Medical Forum WA 0419 Public Edn

Secrets of the Heart AF & Stroke Prevention Exercise and Diet Diabetes, AAA, Statins, etc Atlas, Friedland & Deleuil Unplugged

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GUEST EDITORIAL Mark Balnaves, Managing Editor

Heart to Heart The Clinical Updates focus mainly on cardiovascular matters. The technology and education and training advances have been extraordinary in this field and stand in stark contrast to ancient ways of identifying and dealing with heart disease. But was heart disease common among pre-modern humans? Did people describe it?

What did the ancients know?

Rachel Haja provided a recent historical overview of whether or not the ancients identified coronary artery disease and whether coronary artery disease was, indeed, a problem among the ancients. The paper Coronary Heart Disease: From Mummies to 21st Century appeared in Heart Views in 2017.

A physical test of Egyptian mummies found probable or definite atherosclerosis in 34% of 137 mummies studied.

The researchers conclude that heart disease was common among the ancients. Haja also looked at whether or not the signs and symptoms of coronary artery disease were reported in literature.

Arab cardiologist, Dr. H.A. Hajar Albinali, is given credit for possibly identifying the first and best historical description of angina. The Arabic book Majnoon Lila: Between Medicine and Literature, translated an ancient poem into English. Dr. Albinali concluded that the poet had CAD and died with myocardial infarction.

"My heart is firmly seized By a bird's claws; My heart is tightly squeezed, When Lila's name flows.

My body is tightly bound, My body is tightly bound, Is like a finger ring around."

Ancient Egyptian and Arabic cultures did not collect data on population health. The first selfadministered questionnaire was conducted by Karl Marx, seeking information on worker health. He got no replies. Serious survey tools were a 20th Century innovation with researchers like Paul Lazarsfeld

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The Australian Institute of Health and Welfare’s Australia’s Health 2018 estimated that in 2014-2015 645,000 Australians aged 18 and over, 3.3% of the adult population, had heart disease. One in six adults aged 75 and over are affected.

An estimated 61,600 people aged 25 and over had a heart attack or unstable angina, about 170 events every day.

Coronary Artery Disease was the leading single cause of death in 2016 with 19,100 deaths, representing 12% of all deaths, and 43% of cardiovascular deaths. More than 40% of the deaths resulted from a heart attack.

The impact of CAD increases with remoteness and socioeconomic disadvantage with rates 2.0 to 3.1 times as high among Aboriginal and Torres Strait Islander people as among non-Indigenous Australians and 1.4 to 2.4 times as high in remote and very remote regions as in major cities. The lowest socioeconomic areas compared with the highest socioeconomic areas are 1.3 to 2.2 times as high.

Trends in Cardiovascular Medicine

The skills of cardiologists are already having a major impact on outcomes for patients and the future of coronary care. The American College of Cardiology Cardiology Magazine asked experts what they saw as key trends in 2019.

The answers included greater emphasis on cost and value; greater use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF); new models in the management of mitral valve regurgitation (MR) in heart failure patients; increased use of transcatheter aortic valve replacement (TAVR); increased impact of wearable and implantable devices and the data they collect; and not least the rise of artificial intelligence (AI) in cardiovascular medicine.

Cardiac Care in WA

The Australian context

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

deploying statistical methods. Today, of course, detailed data on population health are common and with wearable devices the capacity to capture more complex data.

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

Competition amongst cardiologists is strong, in an ageing population, and particularly amongst interventional cardiologists.

Imaging is going ahead in leaps and bounds so technological advances in equipment, often expensive, becomes important.

While the cardiologists test out the minutia of cardiac care, testing one intervention against the other, the general practitioner takes a global view. Forgetting to take the white tablets for a variety of acceptable reasons may be the barrier faced by all.

This is a problem of modern times.

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 Mark Balnaves 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

APRIL 2019 | 1

CONTENTS APRIL 2019

INSIDE 6 Have You Heard?

17 Prof Marcus Atlas 24 Dr Greg Deleuil 29 Exercise Intolerance

17

24

6

NEWS & VIEWS 1 Guest Editorial: Heart to Heart - Mark Balnaves PhD 4 Ask an Expert: Endophthalmitis - Dr Tim Isaacs 4 Letters to the Editor: WA’s Chief Pharmacist - Mr Neil Keen 6 Have You Heard?

7 Beneath the Drapes 7 Vale Peter McClelland 9 Incisions: Involuntary Treatment for Addiction - Dr Leon Nixon 13 Retiring Doctors: A Case in Point 19 Closeup: Prof Peter Friedland LIFESTYLE 45 Community Link Booth & Parkrun WA 46 The Funny Side

Wine Winner 47 Wine Review: Latitude 34 Wines,

29 MAJOR PARTNER 2 | APRIL 2019

48 49 50

St. Johns Brook - Dr Craig Drummond Competitions Poetry: Barney Embraces Technology - Dr Peter Burke Comedy Festival Review

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CONTENTS APRIL 2019

CLINICALS

23

27 The Status of Cardiac CT Dr Jeanne Louw

Drugs to Avoid in Heart Failure Dr Matthew Best

34

29 Exercise Intolerance - When to Think of Cardiac Causes A/Prof Andrew Maiorana

35

Aortic Aneurysm In 2019 Prof Patrik Tosenovsky

Cardiac MRI Helps Sort Out MINOCA Dr Adil Rajwani

37 Statins in Older Patients – Who Benefits Dr Michael Davis

29 AF Treatment Without Anticoagulants Dr Michael Nguyen

39 Stroke Prevention in Atrial Fibrillation Dr Joseph Hung

30 Cardioversion in AF Dr Benjamin King

40 Cardiovascular Risks in T2DM Dr Athula Karu

33 How Valuable Is the Standard ECG? Dr Nik Stoyanov

42 New Horizons – T2DM Management Dr Ricky Arenson

INCISIONS

Workplace Culture The Good, The Bad & The Ugly?

Keynote Speakers: Clinical A/Prof Tim Bates, Dr Angela Alessandri Panellists: Dr Frank Jones, Dr Ros Forward & Dr David Oldham

42 The Diabetes Educator Ms Leontine Jefferson

44

Involuntary Treatment for Addiction Dr Leon Nixon

What is the Best Diet for Cardiac Health?

Ms Jo-Anne Dembo

GUEST COLUMNS

10

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11 Do We Have the Management Skills?

Mr Ben Foote

12 Going 'Down Under' May Be a Downer Ms Nicky Gray

15 Social Prescribing Dr Rash Patel

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

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APRIL 2019 | 3

LETTERS

Endophthalmitis?

By Dr Tim Isaacs, Ophthalmologist, Clin Senior Lecturer UWA

ED

What is endophthalmitis?

Intravitreal injections are now common, rising exponentially (last 20 years). But things can go wrong, often late at night, when the treating ophthalmologist is not contactable! This could be a medical emergency. What can another doctor do? ......................................................................

The problem Anti-vascular endothelial growth factor (VEGF) agents such as bevacizumab, ranibizumab and aflibercept, given as endovitreal injections, are used to treat common vitreoretinal disorders such as neovascular age-related macular degeneration, diabetic macular oedema, and macular oedema secondary to retinal vein occlusion.

Endovitreal injections markedly improve visual acuity. The most significant complication is endophthalmitis, which occurs in approximately 0.01 - 0.08% of cases – a cause of significant preventable visual loss. About 50% of people with the infection lose sight, despite the best treatment.

How does it happen?

Bacteria are either inoculated into the vitreous cavity at the time of injection or (much less likely) gain access via the needle tract. Potential sources of bacteria include the patient’s ocular or periocular surface, aerosolised bacteria, or contamination of the needle, instruments, drug or drug vial.

of 105,536 injections, 31% of culturepositive cases were due to Streptococcus1 - often leading to poor visual outcomes, and probably from droplet dispersal of organisms while performing intravitreal injections.

What are the symptoms and signs?

Post-injection endophthalmitis occurs on average 4 days after injection. Look for complaints of severe pain, loss of vision, redness and watering of the injected eye.

Clinical signs may include mucopurulent discharge, swollen lids, conjunctival hyperaemia, hazy cornea, hypopyon (white blood cell exudate in the anterior chamber), and loss of red reflex.

What is the management?

Urgent same-day referral usually results in ‘tap and inject’, with aspiration of vitreous via the pars plana for microscopy and culture, followed by intravitreal injection of broad-spectrum antibiotics.

How can the risk of endophthalmitis be minimised?

Injections have careful attention to asepsis.

Aerosolisation of bacteria minimised by the use of face masks by surgeons, and by remaining silent during injections. Control of the eyelashes and lid margin to avoid contamination of the needle e.g. use of lid speculum.

ED. Dr Tim Isaacs only rarely sees ‘endogenous endophthalmitis’ amongst injecting drug users at RPH, usually from unsafe injecting practices (contaminated needles).

Most common identified organisms are coagulase-negative staphylococci, most frequently S. epidermidis, which may be abundant in the conjunctival flora of the normal human eye. In a meta-analysis

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WA’s Chief Pharmacist Dear Editor, The Chief Pharmacist has primary responsibility to administer the Medicines and Poisons Legislation for the Department of Health. These laws control the pharmaceutical supply chain and regulate substances, from dangerous poisons used in agricultural settings, through to prescribed controlled drugs.

Each year the Medicines and Poisons Regulation Branch manages 3,500 licences and permits, 24,000 authorisations and approvals, and 1.1 million controlled drug records. The Office receives around 30,000 queries on the handling, storage, dispensing and prescribing of medicines annually.

This legislation was updated in 2017 to provide a modern and flexible approach to regulation, with a key feature being more contemporary governance of controlled drugs.

The Department has collected information on controlled drugs since the mid-1990s.

Dispensing records are monitored to identify doctor shopping, dependence, over-prescribing, and regulatory noncompliance. Prescribers can obtain information on patients by contacting the Schedule 8 Medicines Prescriber Information Service on 9222 4424.

The current prescription monitoring approach is limited by an inherent delay in the collection of data. As information is not always accessible to the clinician at point-of-care, an obvious response is to use emerging technologies to increase the timeliness of data transfer.

With the growing acknowledgement of opioid misuse as a serious public health problem, Western Australia, along with other States and Territories, has been working with the Commonwealth on a national approach to monitoring. In the later-half of 2019, the Department will replace the existing regulatory database with a new system. The intent is that this will eventually integrate with a national data exchange, and provide information in realtime, direct to the clinicians desk top.

Between April and June, the Medicines and Poisons Regulation Branch will run several workshops with key stakeholders regarding policy and regulatory issues of prescription monitoring in this new environment. Professional bodies will be participating and individual prescribers are encouraged to contribute their views through these organisations.

Mr Neil Keen, Chief Pharmacist WA

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Pregnancy screening for chromosomal abnormalities performed in Australia

Patients are asking — and clinicians need to be equipped with the right knowledge.

Harmony® is the most broadly studied non-invasive prenatal test (NIPT) for Down syndrome (trisomy 21), Edwards syndrome (trisomy 18), and Patau syndrome (trisomy 13).1-5 The Harmony Prenatal Test uses a proprietary, targeted DNA-based technology to provide you and your patients a greater level of assurance–simply requiring a maternal blood sample.

Harmony can be ordered for expectant mothers as early as 10 weeks1.

While traditional screening can miss as many as 15% of pregnancies with trisomy 21, Harmony’s DNA-based technology of cases.1 Clinicians in more than 100 countries have trusted Harmony.6

To learn more about Harmony, please visit clinicallabs.com.au/harmony, email harmony@clinicallabs.com.au or call 1300 367 674.

Non-invasive prenatal testing (NIPT) based on cell-free DNA analysis is not diagnostic: results should be confirmed by diagnostic testing. Before making any treatment decisions, all women should discuss their results with their healthcare provider, who can recommend confirmatory, diagnostic testing where appropriate. The Harmony Prenatal Test was developed by Ariosa Diagnostics. The Harmony Prenatal Test is performed in Australia. HARMONY PRENATAL TEST and HARMONY are trademarks of Roche. All other trademarks are the property of their respective owners.

1. Norton et al. N Engl J Med. 2015 Apr 23;372(17):1589-97.

2. Norton et al. Am J Obstet Gynecol. 2012 Aug;207(2):137.e1-8.

3. Verweij et al. Prenat Diagn. 2013 Oct;33(10):996-1001.

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4. Nicolaides et al. Am J Obstet Gynecol. 2012 Nov;207(5):374.e1-6.

5. Gil et al. Fetal Diagn Ther. 2014;35:204-11 6. Data on file, Roche

APRIL 2019 | 5

HAVE YOU HEARD?

Researchers in Melbourne say fat adolescents may have brains to match, particularly bigger pleasure and reward processing sensors. The theory is that as adolescents become accustomed to high rewards from impulsivity, body fat acquired from adolescence could develop into obesity with age due to a lack of behavioural change. What behavioural change? The researchers say rewardbased learning and executive control are compromised in overweight or obese people – more easily influenced by TV ads, and less able to control unhealthy urges.

Genetics play a part. Binge eating disorder comes into it. The hope is brain health will be a more accurate indicator of body composition and body fat than BMI.

Do we overtest and overtreat?

Choosing Wisely Australia®, an initiative of NPS MedicineWise, says that difficulty accessing patient records may drive unnecessary tests and treatments. That’s according to 54% of GPs and 61% of specialists surveyed. Health professionals also identified patient expectations, potential for medical litigation and uncertainty of diagnosis as factors. The MedicineWise CEO said, “Empowering consumers to be active partners in their healthcare can help overcome barriers to optimal care.”

Silver Chain trial to reduce medication errors More than 400,000 Australians present to EDs because of medication errors, according to a recent Pharmaceutical Society of Australia report. A Silver Chain trial plans to reduce those errors. The trial is part of Silver Chain’s Integrum Aged Care + clinic, which is helping more than 140 patients, over 65, with complex chronic conditions. A non-dispensing pharmacist liaises with a patient’s usual GP and the dispensing pharmacy to make sure each client receives the right

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Early obesity strikes

Microbiologist and lead author Dr Harriet Whiley

Household showers hide Legionnaires Adelaide is at it again! This time it has found of 68 samples collected from showers, 75% were colonised with Legionella and 64% contained traces of Legionella pneumophilia, the most common cause of the pneumonia like disease. Microbiologist Dr Harriet Whiley said elderly residents, lung disease sufferers, and heavy smokers are most at risk of contracting the disease. The bacterial lung infection causes fever, chills, shortness of breath, coughing and in serious cases can be fatal. The solutions? As if Adelaide isn’t hot and dry enough?

Increased hot water temperature to above 650 and run showers every week to replenish the water sitting in pipes. The study Factors Influencing Legionella Contamination of Domestic Household Showers is available at www.mdpi.com/2076-0817/8/1/27/pdf

medications. Silver Chain's Integrum Aged Care Medical Director, Dr Daryl Kroschel, said self-management and empowering people to understand their conditions, their medications and the associated side-effects were key. GPs will be pleased to learn this includes assisting discharges from hospital in need of support for change in medication or dosage.

Whoever pays the piper…

The studies, funded by a Sanofi Community Support Research Grant, said, “High cholesterol costs Australia $4 billion”. How was this figure worked out?

First. they say more than one in three adult Australians (or 7.1 million people) are estimated to be living with high cholesterol, according to a Heart Foundation report.

Next, high cholesterol is a key risk factor in heart disease and ischaemic stroke – “more than half of the $7.3 billion cost of heart disease, and 12% of the $1.3 billion cost of ischaemic stroke” - is attributed to high cholesterol. Sanofi, produces a series of cardiovascular drugs. In 2017-18 Australians spent close to $100 million out-of-pocket on lipid lowering medications. But compliance is lowish, which concerns the Heart Foundation Group CEO, Adjunct Professor John Kelly AM, who said: “Thousands of heart attacks and strokes could be averted if people aged 45-74 visited their GP for a heart health check and those with high cholesterol were properly treated and managed.” The Heart Foundation recommends that 90% of eligible Australians have heart health checks.

Share the Dignity’s fight to end period poverty Of the 3.2 million Australians currently living below the poverty line, 52% of those are women and young girls. Many of them experience what is referred to as ‘period poverty’ - being unable to afford necessary sanitary products. Share the Dignity charity founder, Rochelle Courtenay said some women cannot afford sanitary products, when it comes to feeding their children.

Share the Dignity started in 2015 to bring dignity to homeless, at-risk women and girls experiencing domestic violence through the distribution of sanitary items.

Woolworths has partnered with the charity to raise one million dollars to install 100 free Dignity Vending Machines.

6 | APRIL 2019

Share the Dignity founder, Rochelle Courtenay and Woolworths MD Claire Peters

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Higher echelon dying

Dementia rates falling

As journalists we get comparison’s galore as people strive to give their disease more clout by saying it is more expensive, has higher figures, targets particular groups, etc than a competing illness. This one is a good example, “Heart disease kills 3 times more Australian women than breast cancer” and “Every day 22 Australian women die, with more than 48,000 being hospitalised each year as a result of heart disease.” This was ages ago but as World Women’s Day is upon us we thought we would pass on the key messages – women should be heart healthy in diet and exercise and keep families together and change the statistics for future generations – join now to change awareness into women’s heart health by joining up www.heartresearch. com.au/wrd/

A South Australian study in The Journal of Gerontology: Medical Sciences has found that dementia rates in Australia are falling. The study of 348,311 older people receiving home care services found the prevalence of dementia fell from 26% in 2005 to 21% in 2014. Researchers say that the findings are consistent with other studies reporting a decline in the prevalence of dementia in the US and the UK, but warn that the drop in rates may be short lived with dementia rates expected to rise again as the population ages. There are more than 436,000 Australians living with dementia. Those figures are predicted to rise above 589,000 people by 2028 and above 1 million people by 2058.

Aussie kids hearts threatened by salt An alarming 80% of Aussie kids are eating too much salt with most of it coming from processed food and fast food takeaways, a report from The George Institute for Global Health, VicHealth and the Heart Foundation has found. The report found high levels and a huge variation in the salt content of children’s meals across the four fast food chains (Hungry Jack’s, KFC, McDonald’s and Subway). A children’s chicken nuggets meal from Hungry Jack’s contained more than an entire day’s worth of salt for a four to eight-year-old child, a McDonald’s Cheeseburger Happy Meal with fries contained almost two thirds of a day’s worth of salt, and a KFC Kids Meal Snack Popcorn contained almost half a days’ worth of salt. The salt content of fast foods like chicken nuggets in Australia can be more than twice as salty as similar meals in the UK.

Diabetic Aboriginal and Torres Strait children West Australian data show a 20-fold higher rate of type 2 diabetes among indigenous children compared with non-indigenous young people. Prof Greg Johnson CEO of Diabetes Australia said the $4m funding will enable a co-design approach involving leading researchers and clinical experts, Aboriginal Community Controlled Health Organisations, policy makers and others to work together.

Breastfeeding helps mothers' hearts Published in the Journal of American Heart Association, the study by the Sax Institute of over 100,000 mothers from New South Wales showed women who breastfed had a 14% lower risk of developing, and 34% lower risk of dying from, cardiovascular disease.

Professor Melinda Fitzgerald with her team from Curtin Health Innovation Research and the Perron Institute for Neurological and Translational Science have won $50 million over 10 years to help improve the lives of people with traumatic brain injuries.

Professor Jeffrey Hamdorf has been awarded Membership in the General Division of the Order of Australia in the 2019 Australia Day Honours’ list for contributions to medical education and all aspects of Bariatric surgery.

Alesha Heath, PhD, a scientist with Perron Institute’s brain plasticity research team has taken up a postdoctoral position at Stanford joining research into brain stimulation for people with mild cognitive impairment.

Hollywood Private Hospital has celebrated 25 years of service. Paul Ramsay took over the Repatriation General Hospital in 1994.

The AMA (WA) has announced on its website that Executive Director Mr Paul Boyatzis intends to retire later this year. AMA (WA) President Dr Omar Khorshid said “Mr Boyatzis has held the positon [sic] for more than 30 years." The announcement went on to say "Mr Boyatzis has agreed to stay on in the role until a replacement is appointed."

continued on Page 9

Vale Peter McClelland Peter, a journalist with Medical Forum for seven years, passed away on Monday March 4 He is survived by his wife Jan Hallam. Peter is described as full of life, sincere, jovial, genuine and an absolute pleasure to know. As one staff member recounts, “It only took me mere moments to know that Peter was special, his effervescent personality and unwavering positivity was overwhelming and infectious.”

Many readers will have had contact with Peter as he went about doing what the magazine strives to do best – sharing the work and commitment West Australian doctors have for the community.

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APRIL 2019 | 7

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HAVE YOU HEARD? continued from Page 7

Women's health and wellbeing The WA Health Networks Unit is developing for the Department of Health’s a new State policy on Women’s Health and Wellbeing. It is designed to complement work currently underway on the WA Men’s Health and Wellbeing Policy. The new policy for women will focus on inequalities in health outcomes between women and men, mainly in at risk groups.

National disability plan grinds on The Department of Communities is half way through hearing evidence from all those involved in the State Disability Plan.

Community workshops across WA were/ are open to everyone including people with disability, family and carers, and those working in the disability/ community services sector. Sessions focus on defining the values of the State Disability Plan and the attitudes and behaviours that better support people with disability. Visit http:// state-disability-plan.eventbrite.com.au for further details and www.communities. wa.gov.au/state-disability-plan

The Australian front cover Recently seen on the front cover of the Australian - 34 Indigenous people have committed suicide in 10 weeks. That’s one death every second day. Apparently 11 were children, prompting doctors and health experts to demand a rethink of how to address the worsening problem, particularly among women and children.

Mark Wenitong, a veteran Indigenous doctor on Cape York, said there needed to be an urgent but considered overhaul of programs to arrest the soaring suicide rate. The Public Heallth Advocacy Institute at Curtin Uni has a Mediawatch service if you would like to contact them on phaiwa@ curtin.edu.au

Asbestos on Nauru An ABC report said refugees living on Nauru have been exposed to potentially deadly asbestos after workers dumped it next to a settlement on the Pacific

Did you stay awake for World Sleep Day? World Sleep Day has come and gone, March 16th. If you have an overweight partner you sleep with, then you probably did stay awake on March 15th. Cambridge Weight Plan’s recent research reveals that over half (59%) of those in WA who have an overweight or obese partner say they don’t get a good night sleep. Snoring scores high on the reasons for loss of sleep overweight or obese partners.

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Watch your gut in flu season Dr Joanna McMillan, a nutrition scientist and Accredited Practising Dietitian, believes gut health is far from a passing health fad with scientific research showing there is a link between our immune and gastrointestinal systems. She says that close to 70% of our immune systems are actually housed in our gastrointestinal tract, so it’s important to keep it in good shape. Dr Jo advises that probiotics can be a valuable strategy for boosting immune function during winter as they have been shown to reduce the number and severity of respiratory infections.

Island. Some refugees have been building sheds with it. Workers from Nauru Utilities Corporation have been handling sheets improperly, many unaware of the hazards.

Of course delayed mesothelioma is the worry, but quantifying the legal risk should keep them talking for some time.

Mesothelioma sufferers and early palliative care A Curtin University study of mesothelioma sufferers has found that early specialist palliative care did not improve their quality of life. Malignant pleural mesothelioma affects more than 700 Australians each year. Prof Fraser Brims, a co-author of the study published in Thorax, said that the global burden of mesothelioma largely reflects the high use of asbestos

throughout the last century, with Australia and the UK having the highest rates in the world. Mesothelioma sufferers experience significant symptoms, low quality of life and a low survival rate, and the treatment of mesothelioma remains a significant challenge. The research explored whether early specialist palliative care, which involves managing the physical, emotional and spiritual aspects of care, soon after the diagnosis of malignant pleural mesothelioma (MPM) led to an improved quality of life and mood for patients and carers, compared with standard care alone.

Automated OSSN detection Researchers have developed an automated non-invasive technique for diagnosing eye surface cancer (ocular surface squamous neoplasia or OSSN). The technique has the potential to reduce the need for biopsies, prevent therapy delays and make treatment far more effective for patients. Mr Habibalahi, Researcher at the ARC Centre of Excellence for Nanoscale BioPhotonics and lead scientist on the project, said that early detection of OSSN is critical as it supports simple and more curative treatments such as topical therapies whereas advanced lesions may require eye surgery or even the removal of the eye.

APRIL 2019 | 9

Involuntary Treatment for Addiction Dr Leon Nixon is an addiction specialist and director of the Involuntary Drug & Alcohol Treatment Unit at Bloomfield Hospital. Here, he tackles a difficult topic for all of us.

In September 2016, the WA Mental Health Commission released Discussion Papers relating to the proposed provision of compulsory alcohol and other drug treatment in WA Courts. It recommended waiting on results from trials in NSW. The concept of addiction and its treatment have always generated controversy.

Brain effects Evidence demonstrates a neurobiological condition with strong genetic predisposition interacting with pre-natal, early life and later environmental factors.

These interactions produce abnormally enhanced limbic dopaminergic drive, inadequately moderated by impaired frontal lobe inhibition.

The resultant craving impairs control of substance use or behaviour, leading to compulsive use or activity that continues despite the affected person’s knowledge of the damage it is doing to health, social, relationship or occupational life. Previously valued activities and important role obligations are neglected and substance use or addictive behaviour becomes the dominant factor.

Earlier approaches required internal ‘motivation’ before an individual was accepted for treatment. Later, experience made it clear that most individuals entered treatment in response to external pressures. The partner’s ultimatum: ‘You either stop drinking, or I’ll leave and take the children.’ And the employer’s final warning: ‘I can’t keep you on if you keep missing Mondays’. With Motivational Interviewing, motivation became the outcome of skilled intervention.

This linked with the improved understanding of the neurobiological nature of addiction and its impairment of a person’s autonomy, has led to renewed interest in involuntary treatment. The international literature on this remains equivocal; comparison of multiple studies is difficult due to the heterogeneity of treatment approaches, which range from simple detention as was practiced under the NSW Inebriates Act 1912, to well supported multidisciplinary assessment and intervention such as is now offered in the NSW Involuntary Drug and Alcohol Treatment (IDAT) Units.

Results, so far An audit of the first 135 people admitted to the Orange, NSW, IDAT Unit was able to report the status of 134 six months after discharge.

Of those, 30% were still abstinent while a further 25% had resumed some substance use but at a reduced level and demonstrated an improved quality of life.

People with alcohol or drug related brain injury so severe it precluded independent living constituted 14%.

About 10% were dead, reflecting the high prevalence of severe physical disease in the cohort admitted (mostly cirrhosis and alcoholic cardiomyopathy). The remainder had relapsed to the previous level of substance use.

Case Report Sue, a 39 year-old, was admitted to IDAT five years ago with alcohol addiction complicating a severe anxiety disorder.

She arrived severely sedated due to medications prescribed for her anxiety.

On arrival she screamed and engaged in head banging as a protest at being “locked up” and as well, when her multiple medications were sequentially removed.

Despite her distress as medications were rationalised and at enforced abstinence from alcohol, she began to respond to CBT for her anxiety. She was discharged home on much reduced medications and functioning appropriately. She had been completely dependent on her mother who was also caring for her Parkinsonian father.

Five years later, she remains abstinent from alcohol, now looks after her mother who has become frail, works full time and has recently become engaged to be married.

She keeps in touch with staff and attributes IDAT with “giving me my life back.”

Our response Some instances of enforced “treatment” have been around for many years.

For example, NSW first passed laws constraining “inebriates” in 1900, and the updated Act of 1912 was in force until the passage of the present Act in 2007. In general, however, the concept of depriving a person of liberty to forcibly intervene in their addiction was met with concern.

It has become obvious that substance use and addictive behaviour disorders were having a major impact on health.

Recent WHO study of global mortality and morbidity records 3 million deaths worldwide due to alcohol, most of these occurring early in life: for the 20-39 year-old group alcohol is related to 13.5% of all deaths.

10 | APRIL 2019

MEDICAL FORUM

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INCISIONS

BACK TO CONTENTS

GUEST COLUMN

Do We Have the Management Skills?

Ben Foote, CEO of the Australian Institute of Management, thinks obvious talent by health professionals is no substitute for management skills. Is he right?

Taking the next step and setting up your own private practice can be an exciting challenge. As an industry leader in your profession, are you are equipped with the knowledge and experience necessary to successfully start and run your own business?

While you have a vision, this is not a business plan. For GPs, investing in business training and developing the appropriate skills and knowledge is a way to the success of your practice.

According to the latest report by The Australian Bureau of Statistics, 60% of new businesses are likely to fail within the first three years of business. This trend has surfaced within the health sector, as young businesses face a wave of challenges that go beyond their industry-specific expertise.

Health career professionals looking to overcome stunted career progression through opening their own practice can benefit from acquiring business training, where they can develop the skills and knowledge needed by successful business leaders.

Finance for non-finance managers Moving from the role of employee to employer requires a critical skillset that understands the financials of business and managing budgets. GPs need to learn how

to analyse financial data and understand all aspects of financial management from planning through to budget review and reporting.

Digital marketing for non-marketers In the first stages of managing a business, money is tight and the last thing you want to think about is marketing. However, marketing can be the life or death of a new business.

It is important to develop a foundational understanding of marketing in the digital age.

Learning how to navigate through digital marketing in terms of strategic planning and reporting is extremely beneficial to any new practice, particularly in bringing in new clients.

There are also many ways to teach employees how to identify, validate and implement innovations that drive business improvement. Employees who can offer new and better ways of doing things, whether it be a service offered or a business operation, are invaluable to any business.

Performance management Understanding the ins and outs of performance management can be a challenge for GPs moving into business management. By learning the best performance management practices, there can be a significant improvement of work practice and client outcomes. Mastering performance management will enable you to manage your own workload and goals while also developing a culture of learning and growth necessary to create a successful new business.

Innovation in the business To uphold the quality and safety of health services offered by your practice, it is important to encourage innovation in the business - analysing industry trends and issues that allow you to identify, validate and implement opportunities that can improve your practice.

Best Practices Since 2002, WA based Medifit has helped hundreds of healthcare providers across Australia create their dream practices.

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Contact Medifit today for a no obligation consultation and benefit from our experience.

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APRIL 2019 | 11

Going ‘Down Under’ May Be a Downer Ms Nicky Gray, as Commercial Director with Head Medical in the UK, tells us about the growing complexity of recruiting doctors from the UK. We are well versed in the hurdles that medical providers in Australia face when trying to recruit doctors from the UK - extensive red tape to navigate and complex legislation and processes to understand. Our knowledge of the market means we have recruited over 600 junior doctors, consultants and GPs into Australia.

Although healthcare systems differ slightly, a doctor who has completed their training in the UK rarely has any difficulty in making the transition. We advise employers to ensure they have a rigorous induction program in place and provide ongoing support to make sure that everything goes smoothly.

Making the decision to relocate your family and life across the globe is one that is not taken lightly by anyone. Many of the doctors we work with take a few years to take a leap of faith to a new country and hospital or practice that they have no experience of. Doctors are still drawn to Australia for a number of lifestyle and career reasons.

Despite being approached by government hospitals and general practices throughout the country who are desperate for doctors, we are consistently hearing in the media of an over-supply of doctors, and various measures are designed to stem the flow of IMGs. There appears to be a never-ending barrage of significant changes that provide an ongoing challenge to recruitment, in particular to General Practice.

In the last two years we’ve seen abandonment of the 457 visa This change happened almost overnight with no prior communication from Immigration, leaving their staff and employers in the dark.

As well, the RACGP have made major changes to the process for IMGs, which has resulted in longer processing times for applications and an increased cost to the

GP of up to $14,000 AUD, not including costs of AMC, AHPRA, Visa or the cost of actual relocation.

The proposed Visas for GPs Initiative will see new legislation resulting in all GPs who are applying for a TSS + ESMS + RSMS visa to obtain a workforce certificate from the rural health workforce agency, who then decide whether that general practice has a genuine need for that particular GP to work with them.

This will override the current DWS status and sponsorship application with Immigration, essentially making both irrelevant. We’re already hearing feedback from practice owners that this will without doubt put a huge strain on their business, making it extremely difficult to recruit highly sought-after doctors from the UK and there is disbelief that such legislation could be passed without any consultation with practices.

Is it a conflict of interest that the power is in the hands of the rural workforce agency when it comes to recruitment of doctors for practices in all locations of Australia?

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12 | APRIL 2019

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GUEST COLUMN

BACK TO CONTENTS

NEWS & VIEWS

Retiring Doctors: A Case in Point ASADA wants a step-down in retirement. Dr David Young now spends more time with his alpacas.

ASADA wants doctors who are stepping down (non-practising doctors) to be able to do just that without being required to meet the same CPD, recency of practice, and police clearance provisions that fully registered doctors follow. On the flipside, retired or non-practising doctors according to the Medical Board cannot offer any medical opinion on anything, anytime, and certainly cannot be available to medically assist anyone or lend a medical hand.

Not good enough?

Dr David Young is a retired anaesthetist, who likes to spend time with his muchloved alpacas He speaks of current ‘recency of practice’ requirements, when he asks, “Does doing anaesthetics for a month, which gets your recency of practice, render you safe as an anaesthetist? I don't think one month a year of anaesthetics is enough, either in one block, or in bits and pieces.”

title, regional tournaments e.g. Asia Pacific, national titles, state titles and many local tournaments.”

“Now, I have been asked to look after karate tournaments as a 'first aider', but Medical Defence thinks that I would be expected by the attendees to work at the 'doctor ' level that they are used to, and I wouldn't have insurance cover.”

As far as assisting others with locums, he must live where anaesthetists aren’t in short supply as he says: “There are enough younger anaesthetists wanting work, so that finding locums is difficult”.

He is more miffed about the erosion of his community standing, particularly amongst karate enthusiasts. He is no longer the volunteer karate team doctor, and instead someone without medical qualifications but with a paramedic or nursing certificate has taken over. He wonders if his experience as team doctor accounts for little after 20 years?

“I started assisting at karate tournaments] in 1983, last one in 2017, during which I officiated at one world title, one junior world

He spoke of the hardening of registration CPD and recency of practice requirements and what this means for people like him.

“I am still asked by the locals for opinions and have to be careful.”

“I used to write scripts and referrals - many situations are obvious enough to refer direct to a specialist, saving time and money. Most of the scripts I wrote were continued from other medicos.”

You get the feeling that not removing the “Dr” title was a shrewd move because more doctors would be up in arms if they lost this, along with other privileges, on retirement.

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APRIL 2019 | 13

14 | APRIL 2019

MEDICAL FORUM

Social Prescribing Dr Rash Patel explains what we can do next when drugs are not enough.

UK experience with social prescribing is positive.

MEDICAL FORUM

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The UK Cox Commission, set up to study loneliness after the murder of MP Jo Cox, estimates 9 million Britons suffer from chronic loneliness, significantly above the figure provided by the Office for National Statistics. No equivalent statistical collection is available in Australia at present.

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A key example of social prescribing can be found in the UK charity The Bromley

by Bow Centre. The Centre links GPs with social services and social groups www. bbbc.org.uk/health-centres/bromley-bybow-health-centre/. Social isolation is associated with a 29% rise in mortality, according to a report published in the 2015 edition of Perspectives on Psychological Science. The UK Office for National Statistics estimates that 2.4 million adult

Britons of all ages suffer from chronic loneliness.

pai

The social prescribing phenomenon is not just about medical intervention, it is about ensuring that people belong to social groups in what is now an epidemic of loneliness in the UK.

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Fatigue

Loneliness is underestimated in the UK. Is it in Australia?

WE HAVE TOOLS TO HELP GPs FIND CANCER EARLIER.

Chest pain

Social Prescribing and Loneliness

We would like to see the same happening right here in Western Australia. We can achieve this, but we need the help of local GPs like yourself. Please, contact us at: Zamiaconnect@gmail.com

Dyspnoea

The basic model involves a GP writing a ‘social prescription’ which refers the patient to the SP Service where the patient

SP has proved to be beneficial in the UK and has been fully embraced by the patients and the National Health Service, which fully supports, funds and encourages the framework application in primary care.

ple Nip rge cha dis ple Nip ion act retr

Ill-health becomes often a symptom of a collective societal and global disharmony.

Social conditions are not conducive to wellbeing; social isolation is epidemic and life lacks meaning and purpose for many. It is not surprising therefore that depression, unhealthy lifestyles and self-medicating with alcohol and other drugs have become the norm.

Social Prescribing (SP) is a framework that enables health care professionals to link patients to non-clinical social interventions. Recognising that people’s health is determined by a range of socioeconomic and environmental factors, social prescribing seeks to address a person's needs in a holistic way and supports individuals with a wide range of social, emotional and practical needs to take greater control of their own health and improve their mental and physical wellbeing.

The benefits of social prescribing are to provide an alternative to pharmaceutical intervention, address social determinants of ill health and promote patient empowerment.

) ars

It is also not helpful for us as doctors as we become aware and frustrated with a system that does not allow us to do our work the way we should. Frustration, burnout, depression and, regretfully, a high rate of suicide are the descriptors of the workforce in health care.

We believe that a pill cannot fix everything and that health services need to adopt a ‘more than medicine’ approach, one which focuses on the individual, their aspirations, needs and assets, and their context within the community. We have been investigating the success of the Social Prescribing framework in the UK and see it as a viable remedy that could help our struggling healthcare system. See www.ncbi.nlm.nih. gov/pmc/articles/PMC2688060/#__sec2title

ast

It is not difficult to anticipate what might happen if a patients’ underlying needs are not met: they will come back; their condition might deteriorate; or they may be admitted to a hospital or ED. All this is not a good outcome for the patient or the health system.

We are a small group of Western Australian doctors and similar minded people with a passion for community health and wellbeing.

is assessed and linked to the appropriate activity in the community. The SP service provides warm referrals, coaching and motivation. It records patient progress and reports back to the GP. Activities provided by voluntary and local community sector could include volunteering, arts activities, music, walking, gardening, cooking, healthy eating, etc.

Bre

Doctors know that there is no pill remedy for every medical condition and they understand how the effects of medications are limited unless a patient’s underlying problems are resolved. We know there is more most patients need but being overwhelmed by work, most of us opt for a quick solution: to grab the prescription pad and write yet another.

What is Social Prescribing?

e (ye

One might ask: When might a doctor overprescribe? What are the effects of overprescribing? And are there any alternatives?

Ag

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GUEST COLUMN

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The RACGP is familiar with the problems of loneliness and UK work on social prescribing.

Find out more at cancerwa.asn.au/gp/fce

APRIL 2019 | 15

Thank you.

Thank you for making us the biggest private hospital in WA 2019 marks the 25th year Hollywood Private Hospital has been part of Ramsay Health Care.

Since that day, we have more than doubled our licensed bed numbers, opened 16 additional operating theatres, built and expanded our standalone mental health facility, The Hollywood Clinic, and made major investments in research and technology. Today, Hollywood is considered the biggest private Hospital in WA and is a leader in a broad range of medical specialities, including urology, cardiology, psychiatry, oncology, neurosurgery and orthopaedics, with over 650 accredited specialists.

And we continue to go from strength to strength, with exciting plans for growth in the near future.

Thank you to our doctors, staff, volunteers and an incredibly supportive community, who have made this possible.

hollywoodprivate.com.au 16 | APRIL 2019

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CLOSE UP

Seeking the Holy Grail of Hearing Research “How can we regenerate these tiny hair cells of the inner ear?”

B

orn in Perth, Prof Marcus Atlas is passionate about giving back to the community the benefits he has received.

surgeons, now retired, who I really liked.

They had a big influence on me. I realised though I had to see what the rest of the world is doing in ENT.”

“I don’t remember being pressured as a kid, I just remember my parents saying you need a fantastic education to be successful and think about the community that gave you this opportunity.”

“I went to Cambridge and Pittsburg in the US, taking up Research and Clinical Fellowships. I returned to Sydney to join St. Vincent’s Clinic and the Garvin Institute in Sydney. I worked for 10 years in Sydney, which was the most wonderful time, I absolutely loved it.”

“This was a theme that I suspect my parents got from their parents who were immigrants.

My grandparents were Polish. Australia is a lovely country to live in. As a family we accepted that we should make sure that we make a contribution to the community that took such good care of us.”

“My father was in the furniture industry.

Dad died of cerebral dementia aged 90.”

Dementia became one of his medical research interests. His mother is 90 and he has an older sister (in Sydney) and a younger brother (married and living with his family in Singapore)”.

How did I get interested in ears?

“Medicine was full of science and biology and really cool. I did it and I loved it. I loved the complexity of it all as well as the human endeavour involved in it. Most doctors end up loving patients; this wonderful relationship with helping their patients.”

“At UWA I started my surgical training and met some Ear Nose and Throat

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“The idea of doing something special in medicine relies on knowing what everyone else is doing. How they achieve things.

How they make things. How they innovate.

How things change. In a big city there is a real opportunity to see that. I saw it in Cambridge. I saw it in Pittsburg. I saw it in America and all the places I visited. I saw as an opportunity to do it in Sydney and in the back of my mind in Perth. How could this be good in Australia and all the people I loved in Perth.”

In Sydney, Marcus was exposed to the work of other key people emerging in the cochlear research, not least Prof Graeme Clark, based in Melbourne. “I remember as a young registrar Graeme Clark coming to meetings. He was basically a scientist and he would go and talk about these unusual things and I remember my colleagues, particularly in Sydney, but also in Melbourne, saying that he would never succeed.”

“Cochlear implantation, early ideas; it dawned on me, that really fantastic ideas weren’t always going to be embraced by clinicians early on and that you had to battle through, battle through. Anything really new is a serious battle.”

Lions and philanthropy in WA Marcus returned to Perth as the first Professor of Otolaryngology in Western Australia. His work as a consultant otolaryngologist at St Vincents and Concord Hospitals in Sydney between 1990 and 2000 and his interest in translating research into practice carried over to the establishment of the Ear Science Institute Australia (ESIA).

“I have learnt that you have to take a business-like approach to be successful in this endeavour of the combination of research, clinical activity and education and training. It was never going to happen because the government wanted to give it to you. There were models I had seen around the world where if you combined your clinical work with your research activities, not only would they inform each other but they would fund each other. They would create a critical mass of activity” “I realised that we had to do it that way, so we had to think about philanthropy and people in the community who could

continued on Page 21

APRIL 2019 | 17

WA COUNTRY DOCTORS’ AWARDS 2019 Congratulations to all Award recipients LONG SERVICE AWARD RECIPIENTS 40 years of service Dr Thomas Buckley Dr Raymond Cockerill Dr Hugh Connolly Dr Aubrey Francis Dr Anthony Higham Dr Graham Jacobs Dr Robert Watt 30 years of service Dr Peter Bairstow Dr Wayne Bradshaw

GP of the Year Award WINNER Dr Peter Van Maarseveen FINALISTS Dr Coert Erasmus Dr Andrew Kirke Sponsored by

Dr Sally Cornelius Dr Alan Kerrigan Dr Andrew Lill Dr Peter Rae Dr Graham Velterop Dr David Waycott Dr Jonathan Williams 20 years of service Dr Leanne Abas Dr Bradley Atkinson Dr Stephen Bingham

Sponsored by Wesfarmers Dr Wynand Breytenbach Dr Susan Chapman Dr Richard Clingen Dr Pieter De Klerk Dr Peter Lines Dr Scott McGregor Dr Toby McLeay Dr Brenda Murrison Dr Sharnee Rutherford Dr Robert Seton Dr Katherine Templeman

Procedural GP/District Medical Officer of the Year

Specialist of the Year Award (Non-GP)

WINNER Dr Ian Taylor FINALISTS Dr Batsirayi Chiureki Dr Peter Ginbey

WINNER Dr Anand Deshmukh FINALISTS Dr Carolyn Masarei Dr Tony Mylius

Sponsored by

Metropolitan-based Specialist Bush Champion Award Medical Leadership Award WINNER Dr Clare Huppatz FINALISTS Dr David Atkinson Dr James Turner Sponsored by

Rising Star/New/Emerging Doctor of the Year Award WINNER Dr Kelly Ridley FINALISTS Dr Harmeet Singh Dr Richard Taylor Sponsored by

WINNER Dr Roland Main FINALISTS Dr Merrilee Needham Dr Stephanie Schlueter Sponsored by

Chairmans’ Award Dr Ian Taylor Sponsored by

18 | APRIL 2019

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CLOSE UP

Prof Peter Friedland: The ENT Doctor and Madiba When Peter Friedland phoned his family to say they might not see him again, he was deadly serious. In the end, it was the violence of South Africa that led him to migrate to Perth.

P

rof Peter Friedland resisted compulsory conscription into the South African Army. At the age of 29 years the Military Police offered him one year’s service in the military instead of serving 3 years under arrest. On a Friday afternoon at 4.00 pm October 1990, a few months after Mr. Nelson Mandela had been released, Peter Friedland was summoned by the most senior Commanding Officer.

“I presented in my formal officer’s uniform, absolutely terrified that I was going to be Court Martialled. Why else do you get summonsed at 4.00 pm on a Friday afternoon when you are an insignificant Lieutenant in the Medical Corps?

“I was told that there was going to be an assassination that night, Mr. Mandela was going to be with President De Klerk at the national press club for a newspaper person of the year award.

‘You are to set up two resuscitation stations at the event in two hours’ time,” he said.

“That was the first time I met Mr. Mandela,” Peter told the Medical Forum.

“I just remembered how tall and dignified he was, he towered above me, with the most beautiful smile and warm hands.”

The Doctor Drug It is not surprising that Nelson Mandela came to recognise in Peter some of the compassion that he himself possessed in great measure. “My late father was a big influence in my life, he was an engineer, and he became ill at a very young age.

He was poorly treated by the medical profession, partly because he didn’t have

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a lot of money and partly because of the arrogance of doctors in the 60s and 70s.”

“Although they were competent, they lacked empathy and caring and compassion. I decided that the medicine I would practice and teach would respect the dignity of every human being, irrespective of their station in life, and their colour, race or creed and whether they could afford health care or could not. Whilst I may not agree with people and their beliefs and what they do with their lives I can always respect the dignity of their narrative and who they are. That dignity is their birthright.”

The supportive part of medicine, the doctor drug, remains key, according to Peter. “Many cancers and chronic diseases are incurable, and doctors often revert to what they have been doing for 2,000 years, giving the patient time and attention and listening to their story.

Respecting their dignity and giving them the time of day, even if only a few minutes, being present with them, that is the true healing and supportive part of medicine that will continue for the next 2,000 years regardless of the technological advances.”

Peter practises what he preaches, helping a school of deaf children in South Africa as his ENT career evolved. “Sixty of them were HIV orphans, looked after by their brothers and sisters who were a mere 12 or 13 years old. The only square meal that got every day was the meal we provided for this school. For 330 pupils, we only had 9 or 10 teachers.”

“At the start we did not have an audiologist to test the children’s hearing and they would sign language. I was very fortunate to come into contact with a very devout Christian individual who ran a hearing aid company in the states. It’s a long story, but

he promised me hearing aids for all these children. We managed to fit hearing aids to some of the children who were moderately deaf and not profoundly deaf, and they could hear for the very first time.”

One of the greatest human beings It was his fateful connection to Mr. Mandela that drew Peter further into his ENT interests. “I never knew exactly why I entered ENT, until I met Mr. Mandela and had the opportunity to treat him. If I was in ENT just to look after this man, then that’s enough for me. It was a privilege to be in the presence of one of the greatest human beings. He was unique in the sense that he lived his talk. We can all talk about going to jail and living 27 years in a tiny concrete cell, but to do it and live 23 years after jail and practice the forgiveness and non-judgement that he preached is incredible.”

After their first encounters, Peter noticed that when Mr Mandela was on TV and at a news conferences, it seemed he could not understand what people were saying.

He could listen to them, but he could not understand their speech.

“I realised that he had a significant hearing loss and his hearing aid was not working.

I was working in the same hospital as his physician and I mentioned to him one day that Madiba couldn’t understand what people were saying to him.”

“Madiba” was how those close to Mr. Mandela addressed him, deeper than a surname it is used as a sign of respect and affection.

“One Sunday afternoon I get a phone call to say that Madiba had flown back from Mozambique. Would I be prepared to come to his house and see him? This was

continued on Page 25

APRIL 2019 | 19

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CLOSE UP continued from Page 17

Seeking the Holy Grail of hearing research embrace it and help us carry it out in what we call a sustainable way. Our clinical and our business activities could fund our research and education activities.”

“Lions were there right from the start.

Lions Hearing Foundation said that we will support you. It was really because we started to recruit wonderful people. Our boards have been full of people in the community. It began with business people, lawyers.

“The Lions Hearing Clinics at the time were barely sustainable. They just did not know what to do with them. Lions had this tradition of taking care of people’s eyes and hearing in our community in Western Australia. They were trying to run hearing clinics, but the hearing foundation did not really have the expertise in that.

To their credit they wanted to be better; they wanted to be informed by evidence; modern audiology facilities, modern audiologists; and they felt that they could not do that.”

“They saw this bloke who was interested in the area of hearing and said, “can you do it?” The clinics are now all part of the Ear Science Institute of Australia. I am so proud of Lions clinics. We employ 35 audiologists, 13 clinics and 10,000 patients a year .”

The ESIA’s critical mass of researchers and clinical skills, has made it the third largest centre of excellence in Australia and recognised internationally. ESIA works with the World Health Organisation (WHO) in its collaborative work to assist nations with evolving audiology teaching needs and hearing aid rehabilitation, especially in the Asia Pacific and China.

Links between hearing loss and dementia The growth of scientific research into hearing loss has a very personal dimension for Marcus. The emerging research demonstrating strong links between hearing loss and dementia touches on his father’s fate.

“We have discovered that hearing loss and dementia are intimately associated with each other. Hearing loss predisposes you to getting dementia and the treatment of hearing loss might stave off dementia, delay the onset of dementia, and even improve some of the symptoms associated with dementia.”

“It is one of the strongest risk factors for dementia, which has all just been relatively new. We have got this group who are trying to unravel the why and then at the same time beginning programs of hearing rehabilitation in patients who are predisposed to getting dementia (NCI, mild cognitive impairment).”

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“If we get mild cognitive impairment, which you and I are scared of getting, we are losing our membrane, and we have a hearing loss. If we treat the hearing loss will it prevent, delay or change the dementia occurrence? It’s very possible. So that is what we are doing. That for me is a very personal and important part of what we do.”

“We have a group that is particularly interested in regeneration of the cells. This is the holy grail of hearing research; regenerate these little nerve fibres so we do not get age related hearing loss. We have got this wonderful group who are from Hong Kong; working with scientists in US and in Europe, about how we can regenerate these tiny hair cells of the inner ear. If we were to make progress on that, then it would be a massive chance for hearing people and hearing loss in the world.”

Legacy Marcus does not want the Western Australian momentum in translational research in ear science to stop. He has left the public health system after 30 years and resigned from his UWA Chair, but he does not plan to stop research or his clinical practice.

“I have been thinking about succession planning for ages now, because I have seen it done badly and seen it done really well, both here in WA and other places.

I am actively working for succession for members and myself. I can’t tell you what we are doing, but we are really actively involved in planning. The Board wants me to stay on and continue my involvement and whilst we are going to look for the right people, both internally and externally.”

The Wellcome project is an example of the type of legacy Marcus sees from excellent translational research. Going to clinical trial next year it restores hearing to patients with painful damaged eardrums by combining science and silkworms to create a tiny device known as ClearDrum.

“To do clinical trials that you began from basic science, it is a real thing. I think that has been a tremendous accomplishment for us. That will be exciting. To be able to translate that into clinical care will be a brilliant proof that if that you join your clinical activities and research activities together, you can really do something special. I think that that is proof of that.”

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22 | APRIL 2019

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CLINICAL UPDATE

Drugs to Avoid in Heart Failure

By Matthew Best, Cardiologist, Nedlands 75% of hospital readmissions are due to medication errors. In older people, I wonder how many are these drugs and HF?

One challenge of looking after heart failure (HF) patients is managing their pharmacotherapy: at least 40% have five or more chronic conditions. This leads to the average HF patient taking 6.8 medications per day, not including over the counter and complimentary medicines. Getting drugs right on guideline-mandated therapy is one thing but we have to avoid getting them wrong too, avoiding any that cause unacceptable side effects in patients.

Inhaled Beta-agonists

This list of drugs for avoidance in general practice, is not meant to be all inclusive.

Decongestants etc

Evidence of a worsening of heart failure is limited to small trials and is not homogenous.

However, there is a proposed mechanism of receptor responsiveness with regular use and HF deterioration. Australian HF guidelines recommend minimising exposure to these, and favouring antimuscarinic agents.

Non-steroidal drugs and Cox-2 inhibitors These are obvious. Prostaglandin inhibition leads to sodium and water retention and blunted response to diuretics.

Observational studies support a risk of HF precipitation or exacerbation.

Thiazolidinediones aka “glitazones” These cause sodium and water retention, generally increasing the risk of worsening HF and hospitalisation. They are best avoided in HF patients, particularly with any symptomatic HF (NYHA II or above)

Central acting calcium channel blockers Verapamil and Cardizem have the strongest negatively inotropic effects and are contraindicated. Dihydropyridones such as nifedipine and (less so) amlodipine have also been linked to worsening heart failure.

Dipeptidyl Peptidase-4 Inhibitors aka “gliptins” Saxagliptin, in particular, in a large trial was associated with an excess of HF hospitalisation. Meta-analysis of all randomized trials of these types of agents has shown an increase in risk of HF. A trial of alogliptin showed a non-significant increase in hospital admission rates for HF but the previous meta-analysis suggests a possible class effect. The exact mechanism is unknown.

Moxonidine This one is somewhat counter intuitive, as this drug reduces sympathetic outflow.

However, a trial in HF patients showed that Moxonidine increased mortality.

Minoxidil A different drug, a vasodilator; in HF patients it increased LVEF but also increased clinical events (worsening HF, death).

Cilostazol In patients with peripheral vascular disease increases walking distance but inhibits phosphodiesterase type 3 and is believed to increase fatal arrhythmia risk. It remains contraindicated in HF.

Biguanides Metformin is safe in stable HF patients with preserved renal function (eGFR >60ml/ min) but should be avoided in unstable or hospitalized patients with HF. The concern is over lactic acidosis.

DIGOXIN x

Etanercept seemed to have no negative impact on HF patients. Infliximab had higher rates of HF hospitalisation or death in NYHA class III or IV patients. These drugs are contraindicated in moderate to severe HF and are used cautiously in milder cases.

Anagrelide Used to decrease the platelet count in myeloproliferative disorders, this drug inhibits phosphodiesterase similarly to milrinone and can cause a high output HF syndrome.

Stimulants A popular choice in my public outpatient clinic, drugs such as dextroamphetamine and methamphetamine are linked with reports of sudden death, myocardial infarct etc.

Pregabalin This can cause a peripheral oedema effect, probably via a similar mechanism to nifedipine.

Causes myocarditis, perhaps through an IgE mediated hypersensitivity; incidence about 1% over 10 years.

ACE-I/ARBs x x

b-BLOCKERS x x

x

x

CCB x x

AMIODARONE x x

WARFARIN x x x

x x x

ACE-I = angiotensin-converting enzyme inhibitors; ARBs = angiotensin receptor blockers; CAM = complementary and alternative medicine; CCB = calcium channel blockers.

MEDICAL FORUM

Tumour necrosis factor-alpha inhibitors

Clozapine

Table: CAMs drug interactions CAM PRODUCT St John’s wort Grapefruit juice Ginseng Hawthorn Danshen Black cohosh Green tea

Prolonged, excessive use of phenylephrine and pseudo ephedrine should be avoided as these drugs act on adrenergic receptors to exert their vasoconstrictive effect.

x

Complimentary/Alternative Medicines (CAMs) Frequently used despite guidelines suggesting they not be, and have no role in HF management. Ephedra like compounds (Ma-haung) should be avoided because of their stimulant effects. CAMs can interact negatively with mainstream drugs. A useful table of interactions is shown here.

Author competing interests: nil relevant.

Questions? Contact the editor.

APRIL 2019 | 23

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CLOSE UP

A Life Devoted to Asbestos Victims “Instead of just a nice doctor who was sympathetic and caring I became one of them.”

D

r Greg Deleuil is the face you want to see if you have been exposed to asbestos. He knows the impact of asbestos at a very personal level.

“When my mother got sick the irony was that she had Mesothelioma from her time in Darwin. She was the matriarch and she cleaned the house built in 1936, filthy with fibro asbestos sheeting, moulded asbestos louvres. The thing with fibro-asbestos is that glues held it all together. I can remember my mother cleaning the louvres and the asbestos would just crumble.”

“What that did was give me status within the asbestos diseases society with whom I had been working for 10 years. They now call me the medical consultant and one of them as well because I have been exposed to asbestos with a first degree relative who died from the disease.”

Greg has been with the Asbestos Diseases Society for 34 years. He stopped his North Perth practice in 2013, but “I see usually about 30 people a week, two mornings a week now. I am 80 years of age and no spring chicken.”

His history and the history of asbestos awareness and intervention are intimately tied together.

Becoming a doctor in the 50s “My father was in civil aviation and Australia was establishing the Kangaroo route from Sydney to London. There were only two planes that used to fly to London from Australia, one was a converted Lancaster bomber, and you can imagine how comfortable that was, and the other was a flying boat. My father was involved in ground to air communications and that is why he went to Darwin.”

24 | APRIL 2019

In 1954, Greg left Darwin for a high school in South Australia. His father was moved to Melbourne soon after, he followed, and jumped a year of high school to do matriculation. “I did quite well in leaving honours,” he said “I got called up for service in the Army and did three months in Watsonia in Melbourne and in the meantime my father got transferred to Perth, Department of Civil Aviation. When I finished my national service obligation I came across to Perth in 1955 and I did not want to go to university. I did not know what I wanted to do. I went to Perth Hospital and worked in the bacterial laboratory, I liked lab work; that dates me.

At that stage in Perth Hospital they were only doing bacterial and not viral research.”

“I was only 18 and when you are in a hospital environment you sort of realise that the doctors are the key; in the 50s they were. In 1956 I saw an ad for a new medical school starting in 1957, and fully trained in WA. I cannot remember my exact emotions, but next day I applied.

My interviewer was Mr Crawley. I finished the course in 1962, the first year to be fully trained in the new West Australian Medical School.”

Greg spent a year at Perth Chest Hospital, later the Sir Charles Gardiner hospital, and then in 1965 started GP locums in Sydney.

In 1968 he caught the Hong Kong flu and, on the advice of a friend and the support of his wife, he decided to return to Darwin.

“I contacted a doctor up in Darwin, David Cox, and of course they were short of doctors up there.”

Mass exposure It was, of course, the wrong time to be in Darwin. Cyclone Tracy hit the city 24-26 December 1974.

“I don’t think anyone cared about asbestos even though Darwin was a fibro asbestos city. You are talking about hundreds and hundreds of houses and you know the proportions they take now when they clean up one building site. In those days at the clean up, and I was there, they were using bulldozers and graders and the uniform was a pair of boots, shorts, and no suits.”

“We will never know how many were affected for several reasons. Navy personnel at that time were also exposed on board ship anyway, so the cleanup was just another exposure to asbestos.”

“The other people who were involved were civilian day labourers. From what I gather they would get paid a few bob for cleaning up. Darwin post cyclone was a real wild west town.”

“You couldn’t see plumes of dust because it was wet, but you could not eliminate it. If the cyclone had come in June then it would have been devastating, but it happened in December.”

Greg and his family were evacuated to Perth in 1975.

The demography of ‘exposees’ “When I came to Perth the government said anyone who had been evacuated could be employed in the health department, so I claimed my job. I worked with the Commonwealth Health Department on vaccinations and medicals. It was an income. Being a refugee doctor from Darwin I was a curiosity in the department.”

“I set up practice. In 1977 I got commissioned as a Captain doctor, in the reserve. I did two years as the Medical Officer, 16th Batallion, Scottish unit. After two years I was invited to be a doctor of the SAS and I worked with them for 27 years.”

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CLOSEUP “One of the things they did was send me to the school of underwater medicine.

The water operations use special types of diving equipment. You need very good equipment for testing ears and lungs. I added diving medicine to my General Practice and, as a result, a person from the asbestos disease society came to see me and I started to see the Society patients.”

“Now, my job is very simple, seeing people who have just been exposed to asbestos; ‘exposees’. This includes the ‘worried well’.

There are so many urban myths about asbestos and part of my job is to try and advise them of what is known about it and what is myths and where they stand and what they have to do and watch for. “ Greg made public the problems of exposure to asbestos, not least by giving lectures overseas, showing photos of Wittenoon, and understanding the changing demography of asbestos exposure.

“The demography of the exposees has changed. When I saw people in 1984 I was seeing people who used to mill the fibres and the wharf labourers who handled it, the workers at James Hardie. All the

trades people involved in constructions, painters, carpenters, plumbers. The big problem with the trades people now is I tell them, your worst exposure was your apprenticeship that came with the territory and times - when they would laugh. We are seeing these now.”

“The demography has changed and what has changed again is the DIY renovators, because once you start renovations it reexposes the asbestos to the outside world.”

“The other cohort that we see are the Wittenoon children who lived there, about 6,000, we think. There is no census. Children used to go up there and stay for six months.

The child could come and go without being registered in any particular way.”

“The irony was that the company Australian Builders Asbestos used to offer tailings, the residue after the extraction from the mineral, to families that would use it for sandpits, blue asbestos, sandpits were blue.”

The three worst words The aim of Greg and the Asbestos Diseases Society is not only to raise awareness but to provide pathways for

action for those being counselled.

“Put it this way, if you have mesothelioma you receive three of the worst English words you could receive. You have a cancer that cannot be cured, a cancer that can be very painful and a cancer that works very quickly. And families are devastated when it occurs. Deaths are normally between 6 to 9 months, but it varies enormously between people.”

Greg recounted that when he was a young doctor in 1963 he had wards of men with lung cancer and they all died. “All died, no women all men. The thing that I am struck with people with Mesothelioma is that they are frantic, nobody can advise them or talk to them. And this is what we have developed, a counselling service that can spend time with them. The individual is shattered, but also the family.”

“We make certain we catch lung cancer, because asbestos can cause lung cancer and with smoking it multiplies the chance of getting lung cancer. If you identify it early enough, then people have a pretty good outlook. Mesothelioma cannot be cured but it can be helped.”

continued from Page 19

Prof Peter Friedland: The ENT doctor and Madiba the moment I dreamed of all my life.”

“I realised he had been wearing analogue hearing aids, which were 30 or 40-year-old technology and made by a company which sent them to him when was he was still in Robben Island in the 1960s. He lost his hearing because he had performed forced labour daily in the limestone quarry. The noises from hitting the stone destroyed his hearing, just as the sunlight destroyed his eyes.”

Peter convinced Mr Mandela to wear digital, top of the range hearing aids. They worked. He could hear and understand.

“But his swollen arthritic fingers from all the years of the stone quarry could not remove the aids or adjust them. I realised how stupid I had been. What’s the use of putting the finest technology in the ear when the person can’t take them out?

I took them away and replaced them attached to big visible moulds. He wasn’t worried about what they looked like. I was worried for him. He had no vanity and couldn’t care less, he was only too happy with them.”

The move to Perth Mr Mandela did not want Peter to move to Perth, but his exposure to the victims of violence became overwhelming.

“I unfortunately operated on over 350 people who had been shot in the head and neck. Three of my closest friends were shot dead, in my presence. The last friend

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was shot and killed in front of me while we were waiting for our children to come off the soccer field. I was holding him and saying a few prayers while the police took the forensics. I made a commitment that within a year I would be out of South Africa and elsewhere.”

talk about too many people in our prisons and not enough space, what are we doing to genuinely rehabilitate people so they do not return to prisons? What are we doing for the individuals who can’t hear the judge or the prison warder and end up classed as disobedient?”

Peter was 46. His friend was killed on the 28th January 2008 and he started in Perth at Sir Charles Gairdner Hospital one year to the day on the 27th January, 2009.

Three years later he was appointed head of department.

Peter also started a charitable foundation with colleagues, Hear Hear for Bhutan, that helps children in Bhutan with hearing loss. “We visited a school of 110 to find none had been assessed by an ENT. I took an audiologist with me. We assessed and examined all of them and fixed those who had never heard in their lives with hearing aids.”

Peter is a gifted educator, committed to teaching and training medical students at UWA and Notre Dame Universities and to training and mentoring ENT surgical trainees. In his ten years in Australia, he was won nine teaching awards. This is combined with his active research in Otology and Head and Neck Cancer at Sir Charles Gairdner Hospital.

Mr Mandela gave Peter his blessing to leave, with one proviso. He should work for the good health of the indigenous people, whether it was in Africa or Australia, didn’t matter “I am involved in rural outreach in the Kimberley’s and Pilbara and would like to help lower the high rates of incarceration of indigenous juveniles in prison. Over 80% of them have hearing loss. I believe that if we can rehabilitate their hearing, we can decrease recidivism. The one-year recidivism rate is over 50%. So, whilst we

“What I love about Bhutan is that it has a happiness index, not a GNP. They are the happiest people in the world on an average wage of sixty to ninety dollars a month.”

“My colleagues took along plain lead pencils that cost 20 cents to give each child. We handed them out and one concerned six-year-old child came to me with a sign language interpreter.” “‘Did I not give you a pencil?’ I asked. She pulled out four pencils and she put three on the table and said ‘you gave me three too many.’ ‘Don’t worry you can keep them,’ I said. ‘No, it’s not fair, each of us only got one pencil and I only need one.’”

APRIL 2019 | 25

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CLINICAL UPDATE

The status of cardiac CT

By Dr Jeanne Louw, Radiologist, Perth To detect patients at risk and diagnose coronary artery disease in a simple and safe way?

Asymptoma�c

45 - 75 years old (Diabe�cs > 40 y.o.)

Framingham Risk Score

Risk in asymptomatic patients using CT Coronary Calcium Scoring CT Coronary Calcium scoring (CAC) has been developed as a way of detecting and quantifying coronary artery atherosclerotic calcification by non-contrast ECG-gated CT. It is superior to any of the traditional risk parameters (Framingham risk score (FRS), IMT and CRP) in predicting cardiovascular events.

A score of 0 has a high prognostic value with very low risk of death (<1% at 10 years).

CAC is most useful in those aged 45-75 years at intermediate risk using the FRS (1020% cardiovascular risk over 10 years), to help reclassify these patients into higher or lower risk categories. CAC may be helpful in lower risk groups (6-10% 10-year risk) when there is also diabetes (age 40-60 years) or a family history of premature cardiovascular disease. Several studies have shown about half of intermediate risk patients can be reclassified: 39% into a lower risk group and 16% into a higher group.

Patients with high risk based on FRS should be treated with optimal medical management and there is little benefit in CAC apart from those patients who are

Fig 1.

h�p://cvdrisk.nhlbi.nih.gov/calculator.asp Intermediate risk

Low risk <10%

10-20%

No treatment

Strong family history, other concerning features

High risk >20% Treat

Reluctant to accept treatment

CAC SCORE 0

No treatment, reassure

1-100

Improve Diet and lifestyle

101-400

Consider treatment (recommend if >75th centile)

averse to statins, where CAC may aid further decision regarding management.

CAC > 400 implies high risk of >20% mortality in 10 years – these patients need optimal risk factor management. Functional imaging (such stress echocardiography or Myocardial Perfusion Imaging) is appropriate since the risk of coronary obstruction is higher.

The radiation dose of CAC is low (at or below 1 mSv), lower than annual environmental radiation in WA which is around 1.5-2 mSv. There is currently no Medicare rebate available in Australia for CAC.

>400 Treat: Aspirin Statins

Fig 2. 35 year old female with exertional chest pain and no coronary artery calcification. Subtotal occlusion due to noncalcified plaque in the LAD artery, seen on this CTCA.

CT Coronary Angiography A calcium score of 0 does not exclude non-calcified plaque leading to stenosis.

Symptomatic patients are best assessed

by CT Coronary Angiography (CTCA), functional imaging or invasive angiography.

The strength of CTCA lies in its high negative predictive value of 97-99%, which makes it ideal to rule out significant coronary artery disease in low to intermediate risk patients with stable chest pain and angina equivalent symptoms.

Luminal stenosis of >50% needs further investigation: either functional imaging (in cases with 50-69% stenosis) or invasive angiography (usually in cases with >70% stenosis).

CTCA allows plaque characterisation of calcified, non-calcified and mixed plaque.

CTCA is emerging as a more advanced risk stratification tool in this respect.

There has been rapid development of CT scanner technology, mainly to reduce radiation dose and avoid motion artefact.

Now, the heart can be imaged in a single heartbeat with certain modern cardiac CT scanners. These advances allow us to image patients with arrhythmia, tachycardia and dyspnoea, with much higher image quality. Radiation doses are much lower (<1 mSv is achievable with the most advanced technology).

Specialist referred CTCA can attract a rebate for low to intermediate risk patients with stable symptoms who would have been considered otherwise for invasive angiography.

Author competing interests: No relevant disclosures. Questions? Contact the editor.

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Exercise intolerance - when to think of cardiac causes

By A/Prof Andrew Maiorana, School of Physiotherapy & Exercise Science, Curtin Uni Regular exercise reduces cardiovascular disease but acute bouts of exercise can unmask underlying cardiac conditions. What symptoms are suggestive of cardiac causes?

“No pain, no gain” has long been a mantra of the exercise enthusiast. However, exercise can bring on “I just don’t feel right!”. The human body experiences symptoms when the heart isn’t coping with the rigours of exercise (quite distinct from the normal feelings of fatigue).

When the heart isn’t coping with exercise Angina. Doctors are familiar with classic myocardial ischaemia; a feeling of crushing or tightness in the chest that develops with

exercise, becomes more severe as exercise increases and resolves with rest.

However, about 50% of people experience atypical symptoms (particularly women), such as a back-ache, ‘heaviness’ in the shoulders or tingling down the left arm.

The feelings don’t have to be painful to be serious. Myocardial ischaemia can occur with little more than mild discomfort… or no uncomfortable sensation whatsoever, just shortness of breath (especially in patients with diabetes).

Heart failure. Breathlessness, muscle fatigue or dizziness are the hallmarks.

Patients with heart failure can experience rapid deterioration in exercise capacity with pulmonary or peripheral oedema

What happens when the heart complains about exercise?

Read on… or the onset of atrial fibrillation or other arrhythmias. They can go from being able to perform routine activities with relative ease, to being unable to get dressed without becoming exhausted, in a matter of days.

Cardiac arrhythmias. These can occur independently of myocardial ischaemia or structural heart defects and may be initiated by exercise. Associated symptoms

continued on Page 33

AF treatment without anticoagulants

By Dr Michael Nguyen, Cardiologist, Nedlands What if someone with atrial fibrillation (AF) doesn’t tolerate warfarin or Novel Oral Anticoagulants (NOACs)? Some alternative treatments still reduce the risk of ischemic stroke in these patients and have better outcomes than doing nothing.

and fluoroscopic guidance in a cathlab, the procedure takes approximately 30 minutes with patients discharged the following day.

It carries minimal risk (<2% major bleeding, pericardial effusion, stroke). Patients can come off oral anticoagulation long-term after the procedure.

Treating the risk Atrial fibrillation is a common disease of ageing, affecting 2% of the population (or >10% in people over 80 years).

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The loss of atrial contractility in patients with AF results in sluggish flow in the left atrium and left atrial appendage (LAA) which is a remnant outpouching. As a result, the risk of clot formation and subsequent stroke (or embolism to other organs) is increased.

Clot formation in AF patients tend to occur in the LAA (up to 90%).

The risk of stroke in AF patients tends to increase with age but other risk factors such as congestive cardiac failure, hypertension, diabetes, female sex and existing vascular disease also contribute to this risk (CHA 2DS2-VASc score). Currently, it is recommended that anyone with AF over the age of 65 or has at least one of the mentioned risk factors should be considered for oral anticoagulation.

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The most serious side-effect from oral anticoagulation is intracranial or gastrointestinal bleeding. Patients with high risk of bleeding (falls risk or underlying haematological disease) and AF, present a problem.

New technique Left atrial appendage occlusion excludes the LAA from the circulation. It is a procedure that plugs the LAA with a special device (the Watchman device or Amulet device) delivered via the femoral vein. Performed under general anaesthesia with transesophageal echo

The safety and efficacy of the procedure was validated with the PROTECT-AF trial which randomised 707 patients with AF to receiving long-term oral anticoagulation (warfarin) versus left atrial appendage occlusion (Watchman device). The study found similar rates of ischaemic stroke in both groups (1.3% vs 1.1%) but significantly less stroke (of any cause), systemic embolism, and cardiovascular death in the left atrial appendage occlusion cohort at 3.8 years (1.5% absolute reduction).

Antithrombotic treatment was given for at least six weeks after device implantation.

Currently, left atrial appendage occlusion is indicated in patients with AF who cannot take oral anticoagulation due to significant bleeding or an underlying haematological condition that precludes them from anticoagulation.

Author competing interests: nil relevant.

Questions? Ask the editor.

APRIL 2019 | 29

Cardioversion in AF?

By Mr Peter Ammon Foot Ankle & Knee Surgery

By Dr Benjamin King, Cardiologist, Perth

The humble cardioversion can Cardioversion restores sinus be a great tool to restore sinus rhythm from atrial rhythm in patients with a common fibrillation (AF) via unpleasant condition. The decision either chemical or to go ahead, however opens a larger – more commonly issue on the overall management of the AF patient.

– electrical (DCCV) means. However, not all AF patients benefit from cardioversion. In medicine, improving symptoms is often the greatest gain so patients with unpleasant AF symptoms represent good motivation to limit AF. Problem persistence Rate control improves some symptoms; however, the intrinsic irregularity of AF often remains disagreeable. Furthermore, some patients have specific symptoms than palpitations alone, including shortness of breath, dizziness and lethargy.

Plantar fascia origin

DCCV can restore sinus rhythm in the vast majority of cases but for how long? With no ongoing anti-arrhythmic effects, AF will recur in more patients without antiarrhythmic drugs, or ablation. Each cardioversion patient should be considered for these measures.

Caution should be applied before cardioversion to ensure the patient has either been anticoagulated without interruption for at least a month or that the AF clearly started within 48 hours. If those criteria are not met, the cardioversion should be deferred or transoesophageal echocardiography used to rule out intra-cardiac thrombus. In all cases, continuing anticoagulation for at least a month post cardioversion is strongly recommended.

Aside from symptomatic AF, others can benefit from rhythm control over rate control alone. Recent evidence supports maintaining sinus rhythm in patients with severe left ventricular impairment as this conveys survival benefit in this group. Patients with tachycardia-mediated cardiomyopathy who cannot be practically rate controlled, would very likely have improved outcomes from cardioversion plus anti-arrhythmic strategies (or indeed a “pace-and-ablate” approach of pacemaker followed by A-V nodal ablation). Patients with acute haemodynamic compromise in AF often need urgent cardioversion as well.

Important considerations in rhythm control Firstly, all parties should be clear that this approach has not been shown to reduce stroke risk and therefore does not have much bearing on anticoagulation.

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

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Secondly, anti-arrhythmic measures are more effective earlier in the natural history of AF. Patients with longer standing persistent AF develop more significant atrial myopathy (dilation, fibrosis, etc.) and therefore have reduced success rates from both medications and ablation to maintain sinus rhythm. Attempting cardioversion in some cases of very long-standing AF with severely dilated atria (or other structural heart disease) could indeed be viewed as futile.

As well as providing a period to compare symptoms in sinus rhythm to those in AF, cardioversion followed by a period of anti-arrhythmics provides a window to address other contributory factors to AF including obesity, sleep apnoea and alcohol intake. Australian research supports aggressive management of these risk factors to improve AF and quality of life outcomes.

Author competing interests: nil relevant.

Questions? Contact the editor.

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CLINICAL UPDATE

How valuable is the standard ECG? Dr Nik Stoyanov, Cardiologist, Murdoch Since standardisation by the American Heart Association in 1954, the humble ECG has been the most commonly performed cardiac investigations. It is a simple, non-invasive, cost-effective way to assess all cardiac clinical settings.

Undifferentiated chest pain For the assessment of undifferentiated chest pain, guidelines recommend an ECG is performed within 10 minutes of clinical contact with patients. In one study, chest pain was the most common indication for performing an ECG in the GP setting (57%), followed by collapse or palpitation (30%). An abnormal ECG, an indispensable investigation in the Acute Coronary Syndrome setting, was associated with a high likelihood ratio (13.3) of future cardiovascular events.

Serious structural and electrical abnormalities The ECG can also be used to diagnose structural cardiac conditions such as hypertrophic cardiomyopathy, as well as Wolff-Parkinson-White syndrome, Brugada syndrome, congenital Long QT syndrome, and electrolyte disturbances. It can also be used to monitor the effects of antiarrhythmic drugs. The 2016 National Heart Foundation guidelines recommend an ECG be performed with newly diagnosed hypertension to assess

KEY MESSAGES The ECG is a simple, safe, noninvasive and cost-effective test.

Smartphone-based rhythm strips rapidly and accurately screen for arrhythmic conditions such as atrial fibrillation. for left ventricular hypertrophy, ischaemic changes, and atrial fibrillation.

Is a standard 12 lead ECG, however, always required? For example, atrial fibrillation is common (5% of patients over the age of 65), and increases ischaemic stroke risk five-fold in the absence of anticoagulation. A rhythm strip may be sufficient for diagnosis as witnessed by the Search AF study – in which a smartphone-based AliveCor iECG recordings performed by pharmacists had a sensitivity of 98.5% and specificity of 91.4% for AF diagnosis compared to an over-read by a cardiologist. Other studies have investigated a practice nurse or receptionist performing iECG recordings, also allowing rapid screening.

The value of the ECG weighs up the hassle of carrying it out against the information it provides. Read on. primary care physicians. Automated interpretation algorithms, whilst useful, have poor correlation with cardiology specialists’ assessment (44.4%; significantly worse than the modest correlation between GP and cardiologist of 58.9%). This makes such algorithms unreliable compared to the GP’s overall clinical judgement in assessing the need for referral.

The standard ECG’s interpretation is the major sticking point for primary care physicians. Despite the importance of ECGs in primary practice, in one study over half of primary care physicians reported one or less ECGs per week and in another study as many as 31% of GPs felt “very” or “fairly” uncomfortable in reading ECGs. Potential solutions may include advances in automated reporting software, upskilling primary care physicians in ECG interpretation, or providing remote support from cardiologists.

References available on request.

General practice and the 12-lead ECG Despite the clear benefits of the ECG in certain patient populations, interpretation of the ECG is a concern amongst many

Author competing interests: nil relevant.

Questions? Ask the editor.

continued from Page 29

BACK TO CONTENTS

Exercise intolerance - when to think of cardiac causes of palpitations, “a racing heart”, dizziness or feeling unwell can occur. Symptoms of relatively benign supraventricular tachycardias can be difficult to differentiate from life-threatening ventricular arrhythmias, so all exercise-induced arrhythmias should be considered serious until proved otherwise. If associated with syncope or near syncope, they should be treated as a medical emergency.

pressures, while radionucleide imaging increases test sensitivity. Exercise stress tests are also indicated for evaluating exercise-induced arrhythmias and hypertension. Cardiopulomonary exercise testing determines peak oxygen consumption (VO2peak). In patients with heart failure, VO2peak < 50% agepredicted is an indicator for advanced therapies such as cardiac transplantation.

Investigations

Treatment

If symptoms occur during exercise, a resting examination is unlikely to be helpful. If symptoms occur during routine activities, a 24-hour Holter monitor may be indicated. An exercise stress test is a firstline assessment for suspected myocardial ischaemia. Stress echocardiography increases the specificity of exercise testing and is useful for evaluating valvular dysfunction and elevated pulmonary

Most patients with cardiovascular disease can undertake light to moderate exercise without symptoms. However, when symptoms are apparent during exercise, medical intervention is often warranted. This may involve pharmacological management, percutaneous coronary interventions or surgery, ablation of arrhythmias, or the implantation of a pacemaker or implantable cardioverter defibrillator.

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In some instances, the best option may be to educate the patient to exercise below their symptomatic threshold, under the guidance of an exercise professional.

APRIL 2019 | 33

Aortic aneurysm in 2019

By Prof Patrik Tosenovsky, Vascular Surgeon, Hollywood The definition of the abdominal aortic aneurysm (AAA) is based on the diameter of 3.0 cm or more. AAA is clinically mostly silent and abdominal assessment may not reveal it due to a poor sensitivity (<50%).

The average growth rate is 1.3mm per year for 3 cm AAA, whilst 5 cm aneurysm grows almost three times faster. Risk factors are age, atherosclerosis, smoking, family history and hypertension whilst diabetes, on the other hand, is associated with lower rate of AAA. Ultrasonography is recommended as the first line imaging for detection and also monitoring of AAA up to the size of 4.9 cm. Regardless of the aneurysm size, patients should be referred to a vascular surgeon for evaluation except for cases with very short life expectancy. Population screening is still recommended for men over 65 years of age but not for women, however, everyone over 50 years of age with a first line relative with AAA should be

The European Journal of Vascular and Endovascular Surgery published over 120 recommendations.

A few warrant discussion.

scanned in ten-years intervals. Smoking cessation, blood pressure control, statin and antiplatelet therapy should be initiated for all patients with AAA of any size.

Those reaching the threshold size for treatment (men 5.5 and women 5.0 cm) should be referred to a centre that performs more than 20 cases per year.

Patients who have either poor functional capacity (< 4 METS) or those with unstable angina, decompensated heart failure, severe valvular diseases or arrhythmia should be referred for a cardiac workup.

Patients with no symptoms, those with stable coronary disease or those with asymptomatic carotid stenosis should not be routinely sent for coronary or carotid revascularisation.

Preferred treatment option is endovascular aortic repair (EVAR) but young patients can be offered open repair..

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CLINICAL UPDATE

KEY MESSAGES Ultrasound scan screening for men over 65 years Endovascular repair is the treatment of choice but young patients should be considered for open repair.

Antiplatelet, antihypertensive and statin therapy is advised for all patients with any size of AAA. routinely recommended. Dual antiplatelet therapy after a coronary intervention is no contraindication for EVAR.

In all patients, pulmonary function testing with spirometry prior to aortic surgery should be considered but chest x-ray is not

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Author competing interests: nil relevant disclosures. References or questions?

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Cardiac MRI helps sort out MINOCA

By Dr Adil Rajwani, Cardiologist and Cardiac Imaging Specialist CMR can be difficult to access due to shortages of adequately trained specialists and lack of funding.

Nonetheless, CMR is pivotal in the evaluation of cardiomyopathies.

Cardiac MRI (CMR) can be invaluable where the mechanism of cardiac injury is uncertain, with contrast-enhanced imaging providing a ‘virtual histology’ of the myocardium. One such setting is Myocardial Infarction with Non-Obstructed Coronary Arteries (MINOCA), which occurs in 5-10% of angiograms undertaken for acute coronary syndromes.

represent a true (atherosclerotic) coronary event with spontaneous recanalisation or non-appreciable culprit, thus dual antiplatelet therapy often continues to be prescribed. By extension, this exposes the remaining 60-80% unnecessarily to bleeding risks.

Case Report A 41-year-old hypertensive male presented with gripping chest pain after emotional stress. He reported non-specific malaise over the preceding 3 days with a cough.

Inflammatory markers were modestly elevated, and Troponin I rose from normal to 150ng/L, with minor anterolateral T wave inversion on ECG. Echocardiography was reported as normal, and angiography documented only mild irregularities. A working diagnosis of myocarditis was made and colchicine was commenced, but dual antiplatelets were also continued due to diagnostic uncertainty. CMR demonstrated an anterior regional wall motion abnormality (not appreciable on

(b)

echo) with oedema and infarction (figure 1), confirming a conventional ‘heart attack’ rather than myocarditis. Colchicine was discontinued, secondary prevention for acute coronary syndrome was intensified, and further investigations to rule out an embolic aetiology are being sought.

Discussion MINOCA is a diagnostic conundrum because several diseases can masquerade as a heart attack, including myocarditis, cardiomyopathies, coronary spasm and others.

However, 20-40% do

CMR is the gold-standard non-invasive modality for quantifying cardiac volumes and ejection fraction. However, the unique ability of CMR to evaluate cardiac scar is particularly informative, determining not just the presence of abnormality but also the mechanism (infarction, inflammation or infiltration). In a large registry of over 600 individuals, an incremental value of CMR for clinical decision-making in MINOCA was observed in over 80% of cases.

(1) The European Society of Cardiology Working Group position paper on MINOCA advocates “cardiac magnetic resonance imaging is the key diagnostic tool to be employed in MINOCA patients.”(2) Further reading: 1. Rajwani A et al. The incremental impact of cardiac MRI on clinical decision-making. Br J Radiol, 2016; 89 2. Agewall S et al. ESC working group position paper on myocardial infarction with non(a) obstructive coronary arteries.

Eur Heart J, 2017; 38:143-153 Author competing interests: nil relevant. Questions?

Ask the editor.

Fig 1: Delayed contrast-enhanced imaging with (a) 2-chamber view and (b) short-axis view showing partial-thickness focal sub-endocardial infarction in the mid anterior wall. The whiter more dense scar tissue shows the area of infarction.

Images courtesy of Western Radiology.

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Statins in older patients – who benefits?

By Dr Michael Davis, Cardiologist, Nedlands Statins are amongst the most commonly prescribed drugs on the PBS. Statin enthusiasm is well justified because a large number of randomised controlled trials have shown long lasting secondary prevention in patients of all ages.

There is less direct evidence from trials for a benefit in patients older than 75 in primary prevention. It is generally believed that statin therapy is warranted in those at high risk of cardiovascular events. Risk estimators are available online or via apps (ASCVD Plus and Heart Risk) but generally, data is not provided for over 80-year-olds.

Cardiovascular events WOSCOPS randomised 45 to 64-year-old men with a high LDL to pravastatin 40 mg or placebo for around 5 years; electronic health records enabled an analysis 20 years later showing those allocated to pravastatin were 21% less likely to die of a cardiovascular cause, reduced coronary events (including myocardial infarction), and a 35% reduction in heart failure(2).

Uncertainty about statin efficacy and safety among older people led to a recent meta-analysis of participant data from 28 randomised controlled trials(3) and of 186,854 participants, 14,483 (8%) were older than 75. Those older patients had a history of vascular disease (55%), myocardial infarction (29%), other symptomatic coronary disease (31%), diabetes (17%), and treated hypertension (60%) and had a baseline LDL level of 3.2 and HDL of 1.3. Statin therapy resulted in a statistically significant 21% proportional reduction in major vascular events, a 25% reduction in risk of coronary revascularization procedures, and a 16% reduction in stroke per 1.0 mmol per litre reduction in LDL cholesterol – across all age groups.

KEY MESSAGES Secondary prevention with a statin at all ages unless limited life expectancy Primary prevention for over 75s only if high cardiovascular risk Use atorvastatin or rosuvastatin to reduce drug-drug interactions Initiate with a lower dose (e.g. atorvastatin 20 mg; rosuvastatin 10 mg) before increasing to achieve target.

Avoid combining statin with macrolide antibiotics, antifungal azoles, and cyclosporine. Reduce the doses of non-dihydropyridine calcium channel blockers Measure CK if muscle pain develops (>10x ULN is significant).

Reduce, replace or rechallenge for SAMS without myopathy.

Muscle symptoms About 10% of patients stop their statins because of perceived side effects, most often muscle symptoms (statin-associated muscle symptoms (SAMS)). Studies show little difference in muscle symptoms between statins and placebo (at most 1%). However, SAMS can be severe, despite the absence of a pharmacological or serological basis in the overwhelming majority of cases. Significant myopathy should be excluded by measuring CK (CK <10x ULN). Rechallenge with lower dose, reduced frequency of dosing such as every other day, or with a different statin can restore therapy for patients at greatest risk of an atherosclerotic cardiovascular event.

Myopathy in older patients is about twice that of younger people but the absolute risk remains low. Contributors are drug

Harms vs Benefits of Statin Rx in 10,000 people (over 5y) achieving 2 mMol/L in LDL-C(1)

BENEFITS 1o prevention: first major vascular event - 500 pts

HARMS New diagnosis diabetes mellitus - 100 pts

2o prevention: recurrent major vascular event - 1,000 pts

Small absolute in HbA1c Statin-associated muscle symptoms (no sig. CK elevation) - <100 pts Myopathy (CK elevation >10x ULN) - 5 pts Rhabdomyolysis - 1 pt Haemorrhagic stroke - 10 pts Severe liver disease < 1pt

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Giving statins beyond 75-years does not seem backed by evidence, except perhaps those at high risk of cardiovascular events. interactions (less so with atorvastatin and rosuvastatin than other statins) and major comorbidities, in particular hypothyroidism, pre-existing muscle disease, and renal impairment.

Higher statin levels and therefore the risk of myopathy is large with macrolide antibiotics, antifungal azoles, and cyclosporine, especially in the elderly, and combining these drugs and a statin should be avoided. Be aware of the need to reduce the doses of non-dihydropyridine calcium channel blockers (verapamil, diltiazem).

Because of the increased risk of side effects and drug interactions in the elderly, starting with a lower dose of statin before increasing to achieve a target LDL level (generally <1.6 mMol/L for secondary prevention) seems prudent.

Impaired cognition?

Are statins associated with impaired cognition? Reassuringly, a meta-analysis of studies investigating use of statins were associated with a reduced risk of all-cause dementia and mild cognitive impairment but, perhaps surprisingly, not of vascular dementia(4).

A cognitive substudy of over 70 yearolds in the HOPE-3 study of primary prevention with candesartan 16 mg plus hydrochlorothiazide 12.5 mg, versus placebo and rosuvastatin 10 mg, versus placebo concluded that only those with baseline systolic BP >145 mm Hg and LDL >3.7 showed slower cognitive decline over 5.7 yrs(5).

References: (1) Newman CB Arterioscler Thromb Vasc Biol 2018; 39: e38–e81.

(2) Ford I Circulation. 2016;133(11):1073-80 (3) Cholesterol Treatment Trialists’ Collaboration Lancet 2019; 393: 407–15 (4) Che-Sheng Chu Scientific Reports 8, Article number: 5804 (2018) (5) Bosch J Neurology 2019 DOI: https://doi. org/10.1212/WNL.0000000000007174

APRIL 2019 | 37

38 | APRIL 2019

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CLINICAL UPDATE

Stroke Prevention in Atrial Fibrillation

By Dr Joseph Hung, Emeritus Consultant Cardiologist, SCGH Atrial fibrillation (AF) is the most common recurrent arrhythmia encountered in clinical practice, and is associated with an overall 5-fold increased risk of stroke and systemic embolism. Oral anticoagulant (OAC) treatment reduces the risk of stroke by 64% and of mortality by 26% when used in patients with non-valvular AF (i.e. AF without moderate-tosevere mitral stenosis or mechanical heart valve).

Despite the proven benefits of OAC therapy, real-world clinical practice suggests a continuing under-use of anticoagulants in AF patients at high risk of stroke. The NHFA/CSANZ Australian Clinical Guidelines for the Diagnosis and Management of AF 2018 highlight the following key points regarding stroke prevention in non-valvular AF. • OAC therapy should be risk-based and account for stroke and bleeding risk factors as well as the patient’s values and preferences (see Figure).

According to the Heart Foundation, too many AF patients are having strokes and should be on anticoagulants. Easier said than done!

• To avoid the cumbersome use of different CHA 2DS2-VA risk thresholds for males and females when recommending anticoagulation, these guidelines recommend a sexless CHA 2DS2-VA score (abbreviated as CHA 2DS2-VA score).

The CHA 2DS2-VA score (0 to 8 points) comprises 1-point each for Congestive heart failure, Hypertension, Diabetes, and Vascular disease (i.e. prior myocardial infarction, peripheral arterial disease, or complex aortic atheroma or plaque) and 2 points each for Age >75 years and Stroke history, TIA, or systemic embolism.

• OAC therapy, to prevent stroke: • Is recommended in men and women with nonvalvular AF whose CHA 2DS2-VA score is 2 or more, unless there are major contraindications to anticoagulation.

• Is not recommended in patients with non-valvular AF whose CHA 2DS2-VA score is 0.

• Should be considered in patients with non-valvular AF whose CHA 2DS2-VA score is 1 especially when their bleeding risk is low.

• Modifiable bleeding risk factors should be corrected in patients for whom anticoagulation is indicated.

Although patients at high risk of stroke are also at high risk of major bleeding, the net clinical benefit nearly always favours stroke prevention if reversible bleeding factors are corrected.

• Non-vitamin K-dependent oral anticoagulants (NOACs; apixaban, dabigatran or rivaroxaban) are recommended in preference to warfarin when anticoagulation is initiated in a patient with non-valvular AF. • In addition to the many pragmatic advantages, NOACs are as good as or better than warfarin in reducing stroke, and bleeding rates are similar or less than warfarin (including a significant reduction in risk of intracranial haemorrhage).

• Antiplatelet therapy is not recommended for stroke prevention in non-valvular AF, regardless of stroke risk, since efficacy evidence is weak and aspirin may have similar bleeding rates to OACs. • Stroke risk may change over time due to ageing or new comorbidities. Hence annual review of low risk patients is recommended to assess stroke risk and the need for anticoagulation.

• Although the risk of dying from AF-related stroke can be largely mitigated by OAC therapy, comorbidities, such as diabetes and heart failure, contribute to increased all-cause deaths in AF patients.

To effectively reduce morbidity and mortality, a comprehensive, patient-centred, integrated care approach by multidisciplinary teams, is recommended.

ED. The author acknowledges the assistance of Cia Connell, National Heart Foundation of Australia, in preparing this article.

References available on request.

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APRIL 2019 | 39

Assessment of cardiovascular risks in T2DM

By Dr Athula Karu, Cardiologist, Perth As diabetes increases in Australia (from 1 in 20 adults) it is associated with a two-fold increase in cardiovascular events (CV). Roughly 20% of diabetics are undiagnosed, particularly in indigenous or remote sub groups.

Risk optimisation vs prevention About 60% have established cardiovascular disease and are in need of secondary risk optimisation rather than prevention. Large studies (e.g. UKPDS) showed optimal T2DM management did not reduce macro vascular CV incidence or death (MACED). Optimisation of concomitant risks remains the corner stone in curbing the CV risks in primary prevention.

Routine treatment with low dose aspirin is not recommended for primary prevention in T2DM though CV risks are high.

ASCEND trial showed that aspirin significantly reduced vascular events but also significantly increased major bleeding in T2DM. Benefits were largely counterbalanced by the increased risk of bleeding. There was no group in which the benefits clearly outweighed the risks in T2DM in the absence of CV disease.

In asymptomatic T2DM, therefore, key strategy in risk stratification should be to prove CV disease if aspirin is to be of any utility.

Using the current American College of Cardiology/American Heart Association (ACC/AHA) atherosclerotic cardiovascular disease website calculator, a typical T2DM patient with normal coronary arteries has a 5.6% 10-year risk of CV event, with the recommendation for moderate-intensity statin therapy; a typical patient with non-obstructive coronary artery disease (CAD) will have 20% 10-year risk of CV event risk, with the recommendation for highintensity statin therapy and consideration of aspirin; a typical patient with obstructive CAD has a 23% 10-year risk CV event, with the recommendation for highintensity statin therapy and a recommendation for aspirin.

40 | APRIL 2019

KEY MESSAGES 1 in 20 Australians have T2DM which brings a two-fold increased risk of CV events.

Two out of three T2DM already have established CV disease and optimal glucose control alone does not reduce CV morbidity or mortality.

Routine screening for CVD in asymptomatics with CTCA or a myocardial perfusion study is not recommended with no conclusive RCTs. Aspirin without established CV disease is not recommended in primary prevention.

TMI risk score is useful in established CV with T2DM to risk stratify, based on 10 clinical variables, and may guide treatment intensity.

New therapeutic agents SGLT2i are recommended in T2DM with heart failure.

To screen or not to screen?

One can hypothesise that by applying above guidelines with a test to confirm asymptomatic CAD would be beneficial.

However, a randomized controlled trial (RCT) examining the role coronary CTCA in 900 asymptomatic diabetics with a mean follow-up of 4 years, found no significant difference in MACED. Furthermore, the DIAD study, a RCT with 1,123 asymptomatic T2DM patients, screening for CAD with a myocardial perfusion study did not significantly reduce the MACED. So far there is no compelling randomised data for screening asymptomatic T2DM for CAD. Primary prevention treatment should target other risk factors in addition to optimal diabetic management with no aspirin unless proven disease.

T2DM with symptomatic CV disease, even if stable, needs thorough testing to confirm established disease so appropriate secondary

The headline says it all! This is the current situation in the complex world of evidence based medicine. prevention or invasive treatment is implemented.

Predicting problems TIMI (Thrombolysis in Myocardial Infarction) risk score in secondary prevention (TRS2P) is a well-established tool in predicting projected event rate of CV morbidity in all patients as well as T2DM patients.

REACH registry data of over 16000 T2DM patients revealed a robust risk gradient for the composite of MACED against TRS2P, with two-year event rates of 0.9% in the lowest and 19.8% in the highest risk groups.

Conventional risk factors displayed a graded risk elevation and hazard ratios for age over 75 (graded risk elevation of 1.6), hypertension (graded risk 1.1), smoking (1.2), ischaemic heart disease (1.7), renal impairment (1.9) and CCF (2.1). The TRS2P predicted a greater absolute benefit with the protease-activated receptor-1 antagonist vorapaxar and the lipid-lowering agent ezetimibe in high-risk subgroups, respectively.

Heart failure events are clinically and prognostically important in patients with T2DM with an odds ratio of 2.1 in CV risks and establishing the degree of LV dysfunction with an echo is recommended.

Sodium and Glucose co-transporter 2 inhibitors (SGLT2i) are now a main consideration in this subgroup.

Recently published meta-analysis have concluded that SGLT2i have moderate benefit in CV endpoint events in patients with established atherosclerotic cardiovascular disease. However, they reduce heart failure morbidity including hospital admission and progression of renal disease in T2DM. The updated Australian heart foundation and Cardiac society of Australia and New Zeeland combine guidelines now recommend SGLT2i and Gliptins in T2DM with CCF. References available on request.

Author competing interests: nil relevant.

Questions? Ask the editor.

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CLINICAL UPDATE

Life changes in a heart beat!

A coronary calcium score CT scan can detect coronary artery disease long before it becomes symptomatic.

Ask your doctor to refer you for a coronary calcium scan. perthradclinic.com.au MEDICAL FORUM

APRIL 2019 | 41

New horizons in type two diabetes management

By Dr Ricky Arenson, Endocrinologist, Murdoch A multitude of new diabetic treatments have emerged over the last decade.

Previously, most intensive type 2 diabetic treatment regimens included either sulphonylureas, insulin or both.

Both ranked in the top five most likely medications to cause an emergency department visit for medicationrelated side effects in a 2011 NEJM study. Sulphonylureas and insulin carry a high risk of hypoglycaemia and weight gain.

Many newer diabetic treatments can reduce blood sugars and HbA1c without significant risk of weight gain or hypoglycaemia benefiting patients trying to lose weight and those recalcitrant about regular blood sugars checks. It is often possible to achieve safe and acceptable diabetic control, even in patients unwilling to check their blood sugars regularly.

The EMPA-REG trial was ground-breaking with Empagliflozin demonstrating a 38% relative risk reduction in cardiovascular death with a median patient follow up of 3.1 years. In the same trial, Empagliflozin patients experienced significant reductions in all-cause mortality, hospitalisation for heart failure and a slower progression of renal indicators, including progression to dialysis. Empagliflozin can also assist with modest weight loss and has an insignificant risk of hypoglycaemia.

New type 2 Diabetic agents have created opportunities for better outcomes in type 2 diabetes, including cardiovascular benefits.

KEY MESSAGES Innovations enable better outcomes with less adverse effects Some newer agents offer CVS weight loss and mortality benefits There are often better options than insulin in type two diabetes

GLP-1 agonists can reduce appetite and weight in type 2 diabetics with an insignificant risk of hypoglycaemia. A number of GLP-1 agonists have shown cardiovascular benefits in trials (e.g.

Liraglutide), although some of these medications are not yet available in Australia. DPP-4 inhibitors have similar efficacy to most other diabetic agents, without risk of hypoglycaemia.

The PBS now funds the use of basal insulin with Byetta, or in combination with a multitude of oral agents- useful in patients unwilling to check their blood sugars frequently. If Diabetics can be encouraged to check their blood sugars first thing in the morning a few times a week to exclude fasting hypoglycaemia, it may be possible to achieve diabetic control by controlling their fasting sugars with basal insulin and their post-prandial sugars with other agents. In addition, SGLT-2 inhibitors and Byetta can be used to offset the weight

gain caused by insulin. These regimens are much more user-friendly and less risky to most Type 2 Diabetics than basal bolus insulin.

Many type 2 Diabetic patients still require insulin or sulphonylureas. However, I seldom recommend these second line.

With insulin initiation in Type 2 diabetics, there is a high risk of weight gain leading to increased insulin resistance and higher insulin needs, which in turn leads to additional weight gain in a vicious cycle.

We need to consider the benefits and risks of insulin initiation carefully in each patient. There are specific circumstances in which insulin may be required to improve morbidity and mortality rates. Clinicians should make considered decisions about which type 2 Diabetics to initiate on insulin because of the multitude of risks to quality of life and weight gain associated.

Author competing interests: nil relevant.

Questions? Contact the editor.

The diabetes educator

By Ms Leontine Jefferson, Diabetes Educator To whom does the job of managing type one (T1) diabetes belong to - the patient, GP or endocrinologist? Type 1 diabetes mellitus management should be a team effort. There are approximately 120,000 Australians with type one diabetes compared to about 2,000,000 with type two diabetes (T2).

Both forms have similarities but are vastly different conditions.

KEY MESSAGES Type 1 patients need tailored support to help them self-manage.

The team is the GP, endocrinologist and credentialed diabetes educator (CDE).

A CDE provides education and puts the patient in touch with technological advancements.

Team approach may work best The cornerstone of management is the GP (generally the first point of contact), who oversees the provision of comprehensive

42 | APRIL 2019

care for the T1 patient. The GPâ&#x20AC;&#x2122;s role is very local. Support and encouragement are essential for the T1 patient to

Those with type two diabetes are almost routinely referred to a diabetes educator. But those with type one can benefit just as much. better self-manage. And involving a Credentialed Diabetes Educator (CDE) and Endocrinologist are important parts of care.

Some patients may be new to T1 in their adult years, yet others grew up with it.

However, they may not have seen an educator/specialist for a variety of reasons.

continued on Page 44

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What is the best diet for cardiac health?

By Ms Jo-Anne Dembo, Principal Dietitian, North Perth Is it the Mediterranean diet?

What about specific nutrients?

What food is good for the heart and circulation?

Research on nutrition and cardiac health is extensive, varied and evolving, targeting foods and nutrients as beneficial for heart health (see Table 1). A key focus is dietary fibre, including components such as beta glucans. Alongside dietary fibre, both omega 3 fatty acids and the polyphenol known as anthocyanins are valuable nutrients for cardiovascular disease (CVD) protection.

fish, both are beneficial as part of a healthy diet. However, research has not confirmed omega 3 fatty acids as supplements that prevent, manage or treat heart disease.

Anthocyanins Anthocyanins are found in vegetables and fruit with red, blue and purple pigments. They have antioxidant properties, and Fairlie-Jones (University of South Australia) describes their cardiovascular benefits, partly due to a reduction in arterial stiffness and blood pressure. While more research is needed, there is scope to recommend consumption of anthocyanin-rich foods.

Overall, no single food or nutrient acts as a magic bullet for cardiovascular health.

Rather, a combination of lifestyle factors and dietary patterns, adopted daily, promote heart health. A diet including vegetables, fruits, lean protein, low fat dairy and wholegrains will likely result in positive cardiovascular health outcomes.

Soluble fibre Foods high in soluble fibre reduce lowdensity lipoprotein (LDL) cholesterol. During digestion, soluble fibre attracts water and forms a gel-like substance, with a duel benefit of removing cholesterol as well as reducing cholesterol absorption. Beta glucans found predominantly in oats and barley, are a type of soluble fibre. In conjunction with a healthy diet, beta glucan at a minimum of three grams daily has been linked to promoting cardiovascular health1.

Fibre and gut microflora The gut-heart connection is an important consideration. A high fibre diet, as well as probiotics in fermented foods such as yoghurt2 increase gut microbiota, subsequently influencing inflammation.

References 1.Bozzetto L et al, Dietary Fibre as a Unifying Remedy for the Whole Spectrum of ObesityAssociated Cardiovascular Risk Nutrients 2018, 10(7), 943.

2.Batson M et al, The Gut Microbiota as a Novel Regulator of Cardiovascular Function and Disease Journal of Nutritional Biochemistry 56 (2018) 15.

3.Fairlie-Jones L et al, The Effect of AnthocyaninRich Foods or Extracts on Vascular Function in Adults: A Systematic Review and Meta-Analysis of Randomised Controlled Trials Nutrients 2017, 9(8), 908.

Furthermore, fermentation of fibre by microbiota may lessen hepatic cholesterol synthesis1.

Author competing interests: nil relevant.

Questions? Ask the editor.

Omega 3 fatty acids Whether omega 3 fatty acids are consumed as plant-based foods or oily

continued from Page 42

The diabetes educator Encouragement from the GP goes a long way to re-establishing healthy relations with a team of health care professionals, perhaps better than the lone approach to taking care of the patient with T1.

A care plan (EPC) under a team care arrangement (TCA) is the best way to refer T1 patients to a CDE. This way the patient can claim a Medicare rebate. Each T1 patient should get enough visits with an educator - a minimum of three p3@rseach year, allocated appropriately.

44 | APRIL 2019

What will patients gain from a CDE? Firstly, up-to-date information around the management of their condition. This includes the latest technology such as insulin pump therapy, continuous glucose monitoring, flash meters, bolus calculators, closed loop options, and implantable sensors. Furthermore, general diabetes education is also critical. We are always learning and growing.

Assisting patients and relieving some of the burden that comes with this chronic condition is invaluable.

Providing greater freedom and control for â&#x20AC;&#x153;the T1â&#x20AC;? ultimately improves health outcomes long term. We are all part of the same team and the patient living with T1 is the driver, and all those in support make their drive a pleasant and safe one.

Recognising our roles will go long way to making a smoother journey.

Author competing interests: nil relevant.

Questions? Contact the editor.

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CLINICAL UPDATE

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NEWS & VIEWS

Community Link Booth to prevent hospitalisations A Community Link Booth, a first, has been established in response to an identified need to reduce the high rate of preventable hospitalisations in Western Australia.

The new booth, staffed by volunteers at Fiona Stanley Hospital, will be a one-stopshop for patients, families and carers to

connect with community-based services and organisations.

The booth is a collaboration between ConnectGroups (a government funded peak body of self help and support groups in WA), the Health Consumers’ Council of WA and Fiona Stanley Fremantle Hospitals Group.

Fiona Stanley Hospital staff will be encouraged to direct patients and their carers to the Community Link Booth upon discharge. The booth is located near the main entrance of Fiona Stanley Hospital and patients, families and members of the public can access the service (8.30am to 2.30pm Monday to Friday).

World’s largest mass sporting event – and you can join free Young and old, over 5 million of them, run 5 km each weekend, at their own pace, to keep fit.

Australians of course run in parkrun, a sponsored and grassroots based event and organisation. Over 40,000 people in 350 communities around Australia are ready on Saturday at 8.30am to start their run.

But it is not only the running alone that makes parkrun popular, it is the social engagement that occurs when people from all walks of life come together, no pun intended. People run, jog and volunteer as part of the morning’s work, capped with coffee and other beverages. parkrun Australia recently teamed up with public health education campaign Live Lighter to promote the event. Live Lighter

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Campaign Manager, Alice Bastable, said that statistics show that many people are still finding reasons not to exercise but the parkrun community response shows that people can be motivated to exercise.

parkrun locations for Western Australia are available on the parkrun website http://www.parkrun.com.au/events/events/

APRIL 2019 | 45

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THE WORLD'S OLDEST JOKES The Sumerian civilisation evolved around Mesopotamia, modern day southern Iraq.

It not only developed recorded writing, but recorded its jokes. The world’s oldest joke that we know of is Sumerian dating back to 1900 BC. It is a proverb, “Something which has never occurred since time immemorial; a young woman did not fart in her husband’s lap.”

Well, it was obviously funny enough to get recorded.

The ancient Egyptians also recorded their jokes. From 1600 BC, “How do you entertain a bored pharaoh? You sail a boatload of young women dressed only in fishing nets down the Nile and urge the pharaoh to go catch a fish.” The joke is thought to be about King Snorfru (or Snefru), 2613 to 2598.

Not all ancient jokes are short. The folk tale of the three ox drivers from Adab, dated back to 1200 BC, is a long joke, and too long to recount here. More importantly, not all the text has survived, perhaps killing the punchline.

Britain’s oldest joke is a crude riddle that features in the Exeter Codex and dates back to the 10th Century AD – “What hangs at a man’s thigh and wants to poke the hole that it’s often poked before? Answer: A key” Britain’s oldest one liner is taken from England’s earliest jest book and was written in 1526 - When a boy was asked by the Law

to say his father’s craft, the boy answered that his father was a crafty man of Law.

First rabbit: “Where are you going in such a hurry?”

The research into the world’s oldest jokes was led by humour expert Paul McDonald from the University of Wolverhampton and presented on Dave TV.

Second rabbit: “Haven’t you heard?

There’s a rumour going round that all camels are to be castrated.”

Humour continues to be a release, especially where oppression is overwhelming. The Stalinist terror in the Soviet Union during the 1930s touched on all levels of society, including the military (one of the reasons the Soviet Union was not ready for war when invaded by Germany in 1941).

Second rabbit: “After they catch you and castrate you, try proving you’re not a camel.”

First rabbit: “But you’re not a camel.”

Two rabbits on a road during the Stalinist terror of 1937.

Beer

winner Dr Stephen McKelvie is a devoted GP with 15 years service in Kalamunda and 15 years in Spearwood. Ready for the hockey preseason, Dr. McKelvie advises that “beer goes well with hockey, preferably after the game.” He also plans to drink his Mash beer, with Medical Forum in mind. “A quality magazine, and the first toast is on us.”

46 | APRIL 2019

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WINE REVIEW

St Johns Brook vineyard St Johns Brook making its mark in Margaret River The St Johns Brook vineyard and winery, located at Yelverton in the Margaret river wine region, forms the main base for the much larger Latitude 34 Wine Company. As well as St Johns Brook Latitude 34 produces wines under the labels Optimus, The Blackwood and Crush. In total there are 126 hectares of vineyard, with 37 hectares located in Margaret River, the other vines all in the Blackwood Valley wine region.

The St Johns vineyard, established in 1998, is planted to Cabernet Sauvignon, Shiraz, Chardonnay, Semillon, Sauvignon Blanc and Merlot – all being iconic varieties for the region. Since 2013 an environmentally friendly approach to production has been a central philosophy, with no use of herbicides, low chemical inputs and a programme of sustainable composting.

By Dr Craig Drummond Master of Wine

Wines chosen for this tasting are from the Reserve range (highest quality fruit and winemaking practices) and the Single Vineyard range (to reflect the character of the particular site). There is also a third label, the Recolte range (wines for consumption now, all varieties being represented).

As well as visiting the Margaret River location there is a Perth cellar sales at 5/28 Hammond Road, Cockburn Central. Also www. Latitude34wineco.com will help with accessing these very worthwhile wines.

St Johns Brook 2017 Reserve Margaret River Chardonnay (RRP $50) This wine is a step up in quality.

A full-bodied Margaret River style. The nose has rich aromas, lifted white peach, overt oak of obvious high quality. Leads on to concentrated fruit flavours, with nectarine and grapefruit. Firm acidity gives a mineral thread and structural definition. Winemaking influence is evident – slightly funky characters probably from a wild yeast ferment, some textural buttery mouthfeel from malolactic ferment and time on yeast lees, and layers of integrating oak adding to the complexity. This wine, my favourite of the wines reviewed, will give enjoyment over the next 6 to 8 years.

St Johns Brook 2016 Single Vineyard Margaret River Shiraz (RRP $28) Nose shows complex savoury and cinnamon spice. Palate is complete, with blackberry and mulberry, spicy/cedary oak and firm tannins. An honest, uncomplicated, easy to drink wine.

St Johns Brook 2016 Reserve Margaret River Shiraz (RRP $50) For my personal consumption I generally choose Shiraz from cooler climates, but I must admit this wine offers those peppery, inky characters of cooler climate fruit. From selected fruit, and given 14 months in 50% new French and Hungarian oak has produced a wine of considerable character. It is uncommon for me to prefer a shiraz ahead of a cabernet from this region.

Has an inviting youthful deep red colour and rich, ripe peppery fruit on the nose. Blackberry, dark cherry and liquorice flavours, fine drying tannins, firm acid, and quality oak all go to make a wine that will live another 10 to 12 years.

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St Johns Brook 2017 Single Vineyard Margaret River Chardonnay (RRP $28) Aromas initially restrained, then opening up with melon and hazelnut, the flavours dominated by stonefruits – peach and pear.

Nutty oak characters, textural linear fruit profile. Balanced fruit, acid and oak. This wine is enjoyable now, and will drink well for a couple of years.

St Johns Brook 2016 Single Vineyard Margaret River Cabernet Sauvignon (RRP $28) A restrained style showing some early development with a garnet colour, red current cedary aromas. Palate characters of blackcurrant and cherry kernel. The tannins are fine grained, ‘dusty’ and drying. Definitely a wine to drink with food over the next 2 to 3 years.

St Johns Brook 2016 Reserve Margaret River Cabernet Sauvignon (RRP $50) Initially restrained, with cassis aromas evolving in the glass.

Flavours of red current and black olive. Evident integrating oak from 14 months in French oak, 50% new. This to me differs from the typical Margaret River cabernet style, being more refined, elegant, of higher acidity and definitive structure. A wine made for longevity, I think it will evolve over 15 years.

APRIL 2019 | 47

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

The Biggest Comedy Show on Earth Billed as a show for those with a short attention span, the Biggest Comedy Show On Earth features a huge line-up of comics performing short and hilarious sets in this fast-paced showcase. The show is part of the Perth Comedy Festival 19 and will be held in The Comedy Club in Murray Street. The Club was purposely built for comedy and opened in 2017.

Rocketman

Event time, Friday 10th May, 9:45pm @ Comedy Lounge Perth from March 13-April 10

In the 1970s it would have been difficult to miss Elton John’s music on the radio or TV. Elton John maintained a close relationship with Australia, a popular destination for his shows.

Movie: John Wick Chapter 3

This biopic starts with Elton’s early life and traces his start as a musician and major points in his life, including his fight with addiction and the difficulties he faced being gay in the not-so-gay 70s. Rocketman is a reference to Elton’s own label The Rocket Record Company.

In this audacious third instalment of the adrenalinefueled action franchise, retired super-assassin John Wick (Keanu Reeves) returns with a $14 million price tag on his head and an army of bounty-hunting killers on his trail.The killing of a member of the shadowy international assassin’s guild known as the High Table leaves John Wick ex-communicado. In a lethal world of blood oaths and ever-changing alliances, John is dogged by the most ruthless hit men and women in the world. Could this be John Wick’ last stand?

Taron Egerton starts as Elton and Richard Madden as Elton’s first manager, John Reid. Egerton sings all the songs in the movie.

In cinemas, May 30

Starring Keanu Reeves, Halle Berry, Laurence Fishburne, Ian McShane, Lance Reddick, Anjelica Huston, Asia Kate Dillon, Mark Dacascos, Jason Mantzoukas.

M E D I C A L F O R U M $ 12 . 5 0

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

Winners from February

In cinemas, May 16

Doctors Dozen: Mash Brewing Company – Stephen McKelvie

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.

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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.

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

Movie: Long Shot

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”).

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Movie: King of Thieves – Michael Hart, Sarah Kurian, Wynand Breytenbach, Roger Tan, Movie: Stan and Ollie – Ian Walpole, Stuart Paterson, Marie Cossmann, Katherine Concanen, Atoosa Salimi, Sara Chisholm, Sally Freight, Richard John, Georgina Pagey, Lawrence Chin, Paul Kwei, Tammy Ryan, Karen Davies, Donna Mak, Ray Barnes Music: The Nature of Why? – Leanne Heredia Musical: Mimma – Jennifer Ha

February 2019

www.mforum.com.au

Charlotte Field (Charlize Theron) is one of the most influential women in the world. Smart, sophisticated, and accomplished, she’s a powerhouse diplomat with a talent for…well, mostly everything. Fred Flarsky (Seth Rogen) is a gifted and free spirited journalist with a self-destructive streak.

The two have nothing in common, except that she was his baby sitter and first crush. When Fred unexpectedly reunites with Charlotte, he charms her with his self-deprecating humour and his memories of her youthful idealism. As she prepares to make a run for the Presidency, Charlotte impulsively hires Fred as her speechwriter, much to the dismay of her trusted advisors.

In cinemas, May 2, 2019

Theatre: Peter Pan Goes Wrong – Bastiaan de Boer, Sheryl McSkimming

48 | APRIL 2019

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POETRY BACK TO CONTENTS

Barney Embraces Technology This poem, by Dr Peter Burke from Nedlands (“I’ve never submitted anything for publication!”) was placed third in WA's premier poetry competition, the 2018 Tom Collins National Poetry Prize, presented by the Fellowship of Australian Writers WA.

P

eter won ahead of 280 entries from around Australia (half interstate poets with many widely published).

Peter says the poetry style follows the bush poets of the 1890s, but driverless tractors and drones have been added to give things a modern twist.

Barney Embraces Technology impressed the chief judge, Prof Dennis Haskell, who commented: "This was the best of the humourous poems and it is funny throughout, helped by some wonderful rhymes, such as "leschaunaltia' and 'saltier', and 'practice' and 'cactus'. It's hard to sustain humour across eleven long-lined quatrains but Banjo Paterson would have been proud of this one!"

As Peter said, “For an amateur bush poet, that’s a nice name to have in the same sentence as your own!”

Well, they buried poor old Toffee, together with his favourite bone And the bloke next door suggested he replace him, with a drone You won’t regret it Barney, urged his techno-­savvy neighbour You needn’t feed nor pay it, it's the perfect form of labour

Barney Embraces Technology Now it’s really very simple this, the rep had half-­explained

So the rep came round in shiny van, pink polo shirt and sunnies

Just use this little tablet to map out your farm’s terrain

And rounded up the Dorpers with his basic drone, “For Dummies”

You mark in all your fence lines and the trees and dams – not sheep

You can’t go wrong, he reassured, I’ll leave it here for practice

And the GPS will drive this little tractor while you sleep

But Barney found it could go wrong, in fact it could go cactus

Well the seats in this new tractor were so comfortable to sit in

A flashing light, a whirring noise, he watched the object fly away

That Barney dozed while satellites controlled its field position

Up and up and up it shot, then left, towards the highway

Following instructions from computers and transponders

His flock of sheep observed it, half amused and half bewildered

The bright red tractor rolled across his little farm, and yonder

As it swooped upon the neighbour’s wife and bloody nearly killed her

It harvested some wheat at first, but then a small collision An unmarked tree which seemed to somewhat alter its position

Barney called the drone to stay. He whistled its attention

It harvested some marron from the bottom of his dam

But on it flew and disappeared, the Cunderdin direction

It harvested his neighbours ewe and traumatised its lamb

His mobile rang -­the sales rep, his voice now dark and cranky That thing was worth three thousand bucks! he cried into his hanky

It harvested his neighbour’s lawn, and all his new hydrangeas Then took off for a patch of blue, and quite surprised some strangers

I’m looking at my screen right now, the salesman told him, sobbing

Who noisily protested as it took the Leschenaultia

He said some more, some sharpish words, but all was lost on Barney

Then watched it roll off eastward, where the soil grew hot and saltier

It’s mustering some emus in a field near Koolyanobbing!

Who saw with perfect clarity, technology was barmy

When Barney woke you should have seen the look upon his face

Technology be damned, old Barney shouted down the line

He found a knob that said ‘return this rotten thing to base’

Computers can’t be trusted and your drone’s a waste of time

And home it went, but sad to say, a final catas-­trophe

You can take your damn transponder and insert it in a log

It harvested his good-­old faithful English sheepdog, Toffee.

I’m walking into town to go and buy meself a dog

MEDICAL FORUM

APRIL 2019 | 49

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COMEDY

Perth Comedy Festival “Incredible, topical, philosophical wordsmiths and storytellers with hilarious insights into the human condition (and airplane food).”

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his is how Jorge Mendis describes the Perth Comedy Festival for 2019. ‘Airplane food’ for Jorge, as director of the Festivals for Perth and Sydney, will no doubt be a part of his diet together with comedians travelling to WA from around Australia and internationally.

Jorge has never done what the Festival’s comedians do, perform. That has not stopped the success of the Perth Comedy Festival and its extraordinary array of comedians and shows.

“The 51 shows that feature some of the best live comedy going around,” Jorge told the Forum.

“After 11 months of planning and emails and ridiculous amounts of coffee, we finally get to sit in the venues and hear the funny people say funny things. Can’t wait!”

Perth comedians Perth is not only hosting comedians from other parts of Australia and the world, it is growing its own comedians, including Nicola Macri whose comedy is described as cerebral and warm-hearted and, according to Fringe Feed “local, fun, and as unique as they come.”

50 | APRIL 2019

Cameron McLaren is another young comedian who cut his teeth at the 2017 Festival.

through Ticketek.

Familiar national faces, like Akmal, will be starring at The Comedy Club and the Regal, bookable

“We pretty much track hundreds of comedians year round and will invite artists who have a new hour of comedy to present their show. Many of the internationals will present in Perth as well as Sydney, Melbourne and or New Zealand Comedy Fests (which are all on around the same time),” Jorge said.

“As for the line-up shows such as The Biggest Comedy Show, the Gala’s and the Perth Comedy Festival Showcase – all of these shows are largely designed as smorgasbords of comedy. Each offers a taste from each of the presenting comedian who will present only a few minutes of their material on the showcases.”

The logistics of comedy Organising Festivals, of course, is not for the faint hearted and success depends on careful planning and the ability to deal with many and varied personalities and egos.

“We sort most of the logistical matters well in advance, “ Jorge said. “We have some

of the best problem solvers on the job looking at everything from artist transfers between venues and shows and ensuring that there are enough lollies in the lolly jars in the various green rooms.”

“The thing with festivals is that you only get one shot each year to get them right.

As such I don’t see any programming decisions as pluses or minuses but really more as growing pains.”

How do you measure success?

Not everyone can stand in front of a live crowd and make them laugh and, as most of us know, live audiences can be unforgiving. Jorge Mendis keeps a careful eye on reactions to events.

“Over the years we have pushed and prodded the Festival to find what we believe to be the right fit for it – primarily in so far as venue choice but also back of house things that aren’t readily visible (venue deals etc).

We are pretty excited about where we are at this year with it and feel that it will sit comfortably in its current form for the next few years.”

“We know that the audience got a laugh last year because we were in the room to hear them laugh.”

MEDICAL FORUM

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