Medical Forum WA Public Edn DECEMBER 2019

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EDITORIAL Jan Hallam, Managing Editor

A Smoking Gun? The Health Minister Roger Cook’s medicinal cannabis announcement on the TV panel show Flashpoint took a few people by surprise, his fellow panellists for a start, including the AMA WA President Dr Andrew Miller and the Police Commissioner Chris Dawson. Just how surprised may be open to conjecture and a small dose of scepticism.

The broad thrust was that the Minister was going to scrap the need for GPs to get specialist approval to prescribe, and he would be directing the department to eliminate the extra State approvals process that has previously been applied to medicinal cannabis.

Now, this confusion could well be wilful, but if someone is selfprescribing street-sourced cannabis for an illness (perceived or otherwise), in their mind it’s medicinal. The weight of anecdote makes this a certainty. What weighs heavily on some of these people’s minds is not the medical efficacy but the legality, for others, it matters not a jot.

So, clearly, laws and regulations do need to be changed – where appropriate – as does the retail cost of the TGA-approved products. While a small vial of TGA-approved cannabis oil sits at the $200-$300-mark, GPs’ prescription pads may not get much of a workout because no one with a chronic condition, for which medicinal cannabis is indicated, will be able to afford it.

Public demand for medicinal cannabis on one hand and policy obfuscation on the other has left the gate wide open for tricky and challenging times ahead, and doctors are caught in the headlights without the usual clinical supports of education or evidence to help them through.

However, medicinal cannabis with THC is classified as an S8 drug so the panel which oversees that catergory will also oversee medicinal cannabis.

Prescribing restrictions will apply for children under the age of 16 and people with a known drug dependency. They will not be able to access the drug without specialist approval.

That’s where both levels of government need to spend some of the extra money they will make in revenue.

The concerns expressed by both Dr Miller and Commissioner Dawson are just as valid now as they were before Flashpoint. More convincing clinical evidence is needed for precision prescribing and public confusion of what is legal and illegal, despite the cannabis producer’s dismissiveness, is real.

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EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au

Money also needs to be spent on public education around the areas of known efficacy and the dangers of thinking medicinal cannabis is completely harmless.

It’s a drug like any other – it can do good and if, abused, it can do harm. It needs to be treated with some caution and respect … and not as a popularity tool.

Journalist James Knox (08 9203 5599) james@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

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DECEMBER 2019 | 1

CONTENTS DECEMBER 2019

INSIDE 10 Close-Up: Neurosurgeon Dr Andrew Miles 14 One Bump Too Many 24 Overseas Service: Madagascar & Bali 30 Beyond the City Limits

10

14 NEWS & VIEWS 1 6 7 20 28

24

Editorial: A Smoking Gun? – Jan Hallam Have You Heard Beneath the Drapes Lifestyle Clue to Alzheimer’s Reversing Type 2 Diabetes?

LIFESTYLE 48 Travel: The Great Ocean Walk – Dr Lin Arias 50 Social Pulse: Perth Orthopaedics 30th Anniversary 51 Wine Review: Rosa Brook – Craig Drummond 53 Fringe World: Choir of Man 54 Competitions mforum.com.au

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2 | DECEMBER 2019

MEDICAL FORUM

CONTENTS DECEMBER 2019

Readership Survey Winner Dianella GP Dr Hoa Pham will be enjoying the hospitality of eateries in the State Buildings after having won the Medical Forum readership survey ‘thank you’ prize. She is pictured here with magazine directors Chris and Karen Walsh.

CLINICALS

5 Lung Adenocarcinoma: A case Study Dr Jenny Grew & DR Nithya Menon

39 Diabetes, Prostate Drugs Modifying Parkinson’s Dr Tim Welborn

Managing Christmas Stress Dr Davinder Hans

43

42 Self-image and plastic surgery in the digital age Dr Linda Monshizadeh

40

Measles – A Spot Diagnosis Dr Aidan Perse

41 Managing Meniscal Tears Dr Satyen Gohil

44 Turning the Tide on Burnout Dr Jenny Brockis

47 Neuroprotection for Stroke Dr David Blacker

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4 Is empathy the best medicine?

Dr Nahat Mavaddat

8 WA’s Grim Opioid Statistics Dr Richard O’Regan

28 Reversing Type 2? It’s Happening Dr Joe Kosterich

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

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DECEMBER 2019 | 3

Is empathy the best medicine?

Where does professional distance become professional compassion?

UWA’s A/Prof Nahal Mavaddat explores the issue.

There is growing evidence that practitioner empathy and its behavioural correlate, compassion, improve patient health outcomes and the benefits are significant.

Studies suggest that with an empathetic approach, patients accept their medical diagnoses more readily, have improved mental health and a reduction in pain.

Studies also show that patients have improved blood sugar control, lung function, wound healing, duration of the common cold, and physical rehabilitation as well as a reduced length of intensive care and hospital stay, and a reduced risk of mortality.

Practising empathy can therefore no longer be considered a soft skill for doctors, but rather a scientific, evidence-based partner with clinical competence in delivering quality health care.

Empathy is more than sympathy, which is simply feeling sorry for another. It is a shared feeling of another’s pain, which frequently leads to a compassionate action to alleviate that pain.

The journalist Daniel Pink famously said that: “Empathy is about standing in someone else's shoes, feeling with his or her heart, seeing with his or her eyes.”

It can help a doctor to gather better diagnostic information; improve patients’ recall of instructions, thereby improving medication compliance; patients are more motivated to make lifestyle changes; and there’s a lowering of patients’ psychological and physical stress with a beneficial physiological flow-on for the nervous and immune system.

Studies also show empathic and compassionate doctors also make fewer medical errors. Just a few words at the beginning and the end of a consultation can make a huge difference to the lowering of patients’ emotional distress and pain and improve clinical practice.

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There’s also benefits for doctors. Even small acts or words of compassion for patients on a daily basis can counteract the burnout that results from the sometimes overwhelming experiences of providing patient care.

Empathy has been thought of as being a hard-wired personality trait. Now, however, it is more often viewed of as a cognitive skill that can be learnt. Trials including those involving medical students and doctors suggest that empathy may indeed be taught to health professionals.

We are, in fact, biologically hard-wired for empathy.

In the 1990s neuroscientist Giacomo Rizzolatti, at the University of Parma in Italy, discovered, while working on bonobo monkeys, ‘mirror neurons’ primarily in the premotor and parietal cortex of our brains.

These neurons fire up when we perform an action or experience pain or touch, and also, importantly, fire up when we observe these in another person – thus mirroring the experience of the other triggering feelings of empathy.

At the University of Western Australia, a Medical Humanities Network of teachers and researchers has been established to promote and research the human side of medicine including the study of empathy.

An undergraduate major in Health Humanities, in which an empathic approach to healthcare is taught, has also commenced this year through the School of Allied Health at UWA for those planning to go on to one of the health professions.

Medical or Health Humanities – fields complementary to medical and allied health studies – combine the arts, literature, creative writing, philosophy, law and other humanities disciplines to help balance the teaching of science with the art of medicine. The aim

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is to create more empathic and balanced doctors and allied health professionals.

One technique with a growing evidencebase is that of ‘object-based learning’ – attentively looking at objects, observing and then reflecting without judgment. At UWA, a collaboration with the Lawrence Wilson Art Gallery has given medical and health humanities students a chance to attend gallery sessions designed to improve their powers of observation and empathy.

Empathy may also be developed through experiencing stories of patients by using creative art (a painting, a piece of music, a verse of poetry, a chapter of a fictional story) to promote powers of deep listening and acceptance. ‘Depth of Field’, a pictorial series of patient images on each of the areas of ageing, stroke and mental health created at UWA, helps students develop these skills through the visual narratives of patients’ stories.

Another emerging method is the use of a range of models of immersive experiences that range from blindfolds and 3D glasses, to reality suits or virtual reality simulators that mirror the experience of being in the skin of patients, especially those with a disability – for example, simulating the experiences of a blind person or someone who has survived a head injury or stroke.

Knowing their benefits, we can all as doctors strive to be empathic and compassionate in our daily interactions with patients. Knowing that these skills can be learnt and taught is encouraging!

For an excellent overview of the role of empathy and compassion in health care see Trzeciak and Mazzarelli.

Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference 2019, Studer Group.

ED: Dr Nahal Mavaddat is Associate Professor, Division of General Practice, School of Medicine UWA

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Major Partner: Australian Clinical Labs

Patient Story: A Comprehensive Case of Lung Adenocarcinoma

By Dr Jenny Grew, Anatomical Pathologist, and Dr Nithya Menon, Anatomical Pathology Registrar The histopathological diagnosis of lung adenocarcinoma is often not considered problematic. However, the diagnostic process is no longer limited to morphology and immunohistochemistry.

The following case study highlights the significant role of molecular testing in the clinical management of patients.

Clinical History Mrs HO is an 82-year-old ex-smoker who presented with a PET-avid, small right upper lobe lung nodule. On CT imaging, the nodule was characterised by a mixed ground glass and solid nodular opacity measuring 13mm and was suspected to represent a slowly resolving infectious or inflammatory process, rather than a malignancy. Her past medical history includes Type 2 diabetes, osteoarthritis, osteoporosis, hypertension, diverticulitis and transitional cell carcinoma of the bladder.

Surgical Pathology Mrs HO subsequently underwent a right upper lobectomy. Microscopic assessment of the lung lesion showed two tumour foci, measuring 0.2mm and 10mm, with features of moderately differentiated adenocarcinoma, predominant (65%) acinar growth pattern (see Figure 1), some papillary growth (30%) and a small component of micropapillary architecture (5%). The tumour cells were columnar with variably enlarged, irregular nuclei, vesicular chromatin and prominent nucleoli. There was no associated lymphovascular or perineural invasion, and the tumour foci were clear of pleural and resection margins.

Figure 1: acinar pattern adenocarcinoma

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Ancillary/Biomarker Testing In the absence of active tumour lesions elsewhere, this tumour was suspected to represent a primary lung tumour rather than a metastasis. Immunohistochemical stains were performed, with the tumour cells showing strong positive staining for CK7 and TTF-1 (see Figure 2), and negative staining for CK20, confirming a lung primary. PD-L1 and ALK immunohistochemical staining was also negative. Molecular analysis was performed and the tumour showed presence of a KRAS mutation but no other gene mutations, including EGFR, were detected.

KRAS mutations are found in 20-25% of lung adenocarcinomas. However, their overall impact on survival is controversial. KRAS mutations have not influenced treatment decisions as there is currently no approved targeted therapy.

Immunotherapy has also emerged as a new treatment modality for lung carcinomas in patients who do not have targetable alterations, using PD-L1 immunohistochemical expression as a predictor of response to PD1 antibody therapy.

Conclusion Both molecular and immunotherapy treatment approaches require pathological molecular biomarker assessment. The clinical expertise of the pathologist is imperative in accurately identifying patients whom will benefit from targeted therapies.

Dr Jenny Grew Figure 2: positive TTF-1 immunohistochemistry

Importance of molecular testing for clinical management Molecular analysis in tumour specimens has become the standard of care in laboratory testing for the clinical management of lung cancers via molecular diagnostics-guided targeted therapies. In cases of lung adenocarcinoma, several gene alterations have been found which include KRAS mutations, EGFR mutations, ALK rearrangements, ROS1 gene fusion, as well as other less common gene mutations/amplifications such as HER2, BRAF, RET, MET, PIK3CA, NTRK1 and others.

Among these mutations, EGFR and ALK are the most clinically relevant as targeted drugs (EGFR tyrosine kinase inhibitors (TKIs) and ALK inhibitors) are available for tumours exhibiting these molecular alterations.

MBChB, FRCPA, AFRACMA Lab: Subiaco Speciality: Anatomical Pathology Areas Of Interest: Cytology, colorectal, gastrointestinal, gynaecology including oncology, head and neck, lung, skin and molecular oncology Phone: (08) 9213 2173 Email: jenny.grew@clinicallabs.com.au Dr Jenny Grew joined our team at Australian Clinical Labs as Clinical Director Anatomical Pathology for WA in 2017. A graduate of the University of Otago (MBChB, 1992) Jenny began pathology training at Christchurch Hospital (NZ), gaining RCPA Fellowship in 2001. Jenny moved from New Zealand with her family (husband Keith and son Dominic) to Queensland in 2007, taking up the role of Pathologist in charge, providing service to 6 public and private hospitals. She is a keen educator and champion of multidisciplinary patient care in private pathology.

1300 367 674 clinicallabs.com.au DECEMBER 2019

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HAVE YOU HEARD?

Autism clinical service The Telethon Kids Institute has launched Clinikids, a unique stand-alone clinical service for children aged between 6 months and 12 years with early developmental delay and/or autism, which will provide access to the best evidence-based therapies and interventions, while integrating worldfirst research into treatment modalities.

Clinikids is the first clinical service provided

by Telethon Kids Institute and the first of its kind in Australia. The clinic intends to reduce the lag between research and clinical application by collaborating with the Telethon Kids’ autism research team led by Professor Andrew Whitehouse.

Federal Health Minister, Greg Hunt, opens Clinikids

Gene genie The Association of Australian Medical Research Institutes (AAMRI) has released a position statement in response to the Australian Greens’ motion to disallow an amendment to the new Gene Technology Regulations currently being debated in the Senate.

The Greens are opposed to deregulation of new genetic modification techniques in animals, plants and microbes, with Senator Janet Rice saying, “this deregulation is reckless and poses huge economic risks to Australia's $48 billion agricultural export industries.”

According to AAMRI, the proposed disallowance will rescind parts of the Gene Technology Act and negatively impact medical research that uses gene technology therapies. AAMRI President Professor Jonathan Carapetis said, “this dangerous situation will not only hinder medical research, it potentially puts the community at risk as gene technology will not be appropriately regulated.”

Booze barns blocked In an attempt to reduce alcohol-related harm, the WA Government has amended the Liquor Control Act 1988 to restrict the size and location of large liquor stores.

These amendments will be the first of their kind in Australia and will require the establishment of liquor stores sized 400 sq m or greater to be at least 5km (in the metropolitan area) or 12km (in regional centres) away from of an existing liquor store of the same size. The Act does not apply to existing large liquor stores if they happen to be within the restricted distance but it will not allow such an existing store to extend.

The Director of Liquor Licensing will also be able to assess whether consumers' needs are reasonably met by existing packaged liquor outlets when assessing a new application for an outlet in a local area.

with Liquor Stores Association of WA, Australian Hotels Association (WA), the McCusker Foundation, WALGA, as well as a range of private companies and peak bodies.

The new MBS items are restricted to a specific list of evidence-based eating disorder treatments and the government will evaluate the scheme after the first 12 months.

Eating disorders and MBS

PathWest & My Health Record

Treatment of complex eating disorders are now covered by the Medicare Benefits Schedule (MBS), providing eligible people with access to psychological and dietetic services. An eating disorder treatment and management plan drawn up by a GP will attract a Medicare rebate.

PathWest is now connected to My Health Record, which will allow patients to access pathology results directly in their online health record. PathWest becomes the first pathology provider in Western Australia to upload direct to their patient’s online health record.

The amendments, based on the recommendations from the MBS Review Taskforce, include a suite of new Eating Disorder Psychological Treatment items in the MBS, 64 in total, such as up to 40 psychological services and 20 dietetic services within a 12-month period.

The results will be made available to the requesting doctor as soon as they become available and patients will have access seven days later.

MRIs & MBS Another amendment has been made to the Medicare Benefits Schedule (MBS) with

Who knows best?

A research study has attempted to understand how doctors’ medical decision making is influenced by patient choices in advanced care directives (ACD). The study, conducted by Advance Care Planning Australia, recruited 21 doctors from a Melbourne hospital and found that ACDs could be problematic, with doctors reporting they would be more interested to act in their patient’s best interest rather than following the directive. The doctors suggested they would be more likely to override their patient’s directive and use their own decision making if:

• The directive is ambiguous, confused or not current

• The directive is not readily available at the point of care

• Their patient’s family is opposing the directive

• The doctor has assessed their patient has a potentially reversable condition

The doctors also suggested some directives may not be particularly effective due to the ability of non-medically trained people to make such medically involved informed choices. Yet, as ACDs are legally-binding documents and patients have a right to make decisions about their care, the findings from this study if representative could prove tricky for everyone.

The changes were drawn up in consultation

6 | DECEMBER 2019

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MRIs for women with, or suspected of having, breast cancer being eligible for a Medicare rebate.

For a patient to be eligible, they will need to have had prior imaging that was inconclusive for diagnosis and a biopsy was not possible.

While for a patient who has been diagnosed with invasive breast cancer to be eligible for an MRI, a discrepancy between their imaging assessment and clinical assessment is required.

Baby brain function app Can the movements of newborns be a potential biomarker for cognitive impairment? The WA-based Early Moves study, led by Dr Jane Valentine and Professor Catherine Elliott, hopes to answer this question.

The researchers will recruit 3,000 parents and their babies for the study and they will be asked to use a bespoke phone app, called Baby Moves, to film their baby’s movements in two, threeminute recordings, taken at two and 12 weeks of age. The Baby Moves app will be developed with machine learning to differentiate between normal and abnormal body movements. After two years, the participant babies, now toddlers, will be assessed for cognitive impairment.

Autonomous but not happy A report by the Brightwater Care Group examined the use of assistive toileting devices for people with an acquired brain injury for patients receiving community-based brain injury rehabilitation.

The report’s authors claim a significant reduction in care requirements for the participants, from 15.3 hours of care a week to 11 hours, decreasing the cost of care by about $630 a participant, per week.

Participants reported increased cognitive and functional independence from the autonomy provided by the devices and a reduction in episodes of incontinence. However, the participants reported a decline in quality of life after the three-month study had concluded, which prompted a call for further study to determine why. The authors recommended an emphasis on client-centred continence care; improved coordination of care; a standardised procedure for the funding of assistive toileting devices.

Professor John Newnham, whose pioneering work in preterm birth has led to the establishment of the Women and Infant Research Foundation and helped make life for WA women and children safer, has been named 2020 Senior Western Australian of the Year. He will be the state’s representative in the category at the Australian of the Year Awards in January.

Dr Anand Deshmuhk, from the WA Country Health Service Pilbara, and Shivani Lala, from Southern Cross Care, are equal recipients of the Eric Dillon Consulting Mental Health Employee Excellence Award, which was announced at the WA Mental Health Awards night.

The WA Government has opened the tender process to build a $16.5 million, 38-bed aged and palliative care facility in Carnarvon. Construction is expected to start in the first half of 2020.

Professor Jon Watson, a Fellow of the Royal Australasian College of Physicians and a Fellow of the Royal College of Physicians, London, has been appointed Executive Dean, Faculty of Health and Medical Sciences at UWA. After practising as a gastroenterologist and physician in Ballarat, Newcastle and Geelong, Prof Watson was appointed as Clinical School Director for Deakin University’s School of Medicine in 2011, and Dean and Professor of Medicine at Deakin in 2014. His undergraduate medical training was at Cambridge University. He trained as a specialist in Newcastle upon Tyne and was awarded a PhD for his studies into liver disease. He is still actively researching Hepatitis C Virus (HCV) related liver disease.

Fiona Stanley Hospital oncologist Dr Indunil Weerasena has been awarded a WA Government Cancer Research Fellowship to continue his work in understanding a highly aggressive and difficult-to-detect form of breast cancer. Dr Weerasena is one of seven researchers sharing $1.2 million as part of the WA Cancer and Palliative Care Network program. Other fellowship recipients are Dr Timothy Humphries (SCGH); Dr Andy Hutchison (FSH), Dr Azim Khan (FSH), Dr Annalise Martin (RPH); and Courtney Wood (PCH).

Former Nationals WA Minister Terry ‘Tuck’ Waldron is the new chairman of Rural Health West. Mr Waldron has taken over from Grant Woodhams, who along with Deputy Chair, Adj/Associate Professor Robyn Collins, and GP Dr Petronella Slootmans, have stepped down from their roles on the board after years of service.

Adj/Assoc Prof Robyn Collins has also stepped down as WA Manager of AHPRA. The new state manager is Ms Karen Banks.

UWA diabetes researcher Dr Lakshini Herat has been awarded the People’s Choice Award at the 2019 Women in Technology WA Tech [+] 20 Awards. Dr Herat is a postdoctoral research officer with the Dobney Hypertension Centre at RPH Research Foundation. Her work focuses on testing a new class of anti-diabetic drug that could be used to treat diabetic eye complications.

Ed Duncan has been appointed the NDIS State Manager Emeritus Professor Mike Daube has been awarded the Cancer Council Medal for Distinguished Service for his role in public health research and policy making for more than 40 years, particularly around tobacco controls.

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DECEMBER 2019 | 7

WA’s Grim Opioid Statistics A multi-faceted approach is needed to rein in the rate of unintentional drug induced deaths, writes addiction medicine specialist, Dr Richard O’Regan.

There is global attention on the optimal use of opioids. Life expectancy in the United States dropped for three successive years from 2015 – the longest sustained reduction in expected lifespan since the period 1915 to 1918 when World War I and the Spanish influenza pandemic made a dramatic impact on life expectancy globally.

Significant drivers of the reduction were drug overdoses and suicides. Overdose rates in the US peaked in 2017 with more than 72,000 deaths registered, of which 47,600 (or 130 people dying each day) were opioid-related.

Australia’s Annual Overdose Report[1] is released to coincide with International Overdose Awareness Day on August 31. This year’s figures continue to show more Australians are dying, with 1612 unintentional drug induced deaths (UDIDs) recorded for 2017 (8.9 per 100,00 population).

Between 2001 and 2017, Australia’s population rose by 28% and the number of UDIDs increased by 64%. Most deaths result from multiple drug toxicity, rather than a single substance causing fatality.

The age group 30-59 years have the highest incidence of unintentional druginduced mortality, and males account for 71.5%. UDIDs among Aboriginal people are three times the rate of non-Aboriginals (19.2 compared to 6.2 per 100,000).

Opioids continue to cause the highest number of deaths, with 904 opioid-related unintentional deaths reported nationally in 2017, while stimulants, anticonvulsants and antipsychotics show the highest rate of increase over the past 10 years.

Benzodiazepines are the second most common group of drugs associated with overdose death, and are usually associated with deaths involving multiple drug use.

While heroin-related deaths have increased substantially since 2012, the likelihood that an overdose death was related to prescription opioid remains significantly higher than for heroin.

In 2017, 64.7% of all opioid-induced deaths were related to prescription opioids, and 26.2% were related to heroin[2].

In 2017, WA recorded 208 UDIDs, with 132 of these being opioid-related[2]. Between 2012 and 2017, WA recorded the greatest increase in rate of UDIDs nationally, rising from 6.4 to 8.1 deaths per 100,000

8 | DECEMBER 2019

population. Perth has the highest rate of UDIDs among the state capitals at 8.5, while regional and rural Victoria has the highest rate of all regions in the country at 9.6. WA recorded the highest rates of deaths involving oxycodone, morphine and codeine, and for fentanyl, pethidine and tramadol, and the second highest rate of heroin-related deaths.

Why is this significant?

Most UDIDs in Australia occur in relation to prescription medication, which means prescribers can influence these figures.

The terms ‘medication stewardship’ and ‘universal precautions’ are increasingly being heard in association with the goal of improving our prescribing habits. Both refer to the safer prescribing of medications with the intent of creating a balance between patient access to appropriate and necessary medications and minimising non-intended use.[3] Prescribers need education and support towards safer use of medications. Recent publications such as those produced by the RACGP on prescribing opioids in pain management[4] provide comprehensive advice on the topic. With WA’s prescription drug monitoring system expected to launch in 2020, prescribers will have a tool with which to make informed prescribing decisions.

Further, access to best practice treatment for opioid dependence needs to be readily available and affordable. Medication assisted treatment comprising of

buprenorphine or methadone maintenance is the mainstay but is restricted to authorised practitioners, and few GPs undertake this work.

Out-of-pocket costs make the treatment unattractive and difficult for patients to afford. WA needs to maintain and expand provision of this vital treatment to ensure those in need are able to enter treatment.

We must explore sustainable means of attracting, retaining and supporting GPs to provide addiction treatment, particularly in regional and remote areas.

Other initiatives such as the provision of take-home naloxone for people likely to experience or witness an overdose are growing, and WA is a leader in Australia with the WA Naloxone Projects. While no single activity alone is sufficient to rein in our rate of opioid and other pharmaceutical UDIDs, the combined application of the above can certainly move WA in the right direction.

References 1. Penington Institute, Australia’s Annual Overdose Report 2019. 2019, Penington Institute: Melbourne.

2. Chrzanowska, A., et al., Trends in drug-induced deaths in Australia, 1997-2017. 2019, National Drug and Alcohol Research Centre, UNSW Sydney: Sydney.

3. Gourlay, D.L., H.A. Heit, and A. Almahrezi, Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med, 2005. 6(2): p. 107-12.

4. Practitioners, T.R.A.C.o.G., Prescribing drugs of dependence in general practice, Part C2: The role of opioids in pain management. 2017.

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Living on the Knife’s Edge Neurosurgery takes steady hands and nerves of steel.

It can be triumph or trouble. Neurosurgeon Dr Andrew Miles says the third ‘T’, training, is the key.

"W

hat's the difference between God and a neurosurgeon?

God doesn't think he's a neurosurgeon.”

One suspects that neurosurgeon Dr Andrew Miles wants to get that joke out early in the conversation – partly to show his self-deprecating side and partly as an acknowledgement that it does indeed run through neurosurgeons’ minds (and others) from time to time.

“It's one of those very demanding specialties. When things go right, operating on someone’s brain, and they come out of it better than when they went in, patients do treat you almost godlike,” he told Medical Forum.

“When things go wrong, particularly with brain tumours, they can go very wrong.

So, you have to have a pretty tough skin.

It's horrible having to tell a patient or their family that they've woken up with a stroke, or they are paralysed down one side of their body, or they can't speak. So, I think, the job does create an individual with certain personality traits.”

“Sometimes it's hard to live with – for the surgeon and people around them. It does take a toll, personally, and not everyone's cut out for the lifestyle. I’ve certainly come home pretty upset but, fortunately, that’s uncommon.”

Reality bites “I’m finding now that it's not only when something bad happens I’m brought up short. At 52, I’m getting to an age where I'm operating on people who are the same age as me. I share common experiences, same age, children the same age. To tell

10 | DECEMBER 2019

them they've got a brain tumour that will probably take their life within a year or two or three, it’s sobering.”

“It’s certainly made me spend as much time as I can with my teenage girls.”

Andrew, one of three children, was two when his English parents immigrated to Western Australia in 1969.

“I come from a what might be best described as a working-class background.

My parents were part of the ‘£10 Pom’ migrations,” he said.

“My father was a carpet layer and in the school holidays he’d take me to work with him. I realised early on how hard he worked and how dragging carpets around with all the bending and stooping was tough on his body. I told him that I didn’t want to do that the rest of my life. His reply was, ‘well, you better study hard and get yourself out of this’.”

“So, I did! I studied hard and thought I might be able to get into medicine. What pushed me over the line was my maths teacher at Greenwood High School, Mr Deering, in Year 11, who told me I’d be lucky to get into university, let alone medicine.”

“I think I’d feel a certain satisfaction if he ever came to me as a patient.”

While Mr Deering put the fuel in the tank, Andrew’s art teacher inspired his creative side, especially his lifelong interest in photography, and his work ethic.

“He told me that if I worked hard, I’d get the success I deserved. In hindsight, that’s been a double-edged sword.”

Why neurosurgery?

All medicine is exacting but it is probably fair to say that focusing on the bits we can’t do without is living on the edge. So how did Andrew decide that neurosurgery was the medicine for him?

“Pure chance,” he said, grinning.

“My very first job as an intern was on the neurosurgery ward, which was pretty tough.

I didn't really know what I was doing, but it was a ward where there was an intern, a junior resident and a senior resident plus two registrars. So, there was a lot of support. Wayne Thomas was a wonderfully supportive mentor as was Bryant Stokes.”

“The following year, I joined the ward as a junior resident and then went onto the training program.”

“What I liked best about surgery and neurosurgery was the quick satisfaction.

There's a patient with a problem. You have to use your intellect to work out what that problem is, then use your hands to fix it.

That’s exciting.”

“One of my fascinations is handmade Swiss watches. People question the cost of watches like that, but take a look at the mechanisms inside, it’s astounding. There are some similarities between watchmaking and surgery. We both work under high magnification doing intricate and difficult work with not a lot of margin for error.”

Of course, fall over that margin in neurosurgery and the consequences are dire. Andrew thinks that’s where the neurosurgical crankiness is born.

“Training was great but that first year of two as independent neurosurgical consultant,

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CLOSE-UP you know, I spent much of my working day scared. I readily admit that. While training there is someone watching over you, then suddenly your name is at the top of the list. You’re the one who takes all of the responsibility,” he said.

Keeping control “I think that is why junior neurosurgeons get a bit of a negative reputation around the place. You're so intense and focused, and try to make what you do as perfect as it can be. When you perceive that people around you are not doing the same thing, you tend to let the stress fly.”

“It's a difficult balance because sooner or later, you've got to get those feelings under control. You can't be screaming at the people around you for the rest of your working life. So, it really does take a good couple of years to get that fear under control.”

At this juncture, Andrew pauses and laughs.

“Of course, once you’ve got the fear under control, that's when the ego kicks in and that's when you start to develop a God complex. Young neurosurgeons have to be to be conscious of that and I’m not excluding myself from this.”

“There’s a middle ground between being fearful and overconfident and arrogant – it’s the moment when you just get on with the job and appreciate the fantastic group of people we work with. I have a fantastic team around me – from anaesthetists and surgical assistants and most importantly, a fantastic group of nurses in both theatres I work at – St John of God in Subiaco and Murdoch. I couldn't do the job that I do, to the standard I want, without them.”

Andrew did his surgical training at SCGH and RPH before heading to Seattle in the United States.

“I chose Seattle because I had an interest in epilepsy surgery and RPH had a comprehensive epilepsy service that I had planned to return to. I went to work with Professor George Ojemann, who had a phenomenal reputation as an epilepsy surgeon. It was privileged to work with him.”

and with the Comprehensive Epilepsy Service. And then while I was there, I also did a spinal surgery fellowship.”

While the experience in the US was special, Andrew believes Australia produces better, more rounded surgeons.

“There is a lot of peer pressure early on and the hours are long, though I think things are a lot better now. It's still a balance though because Australia prides itself on the quality of surgeons who come off the conveyor belt. They are well trained and that doesn’t happen in a lot of countries, even the US,” he said.

“The US centres of excellence are the best in the world, but the vast majority of the population doesn't have access to them.

They go to community hospitals where a neurosurgeon might only do one brain tumour every month.”

“If you're only doing an operation once a month compared to someone who is doing the same thing five times a week, the skill levels will be vastly different. In Australia, the most of us get to the end of our training with a very good, broad experience so the public can be assured that 99% of the time their surgeon will be skilled and well trained. However, how we get there is through experience. It's an apprenticeship.”

Andrew said he resigned from the public system four years after he returned from the US. Mounting up “I got very disillusioned, for a variety of reasons. The work at the Comprehensive Epilepsy Centre was all very stimulating and interesting. But I took on too much.

We had just had a baby, I started a private practice and I was working at Charlie's, Royal Perth, the Mount, Joondalup, so I was running everywhere,” he said. “I had no time.”

“And I was seeing patients in the clinics with spinal pain, more than anything else.

I knew they would probably never get operated on just because the waiting list was so long. That was back it 2003, it was bad. These people would be in agony because of pinched nerve pain and you just knew they’d be put on narcotics.”

“Some of them would get better by Mother Nature, eventually. But a lot of them would be in a lot of trouble, and that was quite disheartening. And then I had the misfortune of being involved in a legal case, about three years into my training.”

“An epilepsy patient needed very complicated surgery where I had to remove fairly large areas of brain. I did cure his epilepsy, but his personality changed and his wife ended up suing on his behalf for failure to warn sufficiently about the side effects. It was a very protracted case – it went on for years and that was hugely stressful.”

“I just decided that I didn’t want to do it anymore. However, I still use the techniques I learnt from George Ojemann for brain tumours in my private practice.”

Andrew’s precision equipment for a large proportion of his career has been his hands, but technology is making a play. He is particularly enthusiastic about neuronavigation for spinal and brain surgery.

“It’s a fancy GPS really. It’s based on the same technology. We can now triangulate the exact location of a tumour which means we can now do brain surgery though a small hole in exactly the right spot. And similarly, in spine surgery, you know to guide the screws into the bone on exactly the right path,” he said.

“That's a big change. I've been doing this minimally invasive spine surgery for about

continued on Page 12

While the work was stimulating, given the exposure of a quantity of cases not often seen in Australia, it was arduous.

US marathon “My wife was unable to work, which was isolating, and the hours in the hospital were extraordinary. If you think we work long hours here, the neurosurgery units over there clock in at 5am and operate until 10pm. The chief residents on their one year of training actually don't leave the hospital. They get about one week out of the hospital every three months and hardly ever see their partners. I lived in the hospital for three months,” he said.

“It was pretty tough.”

“But I ultimately got back to Royal Perth

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Dr Andrew Miles (far right), with Neurospine Institute colleagues Dr Paul Taylor and Dr Michael Kern.

DECEMBER 2019 | 11

continued from Page 11

Living on the Knife’s Edge five years and patient feedback is less pain for less time, and the hospital stay is shorter.”

Robots are also creeping into spine surgery, but Andrew is cautious about being a “too early” adopter of new technology.

AI and IT “I’ve been to a couple of robot courses for spinal surgery and I certainly consider myself open to new technologies. I was one of probably 10 to 15 surgeons across Australia who got involved in artificial disc surgery from the start.”

“Obviously you have to realise there is a fine line between pushing the technology boundaries and using your patients like guinea pigs.”

However, he welcomes computer-based decision making.

“If a computer can help me sift through the massive amounts of data that I couldn’t hope to take in, it will be very, very useful for medicine and amazing for my specialty.

But I don't think that's truly artificial intelligence, that very powerful computing,” Does it replace the skills he has worked so hard and so long for?

“No, I don't think so. It's an adjunct. It's not possible for anyone to know everything. AI will happen in the future but probably not in my lifetime, but I think it would be a horrible society if it were led by a sentient machine.”

“I take heart from Star Trek, you know.

They still had an onboard physician!”

More practically, Andrew believes the immediate future will see all branches of medicine work from a multidisciplinary perspective. He and his partners, Dr Michael Kern and Dr Paul Taylor, have pulled together a team including a general physician, a pain specialist, physiotherapists and an exercise physiologist, with a clinical psychologist also available.

Outcome-based care “I think it will become standard of care. The days of doctors, and surgeons in particular, being solo practitioners doing their own thing and then discharging their patients to their own devices will slowly end. Payers – governments and insurers – won't allow that to happen much longer. They'll want value for their money. And value for their money comes from using every resource we have to get the patient back to function,” he said.

“It's ultimately for the benefit of the patient and its good for the teams as well. It’s very useful to have colleagues on hand to support and discuss difficult cases.”

Andrew is also dedicated to research through his own practice. He is a strong believer in the need for a national spinal surgery registry.

“We bought the licence for the same software being used by the British Spine Registry. In the UK, it is an NHS requirement for funding that all patients who undergo spine surgery be put on the registry detailing their outcomes,” he said.

“We are doing this for our patients now.

They are sent post-operative questionnaires at three months to 12 months. The orthopaedic fraternity are doing it and I hope the Australian Spine Society will mandate a registry in the same way.”

“It’s important to identify good outcomes, but also to identify outliers. We have set up a research foundation and hope to attract some industry support. In a year or two, we'll have a large amount of data that can really support good practice.”

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FEATURE

One Bump Too Many Sporting codes are starting to take the long-term risks of concussion seriously, but as sport makes up a small percentage of cases, it’s time to deal with the other 85%.

C

oncussion, once seen as ‘part of the game’, especially in contact sports, is now treated with caution and stringent returnto-field protocols to ensure further damage isn’t sustained. Depending on the sporting league, there may be defined concussion protocols with medical and allied health professionals to assess their athletes.

However, not all sporting leagues have these procedures.

Another broader and pertinent aspect of concussion is the fact that a majority of them do not occur on a field of play. Nearly 15% of concussions can be attributed to sports, while falls, car accidents, recreational activities and domestic violence account for the majority of reported cases.

The concussive impact is just the beginning of the journey with the majority of cases experiencing continuing symptoms for up to three weeks before resolution. Then there is about 15% of concussion cases that express a plethora of persistent symptoms for weeks, months and sometimes years after the concussion.

These chronic cases, once categorised as post-concussion syndrome, are now clinically named persistent postconcussion symptoms.

Diagnosing a concussion for athletes has progressed with the development of tools such as the Sport Concussion Assessment Tool 5 (SCAT-5), while GPs will diagnose based on their patients’ medical history, a physical examination including a focused neurological assessment, balance and cognitive testing. Even with these tools and procedures, a concussion remains a clinical diagnosis.

So, how are clinicians meant to diagnose and treat concussions without a way of quantifying the severity of the trauma and the individual differences between cases?

Some individuals can absorb a concussive impact without short or long-term consequences, while others can sustain a

14 | DECEMBER 2019

concussion from the same level of impact and experience significant short and longterm consequences.

Further complicating diagnosis is the lesser known sub-concussive impact, where an individual sustains an impact that is below the threshold of expressing symptoms that can potentially cause damage.

There is increasing evidence pointing towards long-term exposure to concussive and sub-concussive impacts being causal to chronic traumatic encephalopathy (CTE), a nascent neurodegenerative disease. Think of a football player taking a hit from a tackle and continuing to play without any issue or symptoms, then continuing to take similar knocks throughout the game, then multiply this over the lifetime of their career and the cumulative damage can be causal to CTE. What is not known is how many bumps is too many, and what is the threshold before the damage is irreversible. As a CTE diagnosis is only possible by post-mortem autopsy, to definitively identify causality is difficult.

Measuring the unmeasurable The fundamentals of a concussion are relatively simple. A mild form of traumatic brain injury (mTBI) caused from an impact to the body or head with enough force to shake the brain and cause it to impact the skull, damaging nerve fibres and small blood vessels. While changes to the brain from an isolated concussion will be resolved without intervention, in the majority of cases, this is dependent on the impact itself and the individual’s susceptibility and resilience to the concussive force.

Yet, concussion severity is difficult to measure as there is a multitude of variables that contribute to the injury, such as the force of the impact, and the neurological and physiological susceptibility or resilience of an individual to the impact.

There is, however, a broad symptomology that goes some way to provide clinicians with enough diagnostic markers to identify if an individual is presenting with concussive

symptoms, such as the SCAT-5 tool.

Melbourne neurophysiologist Associate Professor Alan Pearce is a researcher focused on neurophysiology of sports-related concussion. He uses transcranial magnetic stimulation to observe the central nervous system integrity, comparing concussion injuries in both acute settings and in the longterm potential chronic effects of repeated head trauma.

“There is a constellation of signs or symptoms that won’t necessarily be the same across two individuals. And these range from being knocked out – which occurs in 10% of concussions – to signs of unstable gait or being dizzy or unbalanced,” he said.

“Then you have symptoms such as headaches, nausea, confusion, slurring of words, inability to focus, inability to maintain eye contact or focus. Generally, in that very acute space, people can get quite anxious about what's going on. It could be a set of signs and symptoms relating to the actual observed insult to the brain.”

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“It's a difficult area because there isn't a clearly established definition. Determining if an injury has occurred without clear identification of what sub-concussive impacts have actually been sustained during a person’s life-time or sporting career is problematic,” she said.

Seldom self-reporting Perth neuroscientist Professor Melinda Fitzgerald is a neurotrauma researcher and Deputy Director of the Curtin Health Innovation Research Institute at Curtin University, jointly appointed by the Perron Institute. She is focused on understanding the mechanisms of damage which occurs following a traumatic brain injury and predicting outcomes following a concussion.

Prof Fitzgerald said self-reporting of concussions is an initial barrier to care as people did not necessarily seek medical attention following what was probably a concussive impact.

kind of repeated lower level impacts,” A/Prof Pearce said.

“You can't diagnose a concussion without a set of symptoms and the heterogeneity of symptoms are huge in concussion. The added difficulty is trying to diagnose when an individual is not presenting with any concussions or symptoms.”

The difficulty, he said, was in what was assumed as a concussive impact, such as an athlete taking a heavy hit on the field then continuing playing without expressing any overt symptomology.

“Do you pull them off to try and assess, or, do you not? Particularly if they're saying, ‘I'm fine’. The other added complexity is that concussion is what we call an evolving injury. You can get concussed but symptoms may not show up until several minutes or several hours later, or even the next day.”

Sub-concussive impacts An area of concern is sub-concussive impacts where an individual can experience multiple impacts over time.

“We really don't yet know whether subconcussive hits, for example, heading a soccer ball over a career, is going to lead to longer term problems. While there doesn't seem to be the severity of concussion symptoms reported following repeated sub-concussive hits, it's not yet clear whether there may be longer term outcomes as a consequence of those

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His research has focused on contact sports athlete cohorts that are commonly expected to experience a multitude of sub-concussive impacts over a career.

“We're seeing neurological impairments that correlate to cognitive impairments and some fine motor control changes as well, but they are quite subtle.

These people are not advanced in their impairments. What I've been looking at is the effect on the brain and central nervous system of having multiple concussions, or hundreds or thousands of smaller subconcussive hits, 20 years later.”

According to A/Prof Pearce, the more concussions the brain experiences, the easier it is to be concussed, with less impact force required for concussion symptoms to present. Each subsequent concussion generally requires a longer recovery too, yet why this is the case isn’t clear.

Perth sports doctor Dr Gill Cowen told Medical Forum that while there was ongoing research focused on subconcussive impacts, the evidence was not clear as to the long-term consequences. Even defining what a subconcussive impact is, was problematic.

Dr Cowan is a senior lecturer at Curtin Medical School and chair of the Sports and Exercise Medicine Network in the RACGP Faculty of Specific Interests.

She has worked as a club doctor for numerous teams and sporting leagues.

“We don't yet know if only the more severe cases go to the emergency department.

We don't actually have data on that and it's hard to get that data because you don't know what you don't know. One of the things we really want to get a better handle on is concussion in the community.

How many people are suffering from a blow to the head that results in continuing symptoms? That is potentially not diagnosed properly as a concussion and people are not necessarily seeking medical aid.”

Ultimately, a national database to track concussion cases would be the best way to capture data to see what statistically significant short-term and long-term effects are happening at a populationlevel, Dr Cowen said.

“Historically, there have been problems with people not reporting symptoms and that’s why in sport the SCAT-5 is useful as you have objective assessment tools, as well as subjective reporting of symptoms,” says Dr Cowen.

Complicated long-term effects Although concussions, as far as the broad symptomology is concerned, are relatively well known, the long-term effects are not.

What happens after a concussive impact is where the ambiguity lies.

Prof Fitzgerald is conducting a study investigating the long-term consequences of concussion and, in particular, “being able to identify whether someone will recover normally from a concussion or not.”

“One in five people have continuing symptoms from concussion that last longer than you would normally expect.

Currently we don't know what predicts that kind of continuance of symptoms,” she said.

continued on Page 16

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FEATURE continued from Page 15

One Bump Too Many

If post-concussive symptoms extend beyond three months a diagnosis of persistent post-concussion symptoms (PPCS) may be applicable but it can be challenging to diagnose.

Research has found adult females, but not female minors, to be more susceptible to PPCS after a sport-related mTBI than adult males and minors. Why there is a statistically significant difference in mTBI sequelae between ages and genders is not completely understood but hormonal influences have been theorised as causal.

However, there is an issue of sampling sizes with a large disparity between high number of male participants being studied, compared to females.

Severity of impact One of the difficulties of predicting longterm consequences was that the severity of the impact did not always correlate with worse long-term outcomes.

“It doesn't necessarily follow that a heavier hit leads to a greater chance of prolonged symptoms following concussion. Factors such as a previous concussion, a preexisting neuropsychological condition may play roles and influence how an individual recover and if they were to experience a concussion. We haven't yet looked at genetic factors, but it is possible that they may also play a role in determining vulnerability to longer term problems after a concussion,” Prof Fitzgerald said.

Individual tolerance to impact forces is another variable but there are new technologies able to measure the g-force of impacts.

“The kind of g-forces experienced by concussive impact is very high – up to 100 g-force, which is just extraordinary. It's difficult to measure and we can't yet connect that to clinical outcomes and whether people are experiencing a worse concussion as a result of increased g-forces. It's likely, but we certainly don't know the longer-term outcomes of particular g-forces experienced by the brain,” she said.

Beyond the field of play Although concussions are often seen as a consequence of sports-related impacts,

16 | DECEMBER 2019

the at-risk cohorts, according to Prof Fitzgerald, spread beyond the athlete.

“Younger people are more likely to have impact from sporting activity and perhaps more motor vehicle accidents. But we do see a spike in the elderly with falls,” she said.

“It's really important that this fact is flagged with clinicians and also the general public.

Concussion isn't just sport related.”

Concussion due to domestic violence is another area in which Dr Cowen highlighted the need for vigilance.

On the field of play When presented with a concussion on the field of play, the SCAT-5, designed by the Concussion in Sport Group (CSG), is widely used as a standardised tool for concussion assessment and is integrated into concussion protocols, yet the tool does have limitations. A player could report no symptoms and have a relatively normal clinical assessment, but still be of concern to a clinician, so the medical professional may need to make the diagnosis, or take the player out of the game, based on their clinical judgement. The SCAT-5 however, is “an excellent adjunct to routine medical assessment,” according to Dr Cowen.

For children between the ages of 5-12 years, CSG has developed the Child Sport Concussion Assessment Tool (ChildSCAT-5) and for non-medical professionals CSG has the Concussion Recognition Tool 5 (CRT-5).

“At present, we haven't got an available blood marker or a specific imaging test to assist us, despite ongoing research in this area, and a diagnosis of concussion is down to a clinical assessment. This includes exclusions of cervical spine injury and focal neurology as well as subsequent assessment of the patient for evidence that they may have sustained a concussive injury.”

Measuring the impact Taking the subjective measurement out of concussion and replacing it with quantitative data points is potentially game-changing for concussion diagnosis.

Western Australian start-up HitIQ hopes to achieve that with their smart mouthguard, the Nexas A9, which monitors impacts in real-time.

To understand the product and its potential, Medical Forum spoke with Mr Damien Hawes from HitIQ. “We've taken a custom-fit mouthguard and put a flexi circuitry board inside of it which has three high resolution accelerometers, a small battery inside and Bluetooth

connectivity. The device measures head kinematics specifically as well as linear and rotational forces using the array of accelerometers inside of the mouthguard,” he said.

The device is currently in testing with professional and amateur sports teams and athletes in Australia and the US and, along with similar devices being developed elsewhere, could lead to a breakthrough in real-time concussion diagnosis.

“The process of identifying an athlete with concussion in the field of play comes down to looking for signs and symptoms of a concussion and that’s really difficult in the heat of the battle.”

A device that can measure impact force and bring awareness to coaches and medical staff could also reduce the burden on the athletes to self-report, Mr Hawes said.

“Players often have a warrior mentality and they don't want to show vulnerability during a game, so they are not in the right frame of mind to self-report after a concussive blow. We want our product to be the safety net for players, so they are removed from the field of play if concussed. They get through the risk and they get the appropriate medical treatment. They can recover and get back out on the field.”

The CTE problem Chronic traumatic encephalopathy (CTE) is a difficult topic to broach as diagnosis of the neurodegenerative disease is only possible with an autopsy, yet there are growing concerns that the primary riskfactors in developing this tauopathy are repetitive concussive or sub-concussive impacts leading to chronic neurobiological

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Further complicating concussion recovery and potentially protracting the long-term effects is a multitude of biopsychosocial factors, such as the severity of the underlying brain injury, premorbid coping style and previous head injury. Prof Fitzgerald says factors such as previous concussion or a neuropsychological condition such as depression, anxiety or migraine might have an impact.

FEATURE “I think it's important to note that we actually don't understand a lot about any of the neurodegenerative diseases, including Alzheimer's disease. We still don't understand what causes it, how to treat it. The CTE sceptics seem to hold it to a different level of proof before they’ll accept it, compared to any other disease that I'm aware of.”

Dr Buckland considers CTE to have a relationship with repetitive head injury saying, “it may not be the only cause, but clearly it's highly likely that it's a significant cause.”

The probability of CTE, particularly for atrisk athletes or soldiers exposed to multiple concussive and sub-concussive impacts, is not clear.

“However, we do know that not everyone that has lots of knocks will get CTE. What we don't really have a good idea of is the risk. Is it one in 10, one in 100, one in 1000? It’s really hard to say. I always emphasise this to people: just because you've had a lot of hard knocks doesn't mean you're going to get CTE.”

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Primary health assessments sequelae with pathologically unique disease characteristics; essentially clusters of Tau proteins that disrupt the surrounding brain tissue and change the brain function.

Although CTE is a nascent disease in terms of diagnosis and nomenclature, the precursor diagnosis has been dementia pugilistica – which was, as the name suggests, a disease derived from the sideeffects of boxing and the associate head trauma from competing in the sport.

Post-mortem CTE diagnoses are becoming more common among at-risk athletes due to targeted autopsies, whereas, in the past, awareness of the disease meant there were few undertaken on at-risk athletes. Sydney neuropathologist Associate Professor Michael Buckland suggests this was due to the niche cohort of those suspected to be susceptible.

“I was taught, as were probably all doctors of my generation, that there was this interesting sort of diagnostic anomaly of dementia pugilistica that can be found in boxers. But you would have to have a reason to go looking. At that time, it was just an interesting anomaly only found in professional or serious boxers and unless you had that written in the patient history, you would never go looking.”

Prior to A/Prof Buckland diagnosing the index case of CTE in Australia, his awareness of the disease was due to the work being done in the US, in particular, at Boston University’s CTE Centre.

“When I read what they were describing, I was thinking back over all the brains I had seen and, you know, I'd never seen that before.’ That pathology is distinctive. I don't see that in my routine practice. I see lots

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of Alzheimer's cases and compared to the Tau stains they were publishing, this wasn't Alzheimer's disease.”

Although Tau is present in other neurodegenerative diseases, such as Alzheimer’s disease, Lewy body dementia and frontotemporal dementia, A/Prof Buckland says that it presents with a unique, irregular pattern of accumulation, pathognomonic to CTE. Dr Buckland runs the neuropathology service for New South Wales. Brains that need to be examined for a coronial or hospital autopsy are sent to him, which is how he came to examine the brains of two former athletes.

Alarm bells sound “The first, just on the standard hematoxylin and eosin stain, (and not doing the Tau), this brain had a whole lot of pathology in the hippocampus. You could tell just on the standard H&E stain there was something wrong. That then triggered me to do Tau and a variety of other stains and there it was. I picked up the first Tau stain on the frontal cortex.”

As the majority of concussions are nonsports related, it is surprising that primary health clinicians don’t have a similar standardised tool such as the SCAT5.

Although the SCAT5 can be, and is, used in GP consults, Dr Cowen says it is seen as time consuming and only relevant to sports-related concussive injuries.

While the symptomology may be similar to a sporting concussion, the framework for documenting the event is different.

As a solution, Dr Cowen is working with HealthPathways WA to develop a guide for assessment of concussion in General Practice.

“The aim of the guideline is to make it relevant to all concussions rather than those that are sports related,”she said.

In lieu of an assessment tool, Dr Cowen has some advice for primary health clinicians dealing with concussion cases.

According to Dr Buckland, this was a routine assessment, in which he was not specifically looking for CTE.

“Take a history of the impact – is there a clear description of the mechanism of injury available? – and specifically ask for symptoms or third-party observations.

Ask about dizziness, headache, nausea, vomiting, neck pain, fogginess or just not feeling right. You should enquire if there was loss of consciousness or a loss of protective action.”

“We didn't have a history of dementia in this case, but as soon as I looked at the brain, I could there was a degenerative process going on. The other case, well, I went looking for it and, once again, I didn't have to go looking very hard to see CTE specific Tau,” he said.

“Where there any observations of posturing, or a blank, vacant or confused look at the time of the event? Has there been any memory impairment? Inquire if they've had previous concussions. Ask them to describe themselves before and after the impact.”

As far as definitively identifying the causality of CTE, A/Prof Buckland says the evidence is not clear but he adds,

continued on Page 19

DECEMBER 2019 | 17

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The new norms of post-concussion management The difficulty for patients and clinicians is having to navigate an overabundance of information on concussion and related treatments, many of which are not evidence-based.

“Moreover, it is unclear which treatments are most appropriate for the constellation of concussion symptoms. Thus, evidence-based education as well as treatment and management options are required,” Prof Fitzgerald said.

She added that a graded return to activity after 24 hours was effective for managing and reducing symptoms, then gradually increasing the intensity of the activity, as long as it doesn’t exacerbate the symptoms.

The protocol for managing an individual post-concussion has evolved too. Dr Cowan explains that the previous treatment paradigm of rest until asymptomatic is no longer best practice.

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“Sub-symptom threshold exercise can actually help improve symptoms. Historically, we used to say that a patient should rest until completely asymptomatic. Now we know that after 48 hours, we want patients to start doing more activity, but only to a heart rate level that it is below precipitating the worsening of symptoms.”

To measure the ideal heart rate for threshold exercise, an assessment with the Buffalo Concussion Treadmill Test (BCTT) is effective. The BCTT can evaluate post-concussion symptoms and diagnose physiologic dysfunction while differentiating it from other confounding diagnoses.

The BCTT, based upon the Balke cardiac treadmill test, can measure the clinical severity of the concussion and the amount of aerobic exercise that can be safely undertaken.

By James Knox Professor Melinda Fitzgerald and Dr Gill Cowen are investigating the riskfactors leading to delayed recovery from concussion in the Concussion REcovery Study (CREST) at Curtin University and the Perron Institute. They are seeking participants aged 18-65 years; who have sustained a concussion from any cause; have been diagnosed by a medical doctor, and are within seven days of the concussive event. email: concussionstudy@curtin.edu.au https://redcap.curtin.edu.au/surveys/?s=KYK74NWCJ9

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Lifestyle Clue to Alzheimer Puzzle UK neuroscientist Dr Stephanie Rainey-Smith has moved her work on Alzheimer disease to Perth where she is focusing on early intervention.

I

n 1906, a young research assistant at Munich Medical School gave a lecture about the case of a deceased 55-year-old woman, explaining the woman had been affected by memory loss and disorientation prior to her death.

During the post-mortem they found senile plaque and neurofibrillary tangles in her brain, which had previously only been observed in elderly people. The name of the research assistant? Alois Alzheimer.

The understanding of Alzheimer’s disease has come a long way since Alois’ famous lecture, yet the disease is far from understood, and today it is a major and growing public health issue.

It is estimated that 447,115 people are living with dementia in Australia today, with 250 people diagnosed daily. Dementia is the second leading cause of death, and for women it is the leading cause of mortality.

Dementia is characterised as a group of symptoms that encompass a multitude of neurodegenerative diseases, Alzheimer’s disease being the most prominent, accounting for up to 70% of cases. These diseases are progressive and have no cure.

With an ageing population and subsequent increasing incidence, dementia represents a significant burden to the current and future health care system in Australia. In 2018, dementia was estimated to have cost the Australian economy more than $15 billion, with this figure predicted to increase to more than $36 billion by 2056. By 2058, more than 1 million Australians will have the disease unless a medical breakthrough is made.

To garner a more comprehensive understanding of Alzheimer’s disease and what the contemporaneous research has found regarding early identification and avoidance, Medical Forum spoke to one of WA’s leading researchers in the field, neuroscientist Dr Stephanie RaineySmith, from the Centre of Excellence for

20 | DECEMBER 2019

Alzheimer’s Disease Research and Care, at Edith Cowan University.

outside of clinical trials, some studies have reported findings with up to 90% accuracy.

While completing her doctoral research on motor neurone disease at Kings College London, Dr Rainey-Smith became interested in the work of her colleagues who were researching Alzheimer’s disease, and from then until now, her interest in the condition hasn’t wavered. She was awarded the 2019 WA Young Tall Poppy Science Award from the Australian Institute of Policy and Science for her extensive research.

Development of highly sensitive tools capable of detecting the earliest signs of cognitive decline is also imperative.

Early identification and intervention Dr Rainey-Smith’s primary research objective is the early identification of Alzheimer’s disease (AD) pathology, which can develop in the brain over decades before overt symptoms are recognised and a diagnosis is made.

“By that time, a lot of the damage has been done. The brain is damaged, brain cells have died, the toxic proteins have accumulated,” she said.

Early identification, coupled with intervention, is the best possible strategy.

“We need to use early diagnostic techniques such as brain imaging and hopefully one day a blood test, which is being worked on at the moment, to identify much earlier on individuals at risk so that we can implement strategies that will give us the best chance to diagnose and treat,” she said.

“Earlier the intervention, the better chance of success in terms of slowing the rate at which the pathology accumulates, and thereby delaying symptom onset.”

Academics from the Department of Neurology at the Ohio State University developed a self-administered cognitive assessment instrument called the SelfAdministered Gerocognitive Examination (SAGE), which has been suggested as a reliable tool for identifying cognitive impairment. Although, any findings will not be conclusive, this could be useful for an individual to use before undergoing a clinical evaluation.

Beyond genetic causality As far as genetic risk is concerned, Dr Rainey-Smith said that although there was a form of familial AD that was caused by dominantly inherited genes, it is rare, accounting for only 3% of AD cases, with disease onset occurring much earlier in these individuals, often as young as 30 years.

In the majority of (sporadic) cases, onset occurs after the age of 60. The established theory of AD causality is considered to be a combination of environmental and lifestyle factors with some genetic interaction that affects the brain over time, although this is a fluid understanding as the exact causality is not known.

There has, however, been advances in understanding the connection between apolipoprotein E and AD according to Dr Rainey-Smith.

There have been numerous studies examining the efficacy of blood tests that measure levels of the protein amyloid beta in the blood – if the proteins are reduced below threshold, this suggests amyloid beta deposits have increased in the brain, which is characteristic of AD.

“Apolipoprotein E is important for lipid metabolism and cholesterol transport and we know that there are ties between cardiovascular disease and increased Alzheimer’s risk. Apolipoprotein E is also important for the transport and degradation of amyloid beta, which is one of the hallmarks that accumulates in the brain of an Alzheimer's patient,” she said.

Although a standardised blood test for AD diagnosis is yet to be implemented

“The apolipoprotein E protein is encoded by the APOE gene, which exists in three

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FEATURE forms; ε2, ε3, and ε4. You inherit two copies of the APOE gene, one from each parent, and inheritance of at least one copy of the ε4 form is associated with increased risk of AD. One of the theories to explain this increased risk, centres around the fact that APOE ε4 is associated with less efficient clearance of amyloid beta.”

Pharmacological research exploring new drug candidates as potential treatments for AD are yet to demonstrate efficacy in reducing symptomology such as limiting Tau – one of the other hallmarks of AD that accumulates in the brain. Other research has looked at tumour necrosis factor inhibitors – drugs that suppress the body’s response to a protein that causes inflammation.

reduced rate of pathology accumulation in the brain. And you needn’t have been adhering to that diet for a very long time.

We saw significant benefits over three years with fruit intake being of particular importance.”

Another preventative strategy is sleeping well. Dr Rainey-Smith suggested that poor sleep can increase risk of AD and dementia.

“We've always understood that poor sleep is a symptom of Alzheimer's and dementia, now we are starting to understand that it can also increase our risk.”

continued on Page 23

“We know that inflammation plays an important role in the Alzheimer’s disease process. There are some novel drugs that are under investigation at the moment.

A lot of the clinical trials have failed. But we do think that one of the reasons they have failed is because they've been administered to patients when their brain is already severely damaged, which is why I believe a preventative strategy is currently a more feasible approach, and something that we should thoroughly investigate” Dr Rainey-Smith said.

Preventative strategies The earliest possible intervention would provide individuals with the best opportunity to mitigate the severity of AD in later life, yet this came down to the individual being cognisant of even the slightest decline in their cognitive abilities, she said.

“When someone starts to feel like their memory isn't as good as it used to be, there is evidence that these individuals are at increased risk of getting Alzheimer’s or dementia in the future. This is, ideally, the stage at which we want to start implementing these prevention strategies, to give the best chance of modifying disease course.”

There is evidence to suggest maintaining cardiovascular health is causal to avoiding AD and dementia.

“We are starting to understand that what is good for heart health is also good for brain health. There are things that we can all do and we don't have to have been doing this for decades. People can start any time.

Obviously, the earlier you start, the greater benefit you get.”

Although a healthy diet and plenty of exercise seems like an overly simplistic solution to such a complex disease, this is an area of research with significant efficacy, according to Dr Rainey-Smith.

“There is a lot of evidence that suggests physical activity is important, not just in volume, but also intensity, as well as diet.

My own research has shown that if you adhere to a Mediterranean diet, there is a

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Lifestyle Clue to Alzheimer Puzzle “Putting those three factors together – a healthy diet, plenty of exercise, and good sleep – we've got a good chance of being able to delay or ideally prevent disease onset, and these factors have even been shown to counteract increased risk of Alzheimer’s due to presence of APOE ε4.

“We've got lots more work to do to really understand the disease and what contributes to its development. What we do know is it's a very complicated situation.”

clinic, or we have a lot of studies that we run at the Australian Alzheimer's Research Foundation.”

that combining brain imaging with memory testing yielded a more accurate diagnosis than memory testing alone.

“The other factor is making sure that GPs are aware of the message that what’s good for the heart, is good for the brain. Their patients need to be encouraged to eat well, exercise intensely and sleep well.”

“It's far more accurate than a non-specific memory test. The problem is that with some forms of dementia there is an overlap between symptoms and pathology. An individual might have Alzheimer's disease, but there'll be a vascular component too.

It can hard to clearly differentiate between the types, and mixed forms of dementia also exist.”

Advances in research Scientific understanding of AD is increasing rapidly, according to Dr Rainey-Smith.

“The advent of neuro-imaging techniques such as beta-amyloid imaging, which came to Australia in about 2006, has been a significant advancement. With this new type of brain imaging, we’ve been able to improve our understanding of how the disease process manifests and how the pathology accumulates in the brain, decades before symptoms present.”

Dr Rainey-Smith said that by implementing these lifestyle strategies early, there is the possibility of delaying the onset of symptoms conceivably by three to five years, which is significant for anyone.

Finding a baseline of an individual’s cognitive abilities is ideal for monitoring any decline.

“Then, in the future, if an individual begins to experience issues, they can go back and have another assessment and see how they're tracking compared to their baseline assessment. Self-awareness is very important and you can certainly get some assessments done at a memory

“Retinal imaging is also beginning to show considerable promise as a potential method of tracking disease development, although more work is needed.”

Researchers have found individuals who had a ante-mortem preservation of cognition who show post-mortem evidence of at least moderate Alzheimer disease’ which highlights the ability of some individuals to functionally resist AD despite the presence of plaques and tangles.

The researchers call this ‘cognitive reserve’ and although the ‘how’ and ‘why’ this happens for some individuals and not others cannot be answered presently, it could open the door to further understanding this complex disease.

By James Knox

While a definitive diagnosis can only be made post-mortem, Dr Rainey-Smith said

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Madagascar Hears A number of WA doctors take time from their private practice to offer their services to some of the poorest people. We talk to three doctors who have taken the roads less travelled to give a helping hand.

Dr Latif Kadhim during endoscopic sinus surgery

O

verseas service is nothing new but always rewarding for ENT specialist Dr Latif Kadhim.

While the Iraqi-born doctor was training in Canada in 2007, he went on a medical mission to Thailand and was captivated by the idea of using his skills and knowledge to help some of the poorest citizens of the world.

Next it was a two-week stint on the Africa Mercy ship, a fully equipped floating hospital that plies the waters along the African coast.

affect anyone here, but would make a big difference there.”

“I heard about ADFA from a urology colleague in Bunbury, so I approached Dr Graham Forward (ADFA’s founding director and CEO) with the idea of an ENT mission.

Graham and I did a scoping visit there in October last year and the first trip, 12 days of clinics and surgery, with the ENT team took place in June.”

Joining Latif on that first visit was anaesthetist Dr Dennis Millard, audiologist Dr Dayse Tavora-Vieira, scrub nurse Ms Marika Brandtberg and pre-trip logistics and audiologist Mrs Karin van der Merwe.

Unmet need The team held 179 clinical consultations (66 of them children) and performed 18 surgical operations (13 on children), with follow-up twice daily ward rounds. Nine people were

No surprise then that Latif, who works at Fiona Stanley Hospital alongside his private practice in Perth and Bunbury, found himself in June this year leading the first ENT mission on behalf of Australian Doctors for Africa (ADFA) to Madagascar.

Latif told Medical Forum that he was drawn to Africa because it was so critically underserved for medical help.

“Madagascar is a perfect example. It is a country of nearly 26 million, which is similar to Australia. It has only 14 ENT surgeons in the whole country and most of them are in the capital city, Antananarivo,” he said.

“The disease and unmet need are unbelievable. I can spare four weeks a year from my private practice. It’s not going to

24 | DECEMBER 2019

Team members with patient and family, post-operatively

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Dr Dayse Tavora-Vieira fits a hearing aid

Marika, Dennis and Latif fitted with donated hearing aids, including the very first hearing aid fitted in the Tulear region in the island’s south west.

The team also provided mentoring and training for local surgeons, audiology students and anaesthetic technicians, including a half day seminar in the capital.

Latif said the team received overwhelming support from the WA and Australian medical communities with donations of equipment and supplies from SJOG Bunbury, Medtronic, Stryker, SJOG Subiaco, Fiona Stanley Hospital, Royal Perth Hospital, Storz, Carl Zeiss and Olympus.

ADFA programs in Madagascar were also supported by Australian Government through the Australian NGO Cooperation Program.

Latif is excited to put his endoscopic surgery skills to use on future trips.

“The technique uses an endoscope rather than a microscope, which is bulky and

expensive. I think it’s a perfect technique for Africa because it’s less expensive and it's mobile. It is something that would really benefit the local doctors,” he said.

distributed 18 hearing aids during the trip.

There’s nothing quite like the smile on someone’s face when they hear for the first time.”

“We arranged a seminar on the last day of the trip and endoscopic surgery was included. The audiologist and anaesthetist also presented. Next time we hope to have a hands-on workshop because the local doctors are keen for knowledge.”

Patients can travel miles and for days to attend a clinic and often the entire family would end up staying at the hospital.

Latif said a number of his WA colleagues had expressed an interested in participating on other trips.

Well equipped “They are reassured when I tell them of the type of support and equipment that is available for ENT surgery there and they are also drawn by the number of people they can help.”

“We have a successful model that makes the very best of everyone’s time and the available resources. We tested and

“We advertised the clinics over the radio and people came and expected to be seen and managed in one go. There was one memorable case of a 12-month-old baby with a neck abscess. It took time to get surgery organised. The parents waited patiently at the hospital for several days because they didn’t want to leave before the treatment was completed because there were no services outside of the hospital.”

The next ADFA ENT mission is being planned for April 2020, all going well.

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Dr Mark Duncan-Smith operating in Bali

Plastics in Bali Plastic surgeons Dr Mark Duncan-Smith and Dr Tim Cooper have had long associations with the people of Bali. For Tim, it was a life changing meeting with the inspirational John Fawcett and, for Mark, the trauma of the Bali Bombings.

Mark Duncan-Smith

thought they were so complex, they should not be operated on in Bali.

How did it transpire that you began visiting Bali?

JFF identified numerous patients in Bali with severe burns contractures and so Tim and I have now completed two trips there, almost exclusively for severe burns reconstructive surgery.

My first association with Bali, a place I had never been, began in October, 2002, was being on-call statewide for burns when I got the first call about the Bali Bombings.

I was in Cottesloe, waiting for a takeaway coffee. The next month was spent with the burns team at RPH, dealing with the fallout.

With the upskilling of the medical and nursing staff in techniques and systems, it is extremely unlikely we would ever consider bringing another patient here to Perth. Such a trip is an expensive exercise and a far more cost-effective method is to treat them locally.

When that crisis settled, two Indonesian women from Bali came to RPH and I treated both of them.

In 2004, I went to Bali for the first time to deliver lectures at Sanglah Hospital and build a relationship between the two hospital burns units, just in case a similar disaster happened again. Part of this trip was also to do an Interplast needs assessment of locally treated burns victims who could not afford burns or reconstructive surgery.

(Interplast Australia & New Zealand sends teams of volunteer surgeons, anaesthetists, nurses and allied therapists to countries in the Asia Pacific Region to provide free surgical treatment and medical training.)

I identified three patients who needed

26 | DECEMBER 2019

How often do you go and how long do you stay? significant and complex surgery that could not be undertaken in Bali at the time.

Two patients were treated at RPH (at little hospital cost), and later one at Bethesda Hospital (at no cost).

Several years ago, Tim (Cooper) and I, in association with the John Fawcett Foundation (JFF), treated several patients with extremely bad neck contractures here in Perth. These patients were treated at the Mount Hospital as charity cases. When I saw the pictures of them, I said to Tim I

Tim and I now go each year for a five-day trip. The first day is a clinic to examine and formulate a surgical priority list and theatre plan for the three full days operating in two theatres. We do a ward round on the final day to ensure there are no problems.

What is your clinical focus when you get there?

Identifying the most severe cases, taking into account the anatomy of the deformity, its impact on the patient physically, emotionally, psychologically, developmentally and socially.

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Surgically the clinical focus is to teach local doctors the surgical techniques to deal with these problems.

What sorts of presentations do you see most commonly?

Severe burns contractures are the most common. We often see chins fused to chests, arms as parts of chests and multiple contractures on a limb rendering it near useless.

One case this trip was a four-year-old girl with all four fingers on both hands fused to her palms. That took me 4-5 hours to release them all and place full thickness ‘greets’ to all the raw areas. She should have useful hands again with hopefully all the developmental and social sequelae.

A single joint contracture is considered an easy case.

What do Balinese health professionals need most to care for the health of their community?

The same thing Western Australians need.

Infrastructure, financial resources and capacity to deliver care. In addition, the surgeon we are working with needs training and surgical upskilling to enable him to deal with more of these problems independently.

In Australia, we are extremely fortunate in burns care in that we deal with acute burns with early surgery and skin grafting.

This eradicates the incidence of severe burns contractures, and massively reduces the need for secondary reconstructive procedures.

That is not the case in all countries, often for fear of bleeding a patient out with acute debridement. This is also and exactly the case I found on an Interplast trip to Mongolia a few years ago.

The most comfortable position for a patient with chronic wounds is the fetal position.

Accordingly, the patient’s neck and limbs heal in a flexed position and eventually become fused with the resultant burns’ contracture. A situation that unfortunately can’t be avoided without appropriate acute surgery.

Why is this work important to you?

These patients, who are isolated socially and economically by their conditions,

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would not otherwise get reconstructive burns surgery. To have my degree of expertise and training and not use it to help such patients would be a personal tragedy for me.

four surgeons over the past 23 years and two have visited Perth for upskilling. This was John’s wish that we not only provide a service but teach the local medical staff how to deal with these complex problems.

It also gives me great personal satisfaction to take a boy who crawls on the ground like a crab because both his legs are limited at the knees at 100 to 110 degrees of flexion, do his releases and get his legs near straight with the expectation that he will be able to walk again. I gave this boy a soccer ball on the final day ward round in the hope that it would give him motivation and help with his rehabilitation. The boy and his father looked at me blankly. Not sure he was into soccer!

The service has expanded geographically to include the whole of Nusa Tengara and south Java. Bali, alone, has over 4 million people, so the patient load is never-ending. We identify patients through the foundation’s mobile eye clinics. More recently we have begun collaborating with the Kolewa Foundation, a Dutch charity which is active in Indonesia.

What would you say to another doctor who was thinking of committing to overseas service?

It is not easy to break our busy schedules but it is well worth the effort. I get more out of these trips than I put into them and it also gives me balance to my work here in Perth. A kind of Yin and Yang. Mid-year, I do a seven to 10-day trip to Vanuatu annually, and the Bali trip is in the latter part of the year.

Tim Cooper How did it transpire?

I was first contacted, out of the blue, by John Fawcett in 1997, when I first returned to practise in Perth. He suggested that as I liked to go surfing in Indonesia, I might consider giving back to the people. I started working for the foundation soon after and have continued to do so ever since.

How often and how long?

I visit once or twice a year, usually with a fellow plastic surgeon and sometimes a plastics trainee. A typical visit involves a clinic, where we see follow-ups and new patients and then plan a threeday operating schedule with the final, fifth day set aside for post-op planning.

The operation planning is performed in conjunction with the local surgeon. Threeday operating schedules seem about the optimum time due to limited resources.

We try not outstay our welcome at the hospital in Denpasar. We have been doing it for a long time, so the organisation is pretty slick. It is rare we have to turn away patients. This is important as patients travel sometimes days to see us with relatives in tow.

What is the clinical focus?

We started a cleft lip and palate service originally, as we felt there was an unmet need for this. At that time there were no plastic surgeons in Bali. Over 2000 cases have been operated on by the John Fawcett Foundation (JFF). We have trained

We have become increasingly involved with managing delayed burns cases.

In rural Indonesia, these are managed with dressings and allowed to heal by secondary intention, resulting in disfiguring burns contractures. Originally, we funded complex burns cases to come to Perth.

However, this model has been ceased because of the high cost, social disruption and numbers of patients. Mark and I have now performed two burns visits and we have had acceptable morbidity to enable us to feel comfortable in performing these surgeries.

What sort of presentations?

As well as the cleft lip and palate cases and delayed burns cases, we have also seen complex craniofacial deformities, congenital hand deformities and the odd tumour presentation.

What do Bali Health professionals need?

Educational resources are paramount.

We also enable equipment and dressings donations to reduce the financial burden.

Why is the work important to you?

Giving back is the focus of many health professionals. We come from a very privileged position in a country that is blessed with unbelievable health resources.

You don't have to dig deep below the surface in Indonesia to see the extreme poverty. The foundation was started by John over 30 years ago. He has left a legacy that I would like to continue. The reward is in the giving.

What would I say to other doctors considering this work?

I would encourage any young doctor to aspire to perform voluntary work in any capacity. As plastic surgeons we have unique skills that are readily transferable. My colleagues contribute to many charitable endeavours including Interplast and Operation Smile. The JFF has been for many years supported by ophthalmologists from Adelaide and Perth.

They have revolutionised the management of cataracts in remote and rural settings in Indonesia.

DECEMBER 2019 | 27

Accessing Home Care can be confusing To help we’ve created this simple guide Step 1.

ACAT referral.

You, the GP, refer them for an ACAT assessment via www.myagedcare.gov.au/health-professionals OR

UK GP Dr David Unwin came with the message that reducing carbs can reduce T2 DM symptoms and Dr Joe Kosterich was listening.

If a pill were released tomorrow bringing remission in 50% of people with Type 2 diabetes, there would be enormous interest. Doctors would start patients on it as the newest form of ‘best practice’. If this medication had, effectively, no side effects and promoted weight loss and reversed non-alcoholic fatty liver disease (NAFLD), there would be a stampede.

Ask your

to call us and we will conference call MyAgedCare with them to arrange the referral.

There is no such pill. There is an equivalent. British GP Dr David Unwin has overseen remission of Type 2 diabetes in close to 50% of his patients. He spoke at the Low Carb Down Under conference on the Gold Coast in October.

Your will be contacted by the ACAT to arrange to visit them and work out the amount of help they may need.

His practice has gone from well under the UK average for diabetes control and remission (HbA1c under 5.9) to well above with the lowest amount of prescribing of diabetes drugs in his area. He has addressed the UK Parliament and has written papers in the BMJ. The WA Parliament’s Education and Health Standing Committee travelled to his practice in Southport to learn.

Step 2.

Step 3.

Reversing Type 2?

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with Department of Human Services (DHS) The can call us on 1300 26 26 26 and we can mail the form to them.

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1. ACAT approving their care level. with their income assessment.

2. DHS - this may 3. Home Care Package Assignment take 6 to 12 months.

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Dr Unwin did something remarkable. He listened to his patients and was curious. He learnt from patients that their diabetes control and weight improved when they went on a low carbohydrate, healthy fat diet, basically eating the way people did till the 1970s.

The foreword in the WA committee report The Food Fix – the role of diet in type two diabetes prevention and management notes that the message from Dr Unwin was “ not one of deprivation but one of replacement, rebalancing and flourishing through food choices that ensure blood sugar levels remain stable, putting consumers in control”.

In four words – just eat real food! So simple! And yes, there is evidence.

The other remarkable thing he did was reject doing more of the same. He worked with patients challenging his own beliefs and prevailing orthodoxy, offering hope, not just fear.

This is not easy. UK biochemist Professor Richard Feinmann told the WA committee: “The disconnect between the record of success of low carbohydrate strategies and the negative response of government and private health organisations stands as a major barrier to our ability to confront the epidemics of diabetes and obesity.”

Another submission noted: “It is actually quite difficult to put out a new message because…this very, very good research because it is not based on the current dietitians’ guidelines.” AHPRA has previously pursued Australian doctors for doing what Dr Unwin has done.

There is hope. Recommendation three of The Food Fix calls for the Department of Health to ensure that a very low carbohydrate diet be formally offered as a management option. Recommendation four calls for health care professionals to be made aware of this.

Dr Unwin is no different from us, and his patients are not unique.

We should want to learn from and emulate his success.

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GUEST COLUMN

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2019 Season greetings from WA health professionals The Medical Forum team wishes all our readers and supporters a very Merry Christmas and a Happy New Year

MEDICAL FORUM

DECEMBER 2019 | 29

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FEATURE

Beyond the City Limits The year may very well be winding down, however, medicine does not. People continue to get sick and look to their doctors and other health professionals to help them get back on their feet. In the metro area, patients almost everywhere now, are spoilt for choice. In rural and remote areas, it’s a different story. We asked several rural GPs what their final few weeks of 2019 will entail.

Dr Emily, Webb, GP, Kojonup Where do you live and work? How long have you been there?

I live on a farm in the Shire of Kojonup. My husband moved to the farm in 2007.

What drew you to this destination?

I am a country girl and I really enjoy living on a farm. We have lots of beautiful trees and hills so the scenery is sensational and the community is a supportive, close-knit farming community so it really is a great spot to live. We are only 1.5 hours from Albany and 2.5 hours from Perth and Bunbury, so we are really in the middle of everywhere.

Dr Emily Webb on the family farm in Kojonup.

Picture courtesy of Rural Health West

continued on Page 32

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

30 | DECEMBER 2019

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continued from Page 31

Beyond the City Limits What are the demographics of your community?

How easy is it for them to access health services?

Kojonup has a strong community with definitely a younger demographic than you see in a lot of coastal towns. The main industry is agriculture.

We are recruiting for more doctors, which we greatly need in the Kojonup/Katanning areas. Telehealth and the WACHS emergency telehealth service have greatly improved access to emergency services in our local hospital, for both patients and for staff. We are 40km from our nearest regional hospital which has the local pathology, radiology and inpatient services.

Farming in our area is mixed sheep and cropping, so we have farm workers, shearing contractors and required support industries based in our town. This attracts lots of people from all over the world both for seasonal work and to live.

We have a local museum, Kodja Place, which celebrates the town diversity through the stories of the original inhabitants, the local Aboriginal people, and then the stories of the first migrants who settled the farming areas, coming mainly from the UK and Italy. I love that my children are growing up in a small community.

What are the most pressing health issues in your community?

Distance to services!

have helped my career, and a system that has locums in the local ED which has allowed me to focus on mainly general practice.

What is the impact of that on how you go about your medical practice?

We need to change the image of rural medicine being an 80-hour-a-week job (though the work is here if you would like it!). I hope, as my children grow, to work more in the hospitals, but currently I am happy to do predominantly office-based work, and feel lucky to be able to have the opportunity to work as a doctor and enjoy my family.

It was very daunting when I first started to sometimes be ‘the only doctor in town’ but I do love the variety and the challenge that this provides.

What are the highlights and pitfalls of living and working alongside your patients? How does this affect your family?

In rural medicine you do need skills across all areas of general practice. I currently don’t do emergency on-call work as I have small children, so I try to wave the flag for the ‘I don’t do it all rural doctor’.

I feel that this is a problem for GPs in the city and larger regional areas as well, and I try to maintain boundaries as best as I can.

I feel so fortunate to have had many supportive colleagues around me who

I am currently working by myself in a single-doctor practice. I started in October

How do you maintain connections with your colleagues?

A warm thank you to all of our referrers and colleagues for your support in 2019.

We wish you all a very merry Christmas and a very happy New Year. All the best over the holidays and we look forward to working with you in 2020 and beyond.

32 | DECEMBER 2019

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FEATURE

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FEATURE

this year and am so far enjoying the challenge! I like to attend conferences to maintain medical connections.

I find with rural general practice you do take on the role of being a traditional base for patients and I do send patients to lots of other colleagues, so I do feel like I am part of a team with the many other health professionals in our town and our greater regional area.

Do you feel supported in your practice from colleagues and city-based organisations?

Yes! Where will you be over the festive season? What will you be doing? What’s on the menu?

Christmas always coincides with our very busy harvest time so we really, really look forward to our January camping holiday after the busy period! Thankfully there is a complete harvest and truck movement ban over Christmas, and this year my family is coming to stay for a few days.

Wishing all our valued referrers the very best for the festive season and thank you for your support in 2019.

2020 will see us reaffirm our commitment to quality and we will continue to raise standards as we grow.

Have a safe and happy holiday and we look forward to serving you in the New Year.

The Western Radiology Team.

We usually try to have a traditional ham and roast vegetables on Christmas, and my mum makes a Christmas pudding trifle. Yabbies from the dam are also usually involved!

continued on Page 34

CHRISTMAS...

A TIME TO OPEN OUR HEARTS WITH LOVE AND COMPASSION Wishing our doctors and all involved in the healthcare community a Christmas filled with hope, peace and joy.

www.sjog.org.au

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DECEMBER 2019 | 33

continued from Page 33

Beyond the City Limits Dr Olumuyiwa Jegede, GP, Wyalkatchem Where do you live and work? How long have you been there?

I work and live in Wyalkatchem, in the Wheatbelt. It’s a small community, I reckon; with a population between 600 and 1000. I started here about 15 months ago.

What drew you to this destination?

Rural practice is different from city practice.

You tend to wear different hats as there is always a wide variety of presentations.

And although it can be challenging, it’s also equally rewarding. By the way, I love new challenges and so the decision to move here was a rather easy one for me.

What are the demographics of your community?

The population is evenly distributed between the middle-aged and the elderly.

It’s a predominantly farming community.

What are the most pressing health issues in your community?

Mental health problems seem to be on the rise. However, chronic diseases such

as hypertension, diabetes, obesity and musculoskeletal problems make up the bulk of presentations. Ageing with its attendant medical and psychosocial issues also deserve a mention.

How easy is it for them to access health services?

There is a local hospital which provides a 24-hour service, with an on-call doctor most week days. Availability of telehealth services provide support in certain emergency and inpatient scenarios. Also, few specialist consultations are done via videoconferencing.

However, most patients still have to travel long distances to access specialist and allied health services. The closest facility equipped with CT scanning is about 100km away.

What is the impact of that on how you go about your medical practice?

You sometimes have to think outside the box and improvise with your approach to patient management, while also maintaining accepted standards of care, especially in cases where long-distance

travel might not be either suitable or convenient for the patient.

What are the highlights and pitfalls of living and working alongside your patients? How does this affect your family?

Being a relatively small town, a lot of people have long standing connections and relationships. Therefore, they tend to be aware of what’s happening in each other’s lives.

This is somewhat also brought to fore in their relationship with the doctor and his family. It generally makes you feel a part of the community.

What are the highlights and pitfalls of living and working alongside your patients? How does this affect your family? How do you maintain connections with your colleagues?

Living rural can make you feel somewhat isolated. However, I belong to a few professional groups on social media platforms and that helps. Also, we occasionally connect during CPD events and conferences.

On behalf of all Ramsay Health Care hospitals in WA, Operations Executive Manager Kevin Cass-Ryall wishes all of our referring GPs, specialists and their families a safe and joyful festive season and very happy new year.

S E A S O N ’ S G R E E T I N G S

People caring for people

34 | DECEMBER 2019

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Do you feel supported in your practice from colleagues and city-based organisations?

Yes, I do. The practice principal is always a phone call away. I’m also always on the lookout for webinars to link up to.

Nowadays, there is a wealth of resources available online, on RACGP website and other platforms. I make good use of these.

Moreover, I make it a point to always attend the emergency medicine education and training sessions at Northam Hospital, which are organised every few months. It’s an invaluable resource for rural GPs, especially those involved in hospital ED cover.

Where will you be over the festive season? What will you be doing?

What’s on the menu?

I’ll be having a two-week break. I intend to spend it with family. I might take a trip down south, see more of the country.

ED: Olu and his wife, Amoke, welcome a baby into the family this year. Amoke is pictured here with Rural Health West’s family coordinator Jen Maughan at the Dowerin Field Day this year.

Picture courtesy of Rural Health West.

continued on Page 36

On behalf of Upper GI West, we would like to wish you all a very merry Christmas and a happy New Year.

Thank you for your ongoing support and patronage during 2019 – we look forward to working with you all in 2020.

Enjoy the festivities with your family and loved ones, and please, stay safe.

Kindest regards, Alan, Krishna, Mo, Sanj, Matt and the team at Upper GI West.

MEDICAL FORUM

DECEMBER 2019 | 35

continued from Page 35

Beyond the City Limits Dr Christopher Lam, GP, Christmas Island It’s totally appropriate that Beechboro GP, Dr Christopher Lam is heading to Christmas Island for a couple of weeks’ locum service from December 20. He’d put his hand up for a similar locum in 2016 and enjoyed it so much, he’s returning.

“Christmas Island is a beautiful place to work and the people are really friendly.

There are less than 2000 people on the island – about 1500 are permanent.

Doctors looking after them need to have emergency experience,” Christopher said.

The Christmas Island locals have regular contact the Australian Federal Police and the Royal Australian Navy but Christopher said the locals were familiar with doctors coming and staying for various lengths of time.

While GPs need to have a range of skill sets, Christopher said critical medical emergencies are flown to Perth and that’s a 10-hour flight away.

Christopher works in a 10-doctor practice in Beechboro, when he’s on Christmas Island, there are no more than three GPs on rotation.

“There is a fairly well-equipped hospital on the island but staff have to be up-todate with skills because they have to do everything.”

This visit, Christopher will be accompanied by his partner Tina.

“She joins me from time to time on my locums. If it is short-term and closer to home, she tends not to, but we both love Christmas Island. She really enjoys this aspect of my work.”

“I took some time out of my regular GP practice to work in the ED at Midland for six months. My practice was really supportive then and of me going back to Christmas Island.”

“I am keen to experience different situations and different ways of thinking about medical problems so I find it really useful to do locums.”

Flying Fish Cove, Christmas Island

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Diabetes and prostate drugs modifying Parkinson’s

By Dr Tim Welborn, Endocrinologist, Nedlands Current Parkinson’s disease drugs improve the motor symptoms without influencing the underlying pathology or the natural history. Serendipitous research identified disease modifying properties for Parkinson’s disease in drugs prescribed for unrelated conditions. This has led to detailed studies of animal models, retrospective analyses of large clinical databases, and some clinical trials, to investigate their future potential.

Glucagon-like peptide agonists Exenatide and liraglutide are commonly used injections for the treatment of poorly controlled type 2 diabetes. They mimic the action of the gut hormone glucagonlike peptide (GLP-1), released by the small bowel after food, stimulating insulin secretion, reducing liver glucose output, and enhancing satiety.

The natural hormone is short-lived, but the drug analogues have an extended effect.

Promoting moderate weight loss, they are sometimes prescribed off-label for nondiabetic patients with obesity.

Animal models suggest that these agents normalise brain dopaminergic function. A proof-of-concept open-label clinical trial was conducted using twice daily exenatide in 20 moderately advanced Parkinson’s disease patients, with a comparison group of 24 matched controls.

The treated group demonstrated a marked improvement in a global score for Parkinson’s disease symptoms and

These medications are generally well tolerated. The side effect profile in diabetics and in Parkinson’s disease were similar. Weight loss of about 2.5kg, early nausea and other minor gastro-intestinal symptoms did not lead to drug cessation.

Hypoglycaemia was not recorded.

KEY MESSAGES Current Parkinson’s medications do not influence progression Medications used for type 2 diabetes and prostatism show promise in modifying Parkinson disease progress More research is needed. signs assessing activities-of-daily-living and motor function, and also improved measures of cognitive function. The comparison group showed moderate declines in both scores. Remarkably, 12 months after the treatment group ceased exenatide, the motor and cognitive advantages persisted.

A conventional double-blind placebo controlled trial with a once weekly exenatide injection was conducted, involving 32 patients with moderate Parkinson’s disease on dopaminergic treatment, with wearing-off effects. They were compared to 30 matched controls given placebo injections.

Significant improvement in movement scores occurred in the treated group, and deterioration in the controls. Note – the scores were recorded with all participants ‘off medication’ for at least eight hours.

While on the dopaminergic drugs, there was no significant difference in the scores between the groups. For those on exenatide, some reduction in the dose of levodopa-equivalent drugs was necessary because of emerging dyskinesia.

Alpha-1-blocking agents Terazosin, an oral alpha-1-adrenergic blocker, is used for urinary frequency caused by an enlarged prostate. Two other drugs have similar pharmacology – doxazosin and alfazosin – and these are sometimes prescribed for hypertension.

They relax arterial tension and reduce bladder trigone irritability.

Possible benefits of these agents in Parkinson’s disease have just been reported. They enhance ATP-mediated glycolysis and increase dopamine levels in mammalian brain cells, independent of alpha-1-blockade. Animal model studies of Parkinson’s disease showed terazosin slows or prevents neuro-degeneration in mice and rats. A small prospective study of seven patients with Parkinson’s disease taking terazosin and 13 patients on terazosin or doxazosin or alfazosin, compared with 269 not on these drugs, demonstrated a significantly reduced rate of motor disability.

A large database identified 2880 Parkinson’s disease patients on one of the three drugs of interest. They were compared with 15,409 individuals taking Tamulosin (an alpha-1-blocker that does not activate phosphoglucokinase and does not enhance

continued on Page 40

Aviles-Olmos et al. / Exenatide & Parkinson's Disease

Fig. 1B

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Fig. 1a. Rating scales for activities of daily living and motor function.

Fig. 1b. Change from baseline Fig. 2. Rating scale for cognitive function – change from baseline

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Blinded rating of MSD-UPDRS part 3 off medication (added to open label rigidity scoring)

Fig. 1A

Change in MDS-UPDRS part III off medication

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CLINICAL UPDATE

141 140 139 138

Control

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Cut-off score of DRS for screening of dementia in PD

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DECEMBER 2019 | 39

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CLINICAL UPDATE

Managing Christmas stress

By Dr Davinder Hans, Psychiatrist, Nedlands The festive season is a fun time for many, but can also come with a spike in extra family, financial, and work stress.

The mental health needs of doctors are generally under recognised (or often noticed and under prioritised) throughout the year, but never more so than during the Christmas period, where clinicians are often caring for patients whose own mental health and physical needs may transiently increase for a variety of reasons.

It is too easy to consider ourselves as clinical practitioners and carers of the sick, forgetting our own human side. The holidays can increase expectations for ourselves outside of work (family commitments) too.

We may work during the holiday period looking after patients who are parents, and their children, ensuring they are safe and well, on top of the safety and wellness of our own family.

Many of us have interests, supports, and elements of our identity outside of work, which help to buffer and support us as clinicians. Paradoxically, as the expectations and demands of our clinical roles increase, our engagement in those same supports and interests often reduces or ceases.

KEY MESSAGES Practitioners can easily forget their own needs during times when their patients’ levels of stress increases Take time to support yourself, look out for colleagues, and engage with your families and interests Give yourself permission to access supports and help.

Take this as a rallying cry to be your own primary patient to whom you provide the supportive therapy principles of empathy, unconditional warmth, being non-judgmental, actively engaging in your positive defences (assertively taking some time out, making and sticking to plans for social and leisure activities), and recognising some of your less helpful defences (going it alone, doubling down workload in the spirit of altruism, or ignoring signs of burnout and self-distress).

Recognise that you end up holding some of the emotional distress of your patients, and give yourself permission to seek your own mental health supports as needed. These can come in a variety of forms but might mean seeking or increasing therapeutic engagements for yourself over this period.

Advisor, has doctors of first contact able to provide advice and assistance for medical practitioners.

British psychoanalyst Wilfred Bion discussed the container-contained relationship, which means that part of our role as practitioners involves holding the tumultuous distress of our patients in order to reduce it for them. However, without our own containment, doing this is either impossible or unsustainable. So, for ourselves and our patients, we need to ensure that we monitor and look after our own mental health. You are both valued and valuable and I hope you have a great festive season!

Author competing interests - nil

The Doctors Health Advisory Service of WA (DHASWA), of which I am the Psychiatrist

continued from Page 39

Diabetes and prostate drugs modifying Parkinson’s glycolysis). There were many benefits for those on any one of the drugs: reduced hospital or clinic visits (-23%), reduced Parkinson’s disease complications (-24%).

The same database was interrogated to follow 78,444 patients prospectively. Taking these agents lowered the rate of a new diagnosis of Parkinson’s disease (-38%). The findings suggest that terazosin and related drugs, under real world conditions, reduce the signs, symptoms, complications, and

40 | DECEMBER 2019

incidence of Parkinson’s disease. Since they are used in the geriatric setting, their side effects are clearly tolerable. These include some dizziness, postural hypertension and ankle swelling.

It is remarkable that commonly used drugs for diabetes and prostatism show such compelling pointers to modifying the progression of Parkinson’s disease. Further detailed clinical studies and trials are in progress and their outcomes are awaited

with great interest. More research will be directed to studying the role of gut hormones and enhanced intracellular glycolysis in modifying the course of Parkinson’s disease.

References available on request

Author competing interests – nil

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Managing meniscal tears

By Dr Satyen Gohil, Orthopaedic Surgeon, Murdoch The meniscus is a fibrocartilaginous structure made of predominantly Type 1 collagen. It optimises force transmission acting as a shock absorber in the knee, ultimately protecting the underlying cartilage.

The medial meniscus also acts as a secondary stabiliser of anterior knee translation. The outer third of the meniscus has a blood supply and is termed the ‘red zone’. Tears there have the most favourable prognosis post repair.

Tear symptoms The clinical signs of a meniscal tear are usually a small effusion in an acute tear, joint line tenderness, and a positive McMurray test. Knee hyperflexion usually reproduces patient symptoms.

Indications for meniscal repair Traumatic meniscal tears in young active patients, as meniscus preservation, gives longer term cartilage protection.

KEY MESSAGES In traumatic tears, consider meniscal preservation rather than resection In degenerative tears use conservative treatment first with surgery reserved for those who don’t respond There is no indication for meniscectomy in the setting of advanced OA. Locked knee, due to a bucket handle tear of the meniscus, is considered an orthopaedic emergency. Vertical longitudinal tears in the peripheral zones of the meniscus are more likely to heal due to proximity to the meniscal blood supply.

Combined ACL injury with meniscal tears – meniscal repair protects the knee from further instability and degeneration in combination with ACL reconstruction.

Complete radial tears reaching the periphery of the meniscus should be repaired to restore ring continuity.

Lateral meniscal root tears are usually traumatic and associated with ACL tears.

Trans-osseous repair of the root maintains hoop stresses in the meniscus preventing extrusion, offering some protection from degeneration.

Fig 6a and 6b: Peripheral longitudinal lateral meniscal tear in the red/white zone being repaired with an all-inside technique.

Managing degenerative meniscal tear management in the middle aged to elderly is controversial. Evidence suggests arthroscopic debridement and nonoperative treatment have similar outcomes.

Use simple analgesics and NSAIDS first, followed by a steroid injection at least six weeks after onset of symptoms.

Weight bearing AP radiographs and patella skyline views should be routine to exclude significant osteoarthritis. If, after three months, the patient still complains of mechanical symptoms (e.g. clicking, catching or locking) then specialist referral and MRI can be performed for consideration of arthroscopic debridement.

Medial root tears are often degenerative.

Attempt repair if less than grade one or two chondromalacia but the prognosis is generally poor. If grade three or four chondromalacia, then it’s worth trying intraarticular steroid injection and watching for six weeks. Consider arthroscopic debridement if symptomatic after that. Can ultimately lead to total knee replacement.

Rehabilitation after meniscal repair usually allows full weight bearing with a hinged knee brace and 0-90-degree range of motion for six weeks. Flexion past 90 degrees increases stresses at the repair site and can lead to failure.

If a root repair is performed, patients weight bear in extension for two weeks followed by four weeks at 0-90 degrees of flexion. Following meniscectomy, early weight bearing and full movement is encouraged, usually without crutches.

Author competing interests – nil

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Self-image and plastic surgery in the digital age

By Dr Linda Monshizadeh, Plastic Reconstructive and Craniofacial Surgeon, West Perth We live in an increasingly digital world with many amazing tools in the palms of our hands. With smartphones, tablets or desktops we have our dayto-day lives to manage, as well as our digital lives.

KEY MESSAGES We live in an increasingly digital world ‘Selfie dysmorphia’ and body dysmorphic disorder (BDD) are on the rise and has been attributed to social media

Recent studies indicate average users spend up to three or more hours on social media daily. Unsurprisingly, the line between our real and digital lives is blurring.

Our perceptions of beauty have dramatically changed due to the trends and standards set by celebrities and digital influencers.

Enhanced or filtered images flood our social media platforms projecting unattainable perfection, leading users to experience dissatisfaction with their self-image, low mood and/or depression.

Filters on Snapchat, Instagram and apps such as Facetune, which allows users to alter their complexion or dimensions of any part of their face and/or body, have led to ‘selfie dysmorphia’ with patients seeking cosmetic surgery to resemble their filtered images. Not only are we comparing ourselves to others, but now also to our enhanced filtered images!

Body dysmorphic disorder (BDD) is also on the rise and has been attributed to social media. It is estimated to affect 2.3% of the Australian population and up to 15% of patients seeking plastic surgery. This condition is characterised by preoccupation

42 | DECEMBER 2019

with a perceived defect that is not observable or significant to others. Patients struggle daily with thoughts of their defects and display repetitive behaviour(s) or mental acts in response to those concerns.

Patients suspected with body dysmorphic disorder should have formal psychiatric assessment and treatment. This is paramount as surgery does not relieve any symptoms.

Even patients who do not have BDD report no significant change in their background anxiety or depression after cosmetic surgery although they may be highly satisfied with outcomes of their surgery.

It is important that surgeons relay this to patients as they may have unrealistic expectations of becoming happier after their physical alterations.

Our obsession with physical perfection has raised significant concerns about the psychological impacts social media

Further serious discussions and changes are required to fully address effects of filtered images on mental health and its relation to self-image and plastic surgery. platforms are having on the younger population. Recently Instagram has stated they will ban all augmented reality filters that depict or promote cosmetic surgery amid concerns about mental health.

There are minimal rules and regulations about what can and should be advertised by the aesthetic industry. The majority of plastic surgeons in Australia have a high level of interest in developing best practice standards to ensure ethical use of social media platforms.

Further serious discussions and changes are required to fully address effects of filtered images on mental health and its relation to self-image and plastic surgery.

Author competing interests – nil

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Measles – a spot diagnosis

By Dr Aidan Perse, Travel Physician, Fremantle Food and water, mosquito and airborne diseases are the main risk to travellers, the last category being underappreciated.

Measles outbreaks are current in Israel, Thailand, Japan, Vietnam, Ukraine, the Philippines and New Zealand. The Centers for Disease Control and Prevention (CDC) has a global measles outbreak notice.

Measles (from the Latin meser, relating to miserable) was described by Persian physician Rhazes in the 10th century. He distinguished it from smallpox and believed it to be the worse of the two. Rubeola and Morbilli described the disease in the middle ages. The virus was isolated in 1954, and the first vaccine developed in 1963.

Many doctors have not seen measles and have even less experience with complications. The typical presentation is all the Cs – cough, coryza, conjunctivitis, and (c)Kopliks spots on the buccal mucosa (pathognomonic), together with a maculopapular rash starting from the head and spreading to the torso and extremities, often becoming confluent and clearing in the same order of appearance.

Fever is high but disappears quickly with the onset of the rash. Incubation is up to two weeks, infectiousness from 2-4 days before the rash to four days after.

Diagnosis is confirmed by PCR swabs of nasopharynx and urine PCR during the infectious period.

Complications include otitis media, diarrhoea and pneumonia with encephalitis one in every 2000 cases, and the presentation of subacute sclerosing pan encephalitis years later. Death occurs in 0.1-0.3% of cases and higher in those under age five and the immunocompromised.

Mortality in the developing world is up to 15%, mainly from diarrhoea and pneumonia.

There is emerging evidence the immune system is suppressed for up to five years after infection.

KEY MESSAGES Measles is the most infectious of diseases It remains prevalent outside Australia Full vaccination is vital for travellers.

Virtually everyone born before 1966 is naturally immune and most born after 1982 have had two vaccine doses. The cohort born between 1966 and 1982 is vulnerable.

Many say they have had the disease. For those who haven’t, an extra dose of MMR vaccine (free from Health Department) is recommended – it very rarely causes side effects. Giving a second dose is quicker and easier than checking serology.

Grown in chick embryo, egg allergy was previously a contraindication, but the advanced technical advisory group (ATAGI) approves administration to egg allergic patients as the amount of egg is negligible.

As a live vaccine it should be avoided in the immunocompromised. Other live vaccines (e.g. Varicella and Yellow Fever) should be given together, or delayed by a month.

Global eradication of measles through vaccination has been proposed and is feasible. We’re nearly there with polio, and it’s already been done with smallpox, a disease measles was once confused with.

References available on request

Author competing interests – nil

WHO declared Australia measlesfree in 2014. All subsequent outbreaks have been traced back to an index case from overseas making immunity in travellers vital. While given at 12 and 18 months on the childhood schedule, the first dose can be given as young as six months. Due to the neutralising effect of maternal antibodies, early doses provide only transient immunity, so still give the 12 and 18 month doses if an earlier dose is given.

The MMR vaccine entered our childhood schedule as a single dose for those born after 1966, with 95% efficacy – usually high enough to confer herd immunity. However, measles is probably the most contagious of diseases remaining infectious as an aerosol for up to two hours, and very effective at finding those not immune.

Over 90% of non-immune household or institutional contacts will catch it.

The schedule was changed to two doses, raising immunity to over 99%.

MEDICAL FORUM

DECEMBER 2019 | 43

Turning the Tide on Burnout Dr Jenny Brockis, GP and workplace consultant, City Beach The worst thing I remember from being burnt out wasn’t losing my practice or my health, it was missing out on celebrating our daughter’s birthday.

Lacking the energy to haul myself out of bed, let alone get dressed, I could only listen to the happy sounds of the party at the other end of the house while feeling horribly guilty and ashamed.

While it’s great to wear the superhero’s cape, saving the world and its occupants from the ravages of illness and disease, doctors need to keep sight that we are human, with the same physiological and psychological needs as everyone else.

Having the smarts to get into medicine doesn’t provide superpowers to go beyond the limit of normal human endurance, regardless our high personal standards of professionalism and perfectionism.

It’s time to stop justifying and accepting overwork and chronic fatigue as “business as usual”.

First described by the psychiatrist Freudenberger in 1975, burnout is now classified as an “occupational phenomena occurring as the result of unmanaged stress”, not infrequently accompanied by anxiety, panic attacks and/or depression.

Medscape reported 42% of American physicians are burnt out, with Australian practitioners experiencing similar levels of emotional exhaustion and psychological distress. Burnout is like a fire out of control.

As a high achiever and hard worker, dedicated to your work and passionate about what you do, it can be hard to acknowledge that the fire’s gone out of your belly, that you’re feeling irritated and emotionally distanced from your patients, and just so wretchedly tired. Denial can be very seductive as a firebreak.

But ignoring those signals of distress, the growing sense of frustration and chronic fatigue wears us down to the point that something gives, which is when it can all get awfully messy.

Why don’t we speak up?

As doctors, admitting that we’re not coping, are emotionally exhausted and feeling terrible remains clouded in stigma.

This is due to denial, fear of being judged as weak, or worse, incompetent, fear of losing our ability to practise medicine, our job and future opportunities with selfsacrifice being culturally seen as a sign of commitment and dedication. There is also a lack of support from the system and reluctance and embarrassment at being a patient Self-care is an important start but does not always sit comfortably, or get done. It smacks of self-indulgence, takes time and extra commitment, which when you’re so tired can be hard to find the motivation for.

We need change at a systemic level.

The lead up to Christmas can be especially wearing. The last quarter of the year can feel like the last lap of a very long race uphill. Hanging out for a few days or weeks of respite over the festive season seems

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For more information go to our website www.4antonyhealthcare.com.au or call Denielle on 93391932 or David Sofield 0419151050

44 | DECEMBER 2019

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CLINICAL UPDATE

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CLINICAL UPDATE

REDUCING THE RISK 1. Start with the basics. Yes, it matters to get some regular exercise, take a proper lunch break and get enough good quality sleep.

2. Consider mindfulness meditation or self-compassion training to act as a buffer against stress 3. Commit to non-work activities you find rewarding or give you joy. Volunteering and charity work take us out of our normal sphere of always working, helps to lower stress and elevates mood great, but is insufficient to allow you to fully restore and recover. Tips for reducing risk are in the table.

Burnout is such a waste. It’s time to turn the tide and look at better ways to stay safe and deliver great work, making a positive difference to the health and wellbeing of our patients.

Author competing interests – nil

4. Check in regularly with yourself. Are you undertaking those decisions you made to avoid overwork and adhering to taking regular time off; that quarterly long weekend and annual vacation?

5. Make wellbeing a practice priority for everyone 6. Review workplace practices including the handling of clerical work and appointments. What can be eliminated, improved on or reduced?

7. Regular practice meetings and social events provide an opportunity to make talking about wellbeing and mental health issues the norm. It’s easier to find the courage to share how things are going, when you enjoy a higher level of camaraderie and trust with your colleagues. Sharing stories is also a great way to help you reconnect to your purpose and meaning.

GPs Think Pink for Breast Cancer!

W

ell done and thank you from BreastScreen WA to all the general practices and health centres that participated in the 2019 Health Promotion in the Practice initiative in October, Breast Cancer Awareness month.

This was the 19th year that BreastScreen WA has organised this successful activity with general practices and health centres across WA. It is an opportunity for general practices to think pink for breast cancer, which now affects 1 in 7 women in Australia.

Winner - North Street Medical Centre, Midland

2nd place - Ocean Village Medical Centre, Wembley Downs

Women may book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50

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Mar ‘18

3rd place - Seville Drive Medical Centre Well done to all practices that took part, to view more visit: www.breastscreen.health.wa.gov.au/Newsroom

DECEMBER 2019 | 45

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46 | DECEMBER 2019

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CLINICAL OPINION

Neuroprotection for stroke: renewed hope for success

By Dr David Blacker, Neurologist, Nedlands At the recent Stroke Society of Australasia (SSA) Annual Scientific Meeting in Canberra, I presented the latest results from the experimental stroke group at the Perron Institute and University of Western Australia.

The group, headed by Clinical Professor Neville Knuckey and Associate Professor Bruno Meloni, has been working for many years on strategies to preserve brain tissue in experimental ischaemia, haemorrhage and trauma.

The most promising agent found to date is the poly-arginine peptide R18, which has shown success in preserving neurons in cell models of ischaemia, and in experimental stroke models. They have also shown that R18 is well-tolerated in a haemorrhagic stroke model, confirming that the peptide is potentially safe for use in stroke patients prior to cerebral imaging.

The Perron Institute team has closely followed the work of Canadian researchers, who have also developed a potent neuroprotective peptide, NA-1, currently being assessed in a phase III clinical stroke trial. A major finding is that R18 consistently outperforms NA-1 as a neuroprotective agent in stroke models.

KEY MESSAGES R18 is one of the most effective neuroprotective agents currently under development Further safety studies are required before clinical trials in patients commence R18 could be administered, with the aim of preserving brain tissue, during transportation of stroke or head injury patients from rural settings

In the most recent study using the same facility in Canada as the NA-1 study, based on MRI, R18 reduced infarct volume to a greater extent and significantly improved functional outcomes.

Thus, R18 appears to be an even more effective neuroprotective agent than the current most promising drug being assessed clinically for stroke.

Further pre-clinical safety and toxicity studies are still needed, as is the first in human study, but plans are well under way for a phase II study of R18 in stroke patients. Trial design A paper based on is being strategised. The the study presented prospect of R18 being used as to the SSA has an early intervention to slow been accepted for infarct growth and preserve publication by the journal neural tissue in stroke patients Neurotherapeutics. requiring lengthy transportation times from rural sites to metropolitan centres for mechanical thrombectomy is exciting.

After reviewing the positive experimental data, one of Australia’s most senior stroke researchers, Professor Geoffrey Donnan has provided invaluable advice on the translation of R18 into human stroke trials.

He also presented some of his work with the Royal Flying Doctor Service, including the development of small, lightweight CT scanners which could potentially be carried in RFDS aircraft. In the future, it is possible that R18 could be administered to stroke and head trauma patients at rural centres, or in transit by the RFDS. Author competing interests. The author is involved with research on R18

MEDICAL FORUM

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.

Our emphasis is always on utilising the best available techniques to restore form, function and quality of life.

OUR TEAM Dr David Sofield

Dr Mikhail Lozinsky

Dr David Millar

Dr Yin Min Yew

Jo Milios

Dr Emily Calton

MBBS (WA), FRACS, FRCSE MBBS FECSM

BSc. (Physiotherapy) PhD

FRACS, FEBU MBBS

BSc (Nutrition) PhD

Denielle Rankin Practice Manager Urgent referrals will be seen within 48 hours and we welcome calls for advice anytime on 0419151050 (David Sofield) Or 0426255629 ( Mikhail Lozinsky)

All other enquiries and referrals to Level 1 4 Antony St Palmyra 6157 | Ph 93391932 Fax 93391832 | Email Denielle@sofield.com.au

DECEMBER 2019 | 47

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TRAVEL

Great Ocean Walk‌ In Style One of the most picturesque roads in all of Australia.

And GP Dr Lin Arias knows every inch of it.

E

veryone knows of Victoria’s Great Ocean Road, which starts in Apollo Bay and ends at the inspiring Twelve Apostles. Keen hikers are aware that the Great Ocean Walk, or the GOW, is a one-way 104km walk trail that hugs the rugged, rocky coastline, crosses deserted beaches and traverses through varying forest and heath ecosystems, including the Great Otway and Port Campbell National Parks.

You can certainly carry your own tents and food, and sleep in the great outdoors, you can also, ahem, go in comfort in small organised walking tours.

It was my option and the cares of a wind-swept walk or clambering over slippery and steep muddy tracks become fun talking points when there is a hot shower, a comfy bed and a delicious cooked dinner, plus predinner nibbles, waiting at the end of the day.

48 | DECEMBER 2019

All that was necessary to carry with a light daypack with lunch, water, some extra clothes and my binoculars. Pure backcountry hiking bliss.

Our operator was Inspiration Outdoors, which is Perth-based outfit, but with an operations office in Melbourne, where my trip started along with 11 other walkers. We were picked up by our wonderful guides, Cam and Rita for the four-hour drive to Apollo Bay, so we had lots of time for getting acquainted and hearing about the history of the area.

History of the track Servicemen returning after World War I built the Great Ocean Road. There is a commemorative statue by the entrance gate.

This area has experienced some horrific fires in the past several decades so this present gate has been completely rebuilt.

It is a lovely 8km hike on the first day, from Apollo Bay to Shelley Beach. The day was sunny, the coffee wonderful and everyone keen to start.

The trip involved walks from 8-21km a day.

We were picked up at the end of each day and dropped off at the same spot the next morning, thereby being able to walk the entire track.

The highlights for me included seeing many koalas in the wild. They only eat manna

leaves and tend to strip the trees bare.

They were plentiful along the hike to the Cape Otway Lighthouse. Occasionally a loud grunt/roar broke the air: a male koala was making his presence known. While often the animals were sleeping in the crux of branches, we caught some great views of them climbing and feeding.

Before the lighthouse was built in 1848, this rocky coastline claimed over 600 ships, taking lives and cargo. The lighthouse sits atop 90m-high cliffs where Bass Strait and the Southern Ocean collide. The ocean below the lighthouse churns and it is easy to imagine the joy of immigrants, long at sea, finally sighting land, and then their

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TRAVEL

cries of terror as their ship founders on the reefs and rocks. The view from the lighthouse is wonderful.

A Devonshire morning tea served by Rita in a koala suit added levity to our visit, and valuable calories for the afternoon’s walk, through sand dunes, coastal scrubland and calcified coastal cliffs.

Tempo: Andante The next few days saw us tackling ups and downs along the coastline, with rewards of magnificent views. The group spread out, with everyone walking at a comfortable pace. The sound of the wind in the trees and the distant waves crashing on the rocks, the smell of water and clean fresh air, the steady tromp of boots on the track: what wonderful days.

In addition to enjoying the magnificent scenery, there was abundant opportunity for wildlife spotting. Along the walk there were firetail finches, especially by Johanna’s beach; splendid blue wrens nearly everywhere; a few elusive black wallabies; and lots of gorgeous native flowers.

ocean. In the morning light the Apostles look fresh and bright.

We then had the great fun of a short helicopter ride over the coastline around the Apostles. There are other limestone pillars and islands along the sea line, all given names that are suggested by their shape and, I reckon, someone’s active imagination.

Seeing the coastline from the air gave an understanding of how long and beautiful it is. It also made it possible to realise the difficulties of rescuing a boatload of people who could not swim, while those wooden ships were being smashed into the sharp reef and rocks in a height of a Southern Ocean gale.

of the best known. Many relics from that 1878 wreck are part of an excellent and informative display at the Port Campbell visitor centre. The small town is very picturesque and blessed with great eateries and coffee, so it is worth making a lunch stop and having an amble before getting back on the minibus and taking the inland route back to Melbourne.

It was a great week of wilderness hiking made easy with organised transport, delicious meals and some end-of-the-day creature comforts.

By Dr Lin Arias ED: Lin was a paying walker on this tour led by Inspiration Outdoors www.inspirationoutdoors.com.au

Not surprisingly, many of the beaches we visited along the GOW were named after shipwrecks – the Lock Ard Gorge is one

The end of the walk took us to wonderful lookouts towards the striking limestone stacks that are the Twelve Apostles, which, of course, have dwindled to eight from the constant erosion of pounding seas. No matter, they were still magnificent.

When our party reached it was late afternoon and the darkening light muted their many shades of reds and orange.

More shocking are the hordes of day visitors who take the long bus journey from Melbourne to the Apostles and back. After our blissful walk, the crowd was a shock.

When we return early the next morning, walking the short track from Gibson’s Steps to the Apostles lookouts, we have the wondrous views mostly to ourselves.

Pioneers honoured The steps are named after Hugh Gibson who ran a nearby homestead. It is thought that the 86 steps were carved by the local Kirrae Whurrong people and later used by many fisherman and sailors to reach the

MEDICAL FORUM

DECEMBER 2019 | 49

SOCIAL PULSE 1

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30th anniversary of Perth Orthopaedic & Sports Medicine Centre Orthopaedic surgeon Dr Keith Holt started his solo practice three decades ago and last month he and his 13 partners celebrated POSM’s 30th anniversary. Rather appropriately, the team of doctors and the practice staff celebrated at Optus Stadium, complete with scoreboard fanfare.

1 Group photo (POSM Partners) Back row, from left: Drs David Wysocki, Ross Radic, Peter Annear, Keith Holt, Prof Richard Carey-Smith, Drs Peter Hales, Greg Witherow, Daniel Meyerkort and Antony Liddell.

Front row, from left: Prof Markus Kuster, Drs Travis Falconer, Greg Hogan, Greg Janes, and Jens Buelow.

2 Dr Keith Holt and Anne Fuller.

3 Dr Keith Holt and Trish McGann, who was Dr Holt’s first practice manager and worked at POSM for about 28 years.

4 Group photo (POSM staff) POSM staff, from left: Rose Miceli, Kristy Edwards, Yolanda Bandovski, Karen Davies, Prue Brown, Denise Edwardes, Jennifer Muir, Jill Mihalj, Decima Claite, Melissa Bator, Michelle Princi, Amanda Parry, Trish McGann and Lee Gardner.

5 Optus Stadium.

2

3

4

5

50 | DECEMBER 2019

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WINE REVIEW

Rosabrook’s Winning Pedigree The Rosabrook Estate Vineyard is located about 14km from the Margaret River township and was one of the early vineyards planted in the region back in 1979.

After a succession of owners, the site has found stability as part of the Calneggia Family Vineyards. These also include the labels Calneggia, Bunkers, Bramble Lane and Brian Fletcher. The Rosabrook vineyard has 25ha of mostly the mainstream varieties. The Calneggia family also have other premium vineyards and source fruit from across the region. They are fortunate to have Brian Fletcher as winemaker. Brian has vast experience, both internationally and locally and his prowess, together with the fruit quality of the region, result in wines of finesse.

By Dr Craig Drummond Master of Wine

Rosabrook 2018 Margaret River Sauvignon Blanc Semillon (RRP $20)

Rosabrook 2016 Margaret River Cabernet Sauvignon (RRP $25)

Water white in colour from reductive winemaking. It’s a zesty, fresh, vibrant, clean, crisp, linear wine and a good example of this highly recognised Margaret River blend. Aromatics of cut grass and fresh herbs. Tangy flavours of gooseberry and lime. Firm acidity gives a great finish.

Made from 100% MR Cabernet and showing classis regional characters. This wine has big flavours and needs a couple of years to show at its best. However, I still enjoyed the wine very much, but will definitely tuck away my remaining bottles. The nose is ripe, with blackberry, eucalyptus, and obvious oak. Palate is leafy with stewed plum and menthol. Grippy linear, firm tannins and spicy oak.

A refreshing wine to match seafood or as an appetiser.

Rosabrook 2018 Margaret River Shiraz (RRP $25)

Once these characters settle and further integrate, it will be a rewarding wine.

From a great MR vintage! A medium-bodied style for mid-term consumption. The nose displays redcurrant, thyme and a touch of white pepper. This leads into a spicy palate with redcurrant and slightly briary flavours.

Very enjoyable now, and will reward cellaring for next 2-4 years.

REVIEWER'S

Rosabrook 2016 Margaret River Chardonnay (RRP $25)

PICK

My wine of the tasting – an initially restrained nose quickly opens up with ripe melon aromas and a slight nuttiness from integrated oak. The palate is beautifully supple and mellow. Flavours of nashi pear and melon. Textured. It’s at optimal development, nice balance with everything integrated and ‘in place’.

Acidity gives a fresh clean finish.

I consider this wine great value for money and it went perfectly with my WA king prawns for lunch.

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DECEMBER 2019 | 51

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FRINGE WORLD

Raising the Roof

M

en and pubs are almost as neat a match as a horse and carriage but The Choir of Man, which is a feature of next year’s Fringe World, is more than beer and skittles.

Through the songs and stories of the nine all-singing, all-playing characters at the bar of the make-believe pub, The Jungle, the thorny life issues some men find difficult to talk about emerge.

The show’s creator and producer Nic Doodson said he has had a lot of positive feedback from men who have been brought along by their partners only to find themselves opening up about their own insecurities.

“We get a lot of men coming up to us after the show saying, I didn't really want to come tonight. My wife, girlfriend, whoever, persuaded me, and when I found out there was free beer, I definitely wanted to come along. But actually, I really enjoyed it’,” Nic told Medical Forum.

“We do talk in the show about male mental health and opening your heart to someone

and allowing others in. Men take a lot of exercise, but one of the things they don't exercise that well, is the soft side of all that muscle.”

The Jungle is a slice of theatrical life.

There’s the joker, the Casanova, the hard man and the bore. As the show unfolds, the clichés start falling away.

The Choir of Man debuted at the Edinburgh Fringe a couple of years ago and has toured the world ever since.

The group first headed Down Under to last year’s Adelaide Fringe and were such a hit, WA was a shoo in for 2020.

The schtick of course is the beer.

Nic said that the audience is invited up on stage before the show, which is decked out as a fully functioning bar.

“When people first walk into the auditorium, we invite them to have a drink. We give away about 100 pints of beer before the show starts. Strangers start chatting to each other and then gradually they find their seats and the show proper begins,” Nic said.

NEw SS E aDDRaME & N sly

io u Prevylands a “M unding” po C om

Nic’s background is performance though since he and his wife had their first child four years ago, he has been using his knowledge to create and produce musical productions, the latest is called The Noise Boys which is a tap dance beatboxing show. He’s hoping to bring that to Australia next year as well.

“I really thought I would miss performing, but I find I get even more pleasure now out of seeing my actors and actresses getting the accolades for their great performances,” he said.

Audiences can expect a night of hairraising harmonies, high-energy dance, and live percussion with foot-stomping choreography. The music is a mixture of classic rock anthems and ballads written by the likes of Adele, Queen, Paul Simon, Katy Perry, Red Hot Chili Peppers, Guns ‘n’ Roses among them.

And, did we mention free beer?

The Choir of Man, Ice Cream Factory, 6.30pm, January 17-February 12.

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DECEMBER 2019 | 53

Enter Medical Forum's competitions!

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

Movie: A Beautiful Day in the Neighborhood Tom Hanks puts in a turn as Mr Rogers in this role that fits him to a T. A Beautiful Day in the Neighborhood is a story of kindness triumphing over cynicism, and is based on the true story of the friendship between said Fred Rogers and journalist Tom Junod. The journalist is of course the embodiment of cynicism and, from Rogers, he learns empathy, kindness, and decency.

In cinemas, January 23

Film: Portrait of a Lady on Fire

Movie: Little Women

Set in France in 1760, Marianne is a painter commissioned to do the wedding portrait of Héloïse, a young and reluctant bride who has recently left the convent life. The brief is that Marianne must paint her without Heloise knowing. She observes her by day and secretly paints her at night.

Writer-director-actor Greta Gerwig (Lady Bird, Frances Ha) is a genuine talent and everything she has touched so far has been interesting, provocative and well worth the time and money to go along and see.

So, news that she is directing one of the most beloved period pieces in the canon, Little Women, is cause for anticipation. Here she has drawn on both the novel and the author, Louisa May Alcott’s, writings to take a new angle. In Gerwig’s adaptation, Jo March, as the author’s alter ego, reflects back and forth on her fictional life.

At the heart of it are the March sisters – four young women living amid the turmoil and tragedy of the American Civil War, who are trying to grow up and out in the best way they can. It is different for each and they create a family drama and intriguing feminist narrative of great proportions.

Jo is taken on by Irish actress Saoirse Ronan, Meg

by Emma Watson, Amy by Florence Pugh and Beth

by Eliza Scanlen, with Lauren Dern holding the apron strings of Mrs ‘Marmy’ March. Meryl Streep is thrown in for good measure. It is a wonderful cast and a perfect way to start a new year.

In cinemas, January 1, 2020 MEDICAL FORUM

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

October Competition Winners

Musculoskeletal Issues Doctors for Doctors Rural Workforce Gambling & Health

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

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

O C T O B E R 2 0 19

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Charlize Theron, Nicole Kidman and Margot Robbie headline this revealing look inside the powerful and controversial media empire, Fox News, and the explosive story of the women who brought down the man who created it.

In cinemas, January 16

Fringe: The Choir of Man Blazing a trail across the globe this ‘pub choir’ finally makes its WA debut at the Perth Fringe. The nine ‘blokes’ offer up 90 minutes of pub staples and singalongs with hair-raising harmonies, high-energy dance, and live percussion with foot-stomping choreography. Featuring songs by Adele, Queen, Paul Simon, Katy Perry, Red Hot Chili Peppers, Guns ‘n’ Roses and more.

Ice Cream Factory, 17 January - 12 February, 6.30pm

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Film: Bombshell

Fringe: Casting Off

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

Movie: After the Wedding – Dr Vicki Westoby, Dr Andrew Martin, Dr Stephen Rodrigues

In cinemas, December 26

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Movie: Pavarotti – Dr Ralph Longhorn, Dr Raymond Wu, Dr Helena Goodchild, Dr Michelle Cotellessa, Dr Michel Hung

After an award-winning season at Edinburgh Fringe in 2018, this Melbourne-based all-woman, cross generational circus is heading to Perth as part of Fringe World 2020. Three generations of dynamic women tumble, talk, fly and balance precariously in an absorbing performance where the personal is political, the furious is funny, and the acrobatics are downright dangerous.

De Parel Speigeltent, Woodside Pleasure Gardens, 21 January - 2 February, 6.15pm

Movie: Charlie’s Angels – Dr Jemma Hogan, Dr Warren Saint, Dr Henrietta Bryan British Film Festival – Dr Fiona Sluchniak, Dr Russell Date, Dr Andrew O’Shea, Dr Steve Edlin WASO Discovery Concert – Dr Danielle Paterson

54 | DECEMBER 2019

Wine winner

Dr Diedre Tierney has won the Howard Park wine dozen which features the best of fruit grown in the Margaret River and Great Southern wine regions – sparkling, white, rose and reds. Drops of every hue!

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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”).