Medical Forum WA Public Edn August 2019

Pill Testing Law vs Harm Child & Adolescent Health Preterm Births Childhood Obesity T2DM in Kids, Myopia, Hearing Loss & Growing Pains

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August 2019

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EDITORIAL Jan Hallam, Managing Editor

Hard Questions, Harder Answers Spurred by several incensed correspondents and a mounting dosier of examples, this editorial was going to reprise the disappointment previously expressed by pharmacists’ apparent campaign to move into medical consulting.

But one has to resist echoing global leaders’ foreign policy rants on social media: “If they want war, we’ll give them war” or a particular favourite “They are very, very, bad”.

That will have to wait another day.

The message that rings so loudly throughout the pages of this edition are the dire consequences of ignoring the impact of the social determinants of health. And it is represented in the magazine from so many angles – public health, palliative care, obesity, culturally secure health care, climate change – it shines through all these issues with enormous clarity.

In a system that prides itself on equality, there are some people more equal than others and many who are disadvantaged by no other reason than the fact of where they were born.

This is not an issue that can be solved at the bedside or in the consultation room and it will take a whole-ofcommunity effort to address if we don’t want to see our health system split along the fault lines of postcodes.

The WA Health Minister’s own Sustainable Health Review acknowledges the rising impact of the social determinants of health (SDoH). It’s even thrown some extra cash towards preventative health, which must be

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welcomed for those toiling away in the trenches, but it’s still a miniscule amount given the heavy lifting that needs to be done.

The clock is ticking.

We know the problems. The number of times we have all written, “the burden of chronic disease” in notes or in articles doesn’t bare thinking about.

We even know the solutions – meaningful education, affordable housing, secure employment, an equitable tax system. The development of a new life-saving drug, a new device to keep dying body bits going are laudable but there’s absolutely no denying that it is cheaper to keep people healthy than to stump up the cash when they are sick.

At the risk of raising the red lantern, we need politicians to start acting in good faith for the majority of society and tackle the burden of disease like an economist.

In a week that’s seen the Grattan Institute’s rather grim outlook for the private health system, it foreshadows broader questions of where taxpayers’ dollars should be spent. The answers could be quite scary – not just for those working in health system, but every user of health system.

We regularly read that our health system is the envy of the world for its quality and access.

Many think we are putting that at risk by not taking seriously the challenges of the SDoH and the broader issues they present for our society as a whole.

Heads in the sand, and business as usual may last a few years more, and fortunes are most certainly there to be made – demand alone will see to that – but our children and grandchildren may rue our inaction.

Journalist James Knox (08 9203 5599) james@mforum.com.au

GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

AUGUST 2019 | 1

CONTENTS AUGUST 2019

INSIDE 12 Palliative Care in the Spotlight 16 Pill Testing: Law vs Harm 20 Close-Up: Prof John Newnham 24 The Weigh We Are

16

12

NEWS & VIEWS 1 Editorial: Hard Questions, Harder Answers – Jan Hallam 4 Letters to the Editor:

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24

6 7 10 29 30 33 42 48 49

Culturally Secure Health Care – Prof Juli Coffin Don’t Follow Canada – Dr John Hayes GPs and Breast Screening – Kristen Seaman Have You Heard Beneath the Drapes Spotlight: Mr Bruce Langoulant, Meningitis WA Asking Kids About Hospital Care Protecting Vulnerable Children Redefining Autism Warning Signs of Meth Withdrawal – Dr Kerryn Ashford-Hatherly Wound Photography – Lynette Rodriguez A Perfect Match Kidney

LIFESTYLE 50 Let the Sunshine In 51 Wine Review: Castelli Estate – Dr Martin Buck 52 Social Pulse: SJG Murdoch Dinner; Bethesda Celebration Day 54 Competitions 55 WASO Chorus Vespers /medicalforumwa/

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CONTENTS AUGUST 2019 CLINICALS

5 Molecular Pathology in Clinical Practice Dr Andrew Dean

38 Developing Resilience in Children Dr Mandie Shean

Youth-Onset T2DM Dr Nicholas Forgione

43

42

Managing Baby Health Dr Leon Levitt

Rethinking Growing Pains Ms Nicole Pates

39

41 Getting a Diagnosis Dr David Roberts

44 Myopia in Children Dr Antony Clark

45 Meningococcal Vaccination in WA Dr Astrid Arellano

2019

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AUSTRALASIAN DOCTORS’ H E A LT H C O N F E R E N C E 22-23 NOVEMBER 2019 PE RT H AU ST R AL IA

46 Hearing Loss in Children Dr George Sim

46 Pancreatic Cancer: Insight Prof Mayank Bhandari

47 Foot Pain in the Active Child Dr Colm McCarthy

DO YOU HAVE A PASSION FOR DOCTORS’ HEALTH? Join your colleagues to be engaged by speakers, clinical and practical learning sessions, and social events.

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GUEST COLUMNS

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8 Joke Turns Terribly Serious Dr Bret Hart

34 It’s Also a Boy Thing Dr Kieran Kennedy

35 When Kids are not Kids Anymore Dr Rachel Collins

37 WA’s Climate Health Inquiry Dr Revle Bangor-Jones

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

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AUGUST 2019 | 3

Culturally secure health care

most importantly provide a roadmap to policy and practice.

Dear Editor,

For many Aboriginal people, our first contact with any health care must be as positive as possible. Feelings of being judged, put down or racially vilified not only causes stress that we must carry but more often than not it sets up the cycle of not seeking preventative and interventionbased health care.

Re: Cultural Competence in Health Care, July edition: As the First Australians we are only just starting to see the shifts in what we expect from health services in terms of providing culturally secure care for our people rather than what was imposed on us from a colonial standpoint around a one-size-fits-all for health service delivery.

It has taken many decades for those who forged the pathway in terms of the importance of language, cultural protocol, true and authentic engagement in decision making and leadership, birthing practices, men’s and women’s business, death and dying and, of course, acute care.

Due to disparities of access and the fact that often the point of service delivery is a critical point of intervention (e.g. emergency department), and more often than not it is not a positive experience for many Aboriginal patients, these discomforts perpetuate this cycle of less preventative and intervention-seeking of the health systems.

Culturally secure health care depicts systemic changes at all levels of health service provision. It is not reliant on an empathetic level of leadership but rather one based on human rights and equity.

Cultural security – unlike some other terminologies in the health service provision space – is not just theoretical but practical in its application. It is based on the concept that we all have cultural awareness to varying degrees.

It does not necessarily mean we do anything differently as it is just a basis of knowledge around sameness or difference.

Maori leaders see cultural security depicting a level of safety that keeps cultural practices and norms intact and offers some action towards their observances. Both components are required to reach cultural security, which also incorporates protocols (e.g. men’s and women’s business), and brokerage – a two-way exchange of knowledge pertaining to life beliefs and wellness in order to translate meaning and

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4 | AUGUST 2019

The important difference between cultural security and other terminology is that it is an Aboriginal construct, and carries meaning for the way we want health business to be done.

Prof Juli Coffin, Ellison Professor of Aboriginal Research, Telethon Kids Institute ....................................................................

Don’t follow Canada Dear Editor, In 2016, 14,381 people requested euthanasia in The Netherlands, which has a population of 17 million people.

This is 10% of the total annual death figure.

Based on these figures, WA (population 2.6 million) can expect 2000 requests annually.

This will not happen overnight, but will be the norm in a decade. This is what happens with very liberal euthanasia laws.

The legislation proposed in the Assisted Dying Final Report means that WA will have one of the most liberal euthanasia laws in the world. It is nothing like the ‘very conservative’ Victorian Assisted Dying Law. The Expert Panel has begrudgingly agreed to a 12-month life expectancy timeline, whereas all US states and Victoria have a six-month timeline.

The former AMA WA President, Dr Omar Khorshid, is alarmed that patients with chronic diseases such as diabetes, who are “tired of living” and suffering by being “a burden” will have access to euthanasia.

There is only 30% of public opinion supporting euthanasia for these reasons.

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In a Letter to the MJA, Perth pioneer Palliative Medicine Specialist Prof Doug Bridge and colleagues stated that the Canadian experiment with assisted dying “had left doctors aghast”. “The introduction of Euthanasia in Canada has caused doubt, conflict and crisis”. The proposed WA Law will have the same flawed wording as in the Canadian Law. The advice to Legislators from Canadian doctors was simple. If you legalise euthanasia, don’t involve the medical profession. Euthanasia is not medicine, nor is it palliative care.

WA needs to spend an extra $100 million annually to provide a universal palliative care service. The Government response is to allocate an extra $10.25 million annually, claiming that funding will now be “at record levels”.

Underfunding means that only 10 medical conditions qualify for palliative care. Those denied access will be forced to choose assisted suicide. This is appalling!

References on request

Dr John Hayes, member of Palliative Care WA ....................................................................

GPs and breast screening Dear Editor, Curtin University’s School of Psychology is seeking GPs to participate in a 30-minute, oneon one, face-toface, telephone or Skype interview to understand how GPs discuss breast screening with patients.

Participants will receive a Myer or Coles voucher as a thank you for their time.

If you are interested, please email kristen.seaman@student.curtin.edu.au. The study is part of a research project to obtain a Doctor of Philosophy at Curtin University.

Curtin University Human Research Ethics Committee (HREC) has approved this study (HREC number HRE2016-0214).

Kristen Seaman, PhD candidate, Curtin University

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LETTERS TO THE EDITOR

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Molecular Pathology in Clinical Practice A Case Study by Dr Andrew Dean Peter presented in October 2017 extremely unwell, barely able to stand, describing severe pain in his bones.

From his history which was corroborated by his family he appeared to be deteriorating significantly on a daily basis. The total duration of his illness was only 10 days.

He was noted to have a left posterior triangle lymph node and the decision was made to biopsy this at 11 am on the Thursday morning of admission due to the rapidity of his deterioration.

Australian Clinical Labs were able to provide an in-room cytologist to ensure that the core biopsies contained malignant tissue. Initial staining of the imprint by one of the on-site pathologists suggested that Peter had melanoma and we were told that final confirmatory staining would be available the following day.

St John of God Subiaco Hospital is the only private hospital in Western Australia to have an on-site Next Generation Sequencer and molecular pathology department based here (all other private companies send their molecular studies to the eastern states which can take up to 21 days or more to get a result). I requested that they fast-track the BRAF status of Peter’s tumour, since if melanoma was confirmed, he would need to start treatment immediately.

PET scan carried out by our on-site PET/radiology department confirmed that he had widespread metastatic disease in virtually every bone image including every vertebra, femur, pelvis, shoulders, scapulae and humerus.

At that time, BRAF inhibitors were only available as first line treatment for melanoma and as such it was critical to know the status of the tumour by Friday afternoon as I was seriously concerned that Peter would not survive the weekend.

Sure enough by 4 pm Friday afternoon I was informed Peter’s BRAF mutation status was negative. As our oncology pharmacy is also on site, with ability to compound chemotherapy urgently, Peter started dual immune therapy that afternoon with Ipilumumab and Nivolumab.

By Monday morning, Peter had improved marginally - although what was important was that his rapid daily deterioration had halted. Three days later he was discharged home.

PET/CT scan carried out 12 weeks later demonstrated a complete response to therapy. Peter has remained in complete remission ever since.

I am convinced that without having on-site pathology and the ability to fast-track molecular pathology results, Peter would not be here today.

The close on-site relationship between Australian Clinical Labs, their on-site pathologists, St John of God Subiaco Hospital, radiology department and our oncology department really does allow us immediate access to get the quickest possible histopathology and molecular results. This type of service is not found anywhere else in Western Australia.

Initial PET scan showing metastatic disease in bones and liver

Post-treatment PET scan demonstrating response to therapy

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HAVE YOU HEARD? The Australian Dream Medical Forum published Prof Sandra Thompson and Dr Rosalie Thackrah’s think piece on culturally secure care in the July edition, on the eve of NAIDOC Week. The message promulgated during the week, led by the new Indigenous Affairs Minister Ken Wyatt was First Peoples being given the fundamental right to participate in decisions that affect their lives. Then came The Australian Dream, former AFL player Adam Goodes’ documentary that tells a wider story about race, identity and belonging. The film will unpick the events of the 2013-15 AFL seasons and ask fundamental questions about the nature of racism and discrimination in Australian society today. Walkleyaward-winning writer Stan Grant and BAFTA award-winning director Daniel Gordon join forces to bring this story to the screen. Email editor@mforum.com.au for a chance to win a double pass. It opens on August 22.

Men need reminding GPs are being urged to follow-up their male patients’ participation in the National Bowel Cancer Screening Program. Recent data from the AIHW shows that 60% of the screening kits sent out won’t be used. In the January 2016-December 2017 campaign 4.1 million people were invited to participate yet only 1.6 million responded. In a 2018 study examining the benefits, harms and cost-effectiveness of the NBCSP’s home test kit versus other potential screening approaches found that the current bowel screening program was the most effective strategy to prevent bowel cancer and bowel cancer deaths in Australia. Every patient between the ages of 50 and 74 will now receive a free screening kit in the mail.

Heart in research Lotterywest has granted $2,920,185 towards the establishment of the Kimberley Aboriginal Health Research Alliance, which will be responsible for coordinating and managing the implementation of health research projects in the Kimberley.

The Aboriginal-led alliance will focus on encouraging Aboriginal researchers while also developing Aboriginal research methodologies. The founding members of the alliance are Kimberley Aboriginal Medical Services, WA Country Health Service, Rural Clinical School of WA, University of Notre Dame Nulungu Research Centre, Telethon Kids Institute and the Aboriginal Health Council of WA.

Meth straining resources Specialist psychiatric care for methamphetamine users is lacking in WA, according to the RANZCP. This should come as no surprise for the many who have tried to access drug and alcohol services and been confronted with the barriers-to-entry into psychiatric care, which are primarily cost-based in the private sector. WA has among the highest rates of meth usage in Australia – Perth and Adelaide have the dubious reputation for cities with the highest meth consumption, while regional WA has the highest usage nationally. RANZCP said EDs were not able to offer the most

6 | AUGUST 2019

appropriate care purely due to the lack of specialised staff.

Them bones...

The AIHW has released its Disease expenditure in Australia report and the findings are vast. Total health expenditure in 2015-16 was $170.4 billion (recurrent and capital expenditure combined). This works out to be $7096 per Australian. Hospital costs amounted to $70.7b; non-hospital medical, $22.5b; pharmaceuticals, $13.9b; and dental, $9.9b. With $117b in recurrent health expenditure attributed to specific disease groups, musculoskeletal disorders were found to be the most expensive, accounting for $12.5b; with cardiovascular diseases at $10.4b; general injuries and mental and substance use disorders, $8.9b each. Falls, mostly in the elderly, cost $3.7b.

In context of the wider economy, health expenditure accounted for 10.3% of GDP.

The hospital engine And the AIHW figures keep coming, this time from the Hospital resources 2017–18: Australian hospital statistics.

Total expenditure on the 1350 hospitals in Australia was $71 billion, of these hospitals 693 were public and 657 were private. The majority of the funding, or 62%, was spent on salaries. The hospitals employed a total of 373,234 full-time equivalent staff, with 42% being nurses on an average salary of $101.6k, 12% were medical officers on an average salary of $212k, 16% were diagnostic and allied health workers on an average salary of $96.5k, administration staff made up 18% and earned an average salary of $86k, domestic and care staff made up the 12% and earned an average salary of $66.5k.

on Botox’s global earning potential. AbbVie is not without its own major drug income stream, with the rheumatoid arthritis medication adalimumab or Humira being estimated to earn $20b annually. As part of the deal, AbbVie has taken one of the largest bridging loans on record, with $38b being provided by Morgan Stanley and MUFG.

Opioid deaths in decline After three decades of ever-increasing drug overdose deaths in the US, there is finally some encouraging data. Last year overdose deaths decreased by 5% from the previous year, according to the report Provisional Drug Overdose Death Counts, by the Centers for Disease Control and Prevention. The decrease is attributed to a reduction in opioid painkiller overdoses.

Although the total overdose death figure has decreased, overdoses with fentanyl and methamphetamine continue to rise with 31.9k deaths for the former and 13k for the latter. In total 68,557 people in the US died from drug overdoses in 2018.

Elephant in the room Last month we published a report about the lack of support studies for men whose partners have suffered a miscarriage. It seems there are too many health support services for women either, according to The Pink Elephants Support Network. Of the 400 surveyed, 75% of women reported they were not offered information or leaflets about support organisations after miscarriages and 59% were not offered a referral for emotional support. With more than 100,000 reported miscarriages a year in Australia, that leaves a lot of women and their partners without support or guidance.

Botox boom

Monkey see, monkey do

Sticking with finances, pharmaceutical company AbbVie has announced it will acquire rival drug-maker Allergan for $63b in cash and stocks, with the combined annual sales of both companies being about $48b. Allergan is best known as the patent holder of onabotulinumtoxinA or Botox, with the deal being primarily based

Elon Musk’s latest tech start-up, Neuralink, says it is close to clinical trials for its brain-interface device. Essentially this is a tiny computer chip attached to miniscule, electrode-studded wires, which are connected to the brain by a robotic sewing machine in a “neural lace” pattern so as to avoid blood vessels on the brain’s surface.

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The chip is claimed to receive action potentials and process them into readable code. The applications for the Neuralink device could be vast, yet without it actually being connected to an actual human being, it is purely hypothetical. Neuralink does claim to have successfully connected the chip to rats and monkeys, and a monkey has apparently controlled a computer with its brain. Note, the company is yet to receive FDA approval for the forecasted clinical trials!

Like for Not Like Instagram, the popular image sharing social media app, is trialling a new feature in selected markets, with Australia being one of the first ‘test’ countries. Instagram now hides the number of ‘likes’ a user receives for their posts, with the rationale that it will reduce the competitive nature of posting and the associated anxiety from attributing self-worth to the number of ‘likes’ a post receives. In 2017 the Royal Society for Public Health and the Young Health Movement published the #StatusofMind report, which surveyed 1479 14-24-year-olds in the UK to understand how social media was impacting on their mental health and wellbeing. They found 91% of the 16-24-year-olds surveyed used social media. Out of the five social media

platforms, Instagram was ranked as the most negative in relation to users’ health and wellbeing, with body image, bullying FoMO (Fear of Missing Out), anxiety and depression resulting from using the app.

Perhaps big tech is taking notice and taking some action to reduce harm for some young people’s mental health.

Clear air, good mood Researchers at Flinders University have found continuous positive airway pressure (CPAP) treatment of obstructive sleep apnoea (OSA) can reduce depressive symptomology for patients with cardiovascular diseases (CVD). The research utilised data from the Sleep Apnoea Cardiovascular Endpoints (SAVE) trial at South Australia’s Flinders University, including a systematic review of 20 RCTs including 4255 participants. One of the studies’ principal investigators, Prof Doug McEvoy, said “this is by far the largest trial of its type and one of very few studies reporting such an effect. Patients who have had a stroke or heart attack are prone to suffer from low mood and are 2-3 times more likely to develop clinical depression, which then further elevates their risk of future heart attacks and strokes.”

Breathing walls The WA Department of Health has established a Climate Health WA Inquiry looking into the effect of climate change on human health in WA. Dr Revle Bangor-Jones writes in this issue for input from WA doctors to help shape policy directions in this new era. Perhaps the inquiry might look at greening WA’s many tar tracks as Sydney has done. Two of Sydney’s busiest motorways will be among the first in the world to trial new technology which helps filter air and noise.

Junglefy has partnered with Transurban and UTS to build and test live ‘breathing walls’ which promise to absorb pollution and traffic sound, and cool air temperatures. So if you are travelling to Sydney and find yourself on the Eastern Distributor or the Hills M2, open the windows and smell the fresh air.

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Former Australian Foreign Affairs Minister Julie Bishop will be the next Chair of Telethon Kids Institute. She replaces John Langoulant who is stepping down after 14 years’ service to the board.

A collaboration between UWA, Telethon Kids Institute and 13 health research organisations has identified key differences between cancers that respond to immunotherapy and those that do not. Scientist Dr Rachael Zemek completed the work as part of her PhD at UWA’s National Centre for Asbestos Related Diseases and is now based at Telethon Kids Institute. The study developed a way of analysing cancer samples before treatment and then compared the genes between responding and nonresponding cancers. Her supervisorDr Joost Lesterhuis said the team then identified drugs that could increase expression of the genes to increase the response to immunotherapy treatment.

In this month’s magazine we speak to Prof John Newnham director of Women and Infants Research Foundation and discovered how busy the team has been. Just as we were going to press, news broke that UWA Senior Research Fellow and WIRF microbiologist Dr Matthew Payne has teamed up with Australian molecular diagnostics company SpeeDx to commercialise a new low-cost test to identify women at risk of premature birth. Based on research and results of clinical trials they predict the test could reduce premature birth by up to 30%.

A study from UWA and UNSW and published in the latest MJA has shown that the number of Australians over the age of 70 taking five medicines or more a day has risen to nearly one million people. This places those people at risk of side effects, more frequent hospital admissions and falls. UWA’s Dr Amy Page, who led the study, found a 52% increase in the number of people taking five medicines or more between 2006 and 2017.

Kira Molloy, 19, a second-year computing student at Curtin University has been awarded the Peter Fillery Best Undergraduate Tertiary Student Project of the Year.

She created and coded a program for researchers to identify tumours more efficiently. Her work was conducted during an industry placement at the Harry Perkins Institute.

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INCISIONS

Joke Turns Terribly Serious Keeping a community healthy starts a long time before a medical degree can be employed. Public Health physician Dr Bret Hart explains.

Shit Life Syndrome (SLS) might have been my diagnosis had I known of it all those years ago. Instead, I am ashamed to admit, I used a term which was prevalent at the time to account for my many patients with psychosomatic symptoms; “supratentorial” i.e. it’s all in your head.

Had I used a diagnosis conceived irreverently in jest, I would have done so without realising it would ultimately be taken seriously as being potentially deadly.

The term SLS was first coined by US family physician Dr Doug Farrago in 2001 in the first issue of his Placebo Journal – the MAD magazine of medicine. Nearly a decade later, a GP in North England thought he had discovered a new syndrome describing an unemployed mother with an abusive boyfriend and a young baby to feed coming to the GP because she “…felt shit …and didn’t know what else to do.” He concluded she had low mood caused by adverse life circumstances – “…otherwise known as SLS.” Had he referred her to a mental health service, she wouldn’t have been accepted.

In 2013 (by which time SLS was part of the medical lexicon in the UK) a mental health service intake meeting decided it was inappropriate to accept patients referred with SLS. A professor of psychoanalytic psychotherapy analysed the team’s response and deduced that their empathy was comparable to that applied to their own waste products and yet “… the organization … is confronted by continual pressure from the public and from referrers to provide psychological care and treatment for these same individuals who arouse such intense anxiety and from whom its staff wish to distance themselves.”

Australia’s improving life expectancy is also slowing. In the MJA earlier this year, Lopez finds this “difficult to explain” especially as it’s occurring more than other high income countries. He says it will be difficult to further reduce mortality from ischaemic heart disease, cerebrovascular diseases, and cancer so “…future gains in life expectancy will increasingly depend on controlling other risk factors”. Is one of those risk factors SLS?

If these circumstances – which constitute the social determinants of health (SDoH) – are ‘shitty’, the patient’s health is at risk.

Arguably SLS arrived and was discovered in WA in 1990 by Professor D’Arcy Holman.

He conducted a review of Community Child Health services and discovered that staff “…felt under siege from the community demand for pastoral care, counselling and social welfare services… to render assistance to persons suffering from psychosocial morbidity (PSM).”

His definition of the latter could apply to SLS – “a state of human distress resulting from personal conflict within …an individual, and/or from an adverse social environment.” Holman indicated that the perception (but not evidence) was that “… the need and demand for human services staff to render assistance to persons suffering from PSM had greatly increased since the late 1970s…”

This is well illustrated in an award winning analysis in the Financial Times – see www.ft.com/blackpool. SLS is also blamed by political economist and Hertford College Principal Will Hutton for stopping the longstanding improvement in life expectancy in the UK and USA (and maybe Ireland).

In response, he suggested a community debate on “family, work and personal wellbeing.” It did not happen so it’s long overdue. Also none of Holman’s 172 recommendations were implemented to enhance community child health with a legacy being felt today.

Despite its derogatory connotations, a redeeming feature of SLS is that it should prompt examination of the socioeconomic circumstances in which SLS ‘patients’ were born and where they grew up, live, work and age.

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Surprisingly no one seems to have considered the impact on children of SLS despite the substantial evidence from the Adverse Childhood Experiences (ACE) studies showing that a toxic social environment has profound effects. By combining ACE with SLS you have a perfect pathogenic storm. This particularly applies to the First Nations People and helps explain the challenge in bridging the gap in life expectancy.

The Sustainable Health Review (SHR) indicated “the WA health system cannot hope to improve the SDoH on its own”. If the circumstances which constitute the SDoH lead to SLS, there is a need to respond to Hutton’s call for a “multipronged assault on SLS and the conditions that cause so many to die prematurely.” As a whole of government response is required, this is an opportunity for Premier and Cabinet to lead a taskforce to mount that “assault” and thereby realise “… a vision for the future that is shared with the community, [which…] will be key to supporting people in their pursuit of healthier, more active lives” – to quote the SHR again.

Clearly SLS is not PC. Following the concept of, for example, an obesogenic environment, how about Stressogenic Environment Syndrome (SES) as an alternative with levels of influence summarised in the diagram?

ED Medical Forum will be conducting an e-poll in the coming weeks to hear doctors’ experiences with these types of cases and what they would like to see happen.

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Bruce Speaks, Politicians Listen

I

Bruce Langoulant’s tireless advocacy for research and public health initiatives to prevent meningitis has helped myriad families from going through what his family did.

n 1989, Bruce Langoulant’s daughter Ashleigh contracted pneumococcal meningitis when she was just six months old.

“We spent the 1989/90 New Year in the intensive care unit at PMH. When we came out of there, literally, our world changed,” he told Medical Forum.

This year he was awarded an Order of Australia and was a finalist in the Community category of the WA of the Year awards as recognition of the work he has done co-founding the resource and support centre Meningitis Centre Australia and by helping similar bodies in other states to join forces in the Confederation of Meningitis Organisations. He was also chairman of the Disability Services Commission for 16 years.

Bruce has dedicated his life to making others’ less difficult, including doctors.

“For groups like ours, it is all about raising awareness and giving doctors more time.

If we can help doctors gain more time with this disease, they would at least have a chance of saving our kids.”

The advocacy work has resulted in a broadening of immunisation schedules which means that children can avoid the life-crippling effects of the disease that Ashleigh experiences today.

“Back in the late 1980s, early 1990s, meningitis was not well identified,

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particularly in the media, where it was called a ‘virus’ and then a small story to let people know a child died. Meningitis did not have a profile then but it was dangerous and it was killing kids. There was no vaccines until 1993.”

Yet, it was not just the politicians and the media that were not fully aware of meningitis, it was the medical establishment as well.

“Really, while it may have been in the medical books, there was no panacea for it, no vaccine, so what could they do?

While meningococcal and pneumococcal were dangerous, they looked like all sorts of other things and doctors often wouldn’t see a case in their careers. Not only was it dangerous and rapid acting the learned eyes didn’t have a lot of practice with it.”

As in the case of Ashleigh, her doctor wasn’t able to immediately recognise the severity of the symptoms.

“Doctors could easily say ‘take a Panadol and go home, keep an eye on your child’, while parents were nursing their kids to death, really.”

With dogged determination, Bruce was able to change the public and political narrative but the work goes on.

Lobbying politicians and bureaucrats for policy change can be a glacial process but Bruce takes it in his stride.

“It has taken 27 years and in that time we have lobbied for vaccines to be developed then to have the government fund those vaccines. It’s been a good story. We have been attached to three vaccines over the 27 years.”

“At the State Government level we have worked with Health Ministers John Day and now Roger Cook for the last three years. Good work has been done with the meningococcal ACWY vaccine being introduced for teenagers. All the other states followed.”

“And the vaccine for kids, that was through direct representation by asking how many deaths did they need before they would act. You’ve got a vaccine waiting on the shelf, what are you waiting for?”

“Vaccines are important to stop kids getting the disease, to stop kids being disabled by the disease and to take the burden off parents and the commonwealth.

To give people equal opportunities at life.

That’s what it’s about.”

By James Knox

“The awareness of the disease has changed over the years and with it the political acceptance – we just don’t go away. We do it in a nice, professional way, but advocacy needs to be persistent. I was regarded around town because I did it politely but persistently and, over time with the help of others, we are now listened to more keenly and respectfully.”

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Palliative Care in the Spotlight

Between September 10 and 13, palliative care experts from around the region will be coming to Perth for the first Oceanic Palliative Care Conference.

Dr Elissa Campbell who is a Perth geriatrician and palliative care physician, is the co-chair of the conference. She is also president of Palliative Care WA and was its representative on the expert advisory panel which reported to the state parliament on voluntary assisted dying.

She offered these comments to a series of questions posed to her by Medical Forum.

MF: The inaugural Oceanic Palliative Care Conference has a theme of Universal Access. Considering the national and regional challenges of access to all medical care, what are some of the practical ways we can improve access to Palliative Care (PC) with the resources we have on hand?

EC: We know that there is currently inequitable access to palliative care in WA and right across Australia. Unless there is significant change in the way it is funded and delivered, these inequities will continue to grow.

Access must be available to anyone with a life-limiting illness, regardless of their postcode, diagnosis, age, ethnicity, socioeconomic status or place of care, to enable them to live, and die, as well as possible.

Evidence shows benefits of specialist palliative care early in the disease course of a life-limiting illness, with patients being managed by GPs and their usual care team with specialist palliative care becoming more involved at times of need, such as disease progression or symptom relapse.

Palliative Care WA (PCWA) is keen to see some innovation in the way we deliver and fund palliative care in WA – not just

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specialist palliative care but the vital care that is provided in primary care, aged care and elsewhere. There is also a public health palliative care model called Compassionate Communities that is being championed in pockets around WA, such as the South West and Peel.

In terms of practical solutions, the National Palliative Care Strategy, which was endorsed by all Australian health ministers and released in February 2019, sets a clear pathway forward to address these inequalities. We now need to see significant government investment to implement this strategy. Locally, we have the End of Life and Palliative Care Strategy 2018-2028 along with recommendations from the Sustainable Health Review and the Joint Select Committee on End of Life Choices.

How well served is WA for PC services?

EC: We have high quality specialist palliative care services with robust data from the national Palliative Care Outcomes Collaborative to show they achieve excellent outcomes for their patients.

Some, such as Silver Chain Hospice Care Service, are the envy of other states.

However, many services are working above capacity, and access to palliative care

services is patchy across WA, including the metropolitan area. There are many hospitals across Perth with no access to specialist palliative care, and community services are stretched. Too often, people are only accessing palliative care in the last few days of life, when it is too late to be of maximum benefit.

What can we learn from countries such as Switzerland and Rwanda – from which a couple of the keynote speakers hail? What are they doing that we should be doing?

EC: The line-up of speakers at the Oceanic Palliative Care Conference in Perth this September is certainly first class – with local and international experts joining us to share their knowledge and expertise. I am particularly delighted that Dr Christian Ntizimira from Rwanda will be delivering a keynote address (Stories Behind History: Transcultural Palliative Care in consideration of global health delivery to bring human rights in the centre of positive change) that focuses on palliative care as a human rights issue. He has been at the centre of establishing and implementing a people-

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Palliative Care in the Spotlight centred model for end-of-life care in his home country of Rwanda, which ensures the dignity and humanity of patients and focuses on a home-based approach to care.

But to find out more you’ll have to join us at 19OPCC! For those who can’t attend the conference, Palliative Care WA is hosting a public event on Monday, September 9, featuring Dr Ntizimira and other keynote speakers.

How well served do you think we are in WA for PC services? The WA Government has pledged $41 million for end of life choices and palliative care. Where would PCWA like to see that investment go?

EC: PCWA welcomed the state budget announcement in May 20119 of an additional $41 million for palliative care over the next four years. This additional funding commitment is a good first step and will go some way to ensuring that all West Australians who need it have access to quality palliative care at end of life.

As previously mentioned, we would like to see some innovation in service delivery and models of care, particularly for rural WA and groups who currently are less likely to receive palliative care, and PCWA look forward to working with the government on developing these models. We also would like expansion of our existing palliative care services, which already perform very well but are often unable to meet demand.

How aware is the WA community of issues affecting end-of-life (advanced care directives, palliative care options)? How engaged is the WA

medical community in these issues?

EC: The Joint Select Committee into End of Life Choices and the Ministerial Expert Panel on Voluntary Assisted Dying both had excellent community engagement from people with firsthand experience of end-oflife issues, whether as a patient, a carer or a health professional.

However, we would like to see better awareness of palliative care and advance care planning in the broader WA community, and more people having discussions with their loved ones about their end of life wishes. There are still a lot of misconceptions about palliative care, such as that it is only for the last days or weeks of life. Many of the recommendations of the Joint Select Committee were about educating the community and health professionals, about these issues.

PCWA will be launching a public campaign to raise awareness of Advance Care Planning, supported by our CEO Roundtable members, WA Health and Lotterywest.

The critics of VAD say it is not necessary if there were adequate investment in palliative care. Do you agree with that? Could well-delivered VAD at the end of someone’s life be part of palliative care?

EC: Both opponents and proponents of voluntary assisted dying agree that we need better investment in quality palliative care. More than 16,000 West Australians die each year and more than half could

benefit from palliative care. If legalised, it is estimated that up to a few hundred people a year would access voluntary assisted dying. Quality palliative care is still required for the thousands.

PCWA’s position is that voluntary assisted dying is not part of palliative care practice, because palliative care’s intent is to neither prolong nor hasten death, as defined by the World Health Organisation.

We know that palliative care services make a real difference to the vast majority of peoples’ quality of life and provide support to their families after their death. Regardless of the legality of voluntary assisted dying, palliative care and aged care services will continue to care for the vast majority of Australians at the end of life. This needs to be resourced accordingly.

It is vital that governments across Australia ensure that their palliative care services can support all of those who require assistance, so those people have a real choice in states where voluntary assisted dying is potentially becoming legal. No one should choose to access voluntary assisted dying because they can’t access palliative care.

We know that voluntary assisted dying poses many ethical, personal and professional issues for health professionals, care workers and volunteers who are providing care to people living with a life-limiting illness. One of the plenary panel sessions at the Oceanic Palliative Care Conference will be focused on ethical challenges and their impact on palliative care.

ED: Palliative Care Australia, in consultation with its member organisations, including PCWA, released a set of guiding principles. http://palliativecare.org.au/ wp- content/uploads/dlm_uploads/2019/06/PCAGuiding-Principles-Voluntary-Assisted-Dying.pdf

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Jagged Little Pill Pill-testing at music festivals is a hot political debate but there seems to be a mood for change among the medical profession.

P

ill testing has been pushed to the fore of public debate with a series of deaths in the Eastern States earlier this year due to MDMA, or what the consumer thought was MDMA. It’s a contentious topic with opponents saying it is simply empowering illicit drug use and normalising harmful behaviour, while advocates say it is an evidencebased, harm minimisation strategy.

The ACT has been the first Australian jurisdiction to trial the service “in the interest of public health”. It has held two pill-testing trials and in both instances potentially harmful substances were identified and, in some of those cases, consumers were dissuaded from taking the drugs.

The relative success of the trials has encouraged pill testing advocates to push for a national policy so consumers can make informed choices as to the consumption of illicit substances, in particular MDMA.

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The ACT Health Minister Meegan Fitzharris is pushing to form a policy, telling the Canberra Times the program was "harm minimisation at its core”. However, the move is not without opposition with shadow legal affairs spokesperson Jeremy Hanson telling the newspaper that “MDMA is harmful, it's potentially lethal and what pill testing is doing is potentially encouraging people to take pills that have a very high quantity of MDMA."

as to its efficacy was sparse. At the same time there was an increase in its recreational usage.

There’s the debate in a nutshell. Is pill testing harm minimisation or does it encourage consumers to partake in illegal activities? The answer is not quite so reductionist.

However, the drug in clinical trials is not the same as that made by illicit manufacturers where there are no controls over purity or chemical composition with dealers known to be substituting MDMA with more dangerous substances that have a greater risk of causing harm, such as PMA (paramethoxyamphetamine) and PMMA (paramethoxymethamphetamine).

MDMA, or more specifically 3,4-methylenedioxymethamphetamine, is the base ingredient in the illicit drug Ecstasy. It was initially designed in 1912 to stop abnormal bleeding. In the late 1970s and early 1980s it was used in clinical psychiatry for the treatment of PTSD before being banned because clinical evidence

MDMA’s clinical use The medical community is now circling back to determine MDMA’s usefulness in PTSD treatment with multiple clinical trials being undertaken in the US and Australia, while its use continues to be a regular feature at music festivals and electronic music events.

Is pill testing effective?

The ACT trials would point that way yet the bulk of evidence for pill testing is not based upon these local trials. Australia is behind

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Our study suggests if someone hasn’t taken MDMA before they probably just have to be presented with the pill test results and that is sufficient for them to reduce their risk.

had used MDMA previously and those who had not.

The lead researcher, Dr Ross Hollett, explained some of the findings.

Assessing the risks

the 20 countries across the Americas, Europe and Australasia which have been offering pill testing, some of them for nearly 20 years. Australia’s closest political allies in New Zealand, UK and the US have embraced harm minimisation policies around illicit drug usage.

These programs have produced a plethora of evidence to point to the effectiveness of pill testing to minimise harm to consumers.

Pill testing is not without its supporters in Australia, particularly among the medical profession. Both the RACGP and the AMA support pill testing policy, However,

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governments and politicians are resisting the call.

Medical Forum attempted to canvas a wide range of views to gauge the sentiment of the general public, the medical profession and academics who study illicit substance use.

While WA has not undergone a pill-testing trial such as in the ACT, researchers from Edith Cowan University have conducted a study in which they gleaned a deeper insight into the mentality of illicit drug consumers.

Researchers recruited participants at a prominent WA-based music festival and split them into two cohorts – people who

“We were interested in assessing people’s risk inclinations and using their substance use history as a way of classifying those behaviours. What we found was people were pretty careful when the substance contained harmful contaminates. Both of the groups were going to reduce their risk, compared to any other potential risky behaviour. This was especially true for people who hadn’t used MDMA before.”

First-time users were found to be most inclined to utilise pill testing and to pay heed to the findings.

“Our study suggests if someone hasn’t taken MDMA before they probably just need to be presented with the pill test results to be sufficient for them to reduce their risk. For those who have used MDMA before, might need more encouragement with another strategy alongside to reduce their risk,” Dr Hollett said.

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Jagged Little Pill This further encouragement could come in the form of drug education and/or counselling that accompany pill testing facilities.

While Dr Hollett’s study was based on hypothetical scenarios, the findings were similar to those from the ACT trials, where harmful substances were identified and consumers opted to dispose of the drugs.

Despite this, policy makers are yet to be convinced.

“I think the pill test itself is not really the objective if we are looking at this from a policy and political perspective because people who are opposed to pill testing are concerned about what message it sends,” he said.

“What we need to do is reframe the whole thing as a drug assistance program.

The pill test is a means to invite people through the door and it is after that the most important part of the process happens; that’s when you engage with these substance users and talk about their likelihood to take risks and in the process educate them. This would have a deeper impact.”

One of the main criticisms of pill checking is the idea that by checking illicit substances, authorities are doing drug dealers’ jobs for them, which is why pill testing should be only one element of the interaction between testers and users.

“Anything that connotates a quality control program concerns some people. But if it was reframed as a drug assistance program, the bulk of it is about peer

counselling and education. Pill testing is really a small part of it.”

What do consumers think?

With the debate about pill testing being played out in the media between political polarities, the consumers’ perspectives tend to be forgotten in this discourse.

We spoke to a number of patrons of Perthbased festival and electronic music events, some who have taken illicit drugs, on their views on pill testing.

One 23-year-old male said he thought pill testing was a good idea.

“I would probably make use of the pill testing. If they found the MDMA was harmful, I would probably ditch it. If pill testing became more accessible, I think that would hold the drug dealers more accountable to supply a cleaner product. If you are buying a safer product, the dealer will have to continue selling a safer product.

It will keep them more accountable.”

A 30-year-old concert goer described the idea of pill testing at these events as “100% positive”.

“People are always going to take drugs at events. The best safety measure that can be taken is onsite testing.”

Another patron, a 38-year-old woman, said: “History has shown that people, with or without pill testing, will experiment with drugs at music festivals. It is inevitable, so why not make it safer. Experimenting with Ecstasy in the early 2000s at clubs and festivals, I wish I had been given better

information about the drugs I was taking. I can’t believe 20 years on and it’s still being debated. It’s a no brainer.”

A 27-year-old man offered this perspective: “Pill testing should be a compulsory part of the harm minimisation strategy set up along with first aid etc. Some of the kids who died in Sydney, did so because they took all of their drugs as they walked in [to avoid police sniffer dogs and body searches]. Busting young people as they walk into events does not change anything and only means there will be more tragedies down the track.”

Address: 11 Aberdare Road, Nedlands WA, 6009 Phone: 6457 3404 or 1800 250 223 Email: info@meningitis.org.au Website: meningitis.com.au

18 | AUGUST 2019

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wellbeing are important,” Dr O’Regan said.

“Of course, there is an additional degree of difficulty when it comes to illicit substances. The message that all doctors should be giving about using illicit substances is that their safety is absolutely unknown, so there is no way a person can take it with absolute safety. “If you are going to do it, here are things you can do to make it slightly less dangerous for you, or to reduce the harm you may experience.”

“GPs give brief advice on everything and in terms of substance use, the simple messages are – it is best to try a small amount of the drug before you take the full dose; it is best to have somebody with you that is not using the drug.”

Dr Richard O’Regan, of Next Step Drug and Alcohol Services, sees pill testing a part of a more holistic solution.

“To put it into perspective in regards to pill testing as it has been raised in the media in the past six months or so, the message that keeps coming up is one of, ‘shall we do pill testing at music festivals, and will that keep people safe?’.

This may be part of the question but it is not the full question. The full question is, ‘how can we keep people safe at music festivals?’ and pill testing is part of keeping people safe. However, there are other things

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that need to happen at music festivals, for example, ready access to drinking water, safe places to calm down and take a break, and ready access to first aid.”

Advice for GPs GPs can be placed in a difficult situation when dealing with patients who consume or intend to consume illicit drugs. Dr O’Regan has some simple advice.

“I don’t think a GP needs to be an expert in drugs to give brief advice. Being nonjudgemental, empathetic and somewhat informed, and being able to convey safety messages for the person’s health and

“In a binary system all you can say is, ‘look, don’t take drugs’. That is essentially a large part of the drugs message in Australia, ‘just don’t take drugs’. Now clearly with the tens of thousands of people who get charged with drug-related conditions in Australia, that’s just not working, so there is a need for sensible harm reduction advice.

If we are not doing that, we are doing a disservice to people.”

“A conversation is better than a judgement.

If you are talking to somebody and they are talking back to you, you’re ahead of the game.”

By James Knox The WA Health and Police Ministers’ offices were contacted for comment. No response was received before going to print.

AUGUST 2019 | 19

The Whole Nine Months It takes nine months for a baby to develop and be born. It takes a lifetime to understand how and why.

This has been Professor John Newnham’s life.

J

ohn Newnham, celebrated head of obstetrics and gynaecology at the University of WA and scientific director of the Women and Infants Research Foundation, considers himself something of an explorer. When he was a kid, it was the dream to find Lassiter’s Reef, but his eureka moment would be found deep inside a text book written in 1965 by gynaecologist Derek Llewellyn Jones.

It was reference to the fetus as ‘the passenger’ and the mother as ‘the power’ that had the young medical student thinking.

“I remember saying to the tutor, ‘are you sure it’s just a passenger, and it isn’t doing something meaningful inside there?’. ‘Nah’ was his reply. ‘When its delivered, it heads to paediatrics, end of story’.”

“My plans to become a general surgeon in the Kimberley died at that moment because I realised here was my unexplored continent and I had to study obstetrics to find it.”

“In my early days in the labour ward, I loved the moment when there was just me, the mother and her baby. I would ask

20 | AUGUST 2019

the mother if I could hold her baby and I’d look into the child’s face – each one was different. Some would be overdue and wrinkled and wizened, some were fat and bloated, some were skinny, some were small, some big. Every one of them had had their own unique experiences in the womb.”

“I looked into their eyes and asked them, ‘Where have you been?’ ‘What happened in there and what does this mean for the rest of your life?’.”

“The women thought I was a bit weird but then I’d talk to them and asked them what their journey had been like. They may have had some bleeding, high blood pressure, or their baby hadn’t grown so well, or may have grown too much, it may have arrived too early or too late. No one knew why, and more importantly no one else appeared to be interested.”

“I was hooked.”

Over the years, John has refined his professional destination, culminating in a clinical and research landmark called The Whole Nine Months, which he’s reached with the aid of decades of hard work and a group of colleagues who are as committed as him to lower the preterm birth rate.

John’s search in the early days took him

across the world. From some hair-raising experiences delivering babies in KwaZulu.

Learning outcomes? “How to use my hands very quickly.”

Then to the UK and London’s St Bartholomew’s Hospital.

“I learnt to be a gentleman doctor at Bart’s [cue cheeky Antipodean giggle]. I worked for one of the Queen’s gynaecologists and overall London was a good maturing event for me but I wanted to get on the maternal fetal medicine train, known then as perinatology because they couldn’t think of another name, but it’s grammatically wrong.”

The explorer’s map pointed to the US where a fellowship and a flock of sheep awaited.

“I headed to California to work in two hospitals – the Cedar Sinai Medical Centre, very exclusive and very expensive, and the UCLA County Hospital which was frantically busy looking after everyone else, including many undocumented Hispanics.”

But research was high on John’s mind, which is where the sheep come in.

“There were wartime Nissen huts on the UCLA research campus and they were full of sheep. At the time, all eyes were

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CLOSE-UP on fetal surgery in a hope of correcting birth defects and UWA was funding me to research this.”

“I did my doctorate on fetal sheep, as did everyone in those days. We were sheep researchers but not many of my colleagues knew how to handle a sheep. In 1982 a pregnant ewe cost $1000 and they were trying to wrestle her to the ground – it took four of them.”

“I had the good fortune of being a roustabout when I was 14 on my paternal family’s sheep farm at Boyup Brook, so I knew my way around a shearing shed and a sheep. I also knew we could do this research better back home and for a fraction of the cost.”

“The UCLA research was working out well but it became evident to me that while sheep almost never miscarry after intrauterine surgery, humans would, so our answers lay elsewhere.”

Ultrasound was the new eyes into this hidden maternal fetal world and the key to finding a solution to preterm birth – but first he had to enlist the help of a retired shearer.

Getting to know ewe “When I returned to Perth, I wanted to see if I could ultrasound a sheep and found a pregnant ewe at the Agricultural Department’s research station at Medina.

There were plenty of naysayers because it was incredibly hard to get a clear view of the uterus of a sheep, but I was determined to give it a try. So, I loaded the ultrasound machine into the back of my Datsun coupe and drove down to Medina.”

“The ag department introduced me to an ex-shearer, Neville Mahony. They thought I might need his help! He said, ‘well, doc, you stand down there at the end of a ramp (which was 1.1m high) and I’ll get the

SEVEN INTERVENTIONS TO PREVENT PRETERM BIRTH No pregnancy to be ended until about 39 weeks gestation unless there is obstetric or medical justification Measurement of the length of the cervix at all mid-pregnancy scans.

Natural vaginal progesterone 200mg each evening if cervix <25mm (TV) If cervix <10mm, consider cerclage or progesterone Vaginal progesterone if prior history of spontaneous preterm birth (or PPROM) Women who smoke should be identified and offered quitline support The KEMH Preterm Birth Prevention Clinic sheep’. Neville turned the sheep around as if he was about to start shearing and he said, there you go doc, go through the bare patch. I probed in the bare patch and lifted it as Neville said I should and I could see everything. That opened up an entire new field of research.”

His dream of discovering how to lower the rate of preterm births in his beloved home state inched closer.

But there was a missing link – after 30 years and nearly 400 publications worth of preterm birth prevention studies, so many were negative.

“But I kept looking. I wondered if I needed to package this project bigger and better. I was at a lunch at the university sitting next to a woman who was senior adviser to the Minister for Health. I told her about my idea of a WA preterm prevention package. She looked at me and said, ‘well I hope you have more than tobacco and folate’. She rolled her eyes and talked to the person next to her.”

“That was a defining moment because I realised that I couldn’t launch this thing unless I had pretty good evidence it would work. In 2013, while sitting at a conference in the US, I listened to the release of data by a person I respect enormously. He

had the results of a big US trial that gave progesterone tablets vaginally to women with short cervixes mid-pregnancy to lower preterm birth.”

“Extraordinarily, they couldn’t introduce it across their population because they couldn’t ultrasound everybody at 19 weeks pregnancy. They made the discovery but they couldn’t implement it. At that moment I realised we had the package.”

“I came back to Perth and sat at that desk and wrote the plan. Seven interventions to introduce the measurements of the cervix at all mid-pregnancy scans in WA. That was a key component. Establishing a system where women with short cervixes would get progesterone that night – THAT night, not the next day, but that night.”

Answers at last “It would take expertise, because transvaginal ultrasound is required and extra training is necessary, but it was doable. That was two of the seven interventions, but they were the key ones because they would take the most work.”

“I went to then Minister of Health Kim Hames and Director General of Health Bryant Stokes calling for a clinic for these complicated cases and, they in turn, demanded a business plan. So, I came back to the hospital, sat down with the chief accountant and wrote a plan.”

“We could fund such a service by preventing two early preterm births a year.

In the first year we prevented 47 early preterm births.”

The rush was on to take this program to the rest of the state, and that outreach was funded by Malcolm and Tonya McCusker who on the basis of a 15-second conversation said, the cheque’s in the mail.

“They trusted us,” John said. “I did a whole lap of WA with Michelle Pedretti, KEMH’s chief sonographer, a junior obstetrician called Suzanne Meharry, and one of our midwives. We are now in the middle of another statewide outreach tour.”

The challenge now is to maintain the progress against a rising preterm birth rate, which John believes is due partly to doctors delivering babies from low-risk pregnancies too soon.

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CLOSE-UP Most of them turned out to be teachers. So I started talking about this research. I asked them did they know the age at birth and the birthweight of anyone in their classes, because we need to know these things.”

continued from Page 21

The Whole Nine Months “Babies are not mature until 39 weeks. We have been misled by our predecessors into thinking that term is 37 weeks. It certainly is not. The re-education has been effective in this hospital. We have lowered the singleton preterm birth rate by 20% and have kept it down, but we are losing the battle elsewhere.”

“We have shown we can lower this rate.

We are the first geographical region in the world to lower preterm birth down to the early gestational ages but it’s not a onceoff program. It’s continuous and we have to expand it.”

So, what does a mere two weeks matter for the baby (and its family) – it has 10 fingers and 10 toes and lungs that function?

want to deliver her today? A yes means you have a small chance to prevent a stillbirth.

What do you gain by waiting?”

“This research shows the development of the baby’s brain in that two weeks can have enormous impact on the future life of that child. If we look at a school of 500 kids who had all been electively delivered at 37 weeks, what do we see?”

“Well, we would have saved one stillbirth, but in each class of 30 there will be two children with an externalising behavioural disorder. Across every two classes there will be one child with need for special educational assistance and across every three classes there will be two children with a basic numeracy problem.”

The art of waiting

“This research may hold the key, at least in part, why our schools are overburden with behavioural problems and I don’t understand why people aren’t banging on my door saying you’ve got to do something about this.”

“You’re an obstetrician sitting with a woman at 37 weeks of a low-risk pregnancy contemplating delivering her today or in two weeks’ time. Why do you

“I was asked to speak at a fun initiative called a Pint of Science at a Northbridge pub recently. With pint in hand, I asked the audience of about 30, who are you all?

Recent research led by WIRF’s Dr Scott White has the potential to answer that question with explosive impact.

John explains:

“Of course, there are many potential medical and pregnancy complications where an early birth by induction of labour or Caesarean section is necessary and may save lives, no one is disputing that.

But for all other times, it’s vital to go the whole nine months.”

John’s work and the work of the team has sent ripples through the establishment but none more satisfying for John, who is a cautious about praise, singles out a report in the prestigious American Journal of Obstetrics and Gynaecology as a moment of pride.

“Some things in my life have meant a lot to me. When I was in US, people didn’t know the difference between Sydney and Australia and wondered that I could speak English. I have always wished to show how WA can show the world.”

“After that first year of the preterm prevention, the American Journal of Obstetrics and Gynaecology made it a report of major impact. They thought the initiative was of global importance and it came from a place few had heard of – WA. That was important to me.”

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FEATURE BACK TO CONTENTS

The Weigh We Are Medical Forum asks a GP, a paediatric dietitian, a public health advocate, and a researcher to share their work and views on tackling the obesity epidemic.

I

n the 1990s, 21% of Australian children were recorded as overweight or obese. In 2014-15 that percentage had grown to 27%; one in five children aged between two and four were considered overweight or obese.

Figures for the adult population show 63% of adults in 2015 were considered overweight or obese and that’s earned Australia the ignominy of being the fifth heaviest nation in the OECD. But it is the escalating rates of childhood obesity that is concerning health practitioners and policy makers. A nation of unhealthy children can only lead to a future so overburdened with chronic disease, the health ship will sink.

But unlike other public health crises such as tobacco and to a lesser extent alcohol, tackling the problem of obesity seems to be hamstrung by political, social and cultural prevarication, and at times downright fear of causing unintentional harm.

Obesity is complex – just take a look at Prof Tim Olds’ essay in The Conversation on the decision by sports goods manufacturer Nike’s decision to add a size 32 mannequin into its London store to advertise its active clothing range.

“One side argues that the mannequin normalises obesity and leads obese people to feel that they are healthy when in fact they are not. The other side argues the representations are inclusive, combat fat stigma and encourage fat women to exercise. Both arguments have some merit.”

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As society normalises obesity, the worry is that parents misjudge their children’s weight status which leads to a greater worry.

As Prof Olds puts it, “once you’re on the obesity train it’s hard to get off”. ....................................................................

Dr Lucy Gilkes, GP Lucy is an experienced GP who along with her clinical work, helps UWA medical students learn the art of talking to patients about tricky subjects, and there are few trickier than talking to parents and/or children about obesity.

“Luckily, in general practice, we know our patients and they know us. They have chosen us over other people, so they must like the way we do things. A lot of GPs look for opportunities in a consultation for preventative health.”

“It’s easier in infancy where in that first year of life a doctor commonly weighs children while mapping developmental milestones and growth against a norm. Everyone is keen for them to grow. It’s much harder with an older child if we are looking at obesity.

We just don’t do that as well, I think largely because we are aware of the stigma for the child and the parents’ guilt to have an overweight child, and commonly, they are overweight themselves. So you have to tread warily.”

“It’s not as simple as putting someone on the scales as you did when they were infants.”

Diagnosis is not straightforward, clinicians cannot rely on their visual appraisal only.

A Flinders University study published in 2006 studied GPs’ and paediatricians’ ability to correctly identify children as overweight or obese by visual cues alone; to describe the current management practices of overweight and obese children and compare these with NHMRC Clinical Practice Guidelines.

The authors concluded that doctors were missing opportunities to screen children for overweight and obesity during their everyday practice.

According to NHMRC guidelines, “Body mass index (BMI) should be calculated.

However, for children and adolescents, BMI is not a fixed measure. It varies as body composition changes with normal growth and stage of puberty. It also differs between males and females. Interpretation of BMI values in children and adolescents aged 2-18 years should be based on sex-specific BMI percentile charts.”

Unfortunately these charts are not available on some GP desktop software which makes diagnosis more challenging.

While the Perth Children’s Hospital runs the Healthy Weight Service for children and adolescents with severe and complicated obesity, Lucy said GPs had limited access for many of their patients to outside help.

“It would be nice to think I could send every

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FEATURE overweight child to a dietitian but allied health without a rebate is quite expensive for most families so a lot of it does fall to the GP,” she said “A lot of the focus for the GP is around behaviours and how you bring that into the consultation. Like any tricky conversation, doctors need to seek permission to go there. Raising it with a question if they have health concerns around their weight, or ask ‘could I talk to you about your child’s weight?” If they don’t want to talk on that occasion, it’s important to back off and say it can be discussed at another consultation.”

“It’s important to clarify to the parents what your concerns are, with or without the child in the room.”

“You can raise strategies with them about increasing activity, walking to school, eating regulated meals, limit snacking and sitting down together to eat rather than while watching TV or at the computer. And reminds parents that food isn’t a great reward.”

“There’s anxiety for parents as well in these circumstances. They need guidance too.” ....................................................................

A/Prof Rae-Chi Huang, paediatrician/researcher Telethon Kids Institute Rae-Chi is part of the Origins Study and lead researcher in its Pregnancy Lifestyle Activity and Nutrition (PLAN) project, which is testing whether a lifestyle intervention in early pregnancy reduces offspring adiposity.

“Early intervention, early prevention, is extremely important. To change the trajectory of a child’s entire lifetime of obesity and obesity-related disease, we have been looking at the early life influences that affect a child’s risk – healthy lifestyles during pregnancy, pre-pregnancy BMI,

excessive gestational weight gain, maternal nutrition during pregnancy, maternal stress, breast feeding.”

“We want to determine and understand what those early precursors are and how to alter them to break that intergenerational cycle of obesity – so maternal obesity, excessive gestational weight gain, leading to fetal programming and childhood obesity trajectories.”

“There have been robust population studies in multiple cohorts around the world, including here in WA in the Raine Study, that have observed an independent effect of pre-pregnancy BMI, maternal obesity, and excessive gestational weight gain with an increased risk of childhood metabolic disease.

Rae-Chi said epigenetics was the next frontier, to study if some of these early life environmental influences can alter epigenetics. Epigenetics might be the molecular mediator, for increasing risks in the child.

“We know that about 30-40% of women enter pregnancy being overweight or obese; excessive gestational weight gain; smoking during pregnancy; the duration of breast feeding; environmental pollutants - there’s a whole stack of risk factors for increasing risk of future childhood obesity.”

“We’ve been piloting a study looking at optimising women’s lifestyle and gestational weight gain in an attempt to maximise the downstream positive effects. Our research focus is lowering the risk of a child developing obesity.”

A website app has been developed to give women feedback on their weight gain and offers some education on nutrition, physical activity, and mental health through pregnancy. It also helps with goal setting.

The target gestational weight gain uses the IoM guidelines based on a woman’s prepregnancy BMI which forms the basis of a personalised weight tracker.

Participants are responding positively to the intervention.

“All of the women we asked bar one would recommend the app to a friend. They said things like they felt cared for through the pregnancy, it was nice to feel supported, so I think overall people are pretty keen to do the best they can in terms of lifestyle through pregnancy. It’s a period of high motivation,” Rae-Chi said.

The pilot study involved 57 women but the next phase is to embed the intervention for all 4000 births a year at Joondalup, kicking off in October. ....................................................................

Dr Melissa Stoneham Director, Public Health Advocacy Institute WA (PHAIWA) Melissa has over 25 years’ experience in the fields of public and environmental health and has seen campaigns such as tobacco change public health. Obesity is the next frontier.

At the pointy public health end of the obesity struggle, it’s a many-headed beast that faces groups such as PHAIWA. It’s not just encouraging greater consumer food literacy and health knowledge. It’s also combating stigma, shame, corporate cynicism and political caution. It all adds up to a complex, highly charged environment in which to make positive contributions.

Melissa admits that unlike tobacco, obesity has the advocacy sector working hard to prioritise their campaigns.

“If the Health Minister asks what PHAIWA’s top government asks for alcohol and tobacco, I can tell him. It’s not that easy for obesity, so we ran a workshop recently to establish some targets. It’s such a complex area. It’s not just food but physical activity, the narrative is different in metro to rural; people’s relationship with food is individual; then there’s planning policy development.”

“There is no one single thought but things we want to government to deal with.”

“We know that nearly 80% of our population don’t eat enough fruit and veg. We’d like to see a focus on that. Now that sounds so easy, but it’s far from it. Even I don’t eat five serves a day and I know I should.”

“Our economy and our lifestyles make it harder to eat healthily. We often don’t have time to cook nor do we teach our kids to cook. We don’t run down to the corner store each day for fresh supplies. We rush to the supermarket and grab.”

continued on Page 27

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FEATURE continued from Page 25

The Weigh We Are “At this brainstorm, we talk about food labelling specifically. The government has its policy on health star ratings, which I think, while imperfect, is quite a good model, but not everyone in the advocacy sector agrees.

General food labelling is complicated and requires some literacy and no one has the time to stand in the aisle looking at labels and making decisions.”

“We need to have a labelling system that’s understood.”

“We also want the government to make a significant impact on two hugely important obstacles to healthy eating – the price and access to fast food.”

“Price, access and marketing are the three things that influence people to buy. We would like the government to focus on this and we need to create a groundswell of public opinion to push action along.”

Unpicking those three things – essentially, public health advocates say the price of fast food is too low, fast food restaurants open in new developments before public amenities and big food companies target vulnerable populations with marketing and sponsorship.

“We try to make the public understand the tactics the fast food industry uses to encourage people to eat the unhealthy foods that encourage obesity. We know that these big fast food companies site their restaurants in socio-economic areas where its price point and accessibility is hard to resist. It is too easy for people to access unhealthy food.”

“Advocates have also been looking at sponsorship of sport by fast food and soft drink companies. We know that 60-70% of kids who play sport can recall the sponsors of their favourite team and that normalises fast food and sugary drinks go hand in hand with sport.”

“McDonalds doesn’t sponsor Little Athletics anymore because Healthway has bought that sponsorship out. But it is a good example that not that long ago kids would

run a race with a McDonalds bib and then get a McDonalds voucher for winning. So linking unhealthy fast food with healthy activity was insidious.”

“Big Food wants to encourage kids to think that by supporting their sport or school, they are being great corporate citizens because they want kids to be lifelong customers. But its core business is selling junk food and they’re doing a great job of it.”

Melissa says the public health advocacy sector will be lobbying for changes to planning policy, which will mean working with government across all agencies.

It is about definition, she said. Current planning policy did not define fast food restaurants any differently to the way they would define a five-star restaurant, so under current planning schemes there was no room for planners to judge an application on merit.

But the winds of change are blowing. Local government now has to have a public health plan that aligns with the state public health plan. “That plan says obesity is a problem and councils are having to address these things,” Melissa said. ....................................................................

Eat meals together when possible Include vegetables in most meals and snacks Model the eating and activity you want your child to learn Limit grazing between planned meals and snacks Sit down to eat without distraction a one-off measure in children, plot height, weight and BMI on growth charts. Ideally you need at least three measures of weight over time to make an accurate assessment of a child’s growth.

Some children are naturally bigger than others and that is absolutely normal (we never aim for the child to be on the 50th percentile for anything). Consider if their weight has been tracking along a percentile, regardless of whether it is a high or low. If it crosses percentiles in an upward direction, raise concerns with the parents.

Parents may feel upset or ashamed if their child is labelled as ‘overweight’ and this may stop them seeking further help. Instead of using the terms fat, chubby, overweight or obese (most parents tune out or get angry), I like to say ‘he is above his healthiest weight’ or ‘his weight gain over time exceeds what I’d expect for his body’.

Kyla specialises in fussy eating, childhood weight concerns and paediatric nutrition. She talks about weight with children and their parents every day and has found these useful tips when discussing this sensitive subject.

Diets are never the answer for kids and restricting portion sizes doesn’t work (in fact it makes kids more obsessive about food).

Instead, encourage parents to have set meal and snack times for children and stop any grazing between meals.

Measurement Children don’t often ‘look’ overweight until they’re really above a healthy weight, so height and weight checks as a standard part of any assessment are important.

However, don’t mention a child’s weight in front of them or similarly discuss their results. Remembering that BMI is a population measure and not appropriate as

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NEWS & VIEWS

Asking Kids About Hospital Care

C

hild-centred-care is fundamental to providing appropriate care in paediatric hospitals, but is the care actually child-centred? Researcher Dr Mandie Foster and colleagues set out to explore this question by asking the children themselves.

The research, which is first of its kind and was conducted across children’s hospitals in Perth and in New Zealand, uses a selfreporting 16-item questionnaire, from which an assessment tool has been developed so children can communicate about the care they receive and their experience as a patient. In the past, patient surveys were answered by parents and children may have felt uncomfortable asking staff themselves.

“Up until now there hasn’t been a tool available that children can score their psycho-social-physical needs and a way to determine if those needs are actually being met.”

The researchers identified children’s most important needs: • “To know I am safe and will be looked after.”

• “To get enough sleep at night.”

• “That staff listen to me.”

• “To have places my parents can go for food and drinks.”

• “To have my mum, dad or family help care for me.”

Ultimately, the tool isn’t about children guiding clinicians to the care they receive, rather how the care is delivered and how

the child perceives their experience.

“What we as providers of health care perceive as important may be very different to what children perceive, and if we are not asking questions, then we are doing an injustice to children and we don’t really know if we are meeting their needs.”

“From a child’s perspective, feeling safe is not lots of treats and presents. They just wanted time with their family present to get better.”

ED Australian College of Children and Young People’s Nurses is holding a Master Class for the International Network for Child and Family Centred Care at the Perth Children’s Hospital, October 24, 2.30pm-5.30pm.

Hospitals can be intimidating places for children and often the service provided to them is based upon what the clinicians deem appropriate, but this does not always relate to what the child needs to give them security.

In situations such as this, the tool can provide better patient outcomes, according to Mandie.

“The tool empowers children and gives them a voice both as consumers and recipients of health care. A lot of children’s needs are circumvented by parents and staff acting as proxies because they want to protect the child leaving their perspectives unheard.”

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Looking Out for the Most Vulnerable Securing the health and wellbeing of the community starts with protecting the youngest and most vulnerable, says the man charged with looking out for them.

Commissioner Colin Pettit and students from Girrawheen SHS

C

hildren and young people represent a quarter of the population in WA, yet there is little in the way of government policy based on the best outcomes for this cohort. There is, however, the Commissioner for Children and Young People (CCYP), an independent office that has a remit to act in the interests of anyone in the state up to the age of 18, especially the most vulnerable.

Medical Forum spoke with CCYP’s Commissioner Colin Pettit to discuss the Improving the Odds report which focuses on raising the issues these children are increasingly facing.

The report was born out of a succession of events in 2018, the Vulnerability Speaker Series, which featured international experts, politicians, heads of departments and business leaders with the objective of “finding solutions, rather than pointing fingers”.

“There are a range of indicators in our society showing young people face a higher rate of vulnerability than they have in the past, so we wanted to see what was causing this and what we could do to address it,” Colin said.

Not least of them the sobering statistics that show suicide is the leading cause of death for 13- and 17-year old’s; LGBTI young people are six times more likely to attempt suicide than their peers; and Aboriginal children are 10 times more likely to commit

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that children and young people are not being forgotten when policies, programs and funding is being run out. WA needs this too,” he said.

The CCYP is independent from the government and Colin said his role was to have as many conversations and consultations with young people to get a sense of where they are in life in order to represent their views to government and the wider community.

“It is a challenge but it is a privilege to actually do it because children and young people need a voice,” he said.

Colin with students from Newman SHS

suicide than non-Aboriginal children.

“A number of the recommendations relate directly to how government can make a difference but it is broader than that. The whole community needs to be part of solutions that are led by government.”

The report offers five recommendations: • Establishment of a whole-of-government Child Wellbeing Strategy for WA • Develop and implement a Child Impact Assessment tool for legislation and government policies • Develop, implement and resource a model of independent oversight of services proving support to children and young people • Enable Aboriginal-led solutions • Investigate and resource models to build community capacity to support children and young people’s wellbeing.

The first of the findings highlights the fact that WA does not have a unified child

wellbeing strategy in many of its various governmental departments, which is something the commissioner is intent on changing.

“Such a strategy needs to be resourced, consultative and implemented in a way that acknowledges the importance of children’s development and how we as a society need to help that development so all children can benefit.”

“However, we first need a child impact assessment tool to be used by government and non-government agencies and actually applied to any program or policy they are developing to determine how it will impact on children, if at all, and if it does then we need to see a really good outcome for children.”

Colin said there some government agencies have a tool but its use is not consistent.

“We are noticing countries like New Zealand are applying these sort of tools to ensure

The CCYP unequivocally takes a childcentred approach to crafting policy, which resonates among the children and youth the office consults with.

“Most young people just want to be treated like everyone else and have people who genuinely care about them and engage with them in a respectful way and that’s what our office tries to do on a day-to-day basis.”

Currently the Commissioner’s office is working on a survey on the health and wellbeing of WA children and young people in coordination with the Telethon Kids Institute involving 4500 randomly selected children across the state aged between eight and 18.

“We are sure that it will not only provide really strong conversations across our community but will probably challenge current thinking,” Colin said.

“The big message here is that the vast majority of our children are in a pretty good place but there are growing numbers of kids who are missing out in certain ways and some of the data is quite challenging when you see that.”

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NEWS & VIEWS

Redefining Autism Research published by Telethon Kids Institute seeks to put a halt to damaging labels when it comes to people with autism.

T

he term ‘high functioning’ is frequently used in autism research and diagnosis, yet researcher Dr Gail Alvares has a different story.

The Telethon Kids Institute researcher has recently published a paper debunking the term and the expectations it carries.

“It is not an official diagnostic term but we often use it in clinical research papers and also in everyday language when we talk about autism,” she told Medical Forum.

Dr Alvares and her colleagues analysed The Autism Register, a unique resource to WA, and found a relationship between an intelligence quotient (IQ) above 70 and the term high functioning, which suggested a simplified view of an individual’s functionality purely based on IQ. Initially the term high functioning was used by researchers in the 1980s to categorise an individual if their IQ was above 70, and the term has come to misrepresent these individuals, she said.

“The label high functioning has been used to deny people services and access to funding. The expectation is, if you have a cognitive ability, then you do not have functional disabilities and therefore you might not need support from insurance companies or government funding,” she said.

“What this research says is, that is not correct, and by continuing to use this term we are potentially disadvantaging people who get this label applied to them.”

“GPs are absolutely the first port of call for any person concerned about their child’s development. So it is absolutely essential that they have the right information when they are referring someone for a diagnosis.”

By James Knox

“It implies, if you are doing a cognitive assessment on an individual, an assumption that their functional level is adequate when actually their IQ score is not a good predictor of their functioning scores.”

“We see functioning scores that are quite low, relative to what their IQ would suggest. Research is showing us how inaccurate this label is and how we really need to be using better language when we talk about autism and start to think about not using this term at all.”

From a diagnostic perspective the most accurate terminology is already available in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5).

“You can diagnose someone with autism spectrum disorder with or without and intellectual impairment, so we already have the appropriate language to do that,” she said.

“Using the DSM-5 for terminology is not only more accurate but also more representative of individual needs and differences. Maybe we should be looking at just saying someone has the diagnosis of autism, not assuming what their functional level is.”

The labels high or low functioning also infer a stability in functional levels without considering changes over time.

“People who may have been called lower functioning as children may now be labelled high functioning as adults. That labelling does not really capture the fact that people’s functional abilities change over time as they get more or less support, or as they age and developmental changes occur.”

For Dr Alvares, the best outcome of this research is for it to demystify the diagnostic language surrounding autism and guide academics and clinicians to use the most appropriate terminology to avoid stigmatisation and discrimination of the autistic community.

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Dr Alvares said the labelling had negative economic consequences as well.

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It’s Also a Boy Thing An increasing number of young men are being burdened by the weight of unrealistic body expectations, says health advocate Dr Kieran Kennedy.

Body image is a topic increasingly on the mind of the modern man and it’s weighing them down with increasing force. Concerns about appearance and how things look on the outside have always been around but recent research shows that for young men today, pressures to adhere to new norms abound not only for what it means to be a man, but for what it means to look like one.

Body image is not just appearance, but the importance we place on that appearance and how it interacts with our sense of identity, worthiness and wellbeing. It’s a complex construct and is made up of more than what we see in the mirror.

An increasing number of young men are uneasy about what they see looking back at them in the mirror, and surveys often outline significant proportions of men feel unhappy about an aspect of their body.

Concerns around musculature and body

shape lead the way when it comes to that dissatisfaction. Concern around the chest, arms, shoulders and waist often ride high in studies of male body image issues, alongside a general wish to have a higher muscled, lower body fat physique.

subtype of the DSM V’s Body Dysmorphic Disorder, outlines a growing trend for men to experience psychological distress, impairments in daily life and increasing physical risk to achieve a high muscle mass and low body fat frame.

One study found that on average university-age men felt they needed to be 11kg more muscular and 3.5kg lower in body fat to have their ideal body. Disturbing comparisons show that the body types of action figures marketed to young boys have drastically changed in recent decades too. The Batman of today heralds a set of shoulder, arm and waist ratios physically impossible in human form. Earlier and earlier, our young men are told from the world around them that to be a super hero means to look like one.

This by no mean demonises a healthy focus on fitness or pride in appearance.

As with everything, if it’s bringing more negative than positive overall. or causing distress or impairment. then it can be a sign there’s time for a change.

At its most severe end, body image disturbance in men is leading to increasing rates of male anorexia, binge eating disorder and other disorders of weight and eating. ‘Muscle Dysmorphia’, a

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As with much of men’s mental health and wellbeing, our first move lies in speaking up. Growing research and clinical awareness for the impact body image plays in a man’s identity and mental health continue, and it’s vital that traditional views of body image as only being relevant to women’s mental health start to fall.

ED: Kieran Kennedy is a Psychiatry Resident and a health and wellness advocate.

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When Kids are not Kids Anymore Transitioning from children’s health services to adult health services can be a scary time for children and their families, says Dr Rachel Collins.

LANGUAGE ACQUISITION – THE IMPORTANCE OF TWO EARS

Transition is the process of helping young people and their families to plan and prepare for transfer from paediatric to adult health services.

The ideal timing is still under debate. It is generally agreed that transition should be completed by the time the young person is 18 years of age. However, there are exceptions and it is essential that transfer to adult services only occurs when the young person and their family are ready, referral pathways have been defined, referrals have been made and the paediatric and adult clinicians caring for the patient agree that transfer is appropriate.

The role of general practitioners in transition is crucial and it is strongly recommended that patients are known to a GP before transfer.

Transition has been recognised as an important issue for many years. There has been significant research into the impact of transition on long-term health engagement and it is known that poor transition can lead to adverse health outcomes.

Internationally and throughout Australia successful formalised transition processes, such as the TRAPEZE program in NSW, have been established to provide support and education for patients and their families. These programs provide online resources and links to community services as well as streamlining referral processes and utilising the skills of transition co-ordinators to ensure that patients are referred to appropriate services and supported throughout their transition.

In WA the need to improve transition services has been recognised for years and much important work has been done in this area such the development of the WA Chronic Diseases Transition Framework 2009, however, WA does not currently have a service comparable to TRAPEZE. In 2018, following the launch of the WA Youth Health Policy, PAPAYAS (Planning and Promoting Adolescent and Young Adult Services) was established.

PAPAYAS began as a collaborative education project between Perth Children’s Hospital and Sir Charles Gairdner Hospital. Successful education events across both sites highlighted the interest in transition in WA and emphasised the need to develop and formalise these processes. It has now become a successful collaborative program with a large number of enthusiastic members from paediatric and adult health services.

PAPAYAS is working closely with the WA Youth Health Network to develop a comprehensive, innovative and effective transition process for WA. This process will be developed in close collaboration with young people as well as paediatric and adult health care providers and with primary health care and community services.

It is the responsibility of all health care professionals to identify young people who will require continued care into adulthood, and to begin transition planning with them from the age of 12-13. Raising the topic of transition early gives the young person and their family an opportunity to prepare for moving to adult services and allows them to feel supported through this process.

ED Dr Rachel Collins is a consultant paediatrician at Perth Children’s Hospital.

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Anne Gardner

Andre Wedekind

Post Dip. Aud., BSc

M.Clin.Aud., BHSc (Physiotherapy)

Language acquisition occurs within a critical period in the early years of life and requires hearing and practise to develop.

Most infants begin producing speech-like sounds (babbling) at around 7 months of age, but congenitally deaf infants show deficits in early vocalisations and fail to develop language if not provided with an early alternative (hearing aids, cochlear implants and/or sign language). If provided with an alternative by approximately 6 months of age and before 12months of age then congenitally deaf infants begin to ‘babble’ and soon catch up to their normal hearing peers. Children who have acquired speech but lose their hearing before puberty suffer a substantial decline in spoken language, which is thought to be due to the absence of an effective auditory feedback loop (the ability to hear, monitor and adjust their own speech).

The effects of congenital unilateral deafness cannot be underestimated as studies have shown they demonstrate delays in speech and language comprehension as well as the likelihood of academic difficulty compared to normal hearing peers. Unilateral hearing requires an increased effort to understand speech in noisy environments. Children with unilateral deafness are more likely to demonstrate attention fatigue, behaviour problems and academic weakness compared to bilaterally hearing peers.

Neonatal hearing screening is very effective in identifying congenital hearing loss in newborns. Genetics is thought to be responsible for 50-60% of children with a hearing loss, with about 20% of those having a ‘syndrome’ (Down syndrome, Usher’s syndrome). For around 30% of babies with hearing loss, damage is caused by infections during pregnancy or complication at birth.

Fourteen per cent of those exposed to CMV develop a sensorineural hearing loss of some degree.

For young children and infants under 3 years of age, typical in-office hearing screening methods have poor reliability and may miss children with a unilateral loss, therefore referral to a paediatric audiologist is necessary. All children with an identified risk factor for hearing loss should be monitored closely.

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

AUGUST 2019 | 35

Western Radiology offers a wide range of intervention procedures, including many that are normally performed exclusively in hospital. Procedures are performed daily at all branches by a team of highly-trained, experienced radiologists.

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With branches north and south of the river, Western Radiology provides Advanced Diagnostic Imaging & Interventions in your community.

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www.wradi.com.au 36 | AUGUST 2019

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WA’s Climate Health Inquiry How will our health system cope with significant climate change? The inquiry’s public health adviser Dr Revle Bangor-Jones urges doctors to participate in finding answers.

Hippocrates once wisely said: “Whoever would study medicine aright must learn of the following subjects. First, he must consider the effect of the season of the year and the differences between them.

Secondly, he must study the warm and the cold winds, both those which are in common to every country and those which are peculiar to a particular locality. Lastly, the effect of water on the health must not be forgotten”.

improvement. The inquiry will address both mitigation and adaptation.

While it is not my intention to explore in depth the science of climate change, I do want to encourage you, as health professionals and leaders, to contribute to the Climate Health WA Inquiry.

As health professionals, we have characteristics that make us critical players in the response to climate change.

The effect of climate change on human health extends well beyond heat stress.

The figure below summarises these effects, with the direct effects shown moving from top to bottom, and the indirect effects of environmental, institutional, social, and behavioural factors shown moving through the boxes on the sides.

On March 31, 2019, the Minister for Health announced the establishment of a statutory inquiry into the impacts of climate change on health in Western Australia. The inquiry is reviewing the health system’s capacity to respond to the effects of climate change and will make recommendations for

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The final report is due for release in March 2020. The public submission process opened on June 26 and will continue until the end of August. There will also be a number of public information sessions in both metropolitan and regional areas, followed by a series of formal public hearings.

We are trusted by the community; we are opinion leaders; we are widely distributed and connected; we have a major role in promotion and prevention in health; we may be the first to identify disease; and we are often among the first responders in a disaster.

We a perfectly positioned to: monitor health conditions that may relate to climate change; influence individual practices for mitigation and/or adaptation; drive community resilience; influence government policy; and be advocates for change.

Health services in Australia are responsible for 4-8% of all emissions. While the bulk of this can be attributed to public and private hospitals, there is still much that can be done in all health facilities, including primary care, mental health and community health, to reduce both emissions and waste.

There is evidence that climate change is changing the way health professionals practise. We are more attuned to monitor possible climate-linked conditions such as vector-borne disease, reducing carbon emissions and waste, and responsible prescribing.

The Climate Health WA Inquiry recognises the key role health professionals play in ensuring the health of the community.

We look forward to hearing from you and would especially welcome hearing of any exemplars of sustainable practice that you may have implemented.

Information about the inquiry including the Terms of Reference and submission protocols can be found at health.wa.gov. au/climatehealthwa ED The Climate Health WA Inquiry is being led by Adj/Prof Tarun Weeramanthri, the state’s former Chief Health Officer.

AUGUST 2019 | 37

Developing resilience in children

By Dr Mandie Shean, Psychologist & Lecturer, ECU Everyone wants their child to be more resilient. A resilient child is one that can face the challenges of life and be successful. Resilience is formed through the experience of manageable challenges, the development of skills/knowledge, and self-worth.

Children need to know what steps they can take to overcome, but they also need to believe their life has value and is worth investing in.

Resilience is not about living a perfect life. It is about facing challenges, working through them, and not giving up. Children persevere because they have the skills and knowledge but also because they believe “I am worth it”.

Manageable challenges Manageable challenges are tasks that test us but do not threaten our wellbeing.

At times, in an effort to support children, parents remove these challenges in attempt to make their life better. While this is well intentioned, it can teach the child they are not competent to deal with challenges and consequently become overly reliant on adults to solve their problems.

It’s important to allow children to work through some challenges so they learn that they are capable and they can rely on themselves.

Self-worth Self-worth is the belief that my life has value, regardless of what I do, my achievements, how I look, or what I own.

When one believes their life is worth something, they take positive steps to improve their life.

When people’s worth becomes tied to the wrong things (e.g. how well I did in a test, how many likes I get on Instagram), it becomes vulnerable. Teach your child that those things are fun and/or important, but they are not the most important. Ensure they have real relationships and engage in life to develop their self-worth.

most important thing you can do in a relationship is provide unconditional acceptance. This does not mean you accept poor behaviour, it means you accept the person. This stable love and acceptance provides children with a secure base. When challenges arise they know they have your love, regardless of what is going on.

• Fair boundaries show children they have worth. People protect things that are valuable. Some parents focus on loving their child without boundaries.

However, providing clear boundaries is also love. One of the reasons people do not set boundaries is because they do not want to upset their child. As adults we need to be able to handle their negative response and do what is right for the child. Setting clear boundaries and monitoring these helps children to feel secure and loved.

• Worth can be developed by personal mastery. This mastery does not mean perfection or being better than others – it is growth for the individual. Mastery requires mistakes – all success comes with errors along the way. Learn to deal with the feelings that come from mistakes and remember they are part of normal growth.

Communicate that no one is good at everything – we are all unique and have our own strengths.

• Helping others and having a purpose reduces anxiety and depression.

It also increases connectedness and self-worth. We can provide children with purpose by modelling helping behaviours and provide them with opportunities to help

others in our community and family.

Supporting family members by doing kind things for them, or clean up an elderly neighbour’s yard, or sponsor a child who needs support – you may not feel like doing these things but there is great benefit in helping others.

• Our existence also contributes to our worth. Life has value just because you exist. There doesn’t need to be a reason for our worth, we just need to internalise the idea that worth isn’t earned or lost, it just is.

Coping skills When we believe our life has worth, we work to overcome challenges. However, to do this, we need to have effective coping skills. When we cope we either deal with the emotions of the event (emotion-focused coping) or we deal with the problem (problem-focused coping). People need to feel the emotions before they can think through the problem.

It can be uncomfortable to see other people sad or angry but it is normal (and necessary). Once we have felt the anger/ frustration/sadness we can then think through how we can manage the situation.

Parents can scaffold children’s coping rather than solve the problem for them. Ask them to think of options and consequences – they can then apply these skills to other situations independently.

Author competing interests: nil relevant.

Questions? Ask the editor.

Good sources of worth are built through unconditional and stable relationships, boundaries, mastery, having a purpose, and belief in one’s existence.

• Relationships require respect and trust as a foundation. They also need love, empathy, support, encouragement, and acceptance. Love can be expressed through words (a card or note), physical touch (hug, high five), time spent together, and support (helping them with something). The

38 | AUGUST 2019

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Youth-onset Type 2 diabetes

By Dr Nicholas Forgione GP, Trigg In December 2018, the American Diabetes Association (ADA) published a position statement on evaluating and managing youth-onset Type 2 diabetes (T2D) in response to the worrying increase in the number of children and adolescents being diagnosed.

This trend, reflected internationally, shows that indigenous children and those from disadvantaged backgrounds bear the major burden.

In indigenous Australians, the age-specific rate for T2D is eight times higher for those aged 10 to 14 years, and four times higher for those 15 to 19, compared to non-indigenous Australians. The rise in T2D parallels increased obesity as a major global public health problem.

Start risk-based screening from the onset of puberty or after age 10, whichever comes first – consider in youth who are overweight or obese and have at least one other risk factor (e.g. maternal history of diabetes or GDM, family history, high risk ethnic/racial group, or signs of insulin resistance). There is no validated approach to screening in this age group, so clinicians need to maintain a ‘high index of suspicion’.

While overweight or obesity is a consistent feature of youth-onset T2D, it is no longer a clear differentiating feature from T1D or monogenic diabetes, as many of those children are more likely to be overweight or obese than previously.

Accurate diagnosis is important as it has a major impact on management and outcome. Pancreatic autoantibody testing can differentiate T1D, and genetic evaluation can differentiate monogenic diabetes. It is best to consider hyperglycaemia in children and adolescents a medical emergency, and all should be immediately referred to a specialist centre or paediatric endocrinologist.

Management and outcome KEY MESSAGES Weight loss is Youth obesity and Type 2 diabetes fundamental to are major public health issues management. Our Accurate diagnosis is critical lack of success Multidisciplinary and culturally reflects poorly on appropriate management is key current management strategies. Medication options are limited with only insulin and metformin approved for those under 18.

The longest running study of youth-onset T2D has been the Today 2 Study (presented at 2019 ADA meeting). This confirmed that it is a much more aggressive disease than older onset T2D with both microvascular and macrovascular complications occurring much earlier and accelerating more rapidly. Life expectancy is reduced by 10 or more years.

Tackling obesity is the key to preventing this new public health problem in the young. Clinicians have a role in recognising those at risk and providing both the youth and their families developmentally and culturally appropriate lifestyle advice. Long-term support and involvement of a multidisciplinary team is an appropriate strategy.

The final word is from an editorial from The Lancet published December 2018 – “If the growing prevalence of obesity and type 2 diabetes in youth is accepted as the new normal, society will have grossly failed the next generation.”

References available on request Author competing interests – nil relevant disclosures. Questions? Contact the editor

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Introducing Western Australia’s first dedicated reconstructive urology practice.

At Perth Reconstructive Urology, located at our new facility at 4 Antony Healthcare, Palmyra, we offer a holistic approach to the care of people with urological conditions requiring reconstructive surgery.

Incorporating a dedicated team approach including fellowship-trained reconstructive urological surgeons, urodynamics, on-site outpatient cystoscopy, physiotherapy, sexual health, medically supervised weight loss and gym programs, our mission is to restore quality of life to those suffering from: Urinary incontinence – AdVance sling, ATOMS, Artificial urinary sphincter Erectile dysfunction – medical therapies and penile prosthesis surgery Urethral stricture disease Penile curvature(Peyronnie’s disease) – minimally invasive correction Penile cancer – penis preserving surgery, minimally invasive lymph node dissection Infertility – vasectomy reversal, varicocoele ligation BPH – minimally invasive therapies including Urolift and REZUM Robotic assisted laparoscopic reconstruction including pyeloplasty, ureteric injuries, and reimplantation.

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AUGUST 2019 | 39

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Getting a Diagnosis

By Dr David Roberts Paediatrician Joondalup Most doctors who treat children have become worried about increased childhood mental health and developmental diagnoses.

The causes are probably many but blaming an increase in the stresses of modern life should not accepted without question. We may be inadvertently training our children to fail in coping with everyday life.

Today, many parents present upon the recommendation of the school, claiming their child needs support, with the parents asked to ‘get a diagnosis’. Needing support is a euphemism, meaning the child has either behavioural or academic problems, or both, and the school’s attempts at control and/or remediation have been unsuccessful.

The school’s funding is performance based, KPIs are affected, and its resources threatened. Having a medical cause shifts responsibility for the solution from education to health. The school can claim to be discharging its responsibilities and, in ‘getting a diagnosis’, the school receives more education system funding.

Remediation of academic problems is the core business of teachers not doctors, although some conditions such as Inattentive ADHD can play a part. Referrals from teachers usually do not detail what’s wrong, what’s been tried, and why it hasn’t worked. Teachers also seem unmindful of how seriously most parents view a trial of medication.

School-led action Management of behavioural problems is the core business of psychologists, not doctors. However, Hyperactive ADHD can be implicated. Paediatricians are called upon to make judgements and, as such, we operate in a space which intersects with other professionals, who may align themselves with the school’s agenda. The schools are a referral source.

Baumrind's Parenting Styles RESPONSIVENESS

DEMANDINGNESS

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LOW

HIGH

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LOW

HIGH

Negligent

Permissive

Authoritarian Authoritative

KEY MESSAGES Funding policy encourages labelling of children Behavioural policy is PC not science-based Children are by nature resilient A second problem stems from poor education sector policy settings. Positive Behaviour Support (PBS) is the behavioural system now mandated in WA public and private schools, the disability and child protection sectors.

As an offshoot of Applied Behavioural Analysis (ABA), the technique which has revolutionised autism treatment, PBS’s origins were sound. However, it has always been a part of the Non-Aversive Movement, which prohibits the use of aversive consequences (i.e. punishment) in behaviour management.

Thus, PBS’s principal tools are limited to rewards and antecedent manipulations (eliminating behavioural triggers). The literature of Behaviourism characterises PBS as a fad not a science. This is what has introduced a filter through which research findings and effective treatment alternatives must pass, and whereby it references ‘current thinking’ as its authority.

Teachers are prohibited from using aversive methods (ie punishments), which can be just as effective, less resource intensive and quicker in effect. The teacher’s time, energy and focus are being wasted, to the detriment of the whole class, including the misbehaving child. The classroom is disrupted further because well-behaved children see the misbehaving child not punished but rewarded for bad behaviour, and they copy that behaviour in the hope of receiving the same reward; called vicarious reinforcement.

Another influence causing over-diagnosis of mental health problems in childhood is our

readiness to invoke threats to attachment as a cause of behavioural problems.

Attachment Theory holds that threats must accumulate to become clinically significant.

Risk rarely comes in single packages, and adversity is normal. The protective Resilience System appears to have sufficient redundancy to sustain good development in all children, not just those resilient by nature.

Resilient children do not appear to possess unique qualities. In the face of a threat, a resilience response sets up (and doesn’t exclude) the opportunity for success.

Competence in early childhood is most dependent on secure attachment, and self-regulation. The association between self-regulation and authoritative parenting is very strong.

The work of Dianna Baumrind in the 1960s overturned the originally Freudian view that the child interprets the imposition of boundaries as a withdrawal of love and acceptance. Baumrind proposed that it is incorrect to interpret parenting along a single continuum from democratic to authoritarian.

Rather, parenting style is better described along two continua: responsiveness and demandingness. According to Baumrind authoritative parents are responsive to their child’s emotional needs, while simultaneously holding high (age-appropriate) expectations of their child’s behaviour.

The behavioural or academic problems children now present with reflect their psycho-social context as much as their individual natures. The process of assessment should consider both.

References available on request

Author competing interests – nil.

Questions? Contact the editor

AUGUST 2019 | 41

Rethinking growing pains Traditionally conditions such as Osgood-Schlatter’s Disease (OSD) and Severs Disease have been described as self-limiting, as an apophysitis not negatively affecting growth, and thought to resolve on growth plate closure. However, this is not what we are seeing in clinics and research.

Prof Jens Olesen, a rheumatologist and sports physician at Aalborg University, found those patients with OSD whose initial ultrasound showed a combination of fragmentation of the tibial tuberosity ossification centre, thickening of the patellar tendon insertion and infrapatellar bursitis were more likely to continue to experience persistent pain and dysfunction.

In one perspective cohort study of adolescents with OSD, even at two years after diagnosis, 60% demonstrated persistent tendon changes. Research through Aalborg University showed at two years, 40% report continued OSD related pain, and although severity was variable, these adolescents were impeded in sports participation and recorded lower quality of life. Severs can also have a tangible negative effect on quality of life.

With improved understanding of the long-term effects on participation and quality of life, these conditions should be treated efficiently and effectively.

Active management of the condition is appropriate, rather than simply asking them to cease sporting activities until cessation of symptoms, as past literature suggests.

Why should we re-examine our management of apophysitis? Adolescence is a key developmental period where the apophysis changes to a mature enthesis. It is a critical time for the formation of normal tendon attachment. It is possible that overly aggressive sporting activity and tendon loading during symptomatic OSD may (long term) negatively impact both tendon structure and the risk of adulthood symptoms.

As health practitioners we are efficient at addressing acute pain management through ice, taping, analgesics and deloading. However, are we supporting full return to activities? What else can we do?

Plenty.

Load modification is the mainstay of treatment. Increased practice time has been shown to be a risk factor for OSD onset. Thus, the basic approach is activity modification; deloading is required and using a tool such as the Activity Ladder

KEY MESSAGES Growing pains can negatively impact quality of life Structural changes may persist into adulthood Manage actively rather than “wait and see” Factors such has higher mean BMIs, deficits in muscle strength, reduced jumping ability, reduced flexibility, reduced shock absorption and altered biomechanics can all be addressed to reduce symptoms and improve function.

For calcaneal apophysitis, the use of heel raises or orthoses can provide short-term pain relief and improved participation.

The days of the passive “wait and see” and “rest is best” approach have gone.

Addressing individual deficits and graded loading is an important part of rehab and return to play. Early intervention and appropriate referral are key.

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

Warning Signs of Meth Withdrawal Clinical psychologist Kerryn Ashford-Hatherly takes a deliberate approach to Ice withdrawal for long-term benefits.

Methamphetamine and ice addiction is different to other addictions and the pervasive brain changing impact these drugs have on an individual often remain unseen until there’s a crisis.

It can be very deceptive.

A person might only use meth or ice every few months and don’t believe they have an addiction until they try to stop. Research shows the withdrawal period can be between 30 to 90 days and this is important in terms of recovery because it may take someone up to three months before they are even through the withdrawal stage.

Presentations to GPs are likely to occur when the user wants to stop and is

42 | AUGUST 2019

experiencing high fatigue, insomnia, depression and anxiety symptoms which are all part of the withdrawal stage.

They may not inform their GP that they have used meth or ice and sometimes will present with the aim to acquire scripts for medications which contain codeine and pseudoephedrine hydrochloride.

Other common scripts sought are Benzodiazepines, Dexamphetamine and the weight management medication, Duromine.

abstinence in an ever-diminishing spiral that inevitably leads to family dysfunction, job loss, relationship break-ups and severe medical problems.

The typical stereotype of a meth or ice user is far from the majority. Meth and ice use in Australia occurs across the spectrum.

The drug creates enormous surges of energy and euphoria in the early stages of use and many users in the workforce will inevitably turn to the drug on a regular basis to enable them to work longer over several days.

These medications are commonly used when people are in the early stages of detoxification and withdrawal.

The downside is tolerance to meth and ice develops rapidly which leads to increased frequency and using to avoid going into

Recovery can become a vicious cycle of intense periods of drug taking and

continued on Page 44

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By Nicole Pates Paediatric Physiotherapist, Mt Hawthorn

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Baby health – our approach to management

By Dr Leon Levitt, GP Obstetrician Paediatricians look for uncommon and important medical syndromes or illnesses. They focus on their detection and are very keen to avoid missing something. This leads to investigations, “just in case”, and treating, “just in case".

GPs are trained to play the odds. The most common condition is suspected first and since most children have common short-lived complaints, GPs manage the family from this perspective. Only if there is something out of the ordinary, or special circumstances present, will the GP go looking for the rare condition.

The ‘Paediatrician’ or ‘Specialist’ approach creates more investigations and therefore more cost to the family and the system, and much more parental anxiety. As anxiety is increasing greatly among the newer generation of parents, a wholeof-family approach to investigation and treatment of children is much better.

The “just in case” model of care might make doctors more comfortable about not missing something, and generate repeat consultations, but it may not be in the family’s best interests.

For example, we perform ultrasounds for possible hip dysplasia on neonates and repeat them “just in case” at an alarming rate. Repeat ultrasound and specialist follow-up appointments are created to catch a very rare condition. However, doctors have not missed many cases in previous years through the tried and true process of thorough clinical examination and ultrasounds for those at greater risk e.g. breech.

So whose anxiety or needs are being treated, the doctor’s or the family’s?

Another example. Cow’s Milk Protein Allergy is rare when we keep to clear, proven diagnostic criteria, but many doctors (paediatricians and GPs) suggest this possibility to a mother with a crying

baby with some gut symptoms. This “just in case” suggestion puts so many mothers on dairy free diets and increases the whole family’s anxiety.

Why not first make a diagnosis based on proven criteria? Why treat on hypothesis if the mental (and financial) health of the rest of the family may suffer, with little proven benefit for the child?

This enhances parental anxiety and reinforces the belief that parents should look for ‘what is wrong with my child’.

Perhaps we need to train our young paediatricians and GPs to care for the whole family; to be confident in their clinical knowledge and examination; to make decisions based upon diagnosis not hypothesis; and to focus on reduction of parental anxiety as a major goal.

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AUGUST 2019 | 43

Myopia in children Dr Antony Clark, Ophthalmologist, Lions Eye Institute Myopia is considered a public health epidemic in many Southeast Asian countries where its prevalence has increased rapidly to affect nearly 90% of school leavers.

In Australia the prevalence is lower with significant differences between Southeast Asians (40%) and Caucasians (20%); and while it is not at epidemic levels the prevalence is increasing. Nearly half of the global population is expected to be myopic by 2050.

Myopia results in blurred distance vision when the length of the eye is too long for its focusing power. This lengthening causes thinning of the globe and increases the risk of blinding eye conditions including retinal detachment, macular degeneration, cataract and glaucoma.

It usually begins in primary school (6-10 years old) and typically progresses until late teens/early 20s. While it can be corrected with glasses, contact lenses or even laser surgery, these treatments do not reverse the structural changes in the eye, nor do they slow progression.

The goal of treatment is to prevent children becoming highly myopic (-6.00 D or worse) as beyond this level myopia-related

KEY MESSAGES Myopia is increasing in school aged children Treatment? A low dose atropine trial in WA schoolchildren may help.

complications increase significantly.

Myopia progression can be modified by behavioural and environmental factors.

Less time spent outside and excessive near activity are the most recognised contributors.

Children should be encouraged to spend at least 10-15 hours a week engaged in outdoor activity. This is considered to significantly decrease the risk of myopia from developing. Frequent breaks from any near-activity (including reading, study or device use) of at least 15 minutes every hour should be encouraged. Reading should be done in good lighting which means both room lights and desk lights on since light exposure appears protective.

Two interventions commonly used to reduce myopia progression are orthokeratology lenses (OrthoK) and low-dose atropine (0.01%). OrthoK are

hard contact lenses worn overnight which corrects the eyes prescription so that no glasses are needed during the day. It reduces the rate of progression by 40%.

Disadvantages are the challenges and tolerance of fitting hard lenses in a child, myopic rebound, and the risk of corneal infection.

Low-dose atropine reduced myopic progression by up to 60% in a trial of Singaporean school children. It is used daily for at least two years and is well tolerated with minimal side effects.

However, it has not been proven effective in slowing progression in non-Asian children, children older than 12 years, or in the long term. Despite this, atropine is being prescribed widely to children in the community, though its use is considered off label.

The LEI is undertaking a trial with WA schoolchildren on the safety and efficacy of low-dose atropine.

Author competing interests: Funds for the LEI clinical trial come from the Telethon Perth Childrenâ&#x20AC;&#x2122;s Hospital Research Fund and the Ophthalmic Research Institute of Australia.

Questions? Contact the editor.

continued from Page 42

Warning Signs of Meth Withdrawal withdrawal. Users end up taking the drug just to feel normal.

Meth and ice significantly damage various regions of the brain and in particular the dopamine and serotonin receptors.

Studies show that it can take up to two years for the dopamine receptors to repair once a person stops using. This has consequences for the efficacy of SSRI medication treatment as the receptors are damaged and research has shown there is a higher rate of relapse.

Recovery needs time for the damage to be healed and involve treatment which helps individuals to rebuild their mental skills and learn to cope with life from a position of abstinence.

44 | AUGUST 2019

However, some in recovery do experience noticeable cognitive decline, in particular with memory, which appears to be long lasting.

A treatment program developed by the Matrix Institute in the US and adapted for use in WA is an intensive outpatient group treatment with 4-8 participants at each session. The initial five-month phase requires participants to attend a minimum of three sessions a week while still engaging in work and family life. Family and Support Education sessions are also involved.

Participation requires a full medical assessment from a GP before starting, with regular medical reviews throughout.

In WA the program is not government funded and involves a weekly fee, which is probably less than half of what an addict would spend weekly on drugs. To date 55% of participants completing the

intensive phase of the WA Matrix Program have remained abstinent.

Itâ&#x20AC;&#x2122;s not a program for everyone, but there are many long-term users who have managed to get their lives back on an even keel.

ED: Kerryn Hatherly is a clinical psychologist who is delivering the Matrix WA program. She has worked in the mental health area for 20 years, specialising in alcohol and drug issues, domestic violence and trauma.

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CLINICAL UPDATE

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2014

3

6

4

4

2015

3

3

8

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2016

3

2

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2017

8

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CLINICAL UPDATE 11 18

2018

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7^

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* Rate=annual crude rate per 100,000 population. Rates only provided for those years with complete data. ^Data for current and most recent reporting periods may be incomplete.

Meningococcal vaccination in WA Guide to interpreting notifiable infectious disease data for Western Australia

Note

By Dr Astrid Arellano, Infectious Physician, Subiaco Notification data Diseases includes all cases diagnosed in Western Australia (WA residents and non-WA residents).

Data are preliminary and subject to change as updates are received.

Children under five have more than double the rate of meningococcal W infections of any age group, and Aboriginal children under 12 months of age have 40 times higher rates of invasive meningococcal disease than non-Aboriginal children.

Meningococcal infection notifications in Western Australia, Meningococcal infection notifications in Western Australia, by 5 year age grou by 5 year age group and sex, for the last 01/01/2018 - 31/12/2018 for 12 themonths: last 12 months: 01/01/2018 - 31/12/2018

The national target for childhood vaccinations is 95% but MenACWY coverage in WA for >13 months to <5 years falls short at 79.4%.

The number of meningococcal infections in WA doubled (from 23 to 43 cases) between 2016 and 2017 and have remained steady in 2018 and 2019. Children under five years are the main affected age group (see Fig.1).

The WA childhood MenACWY immunisation program provides the quadrivalent conjugate meningococcal ACWY vaccine for children at 12 months of age as part of the schedule. Catch-up vaccination is available for children aged 13 months to less than five years old but this program ends on December 31, 2019.

Aboriginal children receive MenACWY at six weeks, four, six and 12 months of age within the Aboriginal vaccination schedule.

Adolescents (15-19-year-olds) are the second at-risk group (Fig.1). MenACWY is given to Year 10 students in schools and adolescents aged 15-19 years who miss the school-based programs, or 15-19-yearolds not in school can access the vaccine until further notice via general practice.

The vaccine coverage in this age group, however, is only 61%, which drops off with increasing age. Nineteen-year olds are less likely to be immune than 15-year olds.

5 Year Age Groups

Fig1. Meningococcal notifications in WA, by five-year age group and sex for 1/1/18-31/12/18 Number of Meningococcal infection notifications in Western Australia, by 5 year ag for the last 12 months: 01/01/2018 - 31/12/2018

Targeted meningococcal outbreak response in the Pilbara

Menveo® and Nimenrix® are both equally immunogenic.

There has been a significant increase in invasive meningococcal disease in the Pilbara with four cases clustered around the Roebourne/South Hedland region of WA since January 2019. Therefore MenACWY Nimenrix® vaccine is being provided until December 2019 to all Aboriginal people aged six weeks or over living in at-risk-Pilbara towns (Port Hedland, South Hedland, Karratha, Wickham, Roebourne, Onslow, Nullagine, Warralong, Yandeyarra and Marble Bar) who have not previously received ACWY meningococcal vaccine.

There is evidence that antibody responses after Menveo® and Nimenrix® are modestly higher than a dose of Menactra® and immunity decreases more rapidly with this vaccine. However, if Menveo® and Nimenrix® are not available Menactra® is acceptable and much more preferable than no vaccination.

MenACWY vaccines and vaccine shortage There are three meningococcal ACWY vaccines available.

Menveo®, Nimenrix® and Menactra®.

Menveo® was in short supply in 2018 and therefore Nimenrix® is the vaccine in the immunisation schedule but

Asymptomatic meningococcus carriage in the community is 10% with invasive meningococcal disease occurring uncommonly but causing life-threatening disease. Vaccination is safe, effective and freely available for all at-risk-age groups in WA until December 2019. Beyond that date, MenACWY vaccine will be part of the immunisation schedule for 12-month olds and Year 10/15-19-year-olds. Age groups from six weeks of age are covered by the Aboriginal schedule.

Vaccine coverage is lower than required for herd immunity and the free program has not reached as many children as is required. GPs need to keep in mind to opportunistically vaccinate against MenACWY especially in <five-year olds and teenagers.

References available on request

Author competing interests: nil relevant.

Questions? Please ask the editor.

Fig2. Meningococcal infographic.

MEDICAL FORUM

AUGUST 2019 | 45

Hearing loss and assessments in children

By Dr George Sim , Paediatric ENT Surgeon, Murdoch The ability to hear is critical to a child’s cognitive, emotional and social developments. Any degree of hearing loss in one or both ears can lead to speech and language impairment and is very stressful and concerning for parents.

KEY MESSAGES Hearing loss can have profound consequences All newborn babies in WA can be screened before leaving hospital Testing method is age related

Hearing loss can be conductive, sensorineural or mixed.

The WA Newborn Hearing Service provides screening for babies born in WA, usually performed before mother and baby leave hospital. If there are any concerns, a followup screen will be arranged. The screen is performed through automated auditory brainstem response (AABR).

The age and ability of a child to understand instructions will determine the type of hearing assessments performed. This is usually determined by an ENT surgeon and paediatric audiologist upon preliminary assessment.

Types of assessments Behavioural Observational Audiometry (up to 12 months) uses low, mid and

high frequency noisemakers. The child’s response (e.g. startling or stirring) are noted.

Visual Reinforcement Audiometry (1-3 years) assesses hearing by examining response to sounds at different volumes and pitch. Usually the child is seated on their parent’s lap in a soundproof booth.

The child is rewarded with a toy that lights up and moves when a sound is heard.

Once the child is conditioned to respond to the sound, the intensity of the signal is reduced to determine hearing threshold.

Play Audiometry(3-5 years) involves wearing headphones and will obtain ear specific hearing thresholds. The child is instructed to perform a task such as

touching a toy or putting a block in the box every time a presented sound is heard.

Pure tone audiometry can be used from age five.

AABR involves placing leads on the baby’s head and body and the way the sounds are received by the hearing nerve and brain are recorded to indicate whether or not hearing falls within a normal range. The test can only be carried out while the baby is under natural sleep or laying still.

Otoacoustic emissions measures haircell function in the cochlea by presenting sounds through an ear plug placed in the child’s ear canal. A child with hearing loss will have no response or emission.

Tympanometry measures ear drum compliance in response to sounds and air pressure giving an indication of middle ear effusion. Acoustic reflex tests the response of the ear to loud sounds by evoking the stapedial reflex. A child with hearing loss will have dampened or absent reflex.

If a hearing loss or other ear issues are identified, the management options should be discussed with the parents, ENT surgeon, GP and paediatric audiologist.

HEARING MILESTONES 0-3 months 3-6 months 6-12 months

Startles to sudden/ loud noise Recognises parents’ voice; looks or turns to new sounds Able to imitate simple sounds; knows simple words like ‘mama’, ‘no’

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

Pancreatic Cancer: Insight

By Prof Mayank Bhandari, Hepato-Pancreatico-Biliary and Transplant Surgeon Pancreatic cancer is a lethal condition with poor outcomes and an increasing incidence. It is the fourth leading cause of cancer-related death in Australian men and the fifth leading cause in women with an overall fiveyear survival rate of under 10%.

Surgery for pancreatic cancer and its outcomes have significantly evolved over the past decade. Pancreatico-duodenectomy (Whipple’s procedure), distal or total

46 | AUGUST 2019

pancreatectomy are the surgical options for the resection of pancreatic cancer depending on the anatomical location of the tumour or tumours.

Pancreatic surgery is associated with significant morbidity and mortality. In order to have best outcomes it is important that these surgeries are centralised to use available experience.

Surgical resection with negative margins is the cornerstone of potentially curative

therapy but is possible only in 15-20% of patients at the time of initial diagnosis. In these patients, when surgery is followed by adjuvant chemotherapy, it can achieve a five-year survival of approximately 35%.

About 30-40% of patients with pancreatic cancer present with locally advanced disease (stage III). These patients are not candidates for upfront surgical resection because of major vascular involvement or are borderline resectable cancers where

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CLINICAL UPDATE

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CLINICAL UPDATE

Foot Pain in the active child

By Dr Colm McCarthy, Sports Doctor, Claremont An apophysis is where a tendon or ligament attaches to a bone growth centre which eventually fuses with the adjacent bone as the child matures.

In Calcaneal Apophysitis (Sever’s Disease), a combination of traction on the calcaneal apophysis from the gastrocs/soleus complex and the plantar fascia, and repetitive microtrauma during gait to the actively remodelling bone, cause heel pain and tenderness made worse with activity.

It’s common in children aged eight to 14 (often just before peak growth), who participate in running or jumping sports. Diagnosis is clinical. Treat with activity modification, a heel raise and calf stretching. Symptoms resolve in six to 12 months.

Apophysitis of the fifth metatarsal base (Iselin’s Disease) A traction apophysitis can occur at the insertion of the peroneus brevis to the tuberosity at the base of the fifth

KEY MESSAGES There are a number of conditions particular to the growing foot.

Symptoms often relate to activity or sport.

Most are self-limiting if recognised and treated appropriately. metatarsal. It occurs in children aged eight to 13, more often in sports with recurrent inversion stresses (e.g. netball and soccer).

It presents with pain and tenderness at the lateral foot, worse with activity and improving with rest.

An x-ray may be indicated to differentiate it from a fracture of the base of the fifth metatarsal. Most settle with stretching and activity modification. Immobilisation for a few weeks is sometimes considered.

Osteochondrosis of the navicular (Kohler’s Disease) The navicular ossifies late compared to the other tarsal bones. It may be vulnerable to mechanical compression injury and avascular necrosis. Kohler’s disease usually presents with dorsomedial midfoot pain and a limp, with point tenderness over the navicular mainly in ages four to seven (boys 80%). Radiographs show navicular sclerosis and flattening.

Manage with a short-leg walking cast for six weeks. Symptoms and radiological abnormalities resolve over time with longterm disability rare.

the risk of positive surgical resection margin is high.

For this subset of patients, irreversible electroporation (IRE) or NanoKnife® can be used as a technology to prolong life and treat symptoms. Recent body of evidence suggests that it can also convert these patients to resectable with good mediumterm outcome.

The aim of IRE is to slow the growth of pancreatic cancer by destroying cancer cells. It is an ablation procedure that involves the delivery of a series of high voltage, direct current electrical pulses between electrodes placed within a target area of tissue. These electrical pulses produce an electric field which induces electroporation on cells.

MEDICAL FORUM

Osteochondrosis of the metatarsal head (Freiberg’s Infraction) Disrupted blood supply to the metatarsal head caused by repetitive microtrauma can lead to avascular necrosis and collapse of the articular surface and adjacent bone.

It is most commonly seen in the second metatarsal head in female athletes and dancers aged 13-18. Standing on the forefoot aggravates pain and there is tenderness, swelling and stiffness around the metatarsal head. MRI is the most sensitive investigation.

If diagnosed early, activity modification and footwear modifications/orthotics to offload the second metatarsal head may be successful.

If symptoms persist, a short leg walking cast or boot for four to six weeks can be used with surgery only for advanced cases.

Tarsal coalition While mobile ‘flat feet’ are a common normal variant, a rigid flat foot may suggest tarsal coalition. Congenital fusions of the tarsal bones (most commonly calcaneonavicular) may become symptomatic when a child begins playing sports, or when the coalition ossifies, usually between ages eight to 12.

Depending on clinical and radiological severity, management can range from orthotics or temporary casting to surgery if symptoms are severe.

References available on request Author competing interests – nil.

About 50% of patients with pancreatic cancer are diagnosed with metastatic disease at index presentation. In these patients chemotherapy is palliative and the principal goals are to control disease spread and improve quality of life.

strategies, new research avenues have been explored. There is ongoing research in understanding the tumour biology, the basis of novel targeted agents (e.g. immunotherapy) as well as identifying new biomarkers for this disease.

Recent evidence suggests the neoadjuvant approach with preoperative chemotherapy/ chemo-radiotherapy may improve R0 resection rate in resectable and borderlineresectable patients and may potentially downstage locally advanced disease. This may have a positive impact on survival.

Novel therapeutic modalities such as oncolytic viral therapy and gene editing technology have also been identified as promising in several pre-clinical and early phase clinical trials.

Significant advancement is being made in optimising the neoadjuvant therapy with a better toxicity profile.

Author competing interests: nil relevant.

Questions? Contact the editor.

With limitations in current treatment

AUGUST 2019 | 47

It’s More Than a Quick Snap Photography is making diagnosis and management of wounds more efficient regardless of the location of the patient, but Lynette Rodriguez says there are risks.

A picture can offer valuable information and clinical wound images are often used to provide wound management to individuals in Residential Aged Care Facilities, and the community. The images communicate wound status, aiding with wound assessment in telehealth consultations and when direct patient review isn’t possible.

Wound images aid documentation of wound status as part of the patient record, and are also valuable for education, research, and when there is need to seek opinion from other clinicians.

With the convenience of digital images and smartphone technology, the use of clinical images is becoming more common. A survey of Canadian plastic surgeons and their resident doctors found that 89.1% used their smartphone camera to obtain clinical photographs of their patients; 57% stored the images on the phone, and 73% stored them among personal photos.

A survey of Australian dermatologists and trainees found more than half used their smartphone weekly for sharing clinical images, with 46% storing the images on the smartphone. This is not without risk, particularly if the device is lost or stolen. Deidentification of images to be disclosed to others can help to reduce some of the risk associated with inappropriate disclosure.

Clinicians should follow their organisational guidelines on use of clinical images and personal devices and work within the legal requirements for record keeping, privacy, confidentiality and freedom of information.

When taking a wound image, the patient should be informed of the purpose, how the images will be used, who they will be disclosed to (at that time and in the future), and whether that consent can be withdrawn. Written consent should ideally be obtained.

The device to be used (ideally a workplace camera rather than a personal device) should be ready for use and a secure method for transferring images, if required, determined (e.g. secure application using cloud storage, store and forward system, encrypted email. Short message service (SMS) and Multimedia Service texting (MMS) may not be encrypted or secure).

The image is ideally framed so that any of the patient’s identifying/distinguishing features such as tattoos, birthmarks, jewellery or even unique settings are avoided.

48 | AUGUST 2019

A wound image should be an accurate representation of the wound and so clarity and colour are important making lighting critical for accurate assessment.

Setting the white balance on the camera will help with lighting colour influence.

Natural light is preferred, though not always available. Using a flash is often recommended but may cause glare from moist tissue. We find a white background is generally preferable, however, some guidelines recommend a blue or green background.

Consider what is required from the wound image. Generally, the image is best taken after the wound bed preparation so it is visible. If wound debridement is required, an image prior may also be useful.

Also handy is an image showing anatomical context of the wound as well as close image. A measure alongside the wound can help determine wound size, it is important this is placed so that the wound bed is not partially obscured. Images should be taken with the camera at 90° (perpendicular) to the wound bed to avoid perspective distortion.

If the wound is circumferential, a series of images may be needed. While wound images are helpful recording wound status, assessment requires more information.

Duration of the wound, aetiology, exudate type and amount, odour, presence of undermining, tissue turgor and pain also need to be considered.

Selecting images with a larger file size and higher resolution will provide more detail. Images should be stored in the patient clinical record and/or secure data repository. Ideally the image should then be deleted from the device.

If the images are retained in the device e.g. SD card for a camera, mobile phone, computer or tablet, secure storage of the images may require secure storage of the device itself as theft would put the content at risk.

Smart devices such as a phone or tablet should have password or security protection to help deter unauthorised access. Storing clinical images with personal images risks accidental exposure of confidential images. Image security is a concern not only for the clinician sending the images, but also for the clinician receiving them.

Metadata is attached to a digital image (e.g. time, date, location) and some may have to be removed to de-identify it for sharing or for use other than part of a medical record (e.g. education). The original, unchanged image should be securely stored.

Clinical images are valuable for clinicians involved in wound management though it is important clinicians consider not only their benefits but also the responsibilities and risks associated with their use.

References on request.

ED: Lynette Rodriguez is a Nurse Practitioner based in WA specialising in wound management for national company Wound Innovations, which provides wound management including telehealth and wound education around Australia.

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GUEST COLUMN

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NEWS & VIEWS

Glenis and her Perfect Match Kidney A stroke of very good fortune 50 years ago gave Hamilton Hill resident Glenis Lucanus the opportunity for a long and full life.

O

n 1 July, transplant recipient Glenis Lucanus celebrated 50 years with her life-saving kidney that was implanted by a Royal Perth Hospital team comprising surgeon, the late Dr Gwyn Brockis, and renal physicians, the late Dr James Hurst and Dr Ted Haywood who, despite retiring 25 years ago, still keeps in contact with Glenis.

The 84-year-old Glenis told Medical Forum that she had nephritis as a child which led to her kidney failure and ultimately transplant surgery. She has the longest surviving donated kidney in WA and the third oldest donated kidney in Australia according to the Australian and New Zealand Dialysis and Transplantation Authority (ANZDATA).

She thanks her doctors and her family for good health.

“Right at the very beginning, I thought if I ever got a kidney transplant I’d look after it, and I’ve kept to my promise. My family make sure I do,” Glenis said. “I can’t believe I keep achieving these milestones and I don’t think my family can either, but they are very happy and supportive.”

Glenis’s donated kidney has helped her and husband Bill raise a family of three daughters, and the couple now have six grandchildren and seven great grandchildren.

“He’s as happy as Larry, you’d think it was his kidney,” Glenis said.

We also tracked down Dr Haywood from the transplant team who said a case like Glenis’s was “just incredible”.

“It’s the sort of thing you hope for from an identical twin donor,” he said.

“In those early days there was pretty rudimentary tissue typing, matching was not nearly as good as it is today, and the immuno-suppressive drugs were basic as well. I don’t think they are used anymore.”

“It’s important to mark these milestones.

There was great community spirit at RPH and at Fremantle Hospital.”

Glenis’s consultant is now Dr Helen Rhodes at Fiona Stanley Hospital.

“I have looked after Glenis intermittently since I was a trainee at RPH in 1990, then at Fremantle for almost 20 years and for the past few years at FSH,” Helen told Medical Forum.”

“No credit to the medical teams, other than the initial transplant team or to modern technology – she has been incredibly lucky, receiving a young kidney with excellent function and she has looked after the kidney and herself.”

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“The most remarkable fact is that after 50 years, her current creatinine level is 66umol/L. Tell any doctor that and they will be astonished!”

Kidney Health Australia CEO Chris Forbes said Glenis’s story gave hope to chronic kidney disease patients eligible for a transplant that the procedure could help them live well and for longer.

By Jan Hallam

Top: Glenis Lucanus and her husband Bill.

Above: Glenis with renal physician Dr Helen Rhodes.

KIDNEY HEALTH FACTS The average wait for a kidney transplant is three years.

According to ANZDATA, in 2017 there were 1109 kidney transplants performed in Australia and 187 performed in New Zealand, with live donor transplants contributing 24% and 37% of total transplants, respectively.

The biggest risk factors for kidney disease are diabetes, high blood pressure, established heart problems and/or stroke, family history of kidney failure, smoking, obesity, being 60 years or older, of Aboriginal or Torres Strait Islander origin, or a history of acute kidney injury.

1.7 million Australian adults are affected by kidney disease while 1.5 million of those are unaware of it.

Kidney-related disease kills more people than breast cancer, prostate cancer and road accidents combined.

AUGUST 2019 | 49

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MUSICAL

Let the Sunshine In

T

he old Sixties adage, if you can remember them, you weren’t there, doesn’t hold much water when someone mentions the seminal rock musical, Hair.

first Australian Idol, plays Dionne. While both come to this production of Hair as established performers, the first Australian Hair was a breakthrough for some of theatre’s most enduring stars.

It not only contains some of the most iconic music of the Counterculture – Aquarius, Good Morning Starshine, Hair, I Got Life and Let The Sun Shine In – it also took the Vietnam War protest to Broadway and subsequently around the world. And let’s not forget the inclusion of a nude scene and drug taking which successfully lowered the average age of theatregoers for a generation.

Try Reg Livermore, John Waters and Marcia Hines for starters.

It was a pretty big deal.

So it’s not surprising that it has undergone various revivals over the past 50 years, most recently here in Australia where a national tour kicks off in Perth this month at His Majesty’s Theatre.

Hugh Sheridan, who became a household name during his time in the popular TV series Packed to the Rafters, takes on the role of the tribe’s ‘leader’ Berger. And Paulini, whose commercial singing career was launched by her popularity on the

50 | AUGUST 2019

Paulini spoke to Medical Forum on the eve of rehearsals beginning and she is thrilled to be a part of it.

“The time of its premiere must have been amazing – with young people speaking out loudly about war, racism, violence and the environment. These issues resonate so powerfully today – they are still so important to raise in the community,” she said.

The age of social media and devices that keep our eyes down rather than up and the possible impact they have on our moral courage, however, concerns her.

“I think we have forgotten how to stand up for some of these issues and how to be kind to each other.”

While Paulini is too young to have experienced the social revolution of the

1960s, she does know a great song when she sings one and can’t think of any experience that really tops the thought of singing Aquarius on stage.

“It has to be one of my favourite songs and to sing this anthem is amazing.”

Paulini has only of late exercised her musical theatre feathers. Having for most of her career been a commercial recording and performing artist, being part of a theatrical ensemble is a big learning curve.

“Hair is my third musical (she has performed in The Bodyguard and Saturday Night Fever) and I have had to readjust from having individual autonomy on stage.

If I wanted to adlib or sing a chorus again, I’d sing it again. You can’t do that when you have 20 other people on stage waiting for their cue,” she said.

“I’ve learnt discipline in the theatre and wonderful team work but there have certainly been challenges. I had never acted before and my dancing was my moves, not a choreographer’s but the effort has been well worth it.”

By Jan Hallam

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WINE REVIEW

Castelli Bottles the Taste of the Great Southern Castelli Estate is located on Mount Shadforth in Denmark in WAâ&#x20AC;&#x2122;s Great Southern and was purchased by the Castelli family in 2004. They had a commitment to sourcing the best fruit available and appointed Mark Garland as winemaker to bring a philosophy of balance and structure to cool climate winemaking. The result is some highly recommended wines.

By Dr Martin Buck

2018 Castelli Riesling

2016 Cabernet Sauvignon

This Riesling is a blend of Great Southern vineyard fruit picked in March during an almost perfect season. Floral aromas of blossom and lime with a full palate of fruit, peach, sherbet and medium acid.

Young and lively, ready to appreciate now but will keep nicely.

The Castelli Estate reds took me on a tour of the best fruit in the Great Southern as well as wine styles from Bordeaux to Hermitage. The 2016 Cabernet Sauvignon is Frankland River fruit cold soaked for 10 days to extract flavour and fermented on skins for a month. This has resulted in some amazing flavour extraction with blackberries, tobacco, chocolate and liquorice combining with fine tannins. A nicely balanced wine ready to drink or cellar.

2017 Il Iris Blanc Here is a single vineyard Chardonnay from Denmark picked during a challenging year for winemakers. It was hand-picked, pressed into barrels and left to ferment naturally. A light straw in colour with aromas of new French oak, gunflint and melon, it has a very tight structure. An acid backbone with medium weight fruit and oak. A complex wine which will improve with further age.

2017 Pemberton Chardonnay I found the 2017 Pemberton Chardonnay more to my liking with a lot of Burgundian wine-making techniques and a mix of inoculated and wild yeast. This wine is what cool climate Chardonnay is all about with restrained, clean, limey fruit. Some elegant apricot flavours with soft oak and minerality. Highly recommended with a medium-bodied style and good short-term cellaring.

2016 Frankland River Shiraz The final bottle was the 2016 Frankland River Shiraz and it did not disappoint. In the glass, the wine is a deep purple with a nose of berries, spice and blackcurrant. A full-bodied fruit driven palate with soft tannins, great length and balance. All the finesse of a Syrah but with more bold fruit characters. Still a young wine and will surely gain more complexity with ageing.

REVIEWER'S

Empirica by Castelli 2016 Uvaggio

PICK

This is a blend of Grenache, Mourvedre and Shiraz picked from dry-grown bush vines. The parcels were fermented in open fermenters with whole bunches, gently plunged and aged in large oak casks. Massive fruit flavours, driven by the Grenache, combine to produce aromas of berries and spice with a bold palate. The tannins are very soft and let the smouldering fruit drive the palate. I had to finish the bottle to appreciate how close this wine was to Rhone Valley perfection.

MEDICAL FORUM

AUGUST 2019 | 51

SOCIAL PULSE BACK TO CONTENTS

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SJG Murdoch Annual Doctorsâ&#x20AC;&#x2122; Dinner Murdoch doctors and their partners enjoyed the annual dinner which was held at Frasers this year. The theme celebrated all things Western Australian through local food, gin tasting and a smoking ceremony, dancing and Welcome to Country by Indigenous group Bindjareb Middars. Comedian Urzila Carlson had the crowd in stitches!

1 Dr Melanie Thew, Dr Alan Thomas, Dr James English, Dr Bernard Lee, Joanna Lee and Dr Krishna Epari 2 SJG Murdoch CEO Ben Edwards and Trish Tebbutt 3 Bridget Ammon, Dr Peter Ammon and Melanie English

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4 Priscilla McLellan and Dr Duncan McLellan 5 Dr Jeffrey Thavaseelan and Heidi Thavaseelan 6 Dr Michelle Cowser and Dr Gerald Lim 7 Dr Ian Jenkins and Sharon Connolly 8-9 Welcome to Country by Indigenous group Bindjareb Middars 10 Dr Oscar DaSouza, Dr Mark Hurworth, Natalie Hurworth and Lisha DaSouza

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SOCIAL PULSE Bethesda Celebration Day

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Long-serving staff were recognised at the annual Bethesda Celebration Day with 24 staff reaching milestones ranging from 10 years to 40 years. Robyn Strong has worked in the hospital’s Patient Services area for 40 years. The hospital is celebrating 75 years at its iconic Claremont site. Tuyen Nguyen from the IT Department was awarded the Matron Beryl Hill Exemplary Professional Practice Award by Deborah Bell, Executive Manager, Clinical and Support Services.

1 Long-serving theatre staff: Teddy Deregla (10 years), Nadine Murray (10), Anthony Dias (25), Deborah Bell (Executive Manager), Michael Gibson (20), Penny Charleston (25) and Robyn Simpson (15) 2 Deborah Bell and Penny Charleston

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3 Robyn Strong is congratulated for her 40-year service by board member Grant Robinson and chair Dr Neale Fong 4 Grant and Neale are with Tuyen Nguyen 5 Grant and Neale are with Michael Gibson 6 Grant and Neale are with Nadine Murray

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New sounds A newly formed classical music group, Harmonia Australis, will take classical music to the regions performing Mozart and Handel. While the group is new, at the helm is one of the state’s most respected music directors.

Ian Westrip will conduct Harmonia Australis’s orchestra and chorale in performances of the overture to Mozart’s Marriage of Figaro and Laudate Dominum as well as a stirring rendition of Handel’s Hallelujah Chorus (arr Mozart).

You can catch the new group at St Joseph’s Church, Subiaco (August 23), St Patrick’s Basilica, Fremantle (August 24) and St Boniface Cathedral, Bunbury (August 25).

For more information and bookings www.trybooking.com/BDENS (city) and www.trybooking.com/BDEYB (Bunbury).

On Campus Medical Service, requires part time VR GP, 2 + sessions per week ongoing.

Working with domestic, international students and staff.

Regular sessions (with flexibility) available.

Great opportunity to work in a vibrant dynamic environment with diverse needs.

Accredited practice, well equipped with supportive multidisciplinary team of experienced nurses, psychologists and social workers.

Remuneration 80% of billings, mixed bulk billed and private.

Free on campus parking provided.

An interest in, and experience with, working with young people, mental health, sexual health and immunisation is essential.

Please contact: Lisa Cranfield, Team Leader Murdoch Health: Medical Service Phone 08 9360 2293 | Email l.cranfield@murdoch.edu.au

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AUGUST 2019 | 53

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Movie: The Angry Birds 2 The flightless angry birds and the scheming green piggies take their beef to the next level. When a new threat emerges that puts both Bird and Pig Island in danger, the feathers and trotters need to forge an uneasy truce to form an unlikely super team to save their homes.

In cinemas, September 12

Movie: Amazing Grace

Theatre: Black is the New White Billed as “a razor-sharp romantic comedy that blends Guess Who’s Coming to Dinner with Meet the Fockers gives the audience some idea of the fun in store as brilliant young lawyer Charlotte Gibson brings home her fiancé – an unemployed, experimental composer and a white fella.

The play by Nakkiah Lui was premiered by the Sydney Theatre Company in 2017 to rave reviews and sold out in days. Now it’s Perth’s turn.

Luke Carroll, who plays the narrator, will be in the Perth production and tells Medical Forum that it is the most fun he’s had on stage ever!

“It carries with it some very big social issues wrapped up in a very funny rom-com. People spend a lot of time in the theatre laughing and then spend a lot of the drive home thinking,” he said. “People would stand around in the theatre foyer after the show for a long time talking about the show. Nakkiah has hit the nail on the head.”

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

Winners from June Spider-Man: Dr Devashish Roy, Dr Lee Kaing, Dr Marina Rayside, Dr Wei Hao Lee, Dr Peter Louie

Raining Promises Urgent Care, Pain Management, ENT, Aspirin & Mindfulness

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Palace Cinemas: Dr Nicole Cole, Dr Mandy Croft, Ms Melissa Bator, Dr Shelley Davies, Dr Anita Manes The issuer of these products and services is BOQ Specialist – a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”).

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Scandinavian Film Festival: Dr Cathy Irvin, Dr Min Chan, Dr Cathy Kan, Dr Barry Leonard Crawl: Dr Bill Thong, Dr Astrid Valentine, Dr Yohana Kurniawan, Dr Craig Schwab

Sweeney Todd: Dr Nai Lai

The popular animated Dora the Explorer jumps into the realm of live action and this special adventure takes her out of the Amazon jungle and into the blackboard jungle of high school. The gang is all there – Boots the monkey and Diego – who escape school to save Dora’s explorer parents.

In cinemas, September 19

Movie: The Nightingale

Musical: Hair

Fair Share for GPs

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Our client service centre operates 24/7. It doesn’t matter what time of day or night it is. It doesn’t matter where you are. We’ll ensure that your call is handled by a highly trained team member and that local resources are mobilised and monitored to find a solution for you.

Circus Oz: Dr Ben McGettigan

Movie: Dora and the Lost City of Gold

In cinemas, August 29

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In cinemas, August 29

Set in 1825, Clare, a young Irish convict, chases a British officer through the rugged Tasmanian wilderness, bent on revenge for a terrible act of violence he committed against her family. On the way she enlists the services of an Aboriginal tracker named Billy, who is also marked by trauma from his own violence-filled past.

Heath Ledger Theatre, September 11-22

Like you, when the day comes to an end, we’re still on call

The never-before-seen music documentary captures Queen of Soul Aretha Franklin recording the most successful gospel album of all time, Amazing Grace, with James Cleveland and the Southern California Community Choir. The doco and the album were recorded at the New Bethel Baptist Church in Watts, LA, in January 1972.

June 2019

www.mforum.com.au

Fifty years ago, the original Australian production of Hair romped onto the stage and now a new production is set to let the sunshine in for a new generation. The show, starring Hugh Sheridan and Paulini, features a Grammy award-winning score including the hit songs Aquarius, Good Morning Starshine, Hair, I Got Life and Let The Sun Shine In. His Majesty’s Theatre, August 22-September 1

Choral: WASO Chorus Sings Vespers Sergei Rachmaninov’s deeply personal connection to the sacred music of his Russian homeland is expressed in his stunning choral work, All Night Vigil. Separated into two parts, the evening Vespers and the morning Matins are drenched in rich harmonies that will resonate in St Mary’s Cathedral.

St Mary’s Cathedral, September 22, 2pm

54 | AUGUST 2019

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CHORAL

Bliss in the Cathedral

R

ussian composer Sergei Rachmaninov, beloved for his sweepingly epic, heartracingly romantic piano concerti and symphonies was, in 1915, in and out of Russia conducting in Europe, returning to Moscow to direct the Bolshoi Ballet yet becoming increasingly discomforted by the effects of World War I and the rising tensions that would lead to outright revolution in his country.

Some music historians suggest that his All Night Vigil, which the world knows equally as his Vespers, was his personal homage to his homeland and its sacred musical tradition which Tchaikovsky had revived so magnificently 20 years earlier.

Things certainly wouldn’t be the same a couple of years later.

The piece consists of settings of texts taken from the Russian Orthodox all-night vigil and Rachmaninov set 10 of the 15 sections on chant.

This and the fact that it is, naturally, sung in Russian are some of the challenges facing WASO Chorus and its new choral director Andrew Foote as they prepare to fill the spaces of St Mary’s Cathedral with glorious sound.

This is a new work for both Andrew and the chorus, which the director told Medical Forum provides an extra frisson of excitement among the ranks.

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“When you present something that is fresh to the performers, that can give a performance and edge and to that for an audience inside St Mary’s Cathedral is exciting,” he said.

“What impresses me about the music is that is so serene and to be in St Mary’s on a Sunday afternoon, letting the music wash over you, well that is therapeutic.”

“It was composed for acoustics very similar to St Mary’s. There is about a 5-6 second reverberation in the cathedral and both Rachmaninov and Tchaikovsky before him wrote for these big booming acoustics.

That’s why the piece rolls out. There’s not a lot of fast singing because you would lose the clarity with the reverb. The harmonies just unfold. It’s quite beautiful.”

Learning the Russian text has been helped by having a couple of Russian speakers among the choir but getting the lips around some of those sounds has been certainly challenging.

But the WASO Chorus has faced bigger challenges over the past few years as they have lifted up their voices to the rising expectations of WASO principal conductor Asher Fisch.

The programming of the Vespers was the work of the Chorus’s former director Chris van Tuinen, who has taken up a prestigious appointment as musical director at WA Opera. Andrew said he had taken the lead at several of this year’s chorus events but Vespers will mark the changing of the Chorus guard.

Andrew, who has a distinguished performing reputation here and abroad, will miss his pal, with whom he has collaborated on a number of projects.

“Chris and I worked very well as a team. He was very much on the music and getting it all together, anticipating the 17 different ways a conductor might want a piece to work. I was more the vocal side. Now I’m doing the lot, which is terrific and the WASO Chorus is wonderful to work with.”

“They are as keen as mustard.”

Andrew thinks WA punches above its weight for the quality of our choirs.

“So much is happening in Perth – with small community choral organisations and big symphonic choruses. I reckon we are leading the nation in choral singing.”

How the orchestra perceives the chorus is Andrew’s litmus test of quality.

“I think the WASO Chorus has shown that they can step up and stretch out. The orchestra is my gauge of success. When they look around and smile or clap, that’s a measure of success for me.”

By Jan Hallam

AUGUST 2019 | 55

Like you, when the day comes to an end, we’re still on call

Issues pay no respect to working hours.

You might be on the way home, but that doesn’t necessarily mean that your work is over.

It’s the same for us.

Our client service centre operates 24/7. It doesn’t matter what time of day or night it is. It doesn’t matter where you are. We’ll ensure that your call is handled by a highly trained team member and that local resources are mobilised and monitored to find a solution for you.

Day in, day out. We’re here to help.

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

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