Medical Forum WA 1018 Public Edn

LEARNING OUT BUSH Keep on Moving Knees & Shoulders NIPT & Ultrasound; Psychosis; & Paget’s

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October 2018

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EDITORIAL Jan Hallam, Managing Editor

Will a Royal Commission Make It Better?

Traditionally, our Aged Care issue is in November and this month we would normally, in this column, be discussing how the health system can help people to live better for longer. But then along came the announcement of the Royal Commission into Aged Care Facilities.

And it’s probably not such a big stretch from discussing ‘how people can live better for longer’ to actually hoping that the Royal Commission will share those aims for elderly Australians.

Everyone will have an opinion on the need for a Royal Commission – some will see the transparency that such an inquiry brings as the only way unscrupulous and negligent operators can be exposed and brought to book; some families will be desperate to bear testament to their loved ones’ horrendous suffering so the entire horrendous scenario wouldn’t have been in vain.

Others will see a Royal Commission as yet another delay to the raft of reforms that are on the launch-pad with the clock ticking.

A case in point is the Aged Care Workforce Strategy Taskforce’s 132-page report, A Matter of Care, which was released just a few days before the PM’s announcement. It, in turn, was the result of a Senate inquiry into the Aged Care Workforce which took submissions and testament from families and whistleblowers.

The chair of the taskforce, Prof John Pollaers, said that the strategy outlined in the report could be executed in one to three years and in doing so would then position the industry for the next four to seven years. Its execution would better equip and enable the aged care workforce to support older people to live well.

So what are they advocating? Among 14 actions they include: • The creation of a social change campaign to reframe caring

and promote the aged care workforce

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Marketing Manager Kirsty Fitzpatrick (0403 282 510) advertising@mforum.com.au

MEDICAL FORUM

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

• A voluntary industry code of practice • Reframing the qualification and skills framework—addressing current and future competencies • Defining new career pathways, including how the workforce is accredited • Developing cultures of feedback and continuous improvement.

• Strengthening the interface between aged care and primary/ acute care • Establishing a remote accord • Current and future funding, including staff remuneration • Transitioning the industry and workforce to new standards The Prime Minister has put his own Aged Care Minister in an invidious position. Ken Wyatt claimed on the ABC Four Corners investigation aired recently that action was required, not another inquiry. As we prepared this editorial for press, he and the Health Minister Greg Hunt issued a media release urging the community to have its say on the Commission’s terms of reference. They have been told.

They expect the Terms of Reference to cover: • The quality of care provided to

older Australians, and the extent of substandard care; • The challenge of providing care to Australians with disabilities living in residential aged care, particularly younger people; • The challenge of supporting the increasing number of Australians suffering dementia; • The future challenges and opportunities for delivering aged care services in the context of changing demographics, including in remote, rural and regional Australia;

In their statement they say: “We acknowledge the reporting and concerns raised by the public which has informed the Ministers’ views to proceed with a Royal Commission. Incidences of older people being hurt by failures of care simply cannot be explained or excused. We must be assured about how widespread these cases are.”

Perhaps it’s time for both – a Justice and Healing process and getting on doing the work?

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

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

OCTOBER 2018 | 1

CONTENTS OCTOBER 2018

INSIDE 12 14 17 23

Close-Up: Dr Richard Yin Med Students Northern Exposure Spotlight: Tomasso D’Orsogna

Knee Rehab – Hospital or Community?

12

14

NEWS & VIEWS 1 Editorial: Will a Royal Commission Make it Better? - Jan Hallam 4 Letters to the Editor

17

6 8 9 22

23 MAJOR PARTNER 2 | OCTOBER 2018

Doctors Lack Legal Protection - Dr Alida Lancee Doctors for Doctors (D4D) - Dr David Oldham Stillbirth Dilemma - Dr Gavin Pereira Plans Can Go Awry - Dr Michael Jones Keeping Elderly Home-Fit - Dr Daryl Kroschel Curious Conversation - Dr Michelle Johnston Have You Heard?

Beneath the Drapes Medicolegal: Ageing in Place – A Lawyer’s Perspective - Mr David McMullen

LIFESTYLE 32 Car Review: BMW X4 M-Sport Dr Mike Civil 34 Shooting Stars 35 Wine Review: Giant Steps Dr Louis Papaelias 36 Social Pulse: Genesis Care’s Prostate Care Centre 37 Social Pulse: Coastal Orthopaedic Launch 37 Wine Winner: Dr Rod Mason 38 Funny Side: Australian Etiquette 39 Remembrance Day Concert 40 Competitions Cover picture: Kate Ferguson /medicalforumwa/

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CONTENTS OCTOBER 2018 CLINICALS

5 Myositis Dr Corrine Wallace

25 Investigating the Painful Shoulder Dr Jonathan Spencer

26 Psychosis: Care in the Community Dr Nathan Gibson

28

The Doctors Health Advisory service of WA provides Medical Practitioners with a confidential health service around the clock.

Non-Invasive Prenatal Testing (NIPT) Dr Narelle Hadlow

How to contact: For doctors in crisis or for those wanting to speak with a DHASWA doctor:

27 Adherence in Treating Psychotic Disorders Dr Gordon Shymko

29 The 12 Weeks Obstetrical Scan Dr Anjana Thottungal

(08) 9321 3098 24 hours/day, 7 days/week

For general enquiries and feedback: Ph: 9273 3025 Email: manager@dhaswa.com.au

31 Changes in Paget’s Disease Prof John Walsh

GUEST COLUMNS

11 Reflections on End of Life Care Dr Barry Fatovich

18 Feeling ‘Safe’ to Move Brett Buist

19 Working Those Post-Surgery Moves Adam Spiroff

21 Fixing the Problem of Disease Mr Mike McRae

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

MEDICAL FORUM

OCTOBER 2018 | 3

LETTERS TO THE EDITOR

The findings of the Medical Forum e-poll End of Life Choices indicate that half of the respondents may under-dose their dying patients for fear their treatment may hasten a patient’s death. About half admits to having hastened a patient’s death at their patients’ request to stop suffering.

In the eyes of the law, based on my legal advice, those doctors in the second group may have committed murder. I have experienced this first hand.

The patient receives the care based on their doctor’s stance on this issue.

The palliative care profession will interpret the e-poll findings as a need to educate other doctors. They deny that any medical intervention at the end of life affects the timing of a patient’s death and that adequate symptom relief is always possible “safely” without bringing death forward. “We neither hasten nor prolong death.”

This notion is refuted by evidence and common sense.* If one provides continuous sedation to a healthy person, they will die within weeks.

Furthermore, I observed a senior palliative care specialist order a dose of Naloxone for an elderly dying woman after her prescribed morphine caused significant respiratory depression. She did not want her morphine to trigger the patient’s death and worried that the family may cause trouble for her and the hospital.

The result: Rebound pain and distress for this dying woman! This is utterly unacceptable.

patients vulnerable to poor symptom control in the last phase of life.

Amendment in the law can exempt medical practitioners from criminal or civil prosecution when they treat their patient’s pain or distress, even when this also hastens their death.

South Australia and Queensland are the only two states where such an exemption exists.* The poll also shows that when voluntary assisted dying becomes legal in WA, there will not be a lack of doctors willing to offer this service. Then we, as a profession, are well on our way to moving to truly patientcentred care rather that the authoritarian ‘doctor has all the answers’ days of the past.

Dr Alida Lancee GP, Hilton * References available ED: We want to clarify the e-Poll results (September p17). Doctor Lancee suggests doctors have underdosed when in fact the question asked if doctors had "heard of terminally ill patients not having enough pain relief".

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Doctors for Doctors (D4D) Dear Editor, “Where do I find a good GP?” Asking for help and entrusting your care to another doctor is a big step for many doctors. Historically, doctors are not good at having their own GP, or in seeking psychiatric help if needed.

In response to this need, DHASWA has compiled a list of doctors who have expressed an interest in doctors’ health and are willing to see doctor (and medical student) patients as a priority.

Currently, the list includes GPs and

psychiatrists with a plan to expand to other specialists including psychologists.

The list is going live on our website in late September.

If you are interested in joining our D4D list, or want to access one of the doctors on the list, visit our website www.dhaswa.com.au DHASWA also provides a confidential 24/7 call line that doctors can access for advice or crisis support.

Dr David Oldham, Chair Doctors Health Advisory Service Western Australia ......................................................................

Stillbirth dilemma Dear Editor, The national stillbirth rate of 7 per 1000 births does not reflect the true burden of stillbirth in Australia. Unlike death in older adulthood, these deaths occur when life has hardly begun and contribute to hundreds of thousands of years of life lost every year in Australia.

There is no reason why Australian babies should be relatively more likely to die than babies in other high-income countries like Finland or our neighbour, Singapore, where the rate is 2 per 1000 births.

The most substantial reductions will be achieved by better directing resources to groups at greatest risk, notably Aboriginal Australians who have twice the risk as other Australians, and women who have experienced problems in previous pregnancies.

We conducted a meta-analysis by

continued on Page 6

The current laws fail our patients in two ways: • The patient has no control as to when they die. A voluntary assisted dying Act puts a terminally ill person in control to request an expedited death when the dying process has become unbearable to them.

• Lack of legal protections for doctors providing adequate end-of-life symptomatic relief. This leaves our

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

DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

4 | OCTOBER 2018

Advice is what we ask for when we already know the answer but wish we didn't.

Erica Jong

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Doctors lack legal protection

Major Partner: Clinipath Pathology

By Dr Corrine Wallace Pathologist

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Myositis: Clinical features Inflammatory myopathies are characterised by proximal skeletal muscle weakness and evidence of muscle inflammation. These disorders are rare (Dermatomyositis/ Polymyositis combined incidence of 2 per 100,000 annually). Myositis is generally not painful, with mild discomfort only if present but patients will have weakness on neurologic examination. Patients can also have systemic features like skin rash or interstitial lung disease.

Some patients cannot be subtyped into a specific category and are classified as having ‘non-specific’ myositis.

Pathology testing General laboratory testing: Inflammatory myopathy can increase muscle enzymes including lactate dehydrogenase (LD), creatine kinase (CK), aspartate aminotransferase (AST), and alanine aminotransferase (ALT).

Inflammatory myopathies form several groups according to clinical and pathologic features – all share immune-mediated muscle injury.

• Immune mediated necrotizing myopathy – as a paraneoplastic phenomenon or in association with some medications (including statins) • Polymyositis • Other rarer subtypes Key Points Myositis related autoantibodies • Can help define a particular clinical syndrome within the myositis spectrum including disease severity, pattern of clinical involvement and response to therapy • May be associated with certain histopathologic features.

• Can be seen in some patients with interstitial lung disease without myositis.

• Myositis antibody testing, including HMG CoA reductase antibodies, is generally only indicated if myositis is clinically likely.

Statin associated myositis • Most adverse effects resolve with cessation of therapy. Other more severe forms (necrotizing myopathy) may require immune therapy.

• Can be associated with HMGCoA reductase antibodies in some patients.

Symptoms usually start within weeks to months after statin initiation but can occur at any time.

Potential effects can be divided into

• Dermatomyositis

• Inclusion body myositis

Statins lower serum cholesterol for primary and secondary prevention of cardiovascular disease and dyslipidemia.

A common side effect is muscle pain and weakness, typically seen as proximal, symmetric muscle weakness or soreness with difficulty raising arms above the head, rising from sitting and climbing stairs.

In most cases, statin related myopathy resolves after medication is stopped.

However, immune-mediated necrotising myopathy can persist after cessation and may respond to immunosuppression.

Classification

• Overlap syndromes (with another systemic rheumatic disease)

Statin associated myositis: important points

• Myalgia - muscle discomfort with normal CK

Myositis positive antibody immunofluorescence.

However, these can increase with other muscle disorders, and occasionally patients with myositis have normal CK levels (uncommon and usually with localised forms of myositis).

CK levels can vary in untreated patients with myopathy, however the CK is usually at least 10x the upper limit of normal (ULN) and can reach 50-100x ULN – CK is generally a sensitive marker of muscle inflammation.

Specific laboratory testing: Serum myositis autoantibodies can be divided into myositis-associated antibodies and myositis-specific antibodies. Myositisspecific antibodies are mainly in patients with inflammatory myositis and may inform the prognosis and potential patterns of organ involvement.

Myositis-associated antibodies occur in other autoimmune rheumatic diseases associated with myositis.

The presence of antibodies is becoming increasingly important to help classify and diagnose inflammatory myopathies.

Antibodies to 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) were identified in 2010 in patients with immune mediated necrotising myopathy, 63% of these patients were on statins.

• Myopathy - muscle weakness with or without increased CK • Myositis - muscle inflammation and myonecrosis with increased muscle enzymes either from base line or compared to ULN

• Severe myonecrosis is uncommon (affects <0.5% of patients).

• Necrotizing myopathy – reported to be histologically distinct, noninflammatory statin related myopathy with macrophagocytic engulfment of necrotic muscle fibres. Patients respond to immune therapy and this is presumed to be autoimmune in origin.

• Antibodies to HMG CoA reductase have been seen in these patients.

• HMG CoA reductase antibodies however, can be seen in statin naive patients (37-62% of patients with positive antibodies and myopathy were statin-naive in some papers, another paper reported 94% of patients with antibodies had statin exposure however).

• Adverse effects are not necessarily seen as a progression from less to more severe however necrotizing myopathy and inflammatory myopathy may be a spectrum.

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

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LETTERS TO THE EDITOR

quantitatively pooling results of up to 17 previous studies. A combination of previous experiences, such as delivering an early child (<37 weeks) that is small for gestational age in previous pregnancy resulted in a four-fold increase in the risk of subsequent stillbirth, and if the previous child was born very early (<34 weeks) there was a six-fold increase in risk of subsequent stillbirth.

Therefore, although exact prediction of stillbirth will remain a challenge we do have some useful information that is available prior to pregnancy which gives us time to intervene.

It is important for health providers to be aware of the risks involved for women with a history of adverse birth outcomes and to offer more appropriate antenatal care. Based on our recent participation in the Senate Select Committee Hearing on Stillbirth Research and Education we are confident that actions will be taken to fund and prioritise such research on stillbirth in Australia.

References on request.

Dr Gavin Pereira, WA Perinatal Epidemiology Group, Curtin University ......................................................................

Plans can go awry Dear Editor, I wish to heartily endorse Peter Maguire’s concerns about the overuse of GP mental health plans to facilitate access to the services of psychologists (July 2018).

As someone with past involvement with ministerial advisory councils, I am very conscious of the federal government’s dilemma in finding ways to reward high quality general practice without simultaneously rewarding the high-volume rapid-turnover style of practice. A raft of new item numbers such as the GP mental care plan is an attempt to address that dilemma.

As Peter pointed out, the downside of this good idea is the enormous cost to the taxpayer when it is used inappropriately.

In my GP days I used to get endless frustration with the regular appearance of patients with the request “I just need a mental health plan so that Medicare will pay for my sessions with the psychologist”. Often the patient in question had no previous history of mental health problems and was seeing the psychologist on a self-referred basis.

Some GPs gave in to these requests and, with the wonder of computerised templates, churning out mental health plans has become a big money-spinner for some.

That is a shame because, for those with chronic mental health problems, access to psychological counselling can have enormous benefits.

Dr Michael Jones, Darlington ......................................................................

Keeping elderly home-fit Dear Editor,

hospitalisations that most people would prefer to avoid. A lack of coordination and communication can result in acute care being the first port of call in an exacerbation of a chronic illness.

Silver Chain is currently trialling the Integrum Aged Care + program, which is aimed at patients who are in receipt of (or waitlisted for) Commonwealth Home Support Packages (CHSP) or Home Care packages, and have chronic and complex care needs.

Each client has a dedicated RN case manager, and is supported by a multidisciplinary team. Other members of the team include an exercise physiologist, who provides individual falls prevention and balance exercises; as well as a social worker who focuses on discussions around end-oflife planning and advanced health directives.

A shared-care GP can assist a patient’s usual GP in reviewing clients at short notice and avoiding ED attendance. The program offers transport to the Belmont clinic and provides exercise classes to help clients overcome social isolation.

The program is currently recruiting new clients. The eligibility criteria for the program are: • Patients aged 65+ (or 50+ if ATSI) • 2 or more chronic conditions • 1–5 hospital admissions within the past 12 months • Lives within 25 minutes travel time of Belmont • Lives in their own home.

Despite Australia’s fine health system, for some older Australians it can be difficult to navigate and can often lead to interventions and

Suitable patients can be referred via the Silver Chain website on https://www. silverchain.org.au/wa/health-care/integrumaged-care/ or more information can be obtained by calling 1300 513 535.

Dr Daryl Kroschel, National Medical Director, Silver Chain Group ......................................................................

CURIOUS CONVERSATIONS Dr Michelle Johnston’s first book, Dustfall has just been published to glowing reviews

The book on my bedside table is… the most recent translation of Homer’s The Odyssey and the first to be done by a woman. I heard Emily Wilson speak about the book and it’s both entrancing and poetic. There are, at last count, about eight others as well.

thinking. It makes a space to gather all the wondrous and terrible experiences in your life, see them afresh and then smash them together to create something entirely new.

One moment in medicine I always remember is… discovering that it’s okay to be kind to patients, colleagues, specialists at the other end of the phone and angry relatives. It doesn’t demean your authority in any way, but it does make your working life so much more enriching.

If I could live anywhere in the world for a year... it’d be everywhere from Iceland, Spain, Albany and London to Morocco, New York and Lesbos. And how about Jaipur, a vine-covered farmhouse in southern France, and the Orkneys. Oh yes, a steamy hotel room in Havana and the moors of Scotland. This is not a fair question.

The creative life is… uncoupling your mind from the train of the expected and no longer conforming to a standardised way of

When 2020 rolls around I'd like to be... signing a contract to publish novel number two.

6 | OCTOBER 2018

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OCTOBER 2018 | 7

HAVE YOU HEARD? a competence assessment. Those who opt out of this bureaucratic way of doing things might use job titles such as medics, emergency medical technicians, ambulance officers and first responders.

It’s our national emblem and it may just be the saviour of our sporting heroes’ poor shot knees. News from Sydney indicates that Allegra Orthopaedics, Bone Ligament Tendon (BLT) and Innovative Manufacturing CRC Limited (IMCRC) are examining whether the powerful ligaments in the tails of kangaroos are suitable for eventual use in knee, ankle and shoulder ligamentreplacement procedures. Early proof of concept testing has shown kangaroo tendon is six times stronger than human cruciate ligament. The team is pretty excited. They have pumped $2.4 million into the research which will be conducted over the next three years led by orthopaedic surgeon and head of BLT, Dr Nick Hartnell.

Good news from screening Data released by the Australian Institute of Health and Welfare (AIHW) indicates that people with breast, cervical and bowel cancers detected through national cancer screening programs have better cancer survival outcomes than those diagnosed but who had never been screened. The report, Analysis of cancer outcomes and screening behaviour for national cancer screening programs in Australia, found almost 7000 cases of cervical cancer were diagnosed in Australia in the decade to 2012. About 5% of these cases were diagnosed through cervical screening, with these women having an 87% lower risk of dying from cervical cancer than those who had never had a Pap test. A similar pattern was seen for bowel and breast cancer. The risk of dying from bowel cancer was 40% lower for people aged 50–69 who were diagnosed through the national screening program than for those with bowel cancer diagnosed outside the program. About 11% of the almost 31,500 bowel cancers diagnosed during the 2006–2012 study period were diagnosed through the program. For women diagnosed with breast cancer, the risk of death was 42% lower among those diagnosed through BreastScreen Australia than those who had never screened. About 44% of the almost 73,500 breast cancers diagnosed in 2002–2012 were diagnosed through BreastScreen.

AHPRA freeze and thaw Most doctors would have received an email invitation to renew AHPRA registration online. While some say any savings should come from a national system and wonder where those savings are, AHPRA has responded to hard times by freezing fees, amongst them: The Aboriginal and Torres Strait Island Health Practice Board of Australia $150; The Chinese Medicine Board of Australia $579; The Chiropractic Board of Australia $566. Indexation of a 2.5% increase fell to dentists and specialists $663, for dental prosthetists $589; and dental hygienists and therapists $327. In contrast doctors pay AHPRA $764 (indexed 3% this year), nurses and midwives $170, occupational therapists $110, optometrists

8 | OCTOBER 2018

Meth clinic shows its need

SJGHC CEO Dr Shane Kelly and Dr Peter Bray

Keeping up to speed St John of Gold Health Care has embarked on a large-scale Information Communication Technology project over the next year throughout its hospitals. It has recently released a mobile app for its doctors so that they can be immediately updated on their inpatients’ reports wherever the docs happen to be. The Doctor Connect app was trialled at SJG Subiaco and found to be pretty handy.

Vascular surgeon Dr Peter Bray was a test agent and he sang the app’s praises.

He can review diagnostic test results, access patient information, and locate where his patients are in the hospital. A spokesperson for SJGHC said security was tight for app users with accredited doctors needing their usual login protocols to use the app and they will only have access to their own patients’ records.

$300, osteopaths $376, pharmacists $396, physiotherapists $140, and psychologists $474 (indexed 2.6%). AHPRA must be swimming in money or employees or both!

‘Paramedic’ a protected species AHPRA will now register paramedics under the National Registration and Accreditation Scheme for $275 each. The trade-off for regulation is that the title ‘paramedic’ will become a protected title and only people registered with the Paramedicine Board of Australia can lawfully call themselves a paramedic. Title protection like this might protect the public, presuming the board can somehow control the standards its sets. In the start-up phase, holders of an Australian Qualifications Framework (AQF) level 5 qualification (diploma) from a training body outside of the NSW Ambulance Service, can demonstrate proficiency by showing five years of competent practice as a paramedic in the past 10 years, or undertaking 1700 hours of supervised practice that meets the Board’s requirements, or undertaking

The Urgent Care Clinic at Royal Perth Hospital, which treats drug and alcohol emergency presentations, has had a busy first three months. The UCC (Toxicology) has seen 300 patients up to the end of August – a third were related the methamphetamine use and the rest were alcohol and other drug issues. The Health Minister Roger Cook said the UCC, which has six dedicated treatment bays within the hospital’s emergency department, had relieved pressure on general functions of RPH’s ED. A report shows that 58% of patients presenting to the UCC (Toxicology) were men and men aged between 30 and 49 were the most common. Alarmingly, data collected dispelled the myth that most drug and alcohol affected patients attended EDs at the weekend. In the past three months at RPH, a Tuesday or Thursday lunchtime was likely to be just as busy as a Friday or Saturday evening.

IVF boom The most recent Fertility Society of Australia’s report (operating through University of NSW) has shown at 15,198 IVF babies were born in Australia and New Zealand in 2016/17 as a result of cycles undertaken in 2016 – the highest number in IVF’s 40-year history. The report shows the live birth rate per embryo transfer has increased from 22.5% in 2012 to 26.2% in 2016, the most recent year from which data are available. A major factor in these improved outcomes is an increase in the success rate of frozen embryo transfers, from 20% in 2012 to 27% in 2016. For the first time, there were more thawed embryo transfer cycles than fresh cycles performed in 2016 – almost 60% of babies born through IVF treatment resulted from frozen embryos. The uptake of pre-implantation genetic testing of embryos has also increased by more than 28% up to 7425 in 2016.

HotDoc revs HealthEngine The recent woes of HealthEngine have been well documented and now HotDoc’s CEO Ben Hurst has announced a $5 million capital raising for an online GP booking start-up. Hurst told The Australian Financial Review it was targeting a general shift in the medical centre market, towards systems that facilitated engagement with patients, rather than driving commercial leads. He told the paper that HotDoc had “very early on put a stake in the ground and said this is our company promise and we're going to uphold patient privacy and continuity of care”. The $5 million has come from Right Click Capital and AirTree Ventures and Hurst said the platform will focus on the GP space. “If you can't win in that space,

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Tie me kangaroo down, sport

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Dr Aaron Simpson replaces Dr Sydney Sacks as Clinipath's head of biochemistry The WA Department of Health has awarded Baxter Healthcare a $4.9 million tender for an infection prevention and control (IPAC) system across multiple sites – Gascoyne, Goldfields/Esperance, Kimberley, Mid-West, Peel, Perth Metro, Pilbara, South West and Wheatbelt.

National Allergy Strategy Food Allergy Prevention Project The ASCIA Guidelines for infant feeding and allergy prevention recommend introducing solid foods at around six months but not before four, when baby is ready. The guidelines also recommend introducing common allergy causing foods in the first year of life. Studies show that introducing peanut between 4-11 months can reduce peanut allergy in high risk infants by 80%. Studies also show that babies with eczema may also develop food allergy by exposure to the food through their skin. The allergy project, funded by the federal government, aims to encourage the introduction of common food allergens by 12 months of age and optimise eczema management in babies. The Nip allergies in the Bub website contains practical information for parents and a health professional section. www.preventallergies.org.au moving into other spaces is premature,” he said.

Radiology shake down We discovered a piece of medical business news from earlier this financial year which revealed that Capitol Health had bought six radiology clinics in Perth as part of a $20.3 million expansion into WA and southern Victoria. As reported in The West Australian business pages, the listed Victorian company said it had bought nine independent clinics from four WA buyers, including six in Perth – Imaging Central (Claremont), Integrated Radiology (East Fremantle) and Quinns Medical Imaging

(Quinns Rock), and Spectrum Imaging’s Booragoon Radiology, Forrestfield Radiology and Ellenbrook Radiology clinics. Capitol is paying $17 million upfront and an additional $3.3 million in the first year, subject to the clinics meeting set financial targets. The newly acquired clinics are expected to contribute about $3.1 million a year in profit before interest, tax, depreciation and amortisation on revenue of $16 million. It follows on the heels of WA’s third biggest medical imaging provider, InSight Clinical Imaging (which runs seven clinics in Perth), being bought by another major east coast group, I-MED Radiology.

InSight still bulk bills.

Dean of the Notre Dame medical school Prof Gervase Chaney has joined the board of the Stan Perron Charitable Foundation.

After 25 years at the helm of Anglicare, Ian Carter will be stepping down on June 30 2019.

Prof Wendy Erber, Dr Kathryn Fuller and Henry Hui (pictured) from UWA have won the Eureka Prize for Innovative Use of Technology. They developed an automated method for rapid detection of lymphocytic leukaemia known as the ImmunoflowFISH. Wendy, who is also Executive Dean of Health and Medical Sciences, said the team would now expand the test so it can be applied to other types of leukaemia and cancers.

Fat-fighting footy Two WA universities are waging war against the bulge with a couple of footballs. UWA has chosen the round ball for its MAN v FAT Soccer weight loss program for men established by a team of sports scientists including Dr James Dimmock (left) and Dr Ben Jackson (pictured). The year-round soccer league and weight loss program is open to overweight and obese men of any fitness level. And in this league, your team’s position on the table is decided not only on goals scored but also on kilograms lost.

The idea originated in the UK where in its two-year lifetime was responsible for 5000 men to lose more than 54,000kg. The bar is set high. This current program goes from September until mid-December.

Over at Curtin University, 120 overweight male AFL fans have committed to getting fit in a project run by qualified coaches using their favourite WA team’s training facilities.

The Aussie-FIT project, funded by Healthway, is being run in partnership with the Fremantle Football Club, Curtin University, West Coast Eagles Football Club, Edith Cowan University, Glasgow University and The University of Newcastle. The program runs for 12 weeks with Chief Investigator Dr Eleanor Quested, following with interest as the recruits attend a 90-minute fitness and educational session once a week. This idea also came from the UK. Aussie-FIT builds on the successful Football Fans in Training (FFIT) program, which now operates at more than 30 premier league soccer clubs in Scotland. It has also been rolled out across Europe, as well as for other sports in other countries, such as rugby in New Zealand and ice hockey in Canada.

MEDICAL FORUM

OCTOBER 2018 | 9

Perth Radiological Clinic continues to welcome Prostate MRI referrals from General Practitioners and Specialists.

perthradclinic.com.au 10 | OCTOBER 2018

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INCISIONS BACK TO CONTENTS

Reflections on End of Life Care Einstein wrote: “Life is not a problem to be solved but a mystery to be lived.”

Dr Barry Fatovich believes they are words to be considered in this debate.

The issues around end of life care have come into prominence with the WA Government review on End of Life Choices. As a Silver Chain Palliative Care doctor with at least 15 years’ experience of looking after people wanting to die at home, I offer these thoughts for consideration.

I have seen many people suffering with the disabling effects of terminal disease including people with advanced degenerative neurological diseases and paediatric palliative care. Many experienced varying degrees of pain and other disabling symptoms, and I worked with them and their families and friends as they faced the unknown.

There is a mystery at the heart of existence.

Birth and death are the bookends of life. We don’t know where we have come from nor where we are going. There are biological descriptions for what is happening, but they don’t give us the deeper answers we seek.

There are religious perspectives on what is happening, but these are matters of faith and belief, not objective science.

In our goal of relieving suffering, we have powerful and effective drugs at our disposal. However, they do not eliminate the existential distress that comes with the loss of function.

There are two facets of palliative care that seem to become intermingled. The symptoms associated with advanced cancer can cause pain, nausea and various other disabling symptoms which are related to the biology of the disease.

However, the disease resides in a person and when confronted with the end of their lives and not being able to do what they want, it is this experience and perception of disease that causes suffering.

While we may relieve pain, we do not necessarily relieve suffering. This calls for an entirely different set of skills related to understanding and connecting with the person, as well as personal insight.

Many people are fearful of what will happen to them as they approach the end of their lives and, in their fear and uncertainty, seek a solution (euthanasia) in which they can determine what will happen and when.

Good palliative care can give substantial relief as people approach the end of life. I have seen many people who have, once their pain has been relieved, return to enjoying life and doing what matters to them.

Not every person with cancer has pain.

There is no difficulty if someone wishes to refuse treatment and their voluntary decisions are to be respected.

As people approach the end of their lives, they are vulnerable in so many ways.

They do not want to be a burden on those who care for them (family and health professionals), and it would be easy in this situation for the dying person to ease the suffering of those around them by ending their lives.

This is not sensible decision making, I will kill myself so you don’t have to suffer.

Others have an imagination, fuelled by media stories of intolerable pain, of what might happen as they approach the end of their lives and in this understandable fear want to end the uncertainty. As physicians, our personal response to the challenge of caring for patients with life limiting illness, can affect our patients.

NEw SS E aDDRaME N & iously

Prevylands “Ma unding” po C om

Everyone experiences suffering, it is a part of life. GPs help people through many forms of suffering: major disability, divorce, isolation, homelessness and other major life adjustments. Facing life-limiting illness is yet another area where we can help because of our ongoing relationship with the people we care for.

Our role as doctors is to preserve life and maintain hope, even in the face of death.

There is a motto I learned in medical school, “to cure sometimes, to relieve often, to care always”. To confuse killing someone with caring is to misunderstand our role as physicians, and the essential difference between allowing nature to take its course and honouring someone’s life and actively ending that life. While treatment with narcotics may shorten life, what matters is the motivation behind the decision to alleviate suffering.

We can also help those who are suffering to find meaning in their lives; to help them find a way through with courage and acceptance, and to maintain hope, not for a cure but perhaps for inner peace.

For the families of those who are dying, high quality palliative care can help someone give the gift of a gentle dying to the next generation. Dr Victor Frankl, the author of Man’s Search for Meaning, discovered through his experience in the Nazi concentration camps how a person who has a reason to survive can endure almost anything. When people have a sense of the purpose, or a sense of completion of their lives, it can make what is happening easier to bear. On another occasion Frankl said: “It did not matter what we expected of life, but rather what life expected of us.”

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OCTOBER 2018 | 11

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Change and How to Get There The big picture of climate change has an impact in the GP surgeries and hospitals across the land. Dr Richard Yin is helping make the connection.

F

inding your own space in a profession and indeed the world can be a lifelong process. Some find it quicker than others, but for many of us, how we start out is very rarely how we end up.

In the case of Dr Richard Yin, the Shenton Park GP who has become a respected voice in the WA medical community for his advocacy and activism for action on climate change, it took some confronting events while in the Wheatbelt as a as a young doctor to reset his thinking and his attitude toward medicine.

“I was two years out of medical school and I was ready to leave. I hated it. I don’t think my mind was particularly well and I was overwhelmed with what I had to do not to make mistakes,” he told Medical Forum.

“I credit the time working with my friend Peter Cummins, who was a solo GP in Gnowangerup, for helping me back to medicine. The experience of working in the country and being self-reliant changed something for me.”

“The day I arrived, a car rolled over, and a week later a boiler at the Ongerup sports club exploded with a juniors’ game going on. We didn’t know how many people were coming our way but there was just the two of us until help started arriving from Albany and Katanning, including the Flying Doctor.”

“Being able to do something to help, and being involved in the community and

12 | OCTOBER 2018

witnessing how everyone stuck together, was powerful. Something happened to me.”

and pragmatic – if the technique worked it was great if it didn't, it did no harm.”

Doing your best is OK

“Around that time, the Australian Association of Musculoskeletal Medicine was formed and it started to gain traction in general practice but the only course I could do was a post-grad physio degree at Curtin University, which had an international reputation for the quality of its teaching.”

“I think it was a realisation that unlike medical school, it wasn't about being right but simply about doing the best you could in any given situation and that was good enough. There was also the humility of not knowing, and the appreciation of being able to pick up the phone and ask.”

“I’m still finding my place in medicine but I know it will never be at the centre. I don’t see myself as an ideal GP. I have met others in my practice who seem much more assured in the role and communicate more naturally.”

Regardless of this harsh self-assessment, Richard has been prepared to think outside the box from the start.

An interest in musculoskeletal medicine was piqued as a fifth year student in Albany when he found himself being supervised

by Medical Forum’s medical editor Dr Rob McEvoy. When the young Richard asked some tricky questions, Rob told him “go talk to the physio next door, they know much more than we do.”

He did and became so intrigued by the field of study he wanted to learn more.

“In the 1980s and ’90s the god of general practice, Professor John Murtagh, started running musculoskeletal workshops for GPs – basically what physios and chiros were doing. The workshops were very hands on

Empowering GPs “I was one of only two doctors in my year and I think only a handful in the whole of Australia who had gone through a physiotherapy based training. What has shifted since that time is the model of care, which now involves a more biopsychosocial viewpoint and GPs, I believe, are much better placed for this sort of medicine because that’s what we do on a daily basis.”

The interest in musculoskeletal issues, pain being a major component, led him to collaborate with his friend, physiotherapist Prof Peter O’Sullivan, in the start-up Body Logic. What we shared was a common acknowledgement of the psychosocial dimensions and a focus on function and movement as essential management.

“The most common driver of chronic pain is fear avoidance. Avoidance comes out as a strong predictor of persistent pain. I was interested in the psychosocial dimension and this kind of practice was part of my life for a little while though separate from my

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work in general practice,” he said.

While he no longer has dedicated time away from general practice, he maintains an interest in musculoskeletal medicine and the long-term suffering it can cause. His reading and clinical experience are wide, which have led to some clear views on current practice.

He would like to see more creativity around the standard treatments of acute and chronic pain.

“We need to rethink that two-step process as a linear proposition because pain is evolutionary and each step of that evolution requires different ways of seeing and thinking about the problem. We need to find approaches in that intermediary phase to disrupt acute pain from becoming chronic pain,” he said.

Individuals fall through “The trouble is the literature presents homogeneous data and with it we lose the fine grain. GPs see this all the time. You can have a heart sink patient with severe pain followed by another with similar pain scores but the interaction feels completely different. Different things are operating here but seen through the lens of research these two people could be categorised as the same and yet they are in fact separate.”

“When you’re in the game for long enough, you know that one of those patients is potentially saveable. You can do some remarkable things with a certain type of person that statistically you could go, ‘you know what, you haven’t got a hope in hell’.”

He feels strongly that many patients will never benefit from aggressive and invasive interventions.

“It’s an easy thing to do, refer these patients on, because they are complicated.

WHEN EXPERIENCE COUNTS

However, the consequences of putting them on a path of treatment that focuses solely on a structural cause for pain are often terrible. The approach is so outdated.”

How health dilemmas affect individuals differently is a part of an existential concept Richard has always found intriguing and it has fed into his lifetime journey through Buddhist thought and teaching.

Richard was born in Singapore and his family came to Australia in the 1960s.

Once settled in Perth, the young Richard was fascinated with his conversations with a Buddhist friend of his parents. While he now describes himself as a “liberal Buddhist”, he has found Buddhist teaching and active meditation invaluable for his own mental health and a tremendous aid in his interactions with patients.

“Buddhism for me is I think less about peace, if by that we mean a sort of ‘quietism’, and more about finding truth – an attempt to understand how to live acknowledging suffering, uncertainty and impermanence, and the capacity to find sanity amid the chaos,” he said.

Finding truth’s still point “To that end I think the teachings are particularly helpful in this current period.

They also provide a framework to support those with chronic pain to find meaning within suffering and/or uncertainty.”

The need to speak out on the truth climate change and its impact on health is another part of this journey.

Since the Lancet reported in 2009 that climate change was the biggest threat to health in the 21st century, the message has been filtering out. With each successive year, there has been a parade of extreme weather and environmental disasters which

has made that message clearer for both the community and health professionals.

Richard is heartened by the growth of the Doctors for the Environment organisation and that the Royal Australian College of Physicians has taken up the cause. He now hopes that other colleges and the AMA move beyond position statements, which he says are universally wonderful, but now action and strong advocacy is needed.

“I think these groups don't see climate change and health as part of their ‘core activity’ and have yet to define in a changing world what their core activities should be. There is an overall failure to recognise that social and environmental determinants to health will be the key drivers to our disease burden and the profession’s future workload,” he said.

“We need to have an eye outwards beyond the health sector to understand that unless we take care of these determinants, we won't be able to cope. That includes the looming epidemic of diabetes and obesity and other non-communicable diseases but also what a 3-4 degree hotter world will look like from a health perspective.”

“There is momentum for change but we have yet reached the tipping point where action is inevitable. How far off are we?

Mathematically, one theory of change says we need 10% of the population to change for there to be a tipping point, a more recent psychology paper suggests 25%.”

“Once we get there it will be hopefully downhill, but in the meantime, it is pushing this message uphill and while that is tiring, we are coming close to this tipping point.

While I’m optimistic change will happen, the real issue is whether it will come in time.”

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OCTOBER 2018 | 13

FEATURE BACK TO CONTENTS Pictures by Kate Ferguson

Northern Exposure

Jessica Watson, Tom Godfrey and Annabel Marshall mud crabbing in Derby

S

econd year students from the Notre Dame Medical School have recently returned from their Kimberley placement brimming with stories and experiences.

This year, 93 students headed north with the school’s Domain Chair of Population and Preventative Health, Prof Donna Mak, the architect of the program, as well as the support of Rural Health West.

Unlike clinical placements in the later years of the medical training, these students trek thousands of kilometres from Perth to understand something of the joys and challenges of life in some of the state’s most remote communities.

Students are billeted across the Kimberley and are mentored by host families. They can find themselves wrangling cattle, children, and everything in between.

14 | OCTOBER 2018

This year, Derby resident Sara Hennessy showed a group of students how to catch and handle mud crabs, while students who attended the Djugerari school discovered that a guitar and a song can work wonders. For another group of students at Fitzroy Crossing, lending a final hand in the relocation of human remains, disturbed by the 2017 flooding of the Fitzroy River, gave them deep insight into the lives and culture of the Fitzroy community.

All the time, they listened to what residents of the region had to say about their lives and their health.

Donna said that this was the biggest lesson to learn.

“It’s learning firsthand what it is like to live in this land. It gives students a sense of their own strengths and the strengths of the people who they have lived and worked alongside for eight days,” she said.

Tom Godfrey flying over Derby

MEDICAL FORUM

FEATURE BACK TO CONTENTS Elizabeth Tierney, Michael Genoni and Joshua Briotti at Mimbi Caves

Derby Rodeo

Prof Donna Mak leaving for Mt Barnett Station “It’s all about context. We can teach the science of medicine but students need to be exposed and start thinking about the art of medicine. To develop an understanding of the social determinants of health, you first have to walk in someone else’s shoes. To discover how to treat certain populations, you need to listen to what they want from their health professionals.”

Charlotte Boyle at the Mowanjum Arts Centre

MEDICAL FORUM

“It is a different way of teaching. Before students begin their clinical journey and

learn how to work in these settings, I strongly believe that students need to learn how to live in these settings.”

Ultimately the program aims to encourage recruitment and retention of doctors in these remote WA locations but even for those who decide to stay in the city to practice, an understanding of the emotional toll and the logistics of receiving healthcare far from home and family informs a doctor’s practice for the rest of their career.

OCTOBER 2018 | 15

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No fracture seen on x-ray

Salter Harris 2 Fracture seen on Extremity CT

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SPOTLIGHT BACK TO CONTENTS

In the Med School Swim Former Olympian Tomasso D’Orsogna now second year medical student is discovering a whole new world outside of the pool.

M

edical student and former Olympic swimmer Tomasso D’Orsogna has just returned from a placement in the Kimberley.

The rural immersion program is a part of the second-year syllabus at the University of Notre Dame.

“I’ve never been that far north and it was certainly interesting to see some of the more remote areas of WA. It was a good introduction into rural medicine and an insight into some of the factors that shape indigenous health.”

career that’s nudging the twilight zone is to give something back, says Tomasso.

“I’ve got an ambassadorial role with the Optus Junior Dolphins and it’s great to have a mentoring role helping to develop younger swimmers make the most of their careers. We’ve got some terrific talent coming through, swimmers such as Ashton Brinkworth, Gemima Horwood, Tara Broadbridge and Joshua Edward-Smith so the future of WA swimming is in good hands.”

“I know I’m a little biased but I reckon swimming is the best sport in the world. It’s my passion and it always will be.”

“One of the programs I was involved with was the Remote School Attendance Strategy based in Derby which is designed to get kids back to school. It can be as simple as making sure a kid gets on a bus or providing access to a washing machine so they’ve got clean clothes to wear. That can often require a home visit to speak with parents and care-givers to see what can be done to make life a bit easier for all of them.”

By Peter McClelland

“It’s the first time I’ve visited an Aboriginal community and it was an eye-opening experience. Everyone felt a little humbled seeing the conditions, and there are clearly some long-term challenges. It certainly made me realise that I need to spend more time in remote and rural areas. In fact, I reckon it’ll be essential for my ongoing medical education and professional development.”

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“I know Dad (cardiologist Dr Luigi D’Orsogna) speaks very highly of his time as a Derby-based registrar.”

One of the other hats, or caps in this case, worn by Tomasso is that of competitive swimmer.

“I used to be a part-time student and full-time swimmer but those roles are pretty much reversed now. I’m still swimming competitively but it’s much more for fun now and motivates me to keep fit. I’ll be racing in the State Short Course Championships in a few weeks and after that I’ll be representing Notre Dame at the University Games on the Gold Coast.”

“But it’s unlikely that I’ll be doing any more national competitions, it’s just becoming too hard as the study load increases.”

“There was certainly a lot to think about after the London Olympics.

It was pretty clear that there was some poor decision making at a much higher pay-grade than the swimmers, so it isn’t fair to put all the onus on them. A lot was going on within the broader span of international sport which needed closer examination.”

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“I’d have to say that things turned out pretty well for me with a bronze medal in the medley relay. I was happy with that result.”

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MEDICAL FORUM

OCTOBER 2018 | 17

GUEST COLUMN

There are viable treatment options for a common and painful condition that don’t involve opioids and surgery, says exercise physiologist, Dr Brett Buist.

A recent Lancet Low Back Pain series highlighted such issues as the inappropriately high use of imaging, opioid prescription and injectable/ surgical interventions. The survey contained a patient feedback component with many accounts of spending years on morphine and a living a life that was both tedious and sedentary.

One respondent said that he ‘was in a dark place’ until he decided that enough was enough and elected to ride his bike once around the backyard, and the next day, twice. From there he ended up doing 300km a week resulting in a 30kg weight loss, going off all medication, no pain and much improved mental and physical health.

While imaging, pharmacology and medical services may be important in specific cases, and often demanded by patients, they may also contribute to longer durations of pain, increased absenteeism and greater use of medical services.

It’s important that evidence-based, first line treatments such as exercise and pain education ar e offered and supported by medical professionals. The former, in particular, should be at the forefront of treatment for lower back pain.

output of the interpretation of signals – a ‘protectometer’, essentially – and individual experience of pain will depend upon a patient’s understanding and beliefs regarding ‘safety’ or ‘danger’.

In order to combat a potential opioid epidemic we can use our own ‘drug cabinet in the brain’ to provide effective analgesic effects. Release of endogenous opioids such as enkephalins, dopamine, endorphins and morphine-like substances has been shown to occur during many forms of aerobic and resistance exercise. And, of course, noradrenalin, serotonin and gabapentin are released in greater amounts during exercise.

Even short periods of low intensity exercise are beneficial with further advantages achieved with increased duration, frequency and intensity. It’s worth noting that positive results can be achieved during general exercise and don’t have to be specific to the designated area of pain.

One key aspect is the individual context associated with exercise. Pain is the

That’s why it’s so important to understand an individual’s concerns when he/she asks, ‘am I safe to move?’

In order to avoid unwanted and unhelpful ‘danger signals’ it’s crucial that a thorough assessment using a biopsychosocial approach is carried out by a health professional who understands pain science. We must, simultaneously, reinforce messages that foster confidence and feelings of ‘safety’.

The messages we give to people shape their experiences! When used in the appropriate circumstances, and coupled with pain education, exercise can be a valuable tool to reduce the reliance on opioid medications and the suffering of people with lower back pain.

References available on request.

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Feeling ‘Safe’ to Move

GUEST COLUMN BACK TO CONTENTS

Working Those Post-Surgery Moves When the human body has been put through the mill it’s imperative to move and stretch says physiotherapist, Adam Spiroff.

There’s no doubt that immobilisation post-surgery leads to changes in the body’s physiology and prolonged hospital stays can lead to a significant decline in functional capacity.

Recently I’ve had two patients of similar age, physical capacity and types of surgery with two totally different outcomes. The main difference between them was their respective levels of activity. One was highly active post-surgery – bending, moving, stretching and returning to previous activities within months, while the other was bed-ridden, crutch dependent and often displayed fear avoidance strategies.

Despite being advised by his specialist to ‘move’, the latter believed that any form of pain would prolong his recovery.

Induced inactivity can cause: • Tissue restrictions: hypomobility/ contracture linked with adaptive shortening of soft tissue such as skin, fascia and muscle.

• Cartilage: articular cartilage requires load to maintain integrity. Being immobile leads to softening and fragmenting of cartilage surfaces leading to decreased comprehensive stiffness and/or increased deformity making it more susceptible to injury.

• Collagen: parallel alignment of Type 1 collagen is crucial to functional movement. With immobility there’s an oblique layering of new fibres causing impaired strength and elasticity. Water and glycosaminoglycan content are decreased affecting mechanical strength and diminished healing. Finally, there is an excess of fibrin deposits, which leads to scar tissue.

• Muscle System: being immobile leads to a significant decrease in the rate of protein synthesis, which can start in the sixth hour of immobilisation. Postural muscles are the first area to atrophy.

• Bone: the build up and breakdown of bone is proportional to the forces being applied. If that doesn’t happen, bone is

rapidly absorbed leading to increased osteoclastic activity and decreased rate of new bone formation. Being relatively immobile for three months can result in a 15% decrease in bone mineral density.

Of course, the above is only a snapshot as motor-neurone activity, cardiovascular and pulmonary function, and psychological health can also be affected. All of the above can be minimised and/or eliminated by maintaining some level of activity. So, the moral of the story is to keep moving!

However, we must not underemphasise the importance of communication between specialist and physiotherapist, which will drive the recovery. The physiotherapist is normally advised to achieve certain goals within the first two weeks, then at six weeks and then again at three months.

If there’s a communication failure between the patient, specialist and physiotherapist about the importance of movement, and the negative effects of immobilisation, the road to recovery will be a lot harder.

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Fixing the Problem of Disease The changing definition of disease compels us to ask what it means to be a physician, suggests medical scientist and writer Mike McRae. I’m holding in my hand a green pill that contains 500mg of the broadspectrum antibiotic, Cephalexin.

There’s still more than a dozen left in the pack, but I hope that by the end of the course the last of the microbes laying siege to my lungs will have packed up and turned off the lights.

To be honest, I probably shouldn’t have them at all. Most sore throats are viral, and it was this symptom that the good doctor focused on as my primary concern.

We’d sat without making eye contact, conversation strictly clinical, feel glands, take temperature, tongue depression … say ‘aaaah’ and then back to the computer screen. I’d seen four GPs in the past decade scattered across three cities, two states and a territory so there was little for him to read regarding my seasonal chest infections.

I hadn’t demanded a solution, but facing a full week of work with sinuses and lungs full of green sputum I also wasn’t sure where to hedge my bets. If not for the insistence of my wife I probably wouldn’t have bothered. The consult took less than five minutes and I left feeling decidedly worse, the script almost thrown at me with accusatory reluctance and a string of caveats. I wasn’t spoken to like a medical

scientist, or even a concerned patient. I was treated like a losing bet.

It would be too easy to criticise the doctor.

This was a walk-in clinic on a Sunday evening and I was a ticket number, not a conversation.

Medical practitioners are taught to view the patient as central to their craft yet the system makes that virtually impossible to achieve. Budgets have to be balanced, medical records are a mosaic and stakeholders have unreasonable expectations. The results aren’t optimal and patients are made to feel their suffering is an inconvenience.

The point we’ve arrived at in medicine hasn’t been by accident, and by some accounts it’s a victim of its own success.

The definition of disease has evolved – moving responsibility into the hands of an expert professional to ‘fix’ what is broken. This modern day, ontological model of illness as an intrusion corrupting a healthy body has served us well. We use the science of the aetiological principle

to diagnose anomalies that have a high chance of leading to a prognosis, and maybe even point the way to efficient treatments that will ease suffering.

And it works brilliantly, most of the time.

But this model isn’t cost free. Disease is now viewed as a strict dichotomy between an archetypal body and a deficient one.

As a consequence, patients expect to be ‘fixed’ just as physicians are expected to do the ‘fixing’.

Medicine continues to evolve towards a position where the patient is seen as a complex mix of genes, microflora, environmental effects and personality.

Patient-centred treatment is viewing disease less as a clearly defined checklist and more as a personal experience of suffering.

Our definition of what it means to be ‘unwell’ is changing. As it continues to evolve, we have to also ask how our definition of ‘physician’ will change alongside it?

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OCTOBER 2018 | 21

MEDICOLEGAL BACK TO CONTENTS

Ageing in place Special Counsel David McMullen gives this lawyer's perspective.

Ageing in place’ typically describes someone living in the home and community of their choice as they age, for as long as they are able to do so safely, independently, and comfortably. Understanding the framework set up by the Aged Care Act is central to an understanding of the role of Commonwealth funded aged care and what it means for ageing in place.

What is aged care?

In a statutory sense, aged care is delivered by an approved provider and funded wholly or partly by the Commonwealth Government under the Aged Care Act. It may take the form of: • residential care (nursing and/or personal care provided in a residential facility); • home care (a package of personal care services provided to someone not being provided with residential care); • flexible care (essentially a hybrid).

So, depending on needs, aged care may be delivered in a residential care facility (“RCF”) or in a person’s home.

Access to Commonwealth funded aged care is subject to availability, eligibility and assessment – eligibility assessed by an Aged Care Assessment Team (“ACAT”).

Reported trends include fewer people moving into residential aged care. This is being seen as an end-of-life option, with the average age of entry around 83 and the average length of stay now only 2-3 years.

Conversely, a rise in home care packages reflects the preference of most older Australians to age in place, longer. Indeed, home care is touted as an answer to Australia’s aged care needs into the future – it helps relieve funding strain associated with RCFs and and it can help older people delay or avoid residential care.

Aged care can also be privately funded, but that is not the focus of this article.

The central role of home care A benefit of home care lies in its portability, in that funding follows the consumer. Aged Care Act reforms in 2017 meant all home care packages funded and provided under the Act must be delivered as ‘consumer directed care’ (or “CDC”). Consequently, care recipients control where/how their budgets are spent, and they are not locked in to any particular provider.

Home care (and hence ageing in place)

22 | OCTOBER 2018

can also be provided in a range of different home-like settings, not just the family home.

–The key is to be able to deliver increasingly higher-level care and support as needs change.

To fully understand ageing in place, it is useful to be aware of the different seniors housing options. The main options in WA include: • Retirement villages: Residential developments, occupied by retired residents (mainly 55 years or over) and governed by the Retirement Villages Act. • Lifestyle villages: These are governed by the Residential Parks (Long-stay Tenants) Act and can be specially set up for residents over a specified age.

• Strata titled developments: Communities of retired persons can be set up under the Strata Titles Act, similar to a retirement village, but residents are essentially buying a property asset.

Synergies need not be left to chance.

Partnerships, service agreements and the like can and should be explored between developers and operators of the above, and home care providers. The end result is the facilitation of home care delivery into selfcontained communities of older people. In some cases, quasi aged care communities can be created, which are in fact not RCFs within the meaning of the Aged Care Act.

cannot be guaranteed because RCFs are specifically regulated under the Aged Care Act. To emphasise the point, the retirement villages legislation in WA expressly requires prospective village residents to be notified of this fact. Further, in some cases, co-located retirement villages and RCFs are separately owned or operated; and they can be sold to a third party at any time. Depending on the agreements (or lack thereof) between colocated operators, a smooth transition to an RCF when the time comes may be helped or hindered.

Whilst co-located retirement villages and RCFs may be a selling point - particularly for couples who may need to transition to residential care at different times - the inherent absence of guaranteed entry must always be understood.

The ageing in place experience is best planned for well before a person requires residential care, and must adapt as the person’s needs increase. In this regard, home care under the Aged Care Act can play an essential role.

ED. David McMullen is Special Counsel at Panetta McGrath Lawyers. He focuses on health and ageing and has previously practised law as in-house counsel at a leading provider of high-quality retirement villages, in-home care and aged care services.

How do RCFs fit in with ageing in place?

A seamless transition (right of transfer) to an RCF from other senior’s accommodation

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FEATURE BACK TO CONTENTS

Knee Rehab: Where and Why Medibank Private attempted to find how effective inpatient rehab services were for total knee replacements and has hit some hot water. hospitals had increased by almost 50% between 2009 and 2016, the overseas experience in the 2000s was the opposite – the US saw a decline from 35% in 2003 to 11% in 2009 with a mean rate between 2009 and 2015 of 15%.

A paper published in the latest MJA (Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data, September 2018) on the efficacy of inpatient rehabilitation after total knee replacement (TKR) has caused ripples with the Australian Orthopaedic Association (AOA), which criticised the reports findings and cast doubt on its objectivity.

“Our analysis suggests that less than half of the increase in Australia can be explained by a high proportion of complex patients and reduced acute surgery admission LOS; 50% of the increase was therefore unexplained. Improved techniques for TKR…would be expected to reduce rather than increase the need for inpatient rehabilitation,” the report said.

The authors – a blend of Monash University researchers and data analysts from Medibank Private and KPMG paid by these institutions to undertake the research – studied de-identified Medibank Private funded TKR claims from 35,389 patients in 170 private hospitals in Australia between 2009 and 2016.

The authors further suggested that the most important determinant of whether a patient was admitted to inpatient rehab was the hospital where the TKR was undertaken, even more so than the clinical profile of the patient.

Potential systematic reasons include the fact that private hospitals are “often funded on a day basis, whereby the hospital receives an additional payment per rehabilitation day in addition to the initial TKR surgery payment”.

AOA President Dr Lawrie Malisano said that the report’s analysis was flawed because of inadequate clinical guidelines and other issues surrounding data, and the competing interests of its authors. “…total knee replacement rehabilitation is hampered by a lack of clear evidence-based clinical guidelines with respect to overall best practice for post-surgical rehabilitation. What we have now is that some hospitals are having more success at inpatient recovery while others are seeing more benefit using outpatient recovery programs,” Lawrie said.

Who benefits?

“It is clear that not everyone needs inhospital rehabilitation. What is unclear is who benefits from in-home versus in-hospital rehabilitation. At this time, we just don’t have the data to be able to categorically say that a particularly subgroup of the Australian population benefits over another in regard to rehabilitation programs,” he said.

In their analysis, the authors found: • The mean age was 68.7; 58.6% were women; and 58.4% were from metropolitan areas.

• The overall inpatient rehabilitation rate increased from 31% in 2009 to 45% in 2016 (but varied between hospitals) • The mean age of patients who underwent inpatient rehab was higher

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(71 years) than community/private rehab (67.3 years); more inpatients had surgical complications (1.6% v 1.1%) and more lived alone (7.6% v 1.1%) • Mean length-of-stay (LOS) for the acute surgery episode increased from 2.1 day in 2009 to 5.4 days in 2016. This increased in acute LOS accounted for almost 15% of the increase in the inpatient rehab rate.

In the authors' discussion, they noted that there was a marked variation in the inpatient rehab rates between hospitals… “the rates at more than one-quarter of hospitals significantly exceeded the mean private inpatient rehabilitation rate, and almost half the hospitals significantly exceeded the mean public hospital rate.”

Also, “provider-related factors (hospitaland-surgeon-related) explained three times as much of the variation between hospitals as did patient characteristics (demographic, clinical and surgical attributes); hospital-related factors constituted the major driver category”.

Reducing low-value care They concluded that clinical outcomes evidence “has consistently indicated that inpatient rehabilitation is not superior to community- and home-based rehabilitation, suggesting that health care system costs can be reduced without harming patient outcomes. Reducing low value care will require system-level changes to guidelines and incentives for hospitals as hospital-related factors are the major driver of variation in inpatient rehabilitation practices.”

AOA spokesperson Dr Malisano said that the real and perceived conflicts of interest of the authors and the closed sample size sourced from a single institution were cause for concern.

“As a profession there is a lot of merit in developing clinical guidelines around knee rehabilitation, however greater rigor around research, transparency and data needs to be developed to ensure effectiveness,” he said.

By Jan Hallam

Reverse trends overseas While inpatient rehab in Australian private

OCTOBER 2018 | 23

24 | OCTOBER 2018

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CLINICAL UPDATE BACK TO CONTENTS

Investigating the painful shoulder – a Pandora’s Box?

By Dr Jonathan Spencer, Orthopaedic Surgeon, Hollywood Advanced imaging, particularly MRI, has led to greater accuracy in diagnosing the painful shoulder.

However, too much information can create its own problems.

Shoulder pain is very common in an ageing population. Until fairly recently diagnosis relied on history, examination and plain x-rays, followed by either operative or non-operative treatment. This worked particularly well for fractures, advanced osteoarthritis, rotator cuff arthropathy and massive cuff tear. These conditions generally had signs on the plain films. A normal x-ray resulted in a period of simple treatment or procrastination to see if symptoms would ease.

More accessible MRI results in patients getting scans quickly, which adds to Medicare and patient expense and may not benefit their management greatly. A plain x-ray and USS remains the first line investigation.

Many patients with shoulder pain recover over time, often with simple treatment, and for those who do not settle, an MRI may be indicated.

Today, the mainstay for investigation is USS and MRI. MRI has had the greatest impact, providing very detailed imaging of shoulder soft tissue pathology, which in a proportion of cases has been of great benefit to the treating clinician. However, the excessive information presented can at times result in difficult interpretation over what is relevant and what is not.

However impressive the imaging is, we must remember that it forms only a part of the ‘weight of evidence’ required to make a correct diagnosis, and commence the correct treatment.

The diagnosis is still made with a history and examination, followed by appropriate investigation. We need to interpret scan reports with care and be aware that the reported pathology may not be the cause of the patient’s symptoms.

The words ‘tear’ and ‘bursitis’ can create much anxiety in both the patient (and doctor) and can result in over treatment.

Apparently significant pathology in one group of patients may be completely irrelevant in another.

Further reading:

KEY MESSAGES

For example, a full thickness rotator cuff tear in a 40-year-old is a severe debilitating pathology requiring expedient surgery. The same condition in an 85-year-old can be part of normal ageing and it may become entirely asymptomatic, with surgery not required.

The history and examination should not be underestimated in guiding patient treatment.

Plain x-ray is always the first line investigation.

Imaging reports should be interpreted cautiously and in the each patient’s context.

Equally, a doctor may be led down the wrong path by a scan that reports a ‘partial thickness tear’ and ‘bursitis’ in a 45-year-old female who actually has a frozen shoulder.

Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. Gill TK, et al. Int J Rheum Dis 2014.

Initial assessment of the injured shoulder. Shane Brun, AFP, Vol 41, No.4, April 2012, 217-20, www.racgp.org.au/afp/2012/april/initial-assessmentof-the-injured-shoulder/

Author competing interests: nil relevant disclosures. Questions? Contact the editor

Statins debate rolls on A Spanish study which looked into the patient records of 46,800 people aged over 75 without clinically recognised cardiovascular disease (CVD) concluded that statins showed no benefit in healthy patients aged over 75. However, they did reduce CVD risk people under 85 with type 2 diabetes.

The study was published in the British Medical Journal. Researchers looked at a

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Spanish database of patient records from primary care practices, including information on lifestyle factors, clinical diagnoses, outcomes, referrals, hospital discharge information and prescriptions.

They also studied those with invoices for at least two prescriptions for statins in the study period, and followed them for more than five years. The average age of participants was 77, with 63% women.

Queensland cardiologist A/Prof David Colquhoun criticised the study as flawed because it failed to show if patients took their medication, or if their lipid levels changed. He also criticised the BMJ for publishing such “poor research and [to] allow unsubstantiated statements to be made which are incorrect and which have important consequences regarding cardiovascular health.”

OCTOBER 2018 | 25

CLINICAL UPDATE

By Dr Nathan Gibson, Chief Psychiatrist of Western Australia About 10,000 people in WA have a psychotic disorder. The most acute and severe episodes require hospital care while most people with milder or more persistent psychosis are managed in the community.

Psychoses are a diverse cohort of illnesses affecting the way we think, perceive, feel and engage with the community.

Evidence shows that psychotic illness is still more stigmatised than anxiety and depression, which is a tremendous barrier to care. Clinicians have a role to stamp out stigma starting with the language we use. Is it respectful, or shaming and rejecting?

Hope of finding a single gene causation of psychosis (particularly schizophrenia) has faded. The cause of psychosis often remains multifactorial. Important as a potential focus for treatment, there is now solid evidence for significant personal trauma (e.g. sexual and physical abuse) as a contributory factor for psychosis in some individuals.

Plantar fascia origin

Methamphetamine-related psychosis has featured in the WA media.

Those who use methamphetamine are 11 times more likely to have a psychotic illness than the general community and people with a psychotic illness are twice as likely to be dependent on alcohol or other drugs. Psychoses associated with methamphetamine and other substances are valid and very serious psychoses. They are often extremely challenging to manage, and require assertive, rigorous followup by both mental health services and primary care.

Individuals with schizophrenia are likely to die 20 years prematurely.

Suicide is not the main cause. It is mostly due to cardiovascular and other diseases, which is a massive public health challenge. Overweight, hyperlipidaemia, diabetes mellitus, hypertension and smoking – individuals with schizophrenia and other psychoses have a right to assertive physical screening and interventions.

Management of psychotic disorders is not just about antipsychotics such as risperidone and aripiprazole. They remain a critical, evidence-based component of care but quality care also requires a broader focus on the needs of the individual. Strategies such as cognitive behavioural therapy, family psycho-education and psychosocial supports are evidence-based and equally important.

The ‘Recovery’ paradigm is a worldwide movement that focuses on those with significant mental illness. It is not necessarily about recovery from symptoms, but it’s about fostering hope, patient-focused goals of care and assisting individuals to lead meaningful lives that may contribute to the community. Symptom control is not always the best marker of a good outcome, but self-determination and quality of life must be key in the holistic health picture. It’s nothing new for us: good clinical care has always put the patient at the centre.

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

26 | OCTOBER 2018

BACK TO CONTENTS

By Mr Peter Ammon Foot Ankle & Knee Surgery

Psychosis: aspects of care in the community

Psychoses are complex and extremely serious but there is good evidence for us to be authentically hopeful for our patients with psychotic illness.

Further reading: www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/CPG_ Clinician_Full_Schizophrenia-pdf.aspx

KEY MESSAGES Personal trauma may be a factor in psychotic illness.

Psychotic illness due to substances requires assertive follow-up.

Physical care in psychotic illness is a major priority.

Foster hope – the majority of people do well.

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CLINICAL UPDATE BACK TO CONTENTS

Maintaining adherence in treating psychotic disorders

By Dr Gordon Shymko, Psychiatrist, Director Peel and Rockingham Kwinana Mental Health Service Many factors contribute to a high rate of non-adherence. These illnesses are commonly associated with a lack of understanding, or insight, into the need for treatment. They may often require long term treatment, especially when a diagnosis of schizophrenia is established. Antipsychotic medication, has been associated with a host of side effects unacceptable to many patients.

Second generation or ‘atypical’ antipsychotics, have reduced or at least changed the side effect burden of these medications. Older ‘typical’ antipsychotic medications have a greater likelihood of producing extrapyramidal side effects including tardive dyskinesia. The atypical antipsychotic medications are now generally prescribed as a first line option for patients presenting with psychotic disorders.

However, atypical antipsychotic medications have other potential problems including manifestations of hyperprolactinemia and weight gain, which can reduce adherence.

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The overall reduced extrapyramidal side effect burden of newer agents together with convenient administration has led to a greater use and acceptance of depot antipsychotic medications as a fist line treatment for psychotic disorders. Depot antipsychotic medications are now not only available in atypical preparations but also at extended intervals including three monthly dosing. Given the inherent tendency for non-adherence in the treatment of psychotic disorders, clinicians are increasingly offering a depot antipsychotic medication first line and only introducing the oral counterparts initially to determine tolerance.

Depot antipsychotic medications improve adherence and outcome. Commonly used preparations include aripiprazole depot and paliperidone palmitate depot as first line monthly depots and olanzapine pamoate as a second line monthly depot. Paliperidone palmitate also comes in a three monthly depot preparation.

Earlier use of clozapine in more resistant psychotic disorders that are only partially

Whether we call it poor compliance, adherence or concordance, many patients with psychotic disorders cease psychotropic medications.

It commonly causes relapse and heartache in disorders such as schizophrenia. responsive to treatment has been demonstrated to have a greater impact on reducing illness and enhancing adherence.

As with all treatment regimes, building a positive relationship and rapport with a patient as well as educating the patient and the family / carer around the need for treatment is of great importance.

Moving forward, technology, in the form of smartphone applications and even digital tablets will be of increasing utility.

Author competing interests - nil relevant disclosures. Questions? Contact the editor

OCTOBER 2018 | 27

CLINICAL OPINION

"Does the new NIPT replace the 12-week ultrasound scan?"

By Dr Narelle Hadlow, Chemical Pathologist, CEO, Clinipath Pathology No single prenatal test can address all of the possible congenital disorders.

A low risk NIPT or normal ultrasound does not guarantee a healthy baby.

Good reproductive care requires an informed mother (or couple) and an informed doctor. Between them, they can consider the various screening and diagnostic tests and choose that which best meets their requirements.

Therein lies good medical practice.

What types of abnormalities contribute to the congenital disorders detected at birth?

In 2006, the March of Dimes Birth Defects Foundation in the US reported on the frequency and types of congenital disorders in different countries worldwide1. Their numbers have limitations (noted above) but they provide a useful starting point.

How common are congenital disorders?

The authors estimated that the frequency of congenital disorders in Australia was about 4%, that is, 1 in 25 babies had a congenital disorder. The impact of antenatal screening availability, principally maternal serum biochemistry and ultrasound, was not included but if it were, the frequency of congenital disorders would be approximately 5% (a number that includes both major disorders such as trisomy 13 and less serious disorders such as cleft lip.)

The pie-chart shows the underlying causes of those congenital disorders as understood at that time. Viewed through 2018 glasses, the proportions would be different because we now recognise that some malformations are better characterised as recessive or new dominant single gene disorders.

Nonetheless, there are some important observations.

1. Only about 10% of the congenital disorders are due to abnormalities of chromosome number or structure (shown in red). For the doctor, the options for screening and investigation of possible chromosome disorders include combined first trimester screening, non-invasive

28 | OCTOBER 2018

prenatal testing (NIPT), amniocentesis and cytogenetic studies for couples with recurrent miscarriages. Many of these chromosome disorders lie at the severe end of the spectrum.

The whole process of reproduction is fraught. A cell must shed half of its genetic code, fuse with a half-charged cell from another person, and then build a new individual from scratch. It is hardly surprising that a variety of things can and do go wrong. Expecting that one type of test will detect all the different congenital disorders that can occur is not realistic.

It is not a simple matter to estimate the frequency: recognised recessive disorders vary between ethnic groups; the advanced age of mothers (which affects the prevalence of some congenital disorders), varies across cultures, places and times.

With improvements in the resolution and accessibility of ultrasound, estimates of the incidence of structural malformations are changing. And improved understanding of genetics is re-classifying many such malformations as being due to recessive or new dominant mutations. So it is a brave author who declares the frequency and diversity of congenital disorders in a population.

No-one wants an abnormal baby and with couples conceiving later these notes will help doctors grapple with this potential problem.

Remember please, NIPT is still a screening test (albeit with high sensitivity and specificity), and that confirmatory diagnostic testing of abnormal results by cytogenetics is still needed. Clinicians must also provide thorough pre-test information to patients, ensure patients are able to provide informed consent for this test and provide appropriate post-test counselling. Specific ethical issues such as sex determination should be carefully considered and a decision made with the patient as to the appropriate approach.

2. Approximately 7% of the congenital disorders are autosomal and X-linked recessive (shown in blue), with the parents being unaffected carriers. It is now possible to identify couples at risk of having an affected child by reproductive carrier screening.

3. The great majority of congenital disorders are structural malformations (shown in green).

These range from devastating to trivial abnormalities with the more significant structural abnormalities perhaps detected on ultrasound. Some are now recognised as a feature of a specific chromosome or single-gene disorder, perhaps detected by cytogenetic and genetic testing; others will reflect a complex mix of genes, environmental factors, and chance and will only be identified by ultrasound examination.

References 1. Christianson, A., Howson, C. & Modell, B. March of Dimes: Global Report on Birth Defects. (2006).

ED. Dr Hadlow would like to acknowledge the close assistance of Prof Graeme Suthers (Clinical Geneticist, Sonic Clinical Genetics) in preparing this article.

MEDICAL FORUM

BACK TO CONTENTS

Non-invasive prenatal testing (NIPT)

The answer is ‘no’. We ask a pathologist and obstetric radiologist to explain why. CLINICAL OPINION

BACK TO CONTENTS

The 12 weeks obstetrical scan

By Dr Anjana Thottungal, Perth Obstetrics & Gynaecology Ultrasound, Mt. Lawley

Cell free DNA testing cannot rule out structural abnormalities that occur during the development of a fetus, which is the most common cause of congenital disorders.

Since the introduction of non-invasive prenatal testing (NIPT), an increasing number of women are missing out on detailed 12 weeks scan, due to a misunderstanding by patients and perhaps inadequate information by health professionals during counselling early in pregnancy. This trend could potentially increase the number of pregnancies where the initial diagnoses of major abnormalities are being made at 18-20 weeks anatomy scan.

Important considerations Major technological advances over the past 20 years in the detailed scan at 12-14 weeks (first trimester scan), have improved identification of chromosomal abnormalities and structural malformations of the fetus.

First trimester nuchal translucency (NT) measurement bottom right (Figure 1) has evolved beyond its role for chromosomal anomaly screening.

Detailed imaging of a fetus less than 16 weeks old is now possible with the advent of high-resolution transabdominal and transvaginal ultrasound probes.

The threshold is lower for using transvaginal scans that provide detailed and high resolution images when the fetus is in a difficult position, in women with higher body mass index and in women at high risk for congenital malformations. (First trimester scans also have a role in the early prediction and risk assessment of early

KEY MESSAGES Cell free DNA testing has brought greater focus on the value of the first trimester 12-14 week scan.

NIPT and the first trimester scan, are principally focused on chromosome disorders and structural malformations, respectively.

To effectively use these screening methods, both expectant mothers and their health professionals need to be aware how NIPT and 12-14 weeks scan complement each other.

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Figure 1: at 12-14 weeks–scans of the brain choroids, heart, head in profile, and the whole fetus. onset preeclampsia and preterm labour.)

The advantages of a fetal anatomy survey at 12-14 weeks 1. Ability to see the complete fetus in one view.

2. Increased fetal mobility allows imaging from different angles.

3. There is a lack of boney ossification obstructing views.

4. High-resolution transvaginal ultrasound brings the transducer closer to fetal organs.

5. The number of soft markers and false positives is much lower at the early scan, limiting parental anxiety.

6. Severe anomalies are detected early when the mother has not yet felt movements so that termination involves less psychological trauma for parents.

There is also less risk for the mother.

concluded that an early scan performed by a competent sonographer can detect about 45% of the prenatally diagnosed anomalies, including all lethal ones and 100% of those expected to be detected at this gestation1.

It concluded that early detection of congenital anomalies was important and also confirmed the value of increased nuchal translucency (NT) in over 50% of the early-diagnosed anomalies, as a marker of abnormal development - beyond the role of NT in screening for chromosomal anomalies.

Reference: 1. Effectiveness of 12-13 weeks scan for early diagnosis of fetal congenital anomalies in the cell free DNA era. MJA Kenkhuis, M Barker, F Bardi, F Fontanella et al, Ultrasound Obstet Gynecol 2018; 51: 463-469 Further reading First Trimester Ultrasound diagnosis of fetal abnormalities / Alfred Abuhamad, Rabih Chaoui 1st edition 2018

What are the challenges of 12-14 week scan?

1. Small size of fetal organs.

2. Need to combine the abdominal and transvaginal approaches in some patients.

A recent study covered the effectiveness of the 12-14 week scan for early diagnosis of fetal congenital anomalies. It

OCTOBER 2018 | 29

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CLINICAL UPDATE BACK TO CONTENTS

How the presentation of Paget’s disease has changed Prof John Walsh, Endocrinologist, Nedlands At diagnosis, Paget’s may be symptomatic or clinically silent, present in one bone or many, and its distribution in any given patient (best determined by isotope bone scan) tends to remain constant over time. It is characterised by focal areas of increased bone resorption and formation, resulting in expanded but structurally weak bone, prone to deformity, fracture and (rarely) sarcomatous change.

Prevalence is highest in the UK, followed by Australia, New Zealand and North America. Archaeological studies suggest it first arose in Roman Britain (1 to 400 AD), and then spread, following patterns of European migration. Radiographic surveys in the 1970s, found the disease affected 5% of those over 55 in England and 3% of Western Australians. Since then, the incidence and severity of new cases have each shown a marked decline. The disease is now becoming a rarity.

Genetic and environmental factors

Isotope bone scan showing Paget’s disease in the skull, left scapula, thoracic spine, left femur and right calcaneum.

The aetiology of Paget’s disease is only partly understood; its geographic distribution and frequent occurrence within families suggest genetic predisposition, confirmed in recent studies. An autosomal dominant form of the disease is caused by germline mutations in the SQSTM1 gene, found in about 25% of affected kindreds, and 5-10% of patients with no family history. In the remaining patients with familial and sporadic disease, the disease is polygenic, with common variants in at least 8 genes (identified in genome association studies) predisposing to its development.

The rapid decline in disease incidence and severity (observed even in kindreds with autosomal dominant disease) point to a declining influence of environmental factors but these remain largely speculative. A viral origin for Paget’s disease (long postulated), is supported by in vitro models but conclusive proof is lacking.

Other suggested environmental factors (with little evidence) include local trauma to bone, environmental toxins, tobacco smoking and calcium nutrition.

Nowadays, Paget’s disease is most commonly diagnosed incidentally on diagnostic imaging or because of raised alkaline phosphatase activity on liver function testing.

KEY MESSAGES

Sir James Paget described Paget’s disease of bone in 1876. It has fascinated physicians ever since. However, the aetiology and declining incidence is only partly understood.

A minority of patients have symptomatic disease, most commonly pain in affected bones or secondary arthropathy. Severe, deforming, polyostotic disease (common 20-30 years ago), is now rarely seen. Treatment is indicated in symptomatic patients and those whose disease distribution puts them at risk of future complications (e.g. involvement of long bones or base of skull).

The treatment of choice is a single dose of intravenous zoledronic acid, which induces long lasting remission of disease in most cases.

Oral bisphosphonates can also be used, but high dose treatment for several months is required, making intravenous treatment preferable.

Further reading: Britton C, Walsh JP. Paget disease of bone: an update. Australian Family Physician 2012; 41: 100-103 https://www.racgp.org.au/afp/2012/march/pagetdisease-of-bone/ Paget's Disease of Bone: An Endocrine Society Clinical Practice Guideline https://doi.org/10.1210/jc.2014-2910 Author competing interests - nil relevant disclosures. Questions?

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cnorman@burgessrawson.com.au

burgessrawson.com.au

*Approx

OCTOBER 2018 | 31

CAR REVIEW

It’s got the luxury of a sedan and the grunt of a high-performance machine. What’s not to like?

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lways nice feeling when you hear that you have been asked to review a car that is not even available in WA yet! Walking across the parking lot, the BMW X4 M-Sport edition is an impressive and imposing sight. It’s another member of that particular group of cars that tries to cover multiple concepts, but more of that later.

My guided tour highlighted the particularly nice colour scheme, the nicely shaped front with almost ‘Dracula teeth’ on the sides, the pin-striping of the fine interior and its multitude of functions.

Once in the driver’s seat, all manner of functions and adjustments are possible; with the right amount of lumber support, side support, temperature, favourite radio channel, even air con settings – all ready to be pre-set to my own tastes. Once chosen,

: MEDICAL/CONSULTING

they can be stored and remembered, automatically being recalled when another driver has messed things around!

I then naturally go to place my phone on a convenient shelf in the central console area and am told that it is now being wirelessly charged!

There are all sorts of clever electronic trickery – from the expected to the esoteric.

Voice activated GPS, done! Owner’s

regentswa.com.au

Subiaco 80 Hay Street

Major renovations to be completed by end October 204 sqm medical/consulting rooms- council approved Large reception area Sinks/ plumbing installed in five (5) rooms

Seven (7) car bays Excellent exposure, High volume passing traffic Wheelchair access Long lease available

Rent $250 per sqm + GST & Outgoings

John Watson 0447 758 533 john.watson@regentswa.com.au

32 | OCTOBER 2018

Alex Kotovski 0418 921 594 alex.kotovski@regentswa.com.au

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BMW X4 M-Sport – Fast and Fantastic

CAR REVIEW manual (with animated useful videos), done! Accessing phone functions, but of course! The electronic digital speedo and rev-counter display is great, particularly as it shows the older style analogue appearance – a head’s up display that works well!

All amazing and, possibly, to be expected, but being of the age I am, I am always concerned that with so many electronic wizardry, it will all end in tears when important key functions fail, just when they are needed. Do I need to make sure that I don’t stray too far from a BMW service computer?

Obviously, driving around in such a car attracts attention and during one conversation I discuss the merits of all of these electronic toys. I realized others had similar concerns, but it was only when their older BMW moved towards 500,000km, that they started to play up. That’s impressive, my expensive laptop isn’t that reliable.

Back to the car, there are cameras that seem to see round corners and make maneuvering the behemoth easier! It does seem like a big car, for good reason…it IS a big car, most SUVs are!

The M-Sport version of the motor upfront clearly pulls it along at a decent pace for such a machine. Then you discover the ‘Sports Plus’ button hiding by the gear leaver. Hit that and it becomes a lot more sporty./

on public roads gave no real opportunity to explore the limits of a clearly high performance machine but the sound track is well worth it!

Well there are other M-Sports out there -- large, but sporty machines, which cater to all the needs of up to four adults in great comfort, clearly a Sports Utility Vehicle.

The sound the engine makes, as it revs harder, shifts with blips of the throttle and more purposeful roar make it worth finding that button. The electronic dash changes, more red, more anger perhaps, but possibly more red mist! Clearly in Sports Plus it would be all too easy to hand over your licence to the boys in blue. Driving

So, back to the SUV concept. I always struggle with the ‘why?’ for this type of car. If you want to go off across the countryside, then a Prado is more appropriate; if you want to cruise across this big nation, then surely some of the sedans (by BMW for instance), would be more appropriate? But a sports car?

Clearly this car does a lot more than fill a niche market and other car producers think the same thing. But the BMW X4 does it so well, in spades in fact, that those other car companies have got some serious catching up to do.

By Dr Mike Civil

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OCTOBER 2018 | 33

SPORT BACK TO CONTENTS

Shooting for the Stars

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Improving young Indigenous girls’ engagement with school is gaining traction with the input of a ball and some dedicated women from Netball WA.

here’s more than one way to encourage Aboriginal girls to engage with the classroom and Shooting Stars is leading the way, says Fran Haintz, (pictured below). The general manager of Netball WA Indigenous Programs is a firm believer in the power of sport to forge schools and communities into productive and rewarding partnerships.

“Shooting Stars has been going for three years and the positives are ongoing and diverse. It is run by Glass Jar Australia, the charity arm of Netball WA, and the increase in school attendance in the Kimberley has been spectacular.”

“We’ve seen some girls lift their attendance by one day per week, which is a 20% increase. But we’ve done a lot better than that, too. There are students who are now going to school every day of the week and when you consider that it’s not just education that we’re talking about here it’s a meaningful shift.”

One of the significant aspects of Shooting Stars is its multi-layered approach.

“Spin-offs such as physical health and wellbeing are an important part of being at school so if the girls aren’t there they miss out on that. And some of those areas involve subjects such as sexual health and protective behaviours that are so important for young girls making their way in the world.”

“Our staff works one-on-one with the girls to bring down the barriers that prevent their full participation in the education process.

We have something we call the Yarning Circle, lots of sitting down and talking which is a traditional way for Aboriginal people to share their knowledge.”

A big world out there “The program really tries to expand the girls’ horizons so they become part of something that’s much bigger. We’ll have players from the Eagles and West Coast Fever speak with the girls to aim high, both at school and on the court.”

“And on an even broader scale it’s important to remember that the sport of netball has been a big part of community development in WA for nearly one hundred years.”

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The fact that netball is such an inclusive game with the highest participation rate of any sport in the country makes it the perfect choice for a program such as Shooting Stars.

“There’s an amazing network of people, from teachers to community leaders, right across the state, who support what we’re doing in this school engagement initiative.

The girls might think this is all about school, and they’re right to a certain extent because we are trying to create a friendlier classroom.”

down and work through what’s going on.”

Flexible, inclusive programs “One of the real attributes of Shooting Stars is its flexibility. Every location is different and a program rolled out in Halls Creek isn’t necessarily going to be the same as one in Mullewa. It’s crucial that they’re a good ‘fit’ for a particular community, that’s a real ‘no-brainer.’”

As Fran suggests, there’s plenty of sporting prowess among the girls.

“But it’s also absolutely vital that we create an effective bridge between school and the wider world and the best way to do that is by building a relationship of trust with the girls.”

“It doesn’t take long to see there’s unlimited talent running around a netball court in the Kimberley. I’m a bit of a talent scout, too. I’ll give Netball WA a call and tell them about a hot prospect in Leonora and they’ll come up and have a look.”

“We’ll have a morning meeting in the Girls’ Room, some of them may be hungry and we’ll take care of that. More critically, there are often girls who are just not ready to go into the classroom and we have to address those issues.”

“Half the battle is convincing the girls that a good education combined with a dream of bigger and better things means that anything is possible. Knowing you have good people around you is part of the equation.”

“It’s fair to say that some of them don’t have good coping mechanisms so we’ll sit

By Peter McClelland

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WINE REVIEW BACK TO CONTENTS

Taking Giant Steps After a career as a pioneer brewer (Matilda Bay, Little Creatures) Philip Sexton, a UWA graduate and Margaret River local, established Devil’s Lair winery in Margaret River. Then having sold this award-winning and prestigious property, he turned to Victoria’s Yarra Valley where Giant Steps was born.

As well as a wine lover, Phil also loves jazz and he chose the name Giant Steps after John Coltrane’s legendary recording of the same name. His aim in the Yarra Valley was to make top quality cool climate Pinot Noir and Chardonnay. He began by planting the Sexton Vineyard in 1997. Other vineyards followed so that that there are now a number of different micro climates at the winemaker’s disposal.

Careful attention has been paid to clonal selections of pinot noir and chardonnay. Sustainability is of prime importance in the vineyard. In the winery, practices include only pumping wine once, no additions other than SO2 (no yeast, no acid, no enzymes), no fining or filtration – and attention to detail.

Chief winemaker Steve Flamsteed (pictured) is highly respected and credentialed. In 2016 he was awarded Winemaker of the Year by Gourmet Traveller Wine Magazine for outstanding efforts in the winery. Also of interest is that he is an experienced chef and cheesemaker, a factor which I believe adds an extra dimension to his palate awareness of good balance.

By Dr Louis Papaelias

2017 Yarra Valley Syrah ($35) Made from 100% Shiraz (Syrah being its French name), the whole-bunch fermentation has given this wine pleasing aromatics of berries, white pepper and spice. Agreeable tannins and fine acidity make for enjoyment now. It is a lighter bodied Shiraz compared to its Barossa and McLaren Vale cousins. A Pinot lover’s Shiraz, perhaps?

2017 Yarra Valley Chardonnay ($35) A blend of grapes from a number of different sites in a top vintage year has given this wine floral aromas of white peach and grapefruit, which lead onto a crisp clean palate with an added touch of complex barrel flavours. A very attractive wine in the Chablis style.

2017 Applejack Pinot Noir ($60) At 300m, the Applejack vineyard is one of the highest and coolest sites in the Yarra Valley. In a similar fashion to the chardonnays, this wine incorporates much of what the generic Pinot offers but then raises the stakes in terms of intensity of flavour, complexity and palate length. An outstanding wine worthy of praise and is comparable, I believe, to Burgundies costing two and three times the price.

2016 Sexton Vineyard Chardonnay ($60) Coming from one of the coolest spots in the valley, this is slightly more reticent on the nose than the previous wine but showing more complexity. Tasting reveals a wine of finesse and elegance powered by a generous backbone of natural acidity and long lingering finish This will open up and reveal more in a year or two. Lovely.

2017 Yarra Valley Pinot Noir ($35) Winner of the trophy for best Pinot Noir at this year’s Royal Sydney Wine Show, this is a wine of immediate appeal and charm. It has a lifted bouquet of cherries with some complexity. It’s very easy on the palate with fine tannins and acidity. Supple in the mouth. Great for enjoying now and excellent value for money.

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OCTOBER 2018 | 35

SOCIAL PULSE 1

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Prostate Care Centre Opens Genesis Cancer Care’s holistic Prostate Care Centre at Joondalup was officially opened

by Joondalup mayor Mr Albert Jacob. The centre brings together a network of medical specialists and allied health professionals including Prostate Cancer Specialist Nurse Julie Sykes whose position, a first for Perth’s northern suburbs, is funded through the support of Prostate Cancer Foundation of Australia (PCFA). PCFA launched the Prostate Cancer Specialist Nursing Service in 2012 and Julie joins 46 existing specialist nurses who are currently working in hospitals across Australia.

Radiation oncologist A/Prof Raphael Chee said a man referred to the Prostate Care Centre may physically be seen by one or two consultants but, in most cases, his condition will also be discussed at a multidisciplinary meeting where the entire prostate specialist medical team is present to evaluate and decide upon the best course of action.

1. Dr Ken Michael AC and PCFA board member (left), Genesis Care’s Marisa Bellantoni and Melanie Bunch

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2. Nurse coordinator Greg Bock (left), PCFA nursing program director Sally Sara, specialist nurse Julie Sykes, Genesis Care Director of Nursing Sharon Ray and PCFA’s Belinda Katz 3. Joondalup Mayor Albert Jacob (left) does the honours with PCFA board member Dr Ken Michael.

4. Perth Radiological Clinic’s Caryn Fong (left) with Specialist nurse Julie Sykes 5. PRC radiologist Dr Martin Blake (left), A/Prof Raphael Chee, host Jeff Newman, Wanneroo Mayor Tracey Roberts, Joondalup Mayor Albert Jacob JP, and PCFA’s Dr Ken Michael.

6. Cancer Council WA Melanie Marsh (left) with GenesisCare Director of Nursing Sharon Ray

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Coastal Orthopaedics Expansion Coastal Orthopaedics celebrated the opening of its state-of-the-art new home at Bethesda Hospital in Claremont recently.

The partners – AMA (WA) President Dr Omar Khorshid, Dr Toby Leys, Dr Matthew Scaddan, Dr Paul Khoo, Dr Brendan Ricciardo and Dr Peter D’Alessandro – welcomed 100 guests at a special cocktail event hosted by Tim Gossage. The refurbished and expanded premises were opened by Cottesloe MLA Dr David Honey.

1. Erin Moignard, Dee Hall, Jessica Smith, Cherie Higgins, Cailin Hallworth 2. Dr David Honey with Dr Omar Khorshid 3. Natasha Harris & Dr Peter D’Alessandro 4. Dr Toby Leys & Kath Leys 5. Dr Paul Khoo & Dr Liz Khoo 6. Tim Gossage & Dr Peter D’Alessandro

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Wine winner

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A meeting with the legendary Jack Mann at Houghton’s Winery as a medical student helping to organise the annual Medical Student Dinner piqued an interest in wine for Dr Rod Mason. And he’s still going strong! Rod’s in the South West Cellar Club and the Bunbury Bacchus Club, has spent time in Bordeaux, the Douro Valley and the Veneto.

Rod bemoans his ageing sense of taste and smell and now loves ‘fruit bombs’ such as Amarone della Valpolicella.

And Grange is always on the wish list!

OCTOBER 2018 | 37

Don’t feel as though you should say ‘G’day’ or use the word ‘mate’ a lot. Australians are aware of this stereotype and it can feel a little patronising coming from a visitor. Just saying hello and making good eye contact is fine. A handshake may be appropriate if you’re meeting someone with whom you expect to have an ongoing relationship, like a new work colleague.

A GUIDE TO AUSTRALIAN ETIQUETTE You can discover a lot about how the world sees you by reading tourist guides. Here is some advice given to international students about Australia from Insider Guides’ ‘Belinda’.

TO THE LEFT, TO THE LEFT Australians drive on the left-hand side on the road, and this convention carries over to other parts of our streets as well such as the footpath. When stopping on an escalator, or walking upstairs, always stick to the left and don’t block other people from passing you.

Even in formal situations, Australians tend to prefer first names. Calling someone (even your boss) Mr or Miss, Sir or Ma’am can sound a bit stiff.

QUEUES In Australia the queue is sacred. ‘Pushingin’ in any situation – at a bar, a service desk or a cashier is considered the height of rudeness. Most of the time, it’s pretty obvious where a queue begins and ends, but if you’re in doubt, simply ask ‘excuse me, is this the end of the line?’

If you’re in a crowded place, like a nightclub, pay special attention to who was waiting at the bar to be served before you. If a bar attendant approaches you instead of someone who was there before you, it’s polite to signal that the other person was there first.

"Cats are intended to teach us that not everything in nature has a function."

- Garrison Keillor

LITTERING In 1979 when NASA’s Skylab space station came crashing down in Western Australia, the sleepy town of Esperance issued NASA a $400 fine for littering.

Australians take a lot of pride in the state of their environment and while we’re not as clean as Singapore, littering is not just an affront but is illegal. A concerted ‘anti-litter’ movement began in the late 1960’s and most Australians have grown up with the slogan, ‘Do the right thing – put it in the bin.’

The taboo extends to indoors as well as outdoors. When eating in a food hall, or anywhere where tables and chairs are shared, take rubbish to the bin when you’re finished. In fact, if you can see bins, it’s a sign that you’re expected to use them.

INTERACTING WITH SERVICE STAFF

PERSONAL SPACE Australia is the ninth least densely populated country in the world. Perhaps this is why, even in our busy cities, people like to have a fairly large circle of personal space.

It’s considered rude to brush up against someone unless it’s absolutely necessary (like on crowded public transport). When there is space available, try to stay at an arm’s length away from people. If you have to invade that space for some reason, an ‘excuse me’ or ‘sorry’ is appropriate.

Unless there’s assigned seating, or a theatre is completely full, give strangers a couple of chair spaces between you and them.

38 | OCTOBER 2018

COUGHING, SNEEZING AND ALL THE REST After the Swine flu panic, like many places in the world, Australians have become more conscious of proper respiratory hygiene.

The National Health and Medical Research Council spells out the rules nicely; if you’re coughing or sneezing, use a disposable tissue and if there’s none available, “cough or sneeze into the inner elbow rather than the hand”.

Spitting in public places is a big no-no and (perhaps we need to tell you this, perhaps we don’t) public urination is considered an offence everywhere in Australia. Best not to do it.

Australians have a strong culture of egalitarianism that they don’t like to see violated. No matter their job, treat people with equal respect and use ‘please’, ‘thank you’ and ‘excuse me’ with everyone. Never snap your fingers, whistle or yell at service staff to get their attention. As well as being considered rude, the standard of service you receive may drop a little…

TIME Different cultures have different relationships with time. Common concepts of time include linear, multi-active or cyclical. Like many Anglo-Saxon cultures, Australians have a linear relationship with time. That simply means that time is measured by the clock. It is important to arrive at appointments at the actual time specified (and even be a few minutes early) especially in business situations. However, when invited to someone’s home for a social event, it’s best not to arrive exactly on time, but a little later.

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SAYING HELLO

CHORAL MUSIC BACK TO CONTENTS

Give Us Peace

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ovember 11 marks the centenary of the armistice that ended World War I. That’s a powerfully symbolic anniversary – for all that it achieved, and for all that was lost.

When thinking becomes so disordered by the enormity of such concepts, the arts often step in with crystalline precision. Perth Symphonic Chorus’s Remembrance Day concert will be all the more potent for its representation of raw grief and subsequent hope by the music of Gabriel Faure and Vaughan Williams, and by the poetry of Walt Whitman.

Faure’s Requiem is well known and well loved. In was written over a decade and finally premiered in its present version in 1900 – 14 years before the start of the Great War. On a metaphysical level he mostly adhered to the Catholic mass for the dead, though he expedited passages.

However, he was not unaware of the work’s impact as a piece of theatre.

He wrote of the work: "Everything I managed to entertain by way of religious illusion I put into my Requiem, which moreover is dominated from beginning to end by a very human feeling of faith in eternal rest."

It is an entrée to Vaughan Williams Dona Nobis Pacem – or Give Us Peace, which some think is much more politically charged. It was first performed in 1936 as Europe and Britain began a dreadful waltz towards another bitter and devastating war.

Williams took the poetry of Walt Whitman, which was written during the American Civil War in the 1860s, and gave the narrator some heart-wrenching words to mouth.

For my enemy is dead, a man divine as myself is dead…

Bends down and touch lightly with my lips the white face in the coffin There is no hiding behind any jingoism here. It’s simply a hard truth wrapped in some of the most moving music imaginable.

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Williams also intersplices a speech given by parliamentarian John Bright in the British Commons in 1855 at the time of the Crimean War – “The Angel of Death has been abroad throughout the land; you may almost hear the beating of his wings”.

War is an ancient theme.

The Perth Symphonic Chorus is led by its director Margaret Pride who has worked tirelessly to make this a tribute fitting for such a special occasion.

Soprano Sara Macliver, who will be in First World War nurse’s uniform, and baritone Christopher Richardson in Great War soldier’s uniform, will interplay with the narrator, Perth actor Igor Sas in Dona Nobis Pacem. The choir and soloists will be accompanied by the Perth Philharmonic Orchestra, led by the supremely talented Paul Wright.

Let music be the balm.

By Jan Hallam http://www.perthsymphonicchorus.com.au/ event/centenary/

OCTOBER 2018 | 39

COMPETITIONS

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

Kids Theatre: Gruffalo’s Child The stage adaptation of the much-loved children’s book Gruffalo’s Child by Julia Donaldson and Axel Scheffler, itself a sequel to Gruffalo, comes to Perth in November.

The little Gruffalo decides to ignore her father’s warning and heads into the deep dark wood in search of the Big Bad Mouse.

Music: Katie Noonan’s Elixir with Michael Leunig

Heath Ledger Theatre, November 21-December 2

The Perth Concert Hall will buzz with all sorts of creative energy when award-winning singer songwriter Katie Noonan returns to Perth with artist/cartoonist Michael Leunig and her jazz trio Elixir joins WASO to present Noonan’s Gratitude and Grief collaboration. It will showcase spoken-word poetry, vocals, improvisation and live drawing by Leunig.

Movies: British Film Festival

Noonan will perform a series of original songs and covers, while cartoonist and poet Michael Leunig will draw live on stage, using the music as a source of inspiration for improvisation.

Every show will create something exciting and new.

Iain Grandage, who requires no introduction to WA audiences, will conduct the WASO in this special performance. This multiHelpmann Award-winning composer and music director has collaborated with WASO on a number of occasions in the past and will present his first Perth Festival as Artistic Director in 2020. Grandage was also intimately involved with the Gratitude and Grief project, sharing arrangement duties with Brisbane composer and pianist, Steve Newcomb.

Palace and Luna Cinemas present the 2018 MINI British Film Festival program, featuring some of the most eagerly anticipated films including powerful true stories, literary adaptations and biographies starring some of Britain’s best known and beloved stars, including Michael Caine.

At Cinema Paradiso, Palace Raine Square, Luna on SX and The Windsor, from October 25

Movie: The Girl in the Spider’s Web Cult vigilante Lisbeth Salander, of Stieg Larsson’s Millennium trilogy fame, returns in The Girl In The Spider’s Web, a first-time English adaptation starring Claire Foy (The Crown).

In cinemas, November 8

Perth Concert Hall, October 26, 8pm

Kids Theatre: Potted Potter – Dr Rachel Horncastle Our practice purchase loans provide you the opportunity to: • borrow up to 100% of the purchase price of an existing practice, or of a share in a partnership • make flexible repayments to suit cash flow and tax needs • benefit from competitive fixed and variable rate options • borrow against goodwill and assets rather than against your home

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Find out more at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.

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In cinemas, October 18

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Vivienne Westwood has been an agent provocateur in the worlds of fashion and social change for more than five decades and this documentary seeks to show audiences just how significant an impact she has made.

BIG Shoes

Music: WASO Plays Mozart & Dvorak – Dr Megan Foster Movie: Kin – Dr Twain Russell, Dr Mark Prestage, Dr Lynette Spooner, Dr Alem Bajrovic, Dr Rebecca Burgess

Movie: Westwood: Punk, Icon, Activist

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Winners from August

Child Health: IBD, Chickenpox, T2D, Hyperhidrosis, UDTestis, Rheumatic Fever.

Features and Lifestyle

MAJOR PARTNER

August 2018

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Movie: Ladies in Black – Dr David Storer, Dr Atoosa Salami, Dr Donald Reid, Dr Cynthia Poh, Dr Jane Deacon, Dr Gemma Edwards-Smith, Dr Wendy Sexton, Dr Tania Morris, Dr Tammy Ryan, Dr Jennifer Muir Movie: Searching – Dr Claire Armanasco, Dr Patty Edge, Dr Helen Slattery, Dr Marie Martin, Dr Ray Barnes, Dr Sara Chisholm, Dr Christine Sowman, Dr William Thong. Dr Melissa Bator, Dr Donna Mak

Choral: Remembrance Day Concert This Remembrance Day commemorates 100 years since the signing of the armistice ending the death and destruction of World War I. Such a significant day deserves an equally significant tribute and the Perth Symphonic Chorus has it in spades with Vaughan Williams’ Donna Nobis Pacem and Faure’s requiem.

Perth Concert Hall, November 11, 4pm

Movie: The House with a Clock in Its Walls – Dr Peter Griffiths, Dr Paul Kwei, Dr Susanne Sperber, Dr Moira Westmore, Dr Tammy Barrett-Izzard, Dr Ben McGettigan, Dr Michael Bray, Dr Andrew Toffoli, Dr Georgina Pagey, Dr Sally Freight

40 | OCTOBER 2018

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