Medical Forum – September 2021 – Public Edition

Are health apps doing more harm than good?

Respiratory issue | Silicosis, bronchitis in kids, Cushing’s disease, endobronchial ultrasound MAJOR PARTNERS

September 2021 www.mforum.com.au

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

Living life by the clock

I always swore I would never be lured into buying a wrist gizmo that told me how many steps I had taken that day.

My rationale was that I didn’t need an app to tell me I had walked for 30 minutes – a simple watch with two hands could tell me that – or that my heart rate had quickened when I climbed a steep set of stairs.

And if chose to be a sloth for a day, I did not appreciate being quietly scolded by a judging piece of metal and plastic.

A recent US study found more than half of all mobile phone users have at least one active health app.

Yet here I am, the owner of a watch that not only tells the time in 10 different regions of the world, but prods me with reminders to breathe (yes there is such an alert). It also tells me when I should be going to bed – even dimming its light to get me in the mood.

And, shamefully, I have been known to walk around the house aimlessly at 10.13pm just to close the ‘move’ or ‘stand’ ring, which is a tantalising millimetre away from the daily target.

But it seems I’m not the only one using health tracking, either on a smart device or a watch. A recent US study found more than half of all mobile phone users have at least one active health app.

This month, we explore their pros and cons, and what doctors need to know about the technology increasingly being used by many of their patients.

We also look at the concept of a vaccination passport because it’s becoming increasingly apparent that if you don’t have one, you won’t be needing your other passport. And if we follow France’s lead, sans passeport you might be eating-in a lot too.

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MEDICAL FORUM | RESPIR ATORY HEALTH

SEPTEMBER 2021 | 1

CONTENTS | SEPTEMBER 2021 – RESPIR ATORY HEALTH

Inside this issue 12

24

20 16

FEATURES

NEWS & VIEWS

LIFESTYLE

12 Passport to

1

56 Have skills, will travel

a new world

16 Close-up: GP Dr Ann Ward

20 Health apps – more harm than good?

– physios on the road

58 Love in the time of COVID 59 Wine review:

4 In the news 6 In brief 37 Every breath you take

24 The vape cloud is getting bigger

Editorial: Living life by the clock – Cathy O’Leary

Happs Wines – Dr Martin Buck

– Dr Joe Kosterich

52 Big food picture for T1D

Win Dr Martin Buck reviews wines from Happs, including its impressive Three Hills range. For a chance to win a dozen bottles of Happs PF Red, or one of three copies of a Zen-inspired book by Brigid Lowry, click on the competitions tab at www.mforum.com.au or enter via our weekly newsletter delivered to your inbox. Dr David Pearson is the lucky winner of the Henschke Doctors Dozen.

Winemaker Mark Warren

CONNECT WITH US /medicalforumwa

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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

5

7

9

39

Treating lung cancer with SABR therapy Dr Tee Lim

Why varicose veins come back Dr Luke Matar

Predicting winter viruses with multiplex PCR

By Dr Sudha Pottumarthy-Boddu

Excluding Cushing’s syndrome Dr Michael Page

40

43

44

Infections and biologics during COVID-19 Dr Astrid Arellano

Adolescent cardiac issues Dr Michael Davis

Silicosis – why it’s back and how to find it Dr Stephen Melsom

46

49

53

54

Molecular blueprint for oral leukoplakia Prof Camile S. Farah

Protracted bacterial bronchitis in children Dr Adelaide Withers

Endobronchial ultrasound Dr Ivan Ling

Benign breast Lumps Dr Jose Cid Fernandez

Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Journalist Dr Karl Gruber (PhD) 08 9203 5222 journalist@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Clinical Services Directory Editor Karen Walsh 0401 172 626 karen@mforum.com.au

GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au

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10

31

32

34

Trust, not bribes, key in vax rollout Dr Katie Attwell

Advanced care planning essentials Linda Nolte

Survey hints at push-back on junk food Sheryl Westlund

Coronavirus and industry E/Prof Odwyn Jones and C/Prof Bill Musk

MAJOR PARTNERS

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SEPTEMBER 2021 | 3

IN THE NEWS

BACK TO CONTENTS

Healing the right way The WA Country Health Service has partnered with Edith Cowan University to improve rehabilitation for Aboriginal Australians following stroke or traumatic brain injury.

The Healing Right Way project, funded by the National Health and Medical Research Council, involves cultural security training at some hospital sites in country WA and a new Aboriginal brain injury coordinating service to support survivors and their families in the first six months after injury.

WACHS is providing in-kind support to the project including hosting and assisting medical, nursing and allied health staff to attend training sessions on providing culturally secure care.

Promising drug trial at Murdoch St John of God Murdoch Hospital has played a key role in the global trial of a cancer drug that doubles the disease-free survival time in patients with oesophageal cancer.

The immunotherapy drug, used in the trial CheckMate-577, which is already approved for other cancers such as Hodgkin lymphoma, melanoma and kidney cancer, gives hope to people with early-stage oesophageal and gastroesophageal junction cancer.

The head of SJOG Murdoch’s department of cancer services, Associate Professor Kynan Feeney, said it was hoped the drug would become the new standard of care.

“The cancer is very hard to treat, and most patients learn they have it after it has progressed to a point where they are not likely to survive, so this advancement is significant,” he said.

“The drug can double the diseasefree survival times in patients from 11 months to 22 months, but importantly we now see more people living longer without cancer, meaning there are more people going longer before any relapse of their oesophageal cancer.”

4 | SEPTEMBER 2021

Its research manager Justin Manuel said rural staff could gain experience in research, while contributing to improved services for brain injury survivors in the country. The project is ongoing until early 2022.

Tap and go Some of Australia’s biggest health insurers, including HBF and Medibank, are now allowing members to make claims on the spot by tapping their iPhone or Apple Watch on their healthcare practitioners’ HICAPS terminal, rather than swiping a plastic card.

Baby talk A ground-breaking TED talk piloted at Ramsay Health Care maternity hospitals in WA is set to change the way parents and caregivers view early childhood brain development.

The Thrive by Five TED talk, which was directed by filmmaker Michael Gracey and launched in Australia at Joondalup Health Campus, shows the simple yet life-changing things adults can do to help children thrive. The production is the work of the Minderoo Foundation through its Thrive by Five initiative.

Test for endometriosis Perth-based Proteomics International, the University of Melbourne and Melbourne’s Royal Women’s Hospital have developed the world’s first simple blood test for endometriosis, which affects one in nine women and costs Australia $9.7 billion each year.

The non-invasive test for endometriosis could save women years of suffering. At the moment, there is no simple way to test. The current gold standard for detection

is an invasive laparoscopy. On average, it takes women seven to 12 years to be diagnosed.

A tissue bank of biological samples from more than 900 women will be used to validate Proteomics’ biomarkers.

Painful kids Perth Children’s Hospital has partnered with Boston Children’s Hospital and Harvard University to launch the Comfort Ability Program in WA, which aims to help children and families learn how to manage chronic or recurring pain.

Site director and program coordinator of PCH’s Complex Pain Service Anna Hilyard said that for the first time in Australia the program would be available online and face-to-face, allowing families to participate from their home, school or workplace.

“Too many children live their dayto-day lives in chronic or persistent pain,” Ms Hilyard said.

“Chronic pain can wreak havoc in the lives of children, interfering with school, sleep, friendships and activities. Parents and caregivers are also deeply affected, as they may miss weeks of work caring continued on Page 6

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Treating lung cancer with stereotactic ablative body radiation therapy (SABR) With about 1200 cases each year, lung cancer is the fourth most common cause of cancer in Western Australia, but the number one cause of cancer death.

Non-small cell lung cancer (NSCLC) is the predominant histology type, and approximately 15% of patients present with confined localised disease (stages I-III). Early-stage NSCLC is a curable disease and surgery is standard treatment, providing five-year local control and overall survival rates of between 65-100% and 50-70%, respectively.

However, 20% of patients with potentially curable stage I NSCLC at diagnosis are not suitable for surgery due to poor lung function or medical comorbidities, and some patients decline surgery. The National Comprehensive Cancer Network (NCCN) and the American College of Chest Physicians recommend that all patients with NSCLC be evaluated by a multidisciplinary team to determine operability.

SABR – a comparable option to surgery in selected patients Data has shown that stereotactic ablative body radiation therapy (SABR) achieves comparable local control and survival as surgery in patients with early-stage NSCLC. Today, it is considered standard curative treatment for medically inoperable early-stage non-small cell lung cancer or for those who refuse surgery (NSCLC).

Whether it is an appropriate treatment for patients who are candidates for surgery remains, however, controversial. Currently, there are multicentre, randomised controlled trials (STABLE-MATES, VALOR, and POSTILV) underway to compare surgical resection and SABR in patients with early-stage lung cancer. An additional UK trial (SABRTooth) has recently closed recruitment. The results are yet to be published.

What is SABR? • Extremely precise, SABR uses advanced image guidance to deliver high doses of radiation to the target in 1-5 treatment sessions whilst avoiding surrounding healthy tissue.

• SABR is non-invasive and associated with relatively few treatment-related complications.

• Advanced age is not a barrier to treatment – it is well tolerated in elderly and frail patients.

• Delivery is via either advanced linear accelerator-based machines or CyberKnife®. Both produce comparable treatment outcomes and toxicities in earlystage NSCLC. • In 2010, GenesisCare Wembley was the one of the first centres in Australia, and the first centre in Western Australia, to implement SABR in early-stage NSCLC.

Dr Tee Lim MBBS, FRANCR

Radiation Oncologist, GenesisCare

– References available upon request

Case example

Treatment plan: Four fractions over four days

Highly avid 33mm left upper lobe lung cancer on PET scan before SABR in an elderly patient.

Six months post SABR: complete metabolic response on PET scan. Patient remained disease-free and well at 33-months of follow-up.

Our centres Bunbury • Fiona Stanley Hospital • Hollywood Joondalup • Mandurah • Wembley Tel: 1300 977 062 | connection@genesiscare.com www.genesiscare.com MEDICAL FORUM | RESPIR ATORY HEALTH

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Professor Yogesan Kanagasingam has been appointed Chair in Digital Health and Telemedicine at the University of Notre Dame Australia as part of a research appointment with St John of God Midland Public and Private Hospitals. He will work on cutting-edge practices in digital health and telehealth plans at the hospital.

Curtin University researchers have been awarded more than $1.1 million from MSWA to conduct neurological research focusing on outcomes for people with multiple sclerosis and Alzheimer’s disease. The Curtin Health Innovation Research Institute projects include a trial aimed at reversing the early stages of MS, and a study into how a high-fat diet might promote or reduce the risk of developing MS.

Professor Karen Strickland has joined Edith Cowan University as executive dean of its School of Nursing and Midwifery.

Aged care service provider Silver Chain Group is partnering with WA Health to enhance palliative care, with two pilot programs offering a new overnight respite service for carers and an improved referral process to access in-home palliative care.

IN THE NEWS

continued from Page 4 for their child, and struggle with feelings of helplessness.

We currently offer an intensive interdisciplinary pain program at PCH but places are limited.”

Take heart in vitamin ECU research has found that people who eat a diet rich in vitamin K have up to a 34% lower risk of atherosclerosis-related cardiovascular disease. Researchers examined data from more than 50,000 people taking part in the Danish Diet, Cancer, and Health study over 23 years.

They investigated whether people who ate more foods containing vitamin K had a lower risk of cardiovascular disease related to atherosclerosis. There are two types of vitamin K found in foods – vitamin K1 comes primarily from green leafy vegetables and vegetable oils while vitamin K2 is found in meat, eggs and fermented foods such as cheese.

The study found that people with the highest intakes of vitamin K1 were 21% less likely to be hospitalised with cardiovascular disease related to atherosclerosis.

For vitamin K2, the risk of being hospitalised was 14% lower.

This lower risk was seen for all types of heart disease related to atherosclerosis, particularly for peripheral artery disease at 34%.

First-aid for the needy HIF and St John Giving, the charitable arm of St John WA, have come together to provide vital firstaid training and healthcare to the WA community.

As St John Giving’s first founding partner, HIF has committed $200,000 towards supporting key initiatives that address a variety of needs for vulnerable, disadvantaged and at-risk Western Australians. It will contribute to St John’s first-aid focus programs, its community transport network and its first responder app. continued on Page 8

Breathing easier in Perth’s south Asthma WA has opened Australia’s first paediatric respiratory hub in Cockburn. The hub operates up to three days a month, with a second location hoped to open in West Perth soon. The hub, for people aged four to 18 years, provides paediatric lung function testing, immediate analysis and review by a respiratory specialist, as well as a consultation with a respiratory health nurse in the one appointment.

Until now, families needing a formal diagnosis had to make multiple appointments with various health professionals, often with lengthy waiting lists.

The community-based bulk-billing service, the first of its kind in Australia, aims to provide children and their families with an optimal treatment plan for managing their respiratory health.

HBF has appointed senior financial executive Jennifer Seabrook to its board as a non-executive director.

6 | SEPTEMBER 2021

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IN BRIEF

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MAJOR PARTNER

WHY VARICOSE VEINS COME BACK Disrupted normal anatomy and negative patient psychology (“what’s the point treating, they will just come back”) present significant challenges to the physician treating recurrent varicose veins (RVV).

The literature and our own experience highlight three common and largely preventable causes of RVV: 1. Diagnostic error – incomplete identification of all reflux points 2. Treatment error – inadequate treatment of all reflux points 3. Lack of follow-up and ongoing maintenance.

Ultrasound diagnosis The standard of care before any vein intervention should be a detailed doppler study of the deep and superficial venous system.

by DR LUKE MATAR Dr Matar is a dual-qualified Radiologist and Phlebologist. His personal and family history with varicose veins fuels his ongoing passion for offering the most effective varicose vein treatments available.

As medical director of The Vein Clinic in Perth he has pioneered several innovations in vein treatment and offers a highly tailored and targeted approach to treating venous insufficiency, the cause of varicose veins and a frequent cause of restless legs. adjunct procedure, particularly for smaller veins, the science, literature, and our own experience supports that this is rarely a satisfactory standalone treatment for refluxing saphenous veins.

Whilst nearly all general sonographers are competent at DVT studies, a smaller subset of vascular sonographers are fully competent at specialised chronic venous insufficiency (CVI) studies.

The success of UGFS depends largely on the size and wall thickness of the vein being treated, but is also highly influenced by the choice and concentration of sclerosant as well as the method of administration and skill/experience of the operator.

Typically, non GSV/SSV causes of reflux, including accessory veins, pathological perforator veins, pelvic veins and anomalous veins may not be properly assessed. Deep vein reflux and obstruction may also go unrecognised leading to RVV.

Endothelial damage from sclerosant action in larger veins will often result in temporary closure from “sclerothrombus”, with subsequent clot and fibrinolysis resulting in recannalisation and recurrent reflux leading to RVV.

Incomplete or inappropriate treatment

Endothermal ablation methods (EVLA/RfA) are now clearly established internationally as the gold standard for treating incompetent saphenous veins. Success is far less operator-dependent than with UGFS, closure rates >95% are commonly

Incomplete diagnosis will of course lead to inadequate treatment.

Historically, phlebectomy without treating underlying saphenous reflux, not surprisingly, resulted in high rates of RVV. High ligation and stripping (HLS) is still practised despite striptrack revascularisation and groin neovascularisation in up to 80% of patients on ultrasound studies; albeit with a much lower rate of clinical recurrence.

Ultrasound Guided Foam Sclerotherapy (UGFS) has been shown to have only an overall success rate of around 50%. Whilst a useful

seen across all operators.

Endothermal ablation failures may occur when the wrong veins are treated, inadequate energy is used to close the veins, and incomplete treatment of reflux has occurred (i.e., accessory veins, perforator veins and lowest reflux point not treated) problems that are commonly seen with novice operators.

The diagram (below left), reproduced with permission from Professor Mark Whiteley, illustrates the subtotal vein damage and subsequent recannalisation common following UGFS compared to full-thickness wall damage and true vein involution usual following EVLA.

Incomplete/non-existent follow-up Further research from The Whiteley Clinic has shown that varicose veins may still develop at a de novo rate of around 3% per year despite optimal treatment technique.

If optimal treatment has been performed, new varicose veins will normally develop in veins that were previously disease-free.

This represents natural disease progression and not treatment failure.

It is for this reason that many dedicated vein clinics recommend annual sonographic surveillance and clinical follow-up so that RVV are detected and treated early, when they are less extensive and expensive to treat.

Perth's Only Dedicated Varicose Vein Clinic 6/28, Subiaco Square Road Subiaco WA 6008 (08) 9200 3450 | veinclinicperth.com.au

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IN THE NEWS

continued from Page 6

Big baby test WA diabetes researchers trying to simplify gestational diabetes screening have discovered that a blood test early in pregnancy can help identify Aboriginal women at risk of having large babies. Research leader Associate Professor Julia Marley, from the Rural Clinical School of WA, said the discovery was made through the ORCHID Study, which aims to simplify screening for high blood glucose levels in pregnancy.

“Having a large baby can cause birth complications for mum and these larger infants are more likely to develop obesity and type 2 diabetes in later life, so if we can detect high blood sugar levels using an early pregnancy HbA1c test, we have a chance of reducing that risk,” she said.

This phase of the study, which is funded by a $60,000 Diabetes Research WA grant, includes 68 pregnant women from WA’s Kimberley region and has recently expanded to the Goldfields.

Heart tool A new tool that provides cardiologists with rapid information to treat patients with heart disease and save lives from heart attacks was a finalist in the WA Innovator of the Year 2021 Awards.

Apricot, an advanced coronary artery assessment tool developed by a team of researchers from the University of Western Australia and the Perkins Institute, was named a finalist in both the Rio Tinto Emerging and Wesfarmers Wellbeing Award categories. It aims to provide new information to cardiologists when they are treating patients in the catheterisation theatre. The new information combines the anatomical data that they can see on the images, with engineering-based information they cannot see.

Associate Professor Barry Doyle and Dr Lachlan Kelsey from UWA’s School of Engineering and the Perkins Institute developed the methods over the 8 | SEPTEMBER 2021

Watson offers ‘impawtent’ aid New research has confirmed that hanging out with a furry friend while studying has significant benefits for emotional wellbeing. The ECU project is the first to specifically examine the impact of a wellness dog for paramedicine students.

It involved 89 participants and examined their self-reported emotional wellbeing while the dog was in class. The study found the presence of wellness dog Watson contributed to students' overall improved mental health, aided communication and helped provide a sense of belonging within the university community. Watson also helped students who may have been uncomfortable with dogs become more at ease with them.

past seven years, in collaboration with Professor Carl Schultz, the UWA Chair in Cardiology and interventional cardiologist at Royal Perth Hospital.

provide the first positive physical active experience for many of the participants. As a result of the findings, it will remain part of the treatment model at Pathways.

Fit for play

Curtin goes for Goldfields

A physical activity-based program that develops fitness, movement and social skills using activities such as juggling and pirate adventure play has been shown to boost confidence in children with mental health disorders and motivate them to lead more active lives.

The opening of Curtin Kalgoorlie’s new rural health campus is expected to bring greater regional training opportunities for medical and health science students and help overcome challenges facing the rural health workforce.

Featuring a simulation clinical hospital ward and rooms for clinical training and assessments, the campus is part of Curtin’s Medical School in Bentley.

The Fit for Play program was established by exercise physiologist Kat Fortnum, along with the University of WA’s school of human sciences and Pathways, a specialised Child and Adolescent Mental Health Service program.

Ms Fortnum set out to cater for the physical activity needs of primary school-aged children with disorders including post-traumatic stress disorder, severe anxiety and attention deficit hyperactivity disorder. Following a six-month intervention with 23 children aged six to 12 years of age, research showed that Fit for Play helped

Curtin Vice-Chancellor Professor Harlene Hayne said the Kalgoorlie Rural Health Campus was developed to help address the uneven distribution of medical services in rural WA. “By increasing options available for rural training and providing a base for students to complete practical experiences, our goal is to encourage more graduates to take up employment in the regions,” she said.

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Predicting winter viruses – multiplex PCR is the key Seasonal activity of respiratory viruses is relatively predictable with well-established surveillance systems worldwide to monitor their trends. However, the current COVID-19 pandemic due to SARSCoV-2 virus, started in late 2019 necessitating unprecedented public health measures to control its spread.

The national 2020 Influenza Season Summary1 found: • The GP ILI consultations were four times less than the five-year average for the same period (1.6 versus 8.1 per 100 consultations)1.

• Laboratory confirmed influenza notifications were almost 8 times less than the 5-year average (21,266 versus 163,015)1.

• Admissions resulting from confirmed influenza diagnosis to the sentinel hospitals were markedly lower in 2020 compared to the fiveyear average (15 versus 2,641)1.

Australia is not alone, with these findings corroborated by similar reports worldwide. United States and other Northern Hemisphere countries, the tropics and also the Southern Hemisphere temperate climate countries have all noted a sharp decline to virtually nil influenza activity in the 2020 influenza season, all temporally related to the implementation of the nonpharmaceutical public health measures2. This worldwide decline in influenza notification, while compelling to attribute causality to these measures, the effect of little travel, vaccination and viral interference have also been postulated2.

Respiratory syncytial virus (RSV) activity also remained low in winter 2020, with sustained absence over a four-month period noted in WA3. School age-children are recognised to play a central role in transmission of both influenza and RSV. Even though schools remained open in WA, the noted marked reduction in RSV detections is thought to be consistent with the absence of a sizeable local reservoir and the true lack of local infections3.

In contrast, a marked change in RSV trends4 was noted in early 2021, with:

By Dr Sudha Pottumarthy-Boddu MBBS FRCPA D(ABMM) Dr Sudha Pottumarthy-Boddu has a distinguished career in microbiology with extensive experience in the US New Zealand and Australia. Sudha is a Diplomate of the American Board of Medical Microbiology, and a member of both the Antimicrobial Stewardship Committees and Infection Prevention and Control Committees at multiple St John of God hospitals in WA. Table 1. Clinical Labs Respiratory PCR Panel Diagnoses Jan–June 2019 vs. Jan–June 2021 in WA. Virus Type

Number of Positive Diagnoses Jan to June 2019

Influenza A & B

Jan to June 2021

3487

5

RSV (A & B)

388

441 320

Parainfluenza 1,2,3 & 4

259

Human Metapneumovirus

120

231

Human Adenovirus

176

126

Human Rhinovirus

1064

3280

• interseasonal resurgence of RSV in Australian children and rise in cases • higher median patient age, 18.4 months versus range of 7.3 to 12.5 months (P < 0.001; 2012-19).

more susceptible and immunologically naïve to many serotypes. Additionally, rhinoviruses are non-enveloped viruses, and so less susceptible to inactivation by soap-and-water handwashing7.

This change has been attributed to an expanded cohort of RSVnaïve patients, increased number of older children coupled with waning population immunity4.

The unpredictable nature of the trends of respiratory viral infections in the current winter of 2021 places renewed emphasis on testing for a broad range of respiratory pathogens. This practice has also been advocated by several groups internationally as targeted testing may not hold all of the answers.

Comparative rates of detections of respiratory viruses by multiplex PCR panel at Australian Clinical Labs in WA during the first six months of 2019 versus the same period this year, are detailed in Table 1.

The notable absence of influenza detections among our test cohort from Jan-June 2021 is unsurprising given similar reports from other parts of the world5. In the Netherlands, the incidence and disease severity in 2020 due to human metapneumovirus was not impacted by the COVID-19 outbreak. 6 Human metapneumovirus is recognised to cause respiratory disease not dissimilar to that of SARS-CoV-2 and is noted to circulate independently6.

The cause of the rhinovirus surge, also noted by others, is unclear7. Rhinovirus spread is driven by children who are

Multiplex PCR to diagnose influenza and respiratory viral infections allows for a rapid and accurate diagnosis.

This will enable the clinician to initiate targeted treatment early, avoiding inappropriate antibiotic therapy.

Additional clinical tests recommended based on relevant symptoms: • If you suspect a lower respiratory infection then the appropriate sample is sputum for MCS • If the patient presents with pharyngitis symptoms then obtain a swab from the throat for culture.

– References 1-7 on request The author wishes to acknowledge the ACL-WA molecular team led by Ms Dimbi Crogan and Mr Alvaro Defreitas for their unfaltering efforts during the continued COVID-19 outbreak.

Building Better Partnerships

1300 367 674 | clinicallabs.com.au MEDICAL FORUM | RESPIR ATORY HEALTH

SEPTEMBER 2021 | 9

Trust, not bribes, key in vax rollout Vaccination researcher Dr Katie Attwell argues blanket mandatory COVID-19 vaccination or big financial incentives are not necessarily the best way forward.

Australia’s COVID-19 vaccination rollout has been humbling. In a few short months, we have gone from being the envy of the world to having to manage outbreaks of the Delta variant in our largely unvaccinated population.

As Europe and North America emerge from lockdowns and restrictions, many Australians have been placed back into them. We are left asking what it will take for us to resume our lives.

However, part of the problem might be that life has been too good already, especially in Western Australia. Within our hard border – aside from a few short, sharp lockdowns – we have been able to attend work, school, and participate in social life. Naturally, some people feel that they can wait a bit longer to be vaccinated, or can wait for the brand of vaccine they prefer.

Facing this situation, it is easy to assume that the community is not pulling its weight, and that mandates or incentives are needed. However, apart from key occupations where workers can infect vulnerable patients or transmit disease from active cases, it is much too early for mandates.

Our problem has been less about complacency or hesitancy, and much more about supply.

Outside of NSW, the only people who have been able to easily and quickly access a vaccine are the over-60s. AstraZeneca uptake among over-60s is not complete, but more large-scale and targeted government communications can support and encourage the older population to access their first dose or complete their second.

10 | SEPTEMBER 2021

When it comes to those under 60, there has been a significant lack of Pfizer, and barriers for younger people who are happy to consent to receiving AZ. These barriers include the advice of experts and doctors.

To say it’s complicated would be an understatement.

Meanwhile, non-English speakers have not been engaged through targeted programs. Those who come from countries where they have been abused by the state need supportive and empathic engagement in their language through trusted messengers. There is an urgent need for appropriate government communications to address hesitancy and misinformation.

It’s enormously hard work to make all of these things happen, and so the quick fix appears alluring.

Incentives have been the latest buzz in political and media circles, with the ALP suggesting vaccine recipients receive $300. Purposebuilt incentives have been used

in Australian immunisation policy before, but as part of our long-term and stable childhood vaccination program.

Non-vaccinators were also able to access these incentives using conscientious objection forms. (This kind of exemption was abolished by 2016’s No Jab, No Pay policy.) It is highly unlikely that there would be any personal belief exemptions for COVID-19 vaccine incentives.

Our ‘Coronavax’ social research project indicated that small incentives would be palatable, but large incentives would feel like bribery. Compared to the previous maternity immunisation allowance, there is a big difference between locking in behaviour that is already the social norm (and helping people to vaccinate on time) and paying people to accept a pandemic vaccine.

There is also the issue of undermining pro-social behaviour and people’s intrinstic motivation to contribute to Australia’s COVID-19

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GUEST COLUMN

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GUEST COLUMN exit strategy. And how would people feel if they had already been vaccinated and missed out on the money? This could have a very negative impact on trust in government and social solidarity.

That said, additional payments to support the vaccine access (and any recovery time) of casual or lowpaid workers and welfare recipients would be an equitable way of helping vulnerable individuals to play their part.

Vaccine passports for events and venues are another hot topic. These strategies are being used overseas, making it easier to learn from their successes and replicate them.

The devil always lies in the detail, including whether the policy is tightly enforced and what happens to those who won’t or can’t be vaccinated.

Requiring a recent negative COVID-19 test is a sensible opt-out from a behavioural perspective.

It is more difficult and annoying than getting a vaccine, but not impossible, meaning that people still have a choice. However, if vaccine passports are required for a long time, the resources required for

frequent testing may be costly for government or individuals.

My research on the development of childhood vaccine mandates in Australia, Italy, France and the US state of California shows that there is complexity to these policies. Governments often reach for mandates before they have exhausted other approaches, including tailored and effective communication campaigns or the provision of behavioural-scienceinformed resources for medical providers to use when talking with families.

When vaccines become (more) mandatory, health professionals may be placed in difficult situations with patients who are uncertain or unwilling. That said, one of the reasons that French authorities made more childhood vaccines mandatory in 2017 was to help doctors have more straightforward conversations with patients.

I feel for medical professionals in the current environment. Nobody wanted our vaccine rollout to be this complicated. The Prime Minister’s instruction for younger people to access AstraZeneca through their

doctors has placed both these parties – younger Australians and their doctors – with a heavy weight of responsibility.

There are difficult conversations to be had about risk, safety, fear and consequences. While this is the bread and butter of individual clinical encounters, this time the stakes are high for all of us.

I take heart from knowing that the public have great trust in their doctors. The recommendation and advice of trusted medical professionals recurs as a key factor in vaccine acceptance across the world.

The saying goes that “we are all in this together” – and we are. But some of us play a very big role in helping us get from “this” to “that”.

As a vaccination social scientist, I take my hat off to the medical professionals who are so integral to our rollout. You are trusted, and you are appreciated. Thank you.

ED: Dr Attwell is a senior lecturer and academic researcher at UWA’s School of Social Sciences.

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Passport to a new world COVID-19 vaccinations passports are coming and, as Cathy O’Leary explains, they will mean more than the ability to travel overseas.

Many Australians who travelled overseas in the 1960s still have the scars to prove it – quite literally.

Vaccination against smallpox was often required, and the jab caused a blister to form, resulting in a scab that fell off and left a tell-tale scar the size of a 10-cent piece on the upper arm. Similarly, many people who have travelled to parts of Africa and Central and South America have long accepted the need to be vaccinated against yellow fever – no questions asked.

Now, more than 40 years after smallpox was largely eradicated by global vaccination, mandatory COVID-19 jabs to allow international travel – and probably a lot of movement at home too – seem inevitable.

While Australian Medical Association national president, WA-based Dr Omar Khorshid, dislikes the term “immunity passport” because even a previous COVID infection doesn’t necessarily make someone immune to the variants, he says the concept of a vaccination passport is a “no-brainer” to verify immunisation status.

A precursor records system – Australia’s COVID-19 digital certificate – is already in place, showing completed doses of a coronavirus vaccine. It can be downloaded to a smartphone and used similarly to a digital driver’s licence. It features a coatof-arms hologram and includes the holder’s name, date of birth and a validity tick.

“Even some of the retail groups and hotels, which might have been completely opposed to the concept of vaccination passports a few months ago, are now realising it’s a way to allow their businesses to keep working while we’re still battling a pandemic into next year, which I think we’re going to be,” Dr Khorshid said.

“People need to be able to demonstrate they’ve been vaccinated, especially if we end up in a situation where our public health measures start to differ for people who have been vaccinated versus those who haven’t been.”

Have jab, eat out If the overseas experience is anything to go by, vaccination passports are here to stay, and not just for international travel.

Many countries around the world are slowly introducing varying degrees of restrictions on the unvaccinated, including the UK which from the end of this month will start to require proof of vaccination to enter some high-risk spots.

France has a vaccine passport – pass sanitaire – that people must produce to access a range of places such as sports venues, cinemas, museums,

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FEATURE

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FEATURE nightclubs and festivals, and more recently, even restaurants.

The document, which the government hopes will boost vaccination rates, is shown in the form of a QR code either digitally or on paper and given to those who are fully vaccinated, have a negative COVID-19 test or have had coronavirus and recovered.

Dr Khorshid said French president Emmanuel Macron had thrown his hands up in the air and said ‘fine, you don’t want to be vaccinated then you can’t go to the pub and restaurants.’

“I suspect that’s a place where Australia gets to, and with enabling technologies, digital vaccination passports make a lot of sense.

It will be inevitably needed for international travel but how else it will be used is still a topic for discussion.

“Vaccination passports at this stage are purely a way to demonstrate you’ve had your two doses of vaccine and how that is used going forward in terms of boosters still needs to be worked through.

continued on Page 14

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Passport to a new world continued from Page 13 “But giving Australians access to data, which is already in our immunisation register, makes a whole lot of sense, and being able to put it in your digital wallet on your phone is just a practical decision and makes effective use of technology.”

Mandatory vaccination?

He agrees that the concept of vaccination passports, where legally people must be vaccinated against COVID before they can travel internationally, has broader implications in terms of mandatory vaccination – and incentives to help achieve it.

A federal Labor proposal to offer $300 in cash to anyone fully vaccinated by December 1 recently received a mixed reaction from doctors.

While NSW Doctors Reform Society president Dr Con Costa, who practises in one of Sydney's hotspots, welcomed the idea, others have said it is unethical and the start of a slippery slope in health incentivisation.

Dr Khorshid does not believe COVID vaccination itself will become mandatory, but Australia would probably end up with a quasi-mandatory system because vaccination in the workplace was very much on the table, especially in health care settings.

“I think in a modern society where we’re generally pretty free, there are some things you need to do because it’s your responsibility as a citizen,” he said.

“But we need incentives, and they don’t need to be direct ones. So it might mean being able to get on a domestic flight without being locked down at the last minute – that in itself is an incentive.

Free lotto and beer “There is also evidence from around the world that lotteries have worked, and if we get to the stage where a large proportion of Australians haven’t been vaccinated because they can’t be bothered or haven’t got around to it, then it might help people to prioritise it.

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“Someone was recently offering a free beer and got in trouble, but at the end of the day it might help to give someone a bit of nudge.”

He agrees that the main problem is access to vaccines. The Federal Government should also be putting money into advertising campaigns to make sure the messages are clear, because the biggest enemy is still complacency.

“When we get to the stage of vaccination rates stagnating and having vaccine floating around, specific measures might be necessary, even if you’re philosophically opposed to the idea of financial incentives, but who cares if we can just move on.”

Professor Jaya Dantas, from Curtin University’s School of Population Health, said incentives such as small amounts of cash, lotteries and university scholarships had been used overseas to push up vaccination rates.

we wouldn’t be having so many problems,” she said.

“We vaccinate our pets before we take them outside, but because we made COVID vaccine voluntary, the assumption was that people would use a sensible approach. Instead, people are waiting and watching, and hearing mixed messages about the side effects, with no context.”

“If you’re wishy-washy, people will be confused. However, France, Italy and many Europeans countries have passed laws to make the vaccine more or less mandatory. If you make it really clear that only fully vaccinated people can travel, or work in jobs, or go to public venues, people might protest but many will go and get vaccinated.”

Dr Khorshid says he hopes that when the worst of the pandemic is behind us, it will put some of the complaints we have about our society and our lives into context.

“We’ve seen how quickly everything that we take for granted can be taken away from us, in our rich and isolated country,” he said.

Wishy-washy policy She says the big problem in Australia is that it didn’t mandate the vaccine for any group – it was made totally voluntary.

“This isn’t a world war but it’s a big event that will never be forgotten by those of us who’ve lived through it, and it will change our perspectives in the longer term, and I don’t think that’s such a bad thing.”

“In some ways if we’d mandated it for all over-60s and frontline workers, not just those in health care but security staff and police,

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A life of adventure and learning Dr Ann Ward’s career has afforded her entry into worlds not a lot of people get to see. She’s trekked the Himalayas, worked in Antarctica, doctored in remote communities and now wants to help save native forests in the South West.

By Ara Jansen When Dr Ann Ward told the women of the Aboriginal community of Warmun she was going overseas to work in the Antarctic, they gave her paintings of their country to put in her suitcase with strict instructions – she could go away for a year, but if she was away from them for longer, they would sing her back.

Such is the fraternity and loyalty that the rural GP has engendered in the community she has worked so closely with over decades.

When Ann’s mother died earlier this year, these were the women who called her with healing words and condolences. Even now that she’s moved south, she still consults to a local health group.

It’s one of the rich stories in the tapestry of her life that gives Ann meaning.

She has been entrusted with many stories and believes life would so much less colourful and fun without hearing and sharing them. It’s perhaps also part of what has driven her to have a career filled with amazing experiences.

“You have to be prepared to be open to opportunities and possibilities and try to use your creative intelligence,” she says. “I think a lot of our medicine

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CLOSE-UP is so process driven we overdo things sometimes instead of using our common sense, which is an unfortunate result of defensive medicine.”

Ann studied medicine at UWA, which came as a bit of a surprise after she’d always been told at school that she wasn’t smart enough and it was beyond her reach. Her younger self wanted to be an air hostess because they always seemed to have the best stories. Instead, she got really good marks and decided to do medicine – just to prove a point and with a finger firmly pointed in the air.

Road less travelled Turns out it was an inspired decision which has given Ann a lifetime of opportunity, adventure and privilege. It has allowed her to go where not many others have been. Her career as a rural GP saw her working for the Royal Flying Doctor Service in Meekatharra, as well as in Kununurra and the community of Warmun. She has also worked short stints in Nepal, Tonga and Antarctica.

With a degree fresh in hand, Ann spent five years working in Perth hospitals. During that time, she did her first trek in Nepal and became totally entranced. The following year she took three months off and the company she was trekking with asked her to become a trek leader.

That led to a year as a trek leader and guide in the Himalayas.

seemed content. It’s a different way of thinking and I’ve always been fascinated by that.”

Ann suggests that being half Chinese, half English and growing up in Malaysia before moving to Perth as a child also has some bearing on finding a spiritual home in Nepal and later in the red dirt of the WA’s north.

In the 1990s she trekked 1000km across India as the expedition doctor for her then husband who summited Mt Everest. She later worked for the Himalayan Rescue Association Nepal, a voluntary non-profit group aimed at reducing casualties in the Nepal Himalayas. This began her adventurous habit of taking three months off for a hike or trek.

Ann loves meeting people and finds empowerment in connection as well as a strong sense of attachment to nature in the outdoor work she’s done.

“Some of the people I met in the Himalayas had never been more than 10km from their homes in their whole lives,” says Ann. “Yet they

In 1992, Ann moved to Kununurra and spent the next 26 years working as a rural GP and taking regular trips out to Warmun, an Aboriginal community in the Kimberley, 200km south of Kununurra.

It’s a hugely significant part of her life and a place where she delivered two generations of babies, something she found deeply satisfying. She found community, family and a place where her otherness didn’t feel so other, once again linking her back to many eastern ways.

Fitting in “It’s certainly a different way of thinking. People are less likely to think in terms of self but instead think in terms of community. It’s a great thing and a drawback too – because everyone knows your business and you’re always getting approached on the street about something.

“A connection to country is not something I was born with, but it’s something I very much admire and respect in Aboriginal people.”

Working as a procedural GP obstetrician, she was based mostly in the 30-bed hospital in Kununurra, doing general practice, emergency work, inpatient work, continued on Page 19

Ann Ward on the Dawson Lambton Glacier with Emperor Penguin colony as Medical Officer for Adventure Network International; (main picture left) Ann driving a zodiac in Antarctica.

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SEPTEMBER 2021 | 17

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FEATURE

A life of adventure and learning continued from Page 17 surgery (in obstetrics, gynaecology and skin cancer surgery) as well as flying weekly in a light aircraft to Warmun.

“You never knew what would come through the door. We were 800km from the nearest tertiary hospital and 800km from the nearest RFDS base, so you did the best you could, and you had to work things out from first principles.

“It was stressful, but you had challenges to solve so you had to do it the best way you could with the skills and equipment you had.

It’s the challenge of remote area medicine. You get better by doing it and recognising patterns. You don’t think you know much and then something happens and you realise you know a reasonable amount.”

to contribute, respect and restore the planet.

“We need to respect life on this, our only planet, and learn to respect all life. I really like the term coined by Charles Eisenstein of “interbeing”, which is our inter-existence where all life forces are dependent on each other – what happens to each of us happens to all beings on this planet.”

During her time in Kununurra, it became normal for Ann to take three months off to go trekking or working in inland or coastal Antarctica.

That’s how she came to find herself driving a zodiac in the Antarctic during numerous visits and later being the doctor on a private super yacht charter with the Gates family heading to Antarctica.

She also worked in inland Antarctica supporting tourists and expeditioners and travelled to places like the South Pole, the Dawson Lambton Glacier (to see emperor penguins) and Queen Maud Land.

Apart from being totally exciting, Ann says these experiences were a way to practise medicine in a different way.

Review and relax “I think it makes you are a better doctor when you have some time out,” she says. “Working remotely is intense. I think every decade you should take a year off. That allows you to find yourself outside of who you are as a doctor. The brave part is going without a formal plan.

“I would also encourage everyone to spend time being a rural GP. It’s an amazing role and such a privilege. You get to live with people through births, deaths,

cancer, disease, emotional trauma – and sharing the journey of life. In the country, it’s all interconnected, so you can’t have an unpleasant interaction with a patient and not resolve it. You have to fix it because the community is too small, and you’ll be seeing them in the supermarket or during an emergency!”

Her connection to the land remains strong, which is why Ann now finds herself in Margaret River living on a 2ha bush block which she is revegetating. She’s also joined Nannas for Native Forests and Doctors for the Environment (DEA) to address the “madness” and “irreversible destruction” caused by the logging of the native forests of WA’s South West.

“I feel like a custodian of this land I am living on. I feel it’s important to do something about this situation we are in with our planet. We think that jobs, growth and economic expansion are a necessity when in fact this growth is destroying us.

As humans on this planet, we’re currently on a trajectory toward our demise. I’m trying to do what I can

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Now in her early 60s, she keeps her medical hand in by working two days a week at the Busselton and Margaret River emergency departments, something she really enjoys. She uses her spare time for her other interests such as volunteer revegetation of native bush, being on the board of Nature Conservation Margaret River, environmental activism, swimming in the ocean and yoga.

Finding home Swapping the red dirt for the green of the South West, Ann says she has found her tribe with like-minded people who share her interests.

“The Kimberley is hard and harsh and there’s a lot of extremes and I loved it, but I never thought I would grow old there. It took me about five years to decide to live somewhere else. I found an amazing bush block on the edges of the Margaret River which I’m helping revegetate.

“I have more time to give back and I’m really enjoying the two days in the ED. I don’t want to work all the time – but I have the energy and I do want to contribute.”

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FEATURE

Health apps – more harm than good?

Health apps can track your heart rate, weight, diet and sleep but as Dr Karl Gruber (PhD) reports, they have limitations and can even mislead.

Nowadays it is hard to make eye contact with people when you are out and about because everyone’s face is stuck to their smartphones.

We use smartphones for so much more than making calls. We use them to check the weather, our emails, keep abreast of news, engage in social media, and the list goes on.

Smartphones also host mobile applications, or apps, which come in all flavours and for all purposes. Among the kaleidoscope of apps available, those dealing with health apps have become increasingly popular.

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FEATURE Health apps are a broad range of mobile applications that inform users on virtually any topic about their health. Australia currently stands as the world’s most healthconcerned country with Australians searching for apps relating to weight and mental health more than 100,000 times in the past five years. But, what do we do with these apps and are they safe?

Dawn of the apps Corrie is a smart app that helps patients who have survived a heart attack manage and understand their condition. The app also helps patients keep track of their medications and medical appointments and provides advice on how to improve their lifestyle.

In a recent peer-reviewed study, it was shown that among 800 cardiac patients, Corrie users were at a 52% lower risk of 30-day re-admission for any reason, compared to nonusers.

Dr Amandeep Hansra, a Sydneybased GP, argues that health apps have a lot going for them.

“Health apps can have great benefits because they give consumers more control and insight into their own health and wellbeing.

Being able to measure, record or manage their own health data has been shown to improve compliance and encourage healthy behaviours,” she told Medical Forum.

Dr Hansra, who was formerly CEO and medical director of Telstra’s ReadyCare, is a member of the RACGP’s expert committee for practice technology and management and is managing partner at Caligo Health among other involvements in digital health.

“The ability to monitor their own measurements, for example their heart rate, blood pressure, weight, steps, sleep patterns and blood sugar levels, arms consumers with information they can act on if they are given the right targets and context around the measurements,” she says.

But not all health apps deliver what they promise and with thousands on the market, it is hard to know which are good and which are not.

A scoping review of 74 studies identified a total of 80 safety concerns across a wide range of health apps. Most of the issues, about 83%, were related to the

quality of the health information presented to users. This included incorrect and incomplete information, as well as incorrect or inappropriate responses to users’ needs.

For example, some apps for bipolar disorder incorrectly differentiated between types of patients, and recommended, incorrectly, that some patients should “take a shot of hard liquor before bed”.

Outputs of other health apps were just poorly designed. An app for management of sexually transmitted infections suggested that “Genital warts are bad. If they form in a bunch on your genitals, you will have a very bad time getting them treated and your relationships will shatter.”

Some melanoma risk assessment apps were found to underdiagnose potentially life-threatening melanomas and some blood pressure apps simply did not detect certain conditions such as hypertensive blood pressure ranges. Some apps for diabetes risk assessment were found to report false negative results, and urolithiasis apps were found to

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recommend consumption of a low-calcium diet, which is not supported by current evidence, and in fact has been shown to have harmful outcomes.

Other health apps were found to be misleading users towards a path of harm. For example, among apps used for assessing blood alcohol levels, users were provided with information about how much more alcohol they could consume before their driving ability was compromised. Rather than preventing a problem, such advice could encourage more alcohol consumption, the authors said.

“The downsides are sometimes not obvious to consumers, when they may lose things like loss of personal privacy, they may be misled into making unwanted financial purchases, or the app itself is providing misleading or harmful medical advice,” according to Dr Hansra. “It may lead to them being over diagnosed, underdiagnosed or mismanaged.” continued on Page 23

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FEATURE

Health apps – more harm than good?

continued from Page 21

GPs and smart apps For GPs it can be overwhelming to offer advice about which health apps best suit their patients. With almost 100,000 health-related apps available for Australians, GPs would need to be tech gurus in order give comprehensive and good advice to their patients.

Fortunately, GPs are not on their own when it comes to assessing health apps. There are online guides that provide some sound advice, says Dr Hansra.

“Many of my patients are starting to use mobile apps and if they want advice, I often refer them to groups which have actively assessed mobile health apps such as the VicHealth Healthy Living Apps Guide or I use the Digital Health Guide,” she says.

While these websites do not review every health app on the market, it is a good start. There are also some basic rules that GPs can tell patients about what to look for in a health app.

For example, what happens to private information? Is it safely stored? Who else gets to see it? In a recent Australian study, reported online by Medical Forum, researchers found that about 88% of nearly 21,000 apps contained

software that could potentially be used by third parties to collect users’ private data.

Lead author Associate Professor Shlomo Berkovsky, of the Centre of Health Informatics at Macquarie University, says the study brought up a yellow flag around the potential risks of information leaks in health apps.

“Some risks are benign, and some are more dangerous, but both clinicians and patients need to be aware of these risks and consider them as part of their decisionmaking when deciding on using an app,” he said.

TGA evaluations Beyond privacy, patients should be encouraged to read the terms and conditions and establish if the app is registered on the Australian Register of Therapeutic Goods.

Health apps registered with the ARTG have been assessed for efficacy.

A TGA spokesperson said that the Australian sponsors of medical devices regulated by the authority are required to present evidence

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that demonstrates their device (or app) meets the quality, safety and performance requirements, known as essential principles.

“The evidence needs to show reliability, accuracy, useability, security, the integrity and quality of the data, and how privacy is maintained.

Limitations and use of an app should also be made clear to users as part of instructions for use, terms of use or product disclaimers,” he said.

For mental health apps, GPs can advise their patients to consult with the Australian Commission on Safety and Quality in Health Care and their recently published standards for mental health apps.

The TGA said many health apps should be viewed as sources of information or tools to manage lifestyle. Such apps are not regulated by the TGA, which also means that the efficacy of the app has not been evaluated.

At the end of the day, experts argue users of health apps need to choose wisely, selecting those that are backed by clinical evidence and, ideally, validated by government bodies like the TGA. They are aids, not a panacea for all health problems.

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FEATURE

The vape cloud is getting bigger Studies on the health ramifications of vaping are painting a worrying picture with adolescents getting caught up in the craze.

Dr Karl Gruber (PhD) reports In theory at least, the goal of electronic cigarettes is to help users quit smoking by providing an experience similar to the real thing without the nasty chemicals.

E-cigarettes or vapes are batterypowered devices that heat a liquid, known as an e-liquid, that can contain nicotine or other substances.

As for those that contain nicotine, they are far from safe, according to Associate Professor Jonine Jancey, from Curtin University’s School of Population Health.

“E-cigarettes can contain chemicals such as formaldehyde particulate matter (associated with lung and heart disease) and flavourings that were made to be ingested not inhaled,” she told Medical Forum.

Second-hand smoking from e-cigarettes is also a growing concern. Libby Jardine, Cancer Council WA’s manager for the Make Smoking History campaign, said the council was calling on the WA Government to prohibit the use of e-cigarettes in enclosed and outdoor public places, in the same way as tobacco smoking was already prohibited.

brain of adolescents, affecting concentration, cognition, memory and impulse control. There are also concerns that vaping, particularly among youth, might serve as a gateway to traditional cigarette smoking, with research from the Australian National University finding e-cigarette users are three times more likely to take up traditional cigarette products.

Prof Wayne Hall, from the Centre for Youth Substance Abuse Research at the University of Queensland, argued in a recent article for The Lancet Respiratory Medicine that it was paternalistic because it denied adult smokers the right to use a less harmful form of nicotine.

With these issues in mind, the Therapeutic Goods Administration decided to reschedule nicotine for non-therapeutic human use from Schedule 7 (dangerous poison) to Schedule 4 (prescription-only medicine), effective from October 1 this year. In practice, what this means is that anyone wanting to buy e-cigarettes containing nicotine will need a medical prescription.

“It is also an incoherent form of risk regulation in banning a less harmful product while allowing more harmful tobacco cigarettes to be freely sold,” he wrote.

But GPs need to be clear about the underlying regulatory thinking behind this new law. A TGA spokesperson said nicotine containing e-cigarettes were not first-line treatment for smoking cessation.

“We don’t yet know the impact on the lungs of young children and babies, and medical experts strongly recommend people avoid using e-cigarettes around children or pregnant women,” she said.

“However, for people who have tried to achieve smoking cessation with approved pharmacotherapies but failed, and who are still motivated to quit smoking and have brought up e-cigarette usage with their healthcare practitioner, nicotine containing e-cigarettes may be a reasonable intervention to recommend,” the spokesperson said.

Nicotine might also have negative impacts in the developing

Some experts disagree with the upcoming policies.

24 | SEPTEMBER 2021

The law in WA WA has some of the world’s toughest laws when it comes to vaping, with sales in WA territory being prohibited and subject to penalties up to $80,000. The law in WA is clear. It is an offence under the Tobacco Products Control Act of 2006 to sell anything that resembles tobacco products, regardless of whether they contain nicotine or not. But, in practice, people are simply buying e-cigarette products online. continued on Page 27

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SEPTEMBER 2021 | 25

Meet Western Australia’s largest team of fellowship trained respiratory radiologists

Dr Stephen Melsom

Dr Roche Helberg

Dr Ramon Sheehan

Dr Jeanne Louw

Dr Anuj Patel

Dr Arjuna Somanathan

Dr Mark Teh

Dr Bann Saffar

At Perth Radiological Clinic your chest imaging investigations are reported locally by WA’s largest team of fellowship trained accredited respiratory radiologists: •

Teaching hospital consultant radiologist appointments. Involved in multidisciplinary team meetings at FSH, MIHC, Mount Hospital, SCGH and JHC.

•

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•

Expertise in all types of chest disease including malignancy, ILD, occupational lung diseases, lung cancer screening, vascular diseases and trauma.

Meet our doctors or for more information email info@perthradclinic.com.au

perthradclinic.com.au 26 | SEPTEMBER 2021

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The vape cloud is getting bigger continued from Page 25 In Australia, the number of users of e-cigarettes has increased significantly over the past years, particularly among young people.

According to the TGA, in Australia between 2016 and 2019, the number of current e-cigarette users aged 15-24 increased by about 72,000 (a 95.7% increase).

Among the different vaping options, nicotine-free flavoured e-liquids, which are legal to sell in Australia, are increasingly popular, especially among young people.

Vaping without nicotine The use of non-nicotine vaping products may seem harmless, but research shows otherwise. In a recent study, researchers analysed the ingredients and toxicity of 10 “nicotine-free” e-liquids available in Australia.

The study was led by Associate Professor Alexander Larcombe, from Curtin University, who is also head of the Environmental Respiratory Health Team at the Telethon Kids Institute. Results showed that nicotine was present in six of these “nicotine-free” e-liquids, as well as 16 known and six unknown chemicals. Among the potentially toxic chemicals identified was 2-chlorophenol, a known respiratory and dermal irritant with no established safe exposure level.

More recently, Professor Ben Mullins, Dr Sebastien Allard (both from Curtin University) and A/Prof Larcombe expanded their research and analysed 52 e-liquids currently available for sale over the counter.

All contained at least one or more chemicals with an unknown effect on respiratory health. None of the brands evaluated had an accurate ingredient list, 21% of them actually contained nicotine and more than 60% of these e-liquids contained chemicals likely to be toxic.

“While some of these chemicals may be safe and approved food additives, it has frequently been shown that there is a vast difference between a chemical that is safe to ingest and one which is safe to inhale long-term,” Prof Mullins said in a statement.

Children vaping According to data from the most recent Australian Secondary Students’ Alcohol and Drug Survey, about 14% of participants admitted having used an e-cigarette at least once. The survey interviewed about 20,000 12-17-year-olds nationally.

Official figures from WA high school-aged children are lacking and, according to Mr Armando Giglia, president of the Western Australian Secondary School Executives Association, vaping is still not a widespread problem here.

An Australian Council on Smoking and Health survey last year investigating teenagers vaping showed small numbers, but they had increased slightly this year.

“While it doesn't appear to be a huge issue in our schools, I'm sure it happens, and it will grow,” Mr Giglia said.

Some parents have a different view.

According to one mother of a secondary school student, “lots of teenagers have told me this is pretty common in high school especially the flavouring vaping.”

Another parent said that vaping was a common thing in her child’s high school and the school had to close toilets due to the strong vaping smells.

Why are kids vaping?

So why and particularly how are minors getting access to these products? According to Paul Dillon, director of Drug and Alcohol Research and Training Australia, social media is making vaping attractive. Social media channels such as Instagram, Tik Tok and YouTube are increasingly showing

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more vaping related content, some of it quite attractive to new generations. “If you go to YouTube and look at the tricks they do. I mean, the tricks are incredible,” Mr Dillon told Medical Forum.

A recent study published by researchers from the University of Queensland identified 808 e-cigarette-related videos released on TikTok. The videos were viewed over 1.5 billion times with most videos portraying e-cigarette use positively.

As for how kids are acquiring vaping products, the short answer is friends and classmates. Mr Dillon recalls one case involving two highly enterprising young men.

“We had two young men from Year 12 at a boys’ school, who had a contact in China, and they were able to import quite a lot of these disposable devices,” he said. “They made about $20,000 in advance by selling them to students in local schools.”

While the new law to regulate e-cigarettes may be a step in the right direction, it can be argued more needs to done to deal with online sales and the increased use by school-aged children. Professor Jancey said most purchases of e-cigarettes occurred online.

“It is easy to click on a button online as proof you are 18 and purchase e-cigarettes. Considering this, stopping the illegal importation of e-cigarettes needs adequate border control to ensure these products do not enter Australia, and this will require government support and investment.”

SEPTEMBER 2021 | 27

28 | SEPTEMBER 2021

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SEPTEMBER 2021 | 29

Complex non-melanoma skin cancer patients?

Dermatology Dr Kate Borchard Dr Judy Cole Dr Glen Foxton Dr Qadir Khan Dr Louise O’Halloran Dr Jamie Von Nida Dr Yee Tai

Refer cases to the Non-Melanoma Skin Cancer Advisory Service for multidisciplinary review The benefits of a multidisciplinary approach to patient management are well known. The Non-Melanoma Skin Cancer Advisory Service (NMSCAS) has been established to enhance the care of patients with complex non-melanoma skin cancers.

To submit cases to the NMSCAS for advice or management either: •

Send a detailed referral letter with images and pathology

•

Or visit genesiscare.com/au/refer-a-patient then click on Refer to the WA non-melanoma skin cancer advisory service to download the referral forms.

Case information must be received no later than 1 week prior to the scheduled meeting.

•• NMSCAS meets every third Thursday of the month

NMSCAS specialist team:

 Clinipath Pathology 310 Selby Street North Osborne Park WA 6017

Pathology Dr Trevor Beer Dr Gordon Harloe Dr Joseph Kattampallil Dr Stephen Lee Dr Ben Ryan Plastic surgery Dr Adrian Brooks Dr Sharon Chu Dr Brigid Corrigan Dr Mark Hanikeri Dr Daniel Luo Dr Linda Monshizadeh Dr Remo Papini Radiation Oncology Dr Eugene Leong Dr Susan Mincham Dr Evan Ng Dr Kasri Rahim Dr Craig Wilson Dr Yvonne Zissiadis

Referrals and all enquiries to: mdtskinwa@genesiscare.com 30 | SEPTEMBER 2021

0419 610 298

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Advanced care planning essentials Linda Nolte explains the role of advance care planning in the context of the recently introduced voluntary assisted dying laws.

With voluntary assisted dying (VAD) now a legal option in WA, it marks a significant change in the end-of-life care landscape.

Advance care planning (ACP) is known to improve end-of-life care and should be a priority consideration for West Australians and their health professionals.

While ACP and VAD are frequently conflated in the community, they are two distinct and separate actions. In short, VAD is a decision to end one’s life, while ACP gives a person choice and control over future medical decisions and how they want to live out the rest of their life.

Advance care planning enables people to make choices about the care they want to receive if they become too unwell to speak for themselves. It puts the individual in the driver’s seat, providing a sense of control when facing chronic or progressive disease, cancer, dementia or just old age.

Only 15% of older Australians have documented their future preferences in an Advance Care Directive (also known as an Advance Health Directive in WA).

In a time when the community is seeking greater choice and autonomy over their own care, it is disappointing that so many people are leaving their future medical decisions for others to choose.

VAD/AHD considerations • VAD laws require that the person has decision-making capacity – from the time of request through to the final act.

• An Advance Health Directive (AHD) remains valid and will be respected even if the person loses decision-making capacity.

• An AHD can include instructions to refuse, consent or withdraw from treatment.

• A person cannot make a request for VAD in their AHD. • A person’s substitute decisionmaker (guardian) is not permitted to request VAD on behalf of a loved one.

• VAD should not be considered a substitute for quality ACP or palliative care.

• In the context of a person making a VAD request, ready access to advance care planning, as well as quality palliative care is essential.

It is important to remember that in countries and jurisdictions where VAD is legal, eligibility criteria are restrictive, meaning it is ultimately an option for only a few, whereas advance care planning is and remains accessible and relevant to all adults, regardless of their health status or age.

Key facts about ACP • About 30% of people will not be able to make their own end-oflife medical decisions.

• A third of Australians will die before the age of 75.

• Most people die after a chronic illness, not a sudden event.

Research shows that advance care planning can reduce anxiety, depression and stress.

Advance Care Planning Australia supports the public and healthcare professionals with a dedicated website with access to jurisdictional forms and legal information.

There is free phone support on 1300 208 582, Monday-Friday, 9am-5pm (AEST).

ED: Linda Nolte is program director at Advance Care Planning Australia.

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SEPTEMBER 2021 | 31

Survey hints at push-back on junk food Sheryl Westlund, from WA’s peak diabetes research charity, argues the community shift away from junk food is good news.

It’s a shift that we at Diabetes Research WA welcome.

In the past, when we’ve shared our thoughts supporting ideas such as banning sugary drinks in the workplace and in hospitals, or imposing a sugar tax, we’ve been met with resistance.

But a 2020 survey by the Obesity Policy Coalition reveals that seven in 10 Australians now want governments to step in and protect children from unhealthy food marketing.

This shift is a critical first step in tackling overweight and obesity in children (currently one in four Australian children fit this category) as these health issues are associated with a significant risk of developing chronic conditions such as type 2 diabetes.

Research has shown that resistance to ideas such as policing the junk food industry centres around people wanting to be free to make their own choices.

those involving sport and healthy endeavours), on bus shelters and buses themselves, on billboards, at swimming pools and shopping centres, it’s hard to avoid them.

It’s a valid point that shouldn’t be swept under the carpet.

Kids are still being given processed food industry vouchers for participating in sport, are still being conditioned through marketing to want this type of food to get the accompanying toy, for example, and are now also being targeted while online.

However, if advertising and market tactics of junk food to children are examined carefully, our kids may not have as much free choice as we think.

Britannica.com defines free will in humans as “the power or capacity to choose among alternatives or to act in certain situations independently of natural, social, or divine restraints”.

With junk food ads plastered throughout kids’ and family TV shows, at events we attend (even

One University of Adelaide study found that children would view more than 800 junk food ads each year, if they watched 80 minutes of television a day.

A recent study shows that teens who use a smartphone for more than two hours a day are significantly more likely to eat more

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32 | SEPTEMBER 2021

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or will we be able to buy this type if and when we want?

Many parents we speak to are desperate to reduce their kids’ access to these foods which abound once they step outside their home – from birthday parties to the movies and at the beachside kiosk.

If regulations can play a role in helping reduce the number of ‘reminders’ our kids get about junk foods and help them to lead healthier lives, aren’t they a good thing?

junk food and fewer fruits and vegetables than those spending less time on their phone. Teens spending more than three hours a day on a smartphone are significantly more likely to be overweight or obese.

A United Nations-backed report released last year shows that not only are children and adolescents using social media being bombarded with ads promoting harmful products – from fast food to tobacco and alcohol – but advertisers also sell children’s data

gleaned from electronic games to global tech giants.

With all of this coming at us and our kids, the question is – how ‘independently’ do we, or can we, act?

Do the remaining three out of 10 Australians who don’t support increased government regulation realise the level the industry is going to in order to influence our kids?

As our world evolves, there is talk that data will be “the new oil” and we believe governments need to step in to ensure information regarding our kids and young adults isn’t misused to negatively impact their health.

A line in the sand needs to be drawn by the community now. It’s time to let these industries know – through regulation – what’s acceptable and what’s not, for the health of our children.

And, if we do have free choice, will regulations erode that significantly

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by Healthscope

SEPTEMBER 2021 | 33

Coronavirus and industry – what’s the impact The COVID outbreak at the Tanami gold mine in July exposed mining's vulnerability, write E/Professor Odwyn Jones and C/Professor Bill Musk.

COVID-19 has, and is, shutting down national and regional economies and mining and other industries are not unaffected.

Labour-intensive industries are particularly vulnerable, and every effort must be made to avoid the rampant spread of the virus in the close confines of underground mines as witnessed at the Tanami gold mine in Northern Territory.

Indeed, the infected aerosols, if released by an infected miner, will be transported to other miners at downstream locations due to the nature of mine ventilation.

The International Labour Organisation (ILO) has developed its own COVID-19 and mining prevention and control checklist (V1, May 2020), and here are a few of the issues raised: • Has mine management developed and shared a statement of its commitment to prevent and reduce the risk of exposure to the virus and transmission at the mine-site in consultation with workers and their representatives?

• Have risk assessments specific to COVID-19 been carried out jointly with workers or their representatives and are the identified risks being addressed in the preparedness and response plan?

• Has mine management, workers and their representatives been informed and trained in adopting measures to prevent risks of exposure to the virus and how to act in case of infection?

• Does the training include the correct use, maintenance and disposal of effective personal protective equipment (PPE)?

• Has a high-risk group or “vulnerable persons register” been established?

• Are frequently used facilities and equipment regularly disinfected?

• Is “unnecessary site access” kept to a minimum?

• Is mine management proactively seeking undertakings from 34 | SEPTEMBER 2021

suppliers and contractors regarding their health and hygiene practices and controls?

There are many other useful information sources including WA’s Department of Mines, Industry Regulations and Safety’s COVID-19 information pamphlet and Safety Plan. WorkSafe Tasmania’ has a useful COVID Safe set of guidelines.

It is also noteworthy that there has been a requirement for several years now that mines in WA develop an Infectious Diseases Management Plan.

Despite the ever-changing COVID-19 scenario within Australia, its mining industry continues to operate at more-or-less full capacity, and the sector is considered by governments to be an essential service. Nevertheless, fly-in fly-out work arrangements pose serious challenges to infection control where in large operations, several hundred workers are routinely having to share working and living facilities where physical distancing is difficult to achieve.

Indeed, Mount Isa’s mayor is angry, stating that “while the government is telling us not to go out to cafes and to work from home if we can, we are still flying in workers by the planeload – it just seems ludicrous.”

Underground aerosol transmission In an article published in The Lancet (April 15, 2021), the authors concluded “there is consistent, strong evidence that SARSCoV-2 spreads by airborne transmission. Although other routes can contribute, we believe

that the airborne route is likely to be dominant. The public health community should act accordingly and without further delay.”

The ventilating air stream in underground mines is normally fully turbulent, with random eddies continuously being formed. Such chaotic airflows are ideal to keep infected aerosols airborne.

These exhaled aerosols can, apparently, coalesce with water droplets or solid or liquid pollution particulates (e.g. smoke, smog or diesel fumes). Indeed, the SARSCoV-2 aerosols have been observed on airborne particulates and there is mounting evidence for associating COVID-19 outbreaks with high levels of particulate pollution in the size range 0.2-10 microns (Jarvis M.C., Nov. 2020) Consequently, COVID-19 aerosol particles could move with the underground ventilation airflow whilst remaining infective for an hour or more, which means they could potentially travel great distances.

Little research has been directed at this phenomenon and there is a gap in our knowledge on how the effectiveness of dispersal depends on environmental conditions, particularly turbulence.

An infected cloud of infected aerosols could in more gentle airflows remain reasonably compact (e.g. in laminar airflows or in the gentler regions in turbulent tunnel flows near the roof or sides of mine airways). Even if such a cloud becomes dispersed within the turbulent airflow, the aerosols will still remain infective for quite some time.

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GUEST COLUMN

Unfortunately, most worksites in hard-rock underground mines are located at the face of development headings or stopes where dieselpowered heavy equipment is operating, and where secondary ventilation is required. Consequently, even in the best of situations the effectiveness of secondary ventilation is limited, which can result in the local build-up of pollutants.

These conditions could equally result in the build-up of virus-loading making inter-person transmission to nearby colleagues more likely.

In the open air, winds will also carry and disperse aerosols and its turbulence can keep particles airborne, so that downwind infection could also become a serious hazard.

These fine particulates (<100nm) can also be emitted from a range of anthropogenic sources, such as indoor cooking or diesel engine exhaust fumes in underground mines and can possibly harbour and assist in transporting airborne pathogens.

It is also noteworthy that the activated carbon in diesel engine exhaust has strong adsorptive properties and is acknowledged as a versatile adsorbent of organic, inorganic and pathogenic

contaminants. Many recent studies have found strong positive correlations between atmospheric particulate levels and levels of COVID 19 infections. The influence of atmospheric pollutants in connection of SARS-CoV-2 transmission needs further attention and research.

Conclusion Of all the occupations, underground hard-rock mining provides one of the greatest challenges to employers in carrying out their duty of care for employees during the pandemic.

In order to provide safe working conditions for underground miners employers need to have in place (ILO checklist): • A well-designed Covid-19 risk assessment protocol, drawn up in close consultation with workers and/or their representatives.

• Medical facilities with appropriate equipment for COVID-19 treatment and care, or arrangements for safe transfer to hospital.

• Employers need to ensure employees, as well as contractors, are well-informed and trained to cope with the unique risks relating to varying occupations and tasks.

• A high-risk list of vulnerable workers: i.e. those over 65 years of age and those with underlying medical conditions.

• Adequate hygiene and cleaning facilities and services as well as safe accommodation, dining and leisure facilities based on safe physical distancing.

• Provision of appropriate PPE for all employees who require their use for personal safety.

• Safe travel and transport facilities for employees to and from work sites.

• Employers should aim to maximise vaccination of their workforces update.

However, the most important message is that underground mines have great potential to become locations for superspreading events.

Hence mining operations need to manage the potential for the spread of infection in accordance with the many well-documented riskmanagement and COVID 19-Safe industry guidelines available.

However, there is still much we need to know and this is an area of much needed further research.

References on request

Should women over 75 years stop or continue screening mammograms?

W

hilst screening mammography has been shown to be effective in reducing breast cancer mortality in women aged 50-74 years, the

World Health Organisation has found that there is insufficient evidence of benefit to recommend screening in women 74 years and older.1 As the first point of contact for health issues for many Australians, GPs have a key role in communicating the potential benefits and harms (eg. over-diagnosis and over-treatment) of screening mammography to older women.

A reasonable approach to optimising the benefits of screening for older women is for GPs to individualise their advice based on comorbidity status and life expectancy. A decision to stop breast cancer screening does not mean abandoning health promotion, but rather refocusing on interventions more likely to be of benefit sooner.

Photograph courtesy of BreastScreen Australia

1

Lauby-Secretan B, Scoccianti C, Loomis D, et al. Breast cancer screening—viewpoint of the IARC working group. NEJM 2015

Book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50 Mar ‘18

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BreastScreen WA_75-and-over-landscapehalf.indd 1

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29/07/2021 3:06:39 PM

SEPTEMBER 2021 | 35

Our new cycle fee offer is our commitment to being in this together with your patients Here at Genea Hollywood Fertility, we want to do things differently to help make the journey to a baby a little bit smoother. Providing some certainty around the cost of IVF treatment is just one way we’re doing that.

So, if your patient doesn’t have a baby after three IVF cycles at Genea, they can complete another two at no out of pocket cost*.

We’re confident that our high success rates will give your patients the best chance of having a baby in the least number of cycles possible.

Genea Hollywood Fertility Specialists

Dr Simon Turner

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Genea Hollywood Fertility Level 2, 190 Cambridge Street, Wembley WA 6014 p (08) 9389 4200 w wa.genea.com.au * Terms and conditions and eligibility criteria apply. No out-of-pocket applies to the cycle.

Some exclusions apply such as day surgery, anaesthetist, PGS/PGD costs.

36 | SEPTEMBER 2021

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Every breath you take Different body systems hold different places in our psyche. We think of life (outside the womb) starting with the first breath and passing as taking our last. In between those two bookends, in the main, most of us do not have to think much about breathing. It just happens. When we get “short of breath” it does focus our minds though.

We now understand that the Moderna vaccine has been approved for use in Australia. It says something about how detached Australia (and WA in particular) has become from the rest of the world that the public and even some doctors look down their nose at different vaccines.

It is interesting to reflect on the place the breath holds in various spiritual practices. As an intermittent participant in yoga classes, it always gets me thinking when the teacher emphasises how the breath is the central part of yoga and as important as the movements. Many stress management programs include deep breathing exercises or focused slow deep breathing.

For those who are interested in a small experiment, stop reading for 30 seconds while you take three slow deep breaths in, to the count of five, and out to the same count. Most people report feeling a bit more relaxed after doing this. How fascinating is that!

This month’s theme is respiratory health, and we have articles on endobronchial ultrasound for investigation of lung pathology, diagnosis, and treatment of protracted bacterial bronchitis in children and the effect of biologics on risk of infection, including COVID-19. Silicosis was thought be a disease of the past but has made a comeback. The background to this and a new screening program is examined. We also have articles on oral leukoplakia, adolescent cardiac issues, benign breast lumps, and investigation of Cushing’s syndrome.

We now understand that the Moderna vaccine has been approved for use in Australia. It says something about how detached Australia (and WA in particular) has become from the rest of the world that the public and even some doctors look down their nose at different vaccines.

There are hundreds of millions in the world who would be delighted to access any vaccine. Former deputy CMO Dr Nick Coatsworth has been a voice of reason arguing that the best vaccine is the one you can get. They all work and, yes, all have side effects.

As year’s end approaches, all those who want a vaccine will have had the opportunity to have it and this should take us to over 60% vaccinated. It is important to remind ourselves, especially as doctors, that the virus cannot be eliminated from this planet and must be lived with. The only question is how.

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SEPTEMBER 2021 | 37

NEW Acute Disc Priority Service At NeuroSpine Institute we offer a multi-disciplinary team approach and continually seek to innovate and improve our service pathways to ensure everyone we treat gets the best possible outcome.

We know it can be difficult for patients in severe pain to access surgeons quickly, so we are excited to announce the launch of our dedicated Acute Disc Service, which aims to help the busy GP, Emergency Physician or Specialist easily refer patients who meet the clinical criteria to get the help that they need, quickly.

Our service guarantee For patients that meet the below criteria, they will be seen within 3 working days by NeuroSpine Institute upon receipt of the referral

Referral Criteria: √ Acute – sudden onset of pain (within 30 days)

Plus √ Severe leg (Sciatica) or arm pain (Brachalgia) in a radiculopathic (nerve) pattern WITH proven nerve compression (on MRI or CT)

Dr. Paul Taylor Spine Surgeon

Dr. Greg Cunningham Spine Surgeon

Dr. Andrew Miles Neurosurgeon

Dr. Michael Kern Neurosurgeon

√ Leg weakness, arm weakness or numbness

Or

*Neck and back pain in isolation is not suitable for this service

Email referrals to: acutedisc@nsiwa.com.au or mark your usual referral with ACUTE DISC SERVICE

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Acute Disc Service Referral Form For Privately Insured & Workers Compensation Patients

Dr Greg Cunningham, Spine Surgeon Dr Michael Kern, Neurosurgeon Dr Andrew Miles, Neurosurgeon Dr Paul Taylor, Spine Surgeon

Services requested:

Acute Disc Service Referral Criteria

(Patients seen within 3 working days with the below criteria)

Nominated surgeon request (if available)

√ Acute – sudden onset of pain (within 30 days)

Plus √ Severe leg (Sciatica) or arm pain (brachalgia) in a radiculopathic (nerve) pattern WITH proven nerve compression confirmed with MRI or CT Or

Email acutedisc@nsiwa.com.au for urgent booking

√ Leg weakness, arm weakness or numbness

Imaging scans conducted at: SKG

Perth Radiological Clinic

Medical Director and Best Practice referral templates now available for use !

Other

Patient details Patient Name: Date of Birth:

Next available surgeon

Home Phone:

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Neurosurgery | Spine Surgery | Pain Specialist Medicine | Rehabilitation Medicine Perioperative & General Medicine | Spinal Physiotherapy | Workers Compensation 38 Current | medications: SEPTEMBER 2021 Patient history:

 1800 NEUROSPINE  info@nsiwa.com.au (1800 638 767) � EDI: neurospn (08) 6147 8200 FORUM | RESPIR ATORY HEALTH  HealthLink  MEDICAL

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CLINICAL UPDATE

Excluding Cushing’s syndrome: saliva, urine or serum cortisol?

By Dr Michael Page, Chemical Pathologist, Jandakot Cushing’s syndrome may be suspected in patients with classical features (fat redistribution, proximal myopathy, easy bruising, facial plethora, red/purple striae), hypertension (particularly where a secondary cause is under consideration) or accelerated osteoporosis or diabetes mellitus.

After iatrogenic Cushing’s syndrome due to exogenous glucocorticoid use is excluded, biochemical testing is performed.

A key early biochemical feature of endogenous Cushing’s syndrome is loss of the normal diurnal variation of cortisol secretion. Usually, cortisol secretion is highest in the morning and lower in the evening. In patients with Cushing’s syndrome, this rise and fall is flattened, leading to higher than expected concentrations in the evening, but morning concentrations are frequently unaffected.

Key messages

Careful selection of initial biochemical tests for Cushing’s syndrome is essential if the diagnosis is to be confidently excluded.

Morning or random serum cortisol is not suitable nor recommended by any guidelines for ruling out Cushing’s syndrome.

The most useful tests are easily requested, readily arranged by the testing laboratory and generally convenient for the patient. Late night salivary cortisol, performed twice, is an excellent first choice.

Hence, the measurement of serum cortisol in the morning (other than in the context of an overnight dexamethasone suppression test; see later) is highly insensitive and of

little value in most cases. The main utility of morning serum cortisol measurement is in ruling out adrenal insufficiency.

The three tests that are useful in the initial evaluation of suspected Cushing’s syndrome are late night salivary cortisol (LNSC), 24-hour urine free cortisol (UFC), and the overnight dexamethasone suppression test (ONDST). Each derives its sensitivity from the biochemical characteristics of Cushing’s syndrome.

If suspicion is high, two different tests should be performed. If it is low, two negative LNSC results, two negative UFC results, or one negative ONDST result is generally sufficient to rule out the diagnosis.

continued on Page 41

Figure: Rationale for preferred tests for Cushing’s syndrome (Original figure by MMP)

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SEPTEMBER 2021 | 39

Infections and biologics in the time of COVID-19

By Dr Astrid Arellano, Infectious Diseases Specialist, Subiaco Biologics have revolutionised the treatment of rheumatoid arthritis and psoriatic arthritis. They are increasingly also being used in dermatology, cancer treatment and even MS. Australians spend more than $2 billion a year on biologics and other targeted therapies. However, they can increase the risk of infection.

Particularly in the 12 months after commencement of biologic therapy, upper and lower respiratory tract infections, followed by skin and soft tissue infections are common.

Other infections such as reactivation of tuberculosis, hepatitis B and herpes zoster virus are also well described. TNF inhibitors, such as infliximab and adalimumab have the highest risk, well above that conferred by conventional DMARDs and the autoimmune conditions themselves. The elderly, those with other co-morbidities, particularly diabetes, and those on concomitant steroids are at highest risk.

Predicting infections is difficult because there aren't any biomarkers that reliably predict infections.

However, it is recognised that low

respiratory tract infection.

Key messages

Biologics can increase the risk of infection

Data does not show increase hospitalisations for Covid-19 in those on biologics

Prevention depends on individual circumstances.

They are at risk of common pathogens such as pneumococcus but can also develop fungal and mycobacterial infections. Herpes zoster reactivation can be multidermatomal and atypical without the classic vesicular rash. A high index of suspicion for detecting subtle infection presentations is needed.

Biologics and COVID-19 lymphocyte counts (<0.5 x10^9/L) and a baseline low CD8+ T-cell (<200 cells/uL) predispose to the development of infections in this population. Among patients on rituximab, a low IgG level (6-7g/L) increases the risk of severe infection.

It is important to note that patients on biologics have a blunted immune response to infection and therefore may not develop a fever but could have hypothermia instead. They may not have a productive cough even if they have pneumonia and radiology reveals multi-lobar involvement.

They can also rapidly advance from minor upper respiratory tract viral symptoms to a bacterial lower

Since the beginning of the pandemic there has been concern and anxiety around continuing the use of biologics in these individuals.

Interestingly, several large retrospective studies have shown no excess hospitalisations or increase in the severity of disease or deaths from COVID-19 in this population.

The reason for this is still unknown but one postulate is that biologics modify the cytokine storm due to SARS-CoV-2 infection, thus appearing to have a relatively protective effect.

Biologics have been trialed in patients with an oxygen requirement due to COVID-19. Tocilizumab, an IL-6 inhibitor, has been used in

Table. 1. Common biologic DMARDs and small molecules used in Australia (Adapted from Australian Rheumatology Association). bDMARDs TNF Inhibitors

Mode of action

Indications

Potential infective side effects

Adalimumab

mAb

Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's

TB, skin, soft tissue infections, upper and lower repiratory tract infections Viral reactivation

Etanercept

TNF receptor blocker

Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis

TB, skin, soft tissue infections, upper and lower repiratory tract infections Viral reactivation

Infliximab

mAb (chimeric mouse protein)

Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's, ulcerative colitis

TB, skin, soft tissue infections, upper and lower repiratory tract infections Viral reactivation

Abatacept

mAb binding CD80 and CD86 on APC cells inhibiting costimulation of T cells

Rheumatoid arthritis

TB, skin and soft tissue infections, upper and lower repiratory tract infections Viral reactivation

Rituximab

mAb- mouse protein to CD20 B cells

Rheumatoid arthritis, vasculitis, NHL, CLL

Infections, TB, hepatitis B reacti-vation, reduced IgG, neutropenia

Tocilizumab

IL-6 inhibitor

Rheumatoid arthritis, giant cell arteritis, juvenile inflammatory arthritis

Infections, TB, hepatitis B reacti-vation, neutropenia, perforation in diverticulitis

JAK 1, 2 or 3 (depending on molecule)

Rheumatoid arthritis

Infections, TB, hepatitis B reactivation, higher VZV reactivation risk

TNF Inhibitors

Small molecules JAK inhibitors e.g. tofacitinib, barcitinib, upadacitinib

40 | SEPTEMBER 2021

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of active disease, monitoring with HBV DNA at 3-month intervals is reasonable.

Often forgotten but an important issue in this population is the risk of infection due to long-term steroids (over six months). Once established on a biologic, corticosteroids, if possible, should be tapered.

Ensuring childhood vaccines and boosters (particularly pertussis, influenza, and pneumococcal vaccines) are up to date two to four weeks prior to starting a biologic is best. These vaccines, if not previously administered, should be given at any time during a biologic because they confer protection even if their effect is not optimal once the biologic has started. hospitalised COVID-19 patients.

However, this is not a recognised treatment, and it is only used within clinical trials. Patients on biologics for their rheumatic and autoimmune conditions should continue these drugs during the pandemic.

Data on preventing infection is lacking and recommendations are based on expert opinion. However, it is widely accepted that commencing treatment for latent tuberculosis infection (with rifampicin for 4 months) in those with positive TST or IGRA tests prior to starting a

biologic is important to prevent TB reactivation.

Patients who are HBsAg-positive or anti-HBc-positive receiving rituximab have the highest risk for hepatitis B reactivation. Antiviral prophylaxis with entecavir or tenofovir is recommended in these cases and should continue for at least 12 to18 months after rituximab is completed to avoid late reactivation.

Live vaccines are contraindicated in patients on biologics and herpes zoster reactivation is common, thus primary VZV vaccination to those not immune or the shingles vaccine, need to be administered prior to the biologic starting. COVID vaccines have been shown to be less effective in this population, but they are still indicated and should be encouraged in all individuals on biologics.

Author competing interests- nil

For patients with anti-HBc-positivity receiving other immunosuppressive therapies and with no evidence

Excluding Cushing’s syndrome continued from Page 39 While some doctors may be unfamiliar with LNSC, it is an excellent first choice. It is more convenient for the patient than a 24-hour urine collection, less prone to protocol errors or medication interference than the ONDST and has the required performance characteristics to rule out Cushing’s syndrome in most patients.

The doctor simply provides the patient with two forms requesting “late night salivary cortisol”. The collection centre provides a special collection device to the patient, along with written instructions. At 11pm, the patient removes a small swab from the device, holds it in their mouth for two minutes then places it back into the device. If done on two consecutive evenings,

the patient can return both collection devices to the collection centre during business hours, provided that they are kept in a refrigerator at home in the interim.

Similarly, if UFC is chosen as an initial test, the collection canisters and instructions are provided by the collection centre. As this test measures the total free cortisol excreted in urine across a 24-hour period, it is less susceptible to altered sleep-wake cycles than LNSC. Therefore, it may be a better choice for shift-workers.

others require the patient to obtain the dexamethasone on a prescription.

This test is preferable for excluding autonomous cortisol secretion in patients with adrenal incidentalomas. However, falsepositive results can be caused by oestrogens (including the combined oral contraceptive pill), medications that accelerate the metabolism of dexamethasone, such as some anticonvulsants, and mistiming of the dexamethasone dose in relation to the blood test.

In the case of the ONDST, the patient takes 1mg dexamethasone orally at 11pm, and returns for serum cortisol measurement the following morning at 8am.

Any abnormal result would usually prompt referral to an endocrinologist. Further advice on testing can also be provided by a chemical pathologist at your preferred laboratory.

Some laboratories provide the dexamethasone and instructions;

Author competing interests – nil

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SEPTEMBER 2021 | 41

Silica Dust

Have your patients been exposed?

Perth Radiological Clinic has the expertise to meet the new regulations for low dose chest CT scan for the surveillance of workers exposed to silica dust in the workplace, past or present.

Scan for more information or email

sales@perthradclinic.com.au

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Adolescent cardiac issues

By Dr Michael Davis, Cardiologist, Perth The spectrum of cardiac issues in adolescence is very different than in adulthood. A cardiac cause of chest pain is rare.

Common causes include costochondritis, injury, stress or anxiety, precordial catch syndrome or acid reflux. Pericarditis causes sharp, pleuritic, and mid-sternal pain possibly radiating to the shoulders and is often alleviated by sitting or leaning forward. Cough, dyspnoea, and fever are common.

Ectopics sometimes cause momentary chest discomfort and rapid SVT can cause ischemic pain or even a troponin rise.

Typical exertional angina might suggest a coronary artery anomaly and warrants referral. Isolated dyspnoea is rarely cardiac. Most significant murmurs are identified in childhood. A new or previously unidentified murmur is most likely innocent but consider rheumatic heart disease or hypertrophic cardiomyopathy. Echocardiography is the appropriate first step.

Presyncope and syncope More than 90% of fainting in adolescents is vasovagal, usually diagnosed on history from precipitants and warning symptoms. Orthostatic presyncope or syncope most commonly occurs in adolescents who are salt deficient, sometimes due to overzealous parenting with low salt diets imposed on their physically active offspring. Both these causes of dizziness/fainting can usually be treated with significantly increased salt intake and recognition of symptoms (sitting or lying down if they feel dizzy).

Most serious causes of syncope include arrhythmias related to abnormal atrioventricular pathways (e.g., WPW), cardiac ion channelopathies (e.g., long QT syndrome) or underlying structural heart disease.

Eating disorders can be associated with a variety of cardiac issues, the most worrying being sudden death resulting from arrhythmia.

Key messages

Syncope usually benign, but ECG always and watch for red flags

Palpitations are common and usually benign. ECG.

There are particular considerations for athletes and those with eating disorders.

The QT interval on the ECG can prolong, related to quick or severe weight loss and hypokalaemia/ hypomagnesemia (especially with purging or laxative abuse), and occasionally to cardiac myofibrillar degeneration or even heart failure.

Medications, especially psychotropic drugs, can also prolong the QT. A long QT predisposes to polymorphic VT (“torsade de pointes”), which can degenerate to VF. The 12-lead ECG needs to be monitored closely in anorexia nervosa.

Cardiology referral is indicated when syncope occurs in certain circumstances: during exercise; without warning (no preceding dizziness, muffled hearing, or visual changes); with severe injury; with family history of sudden unexplained death (or drowning, MVA), cardiomyopathy or congenital heart disease; with an eating disorder, when cardiac examination (murmur) or ECG (always perform) abnormal.

Palpitation Some adolescents are aware of rapid heart beating due to normal sinus tachycardia with stress or exercise. Inappropriate sinus tachycardia, as the names suggests, is a sinus rate excessive for the body’s needs and demands exclusion of cardiac conditions (such as heart failure) or systemic conditions (such as fever, anaemia, thyrotoxicosis) where the rate is appropriate. This rare condition responds well to ivabradine.

Ectopics are uncommon in adolescents and generally

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benign and require reassurance.

If associated with symptoms of concern such as rapid palpitation, presyncope/syncope or shortness of breath, then ECG, Holter and echocardiogram.

Postural orthostatic tachycardia syndrome (POTS) is a chronic condition involving the autonomic nervous system characterised by orthostatic intolerance and often beginning after a viral infection, surgery, trauma or pregnancy.

Under the age 19, it is characterised by an increase in heart rate going from lying to standing for 10 minutes of over 40bpm. There are numerous associated symptoms including palpitation and dizziness, “brain fog”, chronic fatigue, sleep disturbance, headache, and gastrointestinal symptoms.

Most with POTS have selfdiagnosed from chat groups and do not have the condition. As well as the characteristic postural heart rate increase, this is a diagnosis of exclusion. Treatment is similar to orthostatic hypotension with salt supplementation and a variety of medications including fludrocortisone, midodrine and ivabradine. The prognosis is favourable with symptoms generally improving in two to five years.

Rapid palpitation with sudden onset and offset strongly suggests paroxysmal supraventricular tachycardia. A 12-lead ECG is essential, and documentation of rhythm with ambulatory ECG monitoring (including devices such as the Kardia or Apple Watch) invaluable.

The patient needs to be taught vagal manoeuvres to terminate episodes (especially Valsalva, gag, iced water to the face). If the ECG shows ventricular pre-excitation (WPW pattern) or symptoms are severe or troublesome then referral to a cardiac electrophysiologist is indicated. For this and other types continued on Page 45

SEPTEMBER 2021 | 43

Silicosis – why it’s back and how to find it

By Dr Stephen Melsom, Radiologist Silicosis was a disease of the distant past. Some of us remember stories about underground miners in the mid-20th century, working in terrible conditions in tunnels filled with the dust created from their old-fashioned pneumatic drills with only a cloth to filter the air. These mine workers would end up terribly disabled, slowly dying as their lungs were destroyed by chronic silicosis.

We felt reassured that our technology had fixed this terrible problem. Modern mining drills used water to prevent dust escaping into the air, and modern mine ventilation and protective equipment kept their air clean. Silicosis disappeared.

Some clinicians kept yellowed x-rays of silicosis patients to show us what they used to see. Occasionally we would see a survivor; a long-retired miner bearing scars and nodules in his upper lungs telling the story of how terrible it used to be to work as a miner.

Then silicosis came back.

Initially in the eastern states, the first of these new cases were diagnosed in 2015. This time many were not miners; they were stonemasons involved in cutting, grinding, and polishing engineered stone to make kitchen benchtops. Many had been previously monitored with chest x-rays, which had been normal. Now they had silicosis, some terminal.

Australia’s first death attributed to engineered stone was a 36-year-old Gold Coast stonemason in 2019.

How did this happen?

The blame is often pointed at artificial stone benchtops, but this is not the only cause.

Various forms of artificial stone have been produced and cut and grinded by stone masons since the 1700s. The white lion at Westminster Bridge in London was sculpted from the first commercially available artificial stone almost 200 years ago (although originally fabricated as a gate emblem for the Lion Brewery down the road, rather than as a symbol of British power).

44 | SEPTEMBER 2021

Why did it take so long to recognise the problem?

Key messages

Previously dust exposed workers may have left their industries and may not be covered by new mandatory employee screening programs.

Consider occupational dust exposure in patients presenting with respiratory symptoms and indicate the history on clinical and imaging referrals.

Chest x-ray is inadequate for assessment. High resolution CT imaging is required as a very low radiation dose study for screening workers.

The more modern ‘engineered stone’ now used in benchtops and bathrooms is generally made from quartz and marble-based materials in resin mixtures. These became commercially available in the 1980s and were first manufactured in Israel. Initially, in Australia, benchtops made from these materials were relatively expensive and exclusive, with the materials often being privately imported from the overseas manufacturers at a greater cost than some natural stone at the time.

In the early 21st century, international manufacturers recognised growing demand for their products in Australia and set up local subsidiaries, increasing availability and reducing cost. Quickly, the beautiful artificial stone benchtops became almost the default standard in Australian homes, with Laminex relegated to business lunchrooms.

Today’s silicosis cannot be solely attributed to more stonemasons making more benchtops. Much of the modern artificial stone material contains a lot more silica (up to 95%) than is found in natural stone (5-50%). Many of these businesses were providing inadequate controls to reduce the fine dust released when the stone is cut or machined.

Consequently, some benchtop workers were inhaling large amounts of silica into their lungs.

Damage from silicosis can be slow and progressive, taking years for symptoms to occur. Additionally, many workers were being checked with chest -x-rays, which failed to identify abnormalities. Some, investigated for symptoms, had been misdiagnosed with other lung diseases which can appear similar to silicosis (e.g., sarcoidosis, respiratory bronchiolitis, old tuberculosis changes). In some cases, the patient’s exposure to silica dust was not considered, or even mentioned.

The doctors at WorkSafe Western Australia saw what was happening in the east and realised our local workers were also at risk. The WorkSafe team organised funding for a clinical trial resulting in 90 workers (mean age = 40, dust exposure over five years with previous normal screening x-rays) who agreed to have a low-dose chest CT. Eight were diagnosed with silicosis. Early changes of lung damage, potentially due to silica inhalation, was found in 44.

In 2021, WA became the first state (and possibly worldwide) to introduce mandatory screening with very lowdose chest CT for workers exposed to silica. Employers of engineeredstone workers with significant dust exposure are now required to provide two-yearly very low-dose CT scan surveillance, and a further scan within two years of leaving the industry.

It is important to remember that not just benchtop workers are at risk of occupational silica exposure. Natural stone workers, demolition workers, construction, abrasive blasting, quarrying and other industries can also be exposed to silica dust, and if at risk require surveillance CT scans every five years.

As this surveillance program involves scans on potentially young and asymptomatic workers, WorkSafe WA has specified that these must be performed at very low doses of radiation. A conventional chest CT scan can potentially require up to 8

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CLINICAL UPDATE Table 1. Work activities that may represent a high-risk exposure Examples of work activities that can generate respirable silica dust particles include: during fabrication and installation of composite (engineered or manufactured) stone countertops excavation, earth moving and drilling plant operations clay and stone processing machine operations paving and surfacing mining, quarrying and mineral ore treating processes

Normal CT chest compared to silicosis CT in WA stonemason, aged 34

tunnelling

Such a low radiation dose was considered acceptable for screening asymptomatic workers. These very low dose CT scans require specialised CT equipment and specific imaging protocols and must be reported by experienced specialist chest radiologists.

construction labouring activities brick, concrete or stone cutting; especially using dry methods abrasive blasting foundry casting angle grinding, jack hammering and chiselling of concrete or masonry hydraulic fracturing of gas and oil wells pottery making

Source: SafeWork Australia

millisieverts (mSv) of radiation.

These very low dose scans use less than 1 mSv of radiation (for reference, the background radiation we receive from living in Perth each year is 2-5 mSv).

In June 2021, the final report from the National Dust Disease Taskforce (NDDT) found that up to 600,000 Australians are potentially being exposed to silica dust across a broad range of industries each year with evidence of nearly one in four stonemasons being diagnosed with silica-related lung disease. The report includes recommendations

for “better support [for] medical, health and other related professionals to improve the diagnosis and management of workers affected by silicosis.”

It is important to remember that many workers previously exposed to dust have already left their industries and will not be covered by the new legislation. It then becomes important to identify those at risk and have a low threshold for CT investigation, particularly if their dust exposure was significant, or if they have respiratory symptoms.

Author competing interests – nil

Adolescent cardiac issues continued from Page 43 of SVT, catheter ablation may be indicated and be curative.

The athlete Because of the belief that sports deaths should be preventable, cardiac screening programs are widespread, but guidelines differ.

Screening includes history and family history, examination, ECG, sometimes echocardiography and even cardiac MRI! The Australian College of Sports and Exercise Physicians recommends screening only elite athletes, with history, examination and resting 12-lead ECG every second year from ages 16 to 25.

A recent study followed over 11,000 15- to 17-year-old, mostly male, English soccer players who underwent screening including ECG and echocardiogram, identifying 42 (0.38%) with cardiac issues capable of causing sudden death, the majority with WPW (n = 26; 62%).

Only two of the 42 had symptoms;

36 had an abnormal ECG and 12 had abnormalities on echo. Significant heart disease not typically associated with sudden death (e.g., valvular disease or septal defects) was found in 225 (2%).

Common normal adolescent ECG variations

Pronounced sinus arrhythmia Short sinus pauses < 1.8 seconds First degree atrioventricular block

Mobitz type 1 second degree atrioventricular block (Wenckebach)

Junctional rhythm Isolated ventricular or supraventricular ectopics

Partial RBBB (rSr V1) T wave inversion in V2 (even V3, V4)

Large precordial QRS voltages.

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During the 20-year study period, 23 adolescents died, eight from a cardiac cause (with autopsy), seven had cardiomyopathy (six had normal cardiovascular screens)!

The overall incidence of sudden death was around 1 in 14,800 person-years. The estimated cost of screening plus follow-up of those 830 with abnormal findings was over AU $8 million.

On top of the financial costs of screening are the psychological and health impact of false positive results. The cost of screening might be better spent on widening the availability of automated external defibrillators and CPR education for adults supervising junior sport. Examples of extremely high successful resuscitation rates have been described in Japan during marathons (with an astonishing 100% survival rate) and in Italy during competitive sport (with a 93% survival rate).

Author competing interests – nil

SEPTEMBER 2021 | 45

Molecular blueprint of oral leukoplakia

By Prof Camile S. Farah, Oral Physician & Pathologist, Nedlands White patches of the oral cavity are a common clinical presentation that can cause considerable concern for patients and confusion for clinicians. There are many underlying causes – from reactive changes such as cheek or tongue biting, through to inflammatory and immune-mediated conditions such as lichen planus, to more significant pathologies such as early cancers or pre-cancers.

The most common pre-cancerous white patch involving the oral cavity is leukoplakia. Oral leukoplakia is defined as a white lesion of the oral mucosa of indeterminate malignant potential which cannot be wiped off, presenting as a mainly well-demarcated plaque of any size with a smooth or textured surface, having excluded other known white lesions either clinically, histopathologically or with the use of a clinical adjunctive device.

The implication of this definition is that the clinical presentation is varied, the histopathology is diverse, and the diagnosis is one of exclusion.

Homogeneous leukoplakia are those which are consistent in white colour, composition and texture across the entire surface of the lesion, while non-homogeneous leukoplakia are those which are either white or mixed red-andwhite (erythroleukoplakia) and are

46 | SEPTEMBER 2021

A

uneven in colour, composition and/ or texture from one area of the lesion to another.

Oral leukoplakias are more common in older males with a history of smoking and alcohol consumption.

They most commonly occur on the lateral surface of the tongue, floor of mouth or soft palate. They are asymptomatic, and often not noted for many years before they become more serious.

Once developed, however, cancer formation in leukoplakia is more

common in females over the age of 65 years without a history of smoking. Treatment can range from a conservative “wait and watch” approach to surgical excision.

Currently there are no effective pharmacotherapeutic approaches to treat leukoplakia. Treatment is aimed at removal of the lesion to decrease the likelihood of cancerisation.

Effectiveness of treatment is determined by adequacy of excision, whereby removal of the macroscopically visible lesion with

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CLINICAL UPDATE

Key messages

Oral white patches can present for myriad reasons, and all lesions should be investigated to exclude pre-malignancy

Increased variation in the clinical appearance of leukoplakia is strongly associated with dysplasia histologically

Current evidence supports excision of leukoplakia where possible to reduce the likelihood of cancerisation.

B

D

C

E

a border of microscopically normal tissue is required.

Understanding of the molecular and genomic landscape of leukoplakia has increased significantly in the past few years, with significant information being generated with advances in molecular pathology.

Genomic sequencing has uncovered molecular signatures for subtypes of leukoplakia, some of which are similar to head and neck cancers. Novel genes have also been identified that drive some leukoplakia and not others.

The role of human papillomavirus as an etiological agent of a subgroup of leukoplakia has also been explored. Only a small fraction (under 5%) of oral leukoplakia are associated with HPV, compared to a greater majority of oropharyngeal cancers (over 85%).

There is building evidence that shows combinations of gene alterations occur together based on the etiological risk factor driving leukoplakia. This has important implications for diagnosis and management, with the possibility of future medical approaches for

treating leukoplakia with novel or repurposed drugs.

Common gene mutations in leukoplakia include TP53, CDKN2A, NOTCH1 and PIK3CA. There are, however, differences noted in HPVpositive compared to HPV-negative lesions, similar to that noted in head and neck cancers. HPVnegative leukoplakia harbour TP53, CDKN2A and TERT mutations, while HPV-positive lesions show P16INK4A mutation, overexpression of p16 protein and abrogated p53 expression.

This pattern of expression, highlighted in the clinical figures displayed, shows a nonhomogeneous leukoplakia on the ventral surface of the tongue (A) in a 55-year-old male with proven severe epithelial

NEW SS RE ADD AME & N iously

Prevylands “Ma unding” po C om

dysplasia/carcinoma in situ on histopathological examination (B), increased expression of proliferation marker Ki-67 (C), p16 overexpression (D) and p53 abrogation (E).

Subsequent HPV genotyping by PCR detected high risk HPV-type 16. More research is required to decipher the molecular blueprint of leukoplakia and to determine the utility of targeted therapies currently being used in the management of cancers.

References available on request Author competing interests – the author has written a book on the topic and has recently received funding from the Australian Government Medical Research Future Fund to undertake genomic sequencing on head and neck cancers and pre-cancers.

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Protracted bacterial bronchitis in children

By Dr Adelaide Withers, Respiratory & Sleep Paediatrician, PCH Cough is the most common paediatric presentation to general practitioners and is associated with morbidity and reduced quality of life. Important points in the history include duration of the cough and whether it is wet or dry.

Protracted bacterial bronchitis (PBB) is the most common cause of wet cough in children, particularly in those less than six years of age.

PBB is commonly misdiagnosed as asthma, and studies reveal that 5970% of children with PBB received asthma treatment before obtaining the correct diagnosis.

Children with PBB have endobronchial infection associated with airway neutrophilia and purulent endobronchial secretions.

The most common organisms causing PBB are Haemophilus influenzae, Streptococcus pneumonia and Moraxella catarrhalis. There is a strong association between PBB and attendance at childcare, as episodes of PBB are often triggered by viral upper respiratory tract infection.

Key messages

PBB is the most common cause of chronic (over four weeks) cough in children

Treatment with antibiotics targeting the most common pathogens for two weeks is indicated

Children with PPB-extended or The features of PBB include chronic wet cough present for over four weeks, absence of an alternative cause and resolution of cough with a two-week course of antibiotics.

Features of history suggesting a diagnosis other than PBB are listed in Table 1.

Various forms of PBB are recognised, with the above features comprising PBB-clinical. PBBmicro additionally requires growth of a single bacterial species from broncho-alveolar lavage (BAL) fluid of over 104 colony-forming units/ mL. However, the vast majority of children with PBB do not require

Table. 1. Features Suggesting an Alternative Cause for Cough.

History

May Indicate

Recurrent otitis media (especially with perforation), neonatal respiratory distress in a term infant, sinusitis

PCD

Failure to thrive, steatorrhoea

CF

Recurrent bacterial infections (especially sepsis, meningitis, Immune deficiency osteomyelitis, abscesses), failure to thrive, rashes Choking with feeds, difficulty swallowing solids or liquids, sounding ‘gurgly’ post feed

Aspiration, trachea-oesophageal fistula

History of choking episode, recurrent lobar pneumonia in the same lobe

Inhaled foreign body

Examination Clubbing

CSLD, CF, PCD

Short stature, low BMI

CF, PCD, CSLD, immune deficiency

Otitis media, sinusitis

PCD

Dextrocardia

PCD

Stridor, wheeze

Airway malacia

Unilateral wheeze

Inhaled foreign body

Focal signs, crackles

CSLD, CF, PCD

Developmental delay, neurological impairment

Aspiration

Abbreviations PCD – Primary Ciliary Dyskinesia CF – Cystic Fibrosis CSLD – Chronic Suppurative Lung Disease

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PBB-recurrent warrant referral to a respiratory paediatrician for further evaluation.

BAL. PBB-extended occurs when the cough requires four or more weeks of antibiotics for resolution and PBB-recurrent when there are more than three episodes in a year.

Children with PBB are usually otherwise well and investigations are unnecessary as PBB is a clinical diagnosis. Chest x-ray commonly shows peri-bronchial infiltrates and should only be requested if there are focal signs suggestive of pneumonia. It is unusual for children with PBB to be productive of sputum. However, if sputum is produced, sending a sample for microscopy and culture is helpful.

If untreated, PBB can progress to chronic suppurative lung disease (CSLD) and eventually bronchiectasis in some children. Risk factors for developing bronchiectasis are PBB-recurrent and infection with Haemophilus influenzae.

It is particularly important that PBB is recognised and treated in Aboriginal children as there is a high risk of progressing to CSLD and later bronchiectasis. Wet cough in Aboriginal children is often normalised and PBB remains underrecognised and under-treated.

For further information regarding management of wet cough in Aboriginal children, readers are directed to the excellent online module ‘Improving Aboriginal Children’s Lung Health’ ( https:// retprogram.org/training/improvingcontinued on Page 51

SEPTEMBER 2021 | 49

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CLINICAL UPDATE

Protracted bacterial bronchitis in children continued from Page 49 aboriginal-childrens-lung-health approved for 2 CPD points in the RACGP CPD Program).

There is high quality evidence that a two-week course of amoxycillin/ clavulanate (organisms causing PBB are often resistant to penicillin by production of a ß-lactamase) is effective treatment for PBB with a course of 5-7 days inadequate.

Although some guidelines recommend an initial treatment course of four or even six weeks, this approach is not recommended in Australia as most children will improve with a two-week course. A shorter duration should lessen side effects, is consistent with antibiotic stewardship to minimise airway dysbiosis and lessens induction of antibiotic resistant bacterial strains.

Alternatives in those allergic to penicillin are macrolides or trimethoprim-sulfamethoxazole. A Cochrane review found no significant

difference in reported side effects, including diarrhoea, between the placebo and antibiotic groups.

Follow-up after treatment, to ensure resolution of cough, is essential. Although a two-week course is generally sufficient, some require a longer course of four to six weeks to achieve cough resolution (PBB-extended).

Children with PBB-extended are more likely to have an underlying respiratory condition (over 50% have tracheomalacia and/or bronchomalacia). PBB-extended may also indicate underlying bronchiectasis. Therefore, children not improving or requiring more than four weeks of antibiotics need referral to a respiratory physician for further investigation.

that abnormal interactions of host and local airway immune, defence and inflammatory mechanisms, muco-ciliary clearance, airway microbiome and biofilm production also contribute to PBB-recurrent.

Children with PBB-extended or PBB-recurrent will usually have a CT scan performed and other investigations may include bronchoscopy and BAL, immune function testing, sweat test, spirometry, barium swallow, videofluoroscopic swallow study, laryngotracheo-bronchoscopy, upper GI endoscopy or genetic tests based on the history, examination findings and clinical course.

– References available on request Author competing interest – nil

Children with PBB-recurrent also warrant referral as they may have an underlying respiratory condition such as immune deficiency, cystic fibrosis, inhaled foreign body or primary ciliary dyskinesia. It is likely

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SEPTEMBER 2021 | 51

Looking at the big food picture for T1D Kids with diabetes should think beyond just carbs, according to Telethon Kids Institute senior dietitian Dr Amelia Harray.

The impact of carbohydrates on blood glucose levels is well known, but emerging evidence suggests people with type 1 diabetes should also consider fat and protein.

Type 1 diabetes is a nonpreventable autoimmune condition that affects more than 1200 children in WA, with about 160 new diagnoses every year. Children living with T1D are at increased risk of developing micro and macrovascular complications and therefore are encouraged to maintain their blood glucose levels within a target range through insulin, diet and exercise.

Closely monitoring dietary intake and adjusting insulin doses accordingly is at the core of diabetes management. Yet, despite advancements in diabetes technology, including continuous glucose monitoring and insulin pumps, high blood-glucose levels (BGL) after eating remain a challenge for many families.

Dietary fat and protein Until recently, the key focus of BGL management in T1D was calculating the amount of carbohydrate eaten and bolusing insulin accordingly.

However, there is a strengthening body of evidence suggesting that fat and protein also impact BGLs, causing delayed hyperglycaemia for up to 10 hours after eating.

This is becoming more widely acknowledged, with the International Society for Pediatric and Adolescent Diabetes and the American Diabetes Association promoting the consideration of extra insulin when eating these meals.

A survey of 100 families attending the Diabetes Service at Perth Children’s Hospital found foods high in fat and protein such as pizza were commonly reported as ‘challenging’ foods to control blood glucose levels after eating.

The mechanisms causing the delayed rise in BGLs have been relatively unexplored in children and adolescents with T1D, yet 52 | SEPTEMBER 2021

of micro and macrovascular health complications.

Key messages

Nutrition education for families living with T1D needs to be tailored to the glycaemic responses of the children

Children and adolescents with T1D are still encouraged to count carbohydrate in a meal and bolus insulin before eating.

varying rates of gastric emptying may be a key factor.

Gastric emptying rates can vary from 1-4 kcal/minute, influencing the timing of insulin required after meals, but is not yet routinely measured in diabetes care. More research is needed in this area to inform clinical practice and further personalise diabetes management.

Recommendations Dietary education and messaging for children with T1D must be tailored to the individual.

If dietary fat and protein are causing BGLs to remain elevated, current recommendations range from swapping to healthier food alternatives, continuing to bolus insulin before eating, using a dualwave function on an insulin pump or split insulin dose, and/or adding approximately 15-20% more insulin.

However, this area is rapidly evolving, and clinicians are encouraged to ‘watch this space’.

Australian children consume excessive amounts of high-fat, high-protein foods. More than 40% of the daily energy (kilojoules) consumed by children and adolescents is from discretionary foods, which are high in energy and low in nutrients.

Discretionary foods are not needed for good health and limiting these foods to only occasionally and in small amounts can reducerisk of obesity, cardiovascular disease and type 2 diabetes. This is particularly important for children living with T1D, as they are at increased risk

Focus on healthy eating Although kids with T1D need to consider and count macronutrients to adjust insulin, dietary recommendations should focus on healthy eating principles and be food-based. People do not consume nutrients in isolation but eat meals and snacks containing a combination of micro and macronutrients (carbohydrate, fat, protein).

The Australian Dietary Guidelines recommend children consume a variety of fruits, vegetables, grains and cereals, milk, cheese and yoghurt, lean meat and meat alternatives. These food-based recommendations also apply to children and adolescents with T1D. When it comes to fat and protein in T1D, similar messages apply.

Rather than prioritising education on how best to bolus insulin for a hamburger and chips, trying to work with families to make a healthy homemade burger with baked chips.

Children’s Diabetes Centre This translational research centre at Telethon Kids Institute and Perth Children’s Hospital is investigating high-fat, high-protein foods and T1D. This includes studies looking at the variability in blood glucose responses, the amount and delivery pattern of insulin required to maintain BGLs after eating meals high in fat and protein, the evaluation of resources and education methods used to inform families about fat and protein and the role of glucoregulatory hormones on BGLs after eating.

Further research includes evaluating models of care to enhance management of children with diabetes. Evidence-based nutrition also requires evidencebased methods of sharing the information.

ED: Dr Harray (PhD) is Senior Research Fellow and Dietitian at TKI’s Children’s Diabetes Centre.

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GUEST COLUMN

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CLINICAL UPDATE

Endobronchial ultrasound

By Dr Ivan Ling, Sleep & Respiratory Physician, Hollywood Endobronchial ultrasound (EBUS) is a bronchoscopy technique which utilises ultrasound imaging to visualise structures around the airway wall, including lymph nodes, blood vessels, lung parenchyma and mass lesions. Broadly speaking there are two types of EBUS: convex probe EBUS (CP-EBUS) and radial probe EBUS (RP-EBUS).

CP-EBUS uses a dedicated bronchoscope with integrated ultrasound probe, providing a view of structures beyond the airway wall with viewing plane parallel to the bronchoscope shaft (Figure A). Inbuilt colour Doppler allows accurate identification and avoidance of vascular structures.

The integrated probe provides the distinct advantage of real-time visualization of trans-bronchial needle aspiration (EBUS-TBNA) using specially designed biopsy needles.

CP-EBUS is commonly used to sample mediastinal and hilar lymph nodes as well as central lung lesions in real-time.

Over the past decade, CP-EBUS has taken up a central role in the

Key messages

EBUS plays a central role in the diagnosis and staging of lung cancer.

Is also useful in the investigation of intrathoracic lymphadenopathy of unclear cause.

Is safe & well tolerated in the hands of experienced operators.

diagnosis and staging of lung cancer. National and international lung cancer guidelines recommend concurrent tissue diagnosis and staging where possible, and CPEBUS is the most frequently used tool which fulfils these needs. It is the preferred first procedure for sampling mediastinal and hilar lymph nodes suspected to be involved with cancer, along with also being capable of sampling centrally located lung or mediastinal lesions.

When used to investigate PET positive or enlarged intrathoracic lymph nodes in the context of suspected lung cancer, the sensitivity of CP-EBUS is in the

Figure legend A. Linear EBUS-TBNA bronchoscope with biopsy needle extended, with schematic diagram and ultrasound image illustrating EBUS guided biopsy of a lymph node.

B. Radial EBUS probe, with schematic diagram and ultrasound image demonstrating location of the probe within a lesion.

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vicinity of 85-95%, with negative predictive value exceeding 90%.

Compared with the traditional ‘standard’ of mediastinoscopy, CP-EBUS sampling is minimally invasive and can be performed as a day procedure. It is capable of accessing a wide range of mediastinal lymph node locations, as well as hilar nodes and central pulmonary lesions, which are not typically reachable via mediastinoscopy.

CP-EBUS is also commonly used in the investigation of mediastinal lymphadenopathy of unclear etiology. In Australian metropolitan areas, the typical clinical case scenario would be to distinguish between sarcoidosis and lymphoma in patients presenting with bilateral hilar adenopathy. In the appropriate clinical context, CP-EBUS has also been used in the diagnosis of lymphadenopathy due to tuberculosis (and other infectious agents).

Radial Probe-EBUS gives a 360-degree view of the airway wall and surrounding structures in a viewing plane perpendicular to the bronchoscope shaft (Figure B).

It can be a useful method which allows sampling of peripheral lung nodules with intermediate risk of malignancy, particularly where percutaneous CT-guided biopsy is considered hazardous (e.g., extensive intervening emphysema, or proximity to blood vessels).

When performing sampling, the RP-EBUS probe with guide sheath is first inserted through to the area of interest via a standard bronchoscope. Once the lesion is localised using ultrasound imaging +/- fluoroscopy assistance, the probe is removed with guide sheath left in place, and conventional forceps or FNA biopsy tools are then deployed. Pooled data from studies where this method is used indicate typical sensitivity of around 60-70%.

continued on Page 55

SEPTEMBER 2021 | 53

Benign breast Lumps

By Dr Jose Cid Fernandez, Oncoplastic Breast Surgeon, Perth Benign breast lumps are common.

Accurate diagnosis and effective treatment of women with benign breast lumps is crucial to relieve their anxiety and/or morbidity.

Fibroadenomas and breast cysts account for most benign breast lumps. What follows is practical advice to understand and manage these two common benign conditions.

Fibroadenomas A fibroadenoma is not a tumour but is considered an aberration of normal breast development that contains a mixture of epithelial and stromal tissue. Clinically fibroadenomas present as discrete, mobile, rubbery lumps in young women, or as an incidental finding on breast imaging of older women.

The majority do not change in size over time, some can become smaller or disappear, and a small proportion get larger, especially during pregnancy and breast feeding. Rapid growth is uncommon but can occur in adolescents (juvenile fibroadenoma) and in older women with other lumps that can resemble fibroadenomas, such as phyllodes (leaf-like) tumours.

A breast ultrasound can usually differentiate a fibroadenoma from a malignant breast lump.

The diagnosis is confirmed with an ultrasound-guided biopsy, either by fine needle aspiration or preferably core biopsy. For the very young (i.e., under 18) with very small fibroadenomas shown unequivocally on ultrasound, biopsy can be omitted and a followup ultrasound at six months is recommended.

For older women, breast lumps are investigated by way of triple assessment, which consists of a clinical breast examination, breast imaging (ultrasound, plus bilateral mammography in the over 35) and a breast biopsy – a benign triple assessment result is reassuring, and follow-up ultrasounds can be useful to monitor size change over time.

Occasionally triple assessment 54 | SEPTEMBER 2021

Ultrasound showing a well defined oval anechoic breast cyst with distal acoustic enhancement (bright up, marked with asterisk) and no evidence of intracystic filling defects – simple cyst.

results are unclear, for example, benign biopsy but worrisome breast ultrasound or mammogram appearance. In this scenario women are advised to have their breast lump surgically excised and examined.

Management depends on the patient’s age, preference, lump size, and biopsy results. Surgical excision can be offered to those who wish to have their lump removed. However, women with histologically proven fibroadenomas less than 3cm in diameter can be reassured of the benign diagnosis.

Surgical excision is recommended in patients with: • Lumps greater than 3cm, or those which cause distortion of the breast contour • Lumps undergoing rapid growth • Biopsy unable to distinguish fibroadenoma from phyllodes tumour Excision for pain is not guaranteed to improve this symptom. Surgery

is performed under general anaesthetic through a cosmetically placed skin incision, usually at the base of the breast or at the edge of the areola – an inframammary approach with tunnelling through the retro-glandular space provides access to most breast lumps and leaves an inconspicuous scar.

Alternatively, small fibroadenomas can be removed with a vacuumassisted core biopsy needle under local anaesthetic.

Breast cysts Breast cysts are fluid-filled distended breast lobules, regarded as an aberration of normal breast involution. Cysts are affected by hormonal changes, thus occurring commonly in pre-menopausal women, and often disappear after the menopause, although they have become more common in older women taking HRT. Clinically they present as discrete breast lumps, often multiple, and some women have cysts bilaterally. Smaller cysts may cause no symptoms and

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Preoperative markings of left breast fibroadenoma and skin incision in the inframammary fold (left), and postoperative hidden scar (right).

Key messages

Fibroadenomas and breast cysts are now not regarded as disease but aberrations of normal breast development and involution respectively

Most fibroadenomas do not require surgical excision, unless large or with equivocal biopsy findings

Breast cysts require aspiration only if symptomatic or complex on ultrasound.

be found incidentally on breast ultrasound or mammogram.

Breast ultrasound is essential to differentiate cystic and solid lesions, and can also distinguish

between simple and complex cysts, the latter characterised by internal echoic filling defects, or thickened wall, and absent posterior acoustic enhancement. As for fibroadenomas, women over 35 have also a bilateral mammography.

Simple asymptomatic cysts can be left alone, and patients can be reassured that they are not cancerous, nor do they increase the risk of cancer. Large or painful cysts require aspiration, usually with a fine needle under ultrasound guidance. The fluid obtained is commonly clear or straw coloured.

Cysts aspirated to dryness and without other demonstrated pathology do not require follow up, although repeat investigation and aspiration can be performed if/when the cyst recurs. If the

fluid yielded is blood stained, it is sent for cytology. If a residual lump is palpable after aspiration this necessitates further imaging and biopsy. Complex cysts are aspirated too, with fluid cytology as necessary also. Core biopsy of thickened wall or cystic wall projections is performed to exclude an intra-cystic papilloma or carcinoma.

It is important to counsel women known to have breast cysts not to assume that a new breast lump is just another cyst, but to seek medical advice for any new breast lump.

Author competing interests – nil

Endobronchial ultrasound continued from Page 53 Additionally, RP-EBUS imaging characteristics can provide further information to guide risk assessment of pulmonary nodules.

Heterogeneous nodules or those with hyperechoic arcs or dots have a high likelihood of malignancy. In contrast, homogeneous nodules are much more likely to be benign.

Safety and tolerability As with other respiratory procedures, careful case selection

by specialist respiratory physicians is important to ensure the best outcomes. In hands of experienced operators, EBUS bronchoscopy is an extremely safe procedure, which can be completed as a day case. In Western Australia, the procedure is most often done with the aid of an anesthetist but can also be performed using local anesthesia and conscious sedation.

self-limited hemoptysis, and fever (usually from bronchial washings or theoretical transient bacteremia).

With RP-EBUS sampling of peripheral lung lesions, there is a small risk of pneumothorax which is comparable with that from percutaneous needle biopsy (3-5%). The reported risk of major bleeding from either form of EBUS is under 1%.

CP-EBUS is well tolerated overall, with the most common side effects being post-bronchoscopy cough,

Author competing interests- nil

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SEPTEMBER 2021 | 55

Have skills, will travel Ara Jansen talks to two physiotherapists who are helping communities that don’t have access to physio, while satisfying their own need to travel.

Eight months ago, two physiotherapists set out on a journey in a pimped-out minibus. Their goal was to offer physiotherapy services to underserved rural and remote communities while enjoying some of the best outdoor adventures Australia has to offer – whether it was a stunning beach, a great sunset or the perfect place to hike, ride or fish.

David Dimech and Clare Austin, both 27, met three years ago. After doing their masters and working full-time in Wollongong, they started thinking creatively about ways to use their skills that also involved sating their passion for travel.

“Through our work we regularly saw how regional people were missing out on our services and in fact health care in general,” says David. “It was even happening in Wollongong. We started thinking about travelling around Australia and wondering how we could incorporate work.”

If they were going to drive around the country, they wanted to do it with something which was more than a car – and had a shower. Enter the minibus.

Totally self-built, thanks to instructional YouTube videos and online forums, the pair designed a comfy tiny home on wheels. It has a kitchen which is sophisticated enough to do a roast dinner and houses a top-shelf coffee machine, a fair-sized bathroom, a fold-out desk and a deck on the roof.

If they want to shower outdoors, the kitchen tap simply swivels out the window.

As the pair usually pick up locum work or contracts, which often come with accommodation, they use the bus to explore on weekends or get off the beaten track between jobs. They called their business Project Physio.

56 | SEPTEMBER 2021

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TRAVEL

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TRAVEL “We consider it our living space and our car to get around,” says Clare. There’s also space for bikes, surfboards and fishing rods as the pair like to keep active. “It’s also a lovely space to do our admin work and we see some clients online.

Getting to have a coffee on the roof looking out over a beach is pretty special too.”

Rather than needing two jobs, the pair will often share one full-time position. As each works part-time, this frees up the other to research, look for the next contract or find gaps in local services.

“Our work can be in the community, a private clinic, a hospital or aged care,” says David. “Working parttime gives us free time and allows us to target areas which might need our help. We do a lot of community work such as in-home visits, hydrotherapy and rehab for neurological or post-operative conditions.

“We also try and figure out ways that the clients aren’t out of pocket.

It’s one of the reasons why we work with government-run programs and community health programs.”

One recent job was over six weeks where David and Clare set up and ran a hydrotherapy program, which the participants could continue after they’d gone.

“In that case, there was another physio in town and they were happy to take the program on board,” says Clare. “We strive to promote independence and autonomy and set our clients up with programs they can do and encourage them to adopt healthy lifestyles to improve their overall physical and mental health.

“Through our journey we hope to encourage other health professionals to take their skills to rural and remote areas around the country and help out communities in need.”

The pair and their bus have recently arrived in WA and they plan to spend at least six months working their way from Broome, south.

ED: Communities interested in working with Project Physio can find them at www.project.physio.

Read this story on mforum.com.au

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SEPTEMBER 2021 | 57

BOOKS

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Love in the time of COVID At a time when mental health has become an essential part of keeping healthy, local author Brigid Lowry offers a wise and witty companion in her new book of essays.

By Ara Jansen

If you only had a year to live, how would you do it?

In her latest book, A Year of Loving Kindness to Myself, author Brigid Lowry gently reveals one way we can live and make the most of our years.

Informed by decades of practising Zen Buddhism and learning about modern psychology, this collection of essays is a calming cup of tea and a balm for the soul. What’s delightful and indeed soothing about Brigid’s book is that she’s letting you know she has bad days, too. and doesn’t always get it right.

It’s a refreshing alternative to selfhelp books by people who say they are on the other side of their stuff and are therefore experts in instructing us how to be as happy as they are.

For the Perth author, the days aren’t always brilliant. Brigid, like all of us, is imperfect.

In September’s essay ‘On Wonder’, the writer paints a spirited picture of spring. She reminds us how often we forget to “bow down to the marvel of our own existence”. She assures us that wonder is indeed a wonderful thing. When in doubt she gently counsels, “lean towards awesome”.

Throughout the book, the author offers strategies and hard-fought 58 | SEPTEMBER 2021

wisdom for finding ease and grace in a life which, try as we might, will sometimes exist side-by-side with suffering.

As an award-winning young adult author with a master’s degree in creative writing, Brigid spent her 20s living in a Buddhist community outside Sydney. This set her on a life-long path of Buddhism and later Zen. “When I was at the Margaret River Writers Festival recently, people who came to my session said they were glad I wasn’t saying I knew everything,” Brigid says. “It’s important to show that and to have some humour about it.

“With all of the things happening in the world – from COVID to #MeToo and the climate change crisis – people need solace and humour, but they don’t need me to be pushy.”

While the timings might not be exact, the events and experiences Brigid relates are real. Making friends with your emotions is wise, she suggests, but murderous rages are not to be encouraged. Walk,

journal, watch funny shows and “do something every day that brings ease to your body”.

“A lot of things I talk about around kindness are found in many religions,” she says. “In the moment, I try to live simply and be kind. I’m interested in what our capacity is to live with difficult feelings and to truly realise that it’s human. But we also have the capacity to hold our own emotions and must know it’s OK to feel gorgeous, horny, cranky or contented. Can we be one with our feelings? All of them? That’s what fascinates me.

“If COVID has taught us anything, it’s that a simple life and pure pleasures such as a cup of tea, a friendly smile or not wearing a mask, are a joy.”

A Year of Loving Kindness to Myself is published by Fremantle Press.

(RRP Hardback $29.95).

Win...

We have three copies of Brigid Lowry’s book to give away, thanks to Fremantle Press. Visit our website www.mforum.com.au and click on the competitions tab.

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WINE REVIEW

Happs dazzles with variety Happs is one of those cellar-door visits in the Margaret River region that always makes me smile.

An almost eclectic collection of sometimes wellknown varieties as well as some that might rarely be found in Western Australia. Happs was producing excellent quality alternative varieties before it became cool to have a sangiovese on your wine list.

The Three Hills range of wines is from their premium Karridale vineyard, which has a cooler climate, and it is producing impressive fruit-driven wines. The Happs wines I reviewed are a small selection of an amazing portfolio of varieties available at their cellar.

Three Hills Margaret River 2020 Chardonnay I started with this chardonnay, which has had wild fermentation in the barrel with lees stirring to produce a full-flavoured, fruit-driven chardonnay. Delicate stone fruit aromas with a touch of new French oak give complexity. The palate is impressive with complex fruit, soft oak influence and good acid. I think this is a wine best to drink young to capture the freshness.

Review by Dr Martin Buck

Happs 2018 Merlot I still have a soft spot for merlot and the Happs 2018 Merlot is showing some great berry and cigar box aromas, savoury flavours with balanced, juicy fruits and silky tannins. Very enjoyable and a great fit for an aged T-bone steak.

PF Red 2019 The PF Red is preservative-free with no sulphur used at any point in the wine-making process. Many people describe wine allergies that are often related to the sulphur preservatives and more ‘natural’ wines have become popular. Using a blend of Three Hills fruit, this is a mediumbodied red with aromas of cherry, spice and oak. The palate is balanced with smooth berry fruit and light oak influence – a great wine for easy drinking and early consumption.

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Three Hills 2016 Charles Andreas Finally, the Three Hills 2016 Charles Andreas is a celebration of all things Bordeaux with premium varieties blended each vintage to create the best expression of this style. A more mature wine with some forestfloor characters, cherry and mocha flavours combining with balanced French oak. Some further ageing will increase the complexity.

S WER' E I V RE

PICK

Three Hills 2018 Malbec

The Three Hills 2018 Malbec was my favourite of the reds and a delight to drink. Deep purple in the glass with an explosion of dark cherries, violets, spice and blackberry – a wine that makes you realise why varietal malbec is amazing when done well. A majestic, fruit-driven malbec with power and balance.

SEPTEMBER 2021 | 59

Margaret River Here we come!

Opening soon, we are on the hunt for GP’s, Nurses and Administrative

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For a cRQǓGHQtLDO Giscussion contact us tRGD\ Dr BrHQGD 0XUUison 0 418 921 73 ( %rHQGD 0XUUison@breckenhealth com au Damian Green 0 423 844 268 ( 'DPLDQ Green@breckenhealth com au

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