be considered for patients with chronic TMJD, especially if they have been unresponsive to treatment.

– References available on request

Management of patients with TMJD necessitates expertise and

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ARTS

Museum's health wonders

At the new Western Australian Museum Boola Bardip you’ll find thousands of stories about us, about where we come from, who we are and how we got here. You’ll also find displays about health and medicine exploring those stories.

After all, our collective health and innovations in the area create a significant picture about our society and how we live.

Whether it be displays related to curious remedies from the 19th century or more contemporary stories, the changes which have occurred in the medical field

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reflect our evolution. Furthermore, it’s interesting to view it from multiple perspectives, to reflect upon the professionalisation of Western medicine alongside the endurance of traditional Aboriginal approaches to wellbeing.

Medical-related stories are shared in many galleries of Boola Bardip and it’s a topic the curators approached from different angles and cultural perspectives – through personal and community based stories and through displays of objects, artworks, interactive exhibits and multimedia.

“There are stories about the Royal Flying Doctors Service, mental health and wellbeing alongside Professor Barry Marshall’s research into peptic ulcers,” says WAM assistant history curator Monika Durrer. “There are also many stories related to Aboriginal health, such as those of the leprosarium Bungarun and other ‘lock hospitals’ around the state, as well as those which focus on traditional approaches to holistic health.”

The Horrible Health display in the Reflections gallery focuses on WA’s identity and social history, told from

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From cigarettes prescribed for asthma to spray-on skin for burns, the Western Australian Museum Boola Bardip explores many of our stories through health and medicine, Ara Jansen writes.

ARTS dirty, smelly place. In fact, the city smelt so bad that an Inspector of Nuisances was employed specifically to sniff out bad smells.

The display contains several medications and medical instruments dating from the last two centuries, some of which are surprising by today’s standards.

Among other objects, there are headache wafers, asthma cigarettes, hair renewer, lead nipple shields, a scarifier (blood-letting instrument) and dental instruments.

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“The asthma cigarettes are particularly intriguing, mainly because the use of cigarettes as a treatment contrasts so starkly with our current understanding of the adverse effects of smoking,” says Durrer.

“Cigarettes such as these were common in the late 19th and early 20th centuries.

Although inhalation therapies had long been used by ancient cultures to treat respiratory complaints, it wasn’t until the 19th century that Western medicine adopted the use of the active ingredient, stramonium, from India.

WA perspectives. It demonstrates how concepts of health, hygiene and disease have changed over time.

According to Durrer, throughout much of the 19th century, it was thought that disease was carried by miasmas or bad odours and, at the time, Perth was an unhygienic,

“These cigarettes fell out of favour as an asthma treatment in the mid20th century as medical research evolved and new methods of treating asthma replaced the use of cigarettes. They were officially phased out in the 1980s due to concerns they were being exploited for their hallucinogenic properties.”

In the Innovations gallery, which showcases Western Australia as a place of ingenuity, imagination, vision and originality, the ReCell Spray-On Skin device, developed

by Professor Fiona Wood, is featured.

The ReCell kit rose to prominence with the 2002 Bali bombings, when Professor Wood and her team at Royal Perth Hospital used it to treat victims of the terrorist attacks. The device works by harvesting healthy skin cells and suspending them in a solution so they can be sprayed onto the wound.

The bedside kit revolutionised the treatment of burns, enabling a postage-sized sample of skin to cover an area 80 times larger. The invention is a prime example of how WA innovation has advanced medical research internationally.

“It is a privilege and an honour to be part of the new museum,” Professor Wood said. “The Museum is a state treasure and highlights the many interesting and wonderful stories of our people and I am proud that my story has been included.”

She says the kit is testament to how innovative WA is and how ideas and translation of research can come to fruition with the right team and sheer hard work.

“The initial development of ReCell is a story that belongs to many West Australians as they supported it with fundraising, either directly with the McComb Foundation (now the Fiona Wood Foundation), or with donations to Telethon which gave Marie Stoner and I the first grant to fund the lab, which allowed us to start our research. Now ReCell is distributed and sold worldwide

by Avita Medical and we are proud that it came from WA.” Her inclusion aside, Professor Wood reminisces that a visit to the museum was always a great outing for her and her kids – and followed by an ice cream stop afterwards.

“Taking my first grandson, James, to the new museum when it first opened brought back a lot of memories of taking my own children. Although, I think James was more interested in seeing meteorites than my own exhibit!

The new museum is truly wonderful and interactive and I am sure many West Australians will feel connected to all the remarkable stories, people and collections.”

Pictures: Courtesy Western Australian Museum Main picture: Michael Haluwana, Aeroture.

Read this story on mforum.com.au

Professor Fiona Wood with her grandson James (left) and friends Penny and Darcy.

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LIFESTYLE

Saving the best for last under the pines

According to the festival’s associate programmer for film, Tom Vincent, Lotterywest Films have saved the best for last and inadvertently chosen films with public health at their heart. The final four dramas in the festival will be screened for a week each in March.

“I really believe that a film is never experienced the same way twice,” Vincent said. “The great dynamic of cinema is that you never know what you are going to get or who is going to be in the audience.

Seeing something with friends and strangers together elevates your senses and you also feel the impact of the film through other people.”

fictional fitness motivator and social media star who is forced to confront the disconnect between her public and private life.

“Sylwia has 600,000 followers and films herself at the gym, through her day and all these moments are public. Privately, she’s in crisis and she doesn’t see until after the audience does that she’s lonely. It’s a rich character study and the kind of film that is very ‘now’.”

The French movie, Gagarine, is a particular favourite of Vincent’s.

Named after a large municipal housing block in Paris that’s about to be demolished, it introduces us to a teen determined to save

his home and community. It slips between the gritty realism of urban life and dreamlike animated sequences that explore Yuri’s hopes of being an astronaut, like the first human in outer space, Russian cosmonaut Yuri Gagarine.

What would happen if you awoke one morning without memories?

That’s the premise for the final film in this year’s season, Apples.

This Greek film struggles with a worldwide pandemic that causes sudden amnesia. A man enrolled in a recovery program gets his instructions via cassette player and captures new memories with a Polaroid.

A woman reasserting her identity after her marriage collapses is the central theme of Ema. Embarking on an odyssey of passionate freedom, Ema rediscovers herself and her sexuality through dance.

“It’s vibrant and almost abstract but you don’t need a lot of story here,” says Vincent of the film from Chile. “It’s sensual, musical and an explosion of dance. I really like the sense that it gives us – to practise art can make us feel human.”

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Ema

Apples

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If you have not yet managed to catch up with the Perth Festival, there’s still time to grab a blanket and enjoy some thought-provoking movies under the stars at the Somerville Auditorium.

By Ara Jansen

LIFESTYLE

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Delicious

“People not claimed by relatives are connected to an agency which gives them instructions on how to become human again – talk to a woman, go to a shop and buy something. He knows the one thing he likes is apples. It’s deadpan, detached and slightly surreal with this absurdist humour.”

Vincent says the past year has proven a great time for independent cinema. “That has a lot to do with mainstream cinema becoming increasingly risk averse and having films in development for years. Independent films are lower financial risk, can turn around in shorter time and are much better placed to tell these kinds of stories.”

There’s also a final screening of kung fu legend Bruce Lee’s Fist of Fury translated into Noongar at Celebration Park in Balga on March 6. It’s the first feature film ever to be revoiced in an Australian language.

ED: Lotterywest Films: book at perthfestival.com.au, via phone on 6488 5555, in person at the Octagon Theatre or on the night from 6pm.

Ooh la la!

The Alliance Française French Film Festival returns to Perth from March 10 to April 17, with a program of more than 35 films at Palace Cinemas Raine Square, Luna Leederville, Windsor Cinema, Luna on SX and Camelot Outdoor.

Featuring the crowd-pleaser Bye Bye Morons, by writer/director/actor Albert Dupontel, which blends dark humour, social satire and tragedy into a frenetic and fast-paced story. It conquered the French box office in 2020 despite being released at the height of the curfews.

Try the thriller Black Box, about one man’s determination to get to the bottom of what caused a horrifying plane crash. Or perhaps on the menu will be Delicious, but viewers are warned to either eat beforehand, or have a reservation in place.

We have five double passes, valid for any film excluding special events. www.affrenchfilmfestival.org

French Exit We also have 10 double passes to French Exit, being released March 18, which stars Michelle Pfeiffer (who has won a Golden Globe for the role) and Lucas Hedges. A Manhattan socialite’s plan to die before the money ran out goes astray and she and her son end up in a borrowed apartment in Paris.

Win...

For your chance to win tickets to the Alliance Française French Film Festival and French Exit, visit our website to enter www.mforum.com.au (click on the competitions tab)

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MARCH 2021 | 51

SJG Murdoch St John of God Murdoch Hospital’s annual doctors Christmas event was held as usual in a marquee by the lake on the beautiful grounds of the hospital. Dr Erik Hagen was awarded the St John of God Murdoch Hospital Doctor of the Year for 2020. Erik is an experienced Emergency Senior Medical Officer, who delayed his retirement during the COVID-19 pandemic.

1 Dr Anurag Goel, Dr Chinar Goel and Dr Lakshmi Fernandes 2 Hazel Rawlins and Dr Jeremy Rawlins 3 Lara Bucher, Dr Dror Maor, Angeline Lee, Dr Omar Khorshid and Dr Thomas Bucher 4 Dr Ian Jenkins and Sharon Connolly 5 Dr Krishna Epari, Elaine Thomas and Dr Alan Thomas 6 Margie Grover, Dr Erik Hagen and CEO Ben Edwards

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SJG Mt Lawley The 2020 St John of God Mt Lawley Hospital Medical Practitioner Soiree was held at the Westin Perth with more than 120 specialists, St John of God Health Care executives and members of the St John of God Mt Lawley Hospital senior leadership team enjoying the celebratory occasion. Singer Claire McGlew, who also works as a music therapist at the hospital, entertained the crowd.

The Doctor of the Year was awarded to anaesthetist Dr Ralph Longhorn for his significant contribution to the hospital’s COVID-19 preparations.

The Dr Ellis Pixley Service Award was presented to Dr Anne Kehoe, who was a consultant paediatrician at St John of God Mt Lawley for 20 years.

1 Doctor of the Year recipient Dr Ralph Longhorn with Mt Lawley Hospital CEO Paul Dyer 2 Dr Hor Kwok, Meggie Zeng, Dr Wendy Cheng, Dianne Sunderman and Dr Andrew Crocker 3 Dr Vincent Lee, Margaret Lee, Dr Joo Teoh, Dr Ken Nathan and Dr Liza Fowler 4 Dr Andrew Yeates, Dr Jonitha Nadarajah and Anthony Phillips 5 Nicole Bairstow, Dr Brett Bairstow and Dr Tek Yew 52 | MARCH 2021

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6 Jenny McRae, Dr Paul McRae, Dr Mal Vincent, Sue Vincent and Mirrella Edwards 7 Bud Ranasinghe and Dr Panchi Kumarasinghe 8 Dr Ellis Pixley Service Award 2020 recipient Dr Anne Kehoe (right) with Dr Fiona Pixley and Mt Lawley CEO Paul Dyer

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CHRISTMAS 2020

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CHRISTMAS 2020 SJG Subiaco St John of God Subiaco Hospital’s annual Christmas Soiree for specialists was held at the RitzCarlton on Friday 20 November.

Hosted by St John of God Subiaco Hospital CEO Prof Shirley Bowen, the event allowed attendees to come together and celebrate the start of the festive season with friends and colleagues.

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Prof Bowen said “It also provided the perfect opportunity to thank specialists for their support throughout the year and recognise retiring specialists Dr Chris Allen, Dr Peter Woodland and Prof Cameron Platell.”

“It was a wonderful evening after a challenging year.”

1 Prof Cameron Platell and Ingrid Platell 2 Dr Jo Colvin, Dr Mangesh Deshmukh, Dr Jagapathi Mokala, Dr Sanjay Gehlot 3 Dr Mark Hands and CEO Prof Shirley Bowen 4 Dr Melissa O’Neill, Dr Ben Walawski and Dr Fiona Langdon 5 Dr Reza Salleh and Group CEO Dr Shane Kelly 6 Dr Peter Woodland and Robin Woodland

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MediBizz Mr Philip Coelho, the founder and director of MediBizz Australia, hosted the annual Christmas dinner and dance with co-hosts Dr Vishnu Gopalan and Dr Jagadish Krishnan at the Astral Ballroom Crown at the Perth Convention Centre. There were 130 guests with representation from Pearsall Medical Centre, Pearsall Dental Centre, Hocking MC, Alkimos MC, Mt Helena MC, Somerly Central MC, Beachside MC, Jurien Bay MC, Olympic MC, Maddington Family Doctors, Secret Harbour Family Doctors, Dawesville MC, Hamilton Hill MC, Cannington Family Doctors, Rainbow Health MC, Austin Lakes MC, Cooby Family Practice and Butler Medical Imaging.

1 Clinton Fonceca and Mel Wilson 2 Dr Kevin Keyhani, Shania Keyhani and Kristina Joseph 3 Dr Vishnu Gopalan and Philip Coelho 4 MediBizz South Group 5 Dr Vishnu Gopalan, Dr Pushpa Yapa and Dr Yuriy Pogorelyuk 6 Sarah and Philip Coelho 7 MediBizz North practices

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Mount Hospital The Mount Hospital staff and doctors enjoyed the river and city views and celebrated the end of a challenging year at their annual Christmas party, which was held at Royal Perth Yacht Club.

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Dr Matthew and Tessa Best and Dr Jason and Michelle Wells Dr Ian and Robyn Gilfillan and Dr Steve Same Dr Justin Ng and Dr Michael Nguyen Dr Peter and Sandy Honey

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CHRISTMAS 2020

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CHRISTMAS 2020 Bethesda Health Care Staff, doctors and volunteers gathered at the Claremont Football Club to celebrate a year that had a lot of triumphs, including the announcement of the new Bethesda Clinic Cockburn project, paired with the struggles that the pandemic brought to elective surgery in WA.

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1 Jenny Bourke, Bethesda chairman Dominic Bourke, Bethesda CEO Dr Neale Fong and Peta Fong 2 Melanie Kwok, Marcia Roberts, Carol Jones, Di Ferrari, Trish Barrett, Michelle Olins 3 Priscilla McLellan and Dr Duncan McLellan 4 Dr Mikhail Lozinskiy and Maria Lozinska 5 Debra Sutherland and Dr Gavin Bowra 6 Linda Carija and Dr Isavel Carija 7 Caroline Vittiglia, Emma Whyte, Aleece Angwin and Freda Casey 8 Susannah Evans, Sonya Conroy, Ali Bennett and Cheryl Decore 9 Dr Jeff Ecker, Dr Neale Fong, Dr Phil Soet and Dr Steven Watson

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CHRISTMAS 2020

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SJG Midland Public & Private Hospital St John of God Midland Public and Private Hospitals held their consultants’ Christmas party at Sandalford Winery.

1 Dr Glen Brand, Dr Lay Kho, Dr Thomas Chemmanam and Dr Ali Aftzal 2 Adelle Ryan, Irene Moore and Dr Emily Woolnough 3 Dr Anna Clare, Dr Premala Paramanathan and Dr Emma Brandon 4 St John of God Midland COO Bryan Pyne, CEO Michael Hogan, Chair Peter Prindiville and Dr Mark Murphy 5 Dr Christie and Manel De Silva 6 Dermot and Dr Siobhain Brennan 7 Dr Jonathan Agunwa, Lindy Agunwa, Shymaa Al-Shawi and Dr Salah Al-Shawi 8 Dr Kenji So, Natalie So, Jaya Gounder and Dr Siva Gounder 9 Mark Gregson and Dr Mary Theophilius 10 Dr Mark Lee, Dr Francesco Piccolo and Dr Jee Kong 11 Dr Michelle Ross-King and Dr Ben King

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