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Innovations & Trends WA’s Cannabis Clinics Autism Guidelines Blockchain in Australia GP Training; Pharmacogenomics

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February 2019

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EDITORIAL Jan Hallam, Managing Editor

Fresh Air, Fresh Thinking The February edition is always a lot of fun to pull together. Much of the time, journalism is about reporting what’s actually happened – Innovations and Technology gives everyone a chance to think big and worry about double blind trials later.

We start 2019 with some chunky themes: the prospect of end-of-life legislation being introduced into State Parliament; the opening of bricks and mortar medicinal cannabis clinics; a not-quite-universal My Health Record ready for blast-off, and a whole lot more if you start unpicking the ‘more hospital beds vs prevention’ debate.

It’s also a workable formula for those other thorny issues, which perhaps may give pause to those at the polar ends to stop a moment to open the window, smell fresh ideas or at least listen to the wind that is carrying them.

This statement from a local GP may be helpful – no one has died from medicinal cannabis.

However, dying is at the heart of the end-of-life legislation.

Unlike the cannabis issue, which from the outside appears to just need boxes to be ticked to gain wider approval from the profession, voluntary assisted dying goes to the core of what it is to be human.

All positions are passionately held from different sides of the spectrum and none too many have any real consensus.

So, it is no surprise that passions within the profession run deep and are felt intensely. It also goes to the core of what doctors do – help people. Some who have contacted the magazine think that means helping people to stay alive until the body fails; for others it’s about helping people along life’s path and, when the end is in sight, to help them lay down their burden.

Privacy, security, efficient and integrated healthcare. Are these mutually exclusive? We’ve written previously about the marshy lands of My Health Record. This year, it stops being a hypothetical. We must all get better at embracing a future that has buttons and algorithms because that time is now and here.

The people running the show need to get a lot smarter at it too.

Following on from December’s interesting report on Blockchain in Estonia, we take a peek at some of the projects in Australia where Blockchain is being used. It would be nice to think that the My Health Record folk might learn from it, too.

The people want it and the system needs it.

When investigating the developments on the local medicinal cannabis front, a bush ‘guesstimate’ was suggested on how many doctors viewed the efficacy and, by extension, the use of legal medicinal cannabis and it went something like: About 10% think it’s the devil’s drug, 10% think it is a cureall and 80% are open-minded and watching with interest as things unfold.

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Marketing Manager Lois Paffett (0403 282 510) mm@mforum.com.au

MEDICAL FORUM

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au

Some doctors have said it’s not fair they should be the ones designated as killers because it goes against their professional and, for some, their religious values. Others see it as their duty.

What exists in the spaces between those views is public opinion. Just like the cannabis issue, which has been brought on by an overwhelming demand from the public, the end-of-life debate carries a large swell of public opinion.

Polls suggest the majority of people want the right to die when they are too sick to go on and this is the principal reason a parliamentary inquiry was established last year. Whether the law will support them in that, we’ll have to wait and see. Whether we all keep open minds (and hearts) is also uncertain but it’s not a bad New Year’s resolution.

Administration Jasmine Heyden (0425 124 576) jasmine@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

Journalist Mr Peter McClelland journalist@mforum.com.au Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

FEBRUARY 2019 | 1

CONTENTS FEBRUARY 2019

INSIDE 10 14 17 18

WA Cannabis Green Light RFDS Sky Safari Autism Guidelines Blockchain in Health

18

10

NEWS & VIEWS 1 Editorial: Fresh Air, Fresh Thinking - Jan Hallam 4 Letters to the Editor

14

6 7 35 37

LIFESTYLE 44 Russia: For the Birds - Dr Lin Arias 46 Theatre: Peter Pan Goes Wrong 47 Beer Review: Mash Brewery - Dr Sergio Starkstein &

48

17 MAJOR PARTNER 2 | FEBRUARY 2019

Toll of Pain and Suffering - Dr Peter Beahan ‘Beg and Grovel Law’ a Missed Chance - Philip Nitschke Have You Heard?

Beneath the Drapes Cyber Security at Work - Jerome Chiew Privacy: Does it Still Exist? - Enore Panetta

54 55 56 56 57 58

Dr Bradleigh Hayhow Christmas Pulse: SJG Subiaco Hospital, SJG Midland Hospital, Ramsay Health Care, RACGP, SJG Mt Lawley Hospital, Bethesda Health Care Social Pulse: Global Cardiology, Liver Foundation Music: The Nature of Why; Mimma Funny Side Sailing away Competitions Exercise for the Elderly

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MEDICAL FORUM

CONTENTS FEBRUARY 2019

CLINICALS

39 Food Allergies: Prevent or Cure?

Clin A/Prof Richard Loh

INNOVATIONS & TRENDS

40 Managing Otitis Externa Dr George Sim

41 Finding HFE Haemochromatosis Prof John Olynyk

24 Probiotics, ‘Hot Goss’ of 2019?

Dr Astrid Arellano

28 Workplace Culture

Pathology Innovations: Pharmacogenomics Dr Narelle Hadlow

25

27

Communicable Diseases General Practice of the Future?

– Keeping Ahead Dr Richard Choong Dr Paul Armstrong

29 Training GPs of the Future A/Prof Janice Bell

30 PET Scans Dr Nat Lenzo

The Good, The Bad & The Ugly?

Keynote Speakers: Clinical A/Prof Tim Bates Dr Sarah Newman Panellists: Dr Frank Jones and TBA

To attend or register for video streaming go to: www.doctorsdrum.com.au

31 Telehealth Access for Rehab Mr Peter Edwards

33 Computer Navigation in TKR Dr Christopher Jones

GUEST COLUMNS

Thursday April 4

7:15 - 8:50am The University Club, UWA SPONSORS

8 Riding to Give Hope to Kids Dr Sue Taylor

21 More than Absence of Disease Dr Sarah Moore

43 Why Do What We Shouldn’t?

Prof Hinze Hogendoorn

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician)

MEDICAL FORUM

FEBRUARY 2019 | 3

Toll of pain and suffering Dear Editor, Re: Dr John Hayes' letter (Inquiry led astray, December 2018), where he describes as outrageous a statement that “closer to 30%” of patients die in pain despite palliative care.

That statement was made by Dr Brien Hennesssy, Head of Anaesthetics at SCGH, during the WA End of Life Choices Inquiry. It was qualified by him as “a guess”.

The most evident observation with respect to estimates of significant pain at the end of life is that the figures provided by ‘experts’ have been wildly variable. Those working in the field have given some of the lowest estimates; zero per cent being the actual lowest.

their terminal and fatal phase with one or more major symptom was 5.1% (that is, the total proportion of bad deaths occurring under palliative care is around 5%). This amounts to 14,754/20 = 737 bad deaths in WA per year as a minimal estimate, or two per day. This cannot be dismissed as insignificant. Surely, one patient suffering overwhelmingly at the end of life is one too many.

In conclusion, the inquiry was not led astray, nor should it stand condemned for not disclosing Brien Hennessy’s sibling relationship with Jill Hennessy. The latter disclosure is a matter of public record in the inquiry’s transcript of Dr Hennessy’s testimony.

Dr Peter G. Beahan, retired anaesthetist, Stirling, Member Doctors for Assisted Dying Choice ......................................................................

With some practitioners expressing the view that suffering may actually be spiritually good for some patients, we may even need a scale that extends below zero!

’Beg and grovel law’ – a missed chance

What Dr Hayes does not state is that the 2% of patients he refers to, those who die in pain, do so under the watch of palliative care. Palliative Care Outcomes Collaboration (PCOC) data come from participating palliative care institutions and services and are therefore likely to show the best practical outcomes; the outcomes of other patients who are not reported to PCOC can reasonably be expected to be worse.

After giving a video submission from Amsterdam into the WA parliamentary inquiry into proposed assisting dying legislation, in which I drew attention to the problems of heavily medicalised end of life laws, I was disappointed in the outcome.

It could be argued that Dr Hennessy’s guess is a conservative estimate, given 2017 data reported by PCOC. The total number who had mild, moderate or severe pain was 41.2%.

For inpatients, this proportion was 35.5%.

Therefore, the assertion that “only 2% die in pain” is a gross underestimation, and a misrepresentation of that work.

In addition, the significance of pain should be taken in the context of overall suffering.

Patients at the end of life may have any number of severe and difficult symptoms that add up to severe suffering, and increase the significance of any addition of pain. These include such things as insomnia, loss of appetite, nausea, bowel problems, breathing problems and fatigue. It is really the subject of total suffering and its overwhelming nature that should be the focus of attention, not just pain in isolation.

PCOC information indicates that the cumulative proportion of patients entering SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.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 the medical profession in Western Australia.

4 | FEBRUARY 2019

Dear Editor

In my presentation I used the example of Prof David Goodall who was old, 104 years, and not sick, but wanting access to a reliable and peaceful elective death. David saw this as his right, and I agreed with him.

I argued in my submission that any proposed legislation which excluded those with rational but non-medical reasons would be challenged. Such legislation would enshrine the medical profession as gatekeepers who assess and dole out the privilege of a peaceful death to those deemed eligible, i.e. those sick enough to qualify.

Clearly my presentation had little impact on those drafting the WA assisted dying laws.

The legislation proposed closely follows that passed by the Victorian parliament which will come into effect later this year.

The Victorian Premier has proudly proclaimed their law as “the world’s 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.

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most conservative”. It seem WA is keen to challenge this title!

I’ve described such laws as ‘beg and grovel’ legislation. Laws that force ‘patients’ to beg doctors for help to die. And doctors are put into the position of gatekeepers and judges tasked with determining eligibility to die. (Was David Goodall “a patient”?).

None of this is healthy. None of this is good for the medical profession.

Clearly my position differs from many others working in the right to die movement to bring about change, but it is a position that comes from experience.

I enthusiastically welcomed the world’s first ‘beg and grovel law’ when the Rights of the Terminally Ill Act passed through the Northern Territory Assembly in 1995. A few months later I found myself trying to make this new law work. The patients begged, and I judged.

I dragged Bob Dent, dying of prostate cancer, from doctor to doctor seeking the three necessary signatures mandated under this new law.

After that final assessment from the psychiatrist, which he dreaded (“he’ll say I’m depressed and won’t sign”), Bob collapsed on his sofa exhausted. I showed him the Nembutal I’d obtained for his death. He looked at the bottle and said, “If I had one of those bottles in the cupboard, do you think I’d be crawling out of bed to see a psychiatrist to get my sanity tested? I’d just go to the cupboard!”

Two weeks later Bob became the first man in the world to receive a legal, lethal voluntary injection, and I started to seriously question my role. I had the drugs in my cupboard, and if I was in Bob’s position, I knew I wouldn’t be off seeing a psychiatrist!

As the Territory law was being drafted, Marshall Perron, the leader of the government and architect of this new Bill said to me that he didn’t want a law that forces very sick people to ‘jump through hoops’. But that is exactly what we got – the world’s first ‘beg and grovel law’.

Now, if there were no other way to address this issue, perhaps there’d be some excuse for the proposed WA legislation – but there is.

One country (and only one) has not gone down this path of trying to codify levels of sickness to determine eligibility. The Swiss argued that suicide was indeed a right

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LETTERS TO THE EDITOR

is proud to announce partnership with Medical Forum

Dear Clinicians, I am delighted to announce that Clinical Labs will now partner with Medical Forum to provide regular insights into clinical pathology practice and pathology news.

Clinical Labs is one of the country’s largest providers of pathology services to public and private hospitals in Australia. We are leaders in molecular testing and are reshaping traditional pathology practice through innovations in precision and personalised medicine.

We employ 3,800 people, including over 90 pathologists who use a single lab information system to manage routine, urgent and specialised testing, validation and reporting for our patients and clinicians. Our 88 NATA accredited laboratories perform around 8 million episodes a year.

We recently announced two strategic national partnerships: one will place Clinical Labs at the forefront of genomics research and testing capability, and the other aims to bring the first non-invasive melanoma test to market under the trademark Melaseq™. For more details, visit www.clinicallabs.com.au.

Overall, our company values close collaboration with our clinical referrers, supporting them through digital platforms that manage our patients’ health, quickly, efficiently and confidentially.

Here in our WA business, we employ over 680 people, have six labs that manage over a million episodes a year and we operate 148 licenced collection centres in convenient locations.

My WA team is also very excited to share news about the recent appointments of two outstanding, internationally recognised Pathologists: Dr Zena Slim and Dr Philip Kaye. I hope you enjoy reading more in their biographies below.

I believe 2019 is going to be a terrific year for Clinical Labs, so please do not hesitate to get in touch if you would like to find out how we can support your practice.

Warm regards,

Shae Seymour WA Chief Executive Officer

Welcoming our new Pathologists DR ZENA SLIM

DR PHILIP KAYE

Dr Slim graduated from the University of Southampton (UK), and trained in anatomical pathology in the UK and New Zealand. Skin pathology and gastrointestinal pathology are her particular areas of interest. However, experience in Cellular Pathology (UK) and recent achievement of Fellowship of the Royal College of Pathologists of Australasia provide a much broader base to her areas of expertise.

Dr Kaye graduated from the University of Cape Town in 1988 with First Class Honours. In 1991, he began his pathology training, electing anatomical pathology as his area of specific interest and completed his training in 1996.

Following his appointment as a Consultant at the Groote Schuur Hospital, in 1999 Dr Kaye worked in general histopathology at Kings Mill Hospital in Mansfield (UK).

Dr Slim's training in pathology at Christchurch Hospital in New Zealand exposed her to a wide range of skin conditions, including a high rate of skin cancers. She also worked as a Senior Fellow in the Sarcoma Unit of the Royal Marsden Hospital in London, gaining experience in soft tissue pathology.

In early 2018, Dr Slim worked closely with world-renowned Dr Eduardo Calonje (co-author of McKee’s Pathology of the Skin) at St John’s Institute of Dermatology. Dr Slim is developing her expertise in molecular pathology and recently gained a Postgraduate Certificate in Cancer, Molecular Pathology and Genomics from Barts Cancer Institute at the University of London.

Dr Kaye then transferred to the Queens Medical Centre at Nottingham University Hospital (UK), specialising in gastrointestinal (GI) and skin pathology. Over the course of his career, Dr Kaye has concentrated on GI, hepatobiliary/pancreatic and medical liver conditions, while maintaining a keen interest in head and neck, skin and thyroid pathology.

He is an active researcher, especially in the areas of Barrett’s oesophagus, oesophageal cancer and non-alcoholic fatty liver disease.

Dr Kaye is also active in education, holding the program director role for histopathology training in the region. Over the past five years, he has been heavily involved with examinations at the Royal College, as the national lead for the histopathology RCPATH part-one exam. Dr Kaye has helped develop a number of UK and European gastroenterology guidelines and has delivered lectures at many national and European meetings in GI, liver and HPB cytology related topics. He is a member of the British Society of Gastroenterology, and served for the past 10 years on the Pathology Section Committee.

23 Walters Drive, Osborne Park WA 6017

26 Leura Street, Nedlands WA 6009

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FEBRUARY 2019 | 5

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ED wait and mental illness The Australasian College of Emergency Medicine (ACEM) has welcomed the WA Government’s move to introduce mandatory reporting of cases involving extreme emergency department waiting times for specialised mental health care. Mental health patients make up only 4% of ED presentations but they are much more likely to stay there for longer than eight hours experiencing aggravating stimuli that make EDs particularly inappropriate for people with mental ill health. ACEM President Dr Simon Judkins said long waits for these people “are harmful and discriminatory”.

The Northern Territory government recently announced a similar step.

Drs Kelly Langford, Tamisha King, Heather-Lynn Kessarls, Shauna Hill and Adriane Houghton

Big but better?

AHPRA and the National Boards have released their annual report for 2017-18.

This organisation has become unwieldy but its size brings no economies of scale as far as registration fees are concerned.

The report highlights its “multi-profession approach to risk-based regulation across the work of the National Registration and Accreditation Scheme” and, as far as the medical profession is concerned, points to its size: more practitioners (702,741 across the 15 regulated professions); ability to keep registrants “trained, qualified and competent” using “over 740 accredited approved programs”; but paradoxically AHPRA received 7276 notifications, “an increase of 5.5% nationally (1.6% of all registered health practitioners)” with the “top three related to clinical care (41.0%), medication issues (12.6%) and health impairment (8.9%)”. There was no mention of milestones around veracity of complaints and communication with practitioners, topics dealt with by the Snowball report.

Though it did say it was “ensuring public safety through monitoring and compliance (5005 practitioners in 2017/18” and through 13 proceedings in the court).

RDAA at the pay table The ACCC has authorised the Rural Doctors Association of Australia to negotiate contracts for the next 10 years with hospitals and health facilities on behalf of rural doctors providing services

Indigenous women break through Five Indigenous women were among 206 UWA students to graduate before Christmas.

Tamisha King, Adriane Houghton, Heather Kessaris and Kelly Langford were awarded a Doctor of Medicine and Shauna Hill was awarded a Bachelor of Medicine and Bachelor of Surgery. Dr King, from the Kimberley, has started her internship at RPH; Dr Houghton, from Port Hedland, a single mother of two aged six and 10 has also started at RPH; Dr Kessaris is from the Northern Territory; Dr Langford, from Fraser Island and Cape York started at Fiona Stanley Hospital; and Dr Hill, from Perth and a single mother of three aged 13, 19 and 20, has started at RPH.

as independent contractors. That is, GPs, locums and other rural doctors, working as VMOs in public hospitals and health facilities. RDAA powers extend to including after-hours services and other primary health care services. Broadly, the ACCC may grant authorisation when it is satisfied that the monopoly agreement offers greater public benefit than any public detriment.

GPs in demand A report on Australian general practice by the Department of Health and NPS MedicineWise shows that the three most frequent reasons why patients go to a doctor are to obtain a prescription, a review of their conditions, and for upper respiratory tract infections. The top five chronic conditions were hypertension (high blood pressure), depression, dyslipidaemia (high cholesterol), anxiety and asthma.

The findings were derived from information from 2.1 million patients who attended 475

general practices across Australia. The report shows that GPs most frequently prescribed penicillin, antidepressants, opioids, and drugs for peptic ulcers and reflux. It also shows that 42% of patients had at least one pathology test. For the full General Practice Insights Report 2016-17, go to www.nps.org.au

More focus on dementia Dementia Australia claims that aged care may be prioritised nationally but dementia is still not core business. More than 50% of people in residential aged care have dementia and 76% of the 436,000 Australians with dementia are living in the community. The $552.9 million allocated to aged care funding includes a focus on improving access to GPs in residential aged care, more support for homelessness and regional and remote services, and an additional 10,000 high-level Home Care Packages. The three key issues flagged

Cost of the Big Dry A UNSW report says the “world’s water supply is shrinking”. The culprit is the drying of soils according to an exhaustive global analysis of rainfall and rivers in 160 countries. Drier soils soak up more of the rain, so less makes it as flow into rivers. For every 100 raindrops that fall on land, only 36 drops are ‘blue water’ – the rainfall that enters lakes, rivers and aquifers and is extracted for human needs. The remaining two thirds of rainfall is mostly retained as soil moisture – known as ‘green water’ – and used by the ecosystem. Drier soils, coupled with the contraction in the geographical spread of each storm event, means extreme rainfall in non-urban places is not resulting in necessary flooding to refill dams. One suggestion is to re-engineer water systems where water supply is shrinking – decrease water-intensive farming, while expanding reservoir storage capacities.

Places such as Arizona and California receive barely 400mm of rain each year, but have engineered their water supply systems to make previously uninhabitable places liveable.

Scientists urge that the cost of inaction could be disastrous. Global economic losses are expected to double from $20 billion over the next 20 years.

6 | FEBRUARY 2019

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by people living with dementia are timely access to diagnosis and support, reducing discrimination and the provision of quality residential and community care services that are underpinned by an appropriately trained workforce.

OncoRes capital raising Perth medical device company OncoRes Medical is one of three finalists in the international ‘Entrepreneurs of the Year’ award. It is developing a microstructure imaging tool to improve the outcome of breast cancer surgery and, as part of the award process, pitched their product to Prince Andrew. OncoRes, which has received $6m venture capital from the Medical Research Commercialisation Fund and hopes to raise $15m to help progress through FDA approval and pivotal clinical trials. OncoRes Medical’s goal is to provide surgeons with an image that shows residual cancerous tissue remaining within the breast, reducing the need for repeat surgery (currently, it occurs in 30% of cases). Prof Christobel Saunders is leading the clinical development.

Regional developments The last of the big hospital spend is coming to fruition with the opening of the new Onslow Hospital and the redeveloped Wyalkatchem-Koorda Health Service.

The Onslow hospital has an expanded emergency department with three acute

care bays and one resuscitation bay; a six-bed inpatient unit, a medical imaging room and a new dental clinic. It has been partly funded by the Chevron-operated Wheatstone Project, as part of its $250 million commitment to upgrading Onslow's social and critical infrastructure. The $4.2 million Wyalkatchem-Koorda Health Service redevelopment includes a new activity room, refurbished patient bathrooms, a new consult room and private triage room adjacent to the emergency department.

ACCC watching insurers The ACCC annual report into private health insurance has found that more people were either abandoning their private health insurance policies or downgrading to lowercost, lower-benefit products as premium increases continue to outpace inflation and wage growth. The report warned private health insurers that in the light of the mandatory policy adjustments to take effect on April 1, they must provide clear, prominent and timely communication with customers regarding changes. If they don’t the ACCC will be watching. By the numbers, in 2017-18, consumers paid about $23.9 billion in private health insurance premiums, an increase of almost $834 million or 3.6% from 2016–17. Hospital benefits paid by health insurers was $15.1 billion and the amount of extras benefits paid was $5.2 billion. As of June 2018, 45.1% of the Australian population held hospital-only or combined health insurance cover, a decrease of 0.9 of a percentage point from June 2017. The proportion of the population holding extras-only policies increased from 8.9% in 2017 to 9.2% in June 2018. About 88% of in-hospital treatments were delivered with no gap payments while the average out-of-pocket expenses from hospital treatment increased by 3.3%.

Sharing data for research

Artificial womb breakthrough Researchers from WA’s Women and Infants Research Foundation (WIRF), UWA and Tohoku University Hospital in Japan were rewarded for their ingenuity when their project to create an artificial womb to save extremely premature babies (22-23 weeks), achieved accolades from the NHMRC. The EVE Therapy which uses an amniotic fluid bath linked to an artificial placenta has shown that premature lambs continue to grow during the two week-long incubation, and show no ill-effects when they are later delivered. Head of WIRF’s Perinatal Research Laboratories and Local Chief Investigator, A/Prof Matt Kemp (pictured), said the Category 7 NHMRC result was great reward for the entire project team and represented a significant milestone in the technology’s future implementation into clinical use.

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An interesting report came across the desk recently by researchers from Capital Markets Co-operative Research Centre (CMCRC), Digital Health CRC and Research Australia into the poor data linkage opportunities for Australian researchers. The Flying Blind report suggests that the good research being done by the 340 research organisations across the country never reaches translational potential because of the blurry bureaucracy of obtaining linked data. They write that this problem does not stem from consumer unwillingness to participate in health research or a lack of technological capacity but rather stultifying risk aversion and fragmentation. “Until we release data for research we are holding back on active industry involvement and technological innovation,” they write. Data security, privacy and confidentiality were not the monopoly of Australians, and many countries such as the US and the UK have developed data governance frameworks and policies that enable efficient data release for research and research translation to policy and practice.

The Perron Institute has awarded Dr Srimathy Vijayan (Royal Perth Hospital) a research scholarship for work on deep brain stimulation (DBS) on sleep and Dr Shereen Paramalingam (Fiona Stanley Hospital) a scholarship for work around respiratory function in people living with Parkinson’s disease.

The WA Government has committed $5.93 million to transform the former Geraldton Sobering Up Centre into a new, 10-bed community mental health service providing short-term residential care.

The former Chief Justice of the Supreme Court, Wayne Martin, is the new chair of the Harry Perkins Institute of Medical Research. He replaces Larry Iffla, who has stepped down as chair but will remain on the board.

Former Federal Court Judge Richard Tracey has been appointed a Commissioner for the Royal Commission into Aged Care Quality and Safety replacing Justice Joseph McGrath. Mr Tracey has begun work last month with fellow Commissioner Lynelle Briggs.

Former UWA medical student Dr Catherine Nguyen, 24, has been awarded the AMA Gold Medal for achieving the highest aggregate mark for all core units over the four years of the Doctor of Medicine course.

Health Minister Roger Cook has announced a two-year $550,000 partnership between Healthway and Football West to improve club environments for children and young people.

Adrian Munro has been appointed CEO of Richmond Wellbeing. He has been the organisation’s Executive Manager of Operations since 2012.

Surfing WA has been awarded a $290,000, two-year Healthway partnership to deliver skin cancer prevention education to about 130,000 Western Australians.

Eleven researchers will share $1 million with the inaugural Western Australian Health Translation Network (WAHTN) Early Career Fellowships.

Funds have been made available from the Commonwealth Medical Research Future Fund (MRFF). They are: Dr Gail Alvares (TKI); Ms Jodie Armstrong (Curtin University); A/Prof Fenella Gill (Curtin); Dr Ariel Mace (CAHS/SMHS); Dr Luke Marinovich (Curtin); Dr Ashleigh McEvoy (ECU); Ms Belinda McLean (CAHS/Curtin); Dr Jing Pang (UWA); Dr Janessa Pickering (TKI); Dr Roslyn Ward (CAHS/Curtin); and Dr Yue Wu (TKI).

FEBRUARY 2019 | 7

Riding to Give Hope to Kids As surgeon Dr Sue Taylor prepares for the sometimes gruelling Ride for Youth, she reflects on the impact the event has on the vulnerable and those who participate.

The care doesn’t stop with the young people. We chatted and shared with their parents, with their teachers. And with each other.

Why am I and my colleagues involved in the Hawaiian Ride for Youth? Suicide is the biggest killer of young Australians. Too slowly, our society is realising that mental illness is an issue that people suffer from, rather than a personality or character flaw from which there is no escape.

The feelings of isolation, despair and hopelessness are not just a normal part of growing up.

The Hawaiian Ride for Youth is known as one of Australia’s best leading charity and fundraising events, and has been growing over the past 17 years, raising funds to support counselling services in our high schools and communities, both rural and urban.

School visits which encourage kids to speak up if they are finding life hard, or to offer help if the need arises have profound impacts on the children as well as the teachers and parents.

One-on-one counselling is available, with face-to-face consultations where possible, and web counselling where necessary.

Access to this service has been increasing into areas of significant unmet need.

But the ride is about much more than raising funds. I saw my own kids bright with

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INCISIONS

Yes, riding 100km against the Geraldton wind in 46 degree heat was tough. But the experience of teamwork and camaraderie, as well as conversations about topics not normally shared with our close friends, let alone people from all different walks of life, made it a very fulfilling and refreshing journey.

new compassion for themselves and their friends after a school visit by Youth Focus.

During Ride Week in 2018 I sat next to a young man in a rural gymnasium (in all my Lycra glory) who was clearly transfixed by the revelation of a real life story being shared up the front: not by a trained psychologist or evangelist, but by a successful businessman – a person you would never guess had struggled with inner demons.

The young people and their teachers recognised that we were visiting their small town not for our own profit or glory. We were there to help because we care.

The leading causes of death and impaired quality of life in Australian adults are related to smoking and obesity. Both can be treated, but it is preferable to prevent them.

Dysfunctional coping mechanisms for anxiety and depression frequently involve food and drugs. I can’t do much about the latter, but the medical profession can help change habits, help with goal-setting and finding a sustainable long-term healthy diet.

Perhaps if the Hawaiian Ride for Youth is successful in reducing the burden of mental illness in our young people, there will be a reduced need for our weight loss services in the long term.

ED: The 700km Hawaiian Ride for Youth takes place on March 26-30. To donate https://www. rideforyouth.com.au/donate/

continued from Page 4

and that assistance, if proffered for nonmalicious purpose, is not a crime. It has nothing to do with sickness or severity of disease. And the role of the medical profession is minimal, an assessment of mental capacity. With mental capacity, sick or not, non-malicious assistance is lawful.

And here in the Netherlands, my new home, there is active discussion and proposed legislation about whether every person over 80 years of age should be issued Nembutal on request – as their right, not just a privilege for the sick.

In Switzerland David Goodall didn’t have to play the sick role to qualify. He had mental capacity, and that was enough.

I think WA has missed an important opportunity; a chance to do something truly innovative, legislating to clearly establish that

8 | FEBRUARY 2019

a peaceful reliable assisted death is a right of all rational adults. Instead they chose the safe and restrictive path that forces the sick to look sicker, and turns doctors into police.

and appear to be lifted from the Medical Boƒard website:

Philip Nitschke, Director, Exit International ......................................................................

• provide medical treatment or opinion about the physical or mental health of an individual • prescribe or formally refer to other health practitioners.

Correction Retired pathologist Dr Nick Smith pointed out an important typo last edition (P19, Senior Docs in AHPRA’s sights?), where in the first paragraph ‘can’ should be replaced by ‘cannot’. A serious error as it turns out. For those interested, Nick has provided this link https://www. medicalboard.gov.au/Registration/Types/ Non-Practising-Registration.aspx and these words of clarification (restricted to doctors with non-practising registration)

“Medical practitioners with non-practising registration must not:

Non-practising practitioners seeking to prescribe and/or refer to other health practitioners may apply for general or specialist registration and will need to meet the Board’s registration standards for: • continuing professional development • recency of practice • professional indemnity insurance arrangements • criminal history”

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FEATURE

WA Moves on Cannabis Green Light It’s taken years of effort but the momentum for medicinal cannabis is gathering pace among both consumers and doctors.

E

ighteen months since the Therapeutic Goods Authority paved the way for the legal prescribing of medicinal cannabis, WA has seen the opening of two bricks and mortar clinics, both in the Subiaco area, and a clutch of solo doctors, predominantly GPs, who are authorised to prescribe.

The average time for the approval process has shrunk from weeks to days and anecdotally, the number of patient inquiries has increased significantly. Across Australia approvals have begun to increase exponentially with just 500 approvals in the first year and over 1000 approvals in November and December last year.

Emerald Clinics, which is a WA company, and Cannabis Access Clinic, an Eastern States group, both opened in December.

And Emerald Clinics opens in Sydney in February with Melbourne, Brisbane, and Adelaide to follow. There has been a steady flow of patients and high demand since opening in December.

A board member of Emerald Clinics and well-known Perth GP and academic Dr Alistair Vickery is implementing the clinical set-up of the Perth operation. He is helping to train local GPs interested in practising at the clinic, as well as collecting clinical and

10 | FEBRUARY 2019

demographic data essential to develop research protocols to examine the efficacy of medicinal cannabis for specific medical conditions and co-morbidities.

“If we can improve and expedite the process which allows patients to access medicinal cannabis appropriately, we will be satisfied.”

Alistair spoke to Medical Forum before the clinic opened when he had been busy recruiting local GPs willing to undergo extra training in the form of online modules devised by Canadian physician Dr Danial Schecter.

That said, Alistair acknowledges that the process is significantly easier than 12 months ago and it is expected to get simpler as more quality clinical evidence emerges.

The Canada experience “Danial has a wealth of experience after a decade of prescribing medicinal cannabis and the research to back him up. We are fortunate to have his expertise. He’s helped me with the writing of the prescribing protocols, which are important because the regulations in Australia and especially in WA are rigorous and demanding,” he said.

“We are keen to build a working relationship with the local GP community, training and recruiting those interested in the use of medicinal cannabis, but more importantly building a shared-care model with the GPs managing such patients with complex issues to help with the prescription of medicinal cannabis across Australia.”

“The TGA has strict regulations regarding who and what they will approve for the prescription of cannabis. Currently, in WA we have an additional barrier to prescription through a secondary statebased process, in contrast to the other states in Australia.”

“I agree that some of the clinical evidence is patchy but that’s not to say there is no evidence for medicinal cannabis. For some conditions such as multiple sclerosis, CINV and chronic neuropathic pain, the TGA agrees that there is sufficient evidence for its prescription,” he said.

Globally it is being studied for • Chronic neuropathic pain • Chemotherapy induced vomiting and nausea (CINV) • Parkinson’s disease • Treatment-resistant epilepsy • Some insomnia and night time agitation particularly in the elderly In WA, studies are being conducted at UWA (sleep) and Curtin (pancreatic cancer) and Emerald Clinics has embarked on its own data collection for patients with specific conditions to improve the knowledge and evidence base.

Cannabis v opioids “The question I would like to ask of a study is whether the use of medicinal

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FEATURE “The THC dose is smaller, especially as we are giving it with CBD, and that combination has been shown to be efficacious and cause fewer negative side effects.”

Dosage and prescribing Where evidence is needed is around dosage. Alistair said Silicon Valley research into prescribing algorithms could be immensely useful in the future.

cannabis is opioid sparing. The deaths from prescription opioids is an evolving and international crisis. If medicinal cannabis, which does not cause respiratory depression, is shown to reduce opioid use then that will be a major breakthrough.

Recent systematic reviews have suggested that this is the case but we need good RCTs or strong observational studies,” he said.

“So, the first clinical trial through Emerald Clinics will be to see if the use of medicinal cannabis reduces the use of opioids. Every patient going through the clinic will be asked to contribute to the data.”

In the broader context, Emerald Clinic is not just about giving West Australian patients access to a pure, legal cannabis product, it also opens a dialogue with West Australian doctors who may be curious about the product and what it can do for some of their patients.

When Medical Forum explored this issue 18 months ago, there was an ambivalence at best among local doctors and open hostility among others. Some pain specialists were particularly vocal in their opposition.

Faculty Views The Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine (FPM) released a statement on medicinal cannabis with particular reference to its use in the management of patients with chronic non-cancer pain.

In the statement it acknowledged the changed regulatory environment for the use of medicinal cannabis and “recognises both the political imperatives underpinning these changes and the community demands that have generated them”.

However, that’s where the love stops. It goes on to state that the FPM adhered to the principle that drugs intended for therapeutic purposes be registered; that patients’ socio-psycho-biomedical needs required strict management particularly associated with polypharmacy; it criticised the lack of what it describes as “scientific evidence” for this cohort; the “adverse event profile of cannabis users, especially in young people” was also concerning;

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and while it acknowledged that trials of medicinal cannabis in isolation were difficult, it believed “that if pragmatic trials of cannabinoids are considered to be necessary, they should be conducted on a coordinated national basis”.

Cannabis and doctors Fast-forward to February 2019 and there are some local pain specialists who are interested in seeing what medicinal cannabis can do in a controlled clinical environment.

Alistair said there was positive support from senior pain specialist Dr Phil Finch and Dr Jen Morgan, who is the head of the acute pain unit at SJG Subiaco Hospital.

He said they had both seen medical cannabis have a positive impact on some of their patients’ recalcitrant pain.

“Doctors – GPs and specialists – are facing an inundation of requests for medicinal cannabis. We have seen some data where 50% of people with chronic neuropathic pain had tried recreational cannabis to control their pain and 30% are taking it regularly,” Alistair said.

“Some who tried it don’t like it, but some stopped taking it because it is illegal.

Patients are being criminalised to get access to cannabis. Essentially that is the problem.”

“If half the people with neuropathic pain are having to buy it from a local illegal dealer and a third of them believe that the illegality is confronting yet are prepared to continue to access illegal drugs for their pain, you have to make some rational conclusion that the stuff must work.”

Alistair has held two seminars for GPs where the most persistent issue raised is patient safety. How does medicinal cannabis differ from illegal cannabis, which is known to do harm for some?

“The typical joint has somewhere between 150-250mg of THC depending on the quality and method of absorption, the drug we are prescribing (at a dose of between 1-3ml a day) is effective at much lower oral doses of 10-30mg of THC often in conjunction with cannabidiol (CBD),” he said.

“If you were to ask me where the weakness is in cannabis research, it’s in the variety of products and combinations of active compounds used in research from whole leaf, with over 450 organic compounds, to highly refined product with one active compound such as THC or CBD.” “People are using different combinations, dosages and excipients for absorption, partly because it is such a complex botanical with over 10,000 years of use for the management of a variety of illnesses.”

“Much of the research is not comparing like with like. It is not the same as, ‘here take 150mg of pregabalin’. That’s why there is so much mainstream scepticism.”

“It’s not true there is no research to support the use of medicinal cannabis. The evidence demonstrates its usefulness with the widespread use of nabiximol (Sativex) to improve spasticity in multiple sclerosis.

It’s just difficult to sift the research in order to be able to compare apples with apples.”

“Emerald’s research will focus on THC and CBD, which are the compounds shown to be effective, and we will be looking at the oral dosing structure that will give the best outcomes, because the product is currently expensive.”

Patients need a referral from their treating doctor to book an appointment at Emerald Clinics. The patients undergo a rigorous initial consultation to screen for suitability followed by close ongoing clinical monitoring once the prescription has been approved. The real expense is the drug itself, which can be about $10-15 a day on a 2-4ml a day dose.

Eyes on the trials Patients won’t be the only ones keeping an eye on cost. As medicinal cannabis becomes more accessible, and if it is proven to be efficacious and reduce opioid usage, it will become a significant issue for governments, health insurers and Big Pharma – none will want to see this ship sail without them.

Cannabis Access Clinics’ Dr Sanjay Nijhawan spoke to Medical Forum from CAC’s offices in Sydney. He said there were a number of ways for patients to come into Cannabis Access Clinic.

continued on Page 12

FEBRUARY 2019 | 11

continued from Page 11

WA Moves on Cannabis Green Light “We accept self-referrers, who will be screened by one of our ‘patient champions’ or by one of our GPs. If the screening proves it appropriate, the patient will go to pre-approval consultation where they will be examined by tele-interview,” he said.

“Or patients can be referred by their GPs or specialists and then go through the same process of evaluation after which, if appropriate, we will set up the approval process.”

“Ultimately the doctor who fills out the paperwork gets their name against that patient’s, so system is the same for all three levels.”

In Perth, Mandurah GP Dr Berenice Blakemore will do some of Cannabis Access Clinics’ face-to-face consultations at the Subiaco clinic but with telehealth, Sanjay said it could cover much larger parts of the state.

“WA is a big state and there are people all over who want to access medicinal cannabis and GPs and specialists are not trained and don’t understand the drug well enough,” he said.

“We, as a medical fraternity have a standard of double-blind studies, which sets the bar. So, before we believe in a drug, every pharmaceutical company needs to tell us about their studies of 20,000 or 30,000 participants, then we evaluate and cause no harm.”

“Marijuana has been taken medicinally for thousands of years but we don’t have those double-blind studies. Our workforce is not trained. Doctors will often write a letter saying they cannot recommend this medication because there is not enough data. However, what clinics are trying to do is open up the channels.”

Sanjay, as a former head of clinical for Primary Healthcare Group, understands how essential communication is for the team managing patient care. CAC has established a similar process of communication.

“We write back to referring doctors telling them what we have done to their patient and what we would like them to review, so there is a dialogue,” he said.

On costs, Sanjay said CAC, which has

clinics in NSW, Queensland and Victoria, had published a pricing report which found a substantial decline in costs – between 50-60% – since January 2018, partly as a result of more reliable supply and increasing demand.

Currently Canada supplies most of the cannabis product but as local producers come on line – Little Green Pharma in WA is now in production – supply issues will impact less on cost.

However, costs will vary on what conditions it is treating. Sanjay said in his clinical experience, pain patients could be looking at $360-$400 a month while epilepsy patients, $600-$1000.

“But that also is highly variable depending on usage, be it oil, spray or wafer.”

In this dynamic clinical and commercial landscape, the old prescribing adage might be appropriate – start low, start slow.

By Jan Hallam For Cannabis Assessment Panel update see page 20.

continued on Page 20

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Sky Safari Scores for RFDS After a stint at Kalgoorlie RFDS, UK-trained Dr David Jones discovers just how big the Wide Brown Land really is.

Dr David Jones RFDS air race

T

here’s something very special about seeing the Australian bush from the air and a stint with RFDS Kalgoorlie inspired Dr David Jones to enter the Classic Safari Outback Air Race in late August 2018. More than 40 aircraft and 100 competitors took to the skies to raise funds for the RFDS.

“The overriding feeling was one of great awe,” said David. “So many people coming together for a unique event that ended up raising more than $500,000. And, in doing so, we flew across this great country from coast to coast departing Archerfield, Brisbane on August 19 and finishing in Broome 11 days later.”

To call it a ‘race’ is something of a misnomer because it’s actually a GPS Navigation Time Trial in which pilots nominate an elapsed time between two visual waypoints and then receive points for accuracy.

“We had two pilots onboard, one of whom was me, and one passenger who came along to enjoy the ride. The aircraft was a Cessna 182 with fixed undercarriage and the entire journey was conducted under Visual Flight Rules (VFR) so any tricky weather made things pretty interesting.

And it almost did! We picked up the aircraft in Langata, Victoria, and the weather was very much like an English winter – strong winds and hammering rain – and we

14 | FEBRUARY 2019

struggled to find a suitable break to get across to Archerfield for the start.”

“It was touch and go for a while but we made it.”

David is well used to English weather conditions.

Determined to fly “I did my medical training in the UK and the placement at RFDS Kalgoorlie was part of my final year elective at Manchester Medical School. It took three years of sheer bloody-mindedness to organise it! Finally, someone said ‘well, just rock up here and we’ll see what we can sort out’.”

“So, in early 2007 I did exactly that and had a wonderful time in Kalgoorlie learning all about remote and aeronautical medicine and qualified later the same year.”

“I was bitten by the flying bug when I was with the RFDS and received my Private Pilots’ Licence about 18 months ago from the Royal Aero Club of Western Australia.

It’s a fairly pricey undertaking and obviously not everybody is in a position to pay for the lessons. I’ve got about 100 hours in my pilots’ logbook now. The Outback Air Race certainly added to the total.”

A big part of flying aeroplanes is the thrill of the unknown and, when the rubber leaves the runway, a lot can happen.

“We had quite a bit of rough flying over the Great Dividing Range near Brisbane, in fact

it was hellishly turbulent and the aircraft was getting chucked around a lot. But the hairiest moment was probably when the aircraft started arriving in Mount Isa.” “With around 40 aircraft in this race it was inevitable that quite a few of us would arrive at a destination at roughly the same time and that can be difficult because you need to keep a good look-out and monitor the radio to find out where all the other aircraft are in the circuit area. Most of the airports don’t have a control tower so there’s no one directing you, but we managed things pretty well.”

“We had three pairs of eyes in the aeroplane and that helps a lot!”

Feat of navigation “There were a few teams that were very competitive but the rest of us weren’t so inclined. We were there to look out the window, enjoy the view and fly as safely as possible. The aim was to fly over a navigation exit point such as a communications tower or a river crossing at a stable height and then estimate the time it would take to complete the entire sector.”

“There’d be shadows flitting across the ground that would make things interesting but it was all good fun.”

David has some wonderful memories of his time with RFDS and shares a few anecdotes with Medical Forum readers.

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SPOTLIGHT

“Obviously a lot of our work was medical emergencies such as car accidents and domestic violence. We had one case where the wife stabbed her husband and they were still arguing the point when we loaded him into the aircraft!”

“There were many paediatric and obstetric cases that we dealt with in pre-arranged, regular clinics. We’d fly out along the Eyre Highway to Eucla and then come back along the roadhouses where we’d land and do a series of consultations.”

“The whole experience was brilliant and absolutely fascinating!”

David makes the point that WA will benefit enormously from the funds raised by the Outback Air Race.

RFDS WA boost “RFDS WA is soon to receive two new PC24 aircraft, I think early this year is the scheduled delivery date. They are highly sophisticated jet aeroplanes, which will halve the sector time between the Kimberley and Perth. They cost around $16m each, so it’s a significant investment.”

“And I’ve been reliably informed that the complete medical fit-out is almost as much as the price of the aircraft!”

But, as David is quick to reinforce, it’s all about the people.

“It takes a lot of hard work and dedication to do this job properly, and that’s not just the doctors either. The nurses actually do the bulk of time in the air and the pilots are often confronted by some very challenging circumstances.”

“The RFDS is a wonderful service providing high quality health care to rural and remote Australia. I’m very proud to have worked with all these amazing people!”

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FEBRUARY 2019 | 15

SPOTLIGHT

Annual Conference 2019 HEALTHY COUNTRY HEALTHY LIVES 23 and 24 March 2019 | The Westin Perth

The Rural Health West Annual Conference brings together influential and topical speakers to discuss the interplay between the environment, our communities and our health.

Country and metropolitan doctors are welcome to register.

KEYNOTE SPEAKERS Professor Paul Worley

Mr Steve Plain

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Emeritus Professor Paul Worley was appointed as Australia’s first national Rural Health Commissioner in November 2017. He is passionate about Australia’s rural and remote communities and health professionals deserving an evidencebased, sustainable, cost effective and well supported rural health system.

Dr Christine Jeffries-Stokes and Annette Stokes Kupi: drinking water and chronic disease in remote Australia Christine (pictured right), is a paediatrician who has been working in clinical practice and research in the Goldfields. She is the Chief Investigator for the Western Desert Kidney Health Project which has demonstrated innovative methods of community engagement.

Overcoming an almost fatal injury, Steve Plain’s incredible completion of the Seven Summits in record time has landed him the Australian Geographic Adventurer of the Year award. Steve will share the highs and lows of achieving his goal of reaching summits on each continent.

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WAR ON WASTE Healthy lives through care of the environment Craig will share his War on Waste journey and address how we can make our country healthy and preserve the environment for future generations. He is best known for his work with The Chaser and going through your bins on the TV program War on Waste.

REGISTER NOW – DON’T MISS OUT ON THIS GREAT CONFERENCE Visit www.ruralhealthwest.com.au/conferences This conference is proudly delivered by Rural Health West in partnership with WA Country Health Service through the Better Medical Care Initiative.

16 | SEPTEMBER 2018

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FEATURE

Autism Guidelines – why do we need them?

The guidelines are not about treatment. Instead, they map out the assessment and diagnosis of Autism Spectrum Disorder using a consensus definition, lacking until now.

T

he 2015 survey by Autism CRC confirmed anecdotal experience of considerable variability in the diagnosis of autism, whether by a multidisciplinary team using rigorous standards or a solo clinician. This huge variability in diagnosis across Australia has in turn led to inequities in access and service delivery. According to Prof Andrew Whitehouse such inequities went against the grain of most Australians.

“It was a really important to develop guidelines that allow the clinical community to speak with a common definition,” he said. “One of the great achievements is that everyone has provided input and come to an agreed position. There are different views between different stakeholders but everyone has kept health care and the child in the front of their mind.”

Consensus gained “If Australian society agrees that we need to provide every child with the best chance in life and then develop healthcare to suit, then it is our professional responsibility to adapt to those standards.”

Paediatricians, psychologists, speech pathologists and psychiatrists are mainly involved. Gaining consensus at a national level has not been easy, requiring a lot of committee work and spades of diplomacy.

A single definition has been achieved in a document that doesn’t feel watered down or ‘dead by consensus’.

“It was a two-year process of hard research and long and productive consultation with all the main stakeholders – all provided positive feedback,” he reflected.

What’s in a diagnosis?

But how much of diagnosis is money driven?

Parents may want an autism label on their child to claim support from government?

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“I have no valued judgement on this whatsoever. Many kids require support that don’t have autism. If an autism diagnosis helps get support then it is difficult to argue against it. In the guidelines we say that diagnosis-based funding is a very flawed model because it drives compromised clinical behaviour, that is, a label applied to kids who don’t necessarily qualify. Instead, support based on functional need is the way to go.”

He acknowledges that the core attributes of autism can vary greatly, hence the inclusion of “Spectrum” in the name.

“On the one hand, you might have someone with limited verbal language, intellectual disability, difficulty toileting themselves, and little hope of independent functioning, all the way to children who interact socially, are able to complete formal education, and hold down stable employment.”

“Autism is a prominent public health issue and there are many parents doing it tough because we are not providing sufficient support for these children to reach their full potential.”

He hopes the Guideline will be a step in the right direction.

“Most children are diagnosed with autism with a median age of about four years.

Prominent supports are behavioural, often aimed at behaviours in the home, at school, and to help them achieve independence.

“In amidst the hurly burly of clinical practice, we sometimes forget that kids grow into adults, and so keeping a focus on how interventions help that person maximise their strengths into and beyond adolescence must be a prominent focus.”

Effects outside health It must have been like trying to herd cats when it came to gaining guideline consensus from clinicians. But how do schools fare given teachers spend a lot of time with affected children?

“One big challenge is that autism is prominent within three government departments – disability, education and health – and autism often slips through the cracks. The worth of the Guidelines is entirely dependent on how they are used and the indications from the Health Department are good so far, making this a prominent document. It’s really important now that education also adopts this as we need to all speak with one voice.”

So everything depends on how the Guideline is used by various lobby groups, something Prof Whitehouse has limited control over.

ED. For those interested, non-invasive registration at www.autismcrc.com.au allows download of full documentation of which the “Summary and Recommendations” is recommended.

By Dr Rob McEvoy

DEFINITION OF ASD “ASD is the collective term for a group of neurodevelopmental disorders characterised by persistent deficits in social communication and social interaction, and by repetitive patterns of behaviour and restricted interests. The behavioural features that characterise ASD are often present before three years of age, but may not become apparent until the school years or later in life. The developmental challenges, signs and/or symptoms can vary widely in nature and severity between individuals, and in the same individual over time, and may be accompanied by mental and physical health problems.”

FEBRUARY 2019 | 17

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FEATURE

A Building Block for Secure Records

T

The case for using blockchain technology in the Australian health care sector is gaining more credibility as start-ups showcase its virtues.

he emergence and rapid growth of disruptive digital technologies and decentralised cryptocurrencies, such as Bitcoin and Ethereum, have brought with them an awareness of the distributed ledger technology that underpins these nascent currencies – that is, blockchains.

The doctor can use their existing prescribing software and the application then sends the prescription to the patient’s phone. The patient can then order their prescription from a pharmacy in the ScalaMed network and have it delivered to their home, making this a new paradigm in a heavily paper-reliant field, thanks to blockchain.

A blockchain is a ledger of linked records, referred to as blocks, that can record transactions efficiently, verifiably, securely and permanently. Health care in particular is seeing a large swell of interest, particularly within the patient information space.

Another variable in an application such as ScalaMed is the empowerment of the individual health consumer as they have complete control of their prescriptions and can easily access them to shop around for the best deal on medications.

The implementation of blockchain technology in the health care industry is in full swing with a number of Australian based companies taking up the charge.

The advantages of patients having access to their prescription history go beyond their individual convenience. There are also positives for practitioners. For instance, if an individual is hospitalised or changes general practitioners, the patient could provide access to their ScalaMed records and doctors can immediately see what medications the patient has, and is, taking.

Who is responsible for the accuracy and currency of this important information is uncertain.

One such company is ScalaMed, an Australian based start-up that is focused on streamlining the process of prescribing and dispensing medicine. In a nutshell, ScalaMed is a mobile-based application that will require the prescribing doctor, patient and pharmacy to be signed-up and integrated into the platform.

Complete med records

There are a growing number of blockchain projects infiltrating the Australian health care industry. Another is the joint venture between three organisations – Agile Digital, Vault Systems and Gulanga – and the federal Department of Health on the Secure Health Data Research and Analytics Platform (SHDRAP).

The aim of SHDRAP is to provide researchers with a centralised cloudbased hub of de-identified public health datasets without the risk of the patient health data contained in the datasets being re-identified. (Depending on the past techniques used to de-identify health records, the datasets could be re-identified leading to a data breach and privacy violation.)

Researchers would be able to access clean datasets within the hub without the requirement to download raw datasets, which almost always contain large amounts of non-required data that need to be cleaned. This can be a problem in itself because what is left once the datasets have been de-identified often contain incomplete data.

Although SHDRAP presented a test case,

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it demonstrated how blockchain could be used to protect patient privacy more effectively while also providing clean data for researchers.

If SHDRAP is rolled out, the opportunities for researchers and ultimately the Australian public are enormous.

MHR and blockchain The controversy surrounding My Health Record has provided opportunities for alternative means of health record storage and access while, simultaneously demystifying how digital health records can benefit patients and practitioners alike.

This is at the core of Wollongong-based start-up Secure Health Chain, which is

soon to launch a pilot program in the Gwynneville Medical Practice.

By using blockchain to create encrypted patient records, akin to digital passports and accessible via a smart phone application, Secure Health Chain aims to provide health consumers a secure platform for them to control their health records while providing medical practitioners and hospitals with accurate and verifiable records.

If this sounds a lot like My Health Record, it is, except the underlying framework is based on blockchain, which is far more secure and verifiable than the technology that My Health Record utilises.

Ultimately, a product such as Secure

Health Chain could face significant competition as the market recognises the benefits of providing an encrypted and impenetrable health record using blockchain. Or conversely, products such as this could serve as an impetus for My Health Record to utilise blockchain as the underlying framework for its network.

The applications and benefits of blockchain in Australian health care are numerous, both for patients, practitioners and hospitals yet the real hurdle is the acceptance of the marketplace to fully embrace the potential benefits of the technology, namely the security and verifiability of data.

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Prescribing Cannabis and WA Health The Cannabis Assessment Panel has been a source of frustration for would-be prescribers with some believing it to be an unnecessary layer of bureaucracy. Mr Keen said the panel was appointed to advise the Health Minister and the department CEO on regulatory and policy matters relating to cannabis based products, including those listed as S8.

Medical Forum asked the WA Department of Health’s Chief Pharmacist Neil Keen about the state-based approval process for S8 medicinal cannabis and the role of the Cannabis Assessment Panel.

He said the current approval process for a cannabis-based product includes online application via the TGA Special Access Scheme portal. The TGA makes an assessment relating to the clinical justification for using an unregistered therapeutic good.

“In parallel, the WA Department of Health will assess suitability by reference to the Medicines and Poisons Act 2014. This assessment will include a review of the patient history of prescribed and dispensed S8 medicines, dependence or misuse, drug-related psychosis and related risks, and other relevant concerns.”

“Where there are concerns of substance misuse, any authorisation provided may contain certain conditions relating to supply, usage or reporting, all of which are designed to reduce the risk of misuse.”

“The assessment and decision process now takes two business days. Authority

to prescribe is provided alongside any TGA approvals as a single response to the applicant. In some cases additional information may be sought and this may extend the time to providing a decision.”

“In many cases authorisation from the Chief Executive Officer (Director General) of Health is required. A decision on an application to prescribe S8 medicines is made by a delegate of the CEO, normally a senior medical officer of the Department of Health. There are administrative mechanisms that allow the delegate to refer complex cases for expert advice to assist in making a decision.”

“Members of the panel included a wide range of specialist practitioners covering most fields related to medicinal cannabis use. The Panel’s remit includes the assessment of applications referred by the delegate for advice on decisions to prescribe. Initially this covered all applications.”

“With the changes to streamline the national and state regulatory processes, the role of the panel has changed. It is now not routinely involved in individual patientbased decisions. The panel continues to provide expert policy advice and at present has a role in quality review of the decisions being made. The ongoing role of the panel is under review, in the longer term.”

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GUEST COLUMN

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GUEST COLUMN

More than Absence of Disease Busselton GP Obstetrician Dr Sarah Moore has drawn on the collaborative knowledge of other healing systems to serve her patients.

I was inspired to become a doctor when I was in Year 8 after hearing a nurse speak at our school assembly about her volunteer work in the Philippines with Operation Rainbow, performing surgery on children with cleft palate and other facial deformities. I was moved by this generous act to relieve suffering and in that moment I decided that medicine would be my path.

needed to initiate contact with a number of local holistic health practitioners who attended that event.

I felt strongly that our community needed a network of passionate, committed holistic practitioners to support it achieve good health.

The response to my invitation was overwhelming. More than 40 practitioners attended that first network meeting with discussions going late into the evening.

The energy in the room was electric. This meeting set the foundation for subsequent meetings, which focused on particular themes including depression, gut health, mind-body connection and relationships and healing. The Holistic Health Practitioners Network (HHPN) has met four

As a medical student and junior doctor, I was drawn to doctors who listened to their patients; who got to know them as a person and aimed to understand and relieve their suffering, not just treat their disease.

As a GP registrar, I became acutely aware that my medical knowledge was not always enough to relieve my patients’ suffering. I had been taught to treat and cure, but when their illness didn’t respond to my medical management, I realised the limitations of my training.

A year after my second daughter was born, I attended a yoga retreat where I met an Ayurvedic practitioner. She described this ancient science in simple terms, and suddenly I understood that there was more to health and healing that I needed to learn.

I became interested in learning more about the complementary health practitioners working in my local area, many of whom had been recommended to me by my patients. I realised I knew very little about what they did or how they helped patients, but it was obvious to me that they were having a positive effect.

Then, in November 2014, I was invited to attend a screening of the film Microbirth, organised by a local community member, Amy Garrett, at the Busselton cinemas. The post-film discussion, chaired by chiropractor Dr Esyllt Graham, was the inspiration I

After this event, I knew this was possible.

Early in 2015 I invited about 30 holistic health practitioners in the South West to attend a meeting in August to introduce ourselves and to learn about the various health modalities available in our region.

Around this time, I also enrolled in a Foundations of Clinical Ayurveda training course with the intention of deepening my own knowledge of this body-mind-spirit approach to health care. I completed this training in 2016.

times a year for the past three years, and our membership continues to grow and diversify.

It’s the networking that has been the highlight for me, and for many others, I am certain. The referral pathways that have developed and the collaboration between practitioners to provide person-centred, holistic health care to our community is powerful.

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GUEST COLUMN continued from Page 21

More than Absence of Disease Personally, I have seen a significant change in the patients I see, and in the way I approach their care. In particular, I have come to understand the difference between healing and cure.

Many patients who come to see me share how they have had doctors tell them there was nothing more that can be done for them; that they must accept there is no cure for their illness and that they must live with their suffering.

South West Wellness Expo was held in October 2016 in Busselton, with over 40 practitioner stalls and about 2000 people attending the event.

Since then we have held two more events, the most recent with a new name, the South West Wellness Festival, on October 28, 2018. These events have been successful in raising community awareness of a range of holistic and integrative ways to manage health.

After hearing their story and identifying the support that might assist in their healing, I have been able to refer these patients to a range of holistic health practitioners.

Although their disease remains, their symptoms have improved and their suffering has reduced.

Of course, there are still many challenges that keep my work interesting. I remain on a steep learning curve, constantly finding myself reflecting on my practice and the intentions underlying my work.

One of the early visions of HHPN was to create an event to bring together practitioners and community members.

Early in 2016, psychologist Jo Edmond shared her vision for a free event for families, children and teens featuring workshops and education opportunities to empower attendees to live healthier, happier lives.

There are times when practitioners within the network have conflicting beliefs to my own. I treat these as opportunities to listen without judgment and try to understand how the practitioner has come to form their belief.

We were overwhelmed by the enthusiastic response from network members and our local community to this idea. Our inaugural

If appropriate, I share my own views, based on my knowledge and experience, while at the same time acknowledging that

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everyone’s perspectives are unique, based on their own life and career journeys. We may not always agree, but we do maintain respect for one another and strive to work collaboratively, if possible, despite our differences.

Opinions of patients can also differ and I use the same approach – by listening and acknowledging their beliefs, they feel heard rather than judged; and feel safe to engage in a conversation, rather than withdraw and reject all advice from medical practitioners who aren’t willing to accept their beliefs.

In this way, we can negotiate and meet halfway, providing the patient with treatment options that they didn’t realise were possible.

In this way, medicine is very much a spiritual path for me. I am continually humbled by the wisdom of my patients and colleagues, who teach me so much about the value of patience, courage, persistence and kindness. I appreciate that I am a small part of the greater whole, and yet my contribution is important and valuable.

ED: Sarah's blog see www.drsarahmoore.com.

Holistic Health Professionals Network www.hhpn.com.au

FEBRUARY 2019 | 23

Probiotics, the “hot goss” of 2019?

By Dr Astrid Arellano, Infectious Diseases Consultant, Subiaco What is the evidence for probiotic benefit and is their cost justified?

What probiotic indications are backed by evidence and how many billion bacterial colony forming units (cfu) should be recommended for what conditions?

Outside the prevention of necrotising enterocolitis and serious sepsis in preterm infants as well as the prevention of Clostridium difficile diarrhoea in adults and children, the jury is out on probiotic use and their widespread recommendation not justified.

probiotic strain bloodstream infections in immunosuppressed individuals. This is an important caution in recommending probiotics in this cohort of patients.

Clostridium difficile diarrhoea There is moderately good evidence that probiotics, specifically the yeast Saccaromyces boulardii, prevent Clostridium difficile diarrhoea in adults and children. Treatment of recurrent Clostridium

The adult gut is an ecosystem consisting of over 500 bacterial species in a symbiotic complex relationship with the human host. Antibiotics are known to affect the gut microbiome reducing the variability of species and this is likely responsible for most antibiotic-induced diarrhoea*.

Probiotics are live microorganisms promoted to have beneficial health outcomes for a number of conditions.

Probiotics and antibiotic-induced diarrhoea (not due to C. difficile or other pathogens) Probiotics are promoted for restoring the gut microbiome and many patients are told that probiotics “have to be taken” whilst on antibiotics. However, there is no quality evidence that probiotics prevent antibiotic induced diarrhoea in healthy adults or that they “preserve good gut flora”. There is also debate and little evidence to back one combination of organisms over others.

In children with acute infective diarrhoea, particularly rotavirus, there is moderately good evidence for reducing the duration of the diarrhoea with Saccaromyces boulardii, Lactobacillus rhamnosus and Lactobacillus reuteri when administered in addition to hydration therapy. This benefit is not clear cut in adults.

Side effects are few except for reports of

24 | FEBRUARY 2019

disorders, probiotics are being trialled in Autism-spectrum disorder specifically for gastrointestinal symptoms, which are 3-4 times more common in autistic compared with healthy children. The proposed beneficial effects are thought to be as a result of modulation of the ‘microbiota-gutbrain axis’ and strengthening a‘leaky gut.’

Probiotics have been shown to alleviate anxiety, mood and memory disturbances in animal models which is an interesting development.

Irritable bowel syndrome (IBS) There is promising but low-level evidence from a small number of studies that probiotics reduce bloating and functional abdominal pain in adults and children with IBS but robust research is needed.

Probiotic composition and mechanism of action The exact composition of a probiotic (strains and numbers of bacterial and yeast species) as well as the delivery system (capsules, powder, fermented milk or yoghurt) and the mechanisms of action (pathogenic bacteria suppression, enhancing mucosal action, modulation of host immune responses) that confer the health benefits are still being elucidated and the “recipes” for managing different conditions are far from certain.

Research is limited on the gut microbiome and the use of hard-tomarket probiotics. Many theories abound and current evidence is detailed here. We have not heard the last of this topic.

Conditions lacking evidence The majority of studies on probiotics are poor quality and heterogeneous, therefore meta-analyses from large cohorts of patients lack the power to make robust recommendations. difficile diarrhoea is problematic as relapses are common even after prolonged courses of metronidazole and tapering oral vancomycin.

Faecal microbiota transplantation (FMT) is a novel and effective treatment for recurrent Clostridium difficile diarrhoea.

Faeces from selected related or unrelated donors are introduced into the gut of affected individuals with 85% cure rates.

This is an example of a human-sourceprobiotic which contains exactly the correct composition of bacteria required to immediately restore gut microbiome.

Necrotizing enterocolitis In preterm infants, probiotics have significantly reduced the risk of severe necrotizing enterocolitis by 47%, death by 21%, late onset sepsis by 14%, hospital stay by 3.77 days and time to full enteral feeds by 1.54 days. Probiotic supplementation does not improve neurodevelopmental outcomes but improves weight gain.

Neurodevelopmental disorders In children with neurodevelopment

There is little evidence for the benefit in reducing frequency and duration of upper respiratory tract infections, or benefit in reducing relapses in ulcerative colitis and Crohn’s disease. Probiotics do not reduce the frequency of recurrent UTIs or the frequency of vulvovaginal candidiasis and there is little evidence they have an impact on allergy and eczema in children.

Probiotic research is an expanding field with many studies underway, however good quality evidence on exact composition and delivery of probiotics are lacking and eagerly awaited.

Further reading: What do Cochrane systematic reviews say about probiotics as preventive interventions?

Vinícius Lopes Braga et al, DOI: 10.1590/15163180.2017.0310241017 ED. The author wishes to acknowledge the support of neonatal paediatrician Dr Gayatri Jape in compiling this article.

Author competing interests: nil relevant.

Questions? Ask the editor.

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INNOVATIONS & TRENDS

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INNOVATIONS & TRENDS

Communicable diseases – keeping ahead of the game

By Dr Paul Armstrong, Director, Communicable Diseases Control Directorate, DoH Improvements in standards of living and advances in public health and clinical medicine, have decreased rates of infectious diseases in the community. However, they remain an ever-present threat and we need to maintain existing disease controls and apply new innovative methods to keep ahead of the game.

The DoH has websites, vaccination programs, and surveillance systems in place and is always looking for innovative ways to make these more effective through primary care.

by AusVaxSafety, a national vaccine safety surveillance initiative, using 272 vaccine providers covering all states and territories (72 in WA). Data for over 1 million vaccination encounters have been gathered, to date.

In 2018, the Department of Health (DoH) received over 47 000 notifications of the 80 reportable communicable diseases and related conditions, double 2008 figures.

Chlamydia, influenza, varicella-zoster, campylobacteriosis and gonorrhoea dominate, however, none engender as much anxiety as invasive meningococcal disease (IMD), the 24th most common notified infection.

The rise of meningococcus serogroup W Since 2013, WA and the rest of Australia has experienced a dramatic rise in IMD due serogroup W meningococcus (MenW) and, to a lesser extent, serogroup Y. MenW became the dominant strain in WA in 2016, surpassing serogroup B disease (MenB) which had held that mantle since 1991.

MenW is a particularly virulent serogroup, with a death rate of 12% (10-year figures; 8% for all other serogroups combined).

MenW cases can present atypically – septic arthritis, epiglottitis, pneumonia – making timely diagnoses more difficult.

MenW cases occur in all age groups but it has a predilection for the youngest in our community, particularly Aboriginal children.

In them, the notification rate in children under-12 months-of-age is 110 times higher and in under-5s is 41 times higher, than in the non-Aboriginal population.

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The good news is that we have a safe and effective method of controlling the disease - a conjugate vaccine that covers meningococcal serogroups A, C, W, and Y. Currently in WA, state and federally funded vaccination programs target teenagers aged 15-19 years, all children aged 1 to 4 years, and Aboriginal children aged 6 weeks to 12 months.

Two thirds of WA children aged 1 to 4 years have now been vaccinated and we expect to see a slowing of spread in the community.

Immunisation safety In 2010, response to a high rate of severe febrile reactions in young children to a particular influenza vaccine, Fluvax (BioCSL), resulted in Australian systems that have significantly improved our ability to detect signals of adverse events following immunisation (AEFI).

Leading the way is Smartvax, a system developed in WA through a publicprivate partnership that uses medical practice software and SMS technology to elicit AEFI data from vaccine recipients in real time. Smartvax has become the main data monitoring tool used

Another important recent advance in immunisation is realising the benefits in vaccinating pregnant women against influenza and pertussis. A concerted health promotion effort has resulted in immunisation coverage rates in WA for these two diseases in 2018 of 55% and 80%, respectively. While the coverage for influenza vaccine is on a par with other settings, the pertussis vaccination coverage is among the highest reported worldwide.

Blood-borne viruses (BBVs) There have been major advances in recent years in the prevention and management of blood-borne viruses, in particular, hepatitis C and HIV. Directly-acting antivirals (DAAs) for hepatitis C have, for the first time, made this disease entirely curable in a high proportion of cases. In addition, treatment regimens are shorter and the side effect profile far less troublesome. Our main challenge is enrolling people with chronic hepatitis C into treatment; from the PBS listing of the DAAs in March 2016-18, only an estimated 22% of those infected with the virus in WA had initiated treatment. GPs are ideally positioned to provide accessible testing, treatment and management of their patients with hepatitis C in the community, and a range of resources and training opportunities have been developed in WA to support them.

In April 2018, highly effective medications to prevent HIV transmission between serodiscordant partners were made available on the PBS. Pre-exposure prophylaxis, or PrEP, will support Australia to meet its target of ending HIV transmission. Already, significant decreases in notifications of HIV have been reported in WA and other jurisdictions.

Of concern, however, is the increased risk of other sexually-transmitted infections due to a concomitant decrease in condom use, and this is being closely monitored through a number of state-based trials.

FEBRUARY 2019 | 25

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INNOVATIONS & TRENDS

The General Practice of the future?

Dr Richard Choong, Board Chair WA Primary Health Alliance Commonwealth led reform impacting general practice is ramping up.

Changes to Medicare item numbers and practice incentive payments, emphasis on data-driven quality improvement and the Health Care Home policy move general practice from fee-for-service towards bundled payments for complex team-based care for enrolled patients. The General Practice of the future must be agile in responding to remuneration that incentivises outcomes and will understand the culture and behavioural change associated with patient enrolment.

GPs ultimately will see the results of the Health Care Home trial (extended to June 2021) and the alternative RACGP trials (ending Dec 2019) emphasising longer appointment times. The aim, is to keep patients with chronic complex medical issues in the community, out of hospital.

Funding is directed to holistic needs rather than episodic treatment.

The General Practice of the future will focus on multidisciplinary team-based care.

Care will increasingly be delivered by high performing partnerships, requiring less professional demarcation and strengthened relationships, between allied health and general practice. We can’t underestimate the impact of pharmacy expanding into primary care. This will challenge both the small general practices and pharmacy businesses, as well as health consumers seeking timely, easy access and reduced out-of-pocket costs.

Our patients are more engaged and informed than ever, expecting more from their health care. They continue to exert considerable influence in shaping the future of general practice. Our obligation is to empower our patients in this journey.

New corporate and ‘corporate like’ models of general practice can be anathema to

Much is happening to steward and support future General Practice, working with GPs to initiate new approaches and responses to the changing face of primary care. traditional ways of practising – in a clinical and commercial sense. The General Practice of the future will take heed of national and international experience balancing business outcomes with the delivery of quality patient centred care.

Revolutionary technology will drive practices.

The addressing of inequity and lack of access through innovative telehealth is a major focus of the State’s Sustainable Health Review. The General Practice of the future will champion telehealth and harness the power of remote monitoring via wearable devices that enable patients to upload and share health data with their health care team.

The next change coming our way is big data analytics – involving descriptive, predictive and prescriptive analytics. Machine learning,

continued on Page 28

We are conducting 10-minute online surveys with GPs across Western Australia to explore any kind of care they provide to their patients in the last 12 months of life.

All participants receive $90 reimbursement for taking part in this project.

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Do you or your practice provide any kind of care for patients in their last 12 months of life?

If you are interested in finding out more about this study or being sent the online survey link, please contact me at:

angus.cook@uwa.edu.au or phone (08) 6488 7805 Professor Angus Cook The University of Western Australia

FEBRUARY 2019 | 27

Pathology Innovations Pharmacogenomics

By Dr Narelle Hadlow, Chemical Pathologist Pharmacogenomics is the study of genetic variations that affect someone’s medication response and metabolism, perhaps causing unexpected responses to a medication e.g.

• unexpectedly low or high blood concentrations (despite recommended dose) • a lack of or excessive response to a medication (despite normal blood concentration) • severe acute reaction e.g. skin rash, hepatitis (despite the medication’s normal tolerance).

By knowing the variations in someone’s genes, the doctor selects a medication and dose that is most likely to be effective and least likely to result in adverse side effects. This ‘personalised’ medicine is a growing trend. Clinical trials have confirmed that pharmacogenomic testing improves positive health outcomes and avoids negative ones, while at the same time reducing costs. Even avoidance of negative outcomes would save significantly as adverse medication reactions account for about 3% of hospital admissions in Australia.

International authorities have identified 15 genes that can guide the prescribing of 30 common medications. Hundreds of other medication-gene combinations show promise (www.pharmgkb.org).

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Genes and FH can predict illness. When medications are required, pharmacogenomics is the science of predicting medication response. allopurinol, and paroxetine. A recent study of 5,400 Australians tested for 4 genes showed that 96% had at least one clinically actionable pharmacogenomic variant.

The prevalence of medications and the frequency of variants that create risk of an adverse outcome hint at the significance of pharmacogenomics in clinical practice, as recently reviewed in Australian Prescriber. For example, with depression we know only 50% of patients respond to their initial medication and <50% achieve remission within 12 months. Two genes, CYP2D6 and CYP2C19, are primarily responsible for the metabolism of many psychotropic medications. Approximately 1 in 6 people have variations in CYP2D6 that slow metabolism, while 1 in 3 have variants in CYP2C19 that accelerate metabolism. Clinical trials have demonstrated that testing of these genes is relevant for prescribing, with tangible benefits for patients and funders.

There is a dearth of pharmacogenomics in clinical practice in Australia, in contrast to the FDA in the US which shows pharmacogenomic information on 15% of medication labels.

There is no such requirement by Australian authorities and instead a general lack of awareness of pharmacogenomics among prescribers, few national guidelines regarding pharmacogenomics, and limited Medicare funding (the exceptions being items for genetic testing of TPMT and HLA-B*5701).

Consideration of a patient’s history, the pharmacogenomic test result, other medications, and therapeutic doses remains a matter of clinical judgement. Despite this innovation in testing, pharmacogenomics should not be the sole arbiter of prescribing decisions. Testing should be requested with the appropriate knowledge and accountability. Some test providers now assist prescribers new to pharmacogenomics by offering tests with authoritative clinician-friendly interpretations (costing the patient $150-250).

For Lease

ED. The author acknowledges Prof Graeme Suthers, Director of Genetics for Sonic Healthcare, in preparing this article. References available on request.

Author competing interests: nil relevant. Questions? Ask the editor.

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The General Practice of the future?

*Approx

General Practice will access knowledge and patient information, intelligently filtered and presented at appropriate times to enhance clinical decision making. WAPHA, along with four other primary health networks, has combined with universities, businesses and public and private healthcare providers to partner the Digital Health CRC – an Australia-wide R & D collaborative combining expertise with data, information and telecommunications to change poor health trajectories, support clinical practice and improve access to quality care.

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INNOVATIONS & TRENDS

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INNOVATIONS & TRENDS

Training the GP of the future

By Prof Janice Bell, CEO WAGPET* ‘The future’s not what it used to be, Dickie.’ When thinking about the future it is easy to bemoan the inevitable and the predictable while fearing the imaginable. Regardless, by 2035 our world is likely to be a very different place for patients and their doctors, and training must respond pre-emptively and accordingly.

All things to all people Sure, there will be wearables, and the internet of things, and blindingly fast connection via personalised real-time avatars. There will be unparalleled access to current, reliable research, and precision medicine will help us choose from an eye-watering array of state-of-the-art (until tomorrow) therapeutics. What is now cutting edge, will reach its tipping point in (and before) 2035, as AI and robots will deliver most health interventions and inform much (if not all) of the diagnostics.

These are the inevitable sustaining innovations, still largely embedded in our current healthcare delivery model, dependent only on how fast Silicon Valley and its satellites can move and how affordable will their products be.

But the consequential change that likely comes with this widespread virtual capability will be much more disruptive.

It will change the shape and place of all health care.

The bio-psycho-social paradigm of general practice will be replaced by a bio-psychosocio-political-economic-spiritual one.

Advances in health care may provide an answer to a problem and at the same time create more problems, often through not asking the right questions early enough.

Government intervention, population distribution, public and private social

services funding, geospatial mapping and needs-based health access, end-of-life conversations and genomic manipulation all require an ethical, human conversation that is way behind our scientific capacity to alter human lives. Health care leadership and policy will not be left to the professions.

Impact of health consumerism Professional distance will diminish as patients will have more of a role in their health care, thanks to the democratisation of knowledge, childhood compulsory health education, and the new ability to choose freely their own healthcare services, both virtual and actual. The paternalism of medicine is already on trial along with its consequent partner, consumer infantilism.

They will choose you if you and your team offer a convenient, affordable, comprehensive service. This includes virtual synchronous consultations and a network of valued service suppliers you offer – each one reflective of your reputation and business, so you choose them well. Patients won’t so often come to us in our time and place; we will need to ‘go’ to them.

So, there will be a greater need for a different kind of doctor, with a different relationship with their patients and community. That doctor will re-educate the people, will guide the people on their health care journey offering judicious, timely, personalised behavioural interventions be they preventative or therapeutic.

Personalisation and survival General practice began as a profession that walked alongside the population, especially when there was nothing else medicine could offer. We will do so similarly when there is too much on offer. We will

NEw SS E aDDRaME N & iously

Prevylands “Ma unding” po C om

continue to describe our profession in terms of relationships, operating as we do in an ecological rather than mechanistic system that transcends the body-mind-spirit schism and concerns itself with real people more than intellectual abstractions.

There are some embedded social determinants and human drivers of health care behaviour – attitudes to wellbeing, death, self-responsibility, all flavoured with fear, anxiety and crowd thinking – and they are less likely to change in 15 years.

That is the doctor we will train in 2035. The general practitioner will possibly be the one medical specialty that survives in large numbers, as robots and technicians deliver most activity-based care more accessibly and affordably but arguably not the care-giver role.

Doctors-in-training will learn first and foremost from their peers – virtual and actual – the fundamental principles of general practice, the one school of medicine that defines itself in terms of relationships, operates in an ecological rather than mechanistic system, transcends the body-mind-spirit schism and concerns itself with people more than abstractions.

They will receive continuous live feedback from their peers, and by their patients, both before being allowed to practise unsupervised anywhere in the world and often in the years to come. The job of the general practitioner – those that adapt to the new bio-psychosocio-political-economic-spiritual world – will return to its roots.

Back to the future? Perhaps, but it won’t be as it used to be, Dickie.

Author competing interests: nil relevant disclosures. *Please note that the views expressed here are those of the author, a GP from East Perth, rather than those of WAGPET or any of the five organisations that use her services. Questions? Contact the editor.

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PET - Innovations Drive Trends

By Dr Nat Lenzo, Nuclear Physician, Murdoch Positron emission tomography (PET) was commercialised in the 1980s CTI Molecular Imaging (acquired by Siemens), Philips, General Electric and suchlike. PET is now a standard imaging test in mainly oncological conditions for which fluorodeoxyglucose (FDG) is the principal tracer. It works on the principle of increased use of glucose by many tumours and FDG, developed in the 1970s, is a short lived tracer with a 2 hour half-life that requires a cyclotron to produce the Fluorine-18 component of this radiopharmaceutical.

15 years before clinical manifestations) and also in helping more accurately target therapy (e.g. Ga-68 PSMA directed stereotactic radiotherapy for oligometastatic prostate cancer).

Finally, it has opened the way for true theranostic imaging where targeted radionuclide therapy is directly linked with a targeted radionuclide diagnostic agent e.g.

Lu-177 dotatate (Lutathera™) for metastatic somatostatin receptor positive neuroendocrine tumours detected on Ga-68 dotatate therapy. This theranostic approach in neuroendocrine tumours is fast becoming the gold standard

PET has come a long way since it was first developed. Not only has use in oncological conditions improved, new tracers have meant new uses.

Siemans PET MRI scanner The innovations and trends for PET scanning can be listed as: 1. New funded indications for PET – gallium-68 octreotate for staging and restaging of neuroendocrine tumours (MBS funded) 2. Likely expansion of FDG PET under MBS to cover breast cancer and other cancers such as gastric cancer, pancreatic cancer and possibly rarer cancers such as adrenocortical carcinoma and Merkel cell tumours.

3. New unfunded PET techniques a. Gallium-68 or fluorine-18 PSMA for staging high risk prostate cancer and restaging in setting of biochemical recurrence (if PSA climbs to > 0.3 ug/L) b. Fluorine-18 amyloid imaging agents for early diagnosis or confirmation of presumed Alzheimer’s disease

FDG-PET MRI whole body image Over the next 10 years specific tumour and other disease agents will make their way onto the commercial market and into diagnostic imaging algorithms for different disease states.

Improvements in technology and understanding of the molecular signatures of disease means we are starting to realise the promise of PET. Molecular imaging with PET is expanding our diagnostic horizons.

It allows a much earlier disease diagnosis (e.g. amyloid PET imaging can detect pre-symptomatic Alzheimer’s disease up

30 | FEBRUARY 2019

diagnostic and treatment strategy around the world for progressive metastatic neuroendocrine tumours.

This theranostic approach is felt to be the next major breakthrough in cancer therapy.

Big pharma is also starting to see this potential (e.g. Novartis has spent US$6 billion acquiring two small theranostic companies – Advanced Accelerator Applications and Endocyte). Will we see more targeted imaging and therapy agents during our professional lives?

c. Fluorine-18 ethyltyrosine (FET) in assessment of brain tumours (particularly recurrence) d. Fluorine-18 DOPA for assessment of Parkinson’s disease e. Use of FDG PET in assessment of infection or vasculitis 4. Use of FDG PET in assessing treatment response in variety of cancers e.g. lung cancer after radiotherapy; oesophageal and gastric cancer after chemoradiotherapy.

ED. Dr Nat Lenzo will give us ‘the basics’ of PET in Perth, in his next article

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INNOVATIONS & TRENDS

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INNOVATIONS & TRENDS

Telehealth access for rehab

By Exercise Physiologist Peter Edwards, Curtin University Exercise Physiology services are helpful for rehabilitation, weightloss and enhancing both physical function and quality of life through exercise. However, many patients find it difficult to access such services, especially when living in rural areas.

The relative shortage of rural allied health professionals makes distance and time a barrier for patients.

Furthermore, the transport burden for the elderly is typically placed on immediate family or friends.

Digital health, or “telehealth” is increasingly recognised as an easy and cost-effective means of accessing such services.

Research supports the use of digital health in diverse clinical scenarios that include mental health, cancer and oncology, neurological conditions, weight management and musculoskeletal conditions, and before and after orthopaedic surgery.

In fact, peer-reviewed publications have recommended telerehabilitation for patients as an alternative to in-person rehabilitation, with no significant differences in clinical outcomes, rehabilitation adherence, and overall satisfaction. Furthermore, research has shown the willingness of patients to engage with allied health professionals online with time and cost savings, for both patient and therapist. For instance, despite no reimbursement via Medicare or private health insurance for online Exercise Physiology services, patient costs start from around $60-70 per session. Workers Compensation can cover such services.

Whilst digital health is predicted to be a large part of medical and health care, the service is still immature, with an obvious disconnect between perceived and actual validity.

A digital health service will ideally incorporate a technology stack that prioritises optimal patient experience, convenience and privacy, that enables secure live video and audio consultation between patient and therapist on any personal device. This allows therapists to, privately, conduct assessments, observe bodily movements for range of motion or biomechanical assessment, and demonstrate both movements and exercise to the patients, very much the same as it would be when in-person.

A comprehensive report of a patient’s function comes back to the referring doctor.

The 400 or so mainly younger exercise physiologists in WA see telehealth as the vehicle of access to their services. Do you agree?

Digital health also permits the remote monitoring of patients via their smartphone, or by using additional applications or noninvasive hardware (such as wearables).

For example, managing a patient’s home exercise online, tracking variables such as exercise adherence, subjective pain and intensity in real time, and objective data such as activity counts, heart rate and biomechanics.

The advantage being that data accurately reflects a patient’s function in their normal environment as opposed to a “moment in time” during a clinical visit, providing the therapist and referring doctor with objective data to work with.

Wait Times Increase for ED and Surgery Nationally, waiting times for elective surgery and ED care are steadily rising, according to two reports released by the Australian Institute of Health and Welfare (AIHW).

Elective surgery waiting times 2017–18 shows the median waiting time for elective surgery – that is, the time within which half of all patients were admitted – has risen since 2013-14.

It was 36 days in 2013-14, 37 days in 201516, and 40 days in 2017-18.

The proportion of patients who waited longer than 365 days to be admitted for their procedure slightly increased from

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1.7% in 2016-17 to 1.8% in 2017-18, but remains lower than five years ago in 201314, when the proportion was 2.4%.

Waiting times also varied depending on the type of surgical procedure. In 2017–18, the longest median wait was for Septoplasty (surgery for a deviated nasal septum) at 248 days, compared with 17 days for coronary artery bypass graft surgery.

Overall, Indigenous Australians continue to wait longer for elective surgery than nonIndigenous Australians, with a median wait of 48 days compared with 40 days.

The Emergency department care 201718: Australian hospital statistics report

shows that there were more than 8 million presentations to public hospital EDs—an average of about 22,000 a day. Between 2013-14 and 2017-18, this increased by 2.7% each year on average.

In 2017-18, 72% of people presenting to emergency departments were seen ‘on time’ for their urgency (triage) category, a decrease from 75% in 2013-14.

Nationally, almost 100% of resuscitation patients (those requiring treatment immediately) and 92% of non-urgent patients (requiring treatment within two hours) were seen on time. For patients requiring treatment within 10 minutes, 76% were seen on time.

FEBRUARY 2019 | 31

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INNOVATIONS & TRENDS

Computer navigation in Total Knee Replacement

By Dr Christopher Jones, Orthopaedic Surgeon, Perth For 15 years, the aim of computer navigation has been to improve the precision and accuracy of component positioning in total knee replacement (TKR). In the UK and the USA only 3-5% of TKRs per year use navigation as part of computer assisted surgery (CAS) whereas in Australia, CAS navigation has increased to 30.8% in 2016 (from 2.4% in 2003).

Given the similarities between the three countries in many aspects of surgical practice, the reasons for this difference are hard to fully elucidate. While current evidence demonstrates that computer navigation improves component alignment in TKR, apart from one subgroup of

mechanical alignment of the lower limb by aligning the components perpendicular to the mechanical axis of the femur and tibia.

Using manual instrumentation, the tibia has a guide set 90 degrees to the mechanical axis while the femur is prepared with an anatomic valgus cut (typically 5-7degrees).

In this way, the overall mechanical alignment of the limb is neutral +/- 3 degrees and the line of force is transmitted from the centre of the hip and the middle third of the knee, to the centre of the talus (Figure 1). Deviation of the mechanical axis away from neutral alignment results in abnormal forces. As well, most TKR components are designed so the bearing forces are transmitted perpendicular to the bearing surface.

The jury is still out on computer use in TKR. Can we afford it and with our ageing patients will it lessen revisions?

Tantalisingly, perhaps one study does.

Using data from the Australian Orthopaedic Association National Joint Replacement Registry, De Steiger et al (2015) compared revision rates of 44,473 CAS navigated TKR compared to 270,545 conventional TKR, over 9-years post-operative follow-up.

For the sub-group of patients < 65 years, there was a significant decrease in the revision rate in the computer navigated group (6.3%, 95% CI = 5.5 to 7.3) compared to the conventional TKR group (7.8%, 95% CI = 7.5 to 8.2). The authors concluded that CAS navigation led to a significant reduction in the leading cause of revision in Australia (aseptic loosening) with a hazard ratio of 1.38 (95% CI = 1.13 to 1.67, p = 0.001) in that patient sub-group.

Looking ahead As Friedman et al said (2017), the value of new technology (benefit divided by the cost) is an increasingly important issue in medicine, and in orthopaedic surgery in particular. There is an increased initial cost of using computer navigation for TKR, estimated by Novak et al (2007) at up to $1500 per case, however the potential cost saving of reduced revisions if improved alignment is proven to increase survivorship needs to be considered.

Fig 1. A. Alignment goals in total knee replacement B. Computer navigated TKA Optimal alignment for TKR has been debated hotly in the orthopaedic literature, with the neutral mechanical axis challenged by proponents of “kinematic alignment”. Despite this debate, the importance of post-operative alignment goal, in terms of TKR longevity, has been clearly established.

Fig 2. CAS for TKR – one such system patients <65years (see below), there is no demonstrated clinical superiority of CAS in terms of improved reported outcomes and/or decreased revision rates in the long term.

Without CAS – what is done Historically, TKR aims to restore the

MEDICAL FORUM

Alignment using computer navigation is more reliable and reproducible than manual guides and multiple systems now exist with rapid advancements in computing power stimulating the next stage in CAS, robotics.

Is CAS better or not?

Interestingly, while neutral alignment independently improves TKR survivorship and computer navigation independently improves the accuracy and precision of alignment; the logical conclusion that CAS navigation will improve TKR survivorship, remains definitely unproven.

References available on request.

KEY MESSAGES Computer navigation for TKR is used more in Australia (30%) than the USA or the UK (3-5%).

Precise alignment goals for TKR are still being debated.

Computer navigation achieves more accurate alignment in TKR. Some patients <65 years have a lower revision rate for computer navigated TKR compared to conventional TKR Otherwise, no overall benefit in patient outcomes for computer navigated TKR has been proven There is increased cost and time associated with computer navigation for TKR

Author competing interests: no relevant disclosures. Questions? Ask the editor.

FEBRUARY 2019 | 33

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PRACTICE MANAGEMENT

Cyber security at work Mr Jerome Chiew is accredited for cyber security and compliance. He says 2FA is one way of conveniently cutting out malicious attacks.

Too many passwords and constantly being asked to create new ones? Is the transfer of patient data secure if you login to the server? You are entrusted with patient information – is the trust well founded?

The Office of the Information Commissioner’s three quarterly reports on notifiable data breaches (since legislation February 2018) show over 40% of the health sector breaches were due to malicious or criminal attacks, of which most were cyber incidents or theft of data. Majority of cyber incidents were result of compromised credentials from phishing attacks.

Health information a likely target Passwords can be the strongest or weakest links in securing access to systems. Most of us are familiar with mandated password rotation policy and complexity requirements (at least 1 letter, 1 number, upper case, lower case, symbol and minimum number of characters). These policies could actually weaken security and access control. How? Users may have a variation of a password they use regularly, then add a number to the end of the password. Each time they are required to change the password, the number at the end increases or the password is reversed.

Because of such predictable behaviour, attackers can narrow the possibilities down very rapidly using various methods. For example, they can gain access to your email account – they compromise a popular web forum, then quickly run through password variations of the logins harvested from the web forum.

Remote Desktop security Most practices have Remote Desktop access to allow clinicians (e.g. those servicing aged care facilities) to access patient data kept in surgery or office servers. However, if direct pathways like this are only secured by the user’s password, this may be insecure.

What can increase security without imposing further restrictions on users?

Firstly, ensure your website has regular patches applied, especially when using a Content Management System like WordPress or its plugins that require frequent updating (as Windows does), all to plug newly discovered vulnerabilities.

The Australian Signals Directorate’s guidelines indicate password complexity is not mandatory for passwords over 14 characters (e.g. a personally

MEDICAL FORUM

meaningful passphrase such as “IusedtoLive@56DownerAv”). Additionally, deprecate the password rotation policy and instead put auditing in place to monitor for suspicion of compromise.

Multifactor (two factor or 2FA) authentication is recommended. This includes Remote Desktop access to enhance security and beef up credential-handling. This requires at least two forms of authentication, something the user knows and something they have.

‘Something you know’ can be a password, passphrase or PIN. ‘Something you have’ could be a fingerprint, USB token or mobile phone. Both forms of identity verification must be presented for authentication (and Remote Desktop access granted).

Any inconvenience is overcome if enough (suitably mobile) “factors” are available to choose from.

For mobile devices, especially laptops, 2FA is not good enough. The laptop must also be fully encrypted (e.g. using Windows

Bitlocker; iPhones have their onboard storage encrypted and some android phones do). Otherwise, anyone can simply remove the stolen drive from the laptop and plug it into another PC and view the contents without any authentication. The same goes with unencrypted phones, tablets, etc.

Microsoft has been advocating for better security using their Windows Hello technology and Azure Multi Factor Authentication service. Windows Hello combines unique biometrics involving the user’s body part such as fingerprint readers and 3D webcams for facial recognition, with a PIN or password to allow users to login to systems.

Azure Multi Factor Authentication service takes this further with more authentication factors such as SMS, mobile authenticator app and even the physical presence of the mobile phone itself through bluetooth proximity sensing.

FEBRUARY 2019 | 35

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Born and raised in Perth, Simon studied medicine and surgery at UWA. He subsequently undertook his orthopaedic surgery training in Perth, and was awarded Fellowship of both the Royal Australasian College of Surgeons (FRACS) and the Australian Orthopaedic Association (FAOrthA) in 2015.

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MEDICOLEGAL

Privacy: Does it still exist?

By Enore Panetta, Panetta McGrath Lawyers Although we share all sorts of information online, we like to think that our medical records are sacrosanct. While we might be content to share our political leanings with Facebook, our private photos with Instagram and our search history with Google, our expectation is that our medical records remain private, only to be shared with our treating doctors. As a health practitioner, you have a professional obligation to maintain and ensure the privacy of your patients’ medical information both online and offline.

The furore around the national roll out of My Health Record illustrates the public’s belief that the privacy of our medical records remains a priority*, even in the current climate of “information oversharing”.

Following public debate and lobbying from peak bodies (including the Royal Australian College of General Practitioners), the Australian Government was forced to enhance the privacy protections of the My Health Record legislation to extend the opt out period, prohibit insurers and employers from accessing health information and to ensure that no information from within My Health Record can be released to a law enforcement agency without an order from a judicial officer.

Other legislative changes mean that there are additional protections for victims of domestic and family violence to stop perpetrators tracking victims through their health records, the removal of automatic parental access to the records of teens aged 14 to 17, and increased penalties for the inappropriate and unauthorised use of information in a My Health Record.

But with some privacy advocates saying that My Health Record and other forms of e-health records carry an intrinsic risk of data breach, what should you do if you suspect there has been a breach of your personal health information? And what can you do as a health practitioner to maintain the privacy of your patient’s medical records?

Be privacy literate Being privacy literate does not necessarily mean opting out of My Health Record (although you may wish to consider whether this is appropriate for you). Individuals, who don’t opt out of My Health Record but still want to control their privacy, can request

MEDICAL FORUM

for specific documents not to be added or to remove records once they have been uploaded. You can also set up alerts to notify you when your records have been accessed.

Being privacy literate also extends to your professional practise. Do you or your rooms have a Privacy Policy? Has it been updated regularly? These are requirements of the Commonwealth Privacy Act. If your practice uses electronic means to communicate health information to patients, have you considered the privacy implications?

Act promptly in the case of a breach If you are using the My Health Record in your practice, your practice must notify the Australian Digital Health Agency and the Office of the Australian Information Commissioner of certain data breaches relating to My Health Record.

This is separate from your obligations under the Privacy Act, however if you have to make a notification under the My Health Records Act, you do not have to also make a notification under the Privacy Act’s Notifiable Data Breaches Scheme.

You must also notify the affected individuals.

this protection is not the same for all health records. As a health practitioner, under the Privacy Act, you do not need to see a warrant before you are allowed to share health information with law enforcement agencies. Under the Privacy Act, you only need a “reasonable belief” that sharing that information is “reasonably necessary” for the enforcement activity.

However, although the law doesn’t require it, it is considered good practice for health professionals to insist on seeing a warrant before disclosing a patient’s health record.

In 2014, a psychiatrist who provided his patient’s health records to the Queensland Police was found by the Federal Court not to have breached the privacy of his patient where records were requested in response to a warrant.

However, in 2015, a GP who disclosed a patient’s health information to the police was found to have breached the patient’s privacy in circumstances where there was no warrant and no formal active criminal investigation. *ED. The West Australian newspaper on 31/12/18 reported on aberrations in the security of My Health Record. It pointed to the extended opt-out period and said many Australians had taken this pathway.

A warrant to provide information to law enforcement?

Although My Health Record Information can only be accessed with a court order,

FEBRUARY 2019 | 37

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CLINICAL UPDATE

Preventing food allergies?

By Clin A/Prof Richard Loh, Head of Dermatology, Immunology and Allergy, PCH Scared parents of children with One in 10 infants in Australia by age food allergy may be relieved by oral 12 months have a challenges done with child safety documented food in mind. allergy. Currently there is no cure for food allergy and management consists of strict avoidance and treatment of accidental exposure.

However, an estimated >50% of people with food allergy have one accidental exposure every three years.

Graduated does of peanut protein powder could help protect against the consequences of accidental peanut exposure. However, rates of severe adverse reactions, study withdrawal due to adverse events, and adrenaline administration were all higher in treatment groups. Oral immunotherapy (OIT) remains a mystery and it is still unknown – will permanent sustained unresponsiveness be independent of regular food intake and maintained even if the food is eliminated from the diet for long periods?

A recent paper using peanut protein coupled with an immunostimulatory adjuvant (in this case a probiotic) suggests that sustained unresponsiveness may be a possibility. A larger follow-up multicentre study (that includes PCH) is currently underway.

Most studies of OIT involve treatment with a single food but because many children have multiple food allergies, researchers are exploring OIT with multiple food allergens.

In addition, approaches include: • OIT with modified food allergens • OIT combined with anti-immunoglobulin E (anti-IgE) • Sublingual immunotherapy • Epicutaneous (patch) immunotherapy • Peptide Immunotherapy If treatments are ready for routine clinical use they are likely to be expensive – an estimated $5-10,000 to cover peanut protein powder for the first 6 months of treatment in the US. With no “cure”, can we prevent food allergies from developing? The recent Learning Early About Peanut (LEAP) study, provides evidence that the introduction of peanut between 4-11 months of age can reduce peanut allergy by 80% in high risk infants (infants with severe eczema or immediate family history of allergies). The Australasian Society of Clinical Immunology and Allergy Guidelines for infant feeding and allergy prevention encourage introduction of the common food allergens by 12 months of age.

Parents, particularly of high-risk infants, are too scared to introduce the common food allergens before aged one, preferring to see an allergy specialist beforehand. However, with the infant often over 12 months when they see the specialist the ‘window of opportunity’ to prevent food allergy, particularly peanut allergy, has been missed.

GPs can support and encourage parents to introduce the common food allergens. If willing, GPs can introduce peanut to the infant in their clinic if the parents are overly concerned. ASCIA has developed information to assist GPs to do this. See www.preventallergies.org.au Some parents may just need reassurance that someone is there should a reaction occur and may introduce the food themselves in their GP’s waiting room.

ED. The author acknowledges the support of Sandra Vale (National Allergy Strategy Co-ordinator) in preparing this article.

MEDICAL FORUM

THE MODERN HEARING AID

Anne Gardner

Andre Wedekind

Post Dip. Aud., BSc

M.Clin.Aud., BHSc (Physiotherapy)

In recent years there has been rapid advancement in hearing aid solutions with regard to sound quality, functionality and service delivery.

The expectations of hearing aid users have reflected those of the general consumer of modern technology. That is, there is now an expectation that technological solutions meet a nexus of aesthetically pleasing design, interconnectedness and functionality. Demands of hearing aid users for hearing aids to be cosmetically appealing means hearing aid advancements have focussed on an inverse relationship between size and performance.

The main goal of digital signal processing within hearing aids has been to improve speech intelligibility even when in competing background noise. To this end algorithms within the device classify the “listening environment” to determine which features should be enabled to achieve optimal speech understanding.

Such features include noise suppression, wind suppression and or microphone sensitivity.

Hearing aids are also moving towards being multipurpose devices. They can be paired to smart phones to stream audio and phone calls. Specialised Apps allow users to control their devices remotely. Some wearable technologies can monitor your steps and also translate language! Hearing aids are combining amplification with AI turning hearing aids into health monitoring devices. The AI system within the hearing aid learns the normal health patterns of the wearer, such as their pulse and breathing rate, sending an alert to a family member if something is off.

Such advances in technology is heralding a change in service delivery. Free online hearing screening tools and apps are available for users to screen their hearing and to determine whether further investigation is warranted. Remote follow up is an exciting new area of audiology. Clients can be fitted in person to ensure a good initial acceptance, physical fit and successful self-management of their new aid(s). Follow ups can be performed remotely by video link which will reduce travel time for country clients and for those with mobility issues.

The modern user of hearing aids has different wants and needs compared to hearing aid users of fifteen years ago. These advancements in hearing aid technology are vital to meet the changing demographics and characteristics of hearing aid users.

51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au

FEBRUARY 2019 | 39

Otitis externa management

By Mr Peter Ammon Foot Ankle & Knee Surgery

By Dr George Sim, Paediatric ENT Surgeon, Murdoch Handled correctly, this supposedly The external simple problem resolves quickly. auditory canal Clearance of the EAC is key as is (EAC) is warm avoidance of triggers. and dark making it conducive for bacteria and fungus. Otitis externa (OE) is an inflammation or localised infection of the EAC usually treated effectively topically rather than with systemic medications.

Pathophysiology The common causes of OE are water exposure (e.g. swimming), moisture (e.g. hearing aid use), insertion of foreign bodies, trauma, and dermatological conditions (e.g. dermatitis).

OE can be acute or chronic bacterial or fungal infections: Pseudomonas aeruginosa and Staphylococcus aureus are the commonest bacteria; 10% are fungal with Aspergillus being the most common, then Candida.

Plantar fascia origin

The presenting symptoms are pain, discharge, erythema and oedema of the EAC, hearing loss, cellulitis and lymphadenopathy.

Malignant OE is a severe infection that has spread to the soft tissues surrounding the EAC and can lead to temporal bone osteomyelitis.

This life-threatening complication, with high mortality, is found more in the elderly or immunocompromised. It may present with severe deep pain out of proportion to clinical finding and granulation tissue on the floor of EAC.

KEY MESSAGES Otitis externa is common and treatment mainly topical Beware malignant OE and refer promptly Prevention measures can reduce recurrence Elderly or immunocompromised patients with severe ear pain should be referred for urgent ENT review to rule out malignant OE. It is also important to ensure other causes of ear discharge e.g. otitis media are not missed.

Treatment Treatment revolves around pain control, removal of infected debris, topical antibiotic drops and avoidance of any trigger factors.

Pain control with adequate analgesia is essential. Very often the infected debris and mucous in the EAC is best cleaned by suctioning under direct vision. Once the EAC is cleaned, topical antibiotic drops are administered for up to three days after the symptoms settle. A wide variety of antibiotic drops are available; quinolone ear drops are effective and safe to use with no risk of ototoxicity.

MR PETER AMMON St John of God Medical Centre Suite 10, 100 Murdoch Drive Murdoch WA 6150 Telephone: (08) 6332 6300 Facsimile: (08) 6332 6301 www.murdochorthopaedic.com.au Murdoch Orthopaedic Clinic Pty Ltd ACN 064 146 774 ABN 23 070 745 210

40 | FEBRUARY 2019

If the EAC is oedematous and narrowed, a wick may need to be inserted. A wick aids the administration of ear drops to treat infection.

If a wick is inserted, the ear should be suctioned clean and examined every 2 to 5 days, until the EAC oedema settles.

Avoid potential causes of OE such as water exposure by keeping the ear dry.

continued on Page 42

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CLINICAL UPDATE

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CLINICAL UPDATE

Finding HFE Haemochromatosis

By Prof John Olynyk, Gastroenterologist, Beaconsfield Clinicians are often on the lookout for HFE Haemochromatosis – most often flagged with family history, elevated iron studies or typical genetic test results. A new Australian research study has

demonstrated that the commonest blood test ordered in Australia (the Full Blood Count - FBC) may also reveal otherwise unsuspected HFE Haemochromatosis.

Haemochromatosis is common but often missed. Testing may change that, starting with the FBC.

Full blood count Evaluate MCV or MCH Figure 1.

MCV <90 fL or MCH <31 pg

MCV 90-94 fL or MCH 31–32.2 pg

MCV >94 fL or MCH >32.2 pg

RECOMMEND No specific investigation for H in absence of clinical features or family history as less than 10% of all H subjects present in this group.

RECOMMEND Current standard of care.

Only investigate for clinical suspicion or family history.

RECOMMEND Investigate for H as 34% of all men and up to 62% of all women with H are present in this group. Enriched to over 30-times prevalence of H compared to general population. continued on Page 42

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CLINICAL UPDATE continued from Page 40

Finding HFE Haemochromatosis Shortly after discovery of the HFE gene in 1996 (HFE stands for HighFe; the HFE gene is on the short arm of chromosome 6 at location 6p21.3), an American study reported observations of elevated haematological parameters in those with the disorder. The recent Australian study, not only demonstrates similar findings, but shows that elevated mean cell volume (MCV) and mean cell haemoglobin (MCH) values are present in treated, untreated and asymptomatic young adult HFE Haemochromatosis people.

The study clearly recommends how to “value add” to the clinical utility of the FBC by suggesting who to evaluate further, depending on the MCV and MCH results (see Figure 1, p41). These findings are being incorporated into the Primary Health Care Pathways in each state, and are already in use in Western Australia.

Subjects of Northern European ancestry with MCV >94 fl or MCH >32.2 pg are at 30-fold enriched prevalence compared

to the general population. This is the same enrichment as seen within families of known HFE Haemochromatosis subjects, perhaps newly discovered; up to 62% of all HFE Haemochromatosis subjects in Australia present above these cut-off values – they should be considered for further assessment of HFE Haemochromatosis.

Conversely, less than 10% of all HFE Haemochromatosis subjects are in the group of individuals with MCV < 90 fl or MCH < 31 pg. For those with values in between, the current standard of care recommendations apply.

Otitis externa management guide Oral antibiotics are seldom required unless there is cellulitis or lymphadenopathy.

Prevention Avoiding the causes of OE will reduce recurrences. Water activities should be stopped for 1 to 2 weeks after the infection has gone. Ear plugs and or swimming caps should be used as a shield from water.

Avoiding moisture and trauma to the EAC minimises recurrence. Water or moisture trapped in the EAC can be dried with a hairdryer.

Reference: Adris N et al. Detection of HFE Haemochromatosis in the clinic and community using standard erythrocyte tests. Blood Cells Mol Dis. 2018;74:18-24.

Author competing interests: nil relevant disclosures. Questions and references?

Contact the editor.

Author competing interests: nil relevant.

Questions? Contact the editor.

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GUEST COLUMN

Why Do What We Know We Shouldn’t?

New Year resolutions are difficult to stick to because habitual routines often get in the way, says Prof Hinze Hogendoorn, but addiction is a whole new ballgame.

Summer is here. Speedos, bikinis and sunscreen are all walking off store shelves. But there are other industries where New Year is a sales bonanza.

How about nicotine patches, fitness club memberships and weight-loss shakes?

A habit has four parts: Routine – a morning cup of coffee; Trigger – it’s approaching 10am; Reward – this might include the physiological effect of the caffeine, but equally so the conversation with a friendly co-worker. Repetition – do it a few times and suddenly you’ll find yourself at the coffee machine every morning!

We’re all going to start trying to stop doing things we shouldn’t be doing.

And one disturbing offshoot is that the habit endures even when the reward is removed.

There’s a well-known research study in which compulsive, popcorn-eating cinema-goers were given a large bucket of stale popcorn and, guess what, yes, they ate it all.

Why is it so difficult to rationally weigh up alternatives and make deliberate choices?

Why do we keep eating when we’re not hungry? Why do we light that ‘last’ cigarette and why is it so hard to consume our daily quota of fruit and veg?

The answers grace the pages of every first-year psychology textbook, tucked away between the faded black-and-white portraits of dusty old professors. Pavlov, Skinner and Watson laid it out for us decades ago – we’re creatures of habit. Ultimately, we amount to little more than a knee-jerk response to primary stimuli – responses over which our thinking brain has little authority.

The good news is that habits are highly sensitive to the triggers that set them off.

When the same experiment was carried out in a conference room instead of a cinema, the popcorn was barely touched. Without the specific cinema trigger, ‘habit’ did not emerge the winner.

Even small details can derail the habit. In a follow-up experiment, researchers asked cinema visitors to eat the popcorn with their

non-preferred hand. Yet again, the stale popcorn was rejected. So, step off the wellworn path ever-so-slightly and it will put your conscious brain back in the driver’s seat.

What does this mean for the person wanting to get into the gym?

Create triggers for your new habit – leave your running shoes on the doorstep so you can’t leave without tripping over them. Redirect the routines that lead you to the sofa – when you come home from work sit down at the table instead. And if you do end up in front of the television, have a go at changing the channels with your off-hand.

It would seem that Aristotle got it about right: “We are that which we repeatedly do.” Selfawareness is a wonderful thing – no stale popcorn for Aristotle.

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FEBRUARY 2019 | 43

TRAVEL

Russian Far East?

It’s for the Birds

Subiaco procedural GP Dr Lin Arias writes here of taking a slow boat up the Russian coast as ship’s doctor.

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he Kuril and Commander islands. Kamchatka and Chukotka magic.

If you are a keen birdwatcher then you’ll know that these are the places of unique birdlife, featuring species of auks and puffins, guillemots, waders, and so many more. Most are migratory and many are endangered.

They are also places of rugged ocean beauty, with grey seas hiding whales, walrus, seals and orca. The land sprouts spring flowers bursting with colour, eager to soak up the fleeting spring and summer sunshine.

The salmon start to congregate at the mouths of rivers as they head upstream to spawn. As they do, hungry brown bears, white beluga whales and spotted harbour seals are waiting … and the hunt is on!

Maritime history fans will shiver knowing that the great Commander Bering and some of his crew lie in lonely graves on Medney island of the Commanders. When we visited the gravesite, many of the Russian crew of the Heritage Expeditions cruise ship came ashore to show their respect for the famous explorer.

I had signed on as ship’s doctor with this NZ-based small cruise ship company which takes people to these kind of wild places.

This trip was to the Russian Far East.

Find a map and search Yuzhno Sakhalinsk and then go north. We weaved through the Kuril islands, stopping at the Commander islands and visited unmarked places along the Kamchatka and Chukotka landmasses until we disembarked at Anadyr.

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For those with extra time, we stayed on board and crossed the Arctic Circle to see polar bears and native cultures on Wrangel Island.

Besides dealing with the inevitable seasickness when the boat was corkscrewing (an very apt description of how it moved!), medically there were rashes and colds, reactions to mosquito bites, a couple of bad burns (do not carry hot tea for two people while on the boat.

You need one hand to hold on at all times!) and a number of injuries from falls.

The worst was a dislocated and clearly fractured wrist. One of our wonderful passengers, on a sunny calm gorgeous day, stepped backwards to take a photo and tripped on the in-deck large cleat. As expected, she put out her hand to break the fall and got what looked like a laterally displaced Colles fracture.

It is very interesting managing trauma when there isn’t an X-ray machine around. It’s back to basics with rest, ice, compression and elevation, after ensuring that nerve and vascular function were not compromised.

Add some very strong pain relief, a sling and a back slab…and many cabin visits over the next 48 hours.

We were a week away from port but thankfully no emergency evacuation was required; just a full plaster four days later.

We stayed in touch post voyage and the patient had a very comfortable flight home to the UK and was managed by an orthopaedic surgeon with a plate and pins.

On the relaxing side, on most evenings, people gathered in the comfortable bar

after dinner to do a species count with the naturalists and share the day’s stories and photos. If you want to learn on your holiday, this is a terrific way to do it. Everyone is enthusiastic and the naturalists add so much to the collective understanding of how life survives in this harsh environment.

It is also a very pleasant way to end another exciting day in the Russian Far East, chatting with fellow travellers, all over a G and T or two.

These voyages are most popular for birdwatchers and for those who love

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TRAVEL wildlife! You won’t come across another passenger ship the whole trip; you’ll meet Russian border guards, all alone on the coast for hundreds of miles. On board, you’ll meet people from around the globe, including Russians keen to visit a rarely seen part of their country.

Getting off the boat is via zodiacs. For passengers with major joint replacements, significant obesity, unfitness or balance, this was the most dangerous part of their trip! There were a few falls, fortunately nothing significant.

Some days we couldn’t make land so we went for a cruise instead to spot whales (blue, grey, fin, humpback, beluga, orca) and seals (harbor, Stellar and Larga), sea otters playing in their kelp beds, and walrus, the latter by the thousands. Most were hauled out on rocky beaches; several groups of large males swam within 10m of our boats, keeping an eye on us as we watched from the zodiacs. They are truly huge creatures.

I left the ship in Anadyr, with a change in staff and most passengers. Ecotourism expedition ship cruising makes for an exciting way to combine primary and emergency care with adventure.

It’s for me!

By Dr Lin Arias

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THEATRE

How Can Peter Pan Go Wrong?

In medicine, a stuff-up can spell tragedy. In the theatre, it can produce pure comedy gold. That’s what producers of the “Goes Wrong” series of plays know all too well. Audiences love to cringe and they love to laugh – a lot.

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fter a hugely popular outing with The Play That Goes Wrong back in 2017, in March Perth can prepare to lurch toward Neverland with Peter Pan Goes Wrong – and given some flying will be involved, safety equipment will probably be required.

Medical Forum spoke to New Zealand actor Jay Laga’aia, who is a much loved face from his work in the Star Wars franchise, ABC TV’s Play School and musicals Lion King and Wicked. He will be heading to Perth for the March season playing the guest narrator, but there is no way a big personality such as Jay can pass up the chance to be a pirate.

“I have realised over the course of my career that if you haven’t played a vampire, a pirate or in my case a ‘cool’ sci fi character (Star Wars), you might as well keep your Shakespearean parts to yourself,” he said.

Jay was given early warning of Peter Pan’s imminent arrival onto the Australian/New Zealand theatre calendar by his wife – who had already bought advanced tickets.

“I then happened to be talking to director Luke Johnson who thought I might be interested. I went online and saw David Suchet playing the guest narrator in the UK production and I thought, ‘I could play that role’. My first choice was to play Peter Pan, but I didn’t think that my fellow cast mates could lift me off the ground. My flying days are behind me now.”

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Jay, who has opened with the show in New Zealand and now Australia, said the play had been a great learning curve and timing had to be spot on.

“We were lucky that we were able to rehearse with the full set and that saved three weeks’ work with the timing of exits and entrances because a show like this is all about timing,” he said.

“I make the joke that if the show was any bigger, on the scale of Wicked say, they would have shut us down for OHS reasons.

You can’t drop big weights onto the floor!

But that’s the fun part of the show. The audience cover their eyes in some parts, but they love it. We are constantly being booed and cheered.”

Jay thinks that shows like Peter Pan Goes Wrong are important to the theatre mix.

“Theatre has to be relevant and affordable.

You can have a fantastic show but if people can’t afford to come to it, it doesn’t get seen. Going to the theatre shouldn’t be a decision whether to eat or not, or to pay the rent or not.”

“Our show is reasonable and family orientated. What you see is what you get.

You come in and laugh out loud. Hearing men, especially, belly laugh the whole way through, for me that’s music to my ears.”

Performance, says Jay, is in his blood and over his career he has shown his versatility but even he can’t let the grass grow beneath his feet.

He has recently published a children’s book and works in the growing bilingual theatre scene in NZ but he says governments need to take the creative arts much more seriously than they do.

“When I talk to students here and in Australia, I am blown away by their talents.

Everyone acts, dances, sings. There are not many jobs I can think of where people have to justify themselves constantly as much as in the arts. The Government must see the arts as an intrinsic part of society because, really, at the end of the day, local creative product is the life blood and lifeline of the community.”

“If you are clever enough and add a sporting name, it will confuse them long enough to get a couple of years of grant before they twig.”

When it comes to Peter Pan Goes Wrong, the cast get nightly bonus cheques paid in laughter.

“For us as a cast, hearing the unbridled laughter of even just one person makes it worthwhile. One night I heard two guys sitting next to each other, slapping their thighs. One lady was clapping for no apparent reason, laughing and clapping.

It’s my job to help people forget their lives for three hours and if we can do that, we’ve done good.”

By Jan Hallam

“My kids need feeding for a start!” he said.

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BEER REVIEW BACK TO CONTENTS

The Monster Mash When we first received our brightly-coloured consignment from Australia’s “Best WA Brewery” we couldn’t help but anticipate an evening of migraines and reflux. After conquering our aversion to pastiche, what we actually encountered was an interesting and well-crafted suite of beers that, on the whole, were far from pretentious. (Star rating out of five)

By Dr Sergio Starkstein & Dr Bradleigh Hayhow

1. The Guv’nor Big Pale Ale (5.6% alc/vol) The notes say: “Biscuity malts and a drying bitterness make for an epic experience”. Whereas we would reserve the term ‘epic’ for other experiences, this beer had an enchanting stone fruit aroma followed by a refreshingly bitter palate, solid aftertaste, and carbonated to perfection.

Sweetness on the nose and bitterness on palate will never disappoint.

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Our score 2. Indian Session Ale (4.4% alc/vol) The notes say: “Hops and more hops…sweeter malts and bingo, Session ale!” To us this beer lacked aroma, but scored some points for its nice turbid colour, refreshing carbonation and a surprisingly floral palate. While it might be targeted at the Sunday arvo crowd, we just can’t warm to session ales: too light for an IPA, too heavy for a mid, and no threat to a decent pale ale.

We did our best to overcome our prejudices.

Our Score: 3. Copy Cat Aipa (6.8% alc/vol) The notes say: “Champion Australian Beer and Champion IPA in 2014… tropical, piney, resinous hop bitterness and aroma.” This IPA has a rich turbid colour and a sweet, creamy nose, with a clean and strong bitterness on the palate and pleasantly gentle carbonation. A serious challenger to Little Creatures IPA… to us, a little better.

Our Score: 4. Freo Doctor WA Lager (4.5% alc/vol) The notes say: “A fresh Pale Lager…A zesty aroma sits on top of the subtle, vanilla malt profile.” Better than most commercial lagers and suitable to our warm dry climate. Good carbonation but far from the style we enjoy.

Our Score: 5. Little New England IPA (3.5% alc/vol) Not too shabby for a mid-strength. Limited nose but good colour and carbonation with a bitterness that seems to punch above its 18 IBUs. A little less sweet and malty than the Little Creatures Rogers, but we didn’t think that was a bad point.

Our Score:

The Verdict MASH (the name of an American satire on medicine that may apply to some state of affairs in our neighbourhood), provides surprisingly good products in tin cans. It is worth trying each of the five beers, and you shall certainly find one of your taste. A nice little surprise for WA!

Wine winner

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His wife Di Comley won in November, 2018, so Prof Gary Jeffrey and his boys might be fighting over the winning Deep Woods wines. Gary is a physicianhepatologist at Charlies, so he knows how much to drink to stay out of trouble.

Although he works to prepare people for liver transplants amongst other things, and recalls that in France they transplant those with alcoholic hepatitis, in Australia, recipients need to show six months sobriety (abstinence) to qualify. In between carrying his wine to the car he mentioned the 20-year latency on primary liver cancer from hepatitis C, and with the virtual cure for hepatitis C, he is not fearful of doing himself out of a job with lifestyle diseases like fatty liver taking over.

FEBRUARY 2019 | 47

CHRISTMAS PULSE BACK TO CONTENTS

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SJG Subiaco Hospital The Medical Practitioners' Christmas Soiree was held at the beautiful Freshwater Bay Yacht Club where colleagues and partners celebrated another busy and rewarding year.

1 Dr Andrew Crocker, Dr Dianne Sunderman, Dr Peter Woodland, Sherry Quirk and Dr Chris Quirk 2 Dr Graham Forward and Jacqueline Gilmore 3 Olivia Garbowski and Dr Marek Garbowski 4 Dr Ralph Longhorn, Siobhan Creamer, Dr Gavin Clark and Dr Husain Nazir 5 Dr Tim Ball and Rachel Ball 6 SJG Subiaco CEO Prof Shirley Bowen, SJGHC Chief Operating Officer Hospitals Bryan Pyne and SJG Board Chair Kerry Sanderson 7 Prof Michael Quinlan and Prof Christobel Saunders 8 Julia Allen, Dr Michael Allen, and Dr Christopher Allen 9 Julian Henderson, Dr Jo Colvin, Rita Maguire

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SJG Midland Public & Private Hospitals The team at Midland headed to the Swan Valley at Mandoon Estate to celebrate the festive season and an exceptionally busy year with the new year promising more excitement with the introduction of Curtin medical students to the scene.

1 Dr Ben King and Dr Michelle Ross-King 2 Dr Birgit Schulz and Ross Andrews 3 Brian Shaddock, Dr Josephine McDonnell and Tennike Jacobs 4 Dr Francesco Piccolo and Lisa Piccolo 5 Dr Glen Brand, Barbie Brand, Michelle Ronchi and Dr Tony Calogero

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6 Jess Jessep, Dr Megan Foster, Dr Simone Bartlett and Ray Horley 7 Dr Jonathon Ng and Dr Ross Littlewood 8 Dr Michael Ma, Dr Mary Huang Fu, Anna Clare, Dr Emma Brandon, Ross Lee 9 Dr Mike Babon, Natalie So and Dr Kenji So 10 Dr Sayanti Banerjee, Dr Amit Banerjee, Dr Amir Tavasoli, Setaresh Samadi, Suwarni Vichi and Dr Simon Vichi

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SJG Murdoch Hospital The annual Christmas bash was held as is tradition by the lake on the hospital grounds. A jazz band and a hawker style food market and freshly shucked oysters kept the guests happy. The CEO of SJG Murdoch Ben Edwards reflected on the busy year that was, saying admissions had never been busier. He also welcomed cardiologist Dr Randall Hendriks to the stage as 2018 SJG Murdoch Doctor of The Year.

1 Dr Andrew and Michelle Christophers 2 Dr Rob Storer and Dr Gerald Soon Keng Lim 3 Dr Shane La Bianca, Loretta Baker and Dr Steve Baker 4 Doctor of the Year Dr Randall Hendriks with Stephanie and Anna Hendriks 5 Dr David Oliver, Michele Oliver, Taka Wild and Dr Andrew Wild 6 SJGHC Group CEO Dr Shane Kelly with SJG Murdoch CEO Murdoch Ben Edwards

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CHRISTMAS PULSE Ramsay Health Care

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Several hundred members of WA’s medical fraternity celebrated in style at the 2018 Ramsay Doctors’ Christmas Party at the State Reception Centre in Kings Park.

Doctors, staff and family mingled and mixed to the dulcet tunes of jazz vocalist Catherine Summers.

1 Christine Cass-Ryall, left, and Ramsay Chief Operating Officer Kate Munnings 2 Danny Sims, Dr Peter Smith, Dr Gerard Hardisty, Dr Greg Witherow and Catherine Witherow

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3 Alexandra Hunting, Dr Rhys Filgate, Eloise Finlayson and Dr Andrew Finlayson 4 Dr Stuart McCormack, Jane McCormack, Dr Mat Samuel, Dr Susan Kuruvilla, Dr Peter Melvill-Smith, Maeve Melvill-Smith, Dr Leighton Chadwick, Matilda Chadwick, Dr Andrew Jackson, Dr Vash Singh, Catherine Jackson and A/Prof Yuben Moodley 5 Dr Greg Janes, Kate Smith, Sandra Honey and Dr Peter Honey 6 Dr Daniel Heredia, Leonie Gardiner, Julianne Allan, Kempton Cowan, Dr Margaret Sturdy, Peter Mott, Kate Munnings, Kevin Cass-Ryall and Amanda Ling 7 Danny Sims and Dr Tony Geddes

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8 Dr Cliff Neppe, Dr Lauren Neppe, Dr Simon Wood and Jacqui Wood 9 Claire Franklin, Dr Paul Moroz and Kempton Cowan

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RACGP The Royal Australian College of GPsâ&#x20AC;&#x2122; WA faculty held its annual thank you to friends and supporters at its West Leederville headquarters which gave colleagues a chance to get out of their busy GP surgeries for a good catch-up!

1 Dr Bill Sands (RACGP national GP of the Year) alongside Dr Anastasia Limawan (Program Training WAGPET) and Dr Ramya Raman (GP from Piara Waters and on the New Fellows Committee).

2 Dr Doug Cordell (University of Notre Dame) and Malvina Nordstrom (IPN) enjoy some Christmas cheer.

3 Dr Sean Stevens (Chair RACGP WA) in discussion with Dr Simon Torvaldsen (right, on RACGP Council).

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SJG Mt Lawley Hospital Medical practitioners from St John of God Mt Lawley Hospital celebrated Christmas and the end of another year at Frasers, Kings Park.

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1 Ms Eva Skira, Chair of the Trustees, SJGHC, and Dr Abanoub Seif 2 Obstetrician and gynaecologist Dr Ken Nathan and Director Business Development Sally Harris 3 Neurologist Dr Susan Ho and gynaecologist Dr Ann Yoong 4 Director Medical Services Dr George Eskander, 2018 Doctor of the Year Award Dr Teck Yew and SJG Mt Lawley CEO Chris Hanna

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CHRISTMAS PULSE 1

Bethesda Health Care Upstairs at the Cottesloe SLSC the Bethesda Hospital congregation came together to enjoy the perfect view of Cottesloe Beach and the scrumptious food. Board chair Dr Neale Fong welcomed guests and introduced Dr Toby Leys who will replace Dr David Sofield as MAC chair.

1 Priscilla and Dr Duncan McLellan and Ian Cooper 2 Paul McCabe Lenka Psar-McCabe 3 Dr Steve and Trisha Lamb, Lynne and Barry Walker (HBF) 4 DON Deborah Bell, Luke Pasotti, Chloe Paterson 5 Rob Reid, Kath and Toby Leys, Neale and Peta Fong 6 Natasha Harris and Dr Peter D'Alessandro 7 Menisha and Dr Patrick Michalka 8 Kath and Dr Toby Leys

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Global Cardiology West Perth Launch The team at Global Cardiology celebrated the opening of its new site in Wellington St West Perth with a launch party that showcased the state-of-the-art Canon Genesis Scanner. Practice principal Dr Rajesh Kanna told the crowd that it made Global Cardiology the only private practice in Australia with a dedicated cardiac CT scanner.

The opening of the West Perth branch takes Global Cardiology’s presence in Perth to four – the other sites are at Murdoch, Kelmscott and Joondalup.

1 Imaging and TAVI Cardiologist Dr Pavan Chandrala at the launch.

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2 Dr Rahesh Kanna and Canon’s national product manager Rob Walczynski with the state-of-the-art Genesis scanner 3 Dr Rajesh Kanna speaking at the launch

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Liver Foundation Fundraiser The Liver Foundation of WA held a fundraising sundowner and an opportunity to hear form Prof Luc and Bronwyn Delriviere about their Antarctic expedition early next year.

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1 IMC John Burgess, Bronwyn Delriviere (from The Liver Centre WA & The Surgeons Collective), Mr Ben Richardson (Chairman of The Liver Foundation), Prof Luc Delriviere (Hepato-biliary & General Abdominal Surgeon) and Michaela Lenon from The Liver Foundation.

2 Dr Siva Sundararajan, Dr Melissa Wong, Dr Adrian Teo and Dr LinJun Mou.

Gift keeps on giving Back in 2014, the Peel Health Foundation, after nearly 10 years of raising funds to help fill the government funding gaps for health projects in the region, wound up. But its legacy continues. Remaining funds and donations were bequeathed to Curtin University – a total of $1.25 million – to create scholarships to help young Peel residents, who would otherwise struggle to afford university, to train for the health workforce. The inaugural 2018 Peel Health Foundation Scholarship is currently supporting eight Curtin health sciences students. Curtin Medical School student Isaiah Attkins (23) is a recipient of one of the scholarships. Isaiah, an Indigenous student who was born in Darwin before moving to Halls Head, was told by his school teachers to give up his dream of becoming a doctor but he forged on, completing his enabling course through the Centre for Aboriginal Studies before being accepted into medicine last year. He wrote to his donors thanking them and vowing to return to the Peel region as a doctor to serve the community that has helped him so much.

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SOCIAL PULSE

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MUSIC

The Nature of Why When the British Paraorchestra comes to town for the Perth Festival at the end of the month, it will take local audiences on a wildly innovative journey that will see audience mix with musicians and dancers on stage in a show entitled The Nature of Why. It could very well become a signature piece as its concept encapsulates everything the paraorchestra stands for – live now, play well and give your heart to the moment.

The director and founder of the paraorchestra, Charles Hazlewood, also embodies that spirit in his vast and broad body of work that sees him playing Mozart one week and working on a production using the music of Frank Zappa the next.

The phenomenon that is the British Paraorchestra, which debuted at the London Paralympics in 2012, began in a very personal way for Charles.

The youngest of his four children was born with cerebral palsy.

“In her short life, she is 12 now, aside from being my beautiful daughter she introduced me to an entire community I hadn’t thought of before – the disabled community,” he told Medical Forum.

“It got me thinking why, with all my work conducting orchestras all around the world, I didn’t meet musicians with disabilities, certainly not in those orchestras. You can’t tell me that there

The Nature of Why will see musicians and dancers together on stage and just to make things especially interesting, the audience is free to wander on stage to watch too. Somehow Charles manages to direct proceedings with deft poise.

are not millions of gifted musicians with disabilities.”

“So where was their platform? Where was their voice? It was about 2010 and the Paralympics was being organised in London. Here was a world event that showed that disability was no barrier to being a world-class sportsperson.”

“It may have taken a long time to get to this point but no one sees the Paralympics as a therapy project. It is world class sport. Now music is much more universal than sport, so what were we doing?”

“We are wasting the talents of millions because we don’t have the right infrastructure in place. No orchestra says disabled people aren’t welcome. The problems are much more fundamental. In the UK, which is pretty enlightened, still has many concert halls that limit access to the stage because of stairs.”

“So the Paralympics was the perfect opportunity to shine a big light on this.

We formed an virtuoso orchestra, like any other professional orchestra, and took to the world stage and it has been going fantastically since.”

The music has been composed by Will Gregory of electronic duo Goldfrapp and it has been choregraphed by Glasgow-based, Australian-born Caroline Bowditch.

This artistic freedom suits Charles to a tee.

“There is complete trust among the orchestra and there is nothing they won’t do for each other or for the performance.

I don’t need to have focused eye contact with the players, some have visual impairment anyway. It is a different way of working where everyone is connected to each other in different ways. The group is tight and flows together – it is just a thing of great beauty.”

“I am always interesting in breaking down the fourth wall in a theatre and having the audience among us is thrilling and it’s exciting for them to experience something different in the theatre.”

By Jan Hallam

Mirusia the magnificent Andre Rieu’s favourite soprano Mirusia Louwerse stars as Mimma in this war drama/musical to open at the Regal Theatre in April. Mirusia has sung with André Rieu’s orchestra for more than 10 years. Now Perth will see her playing

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a young Italian journalist who flees Mussolini’s Italy to take refuge at her Uncle’s Soho nightclub. There’s plenty of smoky jazz and high drama in the show which also features the local talents of The Perth Symphony Orchestra.

FEBRUARY 2019 | 55

When chemists die, they barium.

He headed out for a cup of coffee and paused by her desk to ask,

I'm reading a book about anti-gravity. I just can't put it down.

'When my garage door was open, did you see my Jaguar parked in there?'

I did a theatrical performance about puns. It was a play on words.

She smiled and said, 'No, I didn't. All I saw was an old minivan with two flat tires...’

Why were the Indians here first? They had reservations.

IT WORKS...

I didn't like my beard at first. Then it grew on me.

Did you hear about the cross-eyed teacher who lost her job because she couldn't control her pupils?

When you get a bladder infection, urine trouble.

Broken pencils are pointless.

MAKE IT SNAPPY I dropped out of communism class because of lousy Marx How does Moses make tea? Hebrews it.

Venison for dinner again? Oh deer!

A cartoonist was found dead in his home. Details are sketchy.

I used to be a banker, but then I lost interest.

Haunted French pancakes give me the crepes.

England has no kidney bank, but it does have a Liverpool.

I tried to catch some fog, but I mist.

I thought I had type-A blood, but it was a Typo.

I changed my iPod's name to Titanic.

It's syncing now.

Jokes about German sausage are the wurst.

He then understood his assistant's question about his 'garage door.'

What do you call a dinosaur with an extensive vocabulary? A thesaurus.

All the toilets in New York's police stations have been stolen. The police have nothing to go on.

I got a job at a bakery because I kneaded dough.

Velcro - what a rip off!

I want to be like a caterpillar. Eat a lot; sleep for a while; wake up beautiful Morning: Tired Afternoon: Dying for a rest Night: Can’t sleep

KEEPING IT ZIPPED The boss walked into the office one morning not knowing his zipper was down and his fly area wide open.

His assistant walked up to him and said, 'This morning when you left your house, did you close your garage door?'

I know a guy who's addicted to brake fluid, but he says he can stop any time.

The boss told her he knew he'd closed the garage door, and walked into his office puzzled by the question.

I stayed up all night to see where the sun went, and then it dawned on me.

As he finished his paperwork, he suddenly noticed his fly was open, and zipped it up.

Three old guys are out walking.

First one says, 'Windy, isn't it?'

Second one says, 'No, it's Thursday!'

Third one says, 'So am I. Let's go get a beer...'

TUNING IN A man was telling his neighbour, 'I just bought a new hearing aid. It cost me $4000, but it's state of the art... It's perfect.'

'Really,' answered the neighbour. 'What kind is it?'

'Twelve thirty...'

REVVING UP Morris, an 82-year-old man, went to the doctor to get a physical.

A few days later, the doctor saw Morris walking down the street with a gorgeous young woman on his arm.

A couple of days later, the doctor spoke to Morris and said, 'You're really doing great, aren't you?'

Morris replied, 'Just doing what you said, Doc: 'Get a hot mamma and be cheerful.''

The doctor said, 'I didn't say that... I said, 'You've got a heart murmur; be careful.'

OUCH! A little old man shuffled slowly into an ice cream parlour and pulled himself slowly, painfully, up onto a stool.

After catching his breath, he ordered a banana split.

The waitress asked kindly, 'Crushed nuts?'

'No,' he replied, 'Arthritis.'

Social Sailing Dr Andrew Dunn on Quattro, his 60 ft sloop that normally lives in a pen in Fremantle Fishing Boat Harbour. Andrew is after regular crew – he aims for 10 to 15 crew for day trips and 10 or less for over-night stopovers. It’s free and novices are welcome.

Email direct drandrewdunn@hotmail.com or go to www.meetup.com if sailing is not your thing but you are looking for company.

56 | FEBRUARY 2019

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This girl said she recognised me from the vegetarian club, but I'd never met herbivore.

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COMPETITIONS

Enter Medical Forum's competitions!

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link.

Movie: Stan and Ollie Steve Coogan and John C. Reilly star as Laurel and Hardy, the world's most famous comedy duo. The film focuses on the latter part of the pair’s career as they attempt to reignite their film fortunes by embarking on what becomes their swan song – a gruelling theatre tour of post-war Britain.

In Cinemas, February 21

Movie: King of Thieves A famous thief in his younger years, 77-year-old widower Brian Reader pulls together a band of misfit criminals to plot an unprecedented burglary at the Hatton Garden Safe Deposit. The thieves, all in their 60s and 70s except for one, employ their old-school thieving skills to plan the heist over the Easter holiday weekend.

Movie: A Dog’s Way Home A Dog’s Way Home chronicles the heart-warming adventure of Bella, a dog who embarks on an epic 400-mile journey home after she is separated from her beloved human. Based on W. Bruce Cameron’s bestselling book, this movie is sure to generate plenty of sighs!

Posing as servicemen, they enter the deposit, neutralise the alarms, and proceed to drill a hole into the wall of the safe. Two days later, they manage to escape with over £200 million worth of stolen jewels and money.

When police are called to the scene and the investigation starts, the cracks between the misfit gang members begin to show as they row over how to share the goods and become increasingly distrustful of each other.

In cinemas, February 28

Theatre: Peter Pan Goes Wrong For those who loved the craziness that was The Play That Goes Wrong, team with the addition of New Zealand actor Jay Lala’aia (familiar and loved by many for his roles in two of the Star Wars movies and ABC’s Play School) are coming to Perth to show off the wonders of Peter Pan’s Neverland.

It’s a star-studded cast headed by Michael Caine, Jim Broadbent, Tom Courtenay, Charlie Cox, Ray Winstone and Paul Whitehouse.

In cinemas, February 28

His Majesty’s Theatre, March 7-17 M E D I C A L F O R U M $ 12 . 5 0

Music: The Nature of Why?

Winners from November

Movie – Robin Hood: Dr Markus Schmidt, Dr Yvonne Tan, Dr Jenny Beale, Dr Michel Hung, Dr Bhupinder Singh

Aged Caring N O V E M B E R 2 0 18

Movie – Cine Latino Film Festival: Dr Trixie Dutton, Dr Sally Price, Dr Philippa Adams, Dr Catherine Murray, Dr Colin Stewart

Charles Hazlewood leads the exciting British Paraorchestra with four dancers in theatrical musical experience the likes Perth has yet to witness. The Nature of Why? is part of the Perth Festival and features the music of Goldfrapp’s Will Gregory and gives the audience the opportunity of mix with the performers on APR I L stage.

GP Insights; Consumer Choice; Bottlenecks Thrombectomy for Stroke Exercise; Nocturia; Retinopathy

09 TO 21

November 2018

MAJOR PARTNER

www.mforum.com.au

20 1 9Heath

REGAL THEATRE PERTH

Movie – The Old Man and the Gun: Dr Emelyn Lee, Dr Sai Fong, Dr Clyde Jumeaux, Dr Michael Armstrong, Dr Max Traub, Dr Linda Wong, Dr Christine LeeBaw, Dr Bibiana Tie, Dr Bertha Collin, Dr Palan Thirunavukkarasu

Ledger Theatre, February 22-24

Musical: Mimma In fascist Italy, a young journalist flees to London to her uncle’s Soho nightclub where she discovers a world of jazz and political resistance. As war looms, Mimma witnesses betrayal and fear with her homeland feeling ever farther away and the London becoming increasingly dangerous.

Theatre – Brainchild: Dr Peter Baumgartner WASO – Messiah: Dr Deby Rori

Regal Theatre, April 9-21

A M USICAL O F WAR & FRIEND SH IP

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STARRING MIRUSIA LOUWERSE, JASON BARRY-SMITH, SUZANNE KOMPASS, HOLLY MEEGAN, IGOR SAS COMPOSER RONALD SIEMIGINOWSKI LIBRETTIST GILES WATSON DIRECTOR ADAM MITCHELL ORCHESTRATOR & MUSIC DIRECTOR SEAN O’BOYLE SET & COSTUME DESIGN BRYAN WOLTJEN LIGHTING DESIGN TRENT SUIDGEEST SOUND DESIGN BEN COLLINS FEATURING THE PERTH SYMPHONY ORCHESTRA

FEBRUARY 2019 | 57

Every Age is an Exercise Age Living longer is one thing, continuing to live that longer life well is another matter. Exercise physiologist Katie Stewart says its all in the moves.

I

n 1960. the life expectancy for men was 77 years and 80 for women. These days men can expect to live to 85 and women to 87.

That’s on average an extra 7.5 years of living we have up our sleeves.

The tax that comes with living longer is burden of disease. Some diseases we can’t control but others, such as chronic conditions, which contribute to 61% of our total disease burden, we can do more about.

The top eight chronic conditions released in the recent Australian Health Report by the Australian Institute of Health and Welfare (AIHW) are: cancer, cardiovascular disease, mental health conditions, arthritis, back pain and chronic obstructive pulmonary disease, asthma and diabetes (in that order).

Exercise is one of the cheapest and most effective preventative medicines, complementary treatment interventions and management therapies for maintaining quality of life for people with these chronic diseases. Exercise alongside a healthy diet could reduce risk of disease by 40% (based on 30 minutes of walking five days a week, and weight loss of 3kg for those who are overweight or obese.

When we are younger the greatest barrier to exercise is ‘not enough time’. As we get older ‘poor health or injury’ is our greatest objection.

The irony is that as we age we need exercise more to help prevent these conditions.

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LIFESTYLE

Step into a healthy future A variety of styles, compression & materials for: Travelling Pregnancy Surgery – Sclerotherapy, Pre & Post Op Chronic venous insufficiency Deep vein thrombosis Oedema Lymphoedema Varicose ulcers Varicose veins Wound care Sport Tired aching legs – long standing or sitting (Nurses/Doctors/Truck drivers/ Hairdressers/Teachers etc.)

And much, much more

Here are some simple and time-efficient ways to apply exercise medicine at any age, which can help stop the worrying about what could go wrong and encourage minds and bodies to squeeze more living into those extra 7.5 years: • Chronic Disease Management Referral to an exercise physiologist or physiotherapist can see a tailor made program to suit the individual and their condition.

• 150 minutes of cardiovascular exercise can improve heart and lung function and help prevent depression.

• Strength training twice a week can help hormone and systemic health by supporting healthy posture and reduce risk of falls.

• Yoga or Pilates based regular stretching and functional conditioning twice a week can help prevent back pain, improve balance and reduce joint pain.

• Breathing and mindfulness practice reduces stress and anxiety and improves physical capacity to exercise.

• Brain training exercises and games (eg crosswords, bridge, online cognitive exercises) of any kind can help prevent cognitive decline.

No exercise program should be started without consultation with a GP.

For specialist advice and support, please call: VENOSAN WA on 08 9203 5544 or Email: sales@venosanwa.com.au

venosanwa.com.au 58 | FEBRUARY 2019

MEDICAL FORUM

You don’t buy a practice every week, but we do

It’s a big decision, Huge. For most, it’s a once in a lifetime proposition.

We take this very seriously too.

So much so, that over the last 25 years we’ve developed a process for medical professionals looking to go out on their own.

But we don’t just look at you, we look at the business as a whole. We act as your partners in ensuring that it is a viable and profitable opportunity. We assess everything - location, competition, client-base and growth potential.

Then, and only then, we tailor a loan to meet your needs.

Forgive the pun, but we have a lot of practice when it comes to buying a practice.

Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.

Car loans | Commercial property | Credit cards | Equipment finance | Fit-out finance | Foreign exchange | Home loans | Personal loans | Practice purchase | Practice set-up | Savings accounts | SMSF | Transaction accounts | Term deposits | Vehicle finance The issuer of these products and services is BOQ Specialist – a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”).