Medical Forum – December 2020 – Public Edition

Now, it’s time…

General Medicine issue | Year in Review, bush biteys, sarcopenia, breast surgery, skin cancers

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EDITORIAL BACK TO CONTENTS

Jan Hallam | Managing Editor

The lucky country The magazine has always been a forum for ideas and discussion, and we have been fortunate this year to have had scores of contributors who give up their precious time to share their insights and knowledge.

We have said it a million times over the past few months, but it can’t be said too often – we are so lucky to be here in Australia. We have an orderly democracy (who would have thought!); our country is wide, open and clean; we have a health system populated by highly skilled and caring individuals; and we have enough collective smarts to pay heed to what’s good for us and question that which is not.

As we all prepare to say goodbye and good riddance to a year that beset us with unique challenges, inside these pages you will gain insight about how some of you and your colleagues navigated these uncharted waters, and we thank them for sharing their triumphs and fears.

What comes through is the importance of a cool head in a crisis.

Yes, it’s drawing on training and experience, but there are a couple of essential ingredients – good old common sense and reducing the volume on the chatter. Employ them all and a clear path opens up – I see Christmas up ahead and a New Year, too. We have much to be grateful for.

As a magazine that has walked alongside you during the year, yes, with a limp every now and then just like you, 2021 is an exciting prospect.

Leading the magazine on its next chapter will be WA’s foremost health journalist, Cathy O’Leary, who joins the team as editor in 2021. Cathy will be no stranger to many of you – her work has been awarded and lauded over the past two decades. Her appointment goes back to the start of this editorial – how lucky are we!

After nine years, I am changing saddles – one with extra padding for production editors. How lucky am I! The magazine has always been a forum for ideas and discussion, and we have been fortunate this year to have had scores of contributors who give up their precious time to share their insights and knowledge. There’s another dose of gratitude for the pot.

Just as for your business, 2020 has been quite the ride here at the magazine and we wouldn’t be here without you, our readers, and our advertisers. We are grateful for your support.

So, with the promise of a new year comes some exciting digital offerings, and, of course, the flagship Medical Forum magazine will sail into its second quarter century in full sail.

From all of us here, to all of you there, let’s have a ‘greatful’ Christmas and get ready to rock 2021.

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

DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum.

The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

MEDICAL FORUM | GENER AL MEDICINE ISSUE

DECEMBER 2020 | 1

CONTENTS | DECEMBER 2020 – GENER AL MEDICINE ISSUE

Inside this issue 52

56 Tim Minchin: Damian Bennett, Photographer

8 12 FEATURES

NEWS & VIEWS

LIFESTYLE

8 Surviving general

1

54 Book Review:

practice in 2020

12 Borders and boundaries 52 The magic of Karijini 56 Let 2021 entertain you

Editorial: The lucky country – Jan Hallam

6 In the news 7 In brief 14 The Good, The Bad,

The Edward St Baby Farm

55 Wine Review: St Aidan Wines –Dr Craig Drummond

The Ugly

17 Nasal drops on COVID 18 New chapter of Make

CHRISTMAS 2020

Smoking History – Cathy O’Leary

Doctors Dozen...

Greetings from health professionals Starts page 25

For your chance to win a dozen wines from St Aidan Wines, see the review on Page 55 and go to the website to enter. www.mforum.com.au (click on the competitions tab)

CONNECT WITH US /medicalforumwa

/MedicalForum_

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/medical-forum-wa-magazine

www.mforum.com.au

info@mforum.com.au

MEDICAL FORUM | GENER AL MEDICINE ISSUE

CONTENTS

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

Clinicals

ADVERTISING Advertising Manager Andrew Bowyer (0403 282 510) andrew@mforum.com.au EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au

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Autoimmune thyroid disease A/Prof Louise Smyth

Clinical Christmas Dr Joe Kosterich

Topical therapies for premalignant and malignant skin disease Dr Yee Tai

Preventing burnout in the juggling act of medicine Dr Davinder Hans

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Sarcopenia and Osteoporosis Dr Charles Inderjeeth

Modern surgical Demystifying the management of mildly abnormal FBC breast cancer Dr Steve Ward Dr Jose Cid Fernandez

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 INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Mark Hands (Cardiologist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon)

Christmas infectious diseases and bush biteys Dr Astrid Arellano

Guest Columns

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

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Back to basics Dr Paul Bailey

Understanding children’s emotions Dr Andrew Leech

Post-stroke aphasia A/Prof Erin Godecke

The ‘fourth trimester’ Juan Stephen and Dr Ramya Raman

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DECEMBER 2020 | 3

Back to basics For St John Ambulance Medical Director Dr Paul Bailey, a stint back on the ED tools reignited his passion for medicine.

In March this year, my boss came into my office at work and proclaimed, “PB, all your leave is cancelled!” No problem I thought, there’s nowhere to go anyway.

There was a follow-up, “and you now work full time”.

I had planned on a nice three-day working week supplemented by some additional clinical shifts. That plan went up in smoke in an instant – because of one guy who ate a bat.

2020 has not been the year any of us were expecting.

In many ways my career has been a happy accident. Like many of us, I’ve done some pretty cool things that are actually quite hard to believe from the safe and cosy office of the Medical Director for your ambulance service, St John Western Australia.

There are some stories that my kids have heard so often they can repeat them line by line – “When I was in the army…(toughest 12 days of my life)”; “Cruising out of Nagasaki Harbour with Miss Nagasaki tearfully waving goodbye to Chef Rob Whitely on the Clipper Odyssey…”; “Being interrogated for two hours by two cops in a room with a one way mirror, for taking narcotics into Japan” (Cruise ship resupply); and being the Medical Director for a flight that resulted in a controlled landing onto water of Norfolk Island in 2008 and so on.

Those are just the side gigs. I’ve got a thousand stories. My career in Emergency Medicine has had me working in almost every department west of a line from Port Hedland to Kalgoorlie. And I gave it all up just over 12 months ago to focus on my role within St John Ambulance.

4 | DECEMBER 2020

I had intended on picking up some casual work around the traps this year and then COVID. I worked frontline in high-volume acute emergency departments from 1993 to 2011 when I became the ED Director at SJOG Murdoch – Perth's only private emergency department.

Our small team kept Murdoch ED open in spite of the existential threat posed by the opening of Fiona Stanley Hospital right next door.

That was our proudest achievement.

ED directors tend to end their tenure in one of two ways – the first is known as the ball of fire technique, the second as the handshake and a smile method.

I’ve always favoured the latter. When I walked out the door at Murdoch about this time last year, I felt like my successor didn’t need the past director hanging around. As far as I can tell we all parted on good terms.

Long-term ED directors can become a bit unhinged – you change the things that can be changed (either because they are easy or you have the right skill set) and you’re left with a series of things that aren’t fixable – most commonly due to a personal skillset deficit. Pragmatic decisions need to be made that don’t always sit well. And it’s a hard job having the weight of several hundred mortgages on your shoulders.

Towards the end of my tenure at Murdoch I had a bit of IHP*.

But now it’s time to go back. The practice of clinical medicine is an itch you can’t scratch in any way other than to go and see some patients.

Worried that I would be all at sea, I signed up for two casual shifts on the cushy 10am-7pm time slot, dug out the scrubs, found my ID card and name badge and entered the fray.

I reassured myself with the fact that private EDs are, in many ways, a bit of a sheltered workshop. At least I hoped so.

It was brilliant. So good to reconnect with colleagues – admin, nursing and medical. The ED has become much busier in the past 12 months and many new staff have joined the roster. Great to meet a few patients and their families and actually be able to help. Amazing to run through some CT scans and realise that while I might be very rusty, a lot of those skills are hardwired over many years and were still accessible.

The nursing team at Murdoch are hard-working, accomplished and very procedural in nature – a pleasure to work with.

Then disaster struck – “PB, you know that man in bay 15, we’ve tried a few times and we can’t get IV access”.

“No worries,” I thought, “it’s been more than 18 months since I’ve placed an IV, I’m sure I’ll be able to sort it out.” I’m not that fond of these missed IVs you speak of. I spent ages selecting the best vein and the IV went straight in. A small victory. The old man has still got it!

Other reflections – it’s so good to be part of the team and not be in charge; to just be a humble worker bee was the best. Turn up, do your work and go home. No complaints to deal with, no interpersonal feuds to referee, no queries from administration to respond to.

It was great to be a part of it, for a little while at least, and remind myself of what doctoring is all about.

Compassion, helping, doing your best. The IHP has gone. Now back to the office. *IHP = I hate people

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OPINION

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Investigation of autoimmune thyroid disease Of the major thyroid diseases encountered, autoimmune thyroid disease is the most common and the inclusion of subclinical autoimmune disorders and other disease increases the total burden of thyroid pathology by as much as 10% of the population.

There are four major thyroid autoantibodies that are known to be involved in the pathogenesis of autoimmune thyroid disease.

Anti-thyroglobulin (aTG) is directed against the storage protein in the follicles and is present in around 3% of the general population, up to 30% of patients with Grave’s disease, and up to 60% of those with Hashimoto thyroiditis. It may precede the development of clinical disease by years to decades and can serve as a marker of increased risk.

Antibodies directed at the TSH receptor are present in 1-2% of the general population and up to 100% of patients with Grave’s disease, and include Thyroid Stimulating Antibodies which increase the production of thyroid hormone and its secretion, resulting in hyperthyroidism. Antibody production may persist after thyroid ablative therapy, posing a risk for the fetus in later pregnancies. The TSH receptor is also expressed on retro-orbital adipocytes, although the mechanisms of Graves ophthalmopathy are not limited to the action of this autoantibody.

Anti-thyroid microsomal antibody is directed against a cytoplasmic target involved in the biosynthesis of thyroid hormone. The antibody is frequently used to identify patients with Hashimoto disease where there is gland destruction. Anti-TPO is present in high concentration in up to 99% of cases. It is also present in up to 80% of patients with Grave’s disease and 10-15% of the

By Associate Professor Louise Smyth MBBS GCUT FRCPA

About the Author: Speciality: Immunopathology Phone: 1300 367 674 Email: louise.smyth@clinicallabs.com.au Louise designed and implemented the Pathology program for the School of Medicine at the University of Notre Dame in Fremantle.

She has a Graduate Certificate in University Teaching, qualifying her to supervise candidates for higher degrees as well as teaching undergraduate students.

Louise is most interested in autoimmunity but has extensive experience including transplantation, immune deficiency and allergy.

general population, generally at low concentration.

Sodium-iodine symporter is a thyroid autoantigen with antibodies directed against it in both Grave’s and Hashimoto diseases. Varying frequencies of these antibodies have been reported. It is thought that blocking antibodies inhibit iodine uptake and may contribute to hypothyroidism.

The Thyroid Receptor Antibodies (TRAB) currently available measure stimulating, blocking and neutral antibodies, which are all present in Grave’s disease. This remains important since possible effects on cell-cycle control in thyrocytes subjected to longer term exposure to neutral and blocking antibodies remain. The presence of stimulating TRAB is a sensitive and specific assay for the diagnosis of Grave’s disease, in the presence of thyrotoxicosis. Additionally, positive stimulating anti-TSH receptor antibodies (TSI) following thionamide therapy has a positive predictive value of >90% for relapse.

The European Thyroid Association recommends: • “All patients with a history of autoimmune thyroid disease should have their TSH-R-Ab serum levels measured at the first presentation of pregnancy … and, if they are elevated, again at 18–22 weeks of gestation.

• If the maternal TSH-R-Ab concentration remains high (>3 times the cut-off), monitoring of the fetus for thyroid dysfunction throughout pregnancy is recommended.”

Autoimmune disorders frequently co-exist. The demonstration of thyroid autoimmunity raises the risk of pernicious anaemia/autoimmune gastritis and insulin dependent diabetes, as well as occurring with increased frequency in myasthenia gravis, coeliac disease, hepatitis, vitiligo, premature ovarian failure and Addison's disease. These associations should guide the clinical index of suspicion.

Thyroid antibodies are mainly of IgG class and are therefore actively transported across the placenta.

Building Better Partnerships

1300 367 674 | clinicallabs.com.au MEDICAL FORUM | GENER AL MEDICINE ISSUE

DECEMBER 2020 | 5

IN THE NEWS

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HSS goes local Health Support Services has awarded a $290 million contract to Baxter Healthcare and WA company PureIV to manufacture to manufacture specially prepared medication and supplies used to treat patients with cancers, rheumatoid arthritis and multiple sclerosis.

The contract replaces various separate agreements between pharmaceutical companies and individual hospitals to provide consistent pricing across the WA health system for aseptically compounded cytotoxic and chemotherapy drugs, antibiotics and intravenous feeding solutions. HSS said the contract would save the health system up to $35 million over the next 10 years. Baxter’s Canning Vale facility produces more than 200,000 units of critical medical products for patients in local, regional and remote locations across WA, many of which need to be dispatched to patients within hours of production. Pure IV, located in Shenton Park, combines a purpose-built manufacturing facility with a pharmacy structure which enables dispensing and supply direct to patients.

Recognising the signs Perth Children’s Hospital researchers have published a precursor to clinical guidelines to help doctors to recognise early warning signs of respiratory disease in children with cerebral palsy. The research team include researchers from the Physiotherapy Department, KidsRehab WA and Respiratory Medicine at PCH in partnership with the Ability Centre and researchers at four of the major paediatric hospitals in Australia. Dr Andrew Wilson, PCH Head of Respiratory Medicine, said the research was prompted by growing concerns about the ‘silent’ nature of this disease where warning signs were often only recognised when it was too late. The statement has generated a strong response internationally including from the American Academy of Cerebral Palsy and Developmental Medicine who are already promoting it within their practice pathways for clinicians in the US.

Autism trial It has been a huge couple of months for WA’s Emyria Limited.

The company, which creates data products gathered through its Emerald Clinics, last month signed an agreement with Zelira Therapeutics to conduct an observational trial using a range of medicinal cannabis products for patients diagnosed with Autism Spectrum Disorder. The trial will be conducted through Emerald Clinics and will provide longitudinal realworld data on patients prescribed 6 | DECEMBER 2020

one of Zelira’s products. Data will include patient efficacy and safety relating to co-morbidities, concomitant medications, dosing information and patient responses to treatment as measured using standard ASD clinical and behavioural endpoints. As reported to the ASX, the agreement is worth $115,000 in two instalments over the first 6 months as well as a subscription fee for each patient enrolled in the study, up to a maximum of 150 participants. The term of the agreement is for 12 months with an option to extend the subscription fees on an ongoing basis.

Psychedelic study Emyria also announced to the ASX it was joining a partnership with registered charity Mind Medicine Australia to develop national care program and data registry for psychedelic-assisted therapies.

Under the terms of the partnership, Emyria will design a care model describing how psychedelic-assisted therapies could be delivered safely to patients with major mental health concerns, pending the successful rescheduling of psilocybin and MDMA by the TGA. Mind Medicine Australia will provide access to its international network of experts, clinical trainers and treatment model strategies. The model will start with psilocybin and MDMAassisted therapies and draw on research conducted recently in North America and Europe.

Emyria will also apply its remote monitoring technology and lead the construction of a longitudinal data

registry. The registry will collect real world clinical data on diagnoses, concomitant medications, dosing information and patient responses to psychedelic-assisted treatments as measured using validated clinical and patient-reported endpoints.

Day surgery rethink A statement from the Australian Orthopaedic Surgeons association has urged a rethink of the 24hour or “same-day” knee and hip replacements being promoted by some private health insurers.

They are not, says a panel of AOS surgeons, suitable for many patients.

While there has been an increase in this type of treatment, caution needed to be exercised to ensure that the patient’s best interests came first. “The model beginning to be adopted in Australia where private patients are having surgery in health fund-owned hospitals that make deals with doctors who work in their hospitals is clouded by vested interests,” said Dr Michael Solomon, President of the Australian Arthroplasty Society. Panellist Professor Richard de Steiger added that the length of stay for both hip and knee replacements had reduced from over seven days to four in the past 12 years. “It is important that any further reduction … does not compromise the quality of joint replacement.”

Cannabis price deal Private health insurer Health Insurance Fund of Australia and Little Green Pharma (LGP) have

MEDICAL FORUM | GENER AL MEDICINE ISSUE

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IN BRIEF reached an agreement which will make medicinal cannabis cheaper to HIH members. HIF will pay rebates for medicinal cannabis across all but one of its Extras policies with eligible members receiving up to $105 back per script, though rebates will be subject to individual policy caps. Also part of the agreement, HIH members will be entitled to priority participation in research. It is the first time a major Australian health fund has publicly declared its support for access to medicinal cannabis treatments.

breastfeeding. ABA volunteers logged the concerns of 340 mothers and caregivers regarding care and concerns for 341 infants and young children and one pregnant woman.

ABA helpline volunteers reported that many mothers believed the stress of the COVID-19 pandemic had negatively impacted their milk supply. Coupled with the reduced in-person medical and healthcare services, many mothers were not able to weigh and assess their baby’s growth and development in the usual way at a clinic.

Digital health summit

COVID warnings

The Indo-Asia Digital Health Centre is holding the Digital Health and Telemedicine summit at the UWA Club on December 3 and 4. Convenor Professor Yogesan Kanagasingam said the summit would look at telehome care, closing the gap in remote Aboriginal communities, remote monitoring, AI and machine learning, statewide EMR implementation and data privacy and cyber security among other topics. The summit will also offer a free live stream to rural and remote WA, mainly to Aboriginal Medical Services, GP clinics and nursing posts.

The Department of Health and the Department of Fire and Emergency Services (DFES) have customise the Emergency WA website to allow for future COVID-19 alerts and warnings.

Managed by DFES, Emergency WA is the State's official website for community warnings for a range of emergencies, delivering realtime information during bushfires, cyclones, floods and more. As part of the customisation, a 'human pandemic' icon has been created to identify alerts and warnings specific to COVID-19. This may be just as well given a report to a Senate Estimates committee about the COVIDSafe app, which has only picked up 17 positive contacts, all in NSW, since its launch in late April, at a cost of close to $12 million. Department of Health secretary Prof Brendan Murphy told Senate Estimates that Victoria had actually stopped using the app when the second wave hit the state.

Breastfeeding longer New mothers sought to protect their babies during this year’s COVID-19 pandemic by breastfeeding their infants longer with 64% of women seeking support during lockdowns to increase their milk supply or restart

Heads up The TGA has approved three types of craniofacial implants that act like scaffolding by naturally dissolving over time to leave only natural bone tissue. The 3D-printed polymer implants, which were used in skull replacement surgery in Brisbane last year on a motorcycle accident victim, are made by Singapore company Osteopore. The TGA has approved the company’s craniofacial plugs, strips and meshes. The Australian CEO of Osteopore said that implants had been successfully used in more than 40,000 surgeries in Asia, the US and Europe.

MEDICAL FORUM | GENER AL MEDICINE ISSUE

HBF has appointed Dr Daniel Heredia to the newly created position of Executive General Manager Health Services. Dr Heredia was formerly Deputy CEO and Director of Medical Services at Hollywood Private Hospital.

Bethesda Health Care has appointed Dr Dharjinder Rooprai and Dr Taj Singh as medical directors of its Bethesda Clinic Cockburn, which is expected to open in 2022.

Bethesda chair Dr Neale Fong is pictured here with Dr Singh (left) and Dr Dharjinder (right).

UWA Professor Helen Milroy and Professor Gordon Parker and joint winners of the 2020 Australian Mental Health Prize.

A/Prof Tarun Weeramanthri has been elected the new President of Public Health Association of Australia.

Adj/Assoc Prof Robyn Collins has been appointed chair of the South Metropolitan Health Service Board Chair. Ms Kim Gibson is deputy chair and Mr Colin Murphy has been appointed as new member.

Dr Lachlan Henderson, Group Chief Executive of Epworth HealthCare, has been elected as the new president, while Peter Mott, CEO of Ramsay Health Care’s Hollywood Private Hospital, is the new vice-president of the Australian Private Hospitals Association.

Katanning shire president Cr Liz Guidera and Pilbara physiotherapist David Rigby have joined the board to Rural Health West. Chair Terry Waldron paid tribute to outgoing board member Lynnette Baker.

DECEMBER 2020 | 7

CLOSE-UP

Surviving general practice in 2020

2020 has been, without doubt, the most challenging year of my professional life as a GP. What started as a year of planned work, concerts and holidays has dissolved in a time of world crisis. My little part of the world is my family, both immediate and extended, friends and musical colleagues, and my general medical practice at 435 Fitzgerald St, North Perth.

We are a large general practice. We were hearing about a virus in China in January 2020, and then more obviously in February. At that time, it was confined to China, and then, soon after, a cruise ship in Japan.

My son had a planned holiday to Japan on February 16. There was some concern and discussion about whether this was a good idea to go or not.

Over the next two weeks there was mounting anxiety and some hysteria in Perth and the rest of Australia, even though there had been no COVID-19 cases here.

Panic buying of toilet paper, liquid soap, gloves and masks happened almost overnight with supermarket shelves and chemists depleted. As a medical practice, we had no forewarning. We had masks – but only 50 or so.

We had a few containers of liquid alcohol gel. Happily, we had industrial rolls of loo paper!

I was really concerned at seeing queues of people outside Coles North Perth, well before 8am opening, and then people running to the toilet paper aisle. Shelves were depleted by 8:15 and the supermarket staff were beside themselves.

Staff at the practice were anxious, like the rest of our community. Decisions were being rapidly made, and then unmade as rules came and then were changed without warning. Hours of planning was undone when a new announcement was made. Patients had extremes of anxiety – fearful of catching disease, not going to work, possibly losing work, wanting to be seen while unwell, not wanting to come to the surgery, feeling vulnerable, caring for vulnerable relatives, travelling here from overseas, and later from interstate.

Simple and clear Creating a consistent message for reception to give to patients was immensely stressful.

My email feed was increasing exponentially, and it was giving us multiple sources of advice – WHO, RACGP, Department of Health (Federal), 8 | DECEMBER 2020

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North Perth GP Dr Jenny Fay looks over the past year of stress, fear, worry and new connections and friends.

CLOSE-UP desk as they were being taken by patients inappropriately. We ordered plastic barrier screens for the reception desk – they eventually arrived in mid-July.

We put in distancing measures, removing most of the chairs from the waiting room, and all the toys and magazines. Those patients who did come in were asked to hand sanitise and some had to wait outside on the footpath.

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In March, we decided to triage those who wanted to come to the surgery. This didn’t sit well with any of us. We see sick patients. Not letting them in was unthinkable and worrying for us all. Patients were asked to call us from their car in the car park when they arrived.

A doctor then spoke to them and decided how to proceed – ‘can come in’, ‘can’t come in’, or ‘doctor will go to them in the car park’.

Department Health (WA), Medical defence, AMA, Primary Health Network, HealthEd, local hospitals.

Everyone had their view of how GPs should best handle every aspect of general practice – from personal protective gear, swabs, concern for medical litigation, finance, Medicare changes, further Medicare changes, and then more Medicare changes. It was very disturbing and provoked a lot more angst when different messages were being given.

I was one of only a few people visiting local aged care facilities. My patients there were scared. Some were blissfully unaware.

I asked my own father-in-law if he had heard anything about a virus going around. His reply, “No. No. I don’t think so”. Lucky him. Some were only too aware, and very upset at restrictions that banned family members from visiting. I tried to take my time to chat with them, and to ring relatives to reassure them.

When I visited, there were always a couple of aged residents on the inside of a glass door, trying to talk to relatives outside the glass on a phone or iPad. Facility staff had to schedule appointments for phone calls. This was no way to spend your last days on earth and was very upsetting to witness.

Anxious times I saw a lot more anxiety in my practice. I was becoming anxious myself. The responsibility I felt for our staff and for our patients was immense. It was a struggle to balance keeping my staff safe and well, and the need to see sick patients. I never expected to feel that illness might be risky to see, but that was how it came to feel.

I felt I was a risk to my own family.

Several specialists and doctors consulted me as patients. They were anxious, tired and worried.

Travel and hospitality and the arts businesses have been particularly devastated. It was disheartening to hear of longstanding businesses that collapsed and highly respected people losing their jobs. I found it difficult to console when the future seemed very uncertain.

My friends know it was hard for us in general practice. I had two friends who offered to make me cloth masks. I would never normally think these adequate, but since we were very short of personal protective equipment, I accepted gratefully.

In March, we didn’t have more than a dozen gowns and were short on alcohol gel. We ordered a dispenser (even by August, it hadn’t arrived).

Quite early, we had to remove face masks from the front reception

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There was chaos around COVID testing (throat and nose swabs).

Initially we could do testing, then suddenly we weren’t allowed to, with all patients identifying as at risk having to attend a COVID clinic.

After a while, testing returned to us in GP. As it stands now, I’m swabbing patients but that was only feeling safe to do here in Perth.

Empty surgeries For a few weeks, we had almost no patients in the surgery. I worried about having enough business to keep our staff employed. No one knew how long this was going to last or even if general practice would survive. We reassigned other tasks to our nursing staff, including cleaning duties.

Federal Government introduced telephone and video consultation numbers for the first time under Medicare (previously only available in rural and remote areas of Australia). This was introduced almost overnight on Monday, 16 March. With the sudden introduction, we changed the information given at reception.

Initially, only vulnerable patients were able to have access to telephone consultations – patients over 70 years old; pregnant; or those with a child under 12 months; patients with chronic health conditions and those who identify as ATSI. The rules changed – thankfully – to allow everyone access to phone consults. continued on Page 11

DECEMBER 2020 | 9

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Surviving general practice in 2020 continued from Page 9 Every time there was a change (about fortnightly) the Medicare announcement would come with no notice (e.g. starting tomorrow).

This was a scramble every time as the software providers were caught by surprise and had to provide an upgrade for each change. A lot of hours were needed to keep everything and everyone up to date.

It was curious to have a consultation on the phone. Some things were very simple but I was surprised by what patients thought I could consult about on the phone. I came to realise that my clinical skills of examining and the visual cues I take from a patient were very important.

Consults on the phone seemed superficial and I really hated sitting in a room with no social contact.

They were also a medicolegal nightmare, fearing I would miss something. I missed shaking hands and hugging my patients.

On one day, I was so pleased to find a patient of mine having a blood test. I’d known her for years.

I knew she had cancer. We sat and talked, and she, too, was pleased to see someone face to face. Two weeks later and we had a have a phone consultation as she was now terminal. I tried to convince her it was OK to let her family in to visit, but she wouldn't have it. Her family felt they were a risk to her. I tried to say that this time was important, and short.

Another two weeks later and I was completing her certificates, those that marked her passing. Her funeral took place with only eight family members plus celebrant and funeral attendant under the new COVID rules. This, for a long life well lived, and for a person so greatly loved. We heard many tales of sorrow like this. It was gruelling and very sad.

Survival kit I made a decision to do a few things to help myself at this time: 1. Stop reading social media feeds.

Facebook has a million opinions, very few of them expert. I simultaneously decided not to comment on anything.

2. Only read from a few sources that are reliable – WHO, Department of Health – Federal and WA. I limited where I get my information.

3. Listen to podcasts when I can.

Those by the RACGP president were brilliant as they were based in general practice. One came out every week, beginning in March.

I was so grateful for sound and sane information that was relevant to me. In August we heard that our lovely President of RACGP, Dr Harry Nespolon, who so valiantly put a webcast every week for GPs, had just died of pancreatic cancer. He knew he was sick. He kept working for us as he thought it was important. It was.

4. If I can help, I will. I started a Zoom group for friends on Friday afternoon. Most were retired and therefore having no contact with anyone outside their home.

Those over 70 were considered to be especially high risk. I found my friends, a loving, but slightly desperate crowd, and together we learnt how to use Zoom for meetings, have a chat, sometimes a sing or watch a recording of something nice and just generally catch up.

A couple of times we did some physical exercise, dancing to a song, in the isolation of our own homes!

That was the other thing – no one was doing any exercise. Those with dogs were doing lots of dog walks.

Bike sales were going through the roof as gyms and exercise classes closed. Besides, everyone was too anxious to go out. This “Friday at 5” session became particularly important to me as a circuit breaker.

They were worried about me and it helped to have other people to talk to.

My son came home safely from Japan, prior to mandatory home confinement. But, as he lived with a nurse, the hospitals had already mandated that hospital staff could have no contact with overseas travellers. He came back home to us. But he was a risk to us, to me, to my practice. It was a bonus to have two weeks with him in our home, but I was fearful of a possible source of infection being nearby.

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Scrambling home A staff member (doctor) was close to being caught overseas and scraped in before the deadline of international arrivals closed (also announced suddenly). Some were unwell and had to take longer than usual sick leave so as not to bring any illnesses to work. All had to be tested. One who was older decided the risk was too great at work and took temporary leave. The doctors, nurses, managers and reception pulled together and it was certainly one of our strongest times as a team. I was very proud of them.

My lovely street decided to start driveway drinks on Sunday at 5pm.

Take your choice of drink to the edge of your driveway and chat.

As the year went on, we started to congregate at a street corner, suitably distanced. Even now in November, we all meet and catch up every week at a local place. Very casual, but it has been a wonderful connection through this year and stronger bonds have been made in our community.

Perth, of course, has survived very well and I’m grateful to our public health and government officials who have listened and worked cooperatively. Their leadership has been outstanding. Similarly, our staff came together. We created better systems of communications and updates. We had ignored a section of pandemic planning in our accreditation (“never going to need that”).

We now have every possible contingency recorded and know well how to manage in a pandemic.

We have learned a bundle of new tech options. Zoom is great, with limitations. Family have now heard me singing as I took part in Zoom rehearsals from the privacy of our study. I’ve taken part in and coordinated some concerts. We’re all seeing patients again but are grateful for telephone consulting being another option.

Nothing beats meeting with people face to face, in work and in play. At heart, we are social creatures and this strange time has proven that we need contact with other human beings.

DECEMBER 2020 | 11

FEATURE

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Borders and boundaries Is border control too blunt an instrument as WA moves to a COVID-normal?

Bahnfrend, CC BY-SA 4.0, via Wikimedia Commons

Jan Hallam reports

When the WA Government closed the border on April 5 as its firstline weapon to stop the spread of coronavirus, it was the first time in the state’s history it had closed itself off from the rest of the country.

Over the ensuing seven months, WA eliminated community spread and eased other restrictions, despite heart-racing moments with cargo and ore carriers sailing into our ports with infected crew members, and returning overseas travellers in hotel quarantine testing positive.

The hard border became our own mini iron curtain, but instead of seeing this as an act of totalitarian heavy-handedness, West Australians supported it overwhelmingly and it was the signal for the party to get started – but strictly locals only!

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Somewhere between WA losing the opportunity to host the AFL grand final and winning Clive Palmer’s High Court border challenge, the local appetite for splendid isolation waned. Victoria had run and won a difficult COVID race, NSW had shown its agility at hosing down spot fires and Queensland, WA’s border buddy, was opening up. WA families wanted to be reunited, our businesses needed more customers and dissent crept in.

COVID-normal

On November 14, the border changed from ‘hard’ to ‘controlled’ to allow more freedom of movement, until the November 15 outbreak in South Australia, which up to then was basking in a COVIDfree glow along with WA, the Northern Territory and Tasmania.

Dr Miller has been generally supportive of the government’s border controls and, speaking on the November 14 easing, said it was right to base decisions around COVID numbers in the communities where people are coming from.

When it comes to a pandemic, things change in a blink of an eye and so does the politics.

Regardless of the outcome of the Premier’s decisions as a result of the SA breakout, the AMA WA President Dr Andrew Miller says WA must look to a ‘COVID normal’ because the pandemic is far from over.

“I think that's the only justifiable public health measure. Obtaining discretionary exemptions from policemen was unsustainable and

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FEATURE would have collapsed, which would have left us with no control,” he said. “So, it is a smarter way of doing things. However, the question then becomes, ‘how successful will we be at controlling COVID?’.

In terms of community education, after months of living inside a bubble, there would appear the need for relearning a number of the basic public health rules of physical distancing and hand hygiene.

“We know not everyone will tell the truth and that quarantining is imperfect. So, the risk has increased, which means that we've got to be really good with our surveillance, our tracking and tracing, and isolating.

Dr Miller adds that it is probably time to broach the subject of masks.

“We should already have real-time surveillance in place as they do in other states, and we should have a high-capacity testing system so that we can do things like they're doing in NSW with hotspot testing blitzes.

“That means that we should be using private pathology. There's still a bureaucratic, ideological preference for PathWest, which is a corporatised, profitmaking, government-owned entity.

However, it's very small in comparison to the combined strength and capacity of private pathology in Western Australia, and it has far fewer testing facilities.

“And, of course, our tracking and tracing system has not yet been tested. This talk that it's been used in Victoria has no supporting data as to how many cases it found and how well it performed against Victorian systems. One concern the AMA harbours is that we have been told that the tracing software, which has been developed in WA, is only used by WA and that's a double-edged sword.”

Dr Miller said that while public hospital systems have been as prepared as they can (with a rider that PPE will always be a critical issue), he did hold grave concerns for the preparedness of the federally controlled local aged care sector and general practice, which he believed were not getting the state support they needed.

GPs sidelined “I was at a meeting recently with WA bureaucrats and GP representatives and when asked if GPs were able to be copied into the results from COVID clinics, barriers were put up as to why that was too difficult,” he said.

“GPs have not been brought into state planning, despite them being well located and know their communities very well. They could be incredibly helpful in contact tracing.”

“I think we need to have a community test run. We should use a gathering at Northbridge or a sporting event and make it an opportunity for the public to practise mask-wearing on public transport and observe COVID safe rules. There are prices to freedom.

“And similarly, a registration of attendance at businesses through QR code systems needs to be established as they are in the east.

We are only just starting to look into this now. Everyone's a bit sleepy and feeling pleased with themselves.”

Dr Miller is concerned that the Victorian example which saw 2500 health care workers become infected in the workplace might be replicated here. He would also like to hear the government’s contingency for preventing aged care workers from moving between facilities and other work.

“It's all very much on the nevernever at the moment,” he said.

Smart borders There has been a suggestion of a ‘smart border’ and Dr Miller said he thought it had merit, particularly if it used technology for quarantine rather than relying on hotels.

“I'm also attracted to the idea of a border that can flex and contract, but I’m not confident that the WA team can manage that. Some of the responses I have received on these issues are underwhelming and the ‘black box’ is controlled by a few people in the health department who won't listen to outsiders.

“One of the AMA’s ongoing frustrations is the lack of occupational physicians and hygienists involved in government decision making. These are experts in preventing disease in the workplace and, so far, 80% of COVID spread has occurred in someone's workplace. The other states have used the knowledge of these health professionals and so has the rest of the world.

profession outside of this small group of bureaucrats. It has been very difficult to challenge their decisions from within the profession. At the start of the pandemic, people were being told not to challenge them and to support the public health team.

But that’s not how science works.

It’s been disappointing that our response has been old medical culture of not questioning the authority of the professor.

“I think it has held us back and painted them into a corner on occasions. The issue of airborne spread and who needs airborne protection was a classic example.

They pinned their colours early to the idea that people on the frontline didn’t need N95 masks, when people on the frontline knew, absolutely, they did.

“A new committee has been established now which is sort of a frontline health care committee with occupational physicians and they're making other recommendations and the infection control experts are being sidelined a bit.

“But politicians, of course, have to choose one voice. They can't sift through all the evidence themselves.

So really, this has been a problem of medical culture itself, where we haven't been as agile as we should have been because the medical representation hasn't been as diverse as it should have been at the outset.

A CDC essential “This is where a national Centre for Disease Control would have solved these issues. A CDC would have diverse representation across the spectrum. How many GPs have we seen standing up in front of the news and saying this is affecting myself and my patients, my residential aged care facility – not many and, if they have, they have been slapped down.

“Politicians need to figure out ways of short circuiting their own bureaucracy. We understand, because we deal with the same bureaucracy as they do. I hope they will be more prepared to hear what the wider profession and community have to say – there are some good ideas there.”

Read this story on mforum.com.au

“I am also disappointed at the lack of input from the medical

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FEATURE

What has the COVID-19 taught us, and what do we still need to learn?

Infectious diseases physican Dr Michael Watson considers the answers.

14 | DECEMBER 2020

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FEATURE

When something as dramatic as COVID-19 occurs, it’s always tempting to lament about all the bad things that have happened. That’s why I deliberately chose the title ‘The Good, the Bad and the Ugly’.

Let’s start with the ‘good’ that has come from COVID-19 as there has actually been much good in recent times.

Well it’s every ID physician, public health physician and microbiologist’s dream to hear that there has been so much hand washing and hand sanitising in the community that we ran out of soap and hand sanitiser!

So did all the hand washing make a difference?

It certainly looks like it. If you look at VirusWAtch, (an integrated viral syndromic and laboratory surveillance system I helped set up in 2007 before the last pandemic), you will see something quite remarkable. Influenza simply disappeared from the state this winter and other respiratory viral activity is also way down.

Not only respiratory viral admissions to hospital were way down but gastroenteritis admissions too.

I think it was also fantastic to see democracy in action, with robust lobbying from grassroots medical people with the support of the AMA. I think without that lobbying, the outcome for WA may have been quite different.

Industry lead I was also impressed that industries such as mining were so proactive in protecting their workers (and one of WA’s most essential industries), that they were able to lobby successfully for increased testing for SARS CoV2 and the availability of PPE. The lobbying for health worker safety I think has paid off and although there have been significant health-care worker infections with COVID-19 in Victoria, these appear to have been reasonably well investigated (unlike other countries) and steps are now being taken to mitigate risks so when the almost inevitable 2021 winter epidemic of COVID-19 occurs (if an effective vaccine is not implemented) we should be much better prepared.

The price of petrol is down and greenhouse gas emissions

around the world are in retreat.

Unnecessary business travel has been almost eliminated. Working from home is becoming the norm and is starting to provide social dividends for many (but not all) families and outdoor family activities are on the rise which is also brilliant for our community.

I think we are also much more aware of just how vulnerable our critical supply chains are for basic medical supplies (PPE), but even more concerning were simple things like staple foods such as flour, pasta, rice and milk and also the basics such as soap and toilet paper. I have put this under ‘good’ in the profound hope that everyone (government, business and individuals) will learn from this in the future and mitigate the risks by always ensuring they have sufficient stock on hand in case the supply chains are interrupted in the future.

I guess we have to talk about the bad.

Doing it tough The loss of jobs and the damage to people’s livelihoods around the country has been heart-wrenching.

This will inevitably translate into poorer health outcomes in the future. Although WA was spared the pain in at least some sectors, many people are still hurting.

I was disappointed with the lack of communication and consultation of decision makers in government (you must remember that during a pandemic only a small handful of individuals are responsible for decision making) and I think this showed in some of the decisions being made.

It was clear that private pathology was able (often with the help of the mining industry) to rapidly adapt and increase supply of nuclear acid amplification (NAT) testing, not just for COVID-19 but also for the other respiratory viruses.

The COVID clinics I think were a mistake and (although understandable because of a failure of government to provide adequate resources to public pathology services), the testing in COVID clinics for SARS CoV2 alone (rather than the full range of respiratory viruses) was unwise and needs to be urgently rectified before winter 2021.

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There were also lost opportunities to rebuild VirusWAtch and expand this sentinel GP surveillance system to include all general practices willing to participate and to bring back to WA all of the respiratory viral testing. The government needs to urgently re-invest in WA’s state pathology system to ensure that they will cope with whatever the 2021 winter throws at us.

Protecting GPs If the VirusWAtch system had been fully active and comprehensive, it would have provided the reassurance to patients that general practices were safe to visit. Patient avoidance of visiting their general practices through unfounded fears, may have contributed to the dramatic increase in chronic disease-related illnesses that we are now seeing in our hospital system.

It would be great if more research could be done on this to elucidate the extent of the problem.

Fortunately, I think the ‘ugly’ of COVID-19 was a rare event. Some unpleasant scenes of people squabbling over toilet rolls caught media attention and the temporary incarceration of people in highrise public housing in Victoria was quickly dealt with through democratic processes.

Domestic violence was of course the unseen ugly side to COVID-19 and highlighted the importance of government in continuing to invest more in this area.

Overall, I think we did well as a nation. I think it was clear that we are a country which values Respect (empathy and compassion i.e. understanding and kindness) and that we care for our citizens. It’s now time to fully restore democracy and stand down the emergency response.

We now need to find the new normal for Australia through democratic processes of negotiation and innovation and this process needs to be based first and foremost on Respect.

Read this story on mforum.com.au

DECEMBER 2020 | 15

Providing private mental health inpatient and community care south of the river.

16 | DECEMBER 2020

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NEWS

Nasal drops may help dodge COVID WA researchers are looking at a self-administered drug using antibodies to determine if it temporarily helps fight COVID-19.

Dr Karl Gruber reports Earlier this month, Perth's Linear Clinical Research started a Phase I clinical trial for an antibody-based nasal formulation against SARS-CoV-2. The self-administered drug promises up to four hours of reduced chances of infection from coronavirus.

An international team of researchers has created a nose drop formulation that promises temporary SARS-CoV-2 immunity.

The formulation is the first of its kind and it is composed of SARS-CoV-2 antibodies produced by chickens immunised with the Spike 1 (S1) protein of SARS-CoV-2.

Following exposure to this highly purified protein (i.e. the chickens are not exposed to the virus itself), the chicken’s immune system produces Immunoglobulin Y (IgY) antibodies, which are passed into their eggs in very large quantities. The antibodies are then extracted, purified and formulated into nasal drops, which can be self-administered to provide local and temporary protection from the COVID-19 virus.

“The intent of this approach is to use it prophylactically, particularly in high-risk populations such as health care workers or first responders. It can be used as a daily application inside the nasal passage, with the hope that the antibody will bind to and neutralise any coronavirus that subjects may be exposed to,” said Jayden Rogers, CEO of Linear Clinical Research.

Antibodies are the primary line of defence of our immune system, being responsible for locating and attacking pathogens and other invading particles. IgY antibodies have been extensively used against bacterial and viral infections. In chickens, there is a natural ability to produce IgY against coronaviruses since they are constantly being exposed to Infectious Bronchitis Virus antigens, a relative of COVID-19. Thus, this approach capitalises on a pre-existing immune defence mechanism to produce protective IgY against coronaviruses. These antibodies are also safe and cheap to make, explains Prof Michael Wallach, at University of Technology, Sydney.

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The idea of developing a nasal-drop formulation based on chicken IgY antibodies is Prof Wallach’s brainchild. He first envisioned and applied a similar approach in 2009 for the prevention of pandemic and seasonal influenza infection.

His idea led to a large international company developing a tablet formulation containing IgY antibodies against seasonal influenza, currently available in Japan.

Fast forward to February 2020, Prof Wallach recalls how he became involved in the COVID-19 fight.

“A friend of my son asked me what I was doing about COVID-19, and I said ‘nothing’. And he looked at me very disappointed. Two days later, I said I’d give it a go. Initially I tried to get something happening in Australia but found that it was challenging to get the work done here quickly enough,” he said.

Prof Wallach then decided to contact colleagues at Stanford University, who were immediately interested, and a research team was put together.

“Within 3-4 months of work, we demonstrated that protective antibodies could be raised against COVID-19 by immunising hens with COVID-19 spike protein antigens,” he said. Shortly afterwards, the chicken antibodies were formulated into nasal drops.

Why nasal drops?

The answer is simple: this is where the virus most commonly enters the body.

“The SARS-CoV-2 viral transmission is based on airborne droplets and aerosol. Therefore, eyes, mouth and nose (but not skin, for example) are all routes through which the virus can access the human body,” explains Prof Daria MochlyRosen, from Stanford University and founder of SPARK GLOBAL, the company leading the development of nasal drops.

As SARS-CoV-2 infection enters the nose, it binds to a protein receptor called Angiotensin Converting Enzyme 2 or ACE2 thus gaining entry into the body. ACE2 receptors are most abundant in the nose epithelium, and studies have shown greater abundance of SARS-CoV-2 infection in nose tissue of affected patients.

DECEMBER 2020 | 17

FEATURE

Giving voice to anti-smoking campaign Shock tactics to persuade smokers to butt out are familiar to West Australians. A graphic new campaign featuring WA doctors hopes to draw new attention to the message.

It is more than 40 years since an Australian marketing guru developed a novel anti-smoking television advertisement using kitchen sponges filled with tar to depict the deadly effects of cigarettes on the lungs.

The ‘yuk factor’ was enough to have the advertisement banned briefly in the 1980s – after fierce lobbying by the tobacco industry – while it was slightly altered to satisfy regulators.

It continued to be used on and off throughout Australia, including in WA, in 2014, and was credited for encouraging two-thirds of smokers under the age of 40 to consider quitting when it was rebooted in New South Wales in 2007.

Over the next decades, it was joined by other grim-looking advertisements, some showing the likes of sticky, fatty deposits being squeezed out of the aorta of a young smoker, or a gangrenous foot perched ominously on an operating table, destined for amputation.

In the swings and roundabouts of shock-tactic Quit campaigns, West Australians are now seeing the latest instalment, Voice Box, featuring some of the most graphic images since the early 2000s.

18 | DECEMBER 2020

Coinciding with the 20th anniversary of the Make Smoking History program in WA, its reality-TV brief was to show the physical and emotional devastation of head and neck cancers caused by smoking.

The campaign was launched to coincide with the televised AFL finals series and the television, radio and print advertisements are expected to continue until at least the end of the year.

Its centrepiece is vision of a reallife laryngectomy – the surgical removal of a patient’s voice box – which was filmed at Fiona Stanley Hospital, with additional footage filmed at nearby St John of God Murdoch Hospital.

The leading ‘stars’ are consultant ear, nose and throat (ENT) surgeon Dr Rob Wormald and specialist anaesthetist Dr Hamish Mace, who both spend much of their professional lives trying to salvage bodies racked with smoking-related cancer.

While the male patient readily agreed to have his surgery filmed, the process still required careful planning, according to a FSH spokeswoman.

Permission was only granted because hospital administrators

could see the significant potential of the campaign to persuade more smokers to quit.

Theatre time “Allowing a film crew into an operating theatre during surgery, especially a procedure as complex and long as a laryngectomy, comes with a range of challenges and takes many hours of preparation,” she said.

“Foremost is always patient safety, which cannot be compromised.

“One of the key factors was managing the expectations of the film crew in terms of how much time we could give them to capture the images they required. While they would have preferred to have access to theatres for days and days of filming, the reality was could only allow them access for hours at a time.”

The focus of the Voice Box campaign is less on the deadly nature of smoking, and more on the everyday impact on smokers who can lose basic functions such as speech, with evidence this message can particularly resonate with young or middle-aged smokers.

In the campaign, Dr Mace describes some of the ways in which a person’s life is dramatically affected

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Cathy O’Leary reports

FEATURE

is devastating, and the campaign reflects that.

“Even the more sanitised version of the ads that can be shown before 9.30pm was that, when your voice box is removed, you’ll never be able to shout for your favourite footy team any more, and that plays on people’s fear of their lives being irrevocably changed,” he said.

Clear dangers “People have heard so much that they might die of lung cancer, but they think that message is so passé.

But the thought that you might have your voice taken away from you well before that – that seems to really hit home for a lot of people.”

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ENT Surgeon Dr Rob Wormald for the Voice Box campaign

by having their voice box removed.

After surgery, air passes through a stoma instead of the nose, which can affect the senses of smell and taste.

The patient needs to avoid getting water in the stoma, as it leads directly into the windpipe and down to the lungs.

Speech is also affected. Without the vocal cords the person cannot raise their voice, and that includes barracking for their football team – hence the opportunistic timing of the campaign launch in the lead-up to the AFL grand final.

Screening smokers Dr Mace became involved in smoking cessation after helping to set up a small program at FSH which screens about 5-10 patients a week coming in for surgery for smoking status and offers them nicotine replacement therapy (NRT).

because being in the public eye was “not him at all”.

“I didn’t really enjoy seeing myself, but I’ve had fairly positive response from colleagues and friends, and I appreciate how much the Cancer Council WA and others have done over the years,” he said.

“That takes away that uncomfortable bit for me, because I can see the worth of it and that’s the most important thing.”

Dr Wormald’s public work is almost exclusively head and neck cancers, and more than half of patients are smokers.

“Statistically of all the patients with head and neck cancer – and while there are other causes it’s largely smoking and alcohol – the survival rates are about 50%,” he said.

He told Medical Forum that being involved in the Voice Box advertisements was an eye-opener in terms of the work that goes into such campaigns.

Dr Wormald said that of the 50% who survive, few will escape without some sort of side effect or life-long issue that profoundly affects their quality of life, whether that be pain, swallowing, speech, or their social life.

“It was pretty challenging doing it all and very much outside my comfort zone,” he said.

It affects all ages, while the peak ages are 50s and 60s when people still have a good part of their life left.

Similarly, Dr Wormald said it was strange being filmed for an ad

Dr Mace agrees the impact of head and neck cancer treatment

MEDICAL FORUM | GENER AL MEDICINE ISSUE

Dr Mace said everyone knew about the links between smoking and lung cancer, heart disease and stroke, but few associated head and neck cancers with smoking.

“Apart from laryngectomy, we do other head and neck surgery such as tracheotomy, or glossectomy where we take the tongue out because of cancer, and those people have a bit of their leg taken off and put onto their face, and that’s overwhelmingly from smoking too.

“It can be a horrendously long recovery from these surgeries, not just the time you spend in hospital, because there’s the rehabilitation such as speech pathology, or people having to be fed through a nasal gastric tube for a long period of time.

“The feedback from my nonmedical colleagues has been that the campaign is very confronting, particularly the images of the person having their neck stapled up. Certainly, the laryngectomy specimen is pretty gross, but having a guy’s neck stapled up even made me say, ‘whoa’.

Reality impact “And this campaign is a bit more personal, because it’s a real person here in Perth people are seeing.”

Cancer Council WA chief executive Ashley Reid said the campaign was developed following concerns from WA health professionals and doctors about the low awareness of the causative link between smoking and head and neck cancers, continued on Page 11

DECEMBER 2020 | 19

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FEATURE

Giving voice to anti-smoking campaign continued from Page 19 and life-changing effects of the treatment for such cancers.

“We are so grateful to our anonymous patient for allowing the crew to film their deeply personal operation and to Dr Mace and Dr Wormald for speaking to camera about how much this type of operation changes a person’s life,” Mr Reid said.

New State Government regulations have kicked in over recent months, including banning retail shop assistants under the age of 18 from selling tobacco products.

There has also been significant interest in the Senate Inquiry into Tobacco Harm Reduction which is addressing the contentious issue of nicotine vaping products and due to report to Parliament this month.

He said research was clear that this type of hard-hitting campaign had the potential to save tens of thousands of lives.

Public health experts continue to push the point that while smoking rates have declined significantly, even exceeding many expectations, the battle is far from over.

Since the launch 20 years ago of Make Smoking History – which is funded by the WA Health Department, Healthway and Cancer Council WA – the adult smoking rate in WA has decreased significantly, from 22.5% in the early 2000s to 11.5% in 2018.

Professor Mike Daube, one of Australia’s most experienced tobacco control lobbyists, said it was critical that Make Smoking History continued with hardhitting campaigns, even 70 years after clear evidence emerged that smoking kills.

The current Voice Box campaign comes amid other developments in the tobacco control area, with Australian smokers recently hit with the annual increase in tobacco excise, which means an average pack of 30 cigarettes now costs about $40, while a pack of 40 can cost $50.

Battle continues “Smoking remains our largest preventable cause of death and disease,” he said. “The two major obstacles are complacency, and the activities of the global tobacco industry – now more aggressive, but also more subtle and strategic than ever before.

“This is the time to develop timelines for the phasing out of commercial tobacco sales in WA and nationally. If well planned, with proper cessation support and access for those few who will still by then be smokers, 2030 is a good target date.”

Meanwhile, at a more grassroots level, Dr Mace would like to see the NRT program used at FSH upscaled.

“There’s not a lot of money out there for smoking cessation for inpatients and it’s not as comprehensive as it could be at the frontline,” he said.

“Some people are still smoking even on the day they come in for surgery, and lots of people use the day they come into hospital as the day they quit smoking. But some still smoke afterwards.

“A lot of the literature shows that if you just tell a patient to stop smoking, they’re more likely than not to continue, but if you offer them assistance, one in 20 of those conversations will result in someone quitting for good.

“I’d really like to see more comprehensive funding for that sort of direct smoking support.”

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DECEMBER 2020 | 21

Understanding children’s emotions General practice is well placed to address the impact childhood emotions have on health and development. Dr Andrew Leech explains.

Most of the time, children display what are normal emotional responses to situations – anger when something doesn’t go their way, sadness when dealing with grief, or anxiety when they are going through a difficult situation.

This is a healthy part of childhood that helps form who they are and informs their journey through life.

For some children, stressful life events or a dysfunction within family or school can lead them to develop poor coping mechanisms.

For others, the trigger to mental health decline can be less obvious and requires more thorough history taking.

It is crucially important these children are not only detected when they present to the GP, but supported, listened to and given follow-up arrangements.

Emerging Minds is based on the conviction that children need positive mental health for their physical and emotional development. It works in conjunction with the RACGP and focuses on developing mental health policy, programs and resources to help health professionals be less daunted seeing families with mental health challenges.

This sort of work doesn’t need to be complicated. In fact, small simple changes to your everyday practice can go a long way in improving the lives of children who are struggling.

Studies have shown that more than 13% of Australian children between the ages of four and 11 experienced a diagnosable mental health condition in the past 12 months.

Doctors are uniquely placed in often seeing a child accompanied by parents, siblings and even grandparents from the same family.

I have had the privilege to work with Emerging Minds in developing a training program for GPs who feel they’d like to upskill in this area.

A GP Framework for Child Mental Health Assessment (5-12 years) is a 22 | DECEMBER 2020

course to improve confidence and, in turn, lead to a positive change in the way doctors feel about these tricky consultations. It contains a combination of consultation videos using child actors, along with animations, self-assessments and practice skills on engaging and interacting with children.

The basis of this course and, in turn, general practice assessment of children and families, is four key phases: • Connect – listen and prioritise what the child or parent might be concerned about. Engage with the child. Build rapport through positive interactions.

• Explore – Assess and formulate.

Start to develop a sense of what might be going on. Consider a diagnosis by asking key questions.

• Plan – Plan and manage.

Consider the next best steps to help. Ensure follow-up is arranged. Safety net and ‘hold’ the family so they know they will see you again. Consider creating a mental health care plan or referral.

• Collaborate – Follow up and review. Establish a team-based approach with other health professionals to surround the family with support

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GUEST COLUMN

These phases are not necessarily occurring as a continuum, nor do they occur in every consultation.

However, they are the backbone of our assessment and management of children and are important aspects to consider when uncertain of what to do next.

The course also explores the continuum of a child’s mental health – that every child is unique and has their own set of strengths and vulnerabilities. As GPs, we can figure this out but it takes time, patience and compassion towards the families we often find the hardest on our daily schedules.

Planning treatment is also considered. This might occur in the form of a referral to psychologist, or simple strategies such as using an online service such as The Brave Program, applications including the Child360 app or simple parenting advice and resources.

GPs can be daunted preparing mental health care plans for children.

Perhaps this comes from a concern that children will be labelled with a mental health condition, or concerns over Medicare requirements.

One message that needs to be understood is that children can and do have diagnosable mental health disorders. With the long delays to see child psychiatrists or paediatricians, some of this responsibility falls back on the GP. There will be many occasions where a mental health care plan is entirely appropriate and provides added support to families who are often also financially struggling or cannot wait for the public sector to become involved.

With a new COVID extension to the number of sessions available under this plan, it is even more important to remember the benefit of involving a psychologist, occupational therapist or social worker. The earlier the intervention, the easier that child’s life will become.

Mental health is something all people and all ages possess. Children are particularly vulnerable to social, biological and environmental factors.

GPs have a powerful role to play in recognising the challenges they face and the right time to support them to improve their lives.

ED: Dr Andrew Leech is a GP with special interest in paediatric health and mental health. His podcast, ‘The Kids Health Network’ has interviewed a number of Perth specialists and allied health professionals on common child health topics. He has worked as an advisor for Emerging Minds, the RACPG and the Mental Health Professionals Network.

He was part of this year’s RACGP Future Leaders Program.

An introduction to the new course can be found at https://emergingminds.com. au/resources/podcast/biopsychosocialformulation/ The training module can be found via the Emerging Minds website: https:// learning.emergingminds.com.au/course/agp-framework-for-child-mental-healthassessment-5-12-years https://emergingminds.com.au/resources/ podcast/biopsychosocial-formulation/

Read this story on mforum.com.au

“ When Annie lost her hearing, she began to lose her connection with Jack, too.

I just had to do something.

Nezha Delorme, Amana Living Client Services Manager

“

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“Annie had a stroke and lost her hearing. It became so hard for her to communicate with her friends and family, and it was especially hard on her husband, Jack, who loves her dearly and is her prime carer.

During my training I’d learned how relationships can become strained as physical or communication difficulties arise. So, with the help of our IT team, we created a solution.

We got an iPad for Annie and showed them how to use dictation software that converted Jack’s spoken words into text. It brought so much happiness back into their lives. And into mine.”

Professionally trained. Naturally kind.

1300 26 26 26 | amanaliving.com.au

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M - 0404 871 660 E - richard@kooyonggroup.com.au

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* Terms and Conditions: Offer commences 6 November 2020 and may be varied or withdrawn at any time. The $2,000 cashback is available for new refinance applications received between 6 November 2020 to 31 January 2021.

Only 1 cashback payment per property refinanced will be paid regardless of the number of loans involved and is only available for owner occupier or investment loans over $500,000. Joint applications are only eligible to receive a single payment of $2,000. 1.98 % p.a. fixed interest rate is subject to change by the lender at any time without notice. Loan reverts to the applicable variable rate loan after the fixed term. This promotion is available for approved applicants only. onl Approval is at the complete discretion of the lender. Offer current as at 6 November 2020. Comparison rate: the comparison rate is based on a loan of $150,000 over the term of 25 years. WARNING: This comparison rate is true only for the examples given and may not include all fees and charges. Different terms, fees or other loan amounts might result in a different comparison rate. © 2020 KA JV Pty Ltd. Kooyong Group is a trade mark of KA JV Pty Ltd (ACN 637769361) exclusively licensed to KA JV 2 Pty Ltd (ABN 75640406784). KA JV 2 Pty Ltd (ABN 75640406784), Credit Representative Number 523242 is an authorised credit representative for Australian Finance Group Ltd (ABN 11066385822), Australian Credit Licence Number 389087. Credit services or assistance to which the National Credit Code applies are provided by KA JV 2 Pty Ltd G (a wholly owned subsidiary of KA JV Pty Ltd). Eligibility criteria, terms and conditions, fees and charges apply. Contact us for further details.

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CHRISTMAS 2020 SEASON’S GREETINGS FROM WA HEALTH PROFESSIONALS The Medical Forum team wishes all its readers and supporters a very Merry Christmas and a Happy New Year

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Christmas is a time to celebrate what is important in life and the great gift of love we have received.

To our doctors and all involved in the health care community, we wish you a Christmas filled with love and compassion.

www.sjog.org.au 26 | DECEMBER 2020

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CHRISTMAS 2020

Live long & prosper BACK TO CONTENTS

For the past 10 months, the world has been caught in the headlights of a rampant novel virus. It has changed the way we live, work and play.

As the medical and health sectors scrambled to prepare, great things were happening at the grassroots level of medical practice.

Medical and practice staff works tirelessly, together, to keep servicing, caring and reassuring their patients, when they, themselves were exhausted, anxious and uncertain of how to keep the business of health running, while keeping the team and their families safe.

This Christmas edition, we decided to ask some of the practice and business managers how they helped keep the wheels of medicine on and turning in these extraordinary circumstances and, of course, the important lessons learnt.

Merry Christmas, everyone, and here’s to 2021 – a year informed by experience and sprinkled with promise.

Season’s

Greetings

We wish all our referring doctors and our patients a happy and safe festive season.

Thank you for your support this year and we look forward to working with you again in 2021.

perthradclinic.com.au

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Western Ultrasound for Women In Colin Wee’s words, 2020 has been a “very, very strange year”. The business manager at Western Ultrasound said the early days of COVID threw up a lot of curve balls, stress and anxiety for doctors, patients, staff … and business managers!

“We had risks to the health of patients, staff and the business and had to find ways to mitigate them,” he said. “We decided to keep the business open, so very early on we took a strong stance on COVID protocols.

“We reduced hours, spaced out bookings to avoid overlap, staggered staff rosters, separated into teams to ensure continuity, and strict cleaning after every visit and procedure. We went hard and early as much to alleviate anxiety, but we believed that with the protocols the risks to our patients as well as ourselves were quite low.

Heading into 2021 and living with COVID, Colin says all medical businesses should maintain their caution.

“I think as we go beyond the lockdown, the issue becomes what happens when the patients are not ready to adhere to those protocols. That is a whole separate issue.”

“It is not over and, who knows, something else may come that could be equally as difficult. I’m also thinking technology issues and cyber security – all these things we depend on. So, from my point of view, we are at a point where there is an opportunity to survey the threats at hand and prepare for them.

Colin says while there was a lot of work to be done in those early stages, but once in place, the protocols simply require managing so that the business and patients don’t stray too far from them.

“The key lesson I take away form 2020 is we can take effective steps to deal with the threats. It’s just ensuring that we remain agile and are as adept as possible to do the job as best as we can.”

We hope you have a wonderful festive season and we look forward to working with you in the New Year.

28 | DECEMBER 2020

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CHRISTMAS 2020

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CHRISTMAS 2020

The Surgery, Albany Practice manager Keith Syme finished up his 54-year working adventure at the end of November, seeing his Albany team through the unpredictable COVID waters of 2020. Speaking to Keith, there seems to have been a steady hand on the tiller.

Albany saw some of the first COVID positive patients in WA, when a couple from the Ruby Princess cruise ship returned home.

Albany was to record seven cases in total. Keith said the news sent shockwaves through the Albany community, particularly doctors and nurses.

“We were getting a lot of information (sometimes too much) from local, state and federal sources. It was confusing and

repetitive. The surgery developed a COVID-19 action plan to ensure everyone was informed and well prepared. Along with frequent updates and meetings, it helped keep people as calm as possible,” Keith said.

“We remained opened because we were confident our plan would hold. As part of the preparations, we worked out the script for the frontline receptionists to use, both on telephone and in person, and we had a triage officer at the door.

We also worked hard to get enough PPE, which was a struggle at times, but we managed.

“We also have to thank our local

distillery, Limeburners, and the Mt Romance sandalwood company for our continued supply of sanitiser!

“The extra hours and precautions all worked to provide a greater sense of safety for our frontline clinicians, because obviously they're sitting in the room with people who might potentially have COVID.” Keith said that The Surgery doctors took the initiative early to phone their regular, mostly older patients with comorbidities, who weren’t coming into the surgery, to check in on them. When the telehealth items were introduced, this form of consult took off as did emailed prescriptions.

From our team to yours, we wish you a very happy and safe festive season.

We sincerely value your partnership and support during what has been a challenging year for us all.

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Perth Orthopaedic & Sports Medicine Centre “Who would have thought that health care services, particularly surgeons, would ever be told they couldn’t operate for a period of time.”

Business manager Melissa Bator was recalling the surreal moment when her group’s surgeons were all in their offices and not in surgery for a full five weeks.

“We were all in the office and in fact my hours were longer with lots of contingency meetings because the practice was full of doctors and patients and we had to ensure their and the staff’s safety,” she said “My main takeaway from this year, is the broad scope of a practice manager’s role. We have to find solutions to some very big picture issues.”

As well as ensuring the safe distancing and restricting numbers in the waiting room, patient communication was paramount. Melissa said that where IT came to the fore.

“We relied on our SMS system more and the website needed to be updated quickly so patients knew we were still open for consultation. And of course, team meetings were often over Zoom. Some partners and their staff decided to work remotely, so we adapted.

“Despite the haste of the shutdown, we were lucky that we transition seamlessly for staff to work from home if they needed to.”

Melissa believes the innovations from 2020 that will reach into the future are effective use of IT and the humble phone. “Believe it or not, telephones were huge, with call diverts and a greater use of mobile devices.

Along with this, however, comes the need for greater cyber security.

“The pandemic has also given greater prominence to planning for those things we all think will never happen – they can and do and we need to do something now.”

After a very challenging year, Ramsay Health Care wishes our referring GP’s, specialists and their families a very safe & joy filled festive season.

Kevin Cass-Ryall

Operations Executive Manager, Western Region

Joondalup Health Campus • Hollywood Private Hospital • Peel Health Campus • Attadale Private Hospital • Glengarry Private Hospital

People caring for people

30 | DECEMBER 2020

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CHRISTMAS 2020

On behalf of the Doctors and staff at SKG Radiology, we thank you for your continued support throughout the year and wish you and your family a safe and happy festive season.

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www.skg.com.au

DECEMBER 2020 | 31

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Brecken Health Taryn McClements is the operations manager of the Brecken Health Group – 14 GP clinics located in the South West, Great Southern, Perth north, Perth south and metro areas. In February, when things were getting grisly, the team meetings began – a lot of team meetings.

Communication was the aim and the key to keeping the doors open.

“The team and management meetings were vital to keep everyone on the same page, and it was so important to be open and honest about what we were facing,” Taryn said.

“Our managing director and medical lead Dr Brenda Murrison started doing a series of information videos, which were posted on YouTube then uploaded to our Facebook pages. They were sent to staff and also viewed by patients, who loved them, we had a great response from them.

“They liked hearing the reality from a doctor, someone in their community, who was telling it like it was without sugar coating. She let people know about the shortage of PPE, the importance of telehealth and keeping the continuity of consulting their doctor.”

Taryn said team bonding at the time was also critical in keeping things running and making the staff feel supported and safe.

Susan Black, Dr Jane Ralls, Taryn McClements and Tahnee Pearson at Brecken's Mt Hawthorn clinic

“When there's hard times, I think it brings out the best in everyone.”

Brecken moved hard and fast early on, securing stock of PPE through business and personal contacts, keeping the practices ahead of that particular curve. It has been a good lesson learnt, Taryn said, with a good three months of stock now the norm for all the clinics.

“The year has taught us the importance of planning beyond the normal accreditation requirements. I think every doctor’s surgery will have a thorough pandemic plan now. That’s the silver lining – we are prepared and we have lived it. Everyone's got the equipment, telehealth is set up. It's all ready to roll at the drop of a hat. These innovations and change will build a better future for medical and patient care.”

Thank you to all of the healthcare workers who have selflessly given themselves to others during this trying year.

You are true heroes and from all of us at Mount Hospital, we appreciate you!

150 Mounts Bay Rd, Perth WA 6000 | mounthospital.com.au Community of Care

32 | DECEMBER 2020

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WHEN IT COMES TO VASCULAR HEALTH...

WE’LL TAKE CARE OF YOU Perth Vascular Clinic is WA’s leading vascular solutions centre offering state-of-the-art management and treatment of all conditions affecting vascular health. Dr Marek Garbowski is Perth Vascular Clinic’s leading vascular and endovascular surgeon, experienced in all aspects of diagnosis and management of arterial and venous diseases.

S E A S O N ’ S G RE E T I N GS Dr Marek Garbowski and the Perth Vascular Clinic Team would like to extend our warmest greetings of the season. Best wishes and best of health for the coming year to all our referring doctors, colleagues, their families and staff.

Thank you kindly for your outstanding continued support and we look forward to working with you all in the New Year and mutually caring for the wellbeing of our patients.

Best of health to you all

All enquiries & appointments bookings Phone: 6116 4955 | Email: reception@perthvascularclinic.com.au Visit our comprehensive website

www.perthvascularclinic.com.au MEDICAL FORUM | GENER AL MEDICINE ISSUE

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34 | DECEMBER 2020

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

It’s Christmas Most of us look forward to Christmas and the New Year regardless of whether one sees it in religious terms or not. It is a time to catch up with family and friends and, shock horror, ignore the finger-waggers and enjoy ourselves, maybe even overindulge a bit.

As 2021 approaches, let us hope that our lives increasingly revert to normal whilst we retain the positive changes the pandemic has forced upon us.

The need for letting our proverbial hair down at the end of the year has not been greater in my lifetime. At time of writing the ‘hard’ border was to become a ‘smart’ border enabling those with family and friends interstate to see each other. The impact of separation from loved ones has been underestimated at best, and callously dismissed at worst.

It is time to focus on the positives. As we enter 2021, WA remains blessed by geographic isolation, low population density and a favourable warm(ish) climate. Job losses and business closures have been relatively modest. Our health system has coped admirably. There has been support for local small businesses, and many of us have ventured out to holiday in WA and see parts of the state not previously visited. Our collective mental health has held up better than feared and with the reopening of gyms in June we had only a brief disruption to our exercise regimes.

Normally the December edition has a travel health theme. This year it is a potpourri.

We look at infections caught locally and in particular in relation to bites and stings. With summer upon us there is an article on topical treatment of malignant and premalignant skin cancers.

Looking after our own mental health as medical professionals is often overlooked so we have a timely reminder and some tips. Mammography screening fell off a cliff in April. Catch-up is occurring but more cancer may be on the horizon. New approaches to breast cancer management are examined as well as how to approach minor anomalies on the FBP. Medical Forum would not exist without you – our readers. Your support enables us to continue to publish each month and is much appreciated by all the team here. A big thank you to all.

As 2021 approaches, let us hope that our lives increasingly revert to normal whilst we retain the positive changes the pandemic has forced upon us. Let us be grateful for what we have and for the time we have on this planet. I hope that all of you have an enjoyable festive season and that 2021 brings you joy and prosperity.

MEDICAL FORUM | GENER AL MEDICINE ISSUE

DECEMBER 2020 | 35

Senior Surgeon announces his retirement

Leading Perth colorectal surgeon and surgical academic UWA Professor Cameron Platell has announced his impending retirement from clinical practice.

He will cease all surgery and endoscopy from January 2021 but will continue to consult on a limited basis. He will also continue to participate in the St John of God Subiaco Hospital colorectal cancer multidisciplinary team as well as supervise those PhD students currently enrolled.

Cameron established the colorectal surgery unit at Fremantle Hospital in 1996 and moved to Subiaco full time in 2007. He is renowned in Perth for his outstanding individual clinical outcomes but is held in equally high esteem nationally and internationally for his research into the molecular biology of colorectal cancer and for the comprehensive colorectal cancer database that he has established and meticulously maintained at St John of God Subiaco.

Cameron’s wisdom, technical expertise and academic leadership will be sorely missed.

Colorectal surgeons Jennifer Ryan and Stephanie Chetrit, whose surgical practices at Subiaco have grown

JENNIFER RYAN

STEPHANIE CHETRIT

rapidly, will be attending to the additional referrals while Michael Levitt continues in active clinical practice with an emphasis upon proctology and functional bowel disease.

Gastroenterologists and IBD experts Ian Lawrance and Siva Pulusu retain their extremely busy clinical practices but are readily available for consultation or open access endoscopy.

Thanks to Cameron, Subiaco Colorectal has established itself as a world class multidisciplinary centre for colorectal disease management and academic endeavour.

We thank him immensely and congratulate him on his stellar contribution.

Moving forward, we intend to maintain and enhance the colorectal cancer database, and to foster both clinical excellence and academic pursuit into all aspects of colorectal disease. We remain enthusiastically at your service and at the service of our patients.

MICHAEL LEVITT

IAN LAWRANCE

SIVA PULUSU

Integrated Multi-disciplinary Colorectal Cancer and I.B.D. Unit Perth’s leading colorectal cancer research unit Rapid access to imaging/colonoscopy

St John of God Hospital, Subiaco, Suite 212, 25 McCourt Street For all bookings: 9382 4577 36 | DECEMBER 2020

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CLINICAL UPDATE

Topical therapies for premalignant and malignant skin disease

By Dr Yee Tai, Dermatologist, Edgewater Topical therapies are the mainstay of treatment for solar keratoses, especially on the head and neck, given the frequent need for field therapy rather than spot treatment.

premalignant cells, causing toxicity when activated by light. Traditional PDT can be uncomfortable, but the advent of daylight PDT has resulted in better tolerability. This involves applying the agent and instructing the patient to sit outdoors under direct sunlight for two hours.

Of all the available options, 5-fluorouracil is the most used and has stood the test of time. A recent study compared four treatment approaches in patients with solar keratoses over a 12-month period and found that 5-fluorouracil was superior (74.7% clearance rate) to imiquimod (53.9%), photodynamic therapy (37.7%) and ingenol mebutate (28.9%).

There are various regimens when using 5-fluorouracil cream for solar keratoses, most commonly twice daily for 2-3 weeks. Patients can choose to treat a facial cosmetic unit one at a time or the whole face at once. The former offers better tolerability making it more likely the patient will use it again in future.

It is essential to educate patients that an inflammatory response is required to ensure that the treatment is efficacious. Erosions, ulceration or oedema can rarely occur, and patients should be warned to cease therapy if these occur.

Imiquimod 5% cream has its place in treating solar keratoses, particularly in patients who cannot tolerate 5-fluorouracil. It is usually applied three times weekly for four weeks. Patients will also experience an inflammatory reaction, although it tends to be more

Ingenol mebutate gel has been discontinued in Australia due to reports that it may paradoxically increase the risk of skin cancer in treated areas.

Key messages

5-Fluorouracil cream remains the most effective topical agent for treating premalignant skin disease.

Duration of treatment, tolerability, ability to self-administer and cost need to be considered when selecting a topical agent for patients.

Use topical therapies with caution for treating superficial malignancies in the face and scalp.

marked and exudative compared with 5-fluourouracil. Patients occasionally experience influenzalike symptoms.

Photodynamic therapy (PDT) is where a photosensitising agent is applied to the skin, which is selectively taken up by

NEW SS RE ADD AME & N iously

Prevylands “Ma unding” po C om

5-fluorouracil, imiquimod and traditional PDT can be used for treating superficial basal cell carcinomas and in situ squamous cell carcinomas. Compared with solar keratoses, the regimens are longer, i.e. twice daily for four to six weeks with 5-fluorouracil and once daily for five days a week for six weeks with imiquimod.

Warn patients of a more marked inflammatory response as this can cause premature cessation.

Although reported success rates are in the order of 80%, these treatments should be used with caution, especially on the face and scalp given the risk of follicular extension in these tumours and the possibility of mixed histology tumours. Surgical excision remains the preferred option in these instances.

Author competing interests - nil

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Preventing burnout in the mental juggling act of medicine

By Dr Davinder Hans, Psychiatrist, Nedlands “Just one more patient, one more meeting, one more hour of study…”

It is easy to keep adding that “one more thing” to our day but doing that “little bit extra” can be a slippery slope and, before we know it, we are overwhelmed and experiencing burnout, seldom realising it until after we have started experiencing the ill-effects.

The limited research available about doctors’ wellbeing also has little emphasis on the comparison with the general population. Doctors are at greater risk than the general population for mental health issues.

Suicide rates are higher; doctors are far less likely to have their own GP; and are more likely to self-diagnose and self-medicate due to the misperception that “admitting illness is admitting failure”.

It is worth reflecting on the reasons

Key messages

Allocate time to clarify issues, prioritise yourself and optimise time management

Keep a personal journal, take regular time off, and do leisure activities

Delegate paperwork to practice staff, schedule lunchtime, and prioritise CME during the day limiting evenings out. why we chose a career in medicine, including – our desire to help others; family expectations; a desire for social approval and identity as a reaction to problems in childhood; or low self-esteem. We become caring and meticulous clinicians (important in becoming good doctors) but this contributes to our vulnerability

to emotional ill health. Patient expectations to ‘fix’ their problems can lead to a sense of failure if we are not able to ‘fix’ our own issues.

Strategies to prevent burnout range from self-reflection to simple daily routines. Feeling, or becoming, irritable with patients and colleagues can be a sign of depression. Having regular peer review groups and debriefing is a good first step.

The ability to sense our escalating anxiety is also useful and adopting immediate strategies such as a oneminute meditation between patients, even if it is simply taking a deep breath or sensing five things in our surroundings, can help to reduce our arousal.

Planning time off work and booking our next holiday on return gives continued on Page 39

Perth Breast Clinic at Mount Hospital For over 25 years, Mount Hospital’s “Perth Breast Clinic” has formed a multidisciplinary approach from diagnosis to treatment. We have on site Breast Physicians and Plastic Surgeons who are supported by Perth Radiological Clinic and Western Diagnostics. Facilitating timely assessment and treatment, the Breast Clinic has gone from strength to strength and offers services for diagnosis, follow-up of cancer survivors and surveillance for high risk women.

The Perth Breast Clinic is operated by breast physicians who are doctors with an interest and expertise in diseases of the breast.

Although a referral is not necessary, it is helpful as the information provided on the referral will assist the Perth Breast Clinic in establishing the urgency of the assessment.

A referral also enables the Perth Breast Clinic to arrange appropriate investigations for the day of assessment.

Dr Diana Hastrich Breast Surgeon

P 08 9486 9544 Dr Vineeta Singh Breast Surgeon

P 08 9391 1141 Dr Ed Van Beem

Plastic & Reconstructive Surgeon

P 08 9226 3222

For an appointment, please contact 08 9483 4621.

4/146 Mounts Bay Rd, Perth WA 6000 | mounthospital.com.au Community of Care

38 | DECEMBER 2020

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CLINICAL UPDATE

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CLINICAL UPDATE

Sarcopenia and Osteoporosis, where bone muscle and fat collide

By Dr Charles Inderjeeth, Rheumatologist, Subiaco Sarcopenia is defined as an agerelated disease of low muscle mass and low muscle strength or function. It is of increasing clinical importance due to growing evidence of its health implications and the increasing proportion of older people in the population.

Sarcopenia has been associated with an increased risk and rate of falls, fractures, functional impairment, metabolic syndrome, hospital admission and readmission, poorer prognosis in cancer and liver cirrhosis, surgical morbidity and all-cause mortality. The clinical significance of sarcopenia as a distinct disease entity was established with the assignment of an International Classification of Diseases Figure 1 illustrates the steps involved in assessing for the presence of sarcopenia. In a presentation with poor physical function determine if weakness is present. If so, is there low muscle mass that is the cause? If so then this is the likely cause of weakness ie sarcopenia? If either weakness or low muscle mass is not present, assess for other possible causes.

Risk factors and clinical consequences There is a complex interaction between muscle and bone. The main theory uniting sarcopenia and osteoporosis pathogenesis is the replacement of muscle and bone by adipose tissue with ageing.

Poor muscle mass and function is associated with poor bone mass with the overlap between these two conditions called “osteosarcopenia”.

Clinical Paradigm

Key messages

Sarcopenia and osteoporosis are commonly associated with a frail, ageing population The consequences are significant including falls and fractures resulting in significant morbidity, mortality, loss of function and quality of life.

Early identification and management strategies (prevention) is the most useful strategy until we discover effective pharmacological measures.

Low muscle mass results in reduced muscle strength and function and high falls risk and consequent fracture risk due to poor bone mass (osteopenia or osteoporosis). The consequences are significant for morbidity, mortality, independent function and quality of life.

There are a few international definitions and cut offs for the definition of sarcopenia. A practical algorithm for the assessment of sarcopenia utilises gait speed (physical function), hand grip strength and muscle mass. Grip strength is measured using a hand dynamometer and muscle mass can be measured using DEXA (not HIC funded). Alternative and less readily available assessments include bioimpedence analysis, CT and MRI based muscle mass assessments.

Management is problematic. There is little evidence but significant ongoing research in this area.

The main components are non-

Patient presents with poor physical function WEAKNESS? YES

NO

Low Muscle Mass?

Look for other causes of poor performance

YES

NO

Low mass is possible cause of weakness

Look for nonmass causes of poor physical function

pharmacological . This includes optimising such as nutrition especially adequate protein intake, regular and escalating exercise programs at least three times per week and escalating intensity (weight bearing and resistance), minimising falls risk and addressing underlying associated osteoporosis risk to reduce fracture risk.

Potential pharmacological treatment thus far has not been promising. There is ongoing research into the roles of Vitamin D (anabolic), Monoclonal Myostatin antibodies, IGF1, Androgen Receptor – Testosterone and Selective Androgen Receptor Modulators (SARMS), and soluble ACTRRIIB-FC Fusion protein to block ACTRIIB to promote muscle hypertrophy (animal studies only).

Time will tell.

– References on request Author competing interests – nil

Preventing burnout in medicine continued from Page 38 us something to look forward to.

Ensuring we always take a lunch break, no matter how busy we are, and actively switching off from work mentally at that time – even going for a short walk can be extremely beneficial!

Simply tidying up our work desk at the end of each day, so we start the subsequent day it is in an organised frame of mind, can help.

It is important for us to resist the temptation to feel overly responsible for others; to avoid accepting unreasonable demands; and to consider carefully when asked

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to take on additional commitments that threaten our relationships and personal maintenance time.

With this in mind, I wish you all a restful, relaxing and fulfilling festive season!

Author competing interest – nil

DECEMBER 2020 | 39

Modern surgical management of breast cancer

By Dr Jose Cid Fernandez, Oncoplastic Breast Surgeon, Perth Breast cancer management has changed dramatically over the years. With overall survival rates now above 90%, safe deescalation of surgery is now being emphasised, to minimise surgical morbidity and preserve aesthetic outcomes and quality of life.

Breast-conserving therapy (BCT) is breast-conserving surgery (BCS) and whole-breast radiotherapy.

BCS can be performed with a simple, wide local excision for small cancers. Impalpable cancers can be identified surgically using a metallic clip marked with a guide wire prior to surgery, or increasingly a radioactive seed.

For larger cancers, oncoplastic breast surgical techniques allow for larger resections in smaller breasts, decreasing the need for a mastectomy. Oncoplastic BCS combines the oncological surgical principles with aesthetic plastic surgical techniques, improving cosmetic outcome without compromising local control.

Volume displacement oncoplastic BCS techniques rely on breast rearrangements to reshape the breast into a smaller size, after excising the cancer. A contralateral procedure may improve breast symmetry (e.g. therapeutic reduction mammoplasty is useful for large tumours in women with large pendulous breasts).

Volume replacement oncoplastic BCS techniques use local tissue to fill a breast defect when there is insufficient volume for displacement techniques, or when the patient does not want smaller breasts. Local perforator flaps are the most useful replacement techniques, consisting of excess subcutaneous fatty tissue adjacent to the breast laterally or inferiorly, which can be rotated into the breast defect as a flap on a pedicle supplied by an intercostal artery perforator.

Regardless of the BCS technique, tumour-free surgical margins (minimum 1mm for invasive disease, 2mm for DCIS) are essential.

40 | DECEMBER 2020

Left breast wide local excision and axillary clearance after neoadjuvant chemotherapy, for 2 invasive cancers with metastatic axillary node. Preop (top panel) showing area to be excised (black circle) and marking of flap for reconstruction (blue) on a chest wall perforator vessel (red dot). Postop at 1 year and after radiotherapy (bottom panel, scar only visible with arm up).

Final pathology: pCR breast (no invasive cancer) and axilla (19 benign lymph nodes) – current protocol would have recommended a targeted axillary dissection thus avoiding an axillary clearance.

Key messages

Oncoplastic breast surgery allows more women to have breast-conserving surgery, wider resections, and less frequent involved margins Reconstruction options after mastectomy require careful planning and play a significant role in the psychological recovery from breast cancer Neoadjuvant chemotherapy downstages tumours to permit de-escalation of surgery in the breast and axilla.

Involved surgical margins requires re-excision, with potential for delayed adjuvant therapy and increased patient anxiety. Very low (<10%) re-excision rates can be achieved in oncoplastic BCS with experienced teams in large volume breast cancer centres.

Neoadjuvant Chemotherapy (NACT), traditionally used for locally advanced or inoperable breast cancer, has been extended to downstage large tumours allowing BCS rather than mastectomy.

Tumour response to NACT is dependent on the histological

subtype based on grade, ER, PR, and HER2 status. HER2-enriched cancers and triple-negative cancers have the greatest pathological complete response (pCR) rates.

NACT is the preferred approach for these tumour subtypes, making them potential candidates for BCS, and more importantly, enabling additional chemotherapy for those with residual disease after completion of NACT and surgery.

When BCT is not possible, thoughtful planning of mastectomy, with consideration to breast reconstruction, is important for the emotional recovery from the trauma of breast loss. A skin-sparing, skin-reducing, or nipple-sparing mastectomy, with immediate reconstruction is a good option for selected women.

Reconstruction can be performed with implants as a one-stage directto-implant technique, or two-stage procedure with a tissue expander later changed to a permanent prosthesis. Implants can be placed in a pre-pectoral or sub-pectoral position.

Autologous tissue reconstruction involves pedicled or free-tissue transfer to the breasts. The deep inferior epigastric artery perforator

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CLINICAL UPDATE

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CLINICAL UPDATE (DIEP) flap uses tissue from the lower abdomen and is optimal in selected patients, although a more technically demanding procedure.

The trend to increasing rates of contralateral prophylactic mastectomy at the time of diagnosis of unilateral cancer is concerning, as this is associated with increased complications, and potential delays in cancer treatment, with no survival benefit.

Left breast wide local excision of two invasive cancers. Preop (left) showing area to be excised (black circle) and marking of flap for reconstruction (blue) on a chest wall perforator vessel (red dot). Postop at 6 months (centre, 200 gr of tissue excised) with hidden scar, shown with arm up (right).

In clinically node negative patients, the role of sentinel lymph node biopsy (SLNB) is a well-accepted, reliable method to assess the axilla, with limited arm morbidity compared to axillary lymph node dissection (ALND). A completion ALND can be safely omitted in patients with micrometastasis in the sentinel node(s), (i.e. 2mm or less). The extent of additional axillary surgery for those with a higher disease burden is a subject of ongoing discussion.

In clinically node-positive patients with HER2-enriched or triplenegative tumours, NACT allows for de-escalation of surgical treatment of the axilla. A targeted axillary dissection technique, consisting of a SLNB and specifically removing the affected nodes previously marked with a clip, can accurately restage the axilla after completion of NACT and identify the approximately 40% of women with nodal pCR who avoid a completion ALND. Author competing interests – nil

Breast MRI: 64 mm area of mass enhancement right breast (top left). Core biopsy: invasive ductal carcinoma G3, ER-, PR-, HER2 +, and DCIS, with metastatic axillary node.

Reduction of tumour size after neoadjuvant chemotherapy, to two smaller areas (red circles, top right).

Preop (bottom left) and 5 months postop after bilateral reduction mammoplasties (bottom right – 350 gr of breast tissue removed right; 400 gr left) and right targeted axillary dissection, with postop right breast radiotherapy. Final pathology: pCR breast (no invasive cancer), residual high-grade DCIS with clear margins, 6 benign axillary nodes (2 with chemotherapy induced regression changes).

Dr Manisha Doohan — Gynaecologist MBBS, MRCOG (UK), FRANZCOG

Dr Manisha Doohan, is a consultant in Obstetrics and Gynaecology (O & G). She has been a member of the Royal College of Obstetricians and Gynaecologists (MRCOG), London, since 2012. Having worked in this field since 2004, Dr Doohan completed her basic and advanced training, gaining Certificate of Completion of Training (CCT) from GMC, UK. She worked as a consultant in the UK and held various managerial positions. In 2018, Dr Doohan moved to Perth to join as a consultant in O & G at the King Edwards Memorial Hospital. She is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG).

Dr Doohan has special interests in pelvic pain, contraception, sterilisation, colposcopy, endometriosis, fibroids, menstrual disorders, menopause, prolapse, endometrial ablation, advanced laparoscopic surgery including hysterectomy.

Consultations at: South Perth Hospital, Perth Women’s Health, 76 South Terrace, South Perth 6151 Email: md@perthwh.com

Enquiries: 0402 883 324 For referrals: healthlink—perthwom www.perthwomenshealth.com

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Demystifying the mildly abnormal FBC

By Dr Steve Ward, Haematologist, Nedlands Abnormal results on a full blood count (FBC) can cause significant angst. Yet, there is no such thing as a ‘normal range’. Reference ranges are derived from thousands of samples taken from healthy people. They vary with ethnicity, gender and age. The reference range is the middle 95% (two standard deviations from the mean) thus excluding the top and bottom 2.5% of healthy people.

Results falling just outside the accepted reference range may be due to statistical variability. The sample run multiple times may produce slightly varying results.

Biological variability (test results can vary during the day) and age (FBC parameters may fall with age) influence results. We quote Caucasian ranges, which may not be applicable to other ethnicities.

The further removed a result is from the reference range, the more likely to be truly abnormal. Abnormalities in more cell lines can be more important. Is the defect new or recurrent, and over how long? Longstanding single aberrations without clinical features or consequences are less likely significant. Is it progressive or fluctuating? Are there morphological abnormalities?

Is there a reasonably identifiable cause? What is the clinical context?

In asymptomatic patients with low pre-test probability, the rate of false positive abnormal results will be high, and borderline results do not need investigation.

The total white cell count (WCC), itself, is much less important than the individual white cells. The lower limit of the neutrophils, lymphocytes, monocytes, eosinophils and basophils adds up to much less than the lower limit for total WCC. Similarly, the upper limits also are much higher than the upper limit for total WCC. This is because the ranges were done separately for all.

Rarely does a person have all cells at the lower (or upper) limit. So, if the individual cell counts are normal, the total cell count is not important.

Key messages

Results slightly outside the reference range are common and may not be abnormal The further from the range, or association with symptoms or signs, and multiple abnormalities is more concerning.

Specifics Mild neutropenia is common (e.g. viral infection, autoimmune disorders, drugs, liver disease and hypersplenism, B12 or folate deficiency, hypothyroidism, ethnic variation). Haematologists will rarely investigate a count above 1.0 without immature cells, other FBC defects, or clinical problems.

Recurrent bacterial sepsis is the risk, and usually only under 0.5 for a long time, and even then, uncommon.

Mild neutrophilia is commonly seen in infection, inflammation, acute stress (e.g. acute myocardial infarction (AMI)), heavy exercise, drugs (lithium, steroids), pregnancy, and smoking.

Mild lymphopenia is common and non-specific. Haematologists rarely investigate if isolated without associated features. Almost any sickness can cause mild lymphopenia.

Lymphocytosis is due to acute infection, acute stress response, (e.g. AMI) smoking, or lymphoproliferative disorders. With persisting significant lymphocytosis immunophenotyping can be done, but usually not at the first presentation. Isolated lymphocytosis <5.0 does not usually need investigating.

Monocytosis is seen in chronic infections or inflammation (e.g.

Crohn’s, Rheumatoid) and primary blood disorders. Investigation may be warranted if persistently above 5.0.

marrow disorders are possible.

Basophilia is rarely seen and occurs in myeloproliferative disorders. Other cell abnormalities will be evident.

Thrombocytopenia is common and can be due to blood collection difficulty, viral infection, alcohol, Idiopathic thrombocytopenic purpura (ITP), drugs, pregnancy, autoimmune disorders, and primary marrow disorders. Above 100 is rarely worrying. Between 50 and 100 is usually safe whilst 3050, though usually safe, needs investigation. Bleeding risk increases between 30 and 50 and requires referral. Under 10 carries major spontaneous bleeding risk and warrants hospitalisation.

Thrombocytosis is often reactive (e.g. infection, inflammation), from blood loss (including menorrhagia), iron deficiency, post trauma and less commonly myeloproliferative disorders. Usually below 1000 is not major risk but above 1000 can be risk for thrombosis (or bleeding if myeloproliferative disorder) especially if associated with cardiovascular risk factors.

Mild anaemia is common, and haemoglobin can fall with age.

People generally tolerate a degree of anaemia. An Hb under 80 often causes symptoms needing investigation and treatment to reverse the cause. Between 80 and 100 may be acceptable but requires clinical assessment. Above 100 is usually asymptomatic. MCV helps tailor investigation to potential causes. Investigating isolated mild macrocytosis (1-2fL above range) is probably not helpful.

High Hb & PCV (Hct) may reflect reduced plasma volume (e.g. dehydration, obesity, alcohol smoking), secondary polycythaemia (hypoxic drive) or primary polycythaemia. Haemoglobin above 200 and PCV (Hct) over 0.60 requires urgent assessment.

Author competing interests – nil

Eosinophilia is common in allergy problems. Investigation may be warranted if above 5.0 as primary

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CLINICAL UPDATE

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Christmas infectious diseases and 'bush biteys'

By Dr Astrid Arellano, Infectious Disease Physician, Subiaco With border restrictions easing, travel within Australia at Christmas will be popular. We cannot predict COVID transmission, but vigilance and ongoing community engagement will hopefully control outbreaks. It is interesting that widespread hand hygiene and social distancing have reduced other respiratory viruses and gastroenteritis presentations to extremely low levels.

The lack of overseas travel makes Australians safer from ‘Bali-belly’, but Australia is the country where seemingly every bush critter either bites, stings or wants to eat you.

Crocodiles hunt any animal within their territory, humans included, and although attacks are uncommon, they're frequently fatal.

In one non-fatal case, an attempt to ‘ride’ an adult saltwater crocodile resulted in a bite with a femoral compound fracture and a polymicrobial infection (Aeromonas, Clostridium, Enterococcus, Proteus and Pseudomonas species). This case is a warning not to ‘mess’ with saltwater crocs and a reminder of the dangers of excessive alcohol consumption.

Fig.2 Arthropod bite. Day 1, day 14 and day 25 after an arthropod bite (confirmed on histopathology). Culture negative resolved without treatment.

(Photography courtesy of Mr. Craig Cooper).

peak levels after monsoonal rains.

Broad spectrum antimicrobials with IV ceftazidime or IV meropenem are the preferred empiric agents for these presentations in the north of Australia.

Key messages

Holidays in Australia carry their own risks

Mosquito-borne viruses are common

Being prepared is the key.

In the top end we find an endemic, gram negative, spore-forming and dry-resistant organism: Burkholderia pseudomallei. It causes Melioidosis, a cause of community acquired pneumonia, septicaemia and muscle abscesses reaching

Mosquito-borne infections such as RRV and Barmah Forest occur throughout Australia while Murray Valley encephalitis (MVE) is common in tropical and subtropical regions (fig.1). MVE is endemic in the Kimberley and largely asymptomatic but 1/1000 develop encephalitis (24% mortality, 50% neurological sequelae).

Table 1. Common holiday-related infections and envenomations

Condition

Causative agent

Effects

Diagnosis

Treatment

Tick-bite reaction/ infection

Ricketssia spp.

Majority asymptomatic.

Ricketssia PCR-blood

None or Supportive

Can present with eschar, maculopapular rash, fever, headache, myalgia

Serology

Doxycycline for symptomatic disease

Murray Valley encephalitis

Falvivirus

Majority asymptomatic.

MVE serology

Supportive

Fever, headache, malaise, altered mental state

MVE CSF PCR

Meliodosis

Burkholderia pseudomallei

Cutaneous infection, soft tissue abscess, pneumonia and septicaemia

Wound swabs

Pterois venom

Nitric oxide release: pain and redness at injury site, nausea, vomiting, fever, respiratory distress, convulsions, headache, paraesthesia and numbness of limb

Clinical

Remove spines, clean area, control bleeding, apply heat for 30-90 min (denatures venom), keep <48°C

Muscle cramps, pain in the back, headache, vomiting, sweating, hypertension, tachycardia

Clinical

Supportive with analgesia, anti-hypertensives.

Lionfish envenomation

Irukandji jellyfish envenomation

44 | DECEMBER 2020

Blood cultures

Intravenous antibiotics such as ceftazidime or meropenem

Vinegar may increase discharge of venom

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CLINICAL UPDATE Far North Queensland has frequent outbreaks of Dengue fever due to mosquitos that blow across the Torres Strait. The only effective prevention for arboviral diseases is vector control or mosquito avoidance (DEET repellent and mosquito nets).

Fig.1 Australian climatic zones, the predominant endemic arboviruses of human health significance that occur in those regions. http://www.bom.gov.au/climate/averages/maps.shtml (accessed 9 February 2018)

Arthropod bites and stings are common, and infection is caused by skin staphylococci or streptococci rather than bacteria injected with the bite or sting.

Ticks typically cause an eschar at the site of the bite and less commonly a Rickettsial illness characterised by a maculopapular rash (‘spotted fever’), myalgia, fever and lymphopoenia. It responds to doxycycline therapy.

In the tropical North-West ocean, wearing a stinger-suit or wetsuit is worthwhile to avoid envenomation from Irukandji jelly fish stings (Carukia barnesi), which cause increased catecholamine release explaining the hyper-adrenergic state in the victim. Blue-ringed octopus inject tetrodotoxin, a potent sodium channel blocking neurotoxin, resulting in rapid paralysis. Less deadly but equally painful are coral injuries, which

Prostate

Kidney

Bladder

often become infected (S.aureus, Vibrio spp. and Pseudomonas aeruginosa).

We ought to get used to Australian holidays because skiing trips to Japan, Alaskan dog-sled holidays and trips to visit Santa's Village in Finland are a long way off.

Andrology

Incontinence

Robotics

Female Urology

Preparedness for ‘bush-bashing’, related infections, stings and bites are important in order to enjoy the holiday season and to understand illness presentations of holiday makers within Australia.

Author competing interest – nil

Stones

Fertility

Multidisciplinary

GP UROLOGY

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GUEST COLUMN

Post-stroke aphasia – a marathon, not a sprint.

Research led by A/Prof Erin Godecke has shown that aphasia needs a timely but nuanced approach to therapy. Here she discusses the results.

Neuroscience theory from preclinical research in animal motor recovery underpins the majority of human stroke recovery and rehabilitation research. There are no equivalent models to guide research in the recovery of language after stroke. The premise of the neuroscience motor recovery models is “go hard, and go early”, meaning early intensive motor therapy is so potent that “too much, too early” causes death and poorer recovery for some of the most vulnerable stroke survivors.

The Very Early Rehabilitation in SpEech (VERSE) trial after stroke applied the same neuroscience theory to early post-stroke aphasia recovery and aimed to harness the brain’s natural healing mechanisms with early intensive therapy.

The VERSE trial was a Phase-III, RCT that recruited 246 participants with aphasia after stroke from 17 acutecare hospitals across Australia and New Zealand. Treatment started within the first 14 days of stroke and compared usual care to an extra 20 hours of treatment provided over four weeks.

Using treatment that manipulated the amount of direct talking practice, the VERSE trial implemented: • conversation practice in high doses or massed practice, • task specificity or ‘train as you play’ • task saliency or ‘meaningful practice’.

Outcomes were assessed at 12 weeks and 26 weeks post stroke using linguistic, conversational, quality of life and depression measures.

Participants who received usual care had, on average, 9.5 hours 48 | DECEMBER 2020

Key messages

Aphasia is a chronic condition that responds well to targeted treatment.

Aphasia treatment starting within the first two weeks is essential.

Intensive, early treatment is not better than standard care. of therapy within the first 28 days following randomisation, and participants who received high intensity treatment had on average 22.7 hours of treatment in the same timeframe.

Clinically, the usual care therapy ranged on average from 3748 minutes of direct time on task, provided 2-3 times a week compared to high intensity therapy of 45-53 minutes on task provided six times a week.

Our results showed that participants who received treatment had a vast increase in the Western Aphasia Battery-Revised scores, indicating improved ability to speak and the ability to use a variety of linguistic content to get their message across.

On average, the participants scored more than 26 points more than

baseline scores at 12 weeks, and 31 points at 26 weeks post stroke on a test where five points constitute a clinically meaningful change.

However, between group comparisons, at both timepoints there was no statistical difference on linguistic, conversational, quality of life and depression measures.

The VERSE findings were unexpected based on our pilot studies, which showed statistical and clinical benefit of early intensive intervention (7.5 hours) when compared to less than 14 minutes of therapy across 21 days. The clear lack of benefit of additional therapy in early aphasia recovery should not be mistaken with no therapeutic effect of early treatment.

There is Level 1 evidence for aphasia treatment started within the first month following stroke, however, our results are suggestive of the economic ‘law of diminishing returns’ which postulates that “beyond a certain point, additional inputs produce smaller and smaller outputs”.

The role of spontaneous recovery in early recovery remains elusive. Our trial set out to determine if additional treatment to usual care delivered

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Aphasia, or difficulty understanding, reading, writing or speaking, occurs in up to 30% of acute stroke survivors. Despite Level 1 evidence indicating aphasia therapy is beneficial, little is known about whom to treat with how much therapy at what point in recovery.

enhanced spontaneous communication recovery, rather than undertaking to detect the value of each component.

Very little data are available at an international level to adequately measure spontaneous recovery of language after stroke.

The VERSE results challenge the previously held neuroscience perception that ‘intensive early treatment is better’ when applied to aphasia recovery. It is possible that the prescribed dose of 20 hours of treatment in the first 40 days following stroke is insufficient to demonstrate benefit over 9.5 hours and that a more intensive dose (e.g. 50-60 hours) is required.

The results of this trial indicate that early aphasia therapy is essential to enhance recovery. The treatment in this trial on average, saw people enter the study speaking in twoword phrases with multiple word, sound and grammatical errors and requiring assistance with all communication interactions.

At 12 weeks they had progressed to independently speaking in coherent and appropriate sentences to communicate in everyday interactions. That alone indicates aphasia treatment is worthwhile.

New BreastScreen WA clinic

East Perth - Mardalup

opening in December 2020

The new site replaces the Murray Street Clinic and will be the first BreastScreen clinic in Australia to be co-named with a tradional Aboriginal designation, East Perth - Mardalup.

Our responsibility is to determine and individually tailor the most appropriate dose of treatment for the right person at the right time to enhance long-term aphasia recovery. Our challenge is to rationalise health resources to run the marathon that is aphasia recovery and not spend all our effort in the sprint to the first six months.

– References available on request

Read this story on mforum.com.au

A/Prof Godecke is from the School of Medical and Health Science, ECU Joondalup Campus. She also chairs the support group, Aphasia WA, which offers six community aphasia groups across WA for people living with aphasia.

It is important for women 50 years or over to have a FREE breast screening mammogram at BreastScreen WA every two years.

These are conversation practice groups run by trained volunteers; they are not therapy groups. The groups are in Inglewood, Floreat, Palmyra, South Guildford and Geraldton. Videocall or Zoom access is available. All groups are free to attend.

Once is not enough.

Book your appointment online at

www.breastscreen.health.wa.gov.au or call 13

For information email: aphasiawa@gmail.com Membership: aphasiawamembership@gmail.com Groups: Sandy, 0419 923 522 https://www.facebook.com/AphasiaWA/ www.aphasiawa.com.au

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Clinic locations: Bunbury, Cannington, Cockburn, East Perth - Mardalup, Mandurah, Midland, Mirrabooka, Padbury, Perth - David Jones Rose Clinic, Rockingham and Wanneroo.

Rural locations: Check your local media or the website for mobile screening unit visit dates.

OCT 2020

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GUEST COLUMN

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‘Fourth trimester’: a role for general practice Notre Dame medical student Juan Stephen and Dr Ramya Raman explore how GPs can play a role in identifying postnatal depression.

Perinatal depression often begins in the antenatal period, but it may not be identified until the postnatal check. One in six women experience postnatal depression (PND) in the first year, following childbirth.

PND can significantly impact on their health and their partners and is invariably associated with impaired mother-infant bonding.

Moreover, PND is associated with poor cognitive and emotional development in the infant.

The perinatal period offers opportunities to diagnose and manage mild, moderate and severe mental illnesses mainly because of the greater frequency of contact women usually have with health professionals during their routine antenatal consultations, which often does not occur in postpartum period.

GPs are the usual first port of call for patients, but all healthcare professionals in contact with pregnant women, especially in the postpartum period, should be alert to new symptoms for PND or those of a more chronic nature.

Previous studies show that more than 50% of women with postnatal depression are not identified in a primary-care setting. Often, this is associated with women avoiding help because of the stigma attached with PND.

Existing guidelines

ways of implementing screening mothers for postnatal depression using standardised and validated tools such as the Edinburgh Postnatal Depression Scale (EPDS) and the Depression Anxiety and Stress Scale (DASS-21).

Clinical practice guidelines for perinatal mental health were developed by BeyondBlue in 2011.

The Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) guidelines were subsequently improved upon as ‘The National Perinatal Depression Initiative’ (2013).

Detecting postnatal depression early enables women to seek appropriate treatment and also ensures better outcomes for the mother, baby, their family and the community.

From an economic viewpoint, early identification enables appropriate allocation of resources for healthcare needs.

It is now mandatory to screen for mental-health disorders in pregnancy and post-partum (RANZCOG, 2018). These guidelines recommend that local-health services such as GP practices devise

Against such a background, a clinical audit conducted at a small outer metropolitan general practice clinic in Perth in 2020 determined that 96% of women who presented for their 6 to 8-week postnatal check

50 | DECEMBER 2020

was screened for PND as per the RANZCOG guidelines.

Of a sample of 55 female patients, 53 were screened for postnatal depression. For the 96% of the sample screened for postnatal depression, EPDS toolkit was used.

None of the patients was found to be screened for postnatal depression using the DASS-21.

PND screening As per the RANZCOG guidelines, 100% of women presenting at a GP practice for their 6 to 8-weeks postpartum check should be screened for postnatal depression.

While this audit determined high rates of screening for PND, opportunities for improvement remain to ensure PND identification occurs in the post-natal period.

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GUEST COLUMN

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GUEST COLUMN The sample of 55 women represented 38% of total number of women who presented for their postpartum check at the GP practice between January and December 2019. A larger sample size should allow better extrapolation of results.

It is hoped that this audit will help improve the rates of postnatal depression screening at a GP practice, similar audits across other practices would be necessary before rates of screening at a local, state-wide, or national level can be determined and compared to the national standard.

As a result of the audit, these recommendations were made to the GP clinic: • Every woman is screened for postnatal depression during their 6 to 8-week check using the EPDS and a standardised proforma on the practice software • All visiting staff are educated in the use and necessity of postnatal depression screening for women presenting at the 6 to

8-week postnatal check • Standardised documentation of the EPDS scoring along with the risk category to ensure uniformity is maintained across staff in the practice • Ensuring that the 6 to 8-week postnatal check is recorded under a fixed term such as ‘6 to 8-week postnatal check’ or ‘6 to 8-week postpartum check’ in the practice software to allow for easier identification of patients presenting specifically for this reason • the reauditing done by staff or medical students to assess for improvement of screening rates within the practice.

Importance of audit These recommendations can easily be applied to other practices that might consider a similar auditing process.

GPs are one of the first point of contact for women presenting for their first postpartum check and they are well placed to raise awareness of PND, review and

monitor mental health states in women during their pregnancy, detect early symptoms and initiate further management steps and support the woman and her family through this period.

ED: The authors acknowledge the cooperation of the Skye Medical Team in the conduct of this clinical audit.

In particular, they wish to thank Mrs Stephanie MacKinnon (Practice Manager) and Ms Eleanor Spencer (Office Manager) for their time and support.

Juan Stephen is a final year medical student at the University of Notre Dame.

He is sponsored by the Australian Defence Force and will be commencing his internship at St John of God, Midland Public Hospital in 2021.

Ramya Raman is a GP at Skye Medical Armadale and Clinical Academic with School of Medicine, University of Notre Dame, Fremantle. Ramya is also medical educator with WAGPET and Deputy Chair of RACGP WA Council.

References on request

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ADVENTURE

The magic of Karijini Karijini’s majesty is timeless and offers new experiences for every returned traveller as GP Dr George Crisp discovered.

It’s been over 25 years since my previous visit to the spectacular Karijini National Park and it is certainly no less impressive or aweinspiring than I remembered.

The outdoor restaurant and bar of the Eco Retreat is a very welcome sight after the long drive from Perth, which culminates in several kilometres of dusty red dirt track, and the eco tents scattered in the surrounding wilderness make for a very relaxing and comfortable base from which to explore the park.

Some of the gorges are easily accessible, some visible from viewing platforms, but to get the full experience you really need to hire a guide to explore the deep narrow chasms and pools that make this place so unique.

Joffre Gorge is a short walk from the Eco Retreat and it was with abseiling harnesses, hard hats and inflatable inner tubes that we set off on our first day’s adventure.

Paddling through the cool still water, with intense colours 52 | DECEMBER 2020

reflected off the rocks and deep blue sky above, makes this both an adventurer’s and a photographer’s paradise.

After half an hour or so, the water ends and a short rocky walk brings you to a 4m jump into a deep pool.

The series of gorges are serene and tranquil and feel a world away.

Lunch was on a shady beach before continuing the 6km trip, via junction pool and exiting through Hancock Gorge, all making for a full and rewarding day.

Our second day started with a descent into Weano Gorge through the tortuous smooth water-carved layered rock canyons. Some so narrow and winding that the sky above is no longer visible. At the end of this gorge there is a 60m abseil (through a waterfall if it’s been raining!) down into Red Gorge.

We had an early start the following day for a hike up Mount Bruce, WA’s second highest peak, for sunrise – definitely worth doing for the expansive views across the

plains and surrounding hills – and before the heat of the day sets in.

Our last day started in Knox Gorge.

This progressively narrows to a steep water slide dropping several metres into a shady enclosed pool, then on to the far side for an abseil down into another pool and beyond the massive orange-red walls of Red Gorge. We exited again through Hancock Gorge with its short climb at Regan’s Pool.

These gorges are now rated as Class 5 and 6 and require qualified licensed guides and being roped up for more precarious sections, but it is well worth the extra cost to gain access to the peaceful, magical deeper parts of this ancient gorge system.

Sven from Space Chameleon Adventures provided everything we needed including equipment and catering as well as an introductory afternoon abseiling and learning basic rope skills. It’s actually not difficult, very safe and quite exhilarating.

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ADVENTURE

On our last night at the Eco Retreat, after dinner, we walked back to Joffre Gorge under the brilliant star-studded Pilbara night sky.

I wonâ&#x20AC;&#x2122;t be leaving it so long between visits to Karijini again.

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Grim secrets of Perth’s ‘baby farm’ Retired GP Dr Stella Budrikis unearths the disturbing story of ‘baby farming’ and tragic endings. Ara Jansen reports.

While researching another story, writer Stella Budrikis came across the words “baby farmer” in a newspaper article. Something stuck with her and she kept coming back to those words.

Four years of research and writing later, the result of her investigations led to The Edward Street Baby Farm, published by Fremantle Press.

A baby farm was a term for someone who took in the infants of single mothers or unfortunate families for a fee, with little or no concern for the child’s welfare.

It was like the beginnings of the creche or day care, but often with tragic results.

Australia’s most notorious baby farmer was Perth’s Alice Mitchell, who was tried for the murder of a baby in 1907. Some 37 infants were thought to have died in her care, in the Edward Street house within walking distance of the author’s own home.

Budrikis – like a lot of people – had never heard about the case, though there’s a display about it in the Old Court House Law Museum.

interesting. Family names which are now part of our social and business vernacular appear, alongside an indication of women’s standing in the early 1900s add colour to surround the inquest and trial.

“I didn’t have any idea about writing a book on a baby farm,” she says. “I started with a blog post.

Then I started digging around and curiosity got the better of me.”

She started to discover the other characters that ended up in her book – Harriet Lenihan, Perth’s first lady health inspector and a former classically trained musician, and Dr Ned Officer, who had played football for Essendon before becoming a doctor.

Law responds Even though she has lived in Perth most of her life, Budrikis was discovering parts of local history which were drawing her in. This included the fact that the Alice Mitchel baby farming case prompted immediate demands for changes to child protection laws which the government implemented quickly.

It had lasting flow-on effects including creating momentum for the eventual establishment of King Edward Memorial Hospital for Women. Infant mortality in WA was high – 13 of every 100 babies died in their first year – compared to today, where it’s just over two deaths for every 1000 live births.

While the subject might seem grim, the author writes in the introduction that it’s more the story of how three people and a community “became entangled in a tragic situation and its aftermath”.

Conditions in our then small colonial town, population around 27,000, were primitive. Roads weren’t paved, sewage systems didn’t exist and the town regularly fought off typhoid and outbreaks of the bubonic plague.

Hard times A retired doctor and a life-long writer, Budrikis has worked as a GP, pastoral carer, addictions clinic doctor and a freelance writer. She writes a history blog and published a biography about her great-greatgrandmother, Susan.

“Having been a doctor and GP in the area of drug and alcohol and pastoral care has given me a sense that everything has a story and there’s usually two sides to it. Even the most degraded person is not often what you imagine and there another side to their story.

“Curiosity is what keeps me going with my research and into the writing stage. A story needs some characters with depth and interesting aspects to them. It needs to say something about the general human condition.

“I couldn’t decide even after having written the book what level of deliberateness or how much Alice Mitchell was ignorant or untrained or whether the babies just died. I got the impression she was a really pessimistic person and had low expectations of life.”

ED: The Edward Street Baby Farm, Fremantle Press

The picture of Perth the author paints as a backdrop is also 54 | DECEMBER 2020

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BOOKS

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WINE REVIEW

St Aidan Wines â&#x20AC;&#x201C; quality and diversity in the Ferguson Valley St Aidan Wines is located in the Ferguson Valley, near Bunbury, in the heart of the vast, emerging Geographe wine region. Phil and Mary Smith started planting vines on their property in 1997.

Phil's search was for land within 20 minutes of Bunbury where he works as an anaesthetist. They were fortunate that this placed them in this picturesque valley, their property straddling the Ferguson River. In my past involvement in regional WA wine shows, I realised the potential of St Aidan's early wines, a potential that has now resulted in wines not only of high quality, but also in an impressive diversity of varieties and styles for a boutique vineyard of only three or four hectares. As well as the varieties familiar to us (Chardonnay, Sauvignon Blanc, Semillon, Cabernet Sauvignon and Merlot) they have also ventured into Tempranillo (a Spanish variety gaining popularity in Australia) and Muscat, the latter from which they produce a Moscato and a Liqueur Muscat. It is such a breath of fresh air to see a small producer taking on these wine styles.

St Aidan 2019 Ferguson Merlot (RRP $28) A very good Merlot showing typical varietal expression. Aromas of violets, palate is supple and soft with gentle tannins â&#x20AC;&#x201C; just as Merlot should be.

Blackberry and fruitcake characters.

Balanced and complete with nice fruity finish. A wine for immediate to mid-term consumption.

St Aidan 2019 Ferguson Chardonnay (RRP $35)

Review by Dr Craig Drummond Master of Wine

St Aidan The Sisters Series 2019 Kay Rose (RRP $20) This rose-style is produced from Tempranillo grapes. It displays an onion skin colour, the nose initially restrained, then red fruits emerge, with a savoury edge. The palate is dry, simple, linear and easy to drink.

Fruit characters of cherry kernel and beetroot. Very much in the style of the rose wines of southern France.

Another enjoyable summer wine.

It comes as no surprise that this Chardonnay was awarded a Gold Medal in the recent Perth Royal Wine Show. It displays an attractive limpid mid-gold colour. The nose is alluring, showing immediate complexity, with rich fruit and new oak aromas of toasted cashew. The flavours are rounded and big. Ripe figs, some brioche. Supple buttery mouthfeel from malolactic ferment. Obvious integrating new oak characters from 10 months on lees in French oak. A complex wine, with the structural definition, acid and oak to meld into a lasting wine. Worthy of current drinking, and will be even better in two years.

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St Aidan 2017 Cabernet Sauvignon (RRP $35) A medium to full-bodied style. Colour is brick red with slightly browning meniscus. Nose showing blackberry and herbaceous leafy cabernet characters. Some cedary oak aromas.

The flavours are classic cassis with herbal and forest floor elements.

The tannins are fine grained, oak is integral, drying and linear. This wine is in the elegant style and will go another 3-5 years.

St Aidan 2019 Cassie Moscato (RRP $21) Of the seven wines presented this is my choice for 'wine of the tasting'. Other wines share the same high quality, but this wine shows so much personality. It's attractive salmon pink colour derives from the skin of the Muscat au Petit Gri grape variety (most moscato is made from the Muscat Blanc au Petit Grain variety, which has white skin). Production by a partial fermentation results in high residual sugars giving it the luscious refreshing mouth-feel, and an alcohol level of just 8%. The aromatics are fragrant, even hedonistic, and 'musky'. Palate tastes like fresh grapes, with a slightly petillant mouth-feel, and red fruit flavours in the background. It is charming, delightful and pristine. A great wine for Christmas and summer drinking.

'S EWER REVI

PICK

DECEMBER 2020 | 55

Let 2021 entertain you DANCE West Australian Ballet’s ’21 season kicks off at the Quarry on February 25 in its traditional Perth Festival celebration and continues with a year of traditional (Giselle, 13 – 22 May, Coppelia, 16 – 25 Sep, and The Sleeping Beauty, 18 Nov – 12 Dec) and contemporary (Genesis, 23 – 27 Mar, and STATE, 24 Jun – 3 Jul).

Pictured here is Polly Hilton for STATE. Credit: Frances Andrijich www.waballet.com.au

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ENTERTAINMENT

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ENTERTAINMENT FESTIVALS

THEATRE

Perth Festival:

Fringe World:

Black Swan State Theatre Company:

Tim Minchin is the marquee local hero in a festival dedicated to the local heroes working in the WA arts industry. Minchin appears with WASO in Kings Park as a festival opener on 5 Feb along with the start of a 21-night City of Lights spectacular at the Perth Cultural Centre (5 Feb – 28 Feb).

Paint the Town Fringe kicks off in Northbridge and the CBD on 15 Jan with its usual blend of high-octane cabaret, musicals, burlesque, theatre and circus.

The long-awaited return to mainstage theatre sees Chekov’s The Cherry Orchard (17 Feb – 14 Mar) front and centre as part of the Perth Festival.

Details of the massive month of madness see https://fringeworld.com.au

Details of the company’s 30th anniversary is at https://bsstc.com.au/whats-on/

www.perthfestival.com.au

OPERA OUTDOOR CINEMA Camelot & Luna Outdoor:

The Lotterywest Films:

Arthouse, popular and the cult all collide at these two outdoor legends. Camelot kicks off on 3 Dec with the charming Rams and Luna Outdoor is already open for business with a celebration of David Byrne’s American Utopia.

The iconic Perth Festival film season began on 30 Nov and will continue until 28 March at UWA Somerville.

WA’s acclaimed The Furnace is the opening film Mon 30 Nov – 6 Dec.

https://outdoor.lunapalace.com.au and https://camelot.lunapalace.com.au

West Australian Opera kicks off its 30th anniversary with its free Opera in the Park gala on 26 & 27 Feb (ticket registration essential) with Emma Matthew and Sara Macliver among the talent. The season opener is The Barber of Seville in April and Elijah in May among others.

www.perthfestival.com.au/ categories/film/

MUSICALS Rooftop Movies: Million-dollar views of the city skyline and a screen full of movie magic is part of the FringeWorld cinema package. https://www.rooftopmovies.com.au

The Boy from Oz: An all WA-production of this classic dazzles at Crown Theatre with a preview on 22 Jan. The team from David Spicer Productions are also planning to stage Hot Shoe Shuffle in March. www.crownperth.com.au/ entertainment/live-theatre/theboy-from-oz

MUSIC The WASO season starts with special events – Birds of Tokyo (14-16 Jan) and Ben Folds (28-29 Jan). Its Festival offering is Dreams of Place with the orchestra welcoming the talented WAYO to its ranks.

The master season kicks off with Elgar and Rachmaninov on 4-5 March. https://www.waso.com.au/

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DECEMBER 2020 | 57

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